Chapter 19 Liposculpture
Introduction
Liposculpture is a technique used to restore or improve facial and body contouring by removing localized fat deposits with small blunt-tipped cannulas connected in a suction device. This procedure can be associated with injections of the removed autologous adipose tissue where needed.1,2 It is also named as liposuction, lipoplasty, suction lipectomy or suction-assisted fat removal.
The development of liposuction techniques made the autologous fat injection a more reliable procedure. The term liposculpture was initially used by Fournier to describe syringe liposuction associated with fat injection.3 However, considering the etymology of the word ‘liposculpture’, its concept can be extended for all of liposuction techniques because most of these procedures are performed to improve body shape only by removing fat deposits.
Although many authors have reported good results with the use of suction-assisted liposuction, power-assisted liposuction or ultrasonicassisted liposuction.4,5,6 or vibrating cannulas, others support the use of syringe liposculpture,7,8,9 mainly because this technique is precise and promotes less trauma of the adipose tissue. Therefore, this chapter will detail the main liposculpture techniques with special attention for syringe liposculpture.
Considerations About the Adipose Tissue
Adipose tissue is composed by fat cells organized in lobules. Each lobule has its own vascularization. Adipose cells are originated from fibroblast-like cells, called preadipocytes, which develop to become a mature adipose cell. These cells increase in number along childhood and adolescence10
Therefore, the number of cells is constant along adult life. The accumulation of fat occurs by the increase in deposition of the intracellular lipid, not by the increase of number of adipose cells.11,12
Fat cells are extremely delicate, and should be manipulated with special care.13 Therefore, the amount of viable fat cells will depend on the liposuction technique.
Adipose tissue is divided in two layers: the superficial layer and the deep layer. The superficial layer, also named areolar, represents small compact fat lobules that are separated by a greater number of membranes (septa). Its thickness is uniform in all of the body parts. The deep layer is also named reticular or lamellar ayer. In this layer fat lobules present an irregular distribution as well as a small number of membranes (septa) that show an irregular pattern when compared with the superficial layer.14
The accumulation of fat occurs in the adipose tissue of the deep layer. Patients who are classified as obese present an increase in thickness of this layer.15
Body adipose tissue deposits present variations depending on the gender and the type of hormones. Therefore, presentation will be in two distinct patterns: androgenic pattern and gynecoid pattern. Men present with the androgenic pattern when fat deposits will occur in the abdomen and dorsal regions. On the other hand, women present with the gynecoid pattern when fat accumulation occurs in thighs and ankles.16
Indications
Liposculpture is essentially used for body contouring for aesthetic and reconstructive purposes by the removal of fatty deposits with or without re-injection of the removed fat.10 The technique was described for the treatment of localized fat deposits that may not have responded to efforts of weight loss through exercise and dieting. It is important to stress, however, that liposuction is not a weight-loss method.16 Patients submitting to liposculpture should present with good skin elasticity with no flaccidness or a less elastic skin, as skin in this condition does not tighten so readily around the newly contoured shape.14
Penile augmentation can also be done with fat injection. Panfilov (2006)20 showed that the circumference of the penis increased 2 cm to 3 cm in 88 patients.
Liposuction techniques are also indicated for reconstructive purposes mainly to reduce flap thickness. It also can be used in association with fat transplantation to treat Romberg’s disease, HIV-related lipodystrophy, hemifacial microsomia syndrome and to correct liposuction sequelae.13,21
Other reconstructive indications include: laryngoplasty22 and treatment of urinary incontinence by lipoinjections in the periurethral area.23
Anesthesia and Preoperative Preparation
Liposuction can be performed under local anesthesia with or without intravenous sedation, regional anesthesia (epidural or spinal) and general anesthesia.14
Preparation of the Adipose Tissue to be Aspirated, Materials Used to Perform Liposuction and Surgical Techniques
Since the initial description of the liposuction technique, there has been a significant evolution regarding the preparation of the adipose tissue to be aspirated as well as the operative techniques and the surgical instruments used.24 Therefore, these three aspects of the liposuction techniques will be discussed in detail.
Preparation of the adipose tissue to be aspirated
Preparation of the adipose tissue is also known as ‘injection of the liposuction fluid’. This is very important mainly because the fluid injection determines the amount of fat to be aspirated, the amount of blood loss during the procedure and has a role on some postoperative complications.25
The liposuction technique was initially described with an initial injection of a hypotonic solution containing saline (100 cc), distilled water (20 cc), hyaluronidase (100 U) and epinephrine (0.1 cc).15,21 The purpose of this was to damage the fat cell membrane thus making the later aspiration of the adipose tissue easier.
Fournier, in 1983, described the liposuction technique with no previous injection of hypotonic fluids. This technique was named the dry method. According to this author the hypotonic solution did not damage the surface of fat cells and also increased surgical time. The main disadvantage of the dry method was the greater amount of perioperative blood loss, which required postoperative blood transfusion.3 This method is seldom used today.
In the tumescent method a larger amount of fluid is injected into the area to be aspirated; as much as 2-3 times the volume of adipose tissue to be aspirated. The volume of blood loss is about 1% of the final aspirated volume.16
