The water-jet assistet liposuction WAL

What requirements must a new technique satisfy?

The following points must be satisfied, if a switch is made from a well-established liposuction method to a new technique:

  • The liposuction must be possible with local anesthesia and without general anesthesia;
  • Optimal freedom from pain must be guaranteed;
  • The effect of the local anesthetic must be fast-acting and last long enough;
  • In order to avoid bleeding, the operation must take place under bloodless conditions;
  • During the operation the patient must be able to turn in different positions;
  • Only minimal swelling in the operation area should occur, so that the operation can be performed as precisely as possible;
  • Medication induced side effects must be minimal;
  • The anesthesia fluid must be applied in an exact location and only for as long as necessary. After the procedure, one must be able to remove it as quickly and completely as possible;
  • The operation time must be shortened as much as possible;
  • The anesthesia fluid and the suction cannulae must reach the fat tissue in a targeted manner. Other structures such as blood vessels, nerves or lymph vessels must be spared;
  • The recovery time after the procedure must be shortened;
  • The fat must be removed so that an autogenous fat transplant is possible.

In the following remarks I would like to present you with the facts that these requirements are met by water jet assisted liposuction, and how this is so.

The principle of water jet assisted liposuction (WAL)

Body-Jet for water jet assisted liposuction - Dr. med. Daniel Münch
Body-Jet for water jet assisted liposuction

The introduction of water jet assisted liposuction (WAL) can be designated as a paradigm shift in the methods of liposuction.

Water jet surgery was introduced in 1988, in order to selectively separate tissue and simultaneously protect nerves, blood vessels and lymph vessels. Especially in the area of abdominal surgery (liver, gallbladder, spleen), neurosurgery (brain tumors, herniated discs) and urology (kidneys, prostate), this method using a “gentle” water jet in place of a “sharp” scalpel has established itself. The German company Human-med invented and developed the water jet technique in 1988. In 2004, Human-med  (represented in Switzerland by the company esthetic med) brought the body jet system to market and thus made liposuction by means of water jet possible.

In water jet assisted liposuction, a flushing fluid is introduced into the fat tissue by means of a special, double barreled cannula with flat jet nozzles and immediately - along with the detached fat cells - is suctioned out again through the same cannula via lateral openings. With the simultaneous jet and suction technique, the infiltration of the water stream and the suction can occur at the same time. Because the liquid application takes place only in the suctioned area, a locally delimited effect of the saline solution is produced. Since the retention period within the tissue is short, there is also no swelling. The continuous supply of “fresh” anesthetic fluid to the operative area ensures an efficient effect of the anesthesia, even near the end of the procedure or near the edges of the region.

The gentle flush spray does not cause a sharp cut through the tissue, but rather leads to a relaxation of the fat layer and enables the definite removal of the fat cells while protecting the surrounding tissue. The critical structures such as the blood vessels, nerves or lymph vessels are pushed aside by the jet stream, so to speak, and thus are protected from mechanical injury.  In contrast to previous methods, this is an active process in which the fat cells were passively swollen through diffusion.  With water jet assisted liposuction, it is also an indirect process: it is less of a suction and more of a rinsing. The fat cells are flushed from their connective tissue and are siphoned with a gentle, tissue-protecting negative pressure, without damaging the important structures.

1. Infiltration fluid
1. Infiltration fluid
2. Detaching of fat cells
2. Detaching of fat cells
3. Flushing out and suctioning of the fat cells
3. Flushing out and suctioning of the fat cells
4. The result after suctioning
4. The result after suctioning

The device for water jet assisted liposuction from HumanMed (Body-Jet™, approved by the FDA) uses a closed, sterile and disposable pressure system for the infiltration into a very thin cannula. This cannula is surrounded by an outer cannula, of which the diameter and the number of suction openings at the top vary depending on the purpose.  Both the rate of infiltration and the vacuum pressure in the suction system can be determined separately, such that the water jet and the suction can be controlled independently. For technical reasons, a pulsating and not continuous stream of water is used. The sprays are similar to a powerful shower head, so that a tissue protecting approach is guaranteed.

How does water jet assisted liposuction work?

How does water jet assisted liposuction work? - Dr. med. Daniel Münch

The effect of water jet assisted liposuction can be explained in the following way: if you want to uproot a valuable rose, you can unearth the plant with a spade.  You will damage a few roots in the process.  If however, you wish to be gentler, spray around the roots with a water jet, until it is completely washed free. You will not damage the roots with the water spray.

Jet assisted liposuction - Dr. med. Daniel Münch

Another graphic description of the process compares the fat cells under the skin with a bunch of grapes: with mechanical suctioning, the grapes are destroyed and the fluid is suctioned off, leaving a lot of dead cell material. With water jet assisted liposuction, the grapes are individually loosened from the stem and are siphoned without being damaged. This analogy demonstrates that the blood vessels and connective tissue are optimally protected. Thus, fewer inflammatory reactions are observed during the healing process, and there is an improved reconstruction of the tissue with tighter skin and smoother surfaces. 

How does the anesthesia work?

How does the anesthesia work? - Dr. med. Daniel Münch

Liposuction is ideally conducted under local anesthetic. Before the actual suction phase, the anesthetic fluid, preheated to body temperature is introduced into the treatment targeted fat layer beneath the skin using a very fine infiltration cannula. Depending on the situation, the power of the pulsing, fan-shaped spray emitted from the cannula tip varies. This guarantees a tissue-protecting process, generally with minimal pain.

The anesthetic fluid contains an immediately effective local anesthesia (50ml lidocaine per liter), a anesthetic with long term effectiveness (10ml naropin per liter) as well as a vasoconstrictive drug (1ml adrenalin per liter), which both inhibits bleeding and prevents the fluid from unnecessarily entering the body. Added to this is bicarbonate to neutralize as well as cortisone as an anti-inflammatory drug.

Benefits for the surgeon

Benefits for the surgeon - Dr. med. Daniel Münch

In addition, more areas can be treated in a single session and larger amounts of fat can be simultaneously suctioned, because the body is burdened with smaller volumes of anesthetic fluid. Since the penetration of the anesthetic fluid into the fat cells is not necessary, in contrast to the classic tumescence technique, the waiting time until the onset of the suction phase is eliminated.

Cannula for rinsing and suctioning - Dr. med. Daniel Münch
Cannula for rinsing and suctioning

The gentle removal of fat cells through the pulsating, broadly fanned out water jet facilitates the handling of the suction cannula: this can be done easily and without strain into the rinsed channel in the fat tissue. An easy sliding of the cannula without effort is always a sure sign of a gentle and safe progression without the danger of damaging the tissue. By using his free hand, the operator can assess the height and position of the cannula and the spraying water jet. The surgeon is always certain of the position, the amount and the extent of fat tissue to be removed because of the simultaneous suction of the fat tissue.

By modifying the pressure of the water jet, transitions can also be treated in targeted fashion so that the progression is harmonious. For fine rendering near the edges, the suction is turned off, so that the fat in these peripheral zones is simply dissolved.

For suctioning in places with scar tissue (e.g. from prior operations), or in areas where the tissue is rather rough (e.g. in the neck or on the sides) the pressure of the water jet is increased, so that these areas can also be treated well.

Benefits for the patient

Benefits for the patient - Dr. med. Daniel Münch

Since with the water jet assisted method of liposuction less anesthetic fluid reaches the body, the strain from side effects of the fluid and the drugs is lessened.  The duration of the operation tends to be shorter, and the pain of the procedure is lessened because of the tissue-protecting suction principle. In contrast to conventional infiltration techniques, the water jet uses a pain-free distribution of the anesthetic fluid into the fat tissue. The patient feels this “filling in” not as pain but rather as pressure. It takes effect within a few minutes.

The recovery time after the procedure is also shorter: generally, usual activities are possible again after a few days. Less inflammatory swelling or skin reactions and an increased skin firming effect are other factors in favor of this method. 

Autogenous fat transfer

Autogenous fat transfer - Dr. med. Daniel Münch
The released fat cells can be transplanted

With all previous methods of liposuction, there was only one concern:  namely, to remove fat from the body. The possibility of adding fat to desired locations adds new perspectives and hugely extends the possibilities for liposuction.

Water jet assisted liposuction loosens the fat from the tissue with a gentle water spray, so that individual fat cells are not damaged. This fascinating aspect opened possibilities for the surgeon to use the viable fat cells immediately afterwards in other parts of the body, including the breasts.

Breast augmentation with autogenous fat (Ueberreiter, Berlin)

Treatment of lipomas

Lipomas are common, benign tumors of the connective tissue that can form in any part of the body. They can exist as a single lipoma, or as several lipomas, potentially in clusters. These fat swellings generally grow slowly over the course of years and are comprised of normal fat tissue which is surrounded by a fine shell. Depending on the amount of connective tissue, they may feel softer or harder.

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