Laser liposuction: the Emperor's New Clothes?

Just this week, the American Society for Aesthetic Plasic Surgery (ASAPS) put on an educational webinar for Plastic Surgeons, talking about various recent advances in liposuction. A variety of devices, including Power-assisted Liposuction, VASER, and SmartLipo and the related laser-assisted liposuction devices were reviewed and discussed by the experts.

All of these were compared against the traditional "gold standard" liposuction method of tumescent liposuction, which has been proven to be safe and effective in many published studies. (This is where a thin tube, called a cannula, is hooked to a vacuum, and is used to suction out fat that has been previously injected with a good volume of medication-containing fluid.)

Here are the results:

Power-assisted Liposuction (PAL) got the "thumbs-up" from the panel, as good scientific trials showed that it was as effective as tumescent liposuction, and less fatiguing for the surgeon.

VASER, the latest form of ultrasonic liposuction, was also well received. The panelists liked it for secondary liposuction (i.e. touch-ups) and areas of the body that are fibrous. Some surgeons used it as their primary liposuction tool. Good scientific data was presented to show that this is effective, and safe, as long as the ultrasonic energy applied is not excessive.

Laser-assisted liposuction, such as SmartLipo or CoolLipo, received a veritable beating during the discussions by the experts. Marketing claims by the manufacturers, such as "less invasive", "safer", "more skin tightening", "quicker recovery" and "better results" were each individually addressed and debunked, until not a single one of these claims was left standing. (Cue sound effects: Wham! Biff! Pow!!) Higher laser power machines actually increased the percentages of patients with complications from skin burns.

Essentially, we learned that there was no good scientific proof for any of the laser lipo claims. While these laser lipo machines do remove fat, here's the key point - they haven't been shown to do it any better than the other liposuction devices we already have. And there's been little to no convincing evidence of significant skin tightening in any reputable journal in a double-blinded comparison.

The more honest surgeons in the panel agreed: you can get the same results with any of the current technologies, without spending big bucks for the laser system.

In other words - It's not the hammer, it's the carpenter using it.

A skilled, experienced surgeon will get good liposuction results by using good patient selection and appropriate technique. Other than the questionable marketing to technology-obsessed patients who demand the "latest", there appears to be no additional merit to the laser liposuction methods.

I realize that it may seem hard to believe for those that like to think that the latest laser gadget must be the best. It's a bit of the old story of the "Emperor's New Clothes". Laser liposuction, no matter what smart name you call it, has not been proven to be better than standard liposuction in any controlled scientific trials after several years on the market....and if it were really as marvellous as everyone claimed, we would have had plenty of scientific proof by now.

New study: First generation SmartLipo no better than traditional lipo

Here's an eye-opening study published in the recent issue of Lasers in Surgery and Medicine, comparing the efficacy of laser-assisted lipolysis using various fat-busting lasers, including the first generation SmartLipo and CoolLipo machines (10 watts power). The authors are respected laser experts from La Jolla, California.

Liposuction of the arm was performed, using tumescent technique, with one of three fat removal devices, and the results were evaluated at 1 week, 1 month, and 3 months post-operatively.

In the first comparison between SmartLipo and standard non-laser liposuction, no significant improvement of results over tumescent liposculpture alone was noted using the 10 W Smart Lipo laser.

The second study showed no difference using the 10 W SmartLipo device versus the 10 W CoolLipo laser-assisted lipolysis system.

Finally, the multiplex (combination) 1,064/1,320 nm system appeared to show improvement in skin laxity and fat reduction. However, more complications were seen, with intra-operative thermal burns in 2 of 20 patients using the multiplex system.

Comment: Of course, the laser manufacturers now have increased the power of the laser lipo machines. While this may melt fat more effectively, it also increases the potential for thermal injury. We'll have to see whether the newer, more powerful machines can be actually proven to show a significant difference over standard non-laser liposuction in an objective study. It's great to finally see some science looking at this.

I feel bad for the physicians that spent a lot of money on the first generation (10 watt) machines - they got conned by the lure of new "laser" technology and didn't wait for the scientific proof.

Smart lipo: does it tighten the skin?

Sometimes marketing hype gets way ahead of the science.

That's certainly the way it seems to have been with the current generation of laser-assisted liposuction devices. Promises of skin tightening have been made by most of the manufacturers of these devices (SmartLipo and others) - with very little science to back up the claims.

I keep seeing unhappy laser-assisted liposuction patients (performed elsewhere) for second opinions. While they may be thinner, the treated areas are lax and have a worsening of the cellulite appearance, with a wavy, irregular appearance. Is this an issue related to the technology itself, the user of the technology, or is it one of patient selection? Regardless of cause, for these patients, the "reality" of Smart Lipo just didn't match their expectations.

Finally, in this month's issue of Aesthetic Surgery Journal, is the first scrap of science looking at whether this technology actually causes skin contraction. That's the good news. The bad news is that, in my opinion, the study design is somewhat flawed, so that this new study doesn't really answer the question about which method is best.

Here's what was done: Skin-marking tattoos were used to mark out 5 cm squares on the tummies of some volunteers, who then underwent treatment with the SmartLipo MPX laser-assisted liposuction device. The lasered fat was then aspirated out with a standard liposuction cannula. Digital photography was then used at 1 and 3 months postoperatively to check the degree of skin shrinkage.

The shrinkage of the 5 x 5 cm area was reported as 22% at one month, and 17% at three months, versus the baseline measurements. In plain english, a 17% reduction in area means that the square that started at 5 cm on a side went down to 4.56 cm on a side, a change of about two-tenths of an inch on each side of the square. While this change was reported as statistically significant, it isn't clinically very impressive at all.

Additionally, the study didn't compare the effects of standard liposuction (without laser) to the laser-treated areas. Some or all of this 17% change might just be a result of the skin's natural elasticity - an expected shrinkage once the fat was removed. So, we still don't really know the most important point - whether this is an improvement over standard liposuction, or not.

Bottom line: Finally! Some science on Smart Lipo. It's about time!

In my opinion, the 17% reported reduction in area at three months post-op is not particularly impressive. This degree of contraction is minimal, at best.

Problems with laser-liposuction: who's the Smart one now?

Over the last few months, I have seen an alarming increase in the number of patients that come in for a second opinion about poorly-performed liposuction (done elsewhere, I might add.) All of these casse have been performed with new high-tech liposuction machines, either laser-assisted (like the SmartLipo) or ultrasonic (like the VASER).

I've seen major skin laxity, uneven liposuction, and obvious over-resection of fat leaving major divots and dents. Many of these problems are very difficult to fix, even with fat grafting techniques.

Here's a few observations:

1. All of these cases were performed by physicians and surgeons operating way outside of their specialty. They were not done by plastic surgeons or dermatologists, who are trained during residency in this technique.

2. In the majority of these patients, physical examination of the patient revealed crummy skin tone and poorly elasticized skin. In other words, since this skin won't contract like we want it to after liposuction, it's completely predictable that the post-op results will be poor, with floppy, deflated areas, and a worsened appearance. A surgeon with any significant training or experience in liposuction would have recognized this - and would have avoided performing liposuction in these patients. It's the wrong tool for the job!

3. All of these patients were preoperatively told by their physicians, "This new wonder lipo machine will tighten your skin".

4. All of these patients now say, "Skin tightening clearly did not happen...now I look worse."

5. None of these patients have an easy fix for their issues. All will require complex and expensive revisional surgery.

Lessons:

A fancy hammer does not a good carpenter make. Any doctor can buy (or rent) a fancy lipo machine.

There is, as yet, no reliable scientific evidence that laser-assisted liposuction:
a) tightens the skin, or
b) works better than standard liposuction.
Any claims to the contrary are "spin" or marketing hype; consider the source and what they're selling.

That being said, the problems seen here were not caused by the type of liposuction machine - but by the doofus using it! While the concept of liposuction is easy, getting excellent results with liposuction takes significant skill.

Please be careful about whom you choose to perform your liposuction. Even if it's performed in an office setting, with local anesthesia, liposuction surgery is still SURGERY. Training, experience and credentials matter.