Comparison of Body-Sculpting Techniques

As a modern medical procedure, liposuction was first introduced in 1977 by Dr G. Fischer (Italy), and was subsequently popularized by Dr Illouz (France).  The procedure was significantly improved by the American Dermatologist Dr Klein, who developed the tumescent technique.  This method first infiltrated a diluted local anaesthetic into the subdermal layer prior to vacuuming out the fat cells.  In the 1990s, the French surgeon, Dr Fournier, introduced the concept of liposculpture, the aspiration of fat from one part of the body followed by grafting it to another.

Various technologies have developed over the last two decades, and have continued to transform how surgical body sculpting as practiced.   This article describes the most popular body sculpting technologies, and discusses their pros and cons.

Overview of Body-Sculpting Technologies

All body-sculpting methods have benefits and limitations and the choice of treatment will depend on the specifics of a patient’s body morphology and their objectives.  The technologies reviewed here are:

  • Vacuum Assisted Liposuction (VAL)
  • Water Assisted Liposuction (WAL)
  • Ultrasound Assisted Liposuction (UAL)
  • Power Assisted Liposuction (PAL)
  • Radio Frequency Assisted Liposuction (RAL)
  • Laser Assisted Liposuction (LAL)
  • Fat grafting

Vacuum Assisted Liposuction (VAL)

VAL is the least expensive type of liposuction technology.  It is the easiest to set up, and it has the longest safety record.  This last point, however, is due to the fact that it is one of the oldest lipo technologies.  The figure below shows how a vacuum in the cannula (basically a hollow tube inserted into the sub-dermal fat) is used to aspirate fat cells.

VAL can be used on any part of the body, and can be combined with other body contouring procedures.  Although there are other technologies that produce better results, VAL remains one of the most common for fat harvesting.

As vacuum alone, however, is only partially effective at removing fat cells, it is harder to master, and is more physically demanding for the surgeon.  Uneven contours are more common, and the fine control over the targeted fat layer is not possible.

Recovery from VAL is more prolonged, gives rise to more bleeding and risks of haematoma, and provides poorer skin retraction.

Vacuum Assisted Liposuction

BodyJet – Water Assisted Liposuction (WAL)

WAL has several advantages over VAL.  It addition to removing fat under a vacuum, it infiltrates the sub-dermal fat layer with a pressurised tumescent solution jet stream used for dislodging fat from its matrix of connective tissue.  Infiltration and suction are done at the same time, and this method improves the viability of fat grafting if that is to be part of the procedure.  WAL is a day case procedure performed under local anaesthesia, and the recovery time is faster than for VAL.

WAL requires more expensive equipment and has a longer learning curve for the surgeon, so procedures with this type of technology will be more expensive to the patient.  Also, as the action of the fluid jet is limited to fat localised to the probe tip, the scope of fat removal is less effective than UAL (see next section), and is less capable of handling harder fatty layers.

This means that WAL is not suitable for a precision contouring.  Skin retraction is better than VAL but less effective than for UAL (see suite).


Vaser – Ultrasound Assisted Liposuction (UAL)

In comparison with VAL and WAL, Ultrasound Assisted Liposuction (UAL) has a significant number of advantages.  Instead of simply operating under vacuum, UAL is performed in three stages.  The first stage infiltrates a tumescent fluid into the fat layer that consists of a combination of saline, Lidocaine (an anaesthetic), and Epinephrine (a vasoconstrictor).   This stage prepares the fat layer by infusing it with fluids, supplants the need for general anaesthesia, and greatly reduces the amount of bleeding.  The result is a safer procedure with less post-operative swelling, bleeding, and bruising.

The second stage of UAL is the insertion of a thin wand into the sub-dermal fat layer.  The tip of this wand vibrates at ultrasonic frequencies, and shakes the fat cells loose from their matrix of connective tissue.  The ultrasonic waves affect the cells through a volume of fat, so the effects of UAL are further reaching than WAL.  The waves also help emulsify the fat into the tumescent solution, making the result easier to vacuum out.  This allows UAL to remove more fat per unit of time, and provides the surgeon with much finer control over how and where fat is removed, and it delivers more consistent, reproducible aesthetic results.

The final stage is removing the fat under vacuum, similar to VAL, but with the added benefits just described.

VAL can target fat layers quite precisely, and larger areas can be treated, allowing for more refined body contouring.  Trauma from UAL is much less than for VAL, and is often a day-case procedure performed under local anaesthetic.  Post-operative recovery is faster, and skin retraction is not only more significant, it produces a smoother result.

Because it is a three-stage process, UAL takes longer.  There is also a longer learning curve for the surgeon using this technology.  The equipment is more expensive, making the price higher for the patient, and there are a number of additional potential issues, including:

  1. Seroma (pockets of fluid accumulation) are more likely, and these need to be aspirated during post-operative follow ups
  2. Paraesthesia (numbness) is not uncommon, but typically abates with time
  3. Post-operative induration (hardening of tissues)
  4. Post-operative follow up visits are required



Power Assisted Liposuction (PAL)

Power assisted liposuction (PAL) is similar to UAL in that a tumescent fluid is used, and a vibrating tip is applied during the vacuuming stage.  The vibrations allow the vacuum tip to cover more area per unit time.  However, the vibrations do not create ultrasonic waves, and so the affected cells are those localised to the cannula tip. Moreover, this approach does not emulsify the fat. 

An important advantage of PAL is its ability to shake loose hard fat that may be more tightly held by fibrous connective tissue, scar tissue, or cellulite.

PAL is safe, however, its use does have a higher risk of perforation of viscera.  It is also more traumatic to the tissue matrix, and results in longer recovery times, and more bruising and swelling than UAL.  PAL cannot be used for precision liposuction, and can’t be used on small, delicate areas. As the mechanical action of PAL is more vigorous, fat cells are less viable for transfers.

PALRadio Frequency Assisted Liposuction (RAL) – BodyTite

Radio frequency assisted liposuction (RAL) is a technology that passes electromagnetic waves through the skin between the cannula inside the fat layer to an external electrode just above the skin.  The waves heat the fat cells, causing them to melt, which in turn facilitates their removal by suction.  The approach is considered to be more effective for skin retraction, and effective for problems such as cellulite.

However, as the probe has both an internal and external component (see figure), it can’t be used on all areas of the body.  Also, as there is a heating element, this technology has more risk of creating burns.  Furthermore, it is less effective on hard fat, as this is more difficult to melt.  As the melting process tends to destroy fat cells, the aspirate cannot be used for fat transfer procedures.

RALLaser Assisted Liposuction (LAL) – SmartLipo

Laser assisted liposuction (LAL) has some similarities to RAL.  The technology melts fat by heating it, however, it does this with a laser located at the tip of the cannula.  When the cannula is inside the fat layer, the laser can be used at varying light frequencies to melt fat and reduce bleeding. The LAL laser beam is powerful enough to melt fibrous fat.

LAL is similar to RAL in that it is not suitable for smaller areas, and cannot be used for fat harvesting.  Furthermore, care must be taken to prevent internal burns from the laser.

LALAutologous Fat Grafting

As mentioned in the previous sections of this article, fat removed from one area of the body can be grafted to another.  This can be useful for a few reasons.  Fat grafting allows the cosmetic surgeon to add volume where required, thus re-sculpting the patient’s contours to achieve a more aesthetic look.  This can be important to patients who have suffered from disease (for example, breast cancer) of an accident. It can also be used for strictly aesthetic purposes.  As the patient’s own fat is used, the body usually accepts the grafts with no problems, however, roughly 25 to 50% of the cells will not be viable, and be eventually eliminated by the patient’s body.

There are several potential issues and risks that can occur with autologous fat grafting:

  • Although every effort is made to maintain sterility of the environment and all instruments used, infection is always a risk of surgery
  • Grafted cells can migrate to other, unintended areas, potentially leading to undesired contours or patches of unevenness
  • There is the possibility of cyst formation
  • Lipoatrophy, the loss of fat cells, can occur
  • Sterile necrosis and micro-calcifications are possible
  • Fat embolisms can occur, and these can lead to serious medical consequences... even death
  • Although the procedure uses the patient’s own fat, it is still possible that the body’s autoimmune response is triggered, giving rise to inflammation (panniculitis)

Autologous Fat Grafting