Many of my patients have asked about how VASER (internal ultrasound ‘VASER’ assisted lipoplasty) is different from Smart Lipo and Slim Lipo (Internal Laser-Assisted Lipoplasty). This article, written by a biomedical engineer compares these and several other technologies to reduce subcutaneous fat. I think that the article is well written and informative. When I was looking for a technology, I compared both laser technologies and VASER and came to the same conclusions as the suthor of this paper. In summary, the article describes the superiority of the VASER technology over the other technologies. - Mark D. Epstein, M.D., F.A.C.S.

Body Sculpting Surgery: Technologies and Techniques

by William W. Cimino, Ph.D.

‘Lipoplasty’ is the all-encompassing term that refers to body contouring by sculpting or removal of fatty tissue. The major groups of different technologies and techniques for lipoplasty are described below, along with a short assessment of their respective advantages and applicable volume considerations.

Suction-Based Technologies

Liposuction or Suction-Assisted Lipoplasty (SAL)

• Power-Assisted Lipoplasty (PAL) Ultrasound-Based Technologies
• 
  Internal Ultrasound-Assisted Lipoplasty (IUAL)
• 
  VASER-Assisted Lipoplasty (VAL)
• 
  External Ultrasound-Assisted Lipoplasty (EUAL)

• Transdermal Ultrasound-Assisted Lipoplasty (TUAL) Laser-Based Technologies
• External Laser-Assisted Lipoplasty (ELAL)
• Internal Laser-Assisted Lipoplasty (ILAL) Chemical-Based Technologies

Mesotherapy

Suction-Based Technologies

Liposuction/Suction-Assisted Lipoplasty (SAL)

Liposuction, with all of its many variations, is the predominant form of body contouring surgery today. These variations include liposculpture, tumescent liposuction, suction lipectomy, syringe lipoplasty, and micro-cannula technique. All of these suction-based techniques can be included in a general category commonly referred to as Suction-Assisted Lipoplasty, or ‘SAL’.

SAL is a two-step process that requires the infusion of a wetting solution into the fatty tissues followed by the insertion of a suction cannula that is attached to a suction source. The cannula avulses (tears) and aspirates the fatty tissue fragments which are deposited into a waste canister.

This technology has been around in basic form for more than 30 years and has undergone improvement and refinement during that period. Major advances for the SAL technique include the introduction of the side-ported cannula, the introduction of wetting solutions with drugs for pain and control of bleeding, and overall reduction in cannula size.

Suction-based technologies are not tissue selective. Any tissues, such as nerves, vessels, or collagen structures in the fatty layer that get pulled into the ports on the suction cannula will be torn or avulsed. The technology is reliable, and has been used and studied extensively.

SAL has been used for small to very large volumes of fat removal in lipoplasty.

Power-Assisted Lipoplasty (PAL)

Power-Assisted Lipoplasty (PAL) is essentially a liposuction cannula (SAL) with the addition of a motor-driven reciprocating handle. The primary advantage of this technology is that it makes passage of the suction cannula through the tissues easier for the surgeon but represents no clinical improvement in outcomes or safety relative to SAL for the patient¹.

Surgeons may develop arthritis, ulnar palsy, or carpal tunnel syndrome as a result of the motor-induced vibration². Like SAL, PAL is not tissue selective – any tissues, such as nerves, vessels, or collagen structures, in the fatty layer that get pulled into the ports on the suction cannula will be torn or avulsed.

PAL is generally used for medium to large volumes of fat removal in lipoplasty as it may be too aggressive for smaller, more delicate areas.

Ultrasound-Based Technologies

Internal Ultrasound-Assisted Lipoplasty (IUAL)

Internal Ultrasound-Assisted Lipoplasty (IUAL) uses an ultrasonically vibrating cannula to emulsify (liquefy) adipose tissue during the aspiration process. IUAL technology was introduced with the promise that the ultrasonic technology would provide a level of tissue selectivity due to the emulsification process and thereby improve outcomes relative to those obtained using SAL. However, clinical experience and outcomes with IUAL vary considerably. Some surgeons report no significant clinical change in outcomes^5,6. Some surgeons report an improvement in outcomes^3,4. Others report increased complications or tissue damage relative to SAL⁷. This wide variation in results is in large part explained by the design of the technology which aspirates protective fluids/ tissue while the ultrasonic energy is active, by application of excess power to the tissues, and by the initial insufficient clinical understanding of the technology, all of which prevented consistent and uniform effectiveness⁹.

IUAL is called internal UAL to differentiate it from external UAL (EUAL, explained below). Most IUAL is a two-step process similar to SAL: infusion of a wetting solution into the fatty tissues followed by a combined emulsification and aspiration phase using a hollow ultrasonically powered cannula.

IUAL has been used generally for medium to very large volumes of fat removal in lipoplasty as it may be too aggressive for smaller, more delicate areas.

VASER^®-Assisted Lipoplasty (VAL)

VASER-Assisted Lipoplasty (VAL) represents a third-generation internal ultrasound system that incorporates significant design improvements over the previous two generations of internal ultrasound devices.

VASER technology is the ultrasonic component of an integrated lipoplasty system. The VASER System uses small-diameter, solid, multi-ringed probes to deliver a minimal level of ultrasonic vibrating energy to specifically target and emulsify fatty tissues. Smaller diameter probes and pulsed delivery of the ultrasonic vibratory energy further reduce delivered energy by as much as 50% compared to continuous wave ultrasound used in first and second generations of internal ultrasound-assisted lipoplasty⁸.

By emulsifying the fatty tissue prior to extraction, aspiration can be performed with less avulsion, and hence less tearing of the tissues. The VAL procedure does not utilize standard SAL to remove the emulsified tissues and fluids -rather, specially designed aspiration cannulae, call VentX^® Cannulae, are used to remove the emulsified fluids and minimize avulsion and other tissue trauma associated with standard SAL aspiration devices.

This third-generation ultrasound technology was specifically designed to preserve and spare as much of the tissue matrix as possible, yet still remove the desired amount of fatty tissue. This approach helps minimize post-operative pain and bruising and also addresses the limitations inherent in earlier generation IUAL devices^10,11. VAL was compared to IUAL in a clinical study and found to significantly reduce potential complications relative to the earlier generations of IUAL⁹.

VAL has been used on volumes from the very smallest (face/neck) to very large volumes.

External Ultrasound-Assisted Lipoplasty (EUAL)

External Ultrasound-Assisted Lipoplasty (EUAL) is the application of non-focused ultrasonic energy in the 1-3 MHz range to the skin of the patient prior to the use of standard SAL techniques. The theory is that the externally applied ultrasonic waves disrupt or soften the fatty tissue so that subsequent suction aspiration is easier. However, there has been no scientific substantiation that this additional step, prior to SAL, improves outcomes or safety.

Because SAL is used to remove any fat targeted by the EUAL technique, the outcomes are generally consistent with SAL outcomes. EUAL surgery may involve significantly more time if larger volumes are to be pre-treated with the EUAL device. This technology is not in widespread use today, primarily because the combination of EUAL and SAL has not been shown to be clinically superior to SAL alone.

Because SAL must be used in conjunction with the EUAL device, addressable volumes are the same as SAL, from small to very large, strictly a function of the SAL step.

Transdermal Ultrasound-Assisted Lipoplasty (TUAL)

Transdermal Ultrasound-Assisted Lipoplasty (TUAL) is the application of focused ultrasonic energy directly to the skin of the patient to disrupt the fatty tissue below the skin and does not require removal of the ruptured cells with a suction cannula (SAL). This technology is not currently available for use in the United States, as it has not yet gained Food and Drug Administration (FDA) clearance.

Transdermal ultrasound is a single-step process which involves application of the ultrasonic energy directly to the skin without the prior infusion of wetting solution as required in all other techniques. The body’s natural processes remove the damaged tissues over a period of time after the ultrasound application.

This technology is used to treat only small volumes in a single patient visit, on the order of 250–300 milliliters (cc’s) per treatment. The treatable volume is limited because this approach requires that the patient’s body remove or process the dead or damaged tissue. Because the treated fatty tissues are not removed at the time of surgery, results are not seen until several months after the procedure. Many treatments are required over an extended period of time if more significant volumes are to be addressed.

Laser-Based Technologies

External Laser-Assisted Lipoplasty (ELAL)

External Laser-Assisted Lipoplasty, also called Low-Level Laser-Assisted Lipoplasty, is the application of low-level laser energy to the skin of the patient prior to the use of standard SAL techniques. The theory is that the application of the low-level laser energy causes the fatty cells to produce a transitory pore in their cell membranes, which allows the fat inside the cells to pass to the outside of the cells¹². This claim was subsequently studied for validation, and results showed that the ELAL therapy did not influence the fat cell structure as reported¹³. This technology is not in widespread use today, primarily because the combination of ELAL and SAL has not been shown to be clinically superior to SAL alone¹³.

Because SAL is used to remove any fat targeted by the ELAL technique, the outcomes are generally consistent with SAL outcomes, as are addressable volumes, from small to large, strictly a function of the SAL step.

Internal Laser-Assisted Lipoplasty (ILAL)

Internal Laser-Assisted Lipoplasty (ILAL) uses a small-diameter laser fiber to deliver laser energy directly to

the fatty tissues through an incision in the skin. The laser is reported to operate through photomechanical and photothermal effects¹⁵. In short, these processes cause destruction of cells via coagulation and vaporization due to localized heating and rapid thermal expansion. ILAL was first introduced in the mid to late 1990’s¹⁵ and did not gain wide adoption or use. It has been reintroduced and is marketed as SmartLipo™ and Cool Lipo™.

A contra-lateral study comparing SAL on one side of the patient to ILAL (SmartLipo) on the other side of the patient showed no significant difference in outcomes¹⁴. The American Society for Aesthetic Plastic Surgery issued a guidance statement for this technology stating “Although SmartLipo received FDA clearance in late 2006, alarm bells rang for many experts when discussing this procedure based on the recent publication of data showing that this procedure was no better than traditional liposuction, and that it may present some risks to the liver and kidneys due to the way it releases free fatty acids when destroying the fat cells”¹⁶. The surgical technique for ILAL is a three-step process: (1) infusion of wetting solution followed by (2)application of the laser energy to the fatty tissue then (3) aspiration of the emulsified tissues using SAL. It has been proposed that the suction phase is not required for ILAL but surgeons are generally not willing to risk leaving the laser-affected volumes of damaged or dead tissue in the body. ILAL is therefore applicable only to small volumes as a standalone technology if no SAL step is used. If ILAL is combined with SAL to remove larger volumes, then outcomes consistent with SAL can be expected¹⁴. In this case (ILAL with SAL) the laser is used to treat only a small percentage of the removed tissues.

Chemical-Based Technologies

Mesotherapy

Mesotherapy is the use of a large number of injections of non-FDA approved drug mixtures, most often including phosphatidylcholine. The drug mixture is injected directly through the skin and into the fatty layer using several hundred needle injections to distribute the drugs throughout the fatty layer.

The mesotherapy theory provides that the drug mixture causes the breakdown (cell rupture and cell death) of the fat cells, which are then absorbed by the body. The American Society of Aesthetic Plastic Surgery recently released a position statement on mesotherapy which warns patients, stating: “efficacy and safety are not known, the procedure and the drug mixtures are not approved by the FDA, and that the procedure is often offered by unqualified personnel”¹⁷. Mesotherapy is marketed as LipoDissolve^®, LipoStabil^®, and LipoShape^®.

1. Fodor PB, Vogt PA. Power-assisted lipoplasty (PAL): A clinical pilot study comparing PAL to traditional lipoplasty (TL). Aesthetic Plast Surg., Nov.-Dec.,23(6):379-85, 1999.
2. Shiffman, MA. Editor’s Commentary in Liposuction: Principles and Practice. Editors M.A. Shiffman M.D., and A. DiGiuseppe M.D. Springer-Verlag, Berlin, Germany, 2006; p 405.
3. Kloehn RA. Liposuction with “sonic sculpture”: six years experience with more than 600 patients. Aesth Surg. J. 1996;16:123-8.
4. Zocchi ML. Ultrasonic assisted lipoplasty: Technical refinements and clinical evaluations. Clin. Plast. Surg. 1996;23(4) 575-598.
5. Fodor PB, Watson J. Personal experience with ultrasound-assisted lipoplasty: A pilot study comparing ultrasound-assisted lipoplasty with traditional lipoplasty. Plast. Reconstr. Surg. April 1998;101(4):1103-1116;discussion 1117-9.
6. Karmo FR, Milan MF, Silbergleit A. Blood loss in major liposuction procedures: a comparison study using suction-assisted versus ultrasonically assisted lipoplasty. Plast. Reconstr. Surg. 2001;108(1):241-7; (discussion 248-9).
7. Cardenas-Camarena L, Andino-Ulloa R, Mora RC, Fajardo-Barajas D. Laboratory and histopathologic comparative study of internal ultrasound-assisted lipoplasty and tumescent lipoplasty. Plastic & Reconstructive Surgery. Sep. 2002;110(4):1158-1164.
8. Cimino WW. Ultrasonic Surgery: Power Quantification and Efficiency Optimization. Aesth Surg. J. 2001;21: 233-240.
9. Jewell ML, Fodor PB, De Souza Pinto EB, Al Shammari MA. Clinical application of VASER-assisted lipoplasty: A pilot clinical study. Aesth. Surg. J. 2002;22:131-146.
10. Cimino W.W. “Ultrasound-Assisted Lipoplasty: Past, Present, and Future”, Liposuction: Principles and Practice, Editors M.A. Shiffman, M.D. and A. Di Giuseppe, M.D., Springer-Verlag, Berlin, Germany, 2006, p 225-228.
11. Cimino WW. VASER-Assisted Lipoplasty: Technology and Technique. Liposuction: Principles and Practice, Editors M.A. Shiffman,

M.D. and A. Di Giuseppe, M.D., Springer-Verlag, Berlin, Germany, 2006, p 239-244.

1. Neira R, Arroyave J, Ramirez H, Ortiz CL, Solarte E, Sequeda F,Gutierrez MI. Fat liquefaction: effect of low-level laser energy on adipose tissue. Plast Reconstr Surg. 2002 Sep 1;110(3):912-22; discussion 923-5.
1. Brown SA, Rohrich RJ, Kenkel J, Young VL, Hoopman J, Coimbra M. Effect of low-level laser therapy on abdominal adipocytes
2. before lipoplasty procedures. Plast Reconstr Surg. 2004 May;113(6):1796-804; discussion 1805-6.
2. Prado A, Andrades P, Danilla S, Leniz P, Castillo P, Gaete F. A Prospective, Randomized, Double-Blind, Controlled Clinical Trial Comparing Laser-Assisted Lipoplasty with Suction-Assisted Lipoplasty. Plast. Reconstr. Surg. 118(4):1032-1045, September 15, 2006.
3. Schavelzon, D., Blugerman, G., Chomyszyn, A., “Laserlipolysis”, Liposuction: Principles and Practice, Editors M.A. Shiffman, M.D. and A. Di Giuseppe, M.D., Springer-Verlag, Berlin, Germany, 2006, p 321-325.
4. ASAPS website commentary: http://www.surgery.org/press/news-print.php?iid=476&section=news-lipoplasty
5. http://www.surgery.org/press/news-release.php?iid=475

In November, 2006, silicone gel filled implants were approved by the Food and Drug Administration (FDA) for use in women twenty two years of age and older. Along with this announcement came an interesting recommendation: routine MRI (Magnetic Resonance Imaging) to surveil for implant rupture. Why this new recommendation? Saline implants are prone to device failure just as is a silicone gel implant. After all, the silicone shell of both saline and silicone gel filled implants are identical. Furthermore, saline implants have a valve that silicone implants do not have and this is prone to failure (and leakage) as well. The difference is that if a saline implant leaks, the device will deflate in about 48 hours and there will be a very noticeable difference in breast contour and loss of volume. The saline is absorbed. Saline is nothing more than salt water, a normal component of our bodies. With silicone gel filled implants, on the other hand, should a small defect occur in the implant shell, the silicone will by its cohesive nature most likely remain inside the implant. If a more significant compromise occurs to the implant shell, such as a tear, the silicone gel will be contained by the scar tissue capsule that forms around all breast implants, silicone and saline. There may or may not be any appreciable difference in the breast appearance and feel. There may or may not be some discomfort in the breast. As many of such device failures are asymptomatic, the FDA believes that there should be some type of routine screening for such a situation. MRI’s are ideal for identifying a defect in the breast implant. Although not perfect, they are fairly accurate and do not involve the use of ionizing radiation as is the case with a mammogram and CAT (computerized axial tomography) scan.

The current FDA recommendation is to obtain a MRI examination of the breasts three years after breast augmentation surgery and every two years thereafter. Does this make sense? To put it simply, there will be a certain amount of women who will experience device failure of a silicone gel implant. If you screen everyone every year, then almost all of these problems should be picked up by the MRI scan. If you screen no one, then of course, there will be none of these problems identified. So then, what frequency of examination makes sense? Just like screening for any disease or problem, you have to have an understanding of the actual frequency the problem, the severity of the problem (is it life threatening or a risk to quality of life or the health of the community vs. low health risk) and the costs of the screening program. Most likely, a screening program will not screen everyone each year, which leads to some problems going unrecognized. The other question is: What is the consequence of not recognizing the problem? Will there be a compromise to one’s life, health, livelihood or their family? In the case of breast implants, if a rupture is missed, there is most likely not going to be a significant risk to the patient’s health. Silicone is biologically inert and fifteen years of studying breast implants have demonstrated that they are not a causative factor in the development of any systemic diseases.

The first question is whether or not an MRI, which is an expensive test, is an appropriate first line screening test for breast implant rupture. In screening for cancer, mammogram remains the gold standard for initial screening. If there are any abnormalities seen, then it is ultrasound, not MRI that is used next to investigate further. This is not because MRI is inferior to ultrasound, but rather than ultrasound is a good second screening test and is much more cost effective then proceeding directly to an MRI. Should there still be some question after ultrasound, an MRI may be a good way to go prior to considering surgery in cases where there exists uncertainty as to whether or not a problem exists within the breast. I have found this process to be extremely useful in my cosmetic breast surgery patients (augmentation, lift, reduction) who require routine screening prior to commencing surgery. So why then, is MRI recommended as the initial screening tool for a silicone breast implant rupture? Is it better than less expensive tests?

In an excellent 1998 scientific study at the University of Michigan, Chung found that if ultrasound was the initial screening tool for a breast implant rupture and the ultrasound test was read as normal, the chance of a false negative, in other words, the chance that the normal interpretation of the ultrasound was incorrect and that there really was a rupture which was undetected was only 2.2%. On the other hand, if ultrasound did suggest a rupture, and an MRI was obtained afterwards which also supported a diagnosis of implant rupture, then there was an 86% chance that the implant was in fact truly ruptured. This is a high enough chance of rupture to support the plan of surgical exploration and implant replacement if a true rupture is actually found.

In a separate study in 2001, Cher found that in women with breast implants who have a specific complaint referable to the breast such as pain, capsular contracture or a change in the appearance of the breast, an MRI is better than 80% accurate in predicting an implant rupture. In the absence of such symptoms, the predictive value of MRI is much less, and was not felt to warrant use as a routine screening method for implant rupture in such asymptomatic women. The Royal College of Radiologists in the United Kingdom stated that ultrasound is 91% accurate if it demonstrates an intact implant, not too dissimilar to the results of the University of Michigan study discussed above. Furthermore, they concluded that the initial screening tool should be an ultrasound, followed by MRI (preferably one with a dedicated breast coil and a magnet strength greater than 1.5 Tesla) if the ultrasound suggests a rupture of the implant.

How often does rupture really occur? I use the rough rule of thumb of about 0.5 to 1% per implant, per year. Mentor’s core study of 420 patients demonstrated a 0.5% rupture rate at three years out from surgery, but there have been other studies that don’t show ruptures for even up to seven years (Sharpe and Collis- UK). Does it make sense to have 199 women to undergo MRI to find one rupture (assuming a 0.5% rupture rate)?

So, should one follow the current FDA recommendation and obtain an initial MRI examination of the breasts three years after breast augmentation surgery and again every two years thereafter?

- Consider that as third party payers (your health insurer) have strict clinical guidelines for the authorization of a breast MRI, it is quite possible that these routine MRI’s in an asymptomatic patient may not be paid for by health insurance.
- Consider the fact that a missed implant rupture is highly unlikely to represent a health risk to the individual.

- Consider that a normal ultrasound demonstrating an intact implant is better than 90% accurate

- Consider that the rupture rate is approximately 0.5% after three years.

My personal opinion, based on the information given above, is that the FDA guidelines represent overkill. In other words, I believe that these recomendations are not cost effective, and probably counterproductive. What I mean by stating that the FDA’s recommendations are not cost effective is that less expensive ultrasound is highly effective as a screening tool for implant rupture and given the fact that breast implant rupture occurs with such a low frequency brings into question the relatively frequent intervals that the FDA is recommending for breast surveillance for implant rupture. What I mean by counterproductive is that if the MRI’s are not covered by health insurance (unless there is a clinical problem, and even then possibly only after a mammogram and ultrasound have first been performed) I would not expect most women with breast implants to voluntarily follow these guidelines for cost reasons alone, as they may have to bear the financial burden of these costs. Therefore, less, if not more women will undergo such routine surveillance, which is the opposite of the FDA’s intended goals. I do not know what scientific rationale was used to develop the FDA recommendations, however, based on current scientific data, the FDA recommendations are not supported. The FDA’s recommendations are only just that, “recommendations”, not law and it is up to the individual patient to decide how to use this information. I feel that it is my obligation to present not only the FDA’s position, but my own as well.

The good news for women undergoing breast augmentation with silicone gel implants is is that breast ultrasound, a much less expensive option, is readily available for those women who are interested in routine surveillance of their breast implants. Breast ultrasound is also not “rationed” by third party payers as are breast MRI examinations.

I performed my first breast augmentation in 1990. Over the years a great deal has changed with regard to the approach to this operation. Some surgeons still take the same approach they did twenty years ago. Others, like myself, try to stay current and even set the standard for the procedure (i.e. 24 hour rapid recovery technique)

I have been amazed that patients are still asking the question: When do I need to change my implants? Breast implants are mechanical devices and as such are prone to failure at some point in the future. The question is when. I remember several years ago removing a ruptured saline implant from a woman that was placed sometime in the mid-1970’s. I was amazed that this device, which looked like it was made out of a plastic baggie in comparison to today’s sturdily constructed implants (alright, a little bit of a gross exaggeration!), lasted twenty five years inside this woman’s body before it failed. The fact is, unless I can develop clairvoyant powers and predicts the future, I cannot answer this question. Let me explain. To put it very simply, and understand this is just my opinion, “if you are happy with your breasts then you do not need to change your implants unless you are having a problem.” The following is a list, not necessarily all-inclusive, but a list nonetheless of the reasons that I think a woman should consider revision breast implant surgery:

1. Deflation of a saline implant: If you have a saline implant, then any leak, whether in the silicone shell (the bag itself) or in the valve used to fill the implant, will result in a gradual deflation which will probably take about two days to occur. You will then notice a marked difference in the size of your breasts. No further diagnostic testing is required; you simply need to remove the implant. Your options are to replace it with a similar device, replace both implants with similar devices (if the implants have been in place for several years – this is arbitrary – maybe 8 – 10 years or so), replace the implants with saline implants of a different size if you are having issues with the size or replace both implants with silicone gel implants for a more natural feel to the breasts.
2. Rupture of a silicone gel implant: Rupture of a silicone gel implant is a bit harder to diagnose. With regard to the more recent implants, a small hole in the implant will most likely not leak any silicone gel due to the cohesive properties of today’s implants. If there is a tear in the implant shell, then the silicone will be contained by the natural scar tissue “capsule” that forms around all foreign bodies implanted inside us (a breast implant is a kind of foreign body). Silicone is biologically inert, which means that it won’t react with our bodies in an untoward and dangerous manner. Because the silicone is not absorbed by our bodies (nor does it travel elsewhere in our bodies), the breast will most likely look at feel the same even though the device is compromised. For this reason, the FDA recommends getting breast MRI’s at three years after surgery and every two years thereafter. Due to the infrequency of rupture, this may not be a very effective use of our health care budget and will be the subject of a future blog.
3. Capsule contracture: In this condition, the breast feels hard and may even be uncomfortable. The implant is not changing. Rather, the scar tissue envelope that forms around the implant thickens and contracts, causing the implant to feel firmer. Treatment involves re-exploring the breast, removing the scar tissue causing the problem and replacing with a fresh implant of the same type and size.
4. Asymmetry / breast deformity: If there is a shape issue of the breast that concerns you, and your surgeon believes that he/she can correct this surgically, then it may be reasonable to proceed. This can include issues relating to the first implant surgery such as improper pocket creation, improper implant selection, issues due to weight loss or pregnancy/lactation, malposition or displacement of the implant, palpability/rippling/wrinkling or visibility of the implant, ptosis (drooping) of the breast, lower (pole) breast over-stretching or changes in body habitus where your breasts now look too large or small for your frame.
5. Desire to change implant size: I am a firm believer that if you want to have the best breast (best looking, most natural in shape) for the longest period of time with the least probability of requiring a revision, then you need to subscribe to the belief that for every breast, there is a specific ideal implant volume that will result in a properly filled, natural appearing breast. If you have attained that now, but wish to go larger, then you are playing with fire. You will risk overstretching your breasts and creating a whole new set of problems, including the development of uncorrectable deformities. If you do not have the proper size implants for your breasts, then revision to a different size (larger or smaller) may be indicated. Your surgeon is best positioned to make that determination.

Capsule contracture and implant deflation/rupture are the most common reasons for implant revision surgery. Ptosis may require a mastopexy (breast lift) and palpability/rippling/wrinkling or visibility of the implant is usually best managed by replacement of the implants (if they are saline) with silicone implants.

Nationwide, the three year revision rate for breast augmentation surgery is about 25%. Who would want to undergo such surgery if there were 1 in 4 chances that you will need a second surgery to fix something in within the next three years? This is simply too high. In my practice, the revision rate is around 1 – 2%. Almost all of these cases are due to device deflation and capsule contracture.

Short of the above, if you are happy with the way your breasts look and feel, and are having no problems with them, then there is no reason to re-operate on them. I hope that this article helps to dispel some of the rumors that have circulated for years about breast augmentation surgery.

Part III – A comparison of the available systems – one plastic surgeons personal opinion

There are currently two systems available for computerized imaging and simulation of breast augmentation surgery. Portrait 3D manufactured by AxisThree, a company funded by Siemens and started in 2002. AxisThree claims to use technology developed by Siemens in the Portrait 3D product. Other than the Portrait 3D system, I am unaware of any other products that the company produces. The other system, Vectra 3D, is manufactured by Canfield Scientific, a company specializing in medical imaging with a long history of many successful products including imaging software, which has been in existence about twenty or so years. Canfield is known for its work in standardizing medical photography, so that images can be taken with consistent lighting, positioning and exposure parameters. Their systems are well known to the dermatology pharmaceutical industry, which contracts with them to produce imaging systems for various drug studies. Both systems were released very recently in the past year.

Let’s start with the physical capture device itself. They are pictured below:

(Photos of Vectra 3D on the right, Portrait 3D on the left)

The camera system of the Vectra 3D consists of six 12 megapixel cameras arranged into three pods. The pods use mirrors to permit the imaging of subjects from the side without having to have physical extensions to mount the cameras off to the side. The Portrait 3D system has three cameras of 3 megapixels each. The cameras are mounted on extensions out to the side.

The lighting system of the Vectra 3D consists of high powered flash. This permits imaging without the use of additional lighting. The very bright flash emits much more light than the ambient room light, therefore the room light will not affect the exposure and the room lights can be left on during the imaging process. The Portrait 3D uses LED (light emitting diode) technology. On the Portrait 3D, the LED lighting system requires the user to shut off the room lights to prevent interference of the exposure by the room light.
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Part II – How three dimensional imaging is used in my breast augmentation practice

When I see a patient in consultation for breast augmentation, I inquire as to what the patient is looking to achieve. I examine the patient and make recommendations as to what implant I think is best for them. The exact details of how I do this are beyond the scope of this blog, but suffice it to say, I determine what I think is the best implant to fit a particular patient’s tissues. I then have a discussion with the patient about what implant I recommend. The next question is invariably “what will I look like?” I told them that it is very hard for me to answer that question. Due to the nature that the implants conform to the body’s contours, you cannot put an implant in your bra, or a bag of water or rice. In my opinion there really is no way to see how you will look. Maybe you can get a very cursory idea of size, but I caution them that this, too, is highly inaccurate. So it comes down to a matter of trust. The patient just has to trust me that I will take into account the cup size she wishes to be, mindful of the fact that cup size is not a standard volume as “cc’s” are. You don’t buy a container of milk in A, B, C, D, or DD size. You buy a half pint (for your coffee), pint, quart, half gallon or gallon. These all have defined numbers of cc’s in them. For instance, a quart is 948 cc’s. Implants come in cc’s not cup sizes. The actual cup size is the sum total of how much tissue you start with and how many cc’s of implant you add later. The same implant can look very different in three different women.

I have had the opportunity to be the first in Suffolk County, NY to have a computer system capable of three dimensional imaging and surgical simulation. I have since taken the liberty of introducing the system to my breast augmentation patients who have had their surgery performed prior to my having such technology available. I have posed the following question to many of these patients: Prior to your undergoing breast augmentation surgery, did you have any visual image in your mind as to what your surgical result would look like. Having spent a fair amount of time with my patients in consultation prior to surgery, and that included either reviewing photos of similar patients who underwent breast augmentation or having the patients view such patients on my web site, I was very surprised with what they all (and I mean ALL) told me: all of the two dozen or so patients I queried told me that they had absolutely no idea what they were going to look like after surgery. They told me that they just “trusted me”!
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Part I – What three dimensional imaging systems are

I have always enjoyed technology. Since I was a teenager in the early 1970’s, I loved electronics (computing wasn’t even a hobby back then). For my pre-med major in college, I studied Biomedical and Electrical Engineering at Northwestern. It was there that I obtained a strong background in computers and emerging biomedical technologies. During the latter part of my plastic surgical fellowship training, I saw the advantage to know not only how to operate computers and run software programs, but to learn how to develop tem as well. Several of the software applications I developed over ten years ago, are still in use in my practice today.

When I was a surgical resident, I remember visiting a young plastic surgeon that had a computerized imaging system. It consisted of an inexpensive, low resolution video camera, a computer (one of those early PC’s) and a monitor. He took a photo of my face and showed me how the software could change the image. He deftly demonstrated how he could take my nose, remove it from my face and replace it back, this time upside down. Kind of a cool curiosity, but is it worth it? That was about twenty five years ago. Over the years, I have seen a couple of such imaging systems that could take a two dimensional image (two dimensional means a flat image with height and width, but no depth) and manipulate it somewhat. I was pretty unimpressed by what I saw, until recently.

I practice plastic surgery in the same office as dermatologist Dr. Elyse Rafal, who also is my spouse. Dr. Rafal has always been involved in clinical drug trials with various pharmaceutical companies. These studies rely on high quality, consistent, reproducible photographic imaging. Over the thirteen years I know my wife, I cannot remember a single drug study that required imaging that did not have customized photographic equipment developed by Canfield Scientific, in Fairfield, NJ.
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