Word count: 2529



Word count: 2529

Lipoplasty, Suction Assisted

Mark A. Brzezienski and James G. Hoehn

Department of Surgery, Division of Plastic Surgery

The Albany Medical College

Albany, NY USA

The unifying concept of body contouring surgery is the search for the "ideal" body image. It is this continuing quest by both patients and aesthetic surgeons which has precipitated an exponential rise in the performance of suction-assisted-lipoplasty to remove inappropriately distributed fat. Throughout the last two decades, improved training, surgical technique, and medical management of patients has catapulted suction-assisted-lipoplasty (SAL) from an experimental procedure to a staple in the repertoire of every aesthetic surgeon. In experienced hands, liposuction is now performed routinely, safely, with predictable outcomes, and minimal morbidity.

Obesity has now grown to become a significant health care problem in the United States. Liposuction, even with its ever expanding indications and usage, is in no way a panacea for the treatment of obesity or its incumbent health risks. Indeed some purists remain in the plastic surgical community who feel that its use should be limited to isolated unacceptable areas of fatty accumulation. There are many effective treatments for obesity, but patients who undergo a liposuction anticipating a "quick fix" for their excess weight without the benefits of an alteration in eating habits, exercise program, and behavior modification are being ill-served by their physicians.

History

Operative lipoplasty has been known since the early twentieth century when direct excision employing sharp dissection and curettage was used to remove aesthetically objectionable fatty deposits. The early years of this procedure were shrouded by unacceptable visual results and high complication rates. As late as the 1960's some surgeons reported good results with curette fat resection. However, the results of the technique were not uniformly reproducible and, therefore, discouraging to the surgical community.

The first breakthrough in lipoplasty came with the introduction of negative pressure attached to a curette which utilized a sharp cutting edge by Giorgio Fischer in the early 1970's. Even with these advancements, postoperative complication rates remained too high for many surgeons to venture into this field. However, other investigators such as Kesselring and Temourian advanced the technique by evolving to a larger bore back cutting curette and by confining their fat removal to the deeper fat planes. With these technical advances, the postoperative problems were mitigated and liposuction found its way into the surgical armamentarium.

Yves-Gerard Illouz, In the mid 1970's refined the procedure extensively, and his contributions remain in daily use. His technique involved the use of blunt cannulas, high vacuum suction, and the concept of the creation of multiple tunnels in the deep fat layer. It is this latter "tunneling process" which has served to maintain the vascular and lymphatic integrity and thereby limit injury to the soft tissue and skin overlying the operative site. Using injectable hyaluronidase and saline, he reported fewer complications and consistent, reproducible results. Simultaneously, Pierre Fournier had developed a cross-hatching aspiration technique employing vasoconstrictive, anesthetic injections.

Anatomy

Successful outcomes in suction lipoplasty, as in any surgical procedure, can only be reproduced with a thorough knowledge of the pertinent anatomy. The human body is essentially wrapped in two layers of fat separated by a defined fascial layer (Camper's Fascia). The more dense superficial layer provides a consistent protective padding for the body while the deeper layer is more variable in its thickness and possesses a looser character. It is this deep layer in which gender differences in fat distribution become more manifest. This layer is most amenable to liposuction cannula techniques. If the appropriate aesthetic is to be achieved by liposuction, it is important to reemphasize distribution is vastly sex-dependent. Whereas male adiposity is frequently found in the abdominal or central distribution, females will store fat in the breasts and the periphery, especially in the buttocks and thighs. The ideal waist or thigh thus differs considerably between the sexes, and surgery should be planned and patients informed accordingly.

Patient Selection

The key to a gratifying result in SAL is appropriate candidate selection. There are many facets to the evaluation of a patient for lipoplasty. The surgeon must concern himself, not only with the preoperative intercurrent medical problems; but also with any evidence of psychological or emotional instability. Performing SAL on patients who suffer from body image disturbances, low self esteem or other emotional difficulties without attention to the presenting problem will inevitably lead to patient dissatisfaction and physician frustration. One must be on the look out for the potential of unrealistic expectations, and detailed discussion concerning anticipated results with representative photographic "average" examples of the surgeon's work will aid in the development of a common understanding of the expected results.

Ideally, the candidate for SAL is young, with good skin turgor and isolated areas of excess fat accumulation. Unfortunately, the "ideal" candidate only rarely appears. More than likely, the patient may be middle aged or older with less than taut skin. Moreover, in addition to

localized fatty deposits, a general overweight condition is often present. These are not contraindications to SAL, but preoperative discussions must include a thorough understanding that poor skin turgor may lead to the necessity of later soft tissue resection to correct the loose sagging skin. With these medical and aesthetic caveats in mind, SAL has now begun to lend itself very effectively to the treatment of an ever expanding problem list.

Procedure

Pre-Operative Care

The operative risks of significant blood loss, fluid shifts, transfusion need and anesthesia are assessed carefully for each patient. The first level in the SAL decision making tree must concern itself with whether the procedure should be performed as an inpatient or an outpatient. This decision includes a thorough history and physical examination which is vital to review the patient's general state of health. Routine preoperative testing is then performed much as it is for any operative procedure. Anticipated lipectomy of less than 1500cc is usually safely performed as an outpatient, while resections above this

volume would be considered "large" and more appropriate for -the inpatient setting. Replacement transfusion guidelines vary. Between 15 and 30% of the aspirate from SAL is blood. Thus, the need for pre-operative autologous blood donation to replace intraoperative blood loss must be considered In patient selection, preoperative planning, and patient counseling. Recent studies have noted that fat volumes over 4500cc's can be safely suctioned from patients with mindful intraoperative monitoring, appropriate fluid resuscitation, and transfusion of autologous blood. Some practitioners transfuse patients who have achieved a predescribed aspirate volume, while others choose to individualize transfusion requirements.

SAL can be performed with either a local or general anesthesia. This decision is made after weighing several factors including volume of resection, patient comfort, safety, and physician choice. A general anesthesia, however, remains the standard for the usual Class I or II (low) risk patient undergoing SAL. Most surgeons will opt for some additional infiltrative technique for its hemostatic effects. The tumescent or local anesthetic technique with or without intravenous sedation is the used by many physicians. It relies upon the injection of large volumes of low concentration, anesthetic, vasoconstrictive solutions

into the proposed surgical site. The supporters of this method note that it eases the performance of a more bloodless liposuction without the necessity of a general anesthesia.

Operative Technique

The basic tools of liposuction include a set of blunt cannulas of which there are many styles. They should range from about 2mm in diameter for fine work to about 5mm in diameter. Additionally, a suction machine which produces an appropriate negative pressure provides the force of aspiration. The technique consists of creating small incisions in appropriate sites and passing the cannulas into the deep fatty layer thereby creating a labyrinth of tunnels and/or cross hatchings. The fatty tissue is suctioned away and the bulk of the undesirable area is depleted. The technique is easily learned, however, acquiring the finesse and judgement to create a dependable aesthetic result comes only with experience and attention to patient selection and technical execution.

On the day of surgery, the areas to be treated are marked in the standing position. Patterns such as a target or grid-like crosshatch, similar to that proposed for the passage of the cannulas are made with indelible ink. After transport to the operating room, the patient is prepped and draped accordingly. Incisions are made. Tunnels are created, and suctioning is commenced. Each tunnel receives multiple passes. Larger cannulas are used first then smaller cannulas to refine and blend the lipectomized areas with the surrounding virginal tissue. Movement today is toward the use of smaller and smaller cannulas. There are some surgeons, such as the liposuction pioneer Pierre Fournier, who adhere to the use of a small cannula "needle" and only the suction created by a 60cc syringe. After the operative resection has been completed the incisions are closed with a few fine sutures.

While still on the operating table, the patient is placed in a compressive garment, and/or an elastic tape wrap is applied. The routine use of these garments aids in the mediation of the usual early post operative findings. These findings include edema, bruising, fatigue, discomfort, and hematoma or seroma formation. Prophylactic antibiotics have become standard; and dogmatic adherence to sterile technique with regard to the cannulas and skin incisions will reward the practitioner with few, if any deep infections. Post-operative parenteral steroids are used by some surgeons to limit inflammation and edema, but this issue remains in the realm of surgical style.

Depending on the extent of the procedure, the patient is admitted to the hospital for postoperative monitoring, and fluid resuscitation or discharged to office follow-up. Pain is usually controlled with mild analgesics. Activities are strictly limited until post-operative examination and then gradually increased.

Though the visual effect of the fat removal is immediate, patients are reassured that their final result will not be visible for several months. The liposuctioned tissue, as does any injured tissue, must go through the usual wound healing response. Revisions are discouraged during this time period while patience and occasional physical therapy are advocated.

Expected Outcomes

The most common areas of application continue to be abdomen, flank, buttocks, and thighs. In "appropriate skin type patients", reduction of these areas can be accomplished without skin excisions. The medial knee, calf, and ankle can be contoured, but visualization of the final result is often forestalled by prolonged tissue swelling. Thick upper arms are amenable to SAL, but excellent skin tone is vital to avoid redundant skin folds. More recently, lipoplasty has been extended to the head and neck with gratifying results particularly with submental sagging and fatty accumulation. Combined procedures especially for the treatment of

gynecomastia, breast hypertrophy, and abdominal deformities are now frequently used with excellent results.

Other uses of the technique have included successful treatment of multiple lipomas, and axillary hyperhydrosis. SAL is also employed to harvest the fat grafts which are used for injection to correct contour deformities at various anatomic sites. Selected candidates have even had SAL techniques used to perform more formal facelift procedures. With the introduction of a new subdermal cannula and superficial lipoplasty method by Becker, post treatment skin contracture seems to have been enhanced. This may represent a conceptual advancement.

Satisfaction rates are usually high, but there is some dependence on the anatomic area treated. As in many aesthetic procedures, there are certain areas of the body which lend themselves more adaptably to the liposuction cannula than others. While SAL of the buttocks and thighs yields consistently superior results, the calves and ankles remain difficult areas to treat.

Complications

The best defense against an unacceptable result, once again, is appropriate patient selection. Like all surgical procedures, SAL does have complications, but fortunately, the vast majority are minor. Complications should be discussed with the patient prior to surgery to establish realistic expectations.

The most common complication of SAL is a post-operative contour irregularity. These deformities may be either precipitated at surgery or exaggerated by it. This problem is commonly described as an indentation, ripple, or asymmetry either due to overzealous fat removal or an isolated

intrusion into the superficial subdermal space. Permanent asymmetries such as ptosis may occur post-lipectomy producing an unpleasant result. However, proper patient selection should prevent this event. It is not uncommon for patients to go on to refinements of the areas of primary liposuction particularly if the aspirate volume from the area was high.

Other occasional complications include prolonged swelling, pigment changes, fluid collections, and changes in sensation in the overlying skin. These more minor and temporary conditions, may be treated by massage, or ultrasound therapy. Though not statistically confirmed, these modalities seem to aid in the improvement of these troublesome symptoms.

Systemic complications such as fat or pulmonary embolism, large volume blood loss, disseminated intravascular coagulation, necrotizing skin infections, and body cavity perforation are exceedingly rare but do occur. Other complications including untoward cardiac events and allergic reactions to medications are more often related to the anesthetic technique than to the operative procedure.

In nearly one thousand cases collected in a survey by Hanke, infection occurred in two, and excessive blood loss occurred in five. Aesthetically speaking, 2% of patients had some type of tissue irregularity, while 0.47% and 0.46% had hematoma or seroma formation and prolonged edema respectively.

As an overview regarding these problems, conversant knowledge of the idealized male and female anatomy, appropriate patient selection, reliable technique, and continuing patient education are essential to avoid the pitfalls which lead to a less than perfect result.

Summary

Throughout the past two decades, the field of aesthetic surgery has been witness to the birth and subsequent meteoric rise of a new technology. The technique and art of suction assisted lipoplasty has advanced through multiple refinements more rapidly then any cosmetic procedure in recent history. It is now considered a safe and routinely used tool which provides surgeons with predictable results. With responsible use, liposuction is an excellent technique; but it must be executed with knowledge and judgement at all times and tailored to each anatomic situation to produce the optimal aesthetic result.

References

1. Hetter, G.P. Aspirative Lipoplasty. In Groegiade, G.S., N.G. Georgiade, R. Riefkohl, and W.J. Barwick (eds.): Textbook of Maxillofacial and Reconstructive Surgery, Second Edition, Baltimore: Williams and Wilkins, 1992, p.767.

2. Grazer, F.M. Body Contouring. In McCarthy, J.G. (ed) Plastic Surgery, Volume 6, Philadelphia: W.B. Saunders, 1990, p.3964.

3. Lillis, P.J. and W.P. Coleman(eds), Liposuction. Dermatol. Clin., 8:3, 1990.

4. Caterson, I.D. Management Strategies for Weight Control-Eating, Exercise, and Behavior. Drugs 39(Suppl.3): 20, 1990.

5. Courtiss, E.H., R.J. Choucair, and M.B. Donelan: Large-Volume Lipectomy: An Analysis of 108 Patients. J. Plastic and Reconstr. Surg. 89: 1068, 1992.

6. Becker, H. Subdermal Liposuction to Enhance Skin Contracture: A Preliminary Report. Ann. Plastic Surg. 28: 479, 1992.

7. Drake, L.A., et al.: Guidelines of Care for Liposuction. J. Am. Acad. Dermatol. 24: 489, 1991.

8. Hetter, G.P. (ed): Lipoplasty: The Theory and Practice of Blunt Suction Lipectomy. Boston: Little, Brown and Co., 1984.

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