Liposculpture

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Chapter 19 Liposculpture

Fábio X. Nahas, Marcus V.J. Barbosa, Lydia M. Ferreira

Liposculpture is a technique used to restore or improve facial and body contouring by removing localized fat deposits with small blunt-tipped cannulas connected in a suction device. This procedure can be associated with injections of the removed autologous adipose tissue where needed. ^1,2 It is also named as liposuction, lipoplasty, suction lipectomy or suction-assisted fat removal.

Introduction

Liposculpture is a technique used to restore or improve facial and body contouring by removing localized fat deposits with small blunt-tipped cannulas connected in a suction device. This procedure can be associated with injections of the removed autologous adipose tissue where needed.^1,² It is also named as liposuction, lipoplasty, suction lipectomy or suction-assisted fat removal.

The development of liposuction techniques made the autologous fat injection a more reliable procedure. The term liposculpture was initially used by Fournier to describe syringe liposuction associated with fat injection.³ However, considering the etymology of the word ‘liposculpture’, its concept can be extended for all of liposuction techniques because most of these procedures are performed to improve body shape only by removing fat deposits.

Although many authors have reported good results with the use of suction-assisted liposuction, power-assisted liposuction or ultrasonicassisted liposuction.^4,^5,⁶ or vibrating cannulas, others support the use of syringe liposculpture,^7,^8,⁹ mainly because this technique is precise and promotes less trauma of the adipose tissue. Therefore, this chapter will detail the main liposculpture techniques with special attention for syringe liposculpture.

Considerations About the Adipose Tissue

Adipose tissue is composed by fat cells organized in lobules. Each lobule has its own vascularization. Adipose cells are originated from fibroblast-like cells, called preadipocytes, which develop to become a mature adipose cell. These cells increase in number along childhood and adolescence ¹⁰

Therefore, the number of cells is constant along adult life. The accumulation of fat occurs by the increase in deposition of the intracellular lipid, not by the increase of number of adipose cells.^11,¹²

Fat cells are extremely delicate, and should be manipulated with special care.¹³ Therefore, the amount of viable fat cells will depend on the liposuction technique.

Adipose tissue is divided in two layers: the superficial layer and the deep layer. The superficial layer, also named areolar, represents small compact fat lobules that are separated by a greater number of membranes (septa). Its thickness is uniform in all of the body parts. The deep layer is also named reticular or lamellar ayer. In this layer fat lobules present an irregular distribution as well as a small number of membranes (septa) that show an irregular pattern when compared with the superficial layer.¹⁴

The accumulation of fat occurs in the adipose tissue of the deep layer. Patients who are classified as obese present an increase in thickness of this layer.¹⁵

Body adipose tissue deposits present variations depending on the gender and the type of hormones. Therefore, presentation will be in two distinct patterns: androgenic pattern and gynecoid pattern. Men present with the androgenic pattern when fat deposits will occur in the abdomen and dorsal regions. On the other hand, women present with the gynecoid pattern when fat accumulation occurs in thighs and ankles.¹⁶

Indications

Liposculpture is essentially used for body contouring for aesthetic and reconstructive purposes by the removal of fatty deposits with or without re-injection of the removed fat.¹⁰ The technique was described for the treatment of localized fat deposits that may not have responded to efforts of weight loss through exercise and dieting. It is important to stress, however, that liposuction is not a weight-loss method.¹⁶ Patients submitting to liposculpture should present with good skin elasticity with no flaccidness or a less elastic skin, as skin in this condition does not tighten so readily around the newly contoured shape.¹⁴

The main indications include fat deposits in the abdomen, flanks, ankles, thighs, calves, buttocks, back of the arms, neck or elsewhere.

Because of improvements in technique and the development of less traumatic cannulas, liposuction is also used as an adjuvant to many procedures with no increase in morbidity. The main indications include:

• liposuction of gynecomastia ¹⁵

• liposuction of the jaw and neck area in the facelift ¹⁷

• abdominoplasty with liposuction of the flanks and to reduce ‘dog ears’

• liposuction prior to lipoabdominoplasty ¹⁸

• liposuction prior to the lifting of the thighs and arms.¹⁹

Penile augmentation can also be done with fat injection. Panfilov (2006)²⁰ showed that the circumference of the penis increased 2 cm to 3 cm in 88 patients.

Liposuction techniques are also indicated for reconstructive purposes mainly to reduce flap thickness. It also can be used in association with fat transplantation to treat Romberg’s disease, HIV-related lipodystrophy, hemifacial microsomia syndrome and to correct liposuction sequelae.^13,²¹

Other reconstructive indications include: laryngoplasty ²² and treatment of urinary incontinence by lipoinjections in the periurethral area.²³

Anesthesia and Preoperative Preparation

Liposuction can be performed under local anesthesia with or without intravenous sedation, regional anesthesia (epidural or spinal) and general anesthesia.¹⁴

Immediate preoperative preparation includes urethral catheterization and the placement of an intermittent compressive device on the lower legs to reduce the incidence of pulmonary embolism prevention.

Preparation of the Adipose Tissue to be Aspirated, Materials Used to Perform Liposuction and Surgical Techniques

Since the initial description of the liposuction technique, there has been a significant evolution regarding the preparation of the adipose tissue to be aspirated as well as the operative techniques and the surgical instruments used.²⁴ Therefore, these three aspects of the liposuction techniques will be discussed in detail.

Preparation of the adipose tissue to be aspirated

Preparation of the adipose tissue is also known as ‘injection of the liposuction fluid’. This is very important mainly because the fluid injection determines the amount of fat to be aspirated, the amount of blood loss during the procedure and has a role on some postoperative complications.²⁵

The liposuction technique was initially described with an initial injection of a hypotonic solution containing saline (100 cc), distilled water (20 cc), hyaluronidase (100 U) and epinephrine (0.1 cc).^15,²¹ The purpose of this was to damage the fat cell membrane thus making the later aspiration of the adipose tissue easier.

Fournier, in 1983, described the liposuction technique with no previous injection of hypotonic fluids. This technique was named the dry method. According to this author the hypotonic solution did not damage the surface of fat cells and also increased surgical time. The main disadvantage of the dry method was the greater amount of perioperative blood loss, which required postoperative blood transfusion.³ This method is seldom used today.

Currently, the majority of plastic surgeons use a previous infiltration of a fluid containing saline solution (500 cc) with 1 ml of epinephrine (1 : 1000 000). The final epinephrine concentration of this solution is 1 : 500 000. In cases where there is a small amount of fat to be aspirated (retouching or fat injection) a 20 cc of a 2% lidocaine could be associated with the fluid.

Therefore, liposuction methods can be classified according to the amount of fluid to be injected in the adipose: dry, wet, super-wet and tumescent method.

When the dry liposuction method is applied, there is no fluid infiltration and blood loss is estimated as being between 20% to 45% of the final aspirated volume.

The wet liposuction method includes the injection of 200 to 300 cc of fluid into the area marked prior to liposuctioning. The estimated volume of blood loss is around 4-30% of the final aspirated volume.

The super-wet method is considered when the volume of fluid to be injected into the area to be suctioned is about the same as the volume of fat to be removed.

This is the preferred technique for liposuction by many plastic surgeons, mainly because of the reduced blood loss, which is about 1% of the final aspirated volume.

In the tumescent method a larger amount of fluid is injected into the area to be aspirated; as much as 2-3 times the volume of adipose tissue to be aspirated. The volume of blood loss is about 1% of the final aspirated volume.¹⁶

Materials used to perform liposuction

According to the initial descriptions of the technique, cannulas presented a greater evolution. Initially, blunt-tipped cannulas with more than 5-mm bore were used. These cannulas allowed surgeons to remove a greater amount of adipose tissue; however, it was noted that the number of complications in the postoperative period was directly proportional to the diameter of the cannula. The main and most serious postoperative complication was blood loss and skin irregularities. Illouz demonstrated that if a 1500-3000 cc fat was removed, 25% of total blood volume needed to be transfused in the immediate postoperative period.^15,²⁶

With the purpose of avoiding these complications, new cannulas were developed with small diameters and more perforations to reduce trauma and blood loss, as well as improving the postoperative results. New infiltration fluid formula (with epinephrine) aimed to reduce postoperative skin irregularities and blood loss, and avoid the necessity for postoperative blood transfusion.

Currently, most frequently used cannulas are thin, multi-perforated, blunt-tipped cannulas with a 2-4-mm bore.

Despite the development of new liposuction techniques such as the methods described above, syringe liposuction seems to be the one that allows the best control over the final volume of aspirated fat and results in the best surgical refinement, with the least risk of postoperative complications and need for retouching. Syringe liposuction also allows surgeons to remove a larger number of viable fat cells that can be used for fat transplantation, because of the reduced trauma to the adipose tissue. When fat transplantation is being considered, the removed fat should be re-injected immediately in multiple tunnels, as recommended by Coleman.^27,²⁸ This procedure is widely used to treat depressions or irregularities, improve anatomical structures of the face and body, and treat liposuction sequelae.²⁹

Surgical techniques

Liposuction can be performed using many different techniques and the mechanisms by which the cannulas work are also varied. The main liposuction techniques are: syringe liposuction, suction-assisted liposuction (cannula attached to a vacuum device), power-assisted liposuction, ultrasound-assisted liposuction, laser-assisted liposuction and external ultrasound-assisted liposuction. The last four techniques use a standard suction device to remove the fat.

Syringe and suction-assisted liposculpture are the most commonly used methods of liposuction. In these techniques localized fat deposits are removed via a small cannula, which is inserted into a previously marked treatment region through a stab incision and attached to a syringe or a vacuum device.¹

Power-assisted liposuction was developed to reduce both trauma to nerves and vessels, and surgeon fatigue. In this technique a special cannula is connected to a device that produces mechanized movements so that the surgeon does not need to move the cannula manually.¹⁴ This device can be powered electrically or by compressed air.

Ultrasound-assisted liposuction is also named ultrasonic liposuction. In this technique fat is removed via a special cannula linked in an ultrasound device that transmits vibrations to the treatment region. The vibrations rupture the walls of the fat cells, liquefying the adipose tissue and making it easier to remove. Afterwards, suction-assisted liposuction is performed to remove the liquefied adipose tissue. It is important to stress the potential for skin necrosis with this technique if superficial liposuction is performed.⁴^–⁶

Laser-assisted liposuction works in a similar way to ultrasoundassisted liposuction. There are, however, many reports of skin burns when this technique is used to perform superficial liposuction.³⁰ Therefore, when superficial liposuction is indicated this technique should be avoided.

External ultrasound-assisted liposuction has been described to facilitate fat emulsification, making suction removal easier. Using this technique external ultrasound energy is delivered to the target areas. This technique is not widely used and its effectiveness is doubtful.

The techniques described above were developed to reduce trauma, surgical time and surgeon fatigue, and to facilitate fat suction.^16,³⁰ However, as suction-assisted and syringe liposuction are the most commonly used methods this chapter will detail syringe liposuction; the technique outlined is associated with a previous infiltration of a fluid containing saline (500 ml) and epinephrine (1 : 1000 000) – a super-wet method.

After the application of an antiseptic solution (chlorhexidine gluconate) over the area to be treated, ‘liposuction fluid’ is infiltrated with a 15-25-cm multi-perforated, blunt-tipped cannula inserted through stab incisions made with a 15 blade, adjacent to the area to be aspirated.

The most commonly used cannulas are 2-4-mm bore, 20-35-cm long blunt-tipped, which are attached to a 60 ml disposable syringe.

At the time of surgical planning it is important to verify which areas are to be treated. When the regions to be aspirated include the back, the procedure should be started with patient in prone position. With the patient in this position it is possible to treat a number of regions including: posterior thoracic region, flanks, culottes, thighs, knees and legs. After removal of the desired fat volume, incisions are closed with single 5-0 nylon suture and an adhesive bandage is applied over each incision.

The patient is then turned to the supine position and the antiseptic solution is applied over the previously marked area. In this position, surgeons are able to treat the abdomen and/or the culottes, internal region of thighs, knees and legs if necessary. Again, incisions are closed with single 5-0 nylon suture and an occlusive bandage is applied.

At the end of the procedure a compression garment is applied over all of the treated areas. This garment should be used for 30 days to reduce postoperative swelling and distortions, allowing the skin to adhere to its new position.

Results

Patients with localized fat deposits (not obese) observe excellent longterm results with a significant improvement in body contour.

It is important to stress that liposuction is not an alternative to exercise and diet. Patients should thereafter control their weight to guarantee the best surgical results.

Some clinical examples using syringe liposuction plus super-wet method are shown in the figures.

Fig. 19.1 A, Posterior view of a 31-year-old male before liposuction of the lumbar area and flanks. B, One year postoperative result. Liposuction was performed with syringe.

Fig. 19.2 A, Preoperative oblique view of a 42-year-old female who presented excessive fat deposit in the anterior abdomen, flanks and at the lateral aspect of the chest wall. B, One-year postoperative view after syringe liposuction.

Fig. 19.3 A, A 34-year-old female who presented excess fat in the lateral aspect of the buttocks and thighs. B, Six-month postoperative view after syringe liposuction.

Fig. 19.4 A, A 38-year-old female who presented excess fat in the lateral aspect of the buttocks and thighs. B, Eight-month postoperative view after syringe liposuction.

Fig. 19.5 A, A 28-year-old famale who presented excess fat in the lateral aspect of the buttocks and lumbar area. B, One-year postoperative view after syringe liposuction.

Complications

Complications of liposuction can be minimized by correct selection of the technique to be used, proper preoperative planning regarding the site and volume of fat to be removed, and attention to the principles of the surgical technique. When they do occur, complications can be divided into two categories: 1) systemic and 2) local.

Systemic complications

Systemic complications are most often related to either the liposuction technique or to the patient’s predisposition. Appropriated surgical technique and preventive care should be considered, especially in patients that present a higher risk for complications. The most frequent systemic complications are:

• Pulmonary embolism: The risk of thrombosis is related to blood flow decrease in the lower limbs, trauma and hypercoagulability. The two former factors occur during liposculpture because of the patient’s position during surgery and the duration of the procedure. Hypercoagulability can also occur in patients who present with this condition or when patients are on medications such as birth control pills. Smith et al ³¹ checked the prothrombine time, partial active thromboplastine time, antithrombine III and the thrombineantithrombine complex serum levels in patients who underwent liposuction. These authors verified that there were no changes that could influence coagulation. Prevention can be achieved with the use of compressive stockings, compressive devices for the lower limbs and low-molecular-weight heparin.

• Fat embolism: It has been reported that clinical fat embolism can occur frequently in liposuction. Kenkel et al ³² performed liposuction on six swine and verified that all of them presented small pulmonary emboli verified on the autopsy, although no clinical signs were noted during or after the procedure. It is difficult to avoid this complication and the anesthesiologist should be prepared to avoid progression to vessel obstruction.

• Abdominal perforation: This usually occurs during liposuction but the abdominal wall can also be perforated during fluid infiltration. Existing small hernias (1-2 mm in diameter) can not be diagnosed clinically by ultrasound or by any other imaging methods. Their usual location is in the midline at the umbilical and supraumbilical area. Also, the subcostal area in some patients can be projected and this condition facilitates the penetration of cannulas. As the cannula is moued back and forth, the risk of visceral perforation should always be considered.⁹

Fig. 19.6 A, Frontal view of a 24-year-old female who presented excess fat in the anterior abdomen, flanks and lumbar area. B, One-year postoperative after syringe liposuction. C, Lateral aspect of the abdomen and lumbar area. D, Lateral view on which the distance between the anterior and posterior abdominal wall has decreased significantly one year after the procedure.

The most common serious complication of liposuction technique is pulmonary embolism as a result of blood flow decrease to the lower extremity, trauma and hypercoagulability.

Lidocaine toxicity: Lidocaine toxicity occurs when the serum level of this medication is above 5 μg/ml. Its maximum dose is 7 mg/kg of body weight; however, the maximum subcutaneous safe dose has been estimated to be up to 35 mg/kg of body weight when the super-wet technique is used.

Fig. 19.7 A, A 36-year-old female who presented excess fat in the lateral aspect of the buttocks and thighs. B, Eighteen-month postoperative view after syringe liposuction.

This became possible for several reasons. The volume injected during liposuction promotes some com pression on the wall of the vessels, thus decreasing reabsorption; lidocaine absorption is low in subcutaneous tissue; this drug is diluted in a large amount of fluid which also decreases the reabsorption; and, finally, before the whole amount of injected lidocaine is in the serum, part of it has already been eliminated.

A relevant fact is that lidocaine, when injected into the subcutaneous tissue, has a serum peak of 6-8 hours after the injection. When local anesthesia is used, some of these patients are discharged at the end of the operation so that the higher serum levels can occur when patients are away from the hospital.

High serum levels of lidocaine can lead to seizures, coma and cardiac arrest.

Infiltration of lidocaine has been used in patients who had undergone liposuction under general anesthesia. These plastic surgeons advocate the use of lidocaine to prevent postoperative pain. Perry et al ³³ verified that there is no postoperative pain reduction when this method is used.

• Infection: Localized infection is not rare in patients who have undergone liposuction, especially in those who return to daily activities prematurely. The main concern in these cases is that skin retraction and subcutaneous atrophy may occur. Toxic shock syndrome is the complication of most concern to plastic surgeons. It is a life-threatening complication and is the result of a toxin produced by Staphylococcus aureus. The initial symptoms and signs are non-specific, such as high temperature, diarrhea and vomiting. When hypotension, cutaneous rash and oliguria occur, diagnosis of this syndrome should be considered. Necrotizing fasciitis in liposuction treatment areas is part of the symptoms of this syn drome. These patients need immediate intensive care and radical removal of the necrotic tissue.

Other cited ³⁴ though rare, complications are: vasculopathy,¹⁷ hyperpigmentation,¹⁹ third space fluids shifts, and hemorrhage.⁷

Complications of liposuction beside pulmonary embolism and lidocaine toxicity include infection, visceral perforation, vasculopathy, fluid overload, excessive bleeding, local irregularities, persistent edema, induration, and fat necrosos.

Local complications

Local complications are more frequent than the systemic ones and some of them could be avoided or the effects minimized. Edema, ecchymosis and seroma at the aspirated areas are common events and can occur in almost every surgical procedure.¹⁹ The effects usually disappear 2-3 weeks after surgery.

Although rare, prolonged edema and induration can last for up to 1 year.²⁶ Manual lymphatic drainage³⁵ and the use of a compressive dressing are adjuvant postoperative care procedures that can minimize edema and pain.

Liponecrosis and pseudocyst formation are complications that can occur when the volume of fat injected into one site exceeds 20 cc.^14,¹⁵ These complications can be avoided with the injection of a small amount of fat graft through multiple tunnels.^20,²¹

Depressions or irregularities in the liposuctioned area may also occur after any treatment.¹⁰ These deformities can be treated with fat injection. These complications can occur when patients have excess skin and also if aggressive superficial liposuction is carried out.

Limits

The maximum volume of fat that can be injected has not yet been determined.^36,³⁷ It is known that if a large volume of fat is injected into one area there is a greater possibility of fat necrosis and fat-graft reabsorption, and oily cysts may form. Also, calcification may occur with time.

The risks associated with the procedure increase when a large volume of fat is aspirated. The safety limit for liposuction was around 2000 cc when the dry technique was used. However, after the superwet technique was described by Klein ³⁸ in 1987, surgeons began to remove larger volumes of fat.

During the 1990s there was an increase in the number of fatalities following these procedures in comparison with the previous decade. These casualties did not occur due to hemorrhage but were secondary to other factors. Grazer and de Jong ³⁹ found that the mortality rate for patients who had undergone liposuction was approximately 1 : 5000. The main causes of death were pulmonary embolism (23.1%) and abdominal organ perforation (14.6%). Deaths related to anesthesia, sedation and medication occurred in 10% of the cases; however, this number is probably an underestimate, as most deaths related to lidocaine toxicity occur at home and in 28.5% of the cases an etiologic cause of death was not identified.

The American Society of Plastic and Reconstructive Surgery suggests that using the super-wet technique, removal of up to 5 L of fat is considered within the safety limits.

Larger volume removal should be performed by a well-trained team specialized in large-volume liposuction. Brazil is one of the only countries that have a resolution of the Federal Council of Medicine that limits the maximum volume of fat tissue to be aspirated to 7% of the patient’s body weight. Another limit that should be respected is 40% of the body surface.

References

1. Toledo L.S. Syringe liposculpture: a two year experience. Aesth Plast Surg. 1991;15:321-326.

2. Har-Shai Y., Lindenbaum E., Bem-Itzhak O., Hirshowitz B. Large liponecrotic pseudocyst formation following cheek augmentation by fat injection. Aesth Plast Surg. 1996;20:417-419.

3. Fournier P.F. Reduction syringe liposculpturing. Dermatol Clin. 1990;8:539-551.

4. Zocchi M. Ultrasonic liposculpturing. Aesth Plast Surg. 1992;16:287-298.

5. Bruno G., Amadei F., Abbiati G. Liposculpture with ultrasound: biomedical considerations. Aesth Plast Surg. 1998;22:401-403.

6. Grippaudo F.R., Matarese R.M., Macone A., Mazzocchi M., Scuderi N. Effects of traditional and ultrasonic liposuction on adipose tissue: a biochemical approach. Plast Reconstr Surg. 2000;106:197-199.

7. Fournier P.F. Fat grafting: my technique. Dermatol Surg. 2000;26:1117-1128.

8. Pereira L.H., Radwanski H.N. Fat grafting of the buttocks and lower limbs. Aesth Plast Surg. 1996;20:409-416.

9. Toledo L.S., Mauad R. Complications of body sculpture: prevention and treatment. Clin Plast Surg. 2006;33:1-11.