Patient Selection

The ideal candidates for a breast reduction with ultrasound-assisted lipoplasty (UAL) are patients with juvenile breasts, which usually have fatty parenchyma, or patients with postmenopausal involution parenchyma, with good skin tone and elasticity present. Between 60 and 70% of women with large breasts are candidates for reduction with UAL. The preoperative assessment includes a mammographic study, breast clinical history, evaluation of breast ptosis, and evaluation of the consistency of breast parenchyma.

Preoperative Mammography

Preoperative mammograms (anteroposterior and lateral views), the so-called Ecklund view, are taken to evaluate the nature and consistency of the breast tissue (fibrotic, mixed or fatty parenchyma ), distribution of the fat, presence of calcifications, and areas of dysplasia or nodularity that might necessitate further studies (Fig. 8.1). The presence of fibroadenomas, calcifications, and other suspected or doubtful radiologic findings should be double-checked with ultrasound and a radiologist experienced in breast tissue resonance.

FIG. 8.1 Mammographic evaluation of candidates for breast reduction with the use of ultrasound-assisted lipoplasty (UAL).

(A) A typical fatty breast. This patient is an ideal candidate for UAL. (B) Fibrotic glandular tissue is a contraindication for UAL .(C) Fibrotic mixed tissue. This patient is a candidate for UAL of the posterior upper and lower cone.

Contraindications

In the author’s study, patients with a history of breast cancer or mastodynia were not considered and nor were those fearful of potential sequelae from this new technique.

Furthermore, because the amount and distribution of the breast fat is variable, not all women are candidates for breast volume reduction with UAL. If fat and glandular tissue are mixed, penetration of the tissue may be impossible, as noted by Lejour¹³ and Lejour and Abboud.¹⁴ If the breast tissue is primarily glandular, the technique is not indicated.

Preoperative Planning

The distance from infraclavicular notch and nipple is drawn by hand (Fig. 8.2). Circles indicate the area of major volume to be addressed. A circle of about 5 cm diameter is marked around the nipple.

FIG. 8.2 Distance from infraclavicular notch and nipple: circles indicate the area of major volume to be addressed and a circle of about 5 cm diameter is marked around the nipple.

This area is not addressed by ultrasound as it clearly contains 90% of the breast tissue. Ultrasound energy targets only the fatty tissue of the breast, sparing the parenchymal components.

Infiltration

Infiltration should be divided into the three different layers of the breast: deep, intermediate, and superficial (Fig. 8.3).

FIG. 8.3 The three different layers of infiltration (superwet infusion) of the breast: deep, intermediate, and superficial.

In deeper and intermediate layers I expect a 1.5 : 1 ratio between infiltration and aspirate; in the superficial layer I normally infiltrate twice what I expect to extract (2 : 1 ratio). I use blunt infiltration cannulas, as described by Klein,¹⁵ 15–20 cm long.

It is essential to perform meticulous infiltration of the superficial layers, then to wait a minimum of 15 minutes to allow the epinephrine (adrenaline) to take effect, before starting ultrasound.

In a total of 500 ml of infiltration, normally 400 ml are for deeper and intermediate layers, and 100 ml are for superficial layers.

Skin Incisions

The operation begins with the introduction of the skin protector placed at the incision site, normally placed 1 cm below the inframammary crease. Another incision is normally placed at the axilla, at the same length.

A further incision is placed around the areola margin, and is utilized to address the superficial layers of the upper quadrants, if required. This skin port is designed to protect against friction injuries by the probe during its continuous movement.

The fatty breast is emulsified in the lateral and medial compartments, the upper quadrants and the inferior aspect of the periareolar area. All the periareolar area, where most of the glandular tissue is localized (5 cm circumference around the nipple–areola complex), is preserved.

The deep portion is also emulsified, allowing the breast mold to regain a natural shape through upward rotation, thus increasing the elevation from its initial position, taken from the midclavicular notch. Up to 4 cm of elevation is obtained after proper reduction and stimulation to allow skin retraction and correction of the ptosis.

Two 1.5–2.0 cm stab incisions, one at the axillary line and the other 2 cm below the inframammary crease, are made to allow entrance of the titanium probe.

Through these incisions the surgeon can reach all the breast tissues, working in a criss-cross manner. Recently, the ultrasound device software has been upgraded to provide the same degree of cavitation with less power, which reduces the risk of friction injury and burn at the entrance site; this even allows discontinuing the use of the skin protector.

Probes

With existing technology, a solid probe is more efficacious than a hollow probe for cavitation, which is the physical phenomenon that allows fat fragmentation and destruction. Moreover, the level of ultrasound energy conveyed by a hollow probe is limited, and consequently the level of the cavitations obtained in the tissue is diminished.

The Vaser system (Sound Surgical Technologies, Denver, CO, USA) provides different sizes and lengths of solid titanium probes (Box 8.1) expressly designed to fulfill all purposes in body contouring, as well as being capable of emulsification through the cavitation effect produced by the ultrasound energy. The piezoelectric transducer transforms electric energy into “vibration energy”, thus allowing the solid titanium probe to emulsify the target fat cells.

The efficacy of these probes, which are narrower than the previous technologies available on the market, is connected to their design, as they are provided with rings (one, two, or three) at the tip of each probe. These rings have two special functions:

The number of rings to be chosen depends on the type of tissue: the most fibrotic is treated with one ring, the less dense tissue (pure fat ) with three rings.

These options are not purely an academic difference: the energy and the wavelength of each probe is selected for the target tissue, avoiding unnecessary extra power and wasted energy, which is a potential cause of secondary unwanted complications (already seen with previous technologies).

In breast reduction with pure Vaser, I prefer the 2.9 mm probe, with one ring, for deep layers, and the 3.7 mm, with three rings, for superficial layers.

Technique

The Vaser surgeon may now utilize two further options:

FIG. 8.4 Probes.

Larger probes are recommended in all massive volume cases, including large breasts, and the cone tips in really fibrotic breasts.

Fat Emulsification

In breast reduction with UAL the duration of the procedure varies depending on the volume of reduction, the type of tissue encountered, and the amount of skin retraction required. A breast with purely fatty tissue is easier to treat than one with mixed glandular tissue, in which fat cells are smaller, stronger, and denser (Fig. 8.5).

FIG. 8.5 Probe emulsifying deep layers and undermining the superficial layers.

The author has started utilizing the Vaser ultrasound device with solid probes (2.9–3.7 mm wide). It delivers 50% of the ultrasound energy in comparison with the older Sculpture unit (SMEI, Casale Monferrato, Italy), which was used from 1990 to 2001, while emulsifying fatty tissue much more efficiently. Treatment of the target tissues starts with 10–15 minutes of ultrasound energy in fat tissue, which usually produces between 250 and 300 ml of emulsion.

The surgical planes, with good criss-cross tunneling and adequate undermining, are planned in the preoperative drawings. If large undermining is required for skin retraction, the superficial layers are treated initially. Then the deeper planes are reached, and more time is spent in thicker areas. Surgeons inexperienced in the procedure should be especially cautious when performing the technique, particularly in the subdermal planes.9–12,15–19

Subcutaneous UAL Undermining

Together with UAL application to the fat layers, starting from the deeper layers and progressing to the more superficial ones, it is advisable to thin the superficial layer of the subcutaneous tissue of the upper and lower quadrants by using a different angle pattern, as in standard lipoplasty.^20,21 This superficial undermining with low-frequency ultrasound energy helps to enhance the retraction of the breast skin and to redrape the breast skin to the newly shaped and reduced mammary cone (Fig. 8.6).

FIG. 8.6 Incisions placed at the inframammary crease, axilla, and areola margin.

• Upper quadrants, superficial layers, 2–3 minutes

• Lower quadrants, deep layers, 7–20 minutes.

Mastopexy

Vaser can also be applied in clinical breast surgery cases that present minor degrees of glandular ptosis. As we know, by decreasing the volume of the breast, it is normal to have an upward rotation of the gland itself. Also, the areola tends to shrink when the underlying tissue is diminished in size and volume.

I have applied the technique in clinical cases with the patient expressively refused visible breast cutaneous scars, and the potential correction of ptosis with an anatomical implant. The upward rotation of the breast and the retraction can finally elevate the breast by 2–4 cm from its initial position (Figs 8.9 and 8.10). A supporting bra has to be applied for the first 4 weeks after surgery; despite this, I strongly believe that a similar bra should be advised forever in patients with large breasts or a tendency to ptosis (Fig. 8.11).

FIG. 8.10 Patient 24 years old, 450 ml of aspirate per side, UAL 22 minutes.

(A, C) preoperative views. (B, D) postoperative views.

FIG. 8.11 Patient 32 years old, 550 ml of aspirate per side, UAL 25 minutes.

(A,B) postoperative views.

Histologic Changes

The breast tissue that underwent emulsification with UAL was analyzed histologically by Chun, Taylor and Van Meter (2002)²³ who presented a paper at the American Society for Aesthetic Plastic Surgery (ASAPS) meeting in Las Vegas. They operated on 10 patients with large breasts using the Genesis Contour device (Mentor HS, Santa Barbara, CA, US), with breast UAL. Then, with open surgery, a breast specimen was removed, weighing 430–1530 g.

No gross pathological changes were noted at the time of surgery, and microscopic diagnosis included fibrocystic changes and stromal fibrosis.

No atypia and no malignancies were found. The long-term follow up shows clearly that the emulsified fat, when not aspirated, will dissolve in a few days or weeks.

An area of relative fibrosis may appear at 1 or 2 months, interval; palpable nodes or lumps were a rare event in the large series of patients operated on (from 2002 to 2006, 200 breast reductions and/or pexies were performed, alone or in combination with other body contouring procedures).

In 2006, at the ASAPS meeting in Orlando (FL, USA), Nagy and McCraw (Mississipi University Medical School, St Louis, Missouri, US) first presented the combination of breast fat emulsification by Vaser with open surgery breast reduction. They re-introduced the technique of Raymond Passot, a French surgeon, who in 1925 published the so-called “BUTTON” mammoplasty or the “ no vertical scar” reduction, which became the most common method of breast shaping in Europe before World War II (Fig. 8.12).

FIG. 8.12 The Passot method.

Markings

I start marking the new nipple position, which is from 19–21 cm from the midclavicular point (as in all classic measurements – this is the Pitanguy referral point). Then I mark the inframammary fold, which ranges from 15–23 cm (Fig. 8.13). The flap margin is 8–9 cm below the new nipple site.

FIG. 8.13 (A) Best range of visual is 15–23 cm; (B) Indicating the IM fold.

The existing inframammary fold is marked. Medial and lateral points are marked. The upper quadrants of the breast are infiltrated with tumescent solution, then Vaser is applied to emulsify the fat in this area. In this case, no skin protector is applied, as the skin in this area is due to be de-epithelialized for breast reduction.

After completing aspiration of emulsified fat, the lower flap is detached from the chest wall, with a central large inferior pedicle based on perforators from the pectoralis muscle. The upper quadrants, already treated with Vaser (Fig. 8.14), show the network of the subcutaneous breast tissue, as it appears after emulsification of fat and aspiration. All the supporting structures of the skin (elastic bundles, vessels, nerves, connective supports) are conserved. This pattern is similar to what happens in closed breast reduction. As the flap is reduced, it is advanced to fill the empty space. The new nipple is positioned and centered on its pedicle.

FIG. 8.14 Vaser effect after 500 ml aspiration.

The Passot technique combined with Vaser has been applied to several types of breast ptosis. I have performed large reductions with this technique (up to 2900 g per side) (Fig. 8.15), or operated on the so-called “long breast”.

FIG. 8.15 Large reduction, 2900 g per side.

The typical case where I actually combine the Passot technique with Vaser is a moderate degree of ptosis, 26–28 cm from the midclavicular point, with a mild to moderate hypertrophy (Fig. 8.16). Results are satisfactory and tend to improve with time (Box 8.2).

FIG. 8.16 A (A) Preoperative view. (B) Five months postop, 600 g per side.

Skin Necrosis

Fat necrosis with secondary tissue induration is a typical sequela of ultrasound surgery. When it is localized in small areas, such necrosis can be treated with massage or local infiltration of corticosteroids to soften the area.

Loss of Sensation

Loss of sensation is generally limited to the first 3 weeks after surgery. Recovery is rapid because the central cone of the breast is composed mainly of pure parenchyma and is not touched during surgery. Skin sensation is recovered in a few weeks.

Hematoma

Hematoma formation is another potential complication, though no cases occurred in this series. A photograph of a case of hematoma in a patient treated by another surgeon is shown in Fig. 8.17. This hematoma was localized in the subaxillary region, where the tumescent infiltration was initially administered. The surgeon who performed the operation revealed that the anesthesiologist incorrectly used standard sharp needles rather than blunt infiltration cannulas. The formation of the hematoma, which appeared immediately after the infiltration, was thus related to an incorrect tumescent infiltration technique and not to the breast reduction with UAL.

FIG. 8.17 (A) Skin necrosis of the breast medial flap. The surgeon performed a standard breast reduction and then attempted to debulk the medial flap without infiltration of tumescent solution. Skin necrosis resulted, with spontaneous healing after 3 weeks. (Patient referred by another surgeon.) (B) Breast hematoma caused by infiltration of Klein solution with incorrect instrumentation. The anesthesiologist used a sharp needle rather than the classic atraumatic blunt needle. The hematoma required evacuation, after which regular healing followed. (Case referred by another surgeon.)

Mastitis

Mastitis, an inflammatory response of the breast parenchyma to surgery, occurred in a few patients early in the series. Once surgery was avoided for patients at or near their menstrual period, only a minor inflammatory response was noted. When encountered, mastitis rapidly subsided with immediate treatment consisting of oral anti-inflammatory drugs and wide-spectrum antibiotics for 3 days.

Seroma

Seroma formation is a potential complication of any breast surgery. Regular application of suction drainage and breast compression for several days with a foam pad and a bra prevent this event.

Selectivity and Specificity of Ultrasound

Large amounts of fat are often found in patients with breast hypertrophy, even among thin adolescents. Lejour and Abboud¹⁴ emphasized that once the fat is removed by lipoplasty before breast reduction, the proportion of glandular tissue, connective tissue vessels, and nerves is increased.

These structures are important for maintaining vascularity, sensitivity, and lactation potential. Lejour¹³ affirmed that if the breasts contain substantial fat, weight loss may result in breast ptosis. The degree of recurrent ptosis can be minimized if lipoplasty is performed preoperatively to reduce the fatty component of the breasts. This observation anticipated the great potential of UAL for breast surgery.

The clear limits of standard lipoplasty, with mechanical indiscriminate destruction of fat and surrounding elements followed by power aspiration of the destroyed tissue, are particularly enhanced in breast surgery, where specialized structures have to be carefully preserved.

Because it is a selective technique, UAL may be applied in breast surgery to destroy and emulsify only the fatty component of the breast tissue without affecting the breast parenchyma for which the ultrasound energy has no specificity. The specificity of the technique is connected with the cavitation phenomenon and the efficiency of the system hinges on the type of the titanium probe used and the energy level selected. Lejour¹³ argued that the suctioning of breast fat also made the breast suppler and more pliable, which facilitates shaping, especially when the areola pedicle is long. This consideration is particularly important with fatty breasts, which have a less reliable blood supply. These benefits are significantly increased by the use of UAL because the specificity of this technique spares the vessel network.

The selectivity of UAL was demonstrated by Fisher,^24,25 and Palmieri²⁶ in their studies on the action of the ultrasound probe in rat mesenteric vessels. Later, Scheflan and Tazi²⁵ introduced endoscopic evaluation of UAL. They used a Stortz endoscopic system and camera (Stortz, Tuttlingen, Germany) to videotape the action of the titanium probe within the ultrasound device in the superficial layers, verified by needle depth, after standard infiltration with the tumescent technique. UAL was performed with criss-cross tunnels, and the procedure was recorded on videotape. An adjacent area was treated with standard lipoplasty. The technique was compared with standard lipoplasty, which was also endoscopically assisted and monitored. The authors found that standard lipoplasty appears to be the more aggressive technique, with the mechanical destruction of the entire subcutaneous tissue, despite the use of 2–3 mm wide blunt cannulas.

By contrast, UAL spared vessels, nerves, and elastic supporting fibers. Alterations in breast tissue resulting from the use of UAL were a thickened dermal undersurface, markedly thickened vertical collagenous fibers, intact lymphatic vessels, and intact blood vessels. The horizontal and vertical thickening and shortening of the collagen in the dermis and ligamentous fibers are responsible for the remarkable skin tightening that follows subcutaneous stimulation with the ultrasound probe. This is of great value in breast surgery, where volume reduction has to be accomplished by skin redraping and recontouring of the breast shape.

As noted by Lejour,¹³ retraction of the skin after standard lipoplasty cannot be expected to be sufficient to produce a satisfactory breast shape. Subcutaneous aspiration must be extensive to obtain the necessary skin retraction, and the risk of localized skin necrosis resulting from excessive superficial liposuction cannot be ignored.²⁸

Calcifications

Lejour¹³ and Lejour and Abboud¹⁴ argued that the risk of postoperative fat necrosis or calcifications was the reason many surgeons avoided the use of lipoplasty in the breast. The main cause of fat necrosis is breast ischemia brought about by extensive dissection or direct mechanical damage, with resultant venous drainage. Calcification in breast reduction surgery may derive from an area of fat necrosis or breast necrosis and subsequent scarring. Such calcifications are most often located at the incision lines (periareolar, or vertical scar in the inverted-T approach), where more tension is placed in approximating the lateral and medial flaps. However, when the tension is too high, areas of necrosis could arise from the approximating suture and later cause calcifications that are visible on mammography. However, the risk of such complications in UAL procedures is quite low.

Calcifications in breast parenchyma are to be expected after any mammoplasty procedure. In reduction mammoplasty, it is preferable that they be localized along the breast scars.²⁹ When lipoplasty is performed in addition to the mammoplasty procedure, benign macro-calcifications are slightly more numerous in the parenchyma than they are in breasts reduced without lipoplasty. This may occur because of the trauma caused by lipoplasty or because lipoplasty suction is applied to the most fatty breasts, which are more prone to liponecrosis.³⁰ However, 1 year after fatty breast reduction with UAL, follow up mammography revealed only a slight increase of small microcalcifications, similar to those found after other mammary procedures.

Potential Risks

In November 1998, a conference on UAL safety and effects was held in St Louis, MO, USA, sponsored by the ASERF and the PSEF.³¹ The panel was organized in response to an article by Topaz³² that raised questions about the safety of UAL. Topaz speculated that thermal effects and the free radicals generated during UAL might result in neoplastic transformation and other long-term complications, as a consequence of the physical effect known as sonoluminescence. Those attending the conference represented multiple scientific disciplines, including plastic surgery, physics, lipid chemistry, cancer biology, and mechanical biophysics. The participants agreed that scientists did not yet understand the mechanism of UAL action, though multiple mechanisms were probably involved, such as mechanical forces, cavitations and thermal effects.

Additional research has revealed that long-term complications or negative bioeffects (including DNA damage and oxidation free radical attack) are probably not serious safety concerns for UAL.

With reference to the application of UAL to breast surgery, we investigated the histology of the breast fat tissue before and after UAL breast surgery (with serial biopsies at 6 months and 1 year after surgery) and the mammographic appearance of the breast before and 1, 2 and 3 years after surgery, particularly with respect to calcification. The results were evaluated by a sonologist not directly involved with the clinical research.³³ Histologic studies revealed an increased fibrotic response to thermal insult, with a prevalence of fatty scar tissue, in all specimens evaluated.

Mammography showed a significant increase in breast parenchymal fibrosis. The calcifications that appeared were benign and were typically small, round, less numerous, and more regular than those characteristic of malignancy. Comparison of the mammographic results showed that microcalcifications are less likely to develop with UAL. It is likely that scar tissue caused by breast reduction with electrocautery or by necrosis resulting from the tension of internal sutures may more frequently cause calcifications or irregular mammographic aspects of the operated parenchyma. Particularly in standard breast-reduction surgery, they can appear at the areola line and at the site of the vertical scar.

From a mammographic viewpoint, the typical appearance of a breast reduction with UAL demonstrates predictably less scarring and fewer calcifications than occur in the standard open technique. Courtiss³⁴ reported similar mammographic evidence in a denser breast after breast reduction by lipoplasty alone. No malignancies were reported.

The question of whether potential lactation is affected by UAL remains unanswered. The technique was used for breast reduction and mastopexy in younger and older patients. In the younger group, 16 patients breast-fed their babies regularly. The other 14 patients were lost to follow up. However, none of these patients, or their gynecologists, reported any problems to the surgeon or to the hospital, and no complications have been reported by other surgeons around the world who use this technique.