The liposhaver has an inner and outer cannula. Light suction draws fat into the lateral port, where the rapidly oscillating inner cannula resects a small amount of tissue at a time.
Preoperative and 6-month postoperative views of a patient who underwent liposhaving as an isolated procedure. Neither platysmaplasty nor skin excision was performed.
Becker DG, Cook TA, Wang TD, Park SS, Kreit JD, Tardy ME, Gross CW. A 3-Year Multi-institutional Experience With the Liposhaver. Arch Facial Plast Surg. 1999;1(3):171-176. doi:
From the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, University of Pennsylvania Medical Center, Philadelphia (Dr Becker); the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, Oregon Health Sciences University, Portland (Drs Cook, Wang, and Kreit); the Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, University of Virginia Medical Center, Charlottesville (Drs Park and Gross); and the Tardy Facial Plastic Surgery Institute, Chicago, Ill (Dr Tardy).
Objective To report a 3-year multi-institutional clinical experience with the liposhaver in facial plastic surgery.
Design Nonrandomized, nonblinded, multi-institutional evaluation of the liposhaver in a clinical setting.
Interventions Seventy-two patients who presented for facial plastic surgical procedures underwent surgery with the liposhaver. Seventy-six liposhaving procedures and 74 concomitant procedures were performed. Standardized preoperative and postoperative photographs were obtained.
Outcome Measure Subjective evaluation by the surgeons who performed the procedures.
Results The liposhaver was used successfully in all cases. The fat was cleanly shaved and the contour results were even, without dimpling or significant asymmetry. Operative time was comparable to that of conventional liposuction. There were no cases of facial nerve injury and no evidence of increased bleeding intraoperatively. Two male patients had small postoperative hematomas in the immediate postoperative period that were successfully treated with conservative measures. An additional patient developed a small hematoma on postoperative day 5 that was effectively treated with needle aspiration and a pressure dressing.
Conclusion This 3-year multi-institutional report suggests that the liposhaver continues to offer a precise alternative to conventional liposuction.
LIPOSHAVING may be most appropriately described as the application of advanced technology to direct lipectomy. While time-tested, direct lipectomy with scissors is felt by many surgeons to be somewhat tedious. In contrast, the liposhaving cannula (Figure 1) draws fat (via light suction) into its lateral port, where its rapidly oscillating inner cannula resects a small amount of tissue at a time. This allows direct visualization and an anatomical approach, during which the surgeon can perform submental lipectomy efficaciously and in a precisely controlled manner.
Liposhaver technology has been available for medical use for many years. The original vacuum rotary dissector received its earliest, albeit limited use in the early 1970s for morselizing tissue associated with acoustic neuroma.1-3 Subsequently, soft-tissue shavers were used extensively in orthopedic surgery4 for delicate arthroscopic soft-tissue joint work and more recently in otolaryngology for endonasal polypectomy, functional endoscopic sinus surgery, and other applications.
Gross et al5 reported their preliminary experience in 1995; in 1996, Becker et al6 published a multi-institutional review of liposhaver use. These authors concluded that the precision and direct visualization afforded by direct lipectomy with the liposhaver offer advantages over liposuction. In conventional liposuction, the surgeon typically relies on palpation to ensure thorough and symmetrical removal of fat; however, the vigorous back-and-forth motion of conventional liposuction creates significant temporary soft-tissue trauma with consequent intraoperative edema.
In contrast, liposhaving does not rely on the avulsion technique; therefore, significantly less intraoperative edema results from its use. Furthermore, direct visualization during liposhaving assures even and thorough removal of fat. In this report, we describe an extended experience with the liposhaver.
This clinical trial was undertaken at the Oregon Health Sciences University, Portland (T.A.C., T.D.W., and J.D.K.), the University of Pennsylvania, Philadelphia (D.G.B.), the University of Virginia Medical Center, Charlottesville (C.W.G. and S.S.P.), and the Tardy Facial Plastic Surgery Institute, Chicago, Ill (M.E.T.). Nonrandomized, nonblinded evaluation of the liposhaver in a clinical setting was undertaken in patients presenting for cosmetic facial liposuction, including submental lipectomy and the need for fat removal beneath the face-lift flap. Subjective evaluation of efficacy, precision, operative time, bleeding, edema, adjacent tissue trauma, and other parameters was done by the surgeons who performed the procedures. The surgeons at each institution documented their impressions and the anatomical site where the liposhaver was used and noted whether there was any clogging, complications, or injury to muscle, skin, or other adjacent tissue. Comments on the degree and duration of postoperative bruising were also recorded. Standardized preoperative and postoperative photographs were obtained.
The technique of liposhaving is fairly uniform. Each patient is premarked in an upright position. The procedure is performed with the patient under local anesthesia or local anesthesia with sedation, unless concomitant procedures require general anesthesia.
A flap is elevated in the subcutaneous plane with sharp and scissor dissection through a 1.5- to 2-cm incision in the submental crease, leaving a thin layer of subcutaneous fat on the flap. When concomitant face-lift is performed, some surgeons (eg, T.A.C. and T.D.W.) elevate via the preauricular incision as well. The cervicofacial flap extends from the hyoid medially to just posterior and above the angle of the mandible laterally in the subcutaneous plane.
Under direct vision, the submental and submandibular fat superficial to the platysma muscle is assessed and then resected using a soft-tissue shaver (Linvatec Corp, Largo, Fla, or Xomed Surgical Products, Jacksonville, Fla). A 3.5- or 4.2-mm cannula is typically used, depending on the surgeon's preference. The blade oscillates from 900 to 1500 rpm, again depending on the surgeon's preference. The cannula port is generally directed away from the dermis/undersurface of the skin as liposhaving proceeds. A light touch is essential to avoid damage to deep structures; a scraping action is not necessary and not advisable. Liposhaving of the entire cervical region is achieved. When indicated, the submental fat pad between the anterior borders of the platysma can be contoured as well. If the borders of the platysma muscle are lax and stringy, submental lipectomy may unveil this deformity, which may be hidden preoperatively by fat; this will require concomitant suture plication of the bands for maximal improvement.
During liposhaving, attention is directed to feathering the margins of the treatment area. Some surgeons (eg, T.A.C., T.D.W., and C.W.G.) liposhave these margins, including the area just superior to the mandibular margin, while other surgeons feather over the submandibular margin with a conventional liposuction cannula (eg, M.E.T.) or with the liposhaver in the power-off mode (eg, D.G.B. and S.S.P.); that is, as a conventional liposuction cannula. In all cases, a thin layer of fat superficial to the platysma is preserved over the mandibular border.
The liposhaver can cut muscle even when using a light touch. This may result in intraoperative bleeding that can be treated with point cautery. Liposhaving is essentially performed superficial to the mimetic musculature, which minimizes danger to the facial nerve branches. By not using the liposhaver in the power-on mode over the angle of the mandible, the risk of damaging the facial nerve may be decreased.
In conventional liposuction, it is usually necessary to excise fat that is just lateral to the incision for a smoother contour; this is accomplished precisely and efficiently with the liposhaver. Once liposhaving is complete, hemostasis is achieved with monopolar cautery. A chin implant may be inserted at this time, as indicated. The wound is then closed with a standard 2-layer closure. Drains are not routinely used. A conforming cervicofacial dressing is applied for 24 hours and is then removed and reapplied for an additional 48 hours.
Some differences in technique among surgeons are notable. One surgeon (D.G.B.) elevates in the subcutaneous plane and excises the readily accessible fat with forceps and scissors while an assistant retracts with a malleable retractor. Fat that is located more distally beneath the flap and less accessible to this approach is then readily removed with the liposhaver. The liposhaver is not used in the power-on mode over the angle of the mandible.
Another surgeon (T.D.W.) approaches submental lipectomy by elevating a thick flap in the submental region in a plane immediately superficial to the platysma muscle. A fiberoptic, lighted retractor is used to assist him. The fat that is elevated with the skin flap is then contoured under direct visualization with the 4.0-mm cannula. Suction is adjusted so that the fat is pulled gently into the cannula port. Thus, in this surgeon's approach, the cannula port is directed toward the dermis. Using great care, a layer of fat is left on the skin flap to maintain a desirable flap thickness and to avoid skin injury. A criss-cross pattern is followed until the desired amount of fat has been removed.
Once flap elevation is complete, excessive localized fat deposits may be encountered beneath the face-lift flap. The 3.5-mm liposhaver is used in the oscillate mode to extract and contour any excess fat under direct visualization. Liposhaving maneuvers are confined to fat accumulations that are superficial to the platysma-superficial musculoaponeurotic system complex.
From August 1994 through May 1998, 72 patients underwent liposhaving procedures (Table 1). Sixteen patients underwent surgery at the University of Virginia Medical Center, 42 patients at the Oregon Health Sciences University, and 5 at the Tardy Facial Plastic Surgery Institute. From January 1998 through May 1998, 9 patients underwent liposhaving at the University of Pennsylvania. Sixteen of the 72 patients were men. Isolated liposhaving procedures were performed on 22 patients in this series; the remainder of these patients underwent 1 or more concomitant procedures (Table 2).
The liposhaver was used successfully in all cases. All patients achieved the anticipated contour and profile result (Figure 2 and Figure 3). The fat was cleanly shaved and the contour results were even, without dimpling or significant asymmetry. Operative time was comparable with that required for conventional liposuction. No facial nerve injury occurred. While there was no significant difference in bleeding intraoperatively, the surgeons noted that the liposhaver occasionally cut muscle, even when using a light touch. This resulted in some intraoperative bleeding that was treated with point cautery.
Two small hematomas occurred in the early postoperative period in 2 male patients who underwent concomitant procedures (septoplasty with uvulopalatoplasty in one, chin implantation in the other); both patients were successfully treated with needle aspiration and the placement of a light pressure dressing. A third, female patient underwent liposhaving as an isolated procedure and developed a hematoma on postoperative day 5; this was effectively treated with needle aspiration and a pressure dressing. In the early stage of our experience, a small, superficial laceration of the skin also occurred and was treated, with no adverse result. No further skin lacerations occurred (Table 3).
The uniform impression of the participating surgeons was that the liposhaver enabled them to perform precise, minimally traumatic, and efficient lipectomies. All surgeons felt that postoperative bruising was unchanged or improved compared with typical results.
The advantages of using the liposhaver include the precise removal of fat in a minimally traumatic manner and the ability to remove fat in an open fashion under direct visualization without high suction pressures or the need for a closed system.5-7 While the vigorous back-and-forth motion of conventional liposuction procedures can cause significant temporary soft-tissue trauma with consequent intraoperative edema, liposhaving does not rely on the avulsion technique, and therefore significantly less intraoperative edema results.
The disadvantages of using the liposhaver include the potential susceptibility of vital nerves and vessels to injury by the oscillating cutting blade of the inner cannula. In the head and neck region, the facial nerve branches (the marginal mandibular branch, in particular) and the posterior facial vein are the principal structures at risk. When used in the power-on mode, the liposhaver poses a potential hazard to these vital nerves or vessels in the head and neck. The liposhaver can cut muscle and cause bleeding and damage to other soft tissues. When using the liposhaver in the power-on mode, direct visualization remains the most reliable method to avoid cutting soft tissue. However, when the liposhaver is used in the power-off mode, the subcutaneous fat may be extracted without significant bleeding and without damage to the platysma or the underlying structures. In the power-off mode, the inner cannula can be easily positioned manually so that the blades are recessed and nonpalpable; alternatively, the liposhaver can be used in the closed position, which allows it to operate as a simple probe. When operated in the power-off mode and with the inner blades recessed, the liposhaver is essentially identical to a conventional liposuction device; this allows it to be used in the submandibular area with no increased risk compared with other conventional liposuction devices.5-7
As with conventional liposuction, we recommend that the liposhaver port be directed away from the dermis to avoid the risk of skin injury. Nevertheless, one surgeon (T.D.W) directs the cannula port toward the dermis. This surgeon prefers to elevate the fat with the skin flap and then excises the fat from the flap. As we have pointed out, this surgeon takes great care to retain a layer of fat on the skin flap and feels that this approach is safe. Other surgeons undertaking this approach must recognize the risk of skin injury and must undertake appropriate precautions.
Cost is also a potential disadvantage to liposhaving. The power console is generally available in the same operative settings in which orthopedic arthroscopic surgery (Linvatec Corp) and/or endoscopic sinus surgery (Linvatec Corp and Xomed Surgical Products) is performed. The only additional cost is the individual disposable cannula (<$100 per cannula). However, if the surgeon must purchase the power console, the cost may be prohibitive.
The size of the cannula and the oscillation speed may be selected by the surgeon based on personal preference and experience. While conventional liposuction relies on a rigorous and rapid back-and-forth motion, the liposhaver is properly used in an open approach under direct visualization with a slower back-and-forth motion and a light touch.
Conventional liposuction is time-tested and remains the most widely used approach for the removal of fat. However, liposuction is often inadequate for the optimal removal of septated adipose tissue in the upper midline of the neck between the 2 anterior borders of the platysma muscle. Many surgeons currently augment blunt liposuction in this area with direct excision of adipose tissue. We have found the liposhaver to be particularly helpful in this area.
While advanced powered instruments have been used widely for soft-tissue resection in arthroscopic surgery, endoscopic sinus surgery, and other areas for some time, their introduction to plastic surgery has been more recent. Perhaps as a consequence, the extent of their use in plastic surgery has been limited.
We report extended multi-institutional experience with the liposhaver in facial plastic surgery. Submental adipose tissue lends itself well to the shaving action of this instrument. In selected cases, improved soft-tissue sculpting results when the liposhaver is used beneath the face-lift flap under direct visualization.
We did not undertake a quantitative, objective comparison with traditional liposuction, nor were written patient evaluations of surgical outcome obtained. While the patients in this report were generally pleased, patients who undergo conventional liposuction are also generally satisfied. Our impression was that patient satisfaction was good and comparable for both approaches.
In conventional liposuction, the surgeon typically relies on palpation to ensure thorough and symmetrical removal of fat; however, the vigorous back-and-forth motion used during conventional liposuction creates significant temporary soft-tissue trauma with consequent intraoperative edema that may hinder accurate assessment. We believe that liposhaving represents an application of advanced technology to direct lipectomy that provides surgeons with the tool to perform a procedure under direct visualization with minimal resultant trauma, allowing for increased precision and decreased risk of remnant asymmetric fat deposits.
We noted slight postoperative asymmetries in some patients. It is possible that remnant asymmetric fat deposits may have been left in these cases despite direct visualization. In addition, some postoperative asymmetry may be caused not by asymmetric fat deposits, but rather by other factors related to skin contracture and redraping.
We continue to use the liposhaver for direct lipectomy and continue to feel that it provides advantages. Because it requires low suction pressures and does not rely on a potentially bruising, vigorous back-and-forth motion for fat extraction, liposhaving offers an alternative to current techniques used for liposuction and lipectomy.
Accepted for publication May 25, 1999.
Corresponding author: Daniel G. Becker, MD, Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, University of Pennsylvania Medical Center, Philadelphia, PA 19104 (e-mail: firstname.lastname@example.org).