AMERICAN ACADEMY OF COSMETIC SURGERY

THE AMERICAN JOURNAL of COSMETIC SURGERY

Five and a Half Years' Experience With the A velar Lipoabdominoplasty Procedure: Analysis of Complication Rates Quita Lopez, MD

The American Journal of Cosmetic Surgery Vol. 30, No. 3, 2013 181

ORIGINAL ARTICLE

Five and a Half Years' Experience With the A velar Lipoabdominoplasty Procedure: Analysis of Complication Rates Quita Lopez, MD

Introduction: The Avelar lipoabdominoplasty procedure has been described in the literature as a safe procedure with fewer complications than traditional abdominoplasty because of limited upper abdominal dissection, which spares the superior neurovascular bundles along with the lymphat­ics. In the author's published article in 2008, 80 patient charts were evaluated retrospectively, and the complication rates were compared with other studies presented in the literature. The purpose of this study is to compare the com­plication rates of the first 2 years to the subsequent 3 ~ years since the procedure was adopted. The Avelar mini­lipoabdominoplasty procedures were also reviewed, and the complication rates were compared with those of the full Avelar procedures.

Materials and Methods: A retrospective review was per­formed of records of patients who underwent a full or mini­A velar lipoadominoplasty procedure from July 1, 2007 to December 31,2010.

Results: A total of 89 patient charts were reviewed. There were 73 fulllipoabdominoplasty and 16 mini-lipoabdomino­plasty procedures peiformed by the author. The mean age of the patients was 42 years; 46% had general anesthesia and 54% had conscious sedation. In the 89 patients who under­went both types of procedures, there was 1 case of skin necrosis ( 1.1% incidence compared with a 3. 7% incidence the first 2 years), 4 seromas (4.5% incidence compared with 12.5% incidence in the original study), and no deep venous thromboses or hematomas. For the fulllipoabdominoplasty procedures, the skin necrosis rate was 1.4% compared with 3.9% in the 2008 study, and the seroma rate was 5.5% com­pared with 13.0%. There were 9 small skin dehiscences ( 10% incidence), and there were 4 postoperative infections ( 4.5% incidence). The mini-lipoabdominoplasties had none of these complications.

Received for publication December 5, 2012. From the Aesthetic Laser Center, Fresno, Calif. Corresponding author: Quita Lopez, MD, Aesthetic Laser Center, 6081

N First #101, Fresno, CA 93710 (e-mail: q.lopez@sbcglobal.net). DOl: 10.5992/AJCS-D-12-00060.1

Conclusions: The complication rates have decreased in the subsequent 3~ years compared with the first 2 years. This is probably due to increased surgeon experience, not operating on smokers in the second part of the study, and using the Erchonia EML (Erchonia Medical Inc, Mesa, Ariz) on all patients pre- and postoperatively. The rates were lower than those reported for traditional abdominoplasties. There were none of the above complications for the mini­abdominoplasties using the Avelar technique.

Abdominoplasty is a common procedure for abdominal contouring. Since A velar1

•2 described

his technique of combining liposuction with lipectomy and avoiding large upper flap undermining, the com­plication rates for the procedure have been shown to be lower than with traditional abdominoplasty. Lipoab­dominoplasty and A velar abdominoplasty are terms that are often used synonymously by some surgeons. There have been subtle variations on the technique described by various surgeons. A common theme among all is liposuction along with limited dissection in the upper abdomen and sometimes lower abdomen when a mini versions are performed. The A velar lipoabdominoplasty technique is becoming more pop­ular among surgeons who do abdominal contouring procedures. It is possible to salvage at least 80% of the blood supply to the abdomen.3 Graf et al4 showed that 60% of the perforators were preserved with a modified technique that involved limited upper flap dissection with full en bloc dissection of the lower flap where there was transection of the inferior epigastric and external iliac vessels. The size and flow rate are increased in the remaining vessels due to hypoxic stimulation. This is a technique that the author employs with patients with larger body mass index (BMI) who have a large inferior pannus. Patients with smaller BMis

182

have only the dermis excised, salvaging most of the blood supply along with the lymphatics and nerves.

With the mini-lipoabdominoplasty procedure, lipo­suction is performed in the deep and superficial layers, and the excess skin in the lower abdomen is excised just below the dermis. There is usually no dissection of the lower flap except when lower diastasis is pres­ent. The midline is then dissected up to the umbilicus to allow plication for correction of a diastasis. The umbilicus is not transposed; hence, a small amount of dead space is created, and there is the preservation of an even greater amount of blood supply, nerves, and lymphatics; this probably accounted for there being no complications in the parameters studied.

Methods A retrospective review of medical charts was per­

formed between July 2007 and December 2010. There were 73 full Avelar lipoabdominoplasties and 16 mini­lipoabdominoplasties performed. All of the patients were women. The mean age was 42 years, with a range from 21 to 72 years. The average BMI was 28.6 kg/m2 (range, 20-41 kg/m2). The mean BMI for patients undergoing mini-lipoabdominoplasty was 25.8 kg/m2 (range, 20-31 kg/m2). Forty-four patients had liposuction of other body parts along with the abdominoplasty, and 14 patients had concomitant breast surgery. This included implant placement, implant with simultaneous lift, or just mastopexy. Fat grafting to the face was done in 9 patients, and 5 had simultaneous fat grafting to the buttocks. One patient had a labioplasty procedure at the same time, and another had a brachioplasty procedure. Hence, all of the patients undergoing mini-lipoabdominoplasty had other procedures performed. The overall incidence of concomitant procedures was 75%. All surgery was performed in an accredited office surgery center.

Surgical Technique The patient was marked preoperatively, and tumes­

cent anesthesia consisting of 0.05% lidocaine was used. In a liter of normal saline, 0.8 mg of 1:1000 epinephrine and 10 mg of 8.4% bicarbonate were also placed. Forty-six percent of the patients had general anesthesia, and 54% had conscious sedation. In the original study, 41% had general anesthesia and 59% had conscious sedation. The Erchonia EML Laser (Erchonia Medical Inc, Mesa, Ariz) was used during infiltration to facilitate liquefaction of fat prior to lipo­suction. The Mangubat disruptor was also used before liposuction was initiated. Liposuction was performed

The American Journal of Cosmetic Surgery Vol. 30, No. 3, 2013

below and above Scrapa' s fascia in the upper abdo­men to allow sliding of the flap. Liposuction is also performed aggressively in the lower flap, and Scarpa fascia is usually not well preserved in the author's opinion. Patients with larger BMis who have signifi­cant fat in the lower flap had an en bloc dissection of the lower abdomen and drain placement horizontally in the lower abdomen. Here, the inferior epigastric and external iliac vessels, which are zone 1 and 11 vessels as described by Huger,5 are transected, and there is also injury to the lymphatics in this region. The excess skin is then measured and marked, and it is tested before excision by pulling together with Koeker clamps. The excess skin is excised, the umbi­licus is released, and the stalk is tagged. The vertical midline is also released up to the xyphoid process if needed. This vertical tunnel is mostly limited to the internal borders of the rectus abdominal muscles. A Saldanha retractor is placed in the midline, and the author has made more aggressive releases in the latter 3¥2 years to better plicate the superior fascia for better correction of a diastasis defect. The retractor stretches the midline and allows for better visualization of the fascia. The vessels will be located more laterally on stretched-out abdominal muscles; hence, a larger tunnel can be dissected safely. Fat is resected in the lower midline to expose the fascia, and it is plicated if needed. The incision is closed in 2 or 3 layers, and the umbilicus is transposed. A Jackson-Pratt drain is placed horizontally in patients with full-thickness excision of the lower flap. Activated platelet-rich plasma (PRP; Harvest Technologies, Plymouth, Mass) is sprayed in the flap prior to closure and along the incision after closure. PRP has been shown in the lit­erature to promote wound healing. 6--

11 All patients wear pneumatic compression stockings if they have general anesthesia, and they also have their knees flexed during surgery. All patients wear knee-high compression hose for 14 days, and Lovenox (Aventis Pharmaceuticals Inc, Bridgewater, NJ) is given to high-risk patients for 3 days. Compression garments are worn for a minimum of 2 weeks.

The mini-lipoabdominoplasty procedure is similar, but the umbilicus is not translocated, and there is almost no dissection of the lower flap. Only the mid­line is dissected up to the umbilicus if plication is needed for lower diastasis repair. Drains are not placed in these procedures.

Prior to performing the skin excision, liposuction is performed in the other areas, usually the flanks. As

The American Journal of Cosmetic Surgery Vol. 30, No.3, 2013 183

Table 1. Postoperative Complication Rates (%)

Skin Necrosis Seromas 2008 study (n = 77) Current study (n = 73)

3.9 1.4

noted, 50% of the patients had liposuction of other areas done in addition to the A velar lipoabdomino­plasty. All of the mini-lipoabdominoplasty patients had additional liposuction for improved body contour­ing. Patients undergoing other procedures had those procedures performed prior to the abdominoplasty, except for fat grafting to the face, which was done last.

Results In the original study, 12 the author performed a ret­

rospective review of the charts between June 2005 and June 2007. There were 80 patients, with 77 having full lipoabdominoplasties and 3 having mini-lipoabdomi­noplasties. The mean age of the patients was 44 years (range, 24-76 years). The average BMI was 30.1 kg/m2

(range, 20-42 kg/m2) . There was an overall 3.7% skin

necrosis rate, and the full lipoabdominoplasties had a 3.9% rate, which was lower than most studies found in the literature (range, 1.2-20% ). In the second part of the study, the overall rate decreased to 1.1% and to 1.4% for the fulllipoabdominoplasties (Table 1). This occurred despite more aggressive release of the stro­mal structures in the midline to allow for better fascial plication. No smokers were operated on in the second study.

The overall seroma rate decreased from 12.5% to 4.5%. The full lipoabdominoplasty rate decreased from 13.0% to 5.5% (Table 1). The decreased rate probably reflects better selection of patients who need drain placement. With full-thickness excision of the lower flap, the lymphatic tracks in this area are usually damaged along with the lower part of zone 1 and zone 2 vessels. Hence, the author now places drains rou­tinely in these patients. The Erchonia 635-nm low­level laser was also used on all patients postoperatively in the second series. Most patients were not treated with the low-level laser in the 2008 study. Only patients in the last 2 months of the first study were treated, which amounted to about 12 of 80. The low­level laser has been shown to enhance wound healing and increase vascularization after surgery. 13

•14 This

might also have contributed to the decreased skin necrosis rate in the second series as all the patients

13.0 5.5

Deep Venous Thromboses 0 0

Hematomas 0 0

were treated with the low-level laser. Jackson 15 used PRP on his adominoplasty procedures and showed less seroma formation, and drains were used for a shorter amount of time. PRP was used on most patients in the first and second study.

There were no deep venous thromboses or hemato­mas in either series (Table 1). There was an overall 4.5% infection rate and 10% dehiscence rate in the second series. Most of the infections were minor and were treated with oral antibiotics, and all dehiscences were small. Please see Figures 1 to 9 for before and after photos.

Discussion The lipoabdominoplasty procedure as described by

Avelar1•2 has been shown to be safe and have decreased

complications compared with traditional abdomino­plasty procedures. A velar started performing these procedures in 1998 after doing cadaver studies and research for 10 years. In his studies, he found that lipo­suction below Scarpa's fascia allowed sliding of the superior flap and that the neurovascular bundles were able to be preserved because of limited dissection. He

Figure 1. Sixty-year-old patient (height: 150 em; weight: 84 kg) had liposuction of waist and hips with an Avelar abdominoplasty (side view).

184

Figure 2. Sixty-year-old (height: 150 em; weight: 84 kg) had liposuction of waist and hips with an A velar abdomino­plasty (front view).

measured the length of the preserved vessels and found them to stretch 4 times their length. Fat above Scarpa's fascia was retained to maintain a uniform thickness and avoid irregularities. He also closed Scarpa's fascia to avoid indentations and decrease the tension on the scar. Initially, the excess skin was removed suprapubically and in the inframammary region. The fascia was not plicated in his original studies. Avelar later modified his procedure and pli­cated in the midline and transposed the umbilicus. Liposuction has allowed the surgeon to improve

Figure 3. Thirty-nine-year-old (height: 165 em; weight: 74.5 kg) had liposuction of waist, hips, inner thighs, and knees and an Avelar mini-abdominoplasty (side view).

The American Journal of Cosmetic Surgery Vol. 30, o. 3, 2013

Figure 4. Thirty-nine-year old (height: 165 em; weight: 74.5 kg) had liposuction of waist, hips, inner thighs, and knees and an Avelar mini-abdominoplasty (front view).

patient contouring along with salvaging the neurovas­cular bundles and lymphatics. This allows the flap to be closed without the usual undermining up to the costal margins. Saldanha et al3 showed that the upper flap was undermined only 30% compared with stan­dard abdominoplasties. In their article, Brauman and Capocci16 discussed skin-retaining ligaments, which caused skin creases on patients in the upper abdomen. They felt that these were vertical layers of fascia that attach the skin to the deep fascia and make the down­ward advancement more difficult. The skin will usu­ally retract back later, making the result less aesthetically pleasing. They used scissors or blunt dis­section in lateral tunnels to release the ligaments selectively. With their experience, they were able to preserve the perforators while releasing the ligaments. The authors also felt the release of the skin-retaining ligaments decreased the tension on the skin incision, which is a cause of flap necrosis. They showed a 1.7% necrosis rate in their series of 337 patients (Table 2).

Figure 5. Forty-five-year-old (height: 160 em; weight: 72 kg) had an Avelar abdominoplasty.

The American Journal of Cosmetic Surgery Vol. 30, o. 3, 2013

Figu~e 6. ~ifty-year-old (height: 165 em; weight: 84.5 kg) had lzposuctwn of the lower back, waist, and hips and an A velar mini-abdominoplasty (side view).

Samra et al19 compared complication rates in 161 patients who underwent a lipoabdominoplasty (n = 93) versus a traditional abdominoplasty (n = 68). They found the lipoabdominoplasty had a complication rate of 4.30% compared with 11.76% (P = .126). These were what they called perfusion-related complications, including skin necrosis, wound infection, and wound dehiscence. In the patients who were at high risk, which included smokers and patients with significant upper abdominal scars, the complication rates were not statistically significant.

There are numerous studies in the literature in which wound healing, postoperative pain, and inflammation are improved with the low-level laser. 16.zO-zz.zs .z6 Ben­sadoun and Naif23 performed a meta-analysis on 33 relevant articles, which showed that low-level laser therapy reduced the risk of oral mucositis (relative risk, 2.45). Treatment also reduced the severity of oral mucositis and decreased the duration to 4.38 days. This was clinically significant (P < .0009). The authors concluded that there was moderate-to-strong evidence

Figure 7. Fifty-year-old (height: 165 em; weight: 84.5 kg) had liposuction of the lower back, waist, and hips and A velar mini-abdominoplasty (front view).

185

Figure 8. Forty-six-year-old (height: 155 em; weight: 79 kg) had liposuction of the lower back, waist, and hips and an Avelar abdominoplasty along with breast augmentation (side view).

in favor of low-level laser therapy for treating cancer therapy-induced oral mucositis. It was well tolerated and relatively inexpensive.

The author's decreased skin necrosis rate during the second study probably reflects the use of the low-level laser, which has shown to improve flap survival by 50% in rats. Tenehaus et al24 produced random-pattern skin flaps on mice. Since the low-level laser at 635 nm is known to increase mitochondrial activity and aden­osine triphosphate production in cells, it was used to treat half the animals. Perfusion was measured by laser Doppler before and after surgery. Mean flap loss was 25% in the nontreated group and 9% in the treated group. There was more than a 50% reduction in is­chemia or apoptosis in the zone of stasis in the low­level laser-treated group. This was statistically

Figure 9~ For~-six-year-old (height: 155 em; weight: 79 kg) had lzposuctwn of the lower back, waist, and hips and an Avelar abdominoplasty along with breast augmentation (front view).

186 The American Journal of Cosmetic Surgery Vol. 30, No. 3, 2013

Table 2. Complication Rates (%) as Reported in the Literature

Skin Necrosis Seroma Infection Deep Venous Thromboses Hematomas Lonergan and Mangubat17 (n = 67)* 3 6 7 0 0 Rodriguez and Borsand18 (n = 100)* 2 9 4 0 5 Saldanha et al3 (n = 445)* 0.2 0.4 n/a 0.2 0.2 Brauman and Capocci, 16 (n = 337)t 1.7 1.4 1.4 0 .29 Current study (n = 150)* 2.6 9.3 4.0 0 0

*Lipoabdominoplasty performed. tLipoabdominoplasty with selective release of skin-retaining ligaments.

significant (P < .01). The perfusion measured at the distal flap showed an upregulation at day 4, which was statistically significant between the tested group and control group (P < .05). There was about a 50% increase in blood perfusion in the group treated with the low-level laser.

No smokers were operated on in the second series. The mini-lipoabdominoplasty maintains the most blood supply; hence, there were no cases with skin necrosis.

Overall seroma rates decreased from 12.5% to 4.5%, and fulllipoabdominoplasty rates decreased from 13% to 5.5% (Table 1). Modification of Avelar's original technique involving en bloc dissection of the lower flap causes more dead space formation and injury to the inferior vessels and lymphatics. Huger5 noted that the lymphatic drainage follows the vascular blood supply pretty closely. When a full-thickness excision is performed, there is routine placement of drains in the lower abdomen. The Avelar mini-lipoabdomino­plasty procedures have limited dissection and almost no injury to the vessels and lymphatics. There were no seromas in the 16 cases the author performed. In sum­mary, the potential mechanisms for a decreased seroma rate in the second series is probably due to avoiding injury to the upper and lower abdominal lymphatic vessels. When the lymphatics are injured during an en bloc dissection in patients with larger BMis, drains are

now placed routinely until the serous output is less than 30 mU24 h. Reducing the exposed rectus fascia and having a fat-to-fat interface during closure of the flap might also help. Eliminating the amount of dead space is also a factor. The use of PRP in the lower flap has been shown by Jackson15 to decrease seroma for­mation. The low-level laser10

•11

•13 has been shown to

improve wound healing. This might also have contrib­uted to the decreased rate, but more studies are needed to confirm this.

There were no deep venous thromboses or hemato­mas in either series (Table 1). This is probably in part due to the use of the tumescent solution that contains epinephrine, which causes vasoconstriction, and to the use of compression garments after surgery, along with meticulous dissection and careful control of bleeding. Patients also ambulate the evening of surgery and are mobile and wear compression stockings. Lovenox prophylaxis is also given to high-risk patients.

Table 3 is a statistical analysis of the complication rates between the 2 studies. Even though they are not statistically significant to the P > .05 level, there is a trend toward decreased rates. Having a higher sample size might have shown statistical significance.

Please review Table 2 for complication rates pub­lished by different authors on the abdominoplasty procedure.

Table 3. Results of the z Test Comparing the Complication Rates in the Current Study to the Complication Rates in the 2008 Study*

Proportion for Current Proportion for 2008 Statistical Complication Study (n = 73) Study (n = 77) ZScore P Value (2-Tailed) Significance

All .068 .169 -1.89 .059 P>.05 Skin necrosis .014 .039 -0.96 .337 P>.05 Seromas .055 .130 -1.58 .114 P>.05

*Statistical analysis of the complication rates from the 2 studies showed that the complication rates between the 2 studies were not statistically significant to the P > .05 level, but there was a trend for decreased rates in the current study.

The American Journal of Cosmetic Surgery Vol. 30, No.3, 2013

Conclusion The A velar lipoabdominoplasty has been shown to

be a safe and effective procedure for treating skin laxity and localized adiposity and for correcting dias­tasis recti. In the author's first published study, she showed a decreased complication rate compared with traditional abdominoplasty procedures reported in the literature. Comparing a similar case number in the subsequent 3~ years showed a further decrease in complication rates, probably due to the author's increased experience with the procedure and the use of PRP and the low-level laser to increase skin perfu­sion after surgery.

Mini-lipoabdominoplasty procedures using the A velar technique were performed with other concom­itant procedures for better body sculpting, and there were no noted complications in this series. The author opines that most blood supply is spared since there is very little undermining with the procedure. The addi­tional procedures performed on these patients did not increase the complication rates.

References 1. A velar JM. Abdominoplasty without pannicu­

lus undermining and resection: analysis and 3 year follow-up of 97 consecutive cases. Aesthet Surg J. 2002;22: 16-25.

2. Avelar JM. Abdominoplasty combined with lipoplasty without panniculus undermining: abdom­inolipoplasty-a safe technique. Clin Plast Surg. 2006;33:79-90.

3. Saldanha OR, Frederico R, Daher PF, et al. Lipoabdominoplasty. Plast Reconstr Surg. 2009;124: 934-942.

4. Graf R, de Araujo LR, Rippel R, et al. Lipoab­dominoplasty: liposuction with reduced undermining and traditional abdominal wall flap resection. Aesthetic Plast Surg. 2006;30:1-8.

5. Hugar W. The anatomic rationale for abdomi­nal lipectomy. Am J Surg. 1979;45:612-617.

6. Driver VR, Hanft J, Flylling CP, et al. A pro­spective, randomized trial of autologous platelet-rich plasma gel for the treatment of diabetic foot ulcers. Ostomy Wound Manage. 2006;52:68-74.

7. Sakata J, Sasaki S, Handa K, et al. A retrospec­tive, longitudinal study to evaluate healing lower extremity wounds in patients with diabetes mellitus and ischemia using standard protocols of care and platelet­rich plasma gel in a Japanese wound care program. Ostomy Wound Manage. 2012;58:36-49.

187

8. Saad S, Elhahat A, Elsherbiny K, et al. Platelet-rich plasma versus platelet-poor plasma in the management of chronic diabetic foot ulcers: a comparative study. Int Wound J. 2011;8:307-312.

9. Marx RE, Carlson ER, Eichstaedt RM, et al. Platelet rich plasma: growth factor enhancement for bone grafts. Oral Surg. 1998;85:638-646.

10. Garg AK. The use of platelet rich plasma to enhance the success of bone grafts around dental implants. Dent Implantol Update. 2000;11:17.

11. Marx R. Platlet-rich plasma: evidence to support its use. J Oral Maxillofac Surg. 2004;62:489-496.

12. Lopez Q. Two year experience with the Avelar abdominoplasty. Am J Cosmetic Surg. 2008;25:92-96.

13. Lopez Q. Treatment of large skin necrosis fol­lowing modified A velar abominoplasty with the Erchonia EML 635 nm laser and platelet-rich plasma. Am J Cosmetic Surg. 2009;26:29-34.

14. Yu W, Nairn JO, Lanzafame RJ. Effects of photostimulation on wound healing in diabetic mice. Lasers Surg Med. 1997;20:56-63.

15. Jackson RF. Using PRP to promote healing and prevent seroma formation in abdominoplasty procedures. Am J Cosmetic Surg. 2003;20:185-193.

16. Brauman D, Capocci J. Liposuction abdomino­plasty: an advanced body contouring technique. Plast Reconstr Surg. 2009;124:1685-1695.

17. Lonergan I, Mangubat EA. The A velar lipoab­dominoplasty: initial operative experience and results in 67 consecutive patients. Am J Cosmetic Surg. 2008;25:251-263.

18. Rodriguez F, Borsand MA. One hundred con­secutive lipoabdominoplasty procedures: modified A velar technique for full abdominoplasty without panniculus undermining-advances, morbidity, and complications. Am J Cosmetic Surg. 2011;28:241-250.

19. Samra S, Sawh-Martinez R, Barry 0, et al. Complication rates of lipoabdominoplasty versus tra­ditional abdominoplasty in high-risk patients. Plast Reconstr Surg. 2010;25:693-690.

20. Aras MD, Gungormus M. Placebo-controlled randomized clinical trial of the effect of two different low laser therapies (LLLT)-intraoral and extraoral­on trismus and facial swelling flowing surgical extrac­tion of the lower third molar. Laser Med Sci. 2010;25:641-645.

21. Kim H, Kweon OK, Kim WH. Enhanced wound healing effect of canine adipose-derived mesenchymal stem cells with low-level laser therapy in athymic mice. J Dermatol Sci. 2012;1811:291-295.

188

22. Chow RT, Johnson Ml, Lopes-Martins RA, et al. Efficacy of low-level therapy in the management of neck pain: system review and meta-analysis of ran­domized placebo or active-treatment controlled trials. Lo.ncet. 2009;374:1897-1908.

23. Bensadoun RJ, Nair RG. Low-level laser ther­apy in the prevention and treatment of cancer therapy­induced mucositis: 2012 state of the art based on literature review and meta-analysis. Curr Opin Oncol. 2012;24:363-370.

24. Tennhaus M, Bhavsar D. Efficacy of LLLT for reduction in TNF alpha, cellular apoptosis, and tissue necrosis following induction of a partial thickness

The American Journal of Cosmetic Surgery Vol. 30, No. 3, 2013

burn and ischemic skin flap. Photonics in Dermatology and Plastic Surgery Meeting and SPIE Symposium on Biomedical Optics; 2008; San Jose, Calif.

25. Jackson RF, Roche G, Mangione T. Low-level laser therapy effectiveness for reducing pain after breast augmentation. Am J Cosmetic Surg. 2009;26:144-148.

26. Jackson RF, Roche G, Butterwick KJ, et al. Low-level laser-assisted liposuction: a 2004 clinical study of its effectiveness for enhancing ease of lipo­suction procedures and facilitating the recovery pro­cess for patients undergoing thigh, hip and stomach contouring. Am J Cosmetic Surg. 2004;21:191-198.