57. Liposuction

Cedric L. Hunter, Rohit K. Khosla, Jeffrey R. Claiborne, Simeon H. Wall, Jr.

■ First recorded attempt at lipectomy is attributed to the French surgeon Dujarier, who, in the 1920s, attempted to remove fat from a dancer’s calves using a uterine curette.¹

• Vascular damage resulted in amputation of the leg.

■ In the mid-1970s Giorgio Fischer and his father, Arpad Fischer, developed the “cellusuctiotome,” an instrument made of a hollow curette and blade attached to a suction pump. This method had a high rate of bleeding complications.

■ Yves-Gerard Illouz and Pierre Fournier improved on the prior techniques by replacing the sharp curettes of the 1970s with a cannula and suction system, the introduction of a “wetting solution” containing saline solution and hyaluronidase, and the use of a “crisscross” technique.

• These methods decreased bleeding and contour-associated complications.

■ In the 1980s a dermatologist, Jeffrey Klein, introduced the tumescent technique.

• Tumescent technique: Subcutaneous infiltration of a large volume of diluted lidocaine and epinephrine that expands the fat compartment causing it to become swollen and firm, or tumescent

• Provides local anesthesia and reduces blood loss

ANATOMY

SUBCUTANEOUS LAYERS (Fig. 57-1)

Fig. 57-1 Differences in subcutaneous tissues in various areas of the body.

■ Subcutaneous adipose tissue is divided into superficial and deep layers throughout the body by Scarpa fascia or the superficial fascial equivalent.²

■ For purposes of body contouring, the subcutaneous fat is arbitrarily divided into three layers.3

• Superficial

► Dense fat, adherent to overlying skin

► Aggressive, avulsive, or thermal liposuction methods should be used with great caution in this layer to prevent contour irregularities and skin damage.

• Intermediate

► Safest layer

► Most commonly suctioned layer

• Deep

► Loose and less compact layer

► Can be removed safely in most areas

ZONES OF ADHERENCE (Fig. 57-2)

Fig. 57-2 Zones of adherence.

■ Distal iliotibial tract

■ Gluteal crease

■ Lateral gluteal depression

■ Middle medial thigh

■ Distal posterior thigh

CAUTION: Be very cautious removing fat from zones of adherence. The stiff fibrous network predisposes these areas to postoperative contour deformities.

CELLULITE (GYNOID LIPODYSTROPHY)

■ Peau d’orange and mattresslike deformity seen primarily in women and obese patients

■ Two types⁴

• Primary or cellulite of adiposity: Results from hypertrophic fat cells in the superficial fat between the septa of the superficial fascial system

► Typically present when supine and erect, seen in younger women

■ Check for deviation from ideal contour (Fig. 57-3).

Fig. 57-3 Ideal contour. A, Female. B, Male.

• Female ideal contour

► Concavity below the rib cage that changes to a convexity over the hips and thighs

► Medial and lateral thighs have mild convexities.

► The buttock crease blends laterally with thigh.

• Male ideal contour

► More linear silhouette, less concavity and convexity below rib cage and over thighs

► The buttock crease is squared and linear.

► Flat anterior infraumbilical region

• Note any of the following:

► Asymmetries

► Dimpling/cellulite

► Location of fat deposits

► Areas of adherence

► Hernias and myofascial diastasis

• Check skin laxity.

• Examine spine for scoliosis.

► May cause asymmetry

• Assess for hernias/diastasis.

• See Chapter 3 for further details on photography.

PERIOPERATIVE CONSIDERATIONS

PREOPERATIVE

■ Complete blood cell count if expecting to perform large-volume (>5 L total lipoaspirate) procedure

■ Perioperative IV antibiotics

■ Deep venous thrombosis prophylaxis

• Intermittent pneumatic compression devices should be used intraoperatively.

• Chemoprophylaxis may be given to those at higher risk (see Chapter 11).

HYPOTHERMIA

■ Forced-air warming blankets

■ Consider circulating warm water mattresses

■ Cover exposed body areas.

■ Warm intravenous fluids.

■ Warm operating room.

■ Warm wetting solutions.

POSITIONING

■ Pad all pressure points.

■ Prone position

• Protect face, breasts, and genitals.

• Soft hip roll beneath iliac crest

■ Supine position

• Arm abduction <90 degrees to prevent brachial plexus injury

• Hips and knees flexed at 30 degrees with a pillow

MARKINGS (Fig. 57-4)

Fig. 57-4 Markings. Circled Xs are over zones of prominence, and lines are over zones of adherence.

■ Patients should be marked when they are in an upright position or standing.

■ Use marker to outline areas to be treated.

■ Mark zones of adherence and other areas to be avoided with parallel lines or cross-hatch marks.

INCISIONS

■ Longer for ultrasound-assisted liposuction (UAL) compared with suction-assisted liposuction (SAL) (6-8 mm versus 2-3 mm, respectively).

■ Incisions can be placed anywhere adjacent to areas being treated.

■ Multiple incisions are used for access to target areas, and ideally they are strategically located to allow crisscross suctioning.

• Liposuction from a single access incision may lead to contour deformity.

■ Locations (Fig. 57-5; Box 57-1)

Fig. 57-5 Incisions for buttocks, medial thighs, and abdomen.

LIPOSUCTION CANNULAS5

■ Most tips are blunt with multiple openings set back from the end to allow suctioning of fat with passage of the cannula.

• Blunt tips limit risks of penetration of unwanted structures such as fascia, peritoneum, vessels, and nerves.

■ Suction cannulas range from 1.8 mm up to 1 cm in diameter (typical use for liposuction is 2.5-5.0 mm) with varying cannula lengths.

• Larger suction cannulas are typically used for deeper tissue.

• As suction cannula size increases, the rate of fat removal with each pass increases, as does the risk of contour irregularities.

PHYSICS AND THEORY OF LIPOSUCTION⁶

■ SAL removes fragmented fat through a cannula and tubing into a receptacle.

■ Fragmentation of fat

• “Jackhammer effect”: The cannula striking fatty tissue

• The avulsion of fat into the islets of the cannula as the cannula moves in and out

■ Rate of fat aspiration

• Directly proportional to the diameter of the cannula and suction tubing

• Directly proportional to vacuum pressure

• Inversely proportional to the length of the cannula

• Poiseuille law concepts

► R = (L/r⁴) × K, where R is the resistance, r is the radius of the tube, L is the length of the tube, and K is a constant factor

WETTING SOLUTIONS

PURPOSES

■ Volume replacement

■ Hemostasis

■ Analgesia

■ Klein recipe7

• 1000 ml normal saline solution

• 50 ml 1% lidocaine plain

• 1 ml 1:1000 epinephrine

• 12.5 ml of 8.4% sodium bicarbonate

► Alkalization may decrease pain with infiltration, but is not needed with general anesthesia.

WETTING SOLUTION TECHNIQUE⁸ (Table 57-1)

Table 57-1 Wetting Solution Infiltrate and Estimated Blood Loss by Technique

Infiltrate may contain lidocaine, epinephrine, and/or sodium bicarbonate, depending on surgeon’s preference.

LIDOCAINE IN WETTING SOLUTION^7,9–11

■ Analgesia is provided for up to 18 hours postoperatively.

■ Recommended maximum is 7 mg/kg in the presence of epinephrine (4 mg/kg in the absence of epinephrine).

■ The estimated maximum safe lidocaine dosage using the tumescent technique is 35 mg/kg.

• Peak plasma concentration is 10-14 hours after infiltration.

• Klein’s original study noted doses up to 52 mg/kg with no adverse effect; this has been confirmed in other studies.

• Objective signs of lidocaine toxicity at plasma concentration >5 µg/ml

■ Use of high quantities of lidocaine made possible because of:

• Diluted solution

• Slow infiltration

• Vasoconstriction of epinephrine

• Relative avascularity of fatty layer

• High lipid solubility of lidocaine

• Compression of vessels by infiltrate

LIDOCAINE TOXICITY12 (Table 57-2)

Table 57-2 Plasma Lidocaine Levels and Symptoms of Toxicity

LIPOSUCTION TECHNIQUES

SUCTION-ASSISTED LIPOSUCTION (SAL)^8,13

■ Surgeon’s arm provides energy.

■ Movement of cannula results in mechanical disruption and avulsion to allow fat cell aspiration.

■ External source of suction to facilitate fatty tissue removal (usually 300-600 mm Hg)

ULTRASOUND-ASSISTED LIPOSUCTION (UAL)^13–16

■ First described by Zocchi¹⁵ in 1992

■ Piezoelectric crystals in the probes convert electric energy into high-frequency sound waves that interact with tissue to create interstitial cavities and cellular fragmentation—a process termed, “cavitation.”

• Adipose is more susceptible than muscle, fascia, or neural tissue.

• The emulsified fat is then removed through the cannula.

• Heat is generated as a byproduct.

■ Use a hollow cannula or a solid probe.

■ UAL with improved contouring over SAL for fibrous areas such as:

• Upper abdomen

• Back

• Flanks

• Gynecomastia

■ Three-stage technique

• Stage I: Subcutaneous infiltration with wetting solution

• StageII: Ultrasound treatment to emulsify fat

• Stage III: Evacuation of emulsified fat and final contouring with SAL

■ Key factors to UAL

• The stroke rate is slower than with traditional SAL to allow time for cavitation.

• The dry technique should never be used with UAL (minimum superwet environment).

• The cannula/probe must be moving at all times to limit thermal injury.

• The endpoint is a loss of resistance to probe advancement (Table 57-3).

POWER-ASSISTED LIPOSUCTION (PAL)5,13,17,18

■ Augmented SAL with externally powered reciprocating cannula replicating the to-and-fro motion of the operator’s arm¹⁹

■ Approximately 2 mm motion at rates of up to 4000-6000 cycles/minute

• Electric energy source or medical grade compressed air

• Less wetting solution is required compared to UAL.

■ PAL advantages

• Decreased surgeon fatigue

• Large volumes

• Revision liposuction

• Shortened procedure times

■ PAL disadvantages

• Operator discomfort induced by vibrating handpiece

• Noise generation

• Equipment cost

LASER-ASSISTED LIPOSUCTION (LAL)5,17,20

■ Technique involves subcutaneous insertion of a laser fiber via a small skin incision.

• Fiber is either housed with a cannula or as a single fiber.

■ Most commonly used wavelengths in the United States

• 924/975 nm, 1064 nm, 1319/1320 nm, and 1450 nm

■ Laser acts to disrupt cell membranes and emulsify fat by photothermolysis.

• Different wavelengths vary in their effectiveness to preferentially target adipose cells and photocoagulation of small vessels while excluding surrounding structures.

■ Previously marketed for skin-tightening effect (mostly anecdotal)

• Theory: Heating of the subdermal tissue contributes to possible skin-tightening effect.

• Studies have shown no difference between LAL and conventional techniques.

■ Four-stage technique

• Stage I: Subcutaneous infiltration with wetting solution

• Stage II: Application of energy to the subcutaneous tissues with laser probe

• Stage III: Evacuation of emulsified fat with SAL

► Some advocate skipping this stage in smaller regions (neck) and allowing the body to absorb the liquefied contents.

• Stage IV: Subdermal skin stimulation

■ LAL advantages

• Decreased intraoperative blood loss

• Decreased postoperative ecchymosis

• Possible skin tightening (not confirmed)

■ LAL disadvantages

• Potential thermal injury to skin

• Equipment cost

• Prolonged procedure time

• Increased scarring in adipose tissue bed

• Cannula misguidance due to diminished resistance

WATER-ASSISTED LIPOSUCTION (WAL)^21,22

■ Technique uses a dual-purpose cannula to emit pulsating, pressurized, fan-shaped jets of wetting solution with simultaneous suctioning of the fatty tissue and instilled fluid.

• Injected fluid loosens fat cells while minimizing surrounding soft tissue damage.

■ Can be done in office setting under local anesthetic

■ Two-stage technique

• Stage I: Subcutaneous preinfiltration with wetting solution

► A standard wetting solution for local anesthesia and vasoconstriction

• StageII: Simultaneous infiltration of “rinsing solution” and aspiration

► Lower infiltration setting and lower lidocaine concentration

• Endpoint: Final contour and pinch test

■ WAL advantages

• Reduced pain for patient

• Decreased need for general anesthesia

• Patient awake and able to change positions

■ WAL disadvantages

• Equipment cost

• Prolonged procedure time

RADIOFREQUENCY-ASSISTED LIPOSUCTION (RFAL)23,24

■ Technique uses bipolar radiofrequency energy to disrupt the adipose cell membrane and facilitate lipolysis.

• A hollow cannula allows simultaneous aspiration of liquefied fat.

■ Allows a constant treatment depth

■ Controlled thermal injury at subdermal surface may lead to skin-tightening effect.

■ The external electrode has a thermal sensor that measures skin temperature to prevent thermal injury.

• Once the skin reaches 38°-42° C, thermal heating is complete and completion SAL or PAL contouring is then performed.

• Approximately 30% of aspiration occurs during RFAL.¹⁷

■ Three-stage technique

• Stage I: Subcutaneous infiltration with wetting solution

• Stage II: Radiofrequency energy treatment to emulsify fat

• Stage III: Evacuation of emulsified fat and final contouring with SAL or PAL

• Endpoint: Loss of resistance to forward motion rather than pinch or palpation

■ RFAL advantages

• Decreased surgeon fatigue, especially in fibrous areas

• Decreased ecchymosis

• Possible skin-tightening effect

■ RFAL disadvantages

• Potential thermal injury

• Equipment cost

• Prolonged procedure time

Related posts:

5. Basics of Anesthesia for the Aesthetic Surgery Patient 17. Ablative Laser Resurfacing 35. Lower Blepharoplasty 53. Mastopexy Tissue Glues Nasolabial Fold

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