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Month: February 2012

May is Mommy Makeover Month (Original Article)

May is the month we dedicate to celebrate motherhood. It’s only fitting, therefore, that we also recognize the changes that motherhood brings.

Of course, becoming a mother alters the life of a woman in many ways, often running the gamut of emotional experiences. There are also changes to a woman’s body that accompany growing, carrying and bearing a child.

Pregnancy, and the weight gain that occur, create growth, not only of the baby, but also of the mom. Among the structures that grow to accommodate the new addition is mom’s belly skin. Sometimes the skin has difficulty expanding evenly so it cracks in areas. These cracks in the skin are what we identify as stretch marks.

Labor and delivery also create changes in the woman’s pelvis, allowing the hips to relax and widen during the birthing process. Multiple pregnancies multiply this effect on the woman’s body. These permanent changes are, however, well compensated by the joys of motherhood

The other parts of the woman’s body greatly affected by pregnancy are the breasts. The breasts grow and engorge in preparation for feeding the infant. Many women like the appearance of their breasts during pregnancy because the breasts become full and robust. Often women are disappointed after pregnancy when the breasts lose their fullness and begin to drift downward.

The good news is that many of the undesirable effects on the woman’s body from pregnancy can often be minimized before, or improved afterwards, through good perinatal care, as well as, the judicious and timely use of plastic surgery.


Let’s Start at the Top

            The breasts typically lose their fullness and descend to a lower position after pregnancy. Sometimes the areolae also stretch. The reasons for these changes are simple; gravity and skin tone.

The surgical treatment of post-pregnancy breast changes depends upon the condition. Lack of fullness requires placement of implants to restore volume. Nowadays many implant choices are available. Women who choose to breast feed should defer breast augmentation until the breasts revert back to their dry, pre-pregnancy state, usually 1-2 months after cessation of feeding.

Breast droopiness requires a lift procedure. Lift techniques vary but typically involve a greater degree of scarring than simple breast augmentation. Patients need to be ok with these scars and should have a thorough consultation to review them prior to surgery. Areolae can also be made smaller at the same time. Sometimes patients can benefit from both a breast lift and augmentation to restore position and fullness.


Then There’s the Baby Belly

            The abdomen does the heavy lifting in pregnancy. It’s no surprise therefore, that, after pregnancy, skin redundancy and stretch marks can remain. Another interesting effect of pregnancy is a separation of the paired rectus abdominus (i.e sit-up) muscles. The result is a gap between the muscles resembling a hernia. It is because of this anatomical separation of the muscles that abdominal exercises after pregnancy, such as sit-ups, although beneficial, are of limited value.

In cases of loose abdominal skin, stretch marks, and muscle separtation, the procedure of choice is an abdominoplasty, also known as a tummy tuck. Like the breast lift, tummy tuck surgery requires scars that need to be accepted by the patient. The tradeoff, however, is substantial removal of excess skin and stretch marks, as well as repositioning of the muscles. The result is a dramatic tightening of the belly with a very high degree of satisfaction. Tummy tuck patients are among the happiest in my practice.

Since both the breasts and the belly are affected by pregnancy, women often choose a combination of procedures. Sometimes even other areas, such as the love handles or the thighs also become part of the mommy makeover.

Combination procedures require additional safety considerations with respect to the operating facility and anesthesia. As with all plastic surgery a thorough and honest consultation with an experienced surgeon is key to a happy mommy. Happy Mother’s Day!



About the Author:


Jorge A. Perez, M.D., F.A.C.S. is a board certified plastic surgeon in Ft. Lauderdale. He is a member of the NOVO National Council of Leaders in Breast Aesthetics. He has served as a consultant for both Mentor (J&J) and Inamed (Allergan), leading breast implant manufacturers.

He has lectured internationally on the subject of breast surgery and body contouring and has been selected among the Castle Connolly (U.S. News & World Report) America’s Top Doctors. More information is available at or or call (954) 351-2200.

Medical Animations: A Useful Tool in Medical Malpractice Cases (Original Article)

· Legal Medicine · No Comments

Medical Malpractice in the U.S.


Medical malpractice is big business. Estimates are that medical liability costs in theU.S.exceed $40 billion annually. The stakes for both sides are very high. Plaintiff attorneys, working on contingency arrangements typically front the costs of litigation in the hopes of a giant payday for themselves and their clients. Defense costs are borne by the physicians themselves, either directly or indirectly via insurance premiums. In addition, physicians risk licensure restrictions, damage to their professional reputation and even the potential for loss of livelihood from an adverse verdict.

The past few years have seen sharp surges in malpractice insurance rates driven in part by greater frequency of litigation, larger awards and/or increased defense costs. The average payout, as well as the number of cases with verdicts exceeding $1 million has increased substantially. Attorneys often point to jurors’ capabilities to explain unexpected verdicts.

Juries in the U.S.are selected from the general population pool. Although physicians are included in potential jury pools, they are typically eliminated in medical malpractice cases during the process of jury selection called voidere. Occasionally other medical professionals are selected to sit on juries involving medical negligence. However, more often jurors have little or no medical background. The argument has been made that medical malpractice cases are too technically complex for the average layperson to fully grasp within the brief timetable of a trial. A successful outcome is often linked to the attorney’s ability to effectively convey his point of view.

Attorneys for each side try to create the greatest advantage for their clients by employing a number of legal tools at their disposal. The attorneys argue the case for, or against, the physician’s negligence using traditional evidence such as medical records, witness testimony and medical expert opinions. At trial, medical illustrations and artwork are often utilized to clarify or emphasize a point to the jury. We have incorporated the use of computer graphics to create enhanced medical illustrations.



Medical Animations: What are they?


Illustrations presented at trial have traditionally been static diagrams or sketches presented to sharpen a visual image for the jury. Medical illustrations may be used to demonstrate anatomy or physiologic pathways to help explain pathologic circumstances. Surgical procedures can be illustrated using diagrams from textbooks or journals. Computer technology and advanced software applications have allowed us to take medical illustrations to the next level.

Plastic surgery and dermatology are very visual specialties. Often results are in highly visible areas for the entire world to see. In addition, these procedures are typically photographed by the physician. The photo-documentation incorporated into these procedures creates a unique opportunity for useful medical illustration at trial.

In cases of alleged medical negligence, information is gathered from these photographs, as well as medical records, operative reports, sworn testimony, expert medical examination, and journal or text references. In order to defend against admissibility challenges at trial, the information is totally customized to the plaintiff’s circumstances. The information is loaded onto the computer and using advanced software is enhanced into a dynamic medical animation.


The Animation Team


The process is coordinated by the attorney, the expert physician and the computer graphic artist. The attorney determines the goals to be emphasized by the animation. These goals may be to explain the steps and decision points involved in a particular surgery or perhaps how a revisional procedure could mitigate potential damages.

The lay public often tends to minimize plastic surgery procedures. Despite complex anatomy and surgical physiology, aesthetic procedures are often relegated to simplistic terms such as a “boob job” or a “nose job”. Ironically, these procedures are often difficult to conceptualize, even by other physicians. They require a keen sense of spacial relationships and topography.

Attorneys often feel that educated jurors are more likely to empathize with their client. The medical animation gives the lay person a unique view into a customized operation. Another area where the animations are utilized is to fill in gaps of previous surgery or proposed corrections where photographs may not be obtainable. A proposed surgical correction may significantly impact the damages claimed by a plaintiff.

The expert physician is a critical component of the team. The physician must interface between the goals of the attorneys and the skill of the graphic artist. It is up to the expert physician to incorporate all of the available facts and accurately synthesize the information into a logical educational sequence.

The computer graphic artist is given the great responsibility of making the evidence come to life. The process is similar to creation of a cartoon. Using the available photographs, data and diagrams, the artist undertakes a painstaking, frame-by-frame assembly of the animation. Intervening movement is added by using computer generated images. The process involves an active dialog among the three team members until the final product is created.

(see Case Reports below)




Medical animations are a new tool that can be utilized by physicians and medical malpractice attorneys. They have been used successfully both at trial and at mediation proceedings. Current use of medical illustrations is helpful but only static in nature. Simple verbal descriptions are inadequate for aesthetic cases.

The medical animation is a dynamic, customized and accurate computer graphic that allows jurors a much greater understanding of the relevant issues of a case. The cost of an animation will vary depending on the length and complexity. However, it should be weighed against the potential costs of an adverse verdict.




Jorge A. Perez, M.D., F.A.C.S. is a board certified plastic surgeon in private practice in Ft. Lauderdale Florida. He serves as an expert in matters of medical malpractice. Dr. Perez has been repeatedly selected among the Castle Connolly (U.S. News & World Report) America’s Top Doctors. More information is available at or call (954) 351-2200.


Case Report (C.L.)


The patient is a young female who underwent a conventional, Wise-pattern breast reduction. Post-operatively she developed keloid scars. The surgeon injected her with Kenalog. The peri-areolar scars spread and the patient complained of a deformed appearance. A medical negligence action was filed against the surgeon alleging that the Kenalog concentration was excessive and caused skin atrophy and spread scars.

Upon careful review of the records it was noted that the patient had gained 100 lbs. and her breast size grew from a pregnancy following surgery. The plaintiff was required to undergo an expert medical examination (E.M.E.).

The defense argued that it was the additional breast weight, and not the Kenalog, that caused the scars to spread. Moreover, it was argued that she would benefit from a secondary breast reduction and, based upon the patient’s measurements taken at E.M.E., the surgery would eliminate the entire area of unsightly scarring.

A medical animation was created using the patient’s own photographs, the operative record, measurements taken at E.M.E., textbook diagrams and computer graphics. The goal was to educate the jury about breast reduction surgery and demonstrate how a secondary breast reduction would completely eliminate the patient’s complaints and therefore mitigate any damages claimed. The medical animation was narrated and explained by the expert at trial. The jury returned a verdict in favor of the defendant physician.


Case Report 2


A teenage female underwent breast expansion and reconstruction for significant asymmetry. Years later she underwent a second procedure, including prosthesis exchange and contralateral reduction mammaplasty. The patient sustained complications and a perceived poor outcome from the second procedure and filed suit against her surgeon. She subsequently underwent a third surgical procedure to revise the results.

The three stages of surgery were recreated using the computer-enhanced medical animation incorporating the patient’s records and photographs. Pictures of the patient’s initial pre-operative state were not available; therefore, computer software was used to digitally morph the post-operative photographs to demonstrate her likely appearance.

Liposuction 2012: Are you Lipoconfused? (Original Article)

· Body Contouring, Liposuction · No Comments

The terms are a confusing array of  lipoverbs; liposuction, liposelection, liposculpture, smartlipo, smoothlipo, soundlipo, coollipo, and on and on…

Though the terms may be different, the goals are the same; the removal of undesirable fat from areas of the body to improve the contour with the least amount of damage to the other tissues.


The History of Liposuction: It all Starts with an Idea

            It is certainly plausible that women since the age of Hippocrates have been asking doctors, “Gee, doc, can’t you just suck it out?”. However, modern liposuction began in the mid-1970’s. Gynecologists inGermany began using curette instruments to scrape fat from under the skin surface. The technique, modified by French surgeon and gynecologist Yves Ilouz, quickly evolved to the use of a closed, hollow suction device, similar to instruments used to perform uterine suction procedures.

Throughout the 1970’s and 80’s this new liposuction procedure gained great popularity in theU.S.and throughout the world. Unfortunately, the cannulae used to suction the fat also had a destructive effect on the other structures under the skin, namely the nerves, blood vessels, and fibrous connective tissue. The consequence was prolonged or permanent numbness, rippling of the skin, and bleeding. The latter could be problematic in cases of removal of larger amounts of fat. Anecdotal cases of severe injury and even death occurred during this period, secondary to significant blood loss. Tragic liposuction stories surfaced in the media as the interest in plastic surgery grew in theU.S.and worldwide, a safety stigma that still haunts liposuction to this day.

The Focus on Safety

            In the late 1980’s improved cannula design and smaller diameters diminished the incidence of severe skin irregularities with traditional liposuction. In addition, dermatologists and plastic surgeons began using an injection of liquid solution prior to suction to both provide anesthesia and reduce blood loss.

Formulas can vary but are typically made up of  salt water, a local anesthetic for pain control, and epinephrine to diminish the size of blood vessels. The solution is injected into the fat, prior to suction, to a state of “tumescence”, or tissue engorgement. Tumescent liposuction significantly improved safety and is still widely used today.


Sound Waves, the Next Generation of Liposuction

            Surgeons in Europe andSouth Americabegan experimenting with the use of sound waves to dissolve fat in the 1990’s. They found that waves in the ultrasound range generated a frequency that would burst the fat cells but did little damage to the other structures (blood vessels, nerves, etc.) that were desirable to spare. Ultrasonic energy was, of course, not new to medicine, nor was it unique to plastic surgery. Pregnant women have relied on the safety and accuracy of ultrasounds for decades.

The exciting and very significant improvement offered by ultrasonic lipoplasty, however, was the specificity with which fat could be liquefied and gently removed without collateral damage to nerves, blood vessels and other structures. The procedure is also used in conjunction with tumescent fluid infiltration, so blood loss is negligible. As with most procedures, it requires a skilled and experienced surgeon to achieve the optimal results.


The Laser makes its’ Mark

            Recently laser technology, initially utilized for elimination of facial wrinkles,  has been adapted for use in body contouring. Catchy terms like “smartlipo”, “coollipo” and “smoothlipo” have been cleverly utilized as marketing tools to sell these very expensive devices to surgeons and, in turn, to patients.

The benefits of laser liposuction are still under review by skeptical plastic surgeons. The procedure is slow, can create significant burns, and requires the use of the old fashioned, traumatic, traditional liposuction. In order to achieve the advertised benefits, patients need to insist that the entire procedure be performed using the laser.

Liposuction has evolved since its’ introduction in the mid-1970’s. Advances in technique and equipment have improved the safety and results associated with liposuction. It continues to be one of the most popular procedures in plastic surgery.



About Dr. Perez


            Jorge A. Perez, M.D., F.A.C.S.  was one of 10 U.S. physicians selected as F.D.A. clinical investigators for ultrasonic lipoplasty. He has performed hundreds of procedures and has lectured to thousands of surgeons in over 25 countries worldwide on the subject of liposuction and body contouring.

Dr. Perez has been selected among Castle Connolly/U.S. News and World Report’s America’s Top Doctors. To schedule a consultation with Dr. Perez call (954) 351-2200. To learn more about his practice or any of these procedures, visit

Unveiling the History and Myths of Ultrasonic Liposuction (Original Article)

· Body Contouring, Liposuction · No Comments

Liposuction has evolved a great deal since surgeons originally used coarse curettage techniques to scrape away unwanted subcutaneous fat. Several sentinel modifications have occurred in recent decades to help produce better, safer surgical results. Included among the innovations are improved instrumentation, better patient selection and the incorporation of pre-aspiration wetting solutions.

It was Yves Ilouz, a French gynecologist who was largely credited with the popularity of the technique we now know as liposuction. American plastic surgeons, trained inEurope, adopted the technique and brought it into the mainstream. Three decades and millions of cases later, liposuction remains one of the most popular procedures in plastic surgery.


A Rough Start


The introduction of liposuction into theUnited Stateswas met with mixed enthusiasm in the 1970s. Anecdotal reports soon surfaced of serious complications, even deaths associated with the new procedure. These tragic cases were especially significant because the whole concept of aesthetic, elective surgery was just evolving. The thought of a patient suffering serious complications from a medically unnecessary surgical procedure made these reports newsworthy. The negative media coverage cast a stigma upon the emerging procedure that has remained even to this day.

The reasons for the early catastrophic cases were complex. Among the problems were poor patient selection and varying degrees of practitioner skills. In addition, a lack of appreciation for significant losses of blood volume in the aspirate created hemodynamic instability. In an overzealous attempt to remove large volumes of fat, surgeons often created unacceptably low hematocrit levels.


A Safer Surgery


The mechanism of traditional liposuction, also termed suction assisted lipectomy (S.A.L.) is conceptually simple. A rigid, hollow cannula, connected to a suction machine, is inserted into the subcutaneous space. Rapid, coarse strokes by the surgeon create a series of tunnels, eventually becoming confluent, diminishing the fat panniculus. The underlying problem with the technique is that there is no tissue selectivity. The suction energy evacuates or destroys all elements of the subcutaneous tissue plane, including valuable structures such as blood vessels, nerves and fibrous tissue.

Critics of the procedure describe it as rough and traumatic, translating clinically into a painful, bloody process with a prolonged recovery. In addition, loss of essential connective tissue leads to rippling of the skin, the most common complaint following traditional liposuction. One study reported an 80 % incidence of skin irregularities following S.A.L.

The key to producing a safer result with liposuction needed to include the successful removal of fat tissue while at the same time sparing the other elements of the subcutaneous parenchyma. Several improvements were made towards this goal.

A leap forward occurred in the 1980s with the introduction of wetting solutions. Previously liposuction was a simple one-step “dry” procedure. Wetting solutions vary in their formula and quantity. However, the three fundamental elements to most infiltration solutions are saline, epinephrine and local anesthetic. The saline alters the tonicity of the adiposite, creating a more fragile cell, epinephrine is a potent vasoconstrictor, and the local anesthetic is used for pain relief. The solution is introduced into the subcutaneous tissue as a pre-aspiration step. The overwhelming benefit of wetting solutions is the significant reduction in blood loss associated with the lipoaspiration.


A New Idea

In the late 1980s and early 1990s several surgeons fromEuropeandSouthAmericabegan experimenting with a new concept. These surgeons began using ultrasound energy at a specific frequency to selectively destroy fat cells.

Ultrasonic energy was not new to medicine. Colleagues in other specialties have utilized ultrasound in a great number of both diagnostic and therapeutic capacities. Pregnant women certainly are familiar with the diagnostic uses and safety record of ultrasound. In addition, ultrasonic energy has been harnessed in ophthalmology for phacoemulsification and by urologists performing lithotripsy for renal calculi. Neurosurgeons and general surgeons are familiar with the Cavitron ultrasonic dissection device. Applications for ultrasonic energy continue to grow.

The use of ultrasound for body contouring was innovative. Previously, with traditional liposuction, the aspiration cannula could not distinguish between desirable tissue and fat. Consequently, the parenchymal architecture, including blood vessels, nerves and fibrous elements would be aspirated by the coarse cannula, along with the fat cells.

For the first time the concept of selective tissue aspiration could be achieved. The idea was simple, remove only the elements of the subcutaneous tissue needed to achieve the desired effect and preserve the rest. Like picking off the grapes, but leaving the vine intact.

The application of this energy to plastic surgery was appealing for three reasons. First, ultrasound has an established history of safety. Secondly, the vibratory frequency of the ultrasonic energy can be made specific to the adipocyte. It is this tissue specificity that underlies the mechanism and benefit of ultrasonic lipoplasty. And finally, since the energy for tissue fragmentation does not come from rapid surgical strokes, the process is markedly less traumatic to both the patient and the surgeon.


How it Works


The procedure is performed using a device made up of three component parts. Electrical energy is converted into ultrasonic energy using an ultrasonic generator attached to a handpiece containing a piezoelectric crystal.

The application of ultrasonic energy is an extension of the concept of a conversion of electrical energy to a mechanical wave.  The wave is propagated down a titanium cannula shaft with a specific length producing a nodal sine wave pattern.  The wave is calibrated to intersect at the tip of the titanium cannula producing a specific vibratory frequency of approximately 20-27 kHz.  It is this precise calibration that prohibits bending of the titanium ultrasonic cannulae.

The specific frequency of 20-27 kHz produced by the vibratory tip will affect primarily tissue with the lowest density, defined as tissue impedence.  Fat has the lowest tissue impedence.  Wetting the adipose tissue with tumescent infiltration can even further lower the impedence value.  The result is an energy absorption specific to adipocytes.  Ultrasonic energy absorption by adipocytes at a frequency of 20-27 kHz creates internal cellular instability leading to cell wall fragmentation and implosion.  The phenomenon known as cavitation produces cell destruction leading to fat emulsification.

The end result is that ultrasonic energy yields selective destruction of fat tissue, largely sparing other types of connective tissue.  This tissue selectivity is fundamental to the principles of ultrasonic lipoplasty and is evident at both a gross and microscopic level.  In addition, in vivo endoscopic videos have demonstrated successful fat removal with preservation of soft tissue parenchymal architecture after application of ultrasonic energy.


Born in Europe, Raised in the U.S.


Several surgeons inEuropeandSouth Americabegan experimenting with ultrasonic lipoplasty in the early 1990s. Patrick Maxwell in Nashville Tenneessee and others in theU.S.were also engaged. Instruments were rudimentary and ultrasonic generators were cumbersome, requiring constant calibration.

Nevertheless the early ultrasonic pioneers persisted. The International Society for Ultrasonic Surgery was formed to facilitate an active exchange of information. Michele Zocchi, an Italian plastic surgeon and physicist, is largely credited for introducing and advancing ultrasonic lipoplasty in these early formative years.

Zocchi brought together a small group of physicians from around the world for the first international symposium dedicated to ultrasonic lipoplasty in Algarve Portugal in 1995. The meeting was attended by surgeons fromEurope, theMiddle East, andLatin America. Only a hand full of American surgeons attended. Those of us who were present were very impressed with the potential of the exciting new technology. Also present were American manufacturers eager to produce an ultrasonic device for theU.S.and international markets.

The symposium included clinical presentations and original scientific research. In addition, innovative endoscopic video material prepared by Hassane Tazi fromCasablancagave us a unique internal view of ultrasonic activity at a cellular level. The first I.S.U.S. meeting generated a great degree of excitement among the participants.

Meanwhile in theU.S.the major plastic surgery societies, anticipating the popularity of the emerging technology, formed a task force ostensibly to coordinate the safe introduction of ultrasound. The U.A.L. Task Force created a one day training course combining didactic lectures and a hands-on cadaver lab. The Doctor’s Company, the largest malpractice insurer for plastic surgeons, joined in the effort. The company required its insureds to attend the seminar to obtain coverage for U.A.L. cases.

Ultrasonic assisted lipoplasty arrived in the U.S.mainstream in early 1997. The technology was greeted with great fanfare and hype. U.A.L. was touted as a cure for everything from cellulite to obesity. It was not long before the media began to feature the procedures on mainstream broadcasts such as Primetime and 20/20. Patients began to ask specifically for ultrasonic liposuction. In response, surgeons clamored to take the few available courses.


The Pendulum Swings


The U.A.L. pendulum had reached an apex in late 1997. The momentum soon began to shift, however. Fueled by a series of independent events, enthusiasm for the technology began to diminish.

No doubt the cost associated with the procedure became a significant factor. The two dominant U.S.devices, the Mentor Contour Genesis and the LySonix 2000 were both excellent machines but carried a high price tag in excess of $35,000. Participants in the U.A.L. Task Force course, an unprecedented effort by the combined societies, were charged almost $2,000 for the one day event. Many surgeons began to question the value of an investment in U.A.L.

Confounding the issue of ultrasonic lipoplasty was the introduction of an external ultrasound used as a pre-treatment for traditional suction lipectomy. The device, championed by Dr. Barry Silberg, used transcutaneous ultrasound similar to machines used in physical therapy. In addition, the Silberg device, marketed by Wells Johnson was signicantly less expensive. Though markedly different from internal U.A.L. the procedures were often confused and regarded as equivalent.

The two principal manufacturers of ultrasonic devices contributed to the confusion by engaging in lengthy and costly patent litigation. Instead of applying funds to improve the technology, the companies fought each other. Mentorultimately prevailed in the pyrrhic victory and eventually took over the LySonix assests. It now markets an updated version of the device called the LySonix 3000.

Finally, and most significantly, a number of assertions were made regarding U.A.L. that were not supported by clinical experience. These myths caused surgeons to both fear, and rethink the value of, U.A.L.


The Myths of Ultrasonic Lipoplasty


  1. U.A.L. causes severe burns.


Isolated anecdotal cases of burns associated with U.A.L. surfaced in the late 1990s. They soon self-multiplied much like Mussolini’s air force in World War II*. It is true that ultrasonic lipoplasty differs from traditional liposuction in that there is an exchange of energy. It is possible that prolonged stationary exposure can cause a buildup of thermal energy in the tissues. It is therefore especially important to adhere to the two basic rules of U.A.L. described by Zocchi: keep the tissue wet and keep the cannula moving. However, strict adherence to these two basic rules minimizes any serious risk of burn injury. Data published by this author (1) demonstrated no burns in a series of 351 consecutive cases. The three potential mechanisms of thermal-ischemic injury were outlined in this study.


  1. U.A.L. causes seromas.


Certainly seromas can occur with ultrasonic lipoplasty just as they do with traditional liposuction. However, there is no evidence that any inherent features of U.A.L. predispose to a greater frequency or severity of seromas. To the contrary, our study (1) data reported only 3 small abdominal seromas which all resolved with conservative management. Careful review of published data regarding U.A.L. seromas suggest that these occur more frequently in the abdomen. However, abdominal seromas, which occur with traditional liposuction as well as abdominoplasty, are more accurately a reflection of the difficulty obtaining post-operative compression to the surgical dead space, not the particular technique utilized.


  1. Ultrasonic energy time should be limited to 5 minutes per area because of the risk of burns and seromas.


Based upon myths 1 and 2 some have speculated that the cause of these supposed burns and seromas is related to ultrasonic energy time. Guidelines have been created to limit ultrasonic energy time per area. Some have suggested that energy time should not exceed 5 minutes because of the potential for burns and seromas. Analysis of published data does not support these artificial limits. Our study data revealed no correlation between complications and energy time and no such limits were imposed. Surgeons inEuropeandLatin Americaroutinely use energy in excess of 5 minutes.

More importantly, if one believes that the true value of U.A.L. is its less traumatic, tissue selectivity, then it is illogical to limit ultrasonic treatment to only a few minutes and complete the procedure, and traumatize the tissue, with traditional liposuction. In fact, this is the flaw of so-called “comparison” studies. In any analysis of the two techniques it is important to compare true, complete U.A.L. with traditional liposuction. To date, this author is not aware of such a published comparison. Moreover, this type of study would be limited by ethical considerations.


  1. U.A.L. is an extension, but not a substitute, for traditional S.A.L.


I find this statement confusing yet I have heard it often. Even opponents of the technology admit that the tissue selectivity of U.A.L. make it especially helpful in difficult areas. Tissue higher in fibrous density such as the back, flanks or male breasts respond well to ultrasonic treatment. However, if U.A.L. is better for the difficult areas, why not use it everywhere? In fact, with few exceptions, ultrasonic lipoplasty has become our procedure of choice everywhere. U.A.L. is indeed an acceptable substitute for S.A.L.


  1. It is necessary to complete the U.A.L. procedure with S.A.L.


Many authors favor the use of combined U.A.L. and S.A.L. The reasoning for this sequence is to use the ultrasound to “soften” the tissue, followed by the speedier traditional liposuction to complete the procedure. The flaw in this approach is that any use of traditional S.A.L. diminishes the benefit of the ultrasonic tissue selectivity. Our preferred technique has evolved to even exclude the so-called “mopping up” phase of U.A.L. The procedure in most cases is performed, through completion, with simultaneous and continuous suction and ultrasonic energy.


  1. U.A.L. should be avoided in certain body areas.


Some authors admonish the use of U.A.L. to certain body areas. Using U.A.L. in areas of thinner skin such as the arms, face, neck, inner thighs, knees and even saddle bags has been described as risky. The risks ascribed are primarily associated with burns or devascularization injury. However, clinical data does not support this assertion. In fact, several authors have reported successful results with few complications in these body areas. Our experience in these areas is also free of significant complications with very satisfactory results.


  1. The U.A.L. cannula should be kept > 1cm. deep to the dermis.


The concern again here is the risk of thermal or ischemic injury to the skin. It is appropriate that surgeons treating the underside of the dermis have a level of skill and experience with this area. However, proponents of U.A.L. feel that the greatest opportunity for skin contraction is via stimulation in this plane. It is advisable that suction not be applied simultaneously during this step in order to avoid tissue dessication. Otherwise, subdermal stimulation can be performed safely with adherence to the two rules of U.A.L.


  1. U.A.L. is a treatment for obesity.


Reports inEurope,Latin Americaand theU.S.of large volume liposuction have led some to suggest that liposuction may be an effective adjunct in the treatment of obesity. The tissue selectivity and markedly diminished blood loss associated with ultrasonic certainly make it an attractive option with this strategy. However, many authors have very effectively outlined the potential problems, including significant hemodynamic issues, associated with large volume lipoplasty. Moreover, obesity is regarded as a complex condition, requiring behavior modification in addition to loss of adipose tissue. Our experience is with moderate volume cases (average ~2000cc, largest 7000cc) primarily used for localized body contouring. It is advisable that surgeons choosing to perform large volume U.A.L. do so only after significant experience with smaller cases.


  1. U.A.L. is a cure for cellulite.


Early optimistic reports included the hope that U.A.L. would “cure” cellulite. This has not been the case. However, it is true that U.A.L. is gentler and therefore smoother on the skin than the coarse gouging associated with traditional liposuction. The mechanism has been described as an air brush effect creating a smoother plane in the subcutaneous tissue. This coupled with subdermal stimulation produces a more even skin retraction. Skin irregularities and waves, the most common complaint following S.A.L., are much less common with U.A.L.


  1. U.A.L. is hard to learn.


Certainly any new technology will require a learning curve, both for the specialty as well as for the individual practitioner. We all approach a new procedure from a different level of skill and experience. Complications can occur with any technology, including traditional liposuction. Disastrous complications have been reported with lasers. The assertion, however, that U.A.L. is more dangerous or difficult to learn is not correct. In fact, it is this author’s opinion that with careful adherence to the two basic rules described by Zocchi, U.A.L. can be learned quickly, performed safely and produce satisfactory results.


  1. Ultrasonic energy produces dangerous free radicals.


It has been speculated that U.A.L. creates free radicals as well as potential sonoluminescent or sonochemical by-products. These are theoretical considerations lacking any clinical support. In fact in vivo studies have concluded that there is no evidence of free radical generation. Moreover, the lengthy safety record of ultrasound in ophthalmology and neurosurgery argue against such a risk.


Where Do We Go From Here?


We have seen the ultrasonic lipoplasty pendulum swing from one extreme to the other in the decade since the first international congress held inPortugal. As with any emerging technology, U.A.L. has been the focus of controversy, both scientific and non-scientific. Politicians say that if something is repeated often enough it eventually becomes fact. Many assertions made about U.A.L. are based upon personal bias and not scientific evidence. These assertions have become myths.

The introduction of phacoemulsification by Kelman over three decades ago had no less a tumultuous beginning, yet the ultrasonic procedure is now largely regarded as the standard of care in cataract ophthalmology.

The vacillating interest among surgeons has prompted manufacturers to reconsider their level of commitment to U.A.L. Recent modifications have included changes in cannula design and pulsed energy mode generators. The theory behind pulsed energy devices is to limit ultrasonic energy delivery to the tissues to avoid burns. In this author’s opinion this is a solution in search of a problem since burns can be largely avoided by simply adhering to the two basic rules proposed by Zocchi. More importantly, pulsed energy slows the procedure down, contributing to longer surgical times.

The next generation of U.A.L. devices needs to be faster, less expensive and portable. Existing patent protection will soon expire and other manufacturers may enter the international U.A.L. marketplace.  U.A.L. has great potential for the future.  To insure its continued success, it is necessary for those of us who use U.A. L. to work to dispel the myths and to continue to fine-tune this safe and sophisticated technology. The final result will be improved patient and physician satisfaction.


About the Author


Jorge A. Perez, M.D., F.A.C.S. was one of 10 U.S. physicians selected as F.D.A. clinical investigators for ultrasonic lipoplasty. He has performed hundreds of procedures and has lectured to thousands of surgeons in over 25 countries worldwide on the subject of liposuction and body contouring.

Dr. Perez has been selected among Castle Connolly/U.S. News and World Report’s America’s Top Doctors. To schedule a consultation with Dr. Perez call (954) 351-2200. To learn more about his practice or any of these procedures, visit



* Italy’s dictator Benito Mussolini had a meager air force in comparison to the German Luftwaffe, yet his generals dared not tell him. Instead the generals would fly the same planes from city to city prior to Mussolini’s review.


(1) Perez, J.A., Van Tetering, J.P.B. Ultrasonic Assisted Lipoplasty: A Review of Over 350 cases Using a 2-Stage Technique. Aesthetic Plastic Surg. 27: 68-76, 2003

Ultrasonic Assisted Liposuction (U.A.L.): The Well-Kept Secret of Plastic Surgery (Original Article)

· Body Contouring, Liposuction · No Comments



Liposuction is one of the most common invasive procedures performed in plastic surgery. Statistics published by the American Society of Plastic Surgery indicate that over 300,000 liposuction procedures were performed by board certified or eligible plastic surgeons last year.

Despite a growing demand for the procedure, liposuction continues to be one of the most controversial procedures in plastic surgery. Severe complications, and even reports of deaths, have appeared in the mainstream media, creating questions regarding the safety of liposuction. Early reports of complications stemmed from an underestimated blood volume loss associated with subcutaneous aspiration.

Liposuction was first described in Europe in the early 1970’s. Several surgeons contributed to the new technology. However, French gynecologist Dr. Yves Ilouz, is largely credited with popularizing the innovative body contouring procedure. Liposuction, or more accurately, suction assisted lipectomy (S.A.L.) quickly gained popularity in the United States.


Tumescent S.A.L.


In the 1980’s, in response to excessive blood volume loss, several authors described a pre-suction treatment stage using wetting solutions. The term tumescent infiltration describes the use of such a stage. The process involves subcutaneous infiltration of varying combinations including saline (or lactated Ringer’s solution), epinephrine, and a local anesthetic. The effect of tumescent infiltration is to provide vasoconstriction in the subcutaneous layer and create increased adipocyte fragility. The clinical effect is a diminished blood loss compared to the original dry technique. Tumescent S.A.L. has been the conventional method used in the U.S. since the late 1980’s.

The mechanism of traditional S.A.L. is conceptually simple. A rigid, hollow cannula, connected to a suction machine, is inserted into the subcutaneous space. Rapid, coarse strokes by the surgeon create a series of tunnels, eventually becoming confluent, diminishing the fat pannus. The underlying problem with the technique is that there is no tissue selectivity. The suction energy evacuates or destroys all elements of the subcutaneous tissue plane, including valuable structures such as blood vessels, nerves and fibrous tissue.

Critics of the procedure describe it as rough and traumatic, translating clinically into a painful, bloody process with a prolonged recovery. In addition, loss of essential connective tissue leads to rippling of the skin, the most common complaint following traditional liposuction. One study reported an 80 % incidence of skin irregularities following S.A.L.


Ultrasonic Assisted Lipoplasty (U.A.L.)


In the late 1980’s plastic surgeons in Europe and Latin America began experimenting with the use of ultrasound to achieve subcutaneous lipolysis. The use of ultrasonic energy was not new. Our colleagues in radiology, ophthalmology, obstetrics, gynecology, urology, neurosurgery and other specialties were already familiar with the use of ultrasound in both a diagnostic, as well as therapeutic, capacity. The application of this energy to plastic surgery was appealing however, for two reasons. First, ultrasound has an established history of safety. Secondly, the vibratory frequency of the ultrasonic energy can be made specific to the adipocyte. It is this tissue specificity that underlies the mechanism and benefit of ultrasonic lipoplasty.

The procedure is performed using a device made up of three component parts. Electrical energy is converted into ultrasonic energy using an ultrasonic generator attached to a handpiece containing a piezoelectric crystal. A hollow titanium cannula attached to the handpiece delivers the energy to the tip at a frequency specific to adipocytes of 22,000 cycles per second. The process is similar to phacoemulsification used in ophthalmology.

The cellular effect is membrane fragility and cell implosion, a process known as cavitation. More importantly, the energy at a frequency of 22K Hz. is not absorbed by the other elements in the subcutaneous tissue, thus largely sparing the blood vessels, nerves and fibrous tissue. At a clinical level this translates into less bleeding, less pain, fewer skin irregularities and a faster recovery.

The procedure is performed in a manner similar to traditional liposuction. A small incision is made in the skin followed by tumescent infiltration. However, since it is the ultrasonic energy that does the work and not the forceful suction, the cannula strokes with U.A.L. are slow and smooth instead of rapid and coarse. The technique has been described as a violin or air brush type movement.


U.A.L. in the U.S.A.


The introduction of tumescent U.A.L. into the U.S. mainstream occurred in the late 1990’s. Although early machines originated in Italy and France, two American manufacturers, Mentor Medical, Inc. and LySonix, produced devices for the international market. Great enthusiasm, fueled by media attention touting U.A.L. as the “magic wand” of liposuction, created an eager anticipation of the emerging technology.

Anecdotal reports soon surfaced describing limitations and complications related to the procedure. Among the concerns expressed were the risk of burns and post-operative seroma formation. Some authors recommended limiting the amount of energy time per site and even avoiding U.A.L. completely in certain body areas.

Our clinical experience, however, published last year in the journal Aesthetic Plastic Surgery, and that of others, disputes these concerns. Data collected in 350 consecutive tumescent U.A.L. cases, revealed no burns and few, minor complications and minimal blood loss. Moreover, there was no correlation between U.A.L. energy time and complications. The main disadvantages of U.A.L. are largely related to cost and training. As with any new technology, a learning curve also exists with U.A.L. In addition, the slower stroke movements require additional time. A typical U.A.L. procedure takes approximately 25% longer than the same procedure using S.A.L. Proponents of U.A.L.  feel the benefits of the procedure make the extra time worthwhile.

In summary, ultrasonic lipoplasty is an innovation available to plastic surgeons for body contouring procedures which offers greater tissue selectivity and less connective tissue trauma. The procedure is safe with a high degree of patient satisfaction and can be performed safely by qualified, trained surgeons. Additional time and expense are required. U.A.L. is the our preferred technique for body contouring


About the Author


Jorge A. Perez, M.D., F.A.C.S. was one of 10 U.S. physicians selected as F.D.A. clinical investigators for ultrasonic lipoplasty. He has performed hundreds of procedures and has lectured to thousands of surgeons in over 25 countries worldwide on the subject of liposuction and body contouring.

Dr. Perez has been selected among Castle Connolly/U.S. News and World Report’s America’s Top Doctors. To schedule a consultation with Dr. Perez call (954) 351-2200. To learn more about his practice or any of these procedures, visit



Disclosure: Dr. Perez is a board certified plastic surgeon. He has served as a clinical investigator and consultant to LySonix and Mentor Medical, Inc., leading manufacturer of breast implants and ultrasonic surgery equipment.



Perez JA, Van Tetering J.P.B.: Ultrasonic Assisted Lipoplasty: A Review of Over 350 Consecutive Cases Using a Two-Stage Technique. Aesthetic Plastic  Surgery. 27: 68-76, 2003