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External ultrasonic liposuction (EUL) was made popular in the late 1990's following the tribulations of the 1st and 2nd generation internal ultrasonic liposuction machinery (please see the previous chapter for a distinction). During an external ultrasonic–assisted liposuction procedure, a tumescent or some type of wet technique liposuction is recommended to be used by the manufacturers. This theory is that ultrasound waves "work" and travel best to the fat cells through large amounts of water (transducing medium). Unfortunately, there are no convincing quality paired comparison (right and left) photographic studies published in the surgical peer-review literature. One side should of a study patient should receive EUL and suctioning with standard instruments and the other side of the patient during the same liposuction should receive no EUL but the same pattern and number of passes and vacuum pressure of the standard instruments. The results of both sides should then be compared at 1 week, 1 month, 6 months and 12 months. Unfortunately, these studies do not exist to support the value of EUL. In fact, relatively good studies exist showing that EUL instrumentation, at least what was available in the year 2000, was of no benefit as far as long term photographic results. Therefore, relying on the words of surgeons who advocate and market (make money from) the technique may not be the best course for a reasonable doctor or patient to follow. Surgeons who perform the technique claim that it provides "easier" superficial (high-up) fat removal, that it is "helpful" with cellulite, that it "aids" in the retraction (tightening) of skin, and that it allows for "clear and bloodless" fat removals, among other things. Again, unfortunately no good paired comparison studies exist to support their claims. External ultrasonic liposuction may have the following downsides: the doctor who does the actual "suction" does not usually pass or circulate the external device by him/herself. If the technician or nurse assisting the doctor fails to keep the device in motion at all times, then the patient's skin can be burned. The procedure may take longer, and, therefore, the cost may be greater. Also, the important preoperative (before surgery) markings (with a surgical pen) by which the surgeon knows where to remove the proper amounts of fat (tumescing or adding fluids distorts the natural anatomy) are usually wiped away by the constant motion of the ultrasound device and are lost as a reference during the critical parts of the procedure. Unless patients are re-marked, this is a definite disadvantage associated with external ultrasonic liposuction. It is difficult to re-mark a patient who has already been "tumesced" because the skin and landmarks are distorted
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