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Topics - Dr. Donn Hickman

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1
Face Board / OPTIONS FOR 66 YEAR OLD PATIENT INCLUDING LOWER FACE LIFT
« on: December 19, 2016, 02:56:01 PM »
 Q: Lower Facelift and Other Options for a 66-year-old?

A: Lower facelift in 66-year-old

While it is said that the full impact of a facelift in general, is in the neck and jaw line, the added benefit of restoration of cheek fullness using newer suspension and fat filling techniques, makes a full face lift more satisfying for someone over 60.

The limited scar methods, thread lifts, quick lifts, lifestyle enhancement lifts all attempt to provide a nice smoothing with suspension alone, but most of these cases that are presented have suspension with other treatments including muscle tightening, cheek restoration, eyelid and brow procedures, and skin resurfacing.

A classic neck lift called a Cervicoplasty is a good operation which addresses everything you could possibly do for a sagging aging neck. For those patients opting just for this, they often return pleased but say, oh I wish we did more in the cheeks as you mentioned in the consultation. Some patients have nice cheek fullness and good skin, so that other things like laser, chemical peels, cheek implants, etc can be done at the same time or if further enhancements are desired later, after a well done neck lift.

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2
Face Board / DRY EYES THYROID CONDITION BEFORE MACS FACE LIFT AM I OKAY?
« on: December 19, 2016, 02:55:12 PM »
 Q: Do I need to see my eye doctor first, just to make sure?

A: Dry Eye, Hypothyroid, and Eyelid/MACS Surgery
If you are satisfied that your eye symptoms are well controlled on your current medication, and your thyroid condition is also at a steady state, with a recent thyroid study, and no current eye redness, the surgeon, can, with the working knowledge of tips and traps of eyelid surgery in such patients, you can proceed.  If you are having difficulties with your eyes and thyroid, or have any problems that you are uncertain of, then its best to have these checked out prior to operation.   Since we have the occasion to see patients with eye symptoms that at first glance appear to be due to excess skin, we often obtain thyroid studies or request an eye exam when we are suspicious about thyroid and other disorders.  Hyperthyroidism can be missed by internists when treating hypertension, and the patient constantly complains about eye tearing, or problems with balance and cognition.  Dry eye can be missed as well as some patients  come to the office complaining of tearing, when the tearing is actually  (reactive)  to dry non-lubricated eyes or can be a manifestation of overactive or underactive thyroid disease.   A simple call as stated above, the office of the eye doctor, can allay many of these concerns.  Our best protection against surgically-created dry eyes as experienced plastic and opthalmic surgeons, is to avoid removing too much skin, and identifying weak support to the lower lids well in advance.   If you have dry mouth, and any arthritic symptoms, this too should be investigated.    Best wishes.  Often, in these forums, we understand the experienced eye surgeons having taken your history and having done an examination, will make the proper adjustments to your operation, to avoid issues later.

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3
Face Board / CHEMICAL PEEL RECOVERY
« on: December 19, 2016, 02:53:11 PM »
 Q: How Long Does a Chemical Peel Last?

A: Chemical peel longevity and recovery

It is good to ask yourself what are the goals you seek for your skin. If it just signs of aging, a bland complexion, or light acne, then very superficial to superficial peels plus a strong home regimen is worthwhile. There is almost no recovery with these. If there are heavy lines, wrinkles, and pigmentation and you want your face back, then you would want to take the time for preparation seeking a deeper peel, and some recovery of up to 2 weeks, plus a maintenance regimen. Chemical peels have rebounded in past years, with advanced knowledge and diversity in peeling solutions and application for many skin types.  It is my resurfacing procedure of choice for practically all skin types and skin problems. Best regards for this question.

4
Face Board / CHEMICAL PEEL RECOVERY
« on: December 19, 2016, 02:52:37 PM »
 Q: Chemical Peel Recovery Time

A: Best chemical peel for shortest recovery

It is good to review your goals with the Plastic Surgeon or Dermatologist and inspect the case photos of various peels. The deeper the peel the more pronounced the effect and likewise the more recovery anticipated. Staging peels is a thought, but for the single most effective peel, it is important to know what your goal is and how to get there.

If upon your inspection, the cases show simple freshening and improve skin luster, then a light peel is fine and home maintenance will round out the effects. If you need true crows feet and fine wrinkles about the lips removed, then a medium depth peel is advised. If blemishes, discoloration, and a harsh look with wrinkles is present, then you may wish to take a litte more time for an intervention.

I agree that the VI-PEEL is a good approach, also TCA peels, and modfiied phenol plus croton oil peeling. We all have ways to modify the intensity of the deeper peeling agents customizing these for the busy consumer. We can combine superficial and deep action with the same agent. For the lips and lids we may go a bit more pronounced and suggest makeup at first, while going lighter for the cheeks and forehead. If you are adamant about letting anyone know what you have done, and are a perfectionist at heart, then you might agree to a set of superficial peels over time, and make an ongoing assessment of the results.

There is no magic bullet for absolute skin restoration, but if given the time for a potent peeling regimen to heal, an extraordinary skin renovation can be achieved. Skin sunburn class, skin pigment class, and anthropologic origin all factor in to the doctor's recommendations. If you are not able to comply with a period of recovery, then peeling, laser, and dermabrasion is not advised.

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5
Body Contouring Board / Wrinkled Belly Button
« on: December 16, 2016, 11:09:59 PM »
 Q: Will Tumescent Lipo help me get rid of sagging belly button skin? (Photo)
A consumer asks about a wrinkled belly button and fatty tissue and as to whether liposuction may be helpful----------


A: Wrinkly belly button and some abdominal fat
I am sure you might try one of the non-invasive measures which suggest modest improvement of skin wrinkling, but I believe you will be disappointed. I agree with all other posts, that some form of skin redraping by tucking, is necessary.  A  small scar mini-tummy tuck could be very helpful without muscle work. When you have spent 2000-4000.00 on the measures you mentioned, and then see what you achieved, I think you might be back on this forum again. While some radiofrequency and ultrasound measures can reduce fat and tighten wrinkles, it is entirely possible that the heat generated by these measures can cause more wrinkling of delicate stress marks especially around the belly button.

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6
Body Contouring Board / SMART LIPO
« on: December 16, 2016, 11:08:30 PM »
 A consumer asks about SMARTLIPO or conventional liposuction ---------------------------------------------------------


Q: Which Between Liposuction or Smart Lipo is Better for Young Patients?

A: Liposuction or Smart Lipo on Younger patients

Liposuction is best used, whichever technology is available and promoted by the Practice, in patients of generally good health, with a keene eye on diet and nutrition, who have diet-and exercise-resistant fat and genetic predispositions. The use of ultrasound-assist, power-assist, syringe-assist, internal laser-assist, and even a new external laser-assist are all to be matched against the gold standard which is suction-assist. We use terms like liposuction, liposculpture, microliposculpture, etching, SLIM LIPO, SMARTLIPO, FINAL INCHES, body sculpting, for body fat contouring. While those using the laser find it helpful for selected limited areas of liposuction in one setting, and since the device is in the sub- $200000 range to purchase, it may therefore be promoted more freely in a particular practice.

Tightening can be best acheived in younger patients as a rule with all forms of liposuction since the elastic tissues are more likely to adjust to the fat removal. The use of superficial and deep layer suction promotes the desired contraction in candidates representing all age groups. Laser disruption can induce contraction, but also does mechanical disruption cause contraction beneath the skin by other forms of liposuction. Microscarring appears to be the cause of contraction. Each Practice will have different ideas on this issue.

Have a look at the doctor's BEFORE AND AFTERs with attention to sliming and apparent toning that may be evident. Remeber, liposuction is not a perfected science, and small flaws in contouring may be evident regardless how experienced the surgeon, or how advanced the tools may be. We are searching for the most forgiving device to both the patient and the surgeon, with the fastest, safest, and most successful outcome.

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7
Face Board / Chin Liposuction
« on: December 16, 2016, 11:06:48 PM »
 A consumer asks a question about liposuction of the chin but no photograph has been submitted.  Here is our response------------------------------------------------------------------------------------------

Q: Chin liposuction?

A: Chin liposuction
It would be good to see a photograph and examine the patient in person. Recovery is rather brief, but swelling can remain a few months in some men as compared to women.  Often some patients have localized fat in the neck which makes them look heavy, when in fact, they are not.  You can see this in celebrities who, while fit on film, do display some localized fat that prevents ideal definition of the neck from the jaw line.  The great actor Chris O'Donnell of  the hit show NCIS Los Angeles looks goodon camera, but does display some fullness in the neck  That would be a case where some limited liposuction could enhance the jaw line and under chin zone.  The equally as popular Matthew Perry has the same phenomenon. When he trims down the neck looks defined. When is gains some weight, you can see it particularly in the chin and neck area.  I am using these as examples in popular folks who we see on camera, where a plastic surgeon can identify things he or she can improve.  People can have localized fat in a number of areas that remain despite diet and exercise. This resistant fat is something that plastic surgeons can remedy with liposuction, and other technologies that liquify or melt it.

8
Body Contouring Board / Calf Liposuctrion
« on: December 16, 2016, 11:04:30 PM »
A consumer asks a question as to whether she is a candidate for calf and ankle liposuction for contouring and what device is best----------------------------------------------------------------------------------------------------

 Q: Am I a candidate for calf and ankle liposuction? Should I get Vaser Hi Definition Lipo or traditional liposuction?


A: Calf and Ankle Liposuction Best Technology
Hello scalpelplease:

The doctor may use the device he or she currently has available.  This can be traditional (suction-assist), power-assist, laser-assist,  Vaser (which is a 4th generation ultrasonic device), Tickle Lipo (vibration-assist), Syringe-assist only,  Cooling external fat dissoving technology etc.  For lipo procedures on delicate areas and thin zones of the calves and ankles, it  is my feeling that less intense power be used during the suction. I prefer the traditional (suction-assist) only so I have complete control over the cannula movement.  The small
microcannulaes of 1.7mm, 2.4 mm, and 3.0 mm size are used with this method. The noninvasive tissue cooling devices are not as precise and offer 12-25% improvement over 6-12 months. I believe they are not as ideal for calves and ankles.

With newer devices employing ultrasonic technology, there is less heat and tendency for skin inflammation.  Do not be confused.  Each surgeon will have a different perspective. I personally believe classic suction or traditional liposuction is preferred to avert skin healing issues. Liposuction of the calves and ankles with small microcannulas, is often an overlooked enhancement since many consumers are principally focused on the  abdomen, hips, and thighs.    Best wishes.


9
Face Board / Asian Rhinoplasty
« on: December 16, 2016, 11:01:56 PM »
 A consumer asked a question about rib graft cartilage to the nose-----------------------------------

Q: My question is will the nose rib cartilage be there forever?

A: rib cartilage long term
Each surgeon develops experience with grafting to the nose, and bases his or or her techniques on what works best for them and yes, long term followup from other experiences. While a standard exists for using silicone wrapped in fascia or dermal grafts, on asian noses, and is taught in courses, yet other experts continue to rely on nasal cartilage which can be stiff and create tension in a few cases.  This is usually for secondary and complex noses where no bridge is present preoperatively.  Other less tension options include dermal grafts alone which can melt away in some cases, or our thinking is the use of ear plus or minus septal cartilage with a fascia wrap.  For speed and efficiency some practices prefer silicone and some form of wrap.  We do like ear cartilage and a wrap, as it lasts a lifetime, but from time to time minor adjustments and trims may be necessary. The primary nose, or in fact the primary asian nose with a flat bridge, should be treated with natural bendable ear and or septal cartilage and gently configured so that sharp edges do not appear early or late in the course.  Follow the course with your surgeon.  The rib cartilage might need a trim or adjustment if it does not settle and mold into place.  Our practice does not prefer any silicone or plastic materials for the nose.

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10
Summary of article:   An American Series of Purse String Circular Scar (periareolar) method for breast reduction which follows the method Of Brazilian pioneer Dr. Sampaio-Goes.  No vertical or horizontal scarring.   

Periareolar reduction mammaplasty is usually restricted to smaller hypertrophies with
minimal ptosis. The purpose of this report is to examine the Goes double-skin periareolar
approach without mesh, in challenging bilateral and unilateral hypertrophies with major ptosis,
including patients who are older, endomorphic, have thin elastic skin, or previously operated
asymmetry.

45 patients (37 bilateral and 8 unilateral) underwent a circumareolar skin excision based on 4
geometric chest landmarks, superior anterior tissue resection, central-type pedicle, vertical cone
assembly, areolar fixation, telescoping of an outer circular breast flap onto an inner areolar
circle, and permanent circlage suture. The unilateral group included: 4 reductions opposite to a
mastectomy reconstruction, and 4 reductions with contralateral mastopexy, plus bilateral implant
change in the previously augmented patient.

Average nipple elevation/resection was 7.2 cm/285 gm for bilateral reduction, 7.4 cm/291 gm for
unilateral reduction without implants, and 6.4 cm /131 gm for unilateral reduction with implants.

There were 4 significant complications (4.8%) in 82 breasts. In the bilateral group, there was a dermal
cyst, dermal abscess, and scar granuloma. In the unilateral group, there was a 50% areolar necrosis
and poor scarring in a reduced breast on a previously augmented patient from outside. It was learned
after surgery that tissue resections were done at the original augmentation. Minor complications
occurred in 14 breasts (14.6%).

Average case follow-up (bilateral/unilateral ) was 2 years/9 months.
As the plastic surgeon is reminded of principles, periareolar reduction mammaplasty can be
applied within reason to a broad group of patients with good satisfaction. Breast reduction in
previously operated patients with breast asymmetry and implants should place the surgeon on guard.

11
Breast Board / Small Risk of Rare Cancer with Breast Implants
« on: February 13, 2011, 02:45:02 PM »
FDA to Establish Breast Implant Registry
For Immediate Release: January 26, 2011

ARLINGTON HEIGHTS, Ill. - The American Society of Plastic Surgeons (ASPS) is establishing a national registry for breast implants in collaboration with the Food and Drug Administration (FDA). The registry is being developed in response to reports of a rare lymphoma - Anaplastic Large Cell Lymphoma (ALCL) - in a very small number of women with breast implants.

The ASPS and the FDA agree this extremely rare form of lymphoma is not breast cancer. Of the estimated 10 million implants worldwide, only 34 cases of ALCL have been identified since 1989.

While lymphomas can appear anywhere in the body, this condition appears in the scar tissue that forms around the breast implants. At this time, both the FDA and ASPS remain confident that breast implants are safe and effective.

"ASPS shares the FDA's commitment to patient safety, but we also want to make certain this information does not raise false alarms with our patients," Phillip Haeck, MD, ASPS President, said. "We've been down this path before. For nearly 20 years American women were denied access to their choice of breast implants because of false claims and unfounded science. We are determined this shouldn't happen again."

ASPS recommends that women with breast implants should continue their normal routine in medical care and follow-up, specifically regular self examination and mammography when appropriate. Women with breast implants should watch for changes in their breasts such as pain and swelling and contact their plastic surgeon if they have questions.

"Women who are considering breast implant surgery," Dr. Haeck said, "should do their homework to see if it is right for them. ASPS is committed to helping women make informed choices about their health care and our website plasticsurgery.org is an excellent resource."


12
Summary of article:   An American Series of Purse String Circular Scar (periareolar) method for breast reduction which follows the method Of Brazilian pioneer Dr. Sampaio-Goes.  No vertical or horizontal scarring.    To be published on line in a few weeks.

Periareolar reduction mammaplasty is usually restricted to smaller hypertrophies with
minimal ptosis. The purpose of this report is to examine the Goes double-skin periareolar
approach without mesh, in challenging bilateral and unilateral hypertrophies with major ptosis,
including patients who are older, endomorphic, have thin elastic skin, or previously operated
asymmetry.

45 patients (37 bilateral and 8 unilateral) underwent a circumareolar skin excision based on 4
geometric chest landmarks, superior anterior tissue resection, central-type pedicle, vertical cone
assembly, areolar fixation, telescoping of an outer circular breast flap onto an inner areolar
circle, and permanent circlage suture. The unilateral group included: 4 reductions opposite to a
mastectomy reconstruction, and 4 reductions with contralateral mastopexy, plus bilateral implant
change in the previously augmented patient.

Average nipple elevation/resection was 7.2 cm/285 gm for bilateral reduction, 7.4 cm/291 gm for
unilateral reduction without implants, and 6.4 cm /131 gm for unilateral reduction with implants.

There were 4 significant complications (4.8%) in 82 breasts. In the bilateral group, there was a dermal
cyst, dermal abscess, and scar granuloma. In the unilateral group, there was a 50% areolar necrosis
and poor scarring in a reduced breast on a previously augmented patient from outside. It was learned
after surgery that tissue resections were done at the original augmentation. Minor complications
occurred in 14 breasts (14.6%).

Average case follow-up (bilateral/unilateral ) was 2 years/9 months.
As the plastic surgeon is reminded of principles, periareolar reduction mammaplasty can be
applied within reason to a broad group of patients with good satisfaction. Breast reduction in
previously operated patients with breast asymmetry and implants should place the surgeon on guard.

13
Excerpted from the site of Dr. Ivan Thomas.  Nicely prepared strategy.  Results are very good but demonstrate very minimal breast sag before operation, which can be treated with internal breast release and higher profile implants. See our Breast Augmentation Section which shows even more severe breast sag in breast augmentation patients having no lifting procedures other than implantation.

Breast enlargement in women, who suffer from sagging breasts, can now be performed without scars. Ideally, the best candidate for breast augmentation surgery is one who has firm and perky breast without any sagging. Therefore, most candidates who fit in this category are young women who have never been pregnant. Such candidates, when augmented, will obtain the best possible results with breast implants.

Pregnancy, breast-feeding, weight loss, and the aging process are the most common causes of the breast volume loss leading to deflation and sagging. Women with sagging breasts often feel a loss of feminine appeal. Many believe that inserting breast implants is all that is needed to improve their problem. Unfortunately, the worst possible candidate for augmentation is one who is suffering from severe breast deflation and sagging. Such a candidate, if augmented with implants, will obtain very poor results. The breasts will look longer and saggier, with implants in the bottom and nipples facing downward. The procedure of choice for such a deformity is mastopexy or breast lift, also known as mastopexy, followed by breast augmentation. As regular mastopexy is a trimming and tailoring type of surgery, patients who undergo conventional mastopexy will have to accept scars of various quality and visibility depending on the skin type.

The patient who will benefit most from my new no scar technique of lifting and augmentation, called internal mastopexy, is one who has moderate sagging and wishes to have her breasts enlarged. This procedure requires no additional incisions because it is done through the same small incision made to insert the breast implants. In this technique, the breast tissue is anchored to a higher level on the chest wall, resulting in uplifting of the breast and the nipples without the need to excise skin and leave scars.

In conclusion, if there is severe sagging, conventional mastopexy is the procedure of choice and if sagging is minimal, simple augmentation is all that is required. However, when sagging is moderate, instead of a conventional mastopexy which may reveal undesirable scars, an internal mastopexy or internal lift can be performed with no additional scars. During your consultation, I will be able to determine the best possible procedure for your condition.

14
Breast Board / Internal Bra Lift with Silicone Cups and Straps
« on: December 19, 2010, 08:02:18 AM »
Internal bra gives women a permanent lift, claims surgeon

By Daily Mail Reporter
Last updated at 11:26 AM on 23rd November 2009

    * Comments (15)
    * Add to My Stories

Many women would love to have shapely breasts without needing the help of a bra. Now plastic surgeons have made that possible by developing an internal bra to permanently lift and shape.

The first woman to have internal bra fitted had her operation three weeks ago and surgeons have hailed it as a success.

The bra is fitted in a 40 minute keyhole operation that allows a woman to go into hospital in the morning and be out by lunch time.
bra


Its inventors claim it has none of the drawbacks of a breast implant and will continue to look good for years without sagging.

Avi Cohen, managing director of the company helping develop the bra said: 'The operation went really well and the woman, who is in her 30s, has made a good recovery.

'The bra has given her the lift she wanted. Her breasts look natural and she is happy with the result. The surgeons have done a fantastic job.'

The Cup & Up bra is the invention of leading Israeli plastic surgeon Eyal Gur who has been besieged by women wanting the operation after they discovered his research on the internet.

He said: 'This might not quite be the end of normal the bra, but we've shown that with a very small operation that it's possible to give a woman an internal bra that she can have for the rest of her life.'

Dr Gur believes that women will be able to go bra-less if they want unless they are playing sport when an ordinary bra would be needed for additional support.

The internal bra is a harness-like device is inserted under the skin using a local anaesthetic. The procedure should also be cheaper than a traditional breast lift, which costs around £4,000 and often requires an overnight stay in hospital.

It is similar in shape to a fabric bra, but is made of silicone, the plastic already used in breast implants.

Surgeons make two tiny cuts less than a centimetre wide underneath each breast.
Silicone cups like the ones used in a traditional uplift bra are then are then inserted around 1cm below the skin.

Then surgeons fit fine straps made from a strong material that will hold the bra in place without it sagging These are attached to the ribs between the breast and the shoulder with a pair of titanium screws.

Then they are stitched to the cups and everything is tightened to lift the breasts into the desired position.

 
More...

    * Could fad diets be making the obesity epidemic worse?
    * No scalpel, no scars... but do the new cosmetic 'no-cedures' really work?

Dr Gur said: 'A woman will be able to go back to work after a couple of days rest at home.'

The first woman to receive her internal bra was operated on by Belgian surgeons as part of a year long trial.

Mr Cohen's company, Orbix Medical, is marketing the bra. He believes it will become widely available in Europe within the next 18 months.

'We have enough women volunteers in the trial and we will be doing our second patient just before Christmas,' he said.

'In a year's time we will have enough evidence that it works. Then we will be able to get the green light from the European medical licensing authorities.'

The operation is aimed at women with only a moderate degree of sagging, although a non keyhole version of the operation is being developed for women with more significant sagging.

Dr Gur said: 'There are a lot of younger women whose breasts have started to sag even before they have had children and breast fed. Those who are sagging after having kids want to look like they were when they were teenagers. This operation will give them back youthful breasts.'

He added that it could also be used by women who have had breast reconstruction after mastectomies during cancer treatment.

'These women often complain about their breast shape and position. The internal bra would be really beneficial to women who have had partial or full mastectomies,' he said.

15
CUSTOM ACOUSTIC LIPO (C.A.L) also termed Vibroliposuction is a new take on the popular Power-Assist Liposuction (PALS) which this Practice often uses. 

In technical terms the power-assist method employs a rapidly reciprocating powered  tip, that permits the surgeon
to glide through the fatty deposits reducing the stress on the operator's shoulder and back.  The recently introduced CAL system uses a motion technology called Vibroliposuction where air pressure in the unit producings a complex 360 degree motion of the cannula tip to which helps it glide through tissues extracting fat with efficiency.   The motion is termed ''nutation" .   It is being reported as smoother and better able to loosen fat. 

 As an aside, when using this device under local anesthesia, the vibrations produced may generate a light tickling sensation for the patient who make actually cause them to laugh.   Some 60% of patients may experience this heightened vibratory sensation that prompts them to chuckle.   have had the experience of two patients on whom I have performed some minor local liposuction with a suction device only, and the act of pushing the cannula back and forth did prompt to the patient's to laugh during the procedure.  Often pressure and vibratory sensation can be perceived as heightened tickling and cause the nerve response to incite laughter.

This new device is worth examination, but appears to be similar in reducing stress on the surgeon for the most part.  Further review will determine if it will become popular with plastic surgeons and whether it offers distinct advantages to power-asssist (PALS) liposuction with respect to smoother extraction, shorter operating times, and improved patient outcomes. 

Local anesthesia may not be suitable for everyone, but all methods in current use may be applied with local, sedation, or general anesthesia.    Our current preference for liposuction is Power-Assist for larger longer duration procedures, with standard suction for delicate areas of the neck, calves, and ankles.


KEY TERMS for this new technology

nutation technology of 360 degree cannula motion
tickle liposuction
Custom Acoustic Liposuction
CAL
CALS
Vibroliposuction--------------------
VL Liposuction


Vibroliposuction (VL)

Vibroliposuction represents a development of the PAL concept. In this system, the cannula is activated by air pressure, producing a complex movement of the tip. This movement, combining antero-posterior, superoinferior and parasaggital displacement is called “nutation”. The amplitude of this movement depends on the cannula length and diameter as well as the pressure entering the handpiece. A recent publication by REBELO (44) describes this technique.

REBELO A. Power-assisted liposuction. Clin Plast Surg, 2006, 33 : 91-105.

"In conclusion, this technique allows easier tissue penetration and causes less fatigue to the surgeon"
 one study-------


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