The next advance worthy of mention was that of Ulrich Kesselring.⁸^–¹⁰ Although he used sharp instrumentation attached to suction, he was the first to recommend working in the deep fat compartment just above the muscle fascia. His results were superior to previous ones presented, in no small measure due to his method of patient selection; he performed the procedure only on young women with small amounts of localized fat and elastic skin. Eventually, after a great deal of lively debate with Yves Gerard Illouz at a variety of plastic surgery meetings, Kesselring adopted Illouz’s technique.

Bahman Teimourian was the first surgeon practicing in the United States to make a significant contribution to the evolution of lipoplasty. His work was independent from the European surgeons. In 1976 he was still using scissors for undermining, which he followed by curetting with a modified fascia lata stripper attached to suction. He boldly extended his procedure to many body regions. His complication rate was 30%, characteristic of all curette techniques. He first reported on his technique in 1979 ¹¹ and then later as he modified it.¹²^–¹⁵ Teimourian recognized the importance of separate tunnels, as opposed to a “windshield wiper” type of approach to fat removal. He eventually adopted a cannula technique instead of curettage.

Illouz, briefly mentioned earlier, was responsible for monumental advances. He began in 1977, first reporting on his method in 1980.¹⁶^–¹⁸ His most important contribution was the introduction of blunt instrumentation, using a Karman cannula attached to very high vacuum. There was no undermining and no sharp instrumentation. In this way, he removed fat while sparing the other important structures between the undersurface of the dermis and the subjacent muscle fascia. As a result, complications were dramatically reduced, and the procedure became reproducible in the hands of many other surgeons. The technique was adaptable to a wide range of body regions and, for the first time, its potential as a mainstay of esthetic surgery became apparent. He first presented his blunt lipoplasty technique, which he called “lipolysis,” at the Shirakabe Clinic in Osaka, Japan in 1980. He was the first to introduce the “wet” technique, infiltrating 200–300 cm³ of infusate regardless of the expected volume of aspirate. Blood loss with this technique, as measured by the “lipocrit,” (the hematocrit determination in the infranatant portion of the decanted aspirate), was reduced to approximately 8–10%. By the time his milestone book, Body Sculpting by Lipoplasty, was published in 1989,¹⁸ he became familiarized with the SuperWet technique (the infusate-to-aspirate ratios of 1–1.5 : 1), which he adopted.

The evolution of the wetting solutions will be discussed later in this chapter. In respect to chronology, it is, however, appropriate to mention here that a significant contribution was made in 1984 by Hetter, who added epinephrine to the wetting solutions. This yet further decreased the aspirate lipocrit values to 4–8%. His book, The Theory and Practice of Blunt Suction Lipectomy, published in 1984, remains to this day a highly recommended text for students of lipoplasty at any level.^19,²⁰

Concurrently, Pierre Fournier and Francis Otteni of France were popularizing the use of syringes as the suction source for lipoplasty.²¹ They also favored noncutting edge cannulae. However, they unfortunately continued to advocate the “dry technique;” no wetting solution preinjection. As a result, with their method, lipocrits continued to hover around 20–40%.

Lipoplasty Begins and Gains Popularity in the US

In1982, Illouz presented his technique for the first time in the United States at the Annual Meeting of the American Society of Plastic and Reconstructive Surgeons (ASPRS, now the American Society of Plastic Surgeons, ASPS) in Hawaii. This incited a tremendous amount of interest among American surgeons. Shortly thereafter, then ASPS President Mark Gorney had the foresight to create the “Blue Ribbon Committee.” He appointed Simon Fredericks as Chair. The mission of this committee was to visit Illouz and evaluate his work. Upon their return, the Blue Ribbon Committee published a report with an extensive set of recommendations.

The committee also developed a strategy on how to gradually introduce the procedure to other US surgeons. It organized a number of teaching courses across the country, which did not, however, include live surgery demonstrations and were often taught by surgeons who had yet to perform a case.

Not long after the Blue Ribbon Committee’s visit to Illouz, another group of surgeons, led by Gregory Hetter, also visited the French surgeon at their own expense. This group, soon after their return in 1982, founded the Lipolysis Society, subsequently renamed the Lipoplasty Society of North America (LSNA). The primary mission of this new society was to teach the procedure to American surgeons. To this end, annually, about four “basic teaching courses,” which routinely included live surgery, were presented by the LSNA faculty. By the mid to late 1980s, the LSNA teaching symposia were in full swing. Within a 10-year period, more than 40 basic courses in lipoplasty were conducted. This resulted in widespread familiarization and adoption of the operation. Patient safety issues had a pivotal role during these teachings. Illouz was a faculty member at most of these courses. Fournier was also invited to some of the early sessions.

By 1992, it appeared that LSNA had fulfilled its mission and logic dictated that it should be amalgamated by the American Society for Aesthetic Plastic Surgery (ASAPS). This process, however, took yet another 10 years.

Lipoplasty by this time was now being performed by a rapidly growing number of surgeons around the world. Successful outcomes were consistently reproducible and, when compared to subcutaneous fat and skin excision procedures, the results of lipoplasty seemed almost “magical.”.

Wetting Solutions

When it comes to lipoplasty, safety is intimately interwoven with the proper use of wetting solutions, a subject of primary interest to me for many years.^19,²²^–²⁶

By 1986, having had significant clinical experience with the procedure, I became convinced that the most rational fluid volume infusion-to-aspirate ratio was 1–1.5 cm³ of infusate per cm³ of estimated aspirate, which I then termed the “superwet” technique. This was presented at many plastic surgery meetings and eventually in the plastic surgical literature. As a result of this technique, the lipocrit values were routinely reduced to 1%.

Soon after, in 1987, the tumescent technique was introduced by a California dermatologist, Jeffrey A. Klein. While lipocrit determinations using his approach also hovered around 1% (not unlike the superwet technique), excessive amounts of wetting solution containing local anesthetic, as the sole anesthesia delivery system for the procedure, were infused. Table 44.1 lists the lipocrit values reported for different lipoplasty approaches.

TABLE 44.1 Lipoplasty Approaches and Percentage of Blood Loss in the Aspirate as Determined by Lipocrit Measurements

Lipoplasty Wetting Solutions and Corresponding Lipocrit Values

When applied to major volume removals, Xylocaine toxicity ²⁵ and fluid overload could readily occur, potentially resulting in major complications. Some plastic surgeons, including a few with significant national reputations, not only adopted the tumescent technique but arduously promoted it. They advocated its application to larger and larger volume removals. A “perfect storm” was in the making, which predictably resulted in major lipoplasty complications and a growing number of fatalities nationally.²²^–²⁴ By the early 1990s, while lipoplasty was the most commonly performed esthetic surgical procedure it also had the lowest rate of complications. At this time, the “tumescent technique,” which consists of infusing massive amounts of wetting solutions, using tissue turgor as an endpoint, was popularized. These solutions contain large amounts of lidocaine (Xylocaine), attempting to provide simultaneous anesthesia for the procedure. Proponents of this technique consider the need for an intravenous line and the presence of an anesthesiologist during the procedure unnecessary. The tumescent technique, as popularized primarily by dermatologists,⁷ is the very gradual (up to 3 hours) installation of wetting solution until there is tissue turgor, the skin surface is white, and it has a peau d’orange appearance. Advocates of this technique state that they inject between 3 and 6 cm³ of wetting solution per cm³ of estimated aspirate. Thus, many liters of lidocaine-containing fluid may be injected, which amounts to a highly variable clysis.

The volumes removed as reported by the advocates of the technique often are much larger than with other methods. However, the aspirate contains much more of the instilled wetting solutions and cannot be compared with volumes by volumes when smaller amounts of wetting solutions are administered prior to aspiration. With the superwet method, for example, the supernatant fat routinely comprises as much as 75% to 80% of the aspirate. It is the reverse with the tumescent technique.

For small to moderate volumes of removal, any wetting solution technique is comparatively safe when performed in a healthy, young, aerobically fit patient. The potentially hazardous nature of massive wetting solution infusion techniques as applied to large-volume lipoplasty can result in fluid and lidocaine overload. This scenario was readily predictable ^22,²³ as the trend for using the tumescent technique for large-volume removals was adopted around 1994. As it turned out, unfortunately, the incidence of major complications and fatalities associated with lipoplasty rose rapidly after 1995 (Box 44.1). Consequently, the media and public’s perception of the procedure changed from a safe to a hazardous one.

BOX 44.1

Lipoplasty Fatalities in the United States

1982–1995: 12 deaths; primarily from sepsis, pulmonary embolus

Widespread adoption of tumescent technique

1995–1997: 100 deaths; primarily from fluid overload and lidocaine toxicity

The advantages of the superwet technique, as compared to the tumescent technique, have been amply presented by myself and others.²⁶^–²⁸

Patient tolerance to initial fluid load and the ability to maintain postoperative fluid and electrolyte balance are determined by many factors, such as general health, age, obesity, aerobic condition, volume of aspirate, and size of the surface area suctioned. All of these factors should be considered when determining the safe volume of infusate and aspirate. Flow sheets documenting input and removal volumes are recommended. Lipocrit measurements and the percentage of supernatant fat in the aspirate also are informative.

Xylocaine Toxicity

It is generally accepted that lidocaine up to 35 mg/kg, injected in the subcutaneous fat in solutions containing epinephrine, is safe. It is notable, however, that this dose is in direct contrast with the original recommendation of less than 7 mg/kg published in the Physicians’ Desk Reference. Absorption rates vary significantly, and measurements of peak plasma lidocaine levels are more meaningful than absolute amounts of injected lidocaine in assessing potential toxicity. The danger is amplified by the fact that lidocaine absorption from the subcutaneous fat can peak as late as 10 to 12 hours after injection, by which time the patient usually has been discharged from the surgical facility. Other factors can affect lidocaine toxicity, such as the amount of unbound versus protein-bound lidocaine. In turn, protein binding is influenced by several factors, such as stress, chronic disease, cigarette smoking, oral contraceptives, and anorexiants. Therefore, the correlation between total plasma lidocaine concentration and the predictability of specific toxicity occurring in a given patient is weak at best.²⁴

In summary, the benefits of the tumescent technique (e.g., low blood loss and decreased need for colloid and crystalloid replacement), are realized with the “superwet technique,” but without the hazards of delayed fluid uptake by large clysis, need for drainage, risk of pulmonary edema ⁹ and potential for lidocaine toxicity. Table 44.2 compares the tumescent and superwet techniques.

TABLE 44.2 Comparison of Superwet and Tumescent Techniques

	Superwet (~1 cm³/cm³)	Tumescent (~3 cm³/cm³)
Volume removal	+ + +	+ + +
Blood loss	0– +	0– +
Ecchymosis	+	+
Time to inject	+	+ + +
Fluid load	+	+ + +
Tissue turgor	0– +	+ + +
Ease to sculpt		? ?
Lidocaine load	0– +	+ + +

Ultrasound Technology Emerges

Beginning in 1987 and continuing to this day, there has been, in my opinion, an ill-founded enthusiasm for mechanical manipulation of adipocytes resulting in their fragmentation prior to aspiration. One of these widely popularized approaches is the use of ultrasound energy to emulsify the fat. In 1987, Professor Nicolo Scuderi of Italy was the first to describe ultrasound-assisted lipoplasty (UAL), after which a plethora of publications endorsed the practice of UAL.²⁹^–³¹

My initial impression of UAL was confirmed by a clinical study on my first 100 cases.²⁹ The protocol was to compare traditional suction-assisted lipoplasty (SAL) performed on one side with the results of UAL applied to the contralateral side during the same operation. In this way, patients served as their own control. It was concluded that the benefits of UAL, using all the different UAL devices available at that time, for the most part did not justify the shortcomings associated with its use. It was felt, however, that even at this early stage of the development of UAL devices (first and second generation), the technology offered some tangible benefits in treating body regions with fibrous fat and in secondary lipoplasty.²⁹

In 1997, a meeting in St. Louis, hosted by Leroy Young, was organized with the objective of facilitating the exchange of ideas between leading biophysicists with interest in how ultrasound energy affects adipocytes. In addition to American board certified plastic surgeons, industry representatives were also asked to participate. After meeting William Cimino, one of the PhD biophysicists present, I had the opportunity to offer my clinical contributions to him as he was developing vibration amplification of sound energy at resonance (VASER). This third-generation ultrasound lipoplasty device, when compared to earlier devices, limited the power of ultrasound energy delivery to levels which, while sufficient to fragment adipocytes, were less harmful to surrounding lymphatics, blood vessels, and nerves.³²^–³⁴ I have enjoyed assisting in the refinement of this technology and carrying out its first clinical trials from the inception of the technique in 1997 to the present. Today, there is abundant independent clinical observation by a multitude of surgeons that VASER-assisted lipoplasty (VAL), which the company nowadays has termed as “liposelection,” produces a milder postoperative course and augments the tendency for skin contracture. However, these observations are challenging to document objectively. Currently, there are a number of clinical studies in progress which it is hoped will provide scientifically valid evidence for these outcomes. There are also recent findings showing that the number of stem cells is not reduced in the adipoaspirate obtained with VASER technology compared to traditional lipoplasty.³⁵ (Rubin, personal communication).

External Ultrasound-Assisted Lipoplasty (EUAL)

EUAL, combined with subsequent aspiration of the fat, also has its proponents. Though EUAL may assist with disbursing wetting solutions in the subcutaneous fat, other proclaimed benefits are yet to be proven.

Additional Lipoplasty Advances

In the early 1980s, a number of surgeons, some working independently of each other, introduced the concept of superficial lipoplasty.^36,³⁷ This advanced technique produced impressive outcomes, at least in the short term and only in the hands of experts. In the longer term, the results can deteriorate to a point where skin excisional body lifts become necessary as a salvage procedure.

By the late 1980s, as demonstrated by the precipitous statistical increase in the performance of the procedure, lipoplasty had become the most popular esthetic surgical procedure worldwide. Simultaneously, applications of the operation were extended to include challenging body areas such as lipoplasty of the calves, ankles, arms, male and female breasts, back rolls and abdominal and pectoral etching.³⁸^–⁴⁵

Many surgeons worldwide contributed significantly to the development of the procedure during the decade between 1980 and 1990. Excellent results could be generally expected – depending, of course, on proper training and experience and, to a lesser degree, on instrumentation. Indeed, the majority of patients undergoing lipoplasty procedures experienced uneventful and rapid recovery coupled with satisfactory, if not outstanding, outcomes. On the other hand, premature and overenthusiastic application of technical modifications of the basic procedure led to a significant number of unsatisfactory outcomes. Insufficient training, a cavalier attitude towards this seemingly simple procedure, as well as limitations in technical ability and/or esthetic judgment, all contributed to suboptimal results.

Power-Assisted Lipoplasty Emerges

The technology of power-assisted lipoplasty (PAL)^46,⁴⁷ has also been embraced by a large number of surgeons. This mechanically propelled device lessens the effort expended by the surgeon to extract fat, allowing him/her to concentrate more precisely on sculpting.

With power assistance, a mini sledgehammer-like mechanism drives the tip of the cannula forward and backward at a cpm of 2000–4000 and a stroke distance of 2 mm. This facilitates subcutaneous fat penetration. As a consequence, the surgeon’s physical effort is lessened, and he or she can therefore be more focused on sculpting. I had the good fortune to be involved early in the development of this technology and designed the first clinical studies conducted with it. We also performed endoscopic studies comparing traditional lipoplasty and power-assisted lipoplasty. Under magnification, these studies demonstrated how power-assisted lipoplasty was less traumatic to structures surrounding the fat being aspirated.⁴⁸

Additional Technologies

In 2000, yet another modality, “lower level laser therapy” (LLLT) was introduced with the claim that edema and pain were reduced, wound healing and skin contracture augmented, and larger volumes could be safely aspirated.^49,⁵⁰ In this technique, the subcutaneous fat is pretreated with external laser energy prior to aspiration. Well controlled clinical studies have been unable to substantiate the claimed benefits of LLLT.^51,⁵²

More recently, other laser-related body sculpting methodology has aggressively been promoted, with catchy names such as SmartLipo, Goldlipo, Slimlipo, Smoothlipo, Lipopulse, CoolTouch, as well as a number of other devices. They all utilize laser energy to emulsify the subcutaneous fat. They are all combined with suction during the same operative session and allegedly tighten the overlying skin. It is also claimed that the laser energy is supposed to seal blood vessels as it comes in contact with them and that blood loss is diminished. To my knowledge to date, there have not been any publications in peer-reviewed medical journals convincingly demonstrating the purported benefits. Conceptually, the approach is identical to what we examined in a multicenter study published some 15 years ago.⁵³ In that study, the investigators uniformly found that there was no benefit in using this approach that in any way justified the expense, learning curve, and cumbersome nature of its application.

Improvements in the clinical application of lipoplasty continue. These are fueled by excellent studies, such as those by Kenkel et al, aimed at clarifying our understanding of the physiologic events surrounding the procedure.⁵⁴^–⁵⁶

In summary, the development of subcutaneous fat removal through lipoplasty, a rather minimally invasive approach, especially in comparison to excisional body surgery procedures, has been an exciting and fulfilling one. The procedure, when performed in properly selected patients and by well trained surgeons, has been miraculously successful. Currently, there is a multitude of even less invasive, as well as noninvasive methodologies that are constantly emerging. The noninvasive approaches are based on transcutaneous application of focused energy; ultrasound,^58,⁵⁹ laser or thermal. These techniques are described elsewhere in the book and therefore not addressed in detail in this chapter, even though I have been keenly interested and involved in their development and for that matter, served as Chairman of the Medical Advisory Board to LipoSonix (a high intensity focused nonsurgical body sculpting ultrasound approach) prior to the company having been purchased by Medicis. My main concern with any of these approaches remains one’s ability to carry out fine sculpting and just not “en masse” subcutaneous fat destruction.

It is imperative that we continue to critically evaluate these novel approaches. The goal is to separate potentially deceptive marketing from innovations that are of true clinical significance.

Fundamentals of Lipoplasty

The routine procedure, which consists of proper patient selection, judicious use of wetting solutions, blunt-tipped cannulae, preservation of the superficial layer of subcutaneous fat, moderate-pressure postoperative garments, and a healthy postoperative lifestyle will produce a satisfactory result in most instances.

As with all surgical procedures, prevention of unfavorable results is far simpler than their subsequent management. A comprehensive discussion of all aspects of liposuction is beyond the scope of this chapter; therefore, the “tips, tricks, and traps” I have found helpful in carrying out the procedure will be emphasized. Specific treatments for various body regions will not be described.

Applied Surgical Anatomy of the Subcutaneous Fat

The superficial fascia, an important membrane in some areas of the body and less well developed in others, divides the subcutaneous fat into a superficial areolar and a deeper laminar fat. Localized fat deposits are defined by the superficial fascia enveloping the deposit and fusing with the muscle fascia at the perimeter of the deposit. This fusion is strong and is readily felt when a cannula pierces through it. When a surgeon transgresses this resistance and inadvertently enters with suction the subcutaneous layer of fat, depressions, divots, or dimples can result. In body regions such as the neck, lower abdomen, and outer thighs, this deep fascia layer is well defined. In the epigastrium, hip rolls, knees, calves, and ankle, the superficial fascia is less well defined and is more like a fibrous structure resembling a honeycomb. The superficial fascia is anchored to the undersurface of the dermis by vertical arches of connective tissue, the retinacula cutis. When these are stretched beyond their limits of elasticity, dimples or peau d’orange, as seen in cellulite, occur.

The author believes that this entire superficial fibrous fascia system, which extends between the superficial muscular fascia and the undersurface of the dermis, is the human derivative of the panniculus carnosus.⁶⁰ The vertical fibrous attachments play an essential role in skin contracture after liposuction.

In conventional lipoplasty, suction of the deep fat compartment is common. This is the workhorse area, where the most improvement is seen in the majority of cases. The beginner should concentrate on these areas. Suction of the superficial layer, as well as cannula “discontinuous undermining” over and adjacent to the area suctioned, promotes postoperative skin contracture. Therefore, with the superficial technique, the procedure can be used for larger removals and can be offered to older patients and to patients with more flaccid skin.^36,³⁷ Superficial suction does not eliminate skin excisional body sculpting procedures. Properly performed superficial suction reduces the need for dermolipectomies.

Creative combinations of different techniques allow a customized approach for each patient. With experience, the conventional and superficial suction techniques can be combined skillfully. For example, when suctioning the abdomen, superficial and deep suction are used in the epigastrium. In the hypogastric area, the deep fat under the Scarpa fascia is suctioned primarily. Most suction in the neck is superficial to the platysma and hence is in the superficial layer.

Errors in fat removal from the superficial layer are highly visible. Fat removal from this layer should be as even as possible; otherwise, grooves and irregularities may result. Avoidance is far simpler than subsequent treatment. If a problem caused by excessive extraction is recognized at the time of the initial procedure, whether in standard or superficial suction, fat reinjected at that time seems to survive better than when done as part of a later procedure. This is only a personal and, as such, an anecdotal observation.

Physics and Equipment

Physics is often forgotten by most surgeons. As previously mentioned, in 2005 we took a critical look at all components of a suction system; vacuum source, tubing, cannulae and collection canisters, on a bench model using applesauce mixed half and half with saline, which was compared and found to correspond well to in vivo data.⁵⁷

Vacuum Source, Tubing, and Cannulae

There are two ways to move the dislodged fat down the cannula or tube. The first is to have an air line to the tip of the cannula or an open wound where air enters the lumen and carries the fat fragments back down the tube towards the vacuum. Such systems work with pressures of one-quarter to one-half atmosphere (190–380 mmHg at sea level). The other is to produce so nearly an absolute vacuum that tissue fluids “boil.”

The molecules from the boiling tissue fluids push the fatty fragments down the cannula towards the vacuum. At 20° C (68° F) tissue fluids vaporize, or “boil,” when the surrounding pressure has been reduced to 17 mmHg. This is achieved by typical vacuum pumps, but it can also be achieved when a closed syringe plunger is withdrawn and near-vacuum is achieved. This is the basis for syringe-driven suction (SDS). The suction pump is the traditional approach, but good results can be achieved with either method. The advantages of the syringe technique are: the elimination of aerosols and noise, a closed “anaerobic” system, the ease of washing and storing harvested fat, and the ease of transporting the equipment to another facility. However, the syringe technique may be more time-consuming and untidy. I personally favor syringes for the initial infiltration of wetting solutions for small fat removals, touchup procedures, and harvesting fat for the purpose of autologous fat transfer; I favor the pump for removals of size. The skill of the surgeon is far more important than the type of suction source employed.

Briefly, cannulae should be blunt at the tip, with the opening(s) located sufficiently proximal from the tip to avoid inadvertent removal of subdermal fat. The shortest cannula that can be used to reach the area to be defatted allows for the best control by the surgeon. With smaller-lumen cannulae, the suction power and, therefore, the rate of removal is exponentially reduced. The finer the tunnels, the fewer waves and surface irregularities occur. Cannula diameter is reduced as the procedure progresses from initial debulking to fine sculpting and from a deeper to a more superficial level. Multihole cannulas extract fat quickly and therefore require greater attention. Cobra cannulas, which have their openings at the tip, and other combinations of cutting tip designs are useful in fibrous areas such as the treatment of gynecomastia, the epigastrium, or the periumbilical area. Their use requires diligence.

Our data showed ⁵⁷ that small changes in vacuum (2–3 mmHg) do not appreciably impact aspiration rate, especially when the system includes either a smaller diameter cannula or the smaller diameter (6.35 mm) suction tubing. The most significant effect is the tubing’s internal diameter (ID). For example, the 9.5 mm in ID tubing attached to a 3.0 mm cannula had a slightly higher aspiration rate than the 6.35 mm ID tubing without any cannula attached to it. When using the smaller 6.35 mm ID tubing, the variation in aspiration rate for the different diameter cannulae was small, showing that the tubing diameter dominated flow rates.

Biohazards

Biohazards have not yet been proven to be associated with the use of suction pumps.⁶¹ Vaporization of tissue fluids raises the possibility that bacterial and viral particles may be exhausted into the operating room. It is recommended that a special filter be placed between the collection jar and the pump to reduce this risk. These filters can stop particles larger than 0.3 µm, have a large surface area to allow good air flow, and are reasonably priced. It is recommended that such filters be used with all machines at all times.

Patient Selection

Patient evaluation is the most important step for the surgeon. Wrong choices in psychological, medical, physical, and esthetic evaluation lead to unsatisfactory results, nagging patients, more difficult repeat surgical interventions, and lawsuits.

The psychologically unfit patient, or an individual with low self-esteem, marked anxiety, fear, paranoia, or unrealistic expectations can be difficult to diagnose preoperatively. Time spent with patients showing them representative photographs, encouraging patients to provide magazines or other pictures illustrating their expectations, and the prospective patient’s attitudes toward previous esthetic surgical outcomes and surgeons, are all important. When in question, it is best to avoid surgery. The impression of needing an extensive psychological evaluation or a psychometric analysis in order to accept a patient for surgery is a warning sign by itself.

A comprehensive medical evaluation is in order for the lipoplasty patient as it is for other esthetic procedures. Specifically, it should rule out a history of chronic lung disease, bleeding disorders, thromboembolic disease, and acute or chronic systemic diseases. For example, use of oral contraceptives places the patient at higher risk for pulmonary embolus. Lifestyle and dietary habits can lead to protein deficiency and fluid or electrolyte imbalance. In addition to bulimia, many people have bizarre dietary habits; others exercise excessively without adequate nutritional support and are chronically malnourished, with low iron source, low albumin levels, low potassium levels, or all three. Others may have taken medications such as fenfluramine-phentermine (Fen-Phen), dexfenfluramine (Redux), steroids, diuretics, cathartics, and other potentially hazardous medications. In addition to alcohol and recreational drug dependence, taking megadoses of certain vitamins and other over-the-counter remedies is common, for example, consumption of vitamin E, which can influence clotting.

Testing for hepatitis B or C, or the human immunodeficiency virus, although prudent, does not remove all risks.

Complete physical examination should evaluate patients for pre-existing orthopedic and neurologic conditions that may be aggravated when the patient is put under anesthesia on the operating table.

From an esthetic standpoint, the ideal patient (BMI less than 24.9) for lipoplasty is a relatively healthy, thin, young, person with highly localized subcutaneous fat excess: “figure faults” (Fig. 44.1) with taut skin.

FIG. 44.1 (A, B, C) A 20-year-old woman before and 6 months after lipoplasty for figure faults of the upper and lower abdomen, outer thighs, inner thighs, inner knees, banana rolls, hip rolls. A total amount of 1820 cm³ was removed.

The average candidate (BMI 25–2 9.9) is over 40 years of age, weighs 7–9 kg (15 to 20 pounds) over ideal weight, has a history of weight fluctuations, and has some degree of skin relaxation and/or striae. Although such a patient will experience some improvement from lipoplasty, which may incorporate superficial suction, autologous fat transfer (AFT), and intraoperative and postoperative Endermologie, he or she should be informed that subsequent suctioning and dermolipectomy may be necessary for the most optimal result (Fig. 44.2).

FIG. 44.2 (A, B, C) A 40-year-old woman before and 1 year after lipoplasty of the upper and lower abdomen, hip rolls, outer and inner thighs, inner knees. The total volume removed was 3560 cm³.

The less than ideal patient (BMI over 30) is older, is more than 9 kg (20 pounds) overweight or generally obese, has a history of weight fluctuations, and has clearly loose skin. Striae, soft tissue ptosis with cascading folds of redundant skin, the beginning of abdominal ptosis, banana rolls (sometimes multiple), inner thigh ptosis, or a combination of these features are present on physical examination. In this group, patients older than 55 years seem more readily satisfied with the results of the procedure than their younger counterparts. The patient should repeatedly be informed before surgery of the limitations imposed by their anatomy. A more conservative approach followed by secondary suctioning, after interim skin contraction, and eventual dermolipectomy may be required. Regardless of age and how close to the ideal candidate a patient is, sufficient preoperative discussion(s) to bring postoperative expectations to a realistic level is essential (Figs 44.3 and 44.4).

FIG. 44.3 (A, B, C) A 50-year-old woman before and 8 months after lipoplasty of the upper and lower abdomen, hip rolls, outer and inner thighs, inner knees. A total amount of 4100 cm³ was removed.

FIG. 44.4 (A, B, C) A 63-year-old woman before and 18 months after lipoplasty of the upper and lower abdomen, hip rolls, outer and inner thighs. A total amount of 5720 cm³ was removed. Traditional and superficial suction was carried out.

Visual inspection is not sufficient for adequate preoperative evaluation. Palpation for skin turgor, elasticity, and strength is important. If pinched skin does not return instantly to normal position, lipoplasty by itself is a poor choice. The pinch test demonstrates the difference between body regions with excess localized fat deposits and the surrounding areas. For example, pinching the hypogastric area in a patient who is a good candidate should demonstrate thickness several folds over fat lateral to it. Patients readily relate to this demonstration. It helps them to understand that not all fat is to be removed, that what remains will be in better proportion to the rest of the body, and that what is left is more important than what is removed. For example, in men with large “beer bellies,” the pinch test often demonstrates that the epigastric area has an amount of fat similar to the area lateral to it, which renders this type of patient a poor candidate for liposuction. In these individuals, most of the fat is intraabdominal (greater omentum) and retroperitoneal.

Showing preoperative photographs, especially from the posterior view, to patients during consultation is an important tool to demonstrate what can and, as importantly, what cannot be done about their concerns.

Preoperative Markings

Patient markings are carried out in a standing position and usually are done in a topographic manner. Using indelible marking pens of different colors is useful. Sights of maximum removal and depressions or valleys are appropriately noted. In addition to the localized fat deposits to be suctioned, the areas to be augmented with autologous fat transfer (AFT) are marked. Undesirable skin adhesions to underlying tissue (such as the folds between back rolls), and location of folds to be created (such as better definition of the gluteal folds or design of abdominal etching) are similarly marked. Access incisions needed to reach the areas to be suctioned are placed as close as possible. Shorter cannulas provide better control. When cannula (without suctioning) discontinuous undermining is planned to facilitate skin contraction beyond the borders of suctioning (as in larger cases of gynecomastia), this is also drawn. Photographs taken with the markings in place are used to confirm the surgical plans with the patient and serve as documentation of what was treated. Standardized circumferential multiple-view preoperative and postoperative photographs are also taken.

Postoperative garment size is determined prior to surgery.

Surgical Intervention

Prepping and Patient Positioning

Prepping, whether circumferential (in the standing position) or sequential (on the operating table), is determined by the body areas to be treated and the surgeon’s preference. Surgeon’s preference also dictates optimal patient positioning. Before induction of anesthesia, the different patient positions on the operating table required for a given procedure and the placement of access incisions are checked and adjusted as necessary. Attention is given to padding pressure points (to protecting bony prominences), and care is taken in turning and in preventing injury to the extremities, brachial plexus, face, chest, and genitalia. The neck should be placed in the normal postural position to avoid pinching of the cervical roots.

Infusion of Wetting Solutions

Several different formulations of wetting solutions have been recommended. These formulations do not differ significantly from each other. For the most part, they are isotonic in nature and contain low concentrations of epinephrine and lidocaine. The formulation I currently favor is shown in Box 44.2.

BOX 44.2

Table Infusion Formulation for Superwet Technique

Sequential/segmental infusion

1–1.5 ml infusate/ml of estimated aspirate

1000 ml Ringer’s Lactate + 0.5–1 ml epinephrine 1/1000 + 25 ml

0.25% lidocaine + 1 ml (40 mg) gentamicin ± hyaluronidase

The SuperWet technique, for the reasons detailed earlier in the chapter, is routinely used. In general terms, 1 cm³ of wetting solution for each 1–1.5 cm³ of estimated aspirate is infused. Sequential infusion, as opposed to infusing all areas to be suctioned at once, lessens acute fluid load by clysis and variability of tissue distortion by the wetting solutions. Uniform layering of infusion facilitates sculpting. While for small volumes, such as treatment of necks or inner knees, 60-ml Toomey syringes with infusion cannulae can be used, infusion pumps are better suited for removal of larger volumes.

As a general rule, the volume of wetting solutions administered to a patient undergoing a lipoplasty procedure should not be more than 5000 ml. The lidocaine load should not exceed 35 mg/kg of body weight.

Lidocaine is mixed in the solution to provide pre-emptive and some postoperative analgesia. This use of local anesthetics in the wetting solutions is notably different from the use of lidocaine as proposed with the tumescent technique. Although small volume removals can be performed safely with the analgesia provided by the lidocaine contained in the wetting solutions, this author is of the definite opinion that wetting solutions are not a practical or safe anesthesia delivery system for major-volume lipoplasty. General or epidural anesthesia is recommended.

Pretunneling Extraction and Mesh Undermining

Pretunneling (i.e., passing the cannula when no suction is attached) helps to define the proper plane. The feel in the superficial layer is “gritty”, whereas the feel in the deep fat is smoother. A cannula that is too pointed or has a sharp tip does not as readily provide this important tactile feedback. Suction, once applied, detracts from the tactile sense. Passing the cannula in regular radiating tunnels, a pseudo-plane that better defines the fat to suction is developed. The easy movement of the cannula stops where the superficial fascia fuses at the periphery of the localized fat deposits. When no suction is attached, a puncture wound into the superficial fat causes no lasting effect. Therefore, pretunneling is helpful to define the depth and extent of suction. The extraction should be in radial, not coalescing, tunnels, with long even strokes and additional passes as guided by the preoperative markings. The edges of the deposits are feathered, and “mesh undermining” without suction is extended laterally as needed. Cross tunneling and suction at right angles to the first tunnels can result in additional fat extraction. It is important to compare the extracted area for evenness, within itself and to the surrounding untreated areas, visually and by palpation. Wetting the surface and looking from different angles as practiced in car body repair shops can also help.

Beware of over-resection! Perform the pinch and roll tests often. Avoid a side-to-side windshield wiper motion, which promotes dead space and pseudobursa formation. The cannula lumen is not turned against the deep dermal surface unless an indentation is being created on purpose, such as in abdominal and pectoral chest etching or creation of a gluteal fold. Persistent overworking or a bloody area is avoided.

Knowing when to stop is the hardest part of all endeavors. What is left behind, not how much is extracted, determines the quality of the result. When the aspirate turns bloody, it is time to move to the next tunnel. If the skin appears lax, especially over the abdomen and inner or outer thighs, it is reasonable to stop or, based on the surgeon’s skill and experience, to proceed with the superficial technique. Be careful and remember that secondary suction after initial skin contracture, performed some months later, is an option.

Esthetic sense is hard to describe and is more innate than learned.

Over-resections performed in an attempt to comply with a patient’s preoperative wishes for a “flat stomach” or “skinny straight thighs” may not be in proportion with the esthetically natural curves of the body, which should be known and respected. For example, when a less than ideal amount of fat is left over the trochanter in a female patient with residual hip rolls, she will appear masculinized in the posterior view. Similarly, a scaphoid abdomen void of any periumbilical fullness is not feminine in appearance.

Small refinements can be made with fine cannulas attached to low suction or to syringes. Autologous fat after anaerobic washing and decanting can be transferred to fill areas of pre-existing depressions or over-resection. Selective division of retinacula curis combined with rolling massage and injection of a thin layer of autologous fat following superficial suction has resulted in limited improvement in the appearance of cellulite.

When extraction is complete, the edges of the extracted area are loosened with mesh undermining by passing a very blunt cannula into the surrounding area without suction. This maneuver tends to break up the edge and allow some recontouring of the adjacent tissue. The theory behind such a maneuver is that there are three phases to the improvement seen after lipoplasty: (a) immediate fat cell extraction, (b) subsequent fat cell death, and (c) fibrosis and retraction. Mesh undermining is believed to cause some additional fat cell death at the periphery, which allows a more even transition.

When Performing PAL

The PAL cannula in my experience was found to break up fibrous fat much more readily. This is clearly evident during treatment of gynecomastia, hip rolls, back rolls, of the epigastric area and secondary lipoplasty, all known to be quite labor intensive with traditional lipoplasty (TL). It is the device of my choice for “debulking” a large localized fat deposit. PAL significantly shortens operating time in comparison with TL. For example, during the initial phase of the procedure, it is not uncommon to be aspirating as much as 100 ml per minute. Once experience is gained with it, the device is also found to be a useful surgical tool for performing superficial suction, with the exception of submental suctioning, for which I find the bulk of the handle of the instrument to be cumbersome. In general, using PAL is less fatiguing. The power-assisted cannula is moved at a speed slow enough to allow for the instrument to break up the resistance that it is encountering. Therefore in fibrous areas, the cannula movement is slower. At the appropriate speed, a sensation of gliding through the tissues with considerable ease is imparted to the operator’s hand. The endpoint of suctioning is subjectively determined by the surgeon by using the same esthetic criteria and guidelines that apply to lipoplasty in general.

Based on microscopic studies, performed on specimens from a few patients, the aspirate obtained with PAL was found to be as suitable for autologous fat transfer (AFT) as is the fat obtained with TL.⁴⁶

On the down side, there was some degree of surgeon discomfort noted in using PAL because of the vibration of the instrument transmitted to the operator’s hand. The vibration is diminished by decreasing the speed of cannula movement. There appears to be no noticeable diminution in the efficiency of the instrument as long as it is operated at least 80% of full power (4000 cpm). There is also some noise associated with operating the PAL cannula. While this adds to the noise already present, however, the sound generated by the suction machine muffles to a degree that coming from the PAL instrument.

Early on in one’s experience, it might be wise to use PAL primarily as a debulking instrument, treating larger body areas such as the outer thighs, hip rolls and the abdomen.

When Performing UAL

The fat is emulsified concurrently (hollow cannula technology) or before (solid probe technology) its extraction. To date, the process of emulsification is not fully understood. Although cavitation has been proposed as the principal mechanism, the micro “sledge hammer” effect, imparted by the application of the ultrasound energy to the adipose tissue, also may play an important role.

Larger removals, lower blood loss, better skin contraction/retraction, faster recovery, and smoother postoperative skin surfaces have not been demonstrated convincingly enough to justify general replacement of traditional lipoplasty with UAL. Currently, it is best used in combination with the traditional technique. In addition to expense, however, there is also to consider a tedious learning curve for the surgeon, imposition on the staff, and side effects particular to UAL. These include larger access incisions, longer surgical times, and higher seroma and dysesthesia rates. Thermal damage can occur at the access incisions and at distant sites, but appropriate training can minimize most of these. In UAL, the following measures are recommended: skin protectors at incision sites, a wet surgical towel between the shaft of the cannula and the subjacent skin in contact with it, constant cannula movement while ultrasound energy is being delivered, avoiding extensive ultrasound times in one location, avoiding “end hits,” and keeping the cannula at least 1 cm below the deep surface of the dermis. These general recommendations apply to all UAL devices currently available in the United States. The more powerful the unit is, the steeper the learning curve and the lower the relative safety of the device. The novice UAL surgeon is advised to begin with a lower setting, especially if using one of the more powerful devices. A wet environment is mandatory for fat emulsification. The superwet technique used in combination with UAL adequately satisfies this requirement without the hazards imposed by the tumescent approach. As long as the superficial layer of fat is not exposed to ultrasound energy, the more severe complications, such as permanent pigmentary and prolonged, if not permanent, sensory changes, fibrosis, and extensive skin sloughs, can be mostly avoided. The solid probe approach, unlike the hollow cannula method, does not provide the surgeon with continuous visual feedback of the emulsified fatty material. Still, the solid probe technique may prove to be safer because the subcutaneous structures (nerves, lymphatics, blood vessels, and deep dermis) are not suctioned up against the tip of the cannula, where most of the ultrasound energy is being delivered. The perceived benefits of the third-generation UAL device (VASER) have already been commented on in this chapter.

When first beginning UAL, the value of proper training, cautious graduated experience, and solid surgical judgment cannot be overemphasized.

When Performing Superficial Lipoplasty

In conventional liposuction, suction of the deep fat compartment is recommended. Superficial liposuction,^36,³⁷ as well as just cannula undermining, in the superficial compartment, helps promote postoperative skin contracture. Therefore, when superficial technique is added, larger volumes of fat can he aspirated from any given area, and the procedure can be offered to older patients and patients with more flaccid skin. Also, if skin excision is unavoidable, it will not need to be as extensive.

Fat removal from the superficial layer should be performed as evenly as possible, otherwise grooves and irregularities may result. With experience, one can skillfully combine both deep and superficial suction. For example, when suctioning the abdomen, superficial and deep suction can be used in the upper abdomen, especially in the midline, while fat under Scarpa’s fascia is primarily suctioned in the lower abdomen.

For several years now, suctioning of the superficial fat compartment has been an accepted procedure in certain areas of the body. For example, suction of tile submental region has always been primarily superficial to the platysma and, therefore, in the superficial layer. Because of this, impressive results in the neck are common when suction is used alone. Similarly, good skin contracture is the rule with suction of gynecomastia, inner knees, ankles and epigastric regions.

Superficial or deep suction does not totally eliminate skin excisional body sculpting procedures. Creatively combining these different procedures allows one to custom tailor the surgical plan for each patient. However, I do not approve of the use of a sharp cannula to penetrate even more superficially to a level just subjacent to the dermis. In my view, this is a dangerously aggressive technique that places the deep dermal plexus in jeopardy. This technique has the potential for creating surface irregularities, chronic pigmentary changes and skin sloughs.

In general, for superficial suction, smaller caliber blunt cannulae with openings near the tip work better. For a vacuum source, the suction machine or the syringe aspiration technique can be used equally well. I recommend surgeons become familiar with both.

Large Volume Removals

An arbitrary classification of lipoplasty patients according to the volume of aspirate currently used by the author is listed in. Large-volume lipoplasty is defined as removal in excess of 5000 cm³ of supernatant fat in one operative session. In my judgment, this should be considered only in patients of low anesthetic risk (American Society of Anesthesiologists class I), who are at least in average aerobic shape and have preoperative hemoglobin and hematocrit measurements of above 11 g/l and 30%, respectively. A bleeding time is performed to detect coagulopathy. An erythrocyte sedimentation rate, although nonspecific, detecting cryptic disease processes, is also informative.

Large-volume lipoplasty carries a significantly higher risk. Patient tolerance for this procedure is a function of several different factors, and as such, safety considerations need to be accordingly observed. In addition to age and general health, the percentage of body surface area to be treated is important. The fluid shifts that occur after lipoplasty are not unlike those that occur after a second- degree burn. If the area of injury exceeds 15% of body surface area, morbidity rises disproportionately. The palmar surface of the patient’s own hand and fingers represents 1% of the body surface.

The need to monitor fluid shifts and hemodynamic changes requires close intraoperative and postoperative monitoring, which is best provided by an accredited surgical facility. Injudicious ambulatory discharge of large-volume lipoplasty patients may lead to many potentially dire consequences, such as hypovolemia, oliguria, fat embolism syndrome, shock, renal shutdown, pulmonary embolism, and myocardial infarction.

Large volumes can be removed safely in properly selected patients (Fig. 44.5). Our general guidelines for the preoperative, intraoperative, and postoperative care of lipoplasty patients are listed in Boxes 44.3–44.5. It should be stressed that the amount of wetting solutions (crystalloids) delivered alters the amounts of intravenous fluids required over time. Close communication with the anesthesiologist and careful patient monitoring are essential.

BOX 44.3 Safety Issues in Large-Volume Lipoplasty

Preoperative Considerations

Low anesthetic risk: ASA class I

Erythropoietin for hematocrit <35%

Discontinue Fen-Phen and other potentially hazardous prescription drugs

Evaluate risk for thromboembolic phenomena and treat accordingly

Rule out lifestyle and dietary habits leading to protein deficiency and fluid and electrolyte imbalance

Should be in at least average aerobic shape

BOX 44.4 Safety Issues in Large-Volume Lipoplasty

Intraoperative Considerations

Body heat preservation; silver cap, Bair Hugger, warm infusion fluids

Anesthesia: general or epidural (not local)