Letters to the Editor

I have recently read and digested the article ‘‘External Ultrasound Used in Conjunction with Superficial Subdermal Liposuction: A Safe and Effective Technique,’’ by authors Gasperoni, Salgarello and Gasperoni (Aesthetic Plastic Surgery 24:253–258, 2000). There are several things in the article which needs further explanation by the authors, mostly because many statements and conclusions are unsubstantiated in the article and leave the reader confused regarding the scientific grounds of the article. In other cases statements contradict each other and leave even more questions in readers’ minds. Let me take a few examples of things I would like to have explained further out of the article. The article recommends using glycolic acid [30%] on our patients two to four weeks before surgery, applied topically on areas to be treated with liposuction. It is stated that this treatment will, ‘‘. . . smoothen the skin, remodel elastic fibers, and stimulate dermal collagen production, thus enhancing the skin retraction capability.’’ To my knowledge it seems incredible that this could be accomplished in a time of two to four weeks and, as I have been involved in a skin care clinic in my own practice for me last ten years. I would like to know more about the scientific bases for this statement. We are also told that ‘‘when the skin is flabby a high protein diet or protein supplementmay be suggested to shift the metabolic balance towards proteins in order to improve skin retraction.’’ Does this mean that a patient with a flabby skin, consulting for a facelift, could be treated with a high protein diet instead of surgery and therefore can expect a spontaneous skin retraction? As a plastic surgeon, I am, of course, interested in the scientific basis for the statement above. We are recommended to treat our patients with vitamin C, 1000 mg per day for three months, as an antioxidant. However, in the discussion the authors state that external ultrasound ‘‘carries virtually no risk of free radical formation.’’ lf there is no risk of free radical formation, why would one then prescribe an antioxidant for three months? The authors also recommend keeping general anesthesia thoroughly deep in level, saying that otherwise increased heart rate and blood pressure may cause bleeding, ‘‘This coagulation may thus be excessive, leading to uncontrolled bleeding and eventualIy to DIO.’’ This statement leads me to two thoughts: first, I have never heard of uncontrolled bleeding when doing a minimal liposuction like that the authors discuss and especially not when using a super-wet technique with lidocaine 0.05% and adrenaline. Second, most surgeons doing liposuction with local anesthesia alone would use this concentration of lidocaine for full analgesia of the area [unless internal ultrasound is used]. It eludes me why we would need deep general anesthesia in a case like this. For local anesthesia, the authors are advocating a super-wet solution, which they define as when the volume of the wetting solution equals the estimated aspirate volume. They are using a concentration of lidocaine of 0.3% and recommending a maximum dosage of 20 mg per kg body weight which means that an ordinary woman of 60 kg could be infiltrated with a maximum of 400 ml of local anesthesia solution and subsequently, we would have an aspirate of maximum 400 ml, which makes me wonder what kind of case could be done under these circumstances. When it comes to the act of delivering ultrasonic energy we are told to cover the probe filled with 2–3 cm of ultrasonic gel. It eludes me how any conduction of ultrasound can take place through such a thick layer of gel and l don’t really understand why it should be so thick. We are also told that when delivering the ultrasound, the skin becomes slightly warmer. However, further on in the article we are told that ‘‘external ultrasound does not significantly raise the skin temperature.’’ As a reader, I would like to know whether the skin temperature is raised by the treatment or not, and if so why? Therefore, I urge the editor to ask the authors of the article to kindly extend their thoughts to the readers about how they came to their conclusions, to reveal the scientific sources for their statements, and to clarify contradicting conclusions. I think this is mandatory if we want to hold our journal to a higher standard than commercial magazines.