INTRODUCTION
Massive weight loss (MWL) patients are special
aesthetic group that need prudent decision for
surgical intervention. They have variable degrees
of skin redundancy and residual fat that in common
leave external weaving and disfigurement. The
will known procedures for removing redundant
skin-excess fat complex is surgical excision [17].
These excisional procedures always leave much
scars affecting different areas of the body, replacing
the stigmata of skin redundancy by stigmata of
scars. This render some patient to avoid exposure
to such excisional procedures, some others may
have limited excisional procedures.
Laser liposuction and skin tightening (LALST)
is now a commonly used modality for removal
of unwanted fat and moreover skin reduction. Since
its FDA approved in 2006, studies [7,8,11] have
continued to support early clinical observations of
decreased adiposity, shorter recovery times, and
improved skin shrinkage. The laser lipolysis mechanism
of action is liquefaction of fat, coagulation
of small blood vessels, increased fibroblast numbers,
and stimulation of new collagen formation
with subsequent skin tightening and augmentation
of tissue elasticity.
Radiofrequency and cryolipolysis are additional
modalities supporting lipolysis and collagenesis
externally [13,14,17]. However, these devices are
still short of efficacy and internal application of
laser energy still the most effective method of
reducing subcutaneous fat and enhancing skin
tightening. In this work a retrospective analysis of
the author’s treated post MWL patients. The aim
of this retrospective analysis is to check how much
the introduction of LAL-ST technique in his work
affects the incidence of invasive excisional procedures
in such group of patients.
PATIENTS AND METHODS
The study was classified into 2 groups. They
were before and after LAL was introduced in the
author’s practice. Data analysis of 1235 procedures
over 537 post MWL patients representing the 2
groups (194 and 343 patients in 1st and 2nd groups
respectively) was undertaken. The follow-up period
ranged from 5 months-2 years. In the first group,
89 patients had MWL after bariatric surgery
(45.9%) and the rest 105 lost weight exclusively
through diet and exercise (54.1%). In the second
group,102 patients lost weight through bariatric
intervention (29.7%) and the rest 241 lost weight
through diet and exercise (70.3%).
RESULTS
There was no significant difference in the age,
weight, and regional skin redundancy and subcutaneous
fat thickness in the baseline between two
groups (p<0.05).
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Data analysis revealed that, the number of
MWL patients presented for body contouring increased
after the author introduced LAL in his
work, A reversal in number of patients that had
loss of weight through bariatric surgery and number
of patients who lost weight through diet and exercise
between 1st and 2nd groups (112/82:136/207),
It was noticed that the second group of patients
desired to do multiple procedures than the first
group patients n: 276 (1.4) versus n: 959 (2.9).
There was unnoticed difference in number of procedures
between patients that have post bariatric
MWL and patients that have MWL through diet
and exercise in either group (1.6: 2.3 versus 2.8:
4.3). The number of excisional procedures were
decreased in the second group (33% vs 77.5%).
The overall patients' satisfaction showed variable
results with (81%) of second group being very
satisfied in contrast to (55.5%) in first group. The
number of non-bariatric MWL patients in the second
group was higher in comparison to the first
group (73.8% Vs 55.6%). Improvement in skin
appearance was more higher in the 1st than 2nd
group (79.3% Vs 72.2%).
Case (1) (Group 2): Female patient 35 years old with post bariatric MWL. She has massive fat involution with moderate
soft tissue sagging and external surface irregularities with disproportionate weight loss between her upper and lower body. She
was exposed to 2 sessions of LAL-ST for contouring of her thighs, buttocks, and saddle bag areas. Fig. (A) shows the patient
before starting the first session with marking of the target areas. Figs. (B,C) shows the same patient before starting the second
session of LAL with much skin reduction and fat involution.
(A) (B) (C)
Egypt, J. Plast. Reconstr. Surg., July 2018 319
Case (2) (Group 2): Female patient 29 years old with post MWL through exercise and diet control. Figs. (A,B) shows
massive axillary soft tissue laxity and back rolls redundancy. Single session of LAL-ST was done. Fig. (C) shows marked
reduction of redundant skin and subcutaneous soft tissue involution.
Case (3) (Group 2): Female patient 43 years old with Non-bariatric MWL. Figs. (A,B) showed that the patient had pendulous
abdomen, bilateral arm ptosis, antero-medial thigh lipodystrophy, skin laxity, and cellulite, and lastly submental soft tissue
laxity. Her abdominal problem was addressed through excisional surgery. The wrist of soft tissue laxity in arms, submental,
and thigh regions was managed by LAL. Figs. (C,D) show the result 3 months after surgery with much improvement of the
operated areas. She got much reduction of soft tissue laxity in arms, submental, and thigh regions. She had minor residual upper
abdominal subcutaneous soft tissue excess that was managed by radiofrequency.
(A) (B) (C)
(A) (B)
(C) (D)
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Case (4) (Group 1): Female patient 32 years old with post bariatric MWL. Fig. (A) shows bilateral high grade arm ptosis
and breast ptosis. The patient preferred to address her arm ptosis in this stage. Bilateral brachioplasty through excisional surgery
was done. Figs. (B,C) shows post operative results 3 months after surgery.
(A)
(B) (C)
Case (5) (Group 1): Male patient 29 years old with post bariatric MWL with subsequent massive soft tissue laxity affecting
his breast, abdomen, back, and anteromedial thigh. He was exposed to 3 sessions of excisional surgery. The 1st session was
belt lipectomy, the 2nd was upper body lift, and the 3rd was antero-medial suction assisted thigh lift plus some previous scars
revisional surgery. Fig. (A) shows the patient in the 1st sessions. Fig. (B) shows the patient in the 3rd session with marking of
suction assisted thigh lift and multiple scar revisions of previous excisional procedures. Figs. (C,D) shows the final result after
the 3 sessions with multiple diverse scars that affect different areas of his body.
(A) (B) (C) (D)
DISCUSSION
After FDA approved the first laser lipolysis
device in 2006, rapid influx of many devices with
different wavelengths (924, 968, 980,1064, 1319,
1320, 1344, and 1440nm) were designated and
used for lipolysis and skin tightening [16,5,15,6,19].
Although different wavelengths were suggested
however studies proved that heat, rather than a
particular wavelength, led to lipolysis and tightening
of the skin. On the counter side and according
to some authors [4], the 1320nm wavelength demonstrates
greater fat absorption with less tissue
penetration and scatter and therefore, may be safer
for treatment around more fragile areas, such as
the neck, inner thighs, and arms. In the current
Egypt, J. Plast. Reconstr. Surg., July 2018 321
study A 1320nm wave length laser was used (Cool-
Touch Company, Roseville, California, USA). It
proved its efficacy especially in chin, arms, back,
and inner thigh.
According to Mordon's [12] mathematical analysis
and other additional thermoregulatory studies
[10], internal temperature between 48-50ºC must
be achieved for collagen denaturation and skin
tightening and external temperatures between 38
and 41ºC were identified as safe. Laser companies
usually provide hand held or implanted sensors for
measuring the external temperature [5,7], however
the author never faced this problem. Just avoid
long time exposure of subdermis for laser temperature.
Fast recovery, diminished postoperative pain,
ecchymoses and edema are superior benefits for
laser LAL over conventional ones [7,8,11]. Coagulation
of blood and lymphatic vessels, aspiration
of laser liquefied fat through small cannula size
(~1mm) with subsequent less trauma may explain
these benefits.
Beyond and above fat lipolysis, skin tightening
effect and consequent skin reduction are perhaps
the most significant advantage of laser lipolysis
[1]. This last advantage is of paramount importance
to improve redundant skin in massive weight loss
patients. The author used LAL-ST modality in post
massive weight loss patients. From analysis of data
it was found that., much reduction of the incidence
of excisional surgical procedures was noticed, and
early post operative variable skin reduction was
achieved. However, patients should remember that
skin tightening continues to improve several months
after laser lipolysis due to the delayed nature of
neocollagenesis. Of utmost importance is to know
that achievement of skin tightening equal to excisional
surgery is non sense and patients should
have clear explanation and should be consented
for that. Better achievement may need extra session
of laser skin tightening. It is essential to manage
patient expectations that should be based on understanding
that the skin tightening effect depend
on several variables, including age, genetics, and
skin condition from environmental factors, such
as smoking and sun exposure. The ideal candidate
for laser lipolysis is a patient who is thin, in good
health, and presents with isolated pockets of removable
fat [17]. In our series it was noticed that
candidates with much fat were less likely to note
dramatic results from single session. Evaluating
the quality of the skin tone is essential in laser
lipolysis. Although laser lipolysis can improve
skin tone, however, it may not be able to create a
completely smoothened appearance especially in
exaggerated skin laxity.
The primary indication for laser lipolysis is
removal of unwanted localized fat and modest skin
tightening and reduction [17], also in patients with
external irregularities or uneven areas after a previous
liposuction or other surgical procedures,
such as abdominoplasty (Fig. 3C) [5]. Surgeons
are now combining procedures, such as fractional
laser or radiofrequency devices, with laser lipolysis
to create a synergistic effect of skin tightening
[9.17]. Radiofrequency was used routinely in our
cases postoperatively and improved the final results.
Beyond the standard liposuction, LAL-ST may
play a unique role in certain locations: (1) Fibrous
areas, such as the male breast, hips, arms, inner
thigh, and back rolls (Figs. 2A,B). The smaller
cannula size used for lipolysis may facilitate fat
melting in fibrous locations without the additional
trauma experienced with larger sized cannulas of
standard liposuction, (2) It is ideal in revision
surgeries where small areas of adiposity may not
have been completely removed via previous lipoplasty
or other body contouring procedures, (3)
Lipoma removal [18], (4) Combining modalities
such as combining fractional carbon dioxide laser
resurfacing and laser lipolysis of the submental
region to enhance neocollagenesis and skin tightening
internally as well as externally [18], (5)
Cellulite reduction using laser lipolysis have been
documented [15]. The author used to do superficial
liposuction with small cannula and low voltage
laser skin tightening with the aim to improve
cellulite in some patients. Much improvement was
noted in a single stage procedure and some patients
required extra-refinment stage.
Patients frequently present for body contouring
after MWL resulting from bariatric procedures or
diet and exercise. Results here showed that the
number of non-bariatric patients that were exposed
to LAL-ST are more in comparison to post-bariatric
group. This may be related to certain reasons. AThe
non-bariatric patients prefer non invasive
procedures from the start, B- They are highly
motivated patients than post-bariatric group, CPost-
bariatric group have much skin sagging that
is more candidate for excisional and lifting surgery
than non-bariatric.
The disadvantages of laser lipolysis are possible
localized infection, it is time consuming procedure,
the cost of equipment is very high, and also reported
skin burn and nerve damage due to thermolytic
effect [7,11]. In the author's experience, the actual
complications have been rare. Future considerations
will include more precise laser and light devices,
improved technology, and a reduced side effect
profile. For laser lipolysis specifically, treatments
will be designed to optimize energy output while
minimizing side effects, hastening recovery, and
improving operator time.
Conclusion:
MWL population have very real aesthetic concerns
that need to be addressed in an effective,
definitive, and safe manner. They have variable
degrees of skin redundancy and fat involution and
even localized persistence of hypertrophy. The
traditional ways for dealing with such aesthetic
problems was excision, lifting, and even volumetric
reconstruction. These procedures inevitably end
up with a patient that has been transformed from
a large BMI to a patient with low BMI but with
the stigmata of scars. LAL-ST techniques are recent
era in the field of aesthetic surgery that proved
their efficacy and safety in Non-MWL body contouring.
The study here proved their efficacy in
MWL patients.
