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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

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