LIPOSUCTION

1) Definition:

Liposuction, also known as lipoplasty ("fat modeling"), liposculpture, suction lipectomy, or simply lipo ("suction-assisted fat removal"), is the surgical removal of localized or regional excess fatty tissue.

2) Indications

Despite good health and a reasonable level of fitness, some individuals may still have a body with disproportionate contours due to localized fat deposits. These areas may be due to hereditary or family traits rather than a lack of weight control or fitness. Liposuction must not be considered as a treatment for obesity or a substitute for proper diet and exercise. In Brazil, the surgeon can remove up to 7% of the patient’s body weight, e.g. 10 pounds of fat from a 150-pound person, and so on.

3) Techniques

The procedure lasts an average of 2 to 3 hours, depending on the areas to be treated and on how much fat each area contains. Liposuction can be accomplished either with the use of general anesthesia, with local anesthesia plus IV sedation, or totally by local anesthesia. The incisions are small and can be either sutured or left open for drainage of fluid.

The techniques available are described below, as follows:

a) Areas of the body where liposuction is performed;

b) Amount of fluid injection;

c) Mechanism of liposuction;

d) Superficial x Deep.

a) Areas of the body where liposuction is performed:

• Cheeks, chin, and neck
• Upper arms
• Breast or chest area
• Abdomen
• Flanks (love handles)
• Hips and Buttocks
• Outer thighs (saddlebags)
• Inner thighs
• Inner knees, anterior knees
• Calves and ankles
• Submental (chin/neck)
• Gynecomastia (male breast tissue)

b) Amount of fluid injection:

b.1) Dry liposuction

The dry method does not use any fluid injection at all. This method is seldom used today because of the increased amount of blood loss when compared to the other methods available. Some patients may need blood transfusion depending on the how many areas are treated.

b.2) Wet liposuction

A small amount of fluid, less in volume than the amount of fat to be removed, is injected into the area. It contains lidocaine as a local anesthetic, adrenaline to contract the blood vessels and thus minimize bleeding, and a salt solution (saline). This fluid helps to loosen the fat cells and reduce bruising. The fat cells are then suctioned out as in the dry method.

b.3) Super-wet liposuction

In this method, the infused volume is in about the same amount as the volume of fat expected to be removed (1 cc of infiltrate to 1 cc of aspirate). This is the preferred technique for high-volume liposuction by many plastic surgeons as it better balances homeostasis and potential fluid overload (as with the tumescent technique). 

b.4) Tumescent liposuction

The surgeon injects high volumes of the saline solution (plus lidocaine and epinephrine) directly into the subcutaneous fat to be removed (2-3 cc of infiltrate to 1 cc of aspirate). Due to a potentially large total volume of local anesthetic injected into the tissue, systemic toxicity from lidocaine is a potentially complication, which must be considered with larger volume cases. The blood loss with both the super-wet and the tumescent technique are significantly lower than with the dry method.

c) Mechanism of liposuction:

c.1) Suction-assisted liposuction (SAL)

Suction-assisted liposuction is the standard method of liposuction and the first one developed. In this approach, a small cannula (a hollow stainless steel tube) is inserted through a small incision and attached to a vacuum device (usually a machine, but syringes can also be used to create vacuum). The surgeon pushes and pulls it in a forwards and backwards motion, carefully through the fat layer, breaking up the fat cells and drawing them out of the body by suction. There are numerous types of cannulas that can be used and different ways of performing the procedure, but all of them end up leading to similar results. 

 Examples of Cannulas

c.2) Power-assisted liposuction (PAL)

PAL devices use power supplied by an electric motor or compressed air to produce either a rapid in-and-out movement or a spinning rotation of an attached liposuction cannula. This mechanized movement makes the procedure easier since the surgeon does not need to make as many manual movements. Otherwise it is similar to traditional liposuction (SAL). Some surgeons and the company that sells the instruments (Microaire ®) advocate better results with this method, although there is not enough scientific evidence to support their claim.

 Microaire ®

c.3) Ultrasound-assisted liposuction (UAL)

In ultrasound-assisted or ultrasonic liposuction, a specialized metal probe or metal paddle is used which transmits ultrasound vibrations into the subcutaneous fat. This vibration bursts the walls of the fat cells, emulsifying the fat (i.e. liquefying it) and making it easier to suction out. UAL is a good choice for working on more fibrous areas, like the upper back or male breast area. It takes longer than traditional liposuction (SAL) because after ultrasonic liposuction, it is still necessary to perform suction-assisted liposuction (SAL) to remove the liquified fat. There is slightly less blood loss. There appears to be slightly more risk of seromas (pockets of fluid) which may have to be drained with a needle and skin necrosis (tissue damage leading to localized skin loss). Vaser ®, also known as liposelection ®, is one of the most popular ultrasonic devices used. 

 Vaser probe

c.4) Laser-assisted liposuction (LAL)

Laser assisted liposuction uses thermal and photomechanical energy to affect the lipolysis. The addition of a laser to traditional liposuction possibly increases skin tightening effects through tissue coagulation. It is believed that this procedure offers certain benefits, such as smaller incision with less scarring, less pain, faster healing, less bruising, and increased tightening of the skin. However, the efficacy of this technique as opposed to traditional SAL is still being debated, due to a lack of scientific studies proving its effectiveness and results. There are a number of companies who have developed different liposuction lasers, as follows: SmartLipo ®, CoolLipo ®, ProLipo Plus ®, LipoLite ®, LipoTherme ®, LipoControl ®, SlimLipo ®. 

 Laser Probe

c.5) Twin-cannula (assisted) liposuction (TCAL or TCL)

Twin cannula (assisted) liposuction uses a tube-within-a-tube specialized cannula pair, so that the cannula which aspirates fat, the mechanically reciprocated inner cannula, does not impact the patient's tissue or the surgeon's joints with each and every forward stroke. The aspirating inner cannula reciprocates within the slotted outer cannula to simulate a surgeon's stroke of up to 5 cm (2 in) rather than merely vibrating 1–2 mm (1/4 in) as other power assisted devices, removing most of the labor from the procedure. There's a video on youtbue that better illustrates this method of liposuction (Airbrush Liposculptor ®) - CLICK the link below. A good advantage would be to prevent fatigue in the surgeon, even though the results should be similar to traditional liposuction.

c.6) Water-assisted liposuction (also waterjet-assited liposuction) (WAL)

Waterjet-assisted Liposuction (WAL) was developed by the German company Humanmed in conjunction with German Plastic Surgeons with the aim of improving the results, safety and recovery of liposuction surgery. The Body Jet (R) device has been in use since 2004 but only recently achieved FDA approval. WAL uses a thin fan-shaped water beam, which loosens the structure of the fat tissue, so that it can be removed by a special cannula. During the liposuction the water is continually added and almost immediately aspirated via the same cannula. It is believed that the blood vessels are kept intact, hence less bruising and swelling should be expected after WAL than any other liposuction technique. The utility of this technology is under study and is currently not widely used.

When I was still a resident in 2008, we had a German plastic surgeon come to Brazil and performed a demonstrative procedure in a patient and I had the privilege to participate as his first assistant. The procedure was a little messy due to the high infiltrate volume. The results were similar to any kind of liposuction described previously in this article. 

c.7) External ultrasound-assisted liposuction (XUAL or EUAL)

XUAL is a type of ultrasound-assisted liposuction (UAL) where the ultrasonic energy is applied from outside the body, through the skin. Then, the surgeon needs to suction the fat out through the traditional method (SAL). At this time however, it is not widely used and studies are not conclusive as to its effectiveness. It has also been used as a non-operative and non-invasive technique for emulsifying fat deposits.

d) Superficial x Deep Liposuction:

Most areas of our body have two distinct fat layers:  superficial and deep.  Liposuction is mainly based on the removal of fat tissue from the deep layers. Superficial liposuction is mostly used to obtain a thinner flap with good retraction of the skin as well as to improve cosmetic results in specific areas, for example the abdomen and neck. Note that superficial liposuction should be avoided in some other areas, such as outer thighs (saddle bags), due to increased risk of indentations and worsening of pre-existing cellulite. If overdone, superficial liposuction may lead to conspicuous contour irregularities and excessive skin retraction.

 Contour irregularities (due to superficial liposuction)

4) Innovations

Abdominal Etching: or Ab etching, is a plastic surgery procedure that uses a special cannula to contour and shape abdominal fat pad to provide patients with a flatter stomach. The procedure selectively removes a small amount of fat around the patient's natural muscular contours and shapes or sculpts the abdomen to create a more athletic contour (the famous 6-pack).

5) Combined with other procedures

Liposuction can work as useful adjunts to other procedures, such as rhytidectomy( facelift), mastopexy (breast lift), abdominoplasty (tummy tuck), lower body lift, thigh lift, or buttock lift. In addition, fat can also be used as a natural filler. This is sometimes referred to as "autologous fat transfer (or fat grafting)" and in general, for these procedures, fat is removed from one area of the patient's body, cleaned, and then re-injected into an area of the body where contouring is desired, for example, to reduce or eliminate wrinkles.

Sharp cannulas without suction can be used as a treatment for cellulite, the dimpled skin that typically appears on the thighs, hips, and buttocks.

6) Recovery (briefly discussed here)

Depending on the extent of the liposuction, patients are generally able to return to work between two and ten days. A compression garment and bandages are worn during weeks to months. It is common to happen temporarily after surgery: bruising, swelling, pain (controlled by prescribed medications), numbness, and apparent scars. These will fade after some time.

Most common complications: small contour irregularities and insufficient fat removal.

NEXT ARTICLE WILL BE ON NON-SURGICAL ALTERNATIVES TO LIPOSUCTION

References

1. Mark Laurence Jewell. Lipoplasty. In: M. Eisenmann-Klein, Constance Neuhann-Lorenz, eds. Innovations in Plastic and Aesthetic Surgery. Springer, Berlin Germany; 2006:439-444
2. De Souza Pinto et al. Liposuction and VASER. Ibid, 108-110
3. Information from the US Food and Drug Administration
4. http://seattletimes.nwsource.com/html/living/2008109157_undergarment13.html. 
5. www.liposuction.com
6. http://en.wikipedia.org/wiki/Liposuction
7. Lee Y, Hong JJ, Bang C. Dual-Plane Lipoplasty for the Superficial and Deep Layers. Plastic and Reconstructive Surgery. Volume 104(6), pp 1877-1884, 1999. 
8. Johnson D, Cormack GC, Abrahams P, Dixon A. Computed Tomographic Observations on Subcutaneous Fat: Implications for Liposuction. Plastic and Reconstructive Surgery. Volume 97(2), pp 387-396, 1996. 
9. De Souza Pinto EB, Erazo I, Prado Filho FS, et al. Superficial liposuction. Aesthetic Plastic Surgery. Volume 20: p 111, 1996.
10. Gasparotti M, Lewis CM, Toledo LS. Superficial Liposculpture: Manual of Technique. New York: Springer-Verlag, 1993.