The accumulation of fat in the lower face and its adverse effect on facial aesthetics is of great concern to a number of patients. Smartlipo is a new technology which uses lasers to remove fat, with far less discomfort and bruising than with associated techniques. Essentially, the procedure ruptures fat cell membranes and uses the body's own metabolic processes to remove the leaked fat. With over half a decade of scientific literature and information to show it to be safe and effective, the technique gained DDA approval in the UK in October 2006, and looks set to be a highly effective addition to the treatment of excess fat.
So how has this method of reducing fat or fat cells originated? In the 1970’s fat reduction was a surgical procedure which resulted in significant scars. The technique was then developed by the French into liposuction, then lipaspiration or liposculpture and various different additional methods were added to this to make it more effective. In 1987 a very important step forward was made in terms of procedure prior to liposuction. Using bigger volumes of local anaesthetic diluted with normal saline with the addition of bicarbonate and adrenalin was found to result in a much lower downtime procedure. In the 1990s ultrasonic cannula were introduced which also had significant advantages. But all these techniques had disadvantages by dint of being purely mechanical, which inevitably resulted in problems with blood loss and bruising.
Most new liposuction procedures are done under local anaesthetic. This is helpful, as some people who would perhaps best benefit from surgery are absolutely certain that they don’t want to enter an operating theatre and have a general anaesthetic. In this respect Smartlipo has become very popular both with physicians and patients because it circumvents that possibility.
In terms of technical operation, Smartlipo operates on a familiar wavelength of 1064 nanometres, making it quite a low power machine. There is a new 10 watt machine which is a useful development for larger areas, but the six watt is still the mainstay of Smartlipo treatment. The laser is delivered directly to the tissue being treated by fibre optic and the trade name for this (as it comes from Italy) is lipolisi.
The technique can be used for larger areas – anything from the chin to the upper arms, chest, tummy, thighs and ankles. Smartlipo has even been used successfully underneath port wine stains and birthmarks to coagulate underlying vessels, increasing the effectiveness of subsequent treatments. But predominantly Lipolisi is used for facial aesthetics in treating the submental area and the jowl. This relates to the mid-face triangle in that we are trying to restore an inverted triangle by reducing the jowl and the submental area. But the technique can be used in combination with other treatments like fillers and volumising agents. Smartlipo lends itself to combined treatment, and when moving from reducing volume and tightening the lower face to then restoring volume in the upper face it goes hand in hand with a number of different revolutionising procedures.
Smartlipo uses a small fibre optic laser. This is important because (certainly in the face) it is vital that we avoid damage to large neuro-vascular bundles, delicate superficial nerves, and surrounding structures. One of the key reasons that the laser is so safe is that it delivers power very quickly and then has a long resting period so at least part of the effect is photo mechanical. The fat cells are being broken down without inducing a lot of heat in the area which could damage the nerves. There is also a photo thermal effect but research has shown that the top of the fibre optic is only running at 45 degrees centigrade and as long as you keep it moving and don’t leave it in one place for more than four or five seconds, then you are very unlikely to cause thermal damage. The resulting lysate or oily solution can then be dissolved, dissipating through the lymph system, and is metabolised by the body.
The cannula used for this treatment are one millimetre, can be introduced through a hole made by a non-cannulated needle, making this a minimally invasive procedure with perhaps just a small Steristrip afterwards. The laser also has benefits in terms of its effect on small blood vessels, minimising any blood loss at the time of the procedure while tightening the skin. There are obvious contraindications which would apply equally to any minimally invasive procedure, such as avoiding in pregnancy, autoimmune disease bleeding disorders.
In terms of affecting the treatment, the mechanism is in three parts. With the first pass we are actually running the laser in a sub-dermal layer. The effect is that areas of high energy break down the adipocytes by damaging the cell walls. People often assume that this is a process of obliterating everything in sight, but really it is more subtle than that. In fact we are just breaking the fat cell membranes down, allowing their fat content to leak out, which is why the results take two to four months to allow the body to naturally clear away the resulting lysate. As the laser disrupts the adipocytes, these degrade and dissipate, with the final result being a reduction in number. The population of the adipocytes is fixed in your body from about the age of four and patients often ask “if you remove this fat from here, will it just appear somewhere else?” The answer is “no, it is a permanent effect” and you will be less likely to gain or regain the profile weight in that area. Although there are still fat cells there, so if you try hard enough you can reverse the effect to a degree.
In addition to removing fat, the photo-thermal effect achieves coagulation of small vessels, and the final effect is the photo-stimulation of the collagen fibres, creating collagen remodelling and skin tightening. Here the laser is actually under the epidermis so we are having much more direct effect than other techniques which is why you can achieve such dramatic skin tightening.
In general terms Smartlipo is for more limited but more precise and delicate body contouring. It can be carried out in a minor operation room and the instruments are very fine – unlike a 4mm or 5mm cannula used in other liposuction methods. The technique is also simple. We trace out the area with the patient in an upright position (so you have gravity on your side), infiltrate the local anaesthetic, use the laser and then compression for a very short period.
One of the big safety features of Smartlipo is the guide beam. A red LED guide means that you always know where the tip of the laser is. This means that as long as the light is in view, you are not penetrating deeper structures or causing any danger to deeper structures. Another feature of this laser is that tit has one setting and a pleasantly short treatment time. Post treatment we only need either a biological glue or Steristrips for the small incisions. With compression for the head and neck it is necessary to use a compression band, but patients have to wear it only until the following morning.
With the small volumes as used in the head and neck you wouldn’t expect an effect on a person’s cholesterol or liver functions but there have been studies even on treatments of larger areas, so you can reassure your patients there will be no effect. There is a healthy body of scientific literature underpinning this procedure in terms of its effectiveness and safety and histological studies showing the effect of the laser and the tissues. Larger areas with volumes greater than 500ml can be treated with the addition of gentle aspiration to remove the lysate at the time of the procedure.
It is very important that you don’t select cases that are outside of the parameters which you might wish to improve. Older patients suffering principally from skin laxity and very little fat are not going to respond well to this treatment. Younger patients with fat but good skin texture and elasticity will do much better. Having said this, even an older lady if carefully selected can show very significant improvements. Patients are also often amazed at how little discomfort they have, how little bruising is evident and how little downtime is needed. So ultimately this technique gets us away from multiple treatments with significant pain and swelling and discomfort.
Dr Rupert Gabriel has been a GP with a special interest in surgery for over 15 years and is also a trainer in cosmetic laser surgery, radio frequency surgery, skin surgery and surgical techniques. He is a national trainer for Laser Lipolysis (Smartlipo) in the UK.