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