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.