High Definition Liposculpture Part 2

Art, Science & Surgical Technique

AC
Robert J Troell, MD, FACS

Beauty by Design
The Institute of Advanced Body Sculpting
Call 702-930-8335
Las Vegas, NV
https://www.drtroell.com
Corona del Mar/Newport Beach, CA
http://www.masterpiecemedspa.com
 High Definition VASER Liposculpture
Procedural Steps: Liposuction & Fat Harvesting
Wetting solution infiltrated using superwet technique

Lower suction: -15 to -18 in Hg limits fat & stem cell injury

2.0, 3.0, 3.7, 4.0 & 4.6 mm diameter liposuction cannulas

Use Vented liposuction cannula to decrease cell shearing

Closed fat collection container minimizes air exposure

Speed from harvesting to fat transfer effects survival

High Definition VASER Liposculpture

Female athletic outcome,

Immediately postop
High Definition VASER Liposculpture

Athletic Female Result

Immediately Postop
Athletic Female High Definition
Immediate Postop Result
 Drain Placement

7 mm round
JP drain, 5-7 days

Inguinal- Men
Sacral- women
Postoperative Compression
First Layer in Women
 Female High Definition Liposuction
Fat extraction in superficial & deep layers

Smaller Adipocyte Bundles Minimal Cellular Injury

Before After
Understanding Topographical
Anatomy
 Subclavicular triangle
Chest High Definition Liposculpting

Transition zones

Peripheral Negative spaes

breast area

Pectoralis
line
Upper pole Lower pole
Latissimus Pectoralis
dorsi line

Anatomic Areas of Female Breast

Superficial Framing
Male torso
Deep fat extraction
High Definition VASER Liposculpture
Female Patient

Stealth Surgical Incisions

High Definition VASER Liposculpture

Breast Definition & Axilla

Aggressive Fat Removal
 Breast Fat Grafting
Artistic Surgical Planning
Volume
enhancement
topographically

Fat administration:
Intramuscular
Submuscular
Subcutaneous
Superior half & medially
more fat volume placement
 Chest High Definition Liposculpting

Transition zones

Negative spaes

Pectoralis
line
Arm Definition
Latissimus Pectoralis
dorsi line

Dynamic zones

Negative spaces
Pink line describes a transition zone whereSuperficial Framing
smooth framing must be done
Male torso
Deep fat extraction
 Arm High Definition Liposculpting

Transition zones
Deltoid insertion
Negative spaes
Posterior axillary
crease
Female Arm
Pectoralis
Deltoid insertion line
Arm Definition
Posterior axillary
Latissimus Pectoralis
crease
dorsi line

Dynamic triceps insertion

Dynamic zones
Deltoid insertion
Negative spaces
Posterior axillary
crease Male
Superficial Arm
Framing
Male torso
Deep fat extraction
High Definition VASER Liposculpture
High Definition VASER Liposculpture
High Definition VASER Liposculpture
High Definition VASER Liposculpture
 Fat Processing
Procedural Steps:
Fat collection container divides fat from infranatant by
gravity separation

Begin fat processing as soon as possible

Fat Processing duration of procedure:

P 188- 10 to 15 mins
PureGraft- 15 min
LipoKit- 10 mins

Fat Processing quantity of fat:

P 188- entire fat extraction container
PureGraft- 250 cc & 850 cc
LipoKit- 200 cc
 Fat Transfer
Procedural Steps:
Fat Grafting Locations: Intramuscular (gluteal, pectoral, deltoid, calf),
submuscular (pectoral), subcutaneous (face, all female areas, male
gluteal)

Ensure patient marking accurate: preoperative marking standing

a. estimate volume
b. exact location in recipient areas (muscle belly)
c. correct asymmetries

Infiltrate wetting solution- minimize amount to fat recipient area,

used for comfort & hemostasis (50-150 cc total)

Subcutaneous tunneling, micro-aliquots, multi-planar, radial

placement, low pressure injection
 Ultrasound-Assisted Fat Harvesting
Superior Fat Volume & Cellular Viability

Smaller Adipocyte Bundles Minimal Cellular Injury

 Fat Processing Best Options

LipoKit (lipocondensing
centrifugation)

PureGraft (lipodialysis)

Coleman Technique:
Centrifugation
Cotton-gauze rolling
Filtration (500 or 800 m)
 Fat Harvesting
Origins Fat Collection Canister
 Fat Harvesting
Origins Collection Canister
 Lipocondensing Centrifugation System
(LipoKit/Adivive)
All-in-one, closed, sterile, single-use system:

Wetting Fluid Delivery

Fat Harvesting
Centrifugation
Filtration/Purification
Lipocondensation
Fat Transfer/Injection
Stem Cell Processing
incubator addition
Lipocondensing Centrifugation System

Free Oils
Weighted
Mesh Filter

Adipose
Tissue

Excess
Fluids

Syringe After Centrifugation

 Comparing Fat Processing Methods

LipoKit
Gravity Separation Filtered Centrifugation
Condensation

Post Lipocondensed Centrifugation

 Lipodialysis
(PureGraft)
15 Minute Dialysis

H2O content by 5%

Oil Content to 1- 5%

Stable fat cell numbers

Fat cell viability 5-10%

Two different sized filters

 Lipodialysis
(PureGraft)
15 Minute Dialysis
Preserves stem cells

Removes debris

Removes ruptured cells

Decreases recipient bed

inflammation

Two different sized filters

 Microscopic Fat Graft Appearance

Gravity Separation Centrifugation Lipodialysis

Lipodialysis- less cellular injury & less oil remaining

 Fat Harvesting
Results: Fat Cell Viability Testing
(by American CryoStem)
VASER Harvesting Suction only Harvesting
LipoKIt LipoKIt
91.5% viability 92.1% viability
7.9 x 105 fat cells/cc 5.7 x 105 fat cells/cc

PureGraft PureGraft
81.8% viability 91.5% viability
8.5 x 105 fat 7.2 x 105 fat
cells/cc cells/cc

Schafer et al. ASJ 2013.

Fat cells- 85% Stem Cells- 87%
Rubin. 80% fat survival when
Fat Injection Syringe Preparation
Fat Processing Techniques

Kolliphor P 188 Cell Membrane Stabilizer

Fat Processing Techniques
P 188 Cell Membrane Stabilizer
 Four Main Gluteal Frames
Adhesion zone

Transition
Transitionzones
zone

Negative
Negativespaces
spaces

A-Shape V-ShapeFemale torsoSquare Round

Male torso
(female) (male) (female)
 Gluteal Sculpting

Surgical Goal: 11 Aesthetic Zones

Women:
A shape
Round shape

Men:
Square shape
(muscular)
 High Definition VASER Liposculpture
Artistic Surgical Planning
Frame Shape:

A- Upper lateral hip

C- Mid-buttock
B- Lateral Thigh

Goal: Women-
A or Round shape
Men- Square shape
 Gluteal Sculpting
Artistic Surgical Planning

Vented VentX
Marking: Divide
Liposuction cannulas
buttocks into
(vent at cannula base)
quadrants

Confirm with patient:

desired shape,
asymmetries &
quadrants needing
more volume
 Gluteal Sculpting
Artistic Surgical Planning
Transfer fat in step
sequence Vented VentX
Typical Descending Liposuction cannulas
order of fat transfer (vent at cannula base)
by volume:
1- Upper inner
2- Upper outer
4- Lower outer
3- Lower inner
(may need suction) Sample Patient
Repair asymmetries
 Gluteal Sculpting
Artistic Surgical Planning
 Gluteal Sculpting
Anatomical Aesthetic Zones

1- Presacral space
2- Flank 2 2
3- Transition zone 3 4 3
gluteus max & medius 1
4- Lumbar
5- Lateral Thigh 6 6
6- Gluteus muscle

5 5
 Gluteal Sculpting
Anatomical Aesthetic Zones
11 11
7- Intergluteal space 10 10
8- Midlateral buttock
9- Posterior thigh
10-Lumbar Muscle
11- Latissimus Dorsi
Muscle
8 8
7
9 9
 Gluteal Sculpting
Artistic Surgical Planning

Vented VentX
Transition Zones:
Liposuction cannulas
(vent at cannula base)
d- upper inner gluteal sacral
junction
c- upper outer gluteus
maximus-to-medius junction
b- midlateral gluteal-hip
junction
a- lower lateral gluteal-thigh
junction
 Gluteal Sculpting
Femur Anatomy
Greater trochanter
key landmark

Zones 5 & 8 affected

by greater trochanter

Caution:
limited liposuction in
lateral decubitus
position
 Gluteal Sculpting
Fat Transfer Sequence

1-Reshape frame first:

A B C
2-Gluteal transition zone
feathering
3-Adjust overall gluteal
volume distribution
4-Reshape gluteal
muscle
5-Modify gluteal height
6-Augmentation buttocks
 Gluteal Sculpting
Fat Transfer First Step
Reshape Frame:

A- Upper lateral hip

C- Midbuttock

B- Lateral Thigh

Goal: A shape
 Gluteal Sculpting
Second Step

d
Gluteus
Maximus c
b

Overall Gluteal Volume & Transition Zone Feathering

 Gluteal Sculpting
Gluteus Maximus & Medius Muscles

Fat Transfer Reshapes Gluteal Muscle & Gluteal Height

 PMI
Zone Marking
Complete Fat
Removal
Transitional
Fat Reduction
(Gluteus medius)

Zone 8
(Fat Grafting)
 Gluteal Sculpting
Posterior Aesthetic Zones

Usually requires
Liposculpting Areas Fat Transfer

Zones that Truly Define Buttock Frame & Shape

 Male Gluteal Sculpting

Little fat for transition areas

Most gluteal projection in middle third

IGM Negative spaces:

1. Proximal inner thigh
2. Red zone up to intergluteal crease
3. Trochanteric depression

Thigh:
Differentiation between muscle groups

Goal: Shape of the underlying gluteus maximus muscle

 High
Female Gluteal Sculpting Zones
 Gluteal Sculpting
Fat Transfer Placement

No intramuscular
placement

Fat Graft Placement:

Deep- volume augmentation

Superficial- skin contouring

High Definition VASER Liposculpture
 Fat Transfer
Procedural Steps:
Fat Grafting Locations: Intramuscular (gluteal, pectoral, deltoid, calf),
submuscular (pectoral), subcutaneous (face, all female areas, male
gluteal)

Ensure patient marking accurate: preoperative marking standing

a. estimate volume
b. exact location in recipient areas (muscle belly)
c. correct asymmetries

Infiltrate wetting solution- minimize amount to fat recipient area,

used for comfort & hemostasis (50-150 cc total)

Subcutaneous tunneling, micro-aliquots, multi-planar, radial

placement, low pressure injection
High Definition VASER Liposculpture
Gluteal Intramuscular Fat Grafting

4 mm cannula, 60 cc syringe.
Large size cannula & low
pressure limits fat emboli risks
High Definition VASER Liposculpture
High Definition VASER Liposculpture
High Definition VASER Liposculpture
 Optimizing Fat Administration

Multi-layering fat grafting

Optimizes vascular formation post-grafting

(Ersek RA et al. Plast Reconstr Surg. 1998;101(3): 820-826)

 Optimizing Fat Administration

Viable Fat Graft

Smaller amounts Grafted
< 3mm in diameter

Vascular Compromised Fat Graft

(Carpenada CA et al. Aesth Plast Surg 1994 & Coleman S et al. Plast Reconstr Surg 2007)
 Gluteal Sculpting
Infiltration: Superwet Wetting Technique

Left Buttock

Lower
Back

Intergluteal Crease

Posterior Thigh
 Gluteal Sculpting
Incision & Infiltration

Left Buttock

Infragluteal
Fold

Intergluteal Crease
Inferior Gluteal Crease Incision
 Gluteal Sculpting
Placement of Skin Guard

] 3 mm

Posterior Thigh
VASERsmooth V Shaped Probe

Handpiece & Probe Assembly

VASERsmooth Cellulite Subcision

Posterior Thigh
 VASERsmooth
Buttock Cellulite Subcision

Right Buttock
Intergluteal
Crease

Infragluteal Fold
 Gluteal Sculpting
Soft Tissue Tunneling

Intergluteal Crease Lower

Back

Infragluteal Right Buttock

Fold

Posterior Thigh
 Gluteal Sculpting
Autologous Fat Transfer

Right Buttock

Lower
Back

Intergluteal Crease

Posterior Thigh
Autologous Fat Transfer

Left
Posterior
Thigh
 Gluteal Sculpting
Superficial Fat Transfer

Posterior Thigh
 Gluteal Sculpting
Superficial Fat Transfer Repair

Posterior Thigh
 Fat Graft Components
90% adipocytes
by tissue volume

Loosely adherent
cells assist in
angiogenesis:

Stem cells
Endothelial cells
Pericytes
Fibroblasts
Macrophages
 Autologous Fat Transfer
Essential Cellular Features

Presence of extracellular matrix

Transferred viable adipocytes

Growth factors in cellular millue

Presence of stem cells (resident/donor)

 Theories of Fat Grafting Volume Replacement
Adipocyte death & Adipocyte survival
regeneration 95% adipocyte survival
Dr K Yoshimura Fat cells survive for 1-3
95% fat cell death days post grafting
ADSRC donor site & ADSRC survive up to 5
grafted cells aid in days post grafting
adipocyte regeneration ADSRC donor site &
Bone marrow cells grafted stem cells
travel to recipient bed promote endothelial cell
to stimulate blood formation-
vessel formation angiogenesis

Both theories agree: fat

cells need to be viable at
transfer for graft viability
 Autologous Fat Transfer

Therapeutic Options:

Fat grafting alone

Fat grafting & Stem Cell grafting (Maxstem Celltibator)

Fat grafting with Platelet Rich Plasma (PRP)

Fat & Stem cell grafting with Platelet Rich Plasma (PRP)
 Cell Assisted Lipotransfer (CAL)= Fat + ASCs

Centrifugated
Fat Fat

Conventional
Infranatant Lipotransfer

Thin Centrifugated
Patients Fat
Fat
SVF
Infranatant Mini-CAL

Fatty
Centrifgated
Patients Fat
Fat

SVF
Fat
Full CAL
 Stem Cell-Assisted Lipotransfer (CAL)

Converts stem cell-poor aspirated fat to stem cell-rich fat.

(increased stem cells by 43%)

CAL is safe, effective & superior to conventional lipotransfer.

Cell-Assisted Lipotransfer for Cosmetic Breast Augmentation: Supportive Use of Adipose-
Derived Stem/Stromal Cells . K Yoshimura, F Sato, N Aoi, M Kurita, T Hirohi, K Harii
Journal of Plastic, Aesth Plast Surgery, (2008), 22:48-55.
 Master Stem Cell (ASC) Stem &
Lipid
(Multipotent, undifferentiated,
Used in emergency)
Progenitor Cells
2 - 5% fat layer are ASCs

ASCs cause:
Progenitor Cells (ASC) (Monopotent, committed,
Used in physiologic turnover) 1. Enhance angiogenesis
2. Improve graft survival
3. Reduce postop atrophy
by adipogenesis

ASCs differentiate into:

1. Adipocytes
2. Endothelial cells
3. Vascular mural cells
4. Other stem cells
5. Remain as stem cells

Adipocytes

Vascular endothelial cells

 Gluteal Sculpting
Procedural Steps: Pearls & Caveats

Best/safe outcome awake patient, can assist in surgery positioning

Prone & lateral decubitus position for fat transfer, may stand patient

Minimizing wetting solution prevents hiding deficient areas

Wetting solution causes recipient tissue hemostasis & anesthesia

Incisions: 1. Superior to intergluteal crease

2. Lateral infragluteal crease
 Gluteal Sculpting
Procedural Steps: Pearls & Caveats

VASERsmooth treatment prior to fat transfer

Optimal total time from fat harvesting, processing

and transfer within one hour (goal- < 2 hours)

Harvest & process fat using sterile technique

Multi-planar, micro-deposit fat grafting technique

Subcutaneous tunneling assists in fat transfer

 Gluteal Sculpting
Procedural Steps: Pearls & Caveats

Fat harvesting- use > 3 mm blunt cannula

May need repeat tunneling before additional fat placement

Do not place more fat when fat egresses from incisions

Fat viability improved by adding platelet rich plasma,

cellular cytokines & adipose derived stem cells
 Gluteal Sculpting
Advantages of VASER Liposuction

Fat retains viability with 85% fat cell survival

Stem cell viability with 87% cell survival
Since speed from harvesting to administration effects graft survival,
VASER allows more fat harvested faster
Best skin tightening:
VASER 53% better than Standard & 35% better than Smart Lipo
25 - 30% less blood loss than standard liposuction
(Water-jet least blood loss method)
Allows high definition body contouring: better & faster
Fastest minimally invasive Cellulite treatment (VASERsmooth)
 Advantages of VASER Liposuction
Objective Documentation of Skin Tightening

Points of 50 mm Triangle Using Ultraviolet Dye

Nagy M, Vanek P. A multicenter, prospective, randomized, single blind, controlled

Trial comparing Vaser-assisted lipoplasty to Suction-assisted lipoplasty. 2012;129,
681e-689e.
 Advantages of VASER Liposuction
Time Course for Skin Tightening

Results: @ 6 mths %/L: VAS- 17.0 SAL- 11.1

Conclusion: 53% More Skin Tightening Using VASER
Nagy M, Vanek P. A multicenter, prospective, randomized, single blind, controlled trial comparing
Vaser-assisted lipoplasty to Suction-assisted lipoplasty. 2012;129,681e-689e.
 Advantages of VASER Liposuction

Blood Loss Measurement: Lipocrit Results:

Lipocrit of Infranatant
VAS- 11.2
cc blood per 100 cc aspirate SAL- 14.0

26% Less Blood Loss Using VASER

Nagy M, Vanek P. A multicenter, prospective, randomized, single blind, controlled trial comparing
Vaser-assisted lipoplasty to Suction-assisted lipoplasty. 2012;129, 681e-689e.
 Thank You!

AC
Robert J Troell, MD, FACS

Beauty by Design
The Institute of Advanced Body Sculpting
Call 702-930-8335
Las Vegas, NV
https://www.drtroell.com
Corona del Mar, CA
http://www.masterpieceaesthetics.com