While doing some grocery shopping tonight (yes, plastic surgeons do grocery shopping – my spouse is a dermatologist so we split the household chores) I saw this month’s Life & Style cover story “Heidi’s New Surgery Disaster.” Being a cosmetic plastic surgeon this naturally piqued my curiosity so I bought the magazine and read it when I got home.

The essence of the article is a story about how Heidi regrets all the surgery she had, about ten or so operations performed at once, at a cost of over $100,000. There is an extensive pictorial showing her multitude of scars, which are portrayed as horrific. I am not writing this blog to defend what was done, but rather to make a few comments on my observations and offer my opinion.

1. No one “needs” cosmetic surgery. Sure, we may see someone with a large hump on their nose and say they “need” to have it fixed, but they really don’t. The purpose of cosmetic surgery, as I see it, is to make a person feel better about the way they look, that is, to make them more comfortable in their own skin. There is other reason to have cosmetic surgery than to make you feel better. Never do it for someone else.

2. Do not let your surgeon “talk” you into having anything done that you are not in agreement with. Heidi discussed having liposuction on her legs, but later expressed remorse that the scars did not justify the results and that her surgeon talked her into it. As her surgeon recently and very unfortunately met a tragic end, we will never know the truth about that.

3. Surgery does not happen without scars. All humans form permanent visible scars when their flesh is wounded. Some scars are less apparent than others. As plastic surgeons, we learn how to plan our incisions, close wounds, perform surgery and handle tissues so as to minimize scarring, but we cannot eliminate it. Some patients will form scars more visible than other patients. As surgeons, we have no control over patients biologic wound healing properties. I inform all of my patients of this fact many times over before surgery is performed.

4. Surgery is stressful. Altering your physical appearance, even for the better is stressful. Combining the two can produce stress as well as emotional ups and downs in the immediate period after surgery. This is all normal, and again, I advise all of my patients about this. I even have a cute little diagram that we give them before surgery to explain this. Some patients undergo two or three procedures in a single sitting. With advances in surgical and anesthetic technique, this is rarely an issue. However, where do you draw the line? I am not sure just what the limit should be, but I do believe that ten procedures at once is probably a bit much.

5. With the exception of Heidi Montag’s breast augmentation, I think that most of her results look good. Maybe not perfect, but plastic surgery is rarely perfect. Let’s face it, our tissues are rarely perfect and the surgeon can only work with what he is given, but that doesn’t mean he can’t still deliver exceptional results. My suspicion is that Heidi was not adequately counseled before her surgery about what to expect in terms of results and scars after the surgery. As far as her breast augmentation, I think that that alone can be the subject of another blog, but suffice it to say that it is ill advised to go from an A or B cup to a G cup. The destruction to the breast tissues is irreversible and uncorrectable. A properly performed augmentation based on the natural characteristics of the breasts yields excellent, natural results with minimal risk of problems, both in the short term as well as the long term.

My advice for those interested in plastic surgery is to not be put off by Heidi’s unusual story. Her story is one of a woman with perhaps unrealistic expectations, a long list of features about her body that she wishes to correct, a surgeon who more than pushed the envelope on what in my humble opinion is reasonable and a lack of appropriate preoperative counseling and preparation.

I recommend those interested in cosmetic surgery to do your research. Spend time on the Internet looking at lots of plastic surgery websites. Learn as much about the procedure that you are interested in. Visit several surgeons. Ask lots of questions. Speak to patients who have had the surgery that you are interested in. IF you personally know people who have undergone the surgery that you wish, visit their doctor as well. An informed patient, as with any other consumer, will in the end be the happiest patient.

To your health & beauty,
Dr. Mark Epstein

In my practice, I find that most consultations for facial aging are driven by a patient’s concern about a particular feature of their face that bothers them. Rarely do they ask me for my opinion as to what is making them look older, nor do they have concerns about large areas. And the fact is, many times what the patient is concerned about is a minor factor in making them look aged or tired, and they are overlooking more significant factors. All the components of the face age simultaneously. Around the eyes, sometimes the uppers or the lowers may look more severely aged than the other. Rarely, however, does the patient appreciate the role played by the brow in the appearance of age in their face.

In order to evaluate the upper eyelids, first you need to assess the brow. If the brow is low, there may be hooding of the brow over the upper eyelid; the patient may think they have an upper eyelid problem. The thing is, you do not want to remove excess brow skin to “tighten the upper eyelid” when the problem is, in fact, the eyebrow. If you do this, then you will just tether the brow down, when if fact it needs to be elevated. I manually elevate the brow to where I think it belongs and then I assess the upper eyelid for excess skin. If there is still excess skin after elevating the brow or fat protruding through the skin, then an upper blepharoplasty is indicated. If the brow doesn’t require elevation, then no browlift is required.

In a consultation for a blepharoplasty in my Stony Point plastic surgery office, the lower eyelid is evaluated independently of the upper eyelid. If there is excess skin, then an external incision just under the lashes is required to remove the excess skin. If there is no excess skin, but there is excess fat protruding through the lower eyelid, then I make an incision just inside the eyelid to approach the fat only. When there are a combination of problems, sometimes I use an approach from both sides. This allows me to preserve the middle muscular layer of the lower eyelid to prevent the development of deformities due to scar contracture later.

I have been asked this question more often than I can count. Patients are afraid that after liposuction, if they gain weight, that they will develop a particular deformity due to all the newly formed fat settling in one particular area. This simply isn’t true.

After adolescence, the number of fat cells in our bodies becomes fixed. The fat cells can increase or decrease in size due to the amount of fat to be stored, however, they will not change in number. (The fat stores in our bodies are the way the majority of our energy reserves are stored.) However, after liposuction, the number of fat cells decreases due to the removal and destruction of fat cells from the procedure. If your diet is in good control, and you are not consuming excess calories, then there should be no change in your fat stores. If, however, you consume more calories than you require, there will be deposition of fat. The question is “where?”

The answer is that the fat will be stored where it otherwise would have been had you not had liposuction. If you are female, the most likely place would be your abdomen (outside of the abdominal cavity), flanks, inner and outer thighs and buttocks. If you are male, then the answer is within your abdominal cavity, flanks and chest. If you underwent liposuction of one of these areas (except within the abdominal cavity which is not accessible by liposuction) then the remaining fat cells in those areas will enlarge as well due to the deposition of fat to the other areas listed here.

The end result if you gain weight after liposuction is that you will look heavier, but more like you would have had you not had liposuction, rather than developing a specific deposit of dreaded fat in one area of the body.

To your health & beauty,
Mark Epstein, MD

Women in their 30’s need the real skinny on whether they should start receiving Botox and fillers, microdermabrasion and laser treatments at a younger age to prevent future wrinkling. Logically, many young women wonder if this might be a bit too early and, hence, a waste of money.

Unfortunately, the clock on the aging process begins upon exit from our mother’s womb. If you look at a baby, they have chubby cheeks with plenty of “baby fat”. There is nothing different about baby fat, it is just fat. That baby fat begins to disappear in the first few years of life. Look at a 5-year-old child; already their face is less full of “baby fat.”

The aging process consists of several components:

• Loss of volume (as just discussed),
• Gravitational descent of facial structures (both skin and fat as well as the deeper contents of the face),
• Skin surface wear and tear and
• Biochemical changes to the skin, such as thinning of the dermis and loss of elasticity.

These changes don’t begin when we hit the milestones of 20, 30, 40 or even 50 years of age. Rather, these changes begin immediately as we begin our lives. So then, the question is, at what age to do what?

There are two approaches: Preventative and Reparative.
Preventative is easy, but you really need your parents to have been proactive. When we are children, the last thing we think about as we go outside and play is to put on our sunscreen. Much of the sun damage that occurs to our skin happens when we are children; too young to know to prevent it. And to those of you who are reading this and have small children, take note. You can protect their skin now.

Ok, so what can you do now? Now it’s time for the reparative activities to repair the damage. Just about everyone has some element of damage to their skin due to sun exposure. It is never too late, nor too early to learn how to protect your skin and use topical agents to repair some of the damage to your skin. A knowledgeable aesthetician can evaluate your skin and make appropriate recommendations. I think that anyone concerned about his of her facial appearance should pursue this. It is easy, painless, not very expensive, and can preserve as much of your appearance in the future as possible. Maybe even undo some of the damage you already have.

Where do Botox and fillers fit in? Botox is a purified protein derivative that relaxes muscle. Although Botox has over 100 medical indications for use, in the face it relaxes the muscles that cause facial lines, hence the lines fade. This happens only for as long as the Botox is working, then the lines come back. Botox lasts about three to four months, so it is advisable to repeat treatments at those intervals to maintain your new look. Fillers, on the other hand, replace lost volume to the face and fill lines that are not due to muscle activity, such as the nasolabial folds, or “smile lines” on your face. Most fillers are temporary, lasting from 4 to 24 months, depending on the particular filler. I personally do not believe in permanent fillers such as silicone as there have been some problems with them, and facial aging continues, so what looks good now, may not look good at all in several years. I think that anyone over 18 years who has concerns about facial lines that would be improved with Botox and/or fillers, or wishes to enhance the fullness of their lips should give consideration to using Botox/fillers.

There are many other non-surgical treatments for facial aging of varying efficacies. It is beyond the purpose of this blog to evaluate each one, but this group includes chemical peels (of which there are several types), microdermabrasion, and radiofrequency treatments. I do not believe that there are any age minimums here either, so if you are over 18, I think that these can be considered. The main thing is to find a knowledgeable plastic surgeon or dermatologist to consult.

There are many different types of laser treatments. Laser treatments and chemical peels are essentially facial resurfacing treatments. By removing the outer layer of the skin, the skin will re-heal by generating a new outer layer. Different peels and laser treatments ablate (remove) the skin to different depths. The deeper you remove the outer layer of skin, the more rejuvenation you get, but there is more downtime and potential for scarring. Young women (and men!) with minimal sun damage can benefit from light peels even while still in their early twenties. As you age, and as there is more damage to the skin from the sun (and there is also a strong genetic and environmental component) deeper peels and lasers may be required. Again, this is best discussed with your dermatologist or plastic surgeon.

The next issue is surgery. The purpose of surgery is to remove excess skin, elevate and re-position structures that have fallen due to gravity and to improve on issues that may have existed even before noticeable aging. Surgical procedures include facelift (rhytidectomy), eyelift (blepharoplasty), browlift, nasal surgery (rhinoplasty) and liposuction (usually the neck and jowls). Most all surgical procedures can be repeated as the aging process continues.

When deciding if it is too early to think about surgery, I would suggest putting aside your age and just look at the deformity. If your plastic surgeon feels that a substantial improvement can be had with the procedure, then it might be worth proceeding, even if your chronological age may be earlier than you would think would be appropriate for the given procedure. For instance, I have several patients who have consulted me for facelift and eyelid surgery even though they had the surgery 10 or 15 years earlier. The previous surgery is in no way a hindrance to the performance of a quality surgery once again.

The bottom line is to use the technologies at our disposal to maintain your youthful look as long as possible. Each of us ages in our own way. For some, Botox and fillers at 24 is a normal and correct choice. For others with a different set of genes and different habits with the sun, alcohol and tobacco, they may not need this until they are 40. The mirror will give you clues and your board-certified plastic surgeon can help you make the right decisions.

To your health & beauty,
Dr. Mark Epstein

Occasionally, during a breast augmentation consultation with me in our Stony Brook plastic surgery practice, a woman expresses concerns about her ability to breastfeed later on, should she wish to do so. With so many women committed to breastfeeding their infants, I want to be certain you have the facts about breast enhancements and future nursing.

Successful breastfeeding, with or without implants, is based on the ability of the breast to create milk, the ducts to carry that milk to the nipple and, lastly, the nipple to release milk to the child. That said, my personal belief is that there is potentially (although not necessarily) more risk of interference with the ducts that carry the milk from the breast gland to the nipple with a nipple incision, areolar revision, etc., than with breast implants. As I personally prefer placing the implant under the muscle, interference with breastfeeding has not been a concern at all for my patients. I cannot think of a single instance in my career when a woman told me after breast augmentation surgery that she was no longer able to breast feed, whereas she had successfully done so prior to surgery. Even in patients who have had placement of the implant above the muscle, theoretically there should be no interference with the ability of the milk to pass from deep within the breast through the ducts to the nipples.

However, in my experience with women coming in for breast reduction, I’ve seen women who said they had been unable to breast feed. Whether this is size related is unknown, but this was not due to an implant.

If you have questions about breast enhancements, be sure to call our office for information.

To your health and beauty,
Dr. Mark Epstein

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^®.

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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