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Disclaimer:

Author has no financial interests in any company involved with liposuction and if any company name is mentioned it is only for clarification and does not denote any preference.

History of Liposuction

Europe:

1926: France - Dujarier - Curettage removal of fat from the ankle of a ballerina, who then suffered gangrene and amputation.

1960's: France - Surgeons used primitive curettage techniques with morbidity and excess bleeding.

1974: Italy - Fischer a Gynecologist used rotating blades in a cannula to remove fat.

1977: France - Illouz reported modifications with blunt cannulas and fluid infusion plus high pressure vacuum (suction).

1977: France - Fournier worked with Illouz and used syringes to remove fat.

America:

1986: Crocket, Dolsky, Lack, Leventhal, Nathanson and Jackson visited London, France and Italy, observing surgeons using different modalities at that time and then brought back their information and openly taught liposuction in the United States under the auspices of the AACS. Other early teachers were Elam, Fenno, Tobin and others.

1985: Klein and Lillis described in detail a method of injecting large amounts of dilute local anesthesia (lidocaine and epinephrine) into the tissue to be liposuctioned so that the liposuction could be done with little or no bleeding under conscious sedation or no sedation at all.

LIPOSUCTION TECHNIQUES:

Dry Technique: (No longer used - dangerous!) Required general anesthesia as no local anesthesia was used. Much more bleeding and blood loss often requiring blood transfusion.

Wet Technique: Also required general anesthesia. Small amounts of local anesthesia and Epinephrine.
Blood loss still excessive - (15%-20% of aspirate) and therefore still dangerous.

Super Wet Technique: About half the volume of local anesthesia was used compared with Tumescent technique but still generally required general anesthesia. Blood loss about 8% of aspirate and was more than Tumescent but less than Wet technique.

Tumescent Technique: "Tumescent" means swollen and firm - obtained by injection of large amounts of DILUTE Lidocaine and Epinephrine, 5-40 times the amount commercial preparation: 1 gram of lidocaine + 1 mgm. of epinephrine in 50ml. vs Tumescent: 1 gram lidocaine + 1 mgm. epinephrine in 1000ml.

Advantages:

Epinephrine causes vasoconstriction which results in much less bleeding and slow absorption of lidocaine with much less chance of toxity.

Absorption of undiluted preparation - 1 hour

Absorption of tumescent preparation - 24-36 hours

Slow absorption of Epinephrine does not result in huge increases in heart rate as seen with undiluted preparations such as are used in dentistry.

Less IV fluids are required as much of the tumescent fluid is absorbed by osmosis.

Due to the very efficient local anesthesia that can be obtained, much less IV sedation is needed and general anesthesia can be avoided with its inherent risks.

Ultrasonic Liposuction(UAL): Required large doses of tumescent fluid and used a metal probe (sometimes with a fluid cooling sleeve) or a metal paddle. This form of ultrasonic liposuction has been pretty much discarded due to skin burns as heat was generated by the ultrasound energy near the skin portal.

Vaser Ultrasonic Liposuction: Again an ultrasonic method of emulsifying fat which is then removed by traditional liposuction. Requires protective ceramic skin sleeves. Also called Liposelection.

Power Assisted Liposuction (PAL): Uses 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. Allows for less fatigue to the surgeon due to easier passage of the cannula through the tissues.

Tickle Lipo - Nutational Infrasonic Liposculpture (N.I.L): The low frequency infrasonic vibration apparently allows for removal of body fat while apparently respecting the other body tissues, claiming to result in smooth contouring and more rapid recovery. The whirling nutational motion apparently works well in more fibrous areas, secondary liposuction, backs and males and is said to be less tiring to operators. Cannulas are activated by air pressure so no heat is envolved. Fat removed is said to contain more viable fat cells and more adipose derived regenerative cells (ADRC's).

Laser Liposuction:

SmartLipo: Claims to emulsify fat, cause small blood vessel coagulation and cause collagen retraction and skin tightening.

Uses different wavelengths for these functions.

1064nm - for liquefying fat
1320nm - for stimulating collagen formation

SmartLipo Triplex: uses an added wavelength 1440nm - said to have better targeting by fatty tissue. CoolLipo: Said to be designed specifically for smaller areas of fat such as in the face or neck. Uses 1320nm wavelength for collagen effect and skin tightening and a short pulse with high peak power said to protect tissues other than fat.

ProLipo Plus: Also uses two wave lengths 1064 and 1319 (1320) separately or together.

LipoLite: Tiny cannula and fiber optic laser apparently allow for minimal invasiveness for small resistant areas. Uses short pulses of low energy or longer pulses of higher energy. Said to be useful in areas that are more fibrous like in gynecomastia. May be combined with traditional liposuction for larger areas.

Lipotherme with LipoControl: Small laser in a cannula but the wavelength is 980nm. LipoControl is the addition of an actual screen image of the patient's area of treatment beneath the skin so the surgeon can see what they are doing using heat imaging to map the location of the laser. The laser power strengthens and weakens as the surgeon moves the cannula under the skin and switches off, if the surgeon stops.

Said to be useful for small precise areas.

Cellulaze: Small laser introduced through a small cannula to break up small pockets of fat, then SideLaze is used to thermally subcise fibous septae and then the laser is used to deliver energy to the hypodermal layer to heat the collagen and thus obtain skin shrinkage.

Water assisted liposuction: The water jet assisted liposuction uses a slightly pressurized stream of saline to dislodge the fat cells which are simultaneously removed by liposuction. The procedure claims to be minimally invasive with less force needed to remove the fat, less bruising and swelling with shorter recovery time.

Liposuction with Radiofrequency (BodyTite): A probe is introduced under the skin and a transducer is attached and is situated above the skin opposite the end of the probe where energy flows between the two. Heat is monitored by the external skin portion of the device and will turn off the device if the temperature of the skin rises above a certain level - usually set at 38 degrees. Claimed advantage is easier liposuction, less bleeding due to coagulation of vessels and significant skin tightening.

Non-Invasive Body contouring devices: As these are not actually accomplishing liposuction, they have not been included in this discussion.

CONCLUSIONS:

Many different modalities and techniques have been introduced for body contouring in the last four decades. Many have been discarded and some are still being investigated in the hope of finding the perfect answer, but overall with liposuction some statements are self-evident:

  • Tumescent liposuction is essential for all techniques
  • For inexperienced, beginning operators "less is more" - that is rather do multiple sessions of liposuction than attempt to suction out more than recommended amounts.
  • Use small cannulas carefully as they could penetrate vital organs more easily.
  • Use small cannulas superficially to get smoother results.
  • Use large cannulas carefully as they can remove too much fat and establish a tract that can be difficult to avoid re-entering. Use them only deeply in patients with thick layers of fat.
  • Be careful with lasers - they can cause complications.
  • Do not jump right into a new technique without careful consideration, observation of more experienced surgeons, and discussion with your peers. Buying the wrong or soon to be obsolete device can be a costly mistake.
  • Manufacturers usually make very strong claims regarding their product.
  • Great results can still be obtained with simple techniques. Start with the basics and work up to more complex techniques.
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A. Chasby Sacks, MD, CIME, MB BCh, FAACS., FICS, is board certified by the American Board of Cosmetic Surgery and he is also a full Fellow of the American Academy of Cosmetic Surgery. He has been in private practice for 40 years. Dr. Sacks is a member of the American Society of Liposuction Surgery, the American Society of Cosmetic Breast Surgery, and is a Fellow of the International College of Surgeons. He has served on the Board of Trustees of the American Academy of Cosmetic Surgery where he also has served as Treasurer. Dr. Sacks currently is a Trustee of the American Board of Cosmetic Surgery, has served as their Treasurer, and is also an examiner for this Board's examination process.

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