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.

Summary

1. Liposculpture is a technique that remodels the body and facial contouring by the removal and addition of fat
2. It is indicated for reconstructive and cosmetic purposes
3. A very convenient donor site is the infra-umbilical area
4. Outcomes have improved in the last few years because of the improvement of technical details
5. Complications are rare but some of them are life threatening and must be recognized and avoided
6. Pulmonary embolism is the most frequent cause of death in liposuction
7. The limit of liposuction has not yet been defined
8. Removal of up to 5000 cc is related to a reduced number of systemic complications
9. The main challenge of plastic surgeons in the future is to decrease the rate of fat resorption in liposculpture

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 adolescence10

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 gynecomastia15
• liposuction of the jaw and neck area in the facelift17
• abdominoplasty with liposuction of the flanks and to reduce ‘dog ears’
• liposuction prior to lipoabdominoplasty18
• 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: laryngoplasty22 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

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