My name is Dr. Robert Troell; a Stanford University trained facial plastic surgeon, also trained by the developer of tumescent liposuction. I have the honor and the privilege of being the fifth surgeon in the United States to perform this revolutionary new technology know as water jet assisted liposuction, or the Body-Jet. It is my pleasure to guide you through this presentation on the complete process of water jet assisted liposuction.
A tremendous advantage of this Body-Jet liposuction technology is the elimination for a need for any purification of the harvested fat to be used in both body and facial fat grafting.
The Body-Jet is manufactured in Germany by Human Med. Eclipsemed is the sole US distributor, which adds to its fractional carbon dioxide laser known as DOT therapy. Modalities may be added to the standard tumescent liposuction techniques in the hopes of providing a superior outcome, including ultrasound, power and laser assisted technologies.
This water jet assisted liposuction video presentation is divided into chapters focusing on: preoperative consultation, presurgical preparation, Body-Jet device assembly, the infiltration phase, the irrigation and aspiration phase, drying phase, and finally the chapter of the fat harvesting and fat grafting.
The preoperative consultation and body contouring [in] liposuction includes: the initial history, physical examination, and is completed by the surgical consent discussion. Once the patient has decided to proceed with the liposuction procedure using Body-Jet technology and the sites of redundant fatty tissue they desire treated, the liposuction consent form is reviewed. General information highlighting all modalities of liposuction, local verses intravenous sedation, and the process is completed by discussing the benefits, limitations, risk, and possible complications.
The most common side effects are: skin contour irregularities and asymmetries. The American Society of Plastic Surgery have consent forms that can be purchased and customized to the surgeon’s specification.
Presurgical preparation includes standard preoperative photographs, oral sedative medications, marking areas of liposuction, intravenous line and monitor placement, anesthetic solution preparation, surgical prep and draping.
Patient preoperative digital photographs are taken with adequate lighting in front of a cobalt blue background. Standard views include anterior, lateral, posterior, and we can also perform oblique views. These photographs are taken in the standing position.
The next step in the presurgical preparation is patient marking; this is routinely performed in a standing position. A [sharp ink] marker is preferred on the body areas because it is difficult to remove during the prep. The perimeter of liposuction is delineated and the bony landmarks identified. Face and neck areas are marked with a surgical pen because it’s easier to remove postoperatively. The areas for redundant fatty removal are marked with circles. Areas of indentations are identified with hash marks.
The standard of care for any significant liposuction procedure is the placement of an intravenous line. Cardiac monitor placement include a pulse oximetry, blood pressure cuff, and EKG. The tumescent anesthetic solution is prepared preferably by the surgeon or a reliable professional personnel. Epinephrine, sodium bicarbonate, and lidocaine are used with normal saline. An alternative is to use [lactated ringers]. We use either a three liter bag or a one liter bag with the Body-Jet technology. The bags are warmed prior to placing the medications, and when the medications are being placed in the bag they are labeled by ‘TS’ for tumescent solution. It’s good to use the same sequence, I prefer to use epinephrine first, one amp in each bag of one liter saline, this is followed by sodium bicarbonate, with a one liter bag 10 cc is used, and finally 1% lidocaine.
To caution surgeons: 2% lidocaine should not be placed in the operating room because double the dose can be given to the patient causing lidocaine toxicity.
Once the administration of medications is completed, the bag is placed on the Body-Jet machine. The infiltration phase uses 50 cc of 1% lidocaine for one liter bag of normal saline, and irrigation and aspiration phase only 25 cc. For patient comfort the antiseptic solution is heated to about or slightly above body temperature. This is followed by the standard sterile patient prepping and draping procedure. I prefer sterile towels to large drapes as this provides a more reliable sterile field.
Body-Jet device assembly includes Aqua Shape lipo collector assembly, single-use tubing apparatus attachment, and Body-Jet machine settings are applied. All components of the Aqua Shape lipo collector are organized before assembly. The assembly of the container insert commences with the perforated ring placed on the bottom of the container insert, followed by the fine filter, and then the retaining ring. The container insert is then placed into the collection container. The container seal is placed around the container lid. Place one end of the silicon hose onto the short attachment cylinder of the container insert, while the other end is placed into the other side of the container lid. The O ring is placed into the groove of the reducer then the reducer is transferred to the peripheral hole on the container lid. Sterile saline is placed into the lipo collector, and the lid applied. Secure the suction tubing from the patient onto the reducer of the lipo collector. The single-use tubing filter is placed in the Body-Jet machine. Place one end of the suction tubing to the centre of the lipo collector, and the other end the storage container located on the Body-Jet machine.
The Body-Jet machine has two LCD screens, the left indicating tumescent solution flow rate, one to five, the right indicating the total amount of tumescent solution used. The preferred flow rate is two or three. The gauge positioned above the LCD screens records the vacuum force in millimeters of mercury. The Body-Jet has higher vacuum force capabilities than typical liposuction machines.
The infiltration phase commences with local anesthesia injected into the planned incision sites. I prefer to make incisions with a 2 mm dermal punch. However, making small incisions with an 11 or 15 blade may be preferred. A 3.5 millimeter infiltration cannula is attached to the single-use tubing apparatus and tightened. The infiltrator emits a pressured [L] shaped beam of water at a 30° angle. Subsequently, the infiltrator is then primed by depressing the foot pedal to allow a tumescent solution flow through the tubing. The infiltration phase of patient anesthesia begins with placing of the infiltration cannula through an incision, then a tumescent solution flow starts by depressing the foot pedal. This phase should take only one third of the amount of time, and usually about 20-30% of the solution volume as the standard tumescent liposuction technique.
An alternative method for this internal anesthesia is to use a standard infiltrator cannula [classified] less than two millimeters in diameter connected to a standard infiltrator machine.
There are three different types of irrigation and aspiration cannulas of varying sizes. There are green, gold, and silver handled cannulas. The edges of the holes on the gold handled cannulas are dull, as opposed to the silver handled cannulas which are sharp. Gold handled cannulas have four holes circumferentially, where the green handled cannulas have two holes on one side only.
In the initial part of the irrigation and aspiration phase, short slow strokes are used, which can be altered to longer more rapid strokes as the tissue resistance decreases. These movements are based on the observance of patients’ discomfort, or blood in the suction tubing. When more discomfort is observed, shorter and slower movements should be performed.
As can be observed here, long slow strokes are removing fat cells with the absence of blood, atypical of the standard tumescent liposuction technique. The application of the water jet enables the surgeon to use less mechanical force in the liposuction process, thus creating less soft tissue trauma. This results in little blood contamination of the harvested fat.
The drying phase uses no tumescent solution or irrigation, only aspiration and other residual solution. Typically, only between 200 and 500 cc of tumescent is now retrieved, which is less than half of the standard tumescent liposuction technique.
Because of the limited mechanical trauma using this water jet assisted liposuction technique postoperative discomfort is decreased by 75%, swelling decreased by approximately 60%, and bruising decreased by more than 50%. The advantages short term of postoperative recovery does not compromise the long term cosmetic outcome.
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Dr. Robert J. Troell, MD, FACS (Las Vegas)
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