Liposuction, Suction Assisted Lipectomy Body Contouring Techniques Toronto
Body Contouring Toronto – History of Body Contouring

  • 1939 – Babcock described surgical procedures for contouring of abdomen and breasts
    • Pitanguy
    • Regnault
Body Contouring Techniques

  • Suction – Assisted Contouring
    • Suction Assisted Lipectomy, Ultrasound Assisted Liposucion, Power Assisted Liposuction
  • Excisional Contouring
    • Abdominoplasty
    • Medial / lateral thigh lift
    • Buttock lift
    • ‘Torsoplasty’ / ‘Flankplasty’
    • Arm lift
    • Neck lift
    • Facelift
    • Breast reduction / augmentation / lift
    • Contouring of the face and skull
    • Autologous Fat Transfer
Development of Suction Lipectomy

  • 1921 – Dujarrier used uterine curette for removal of fat from knee area of ballerina – femoral arterial injury led to amputation
  • 1960s – Schrudde removed localized subcutaneous fat deposits through small stab incisions , sharp curette, secondary suction to remove debris
  • 1978 – Kesselring and Meyer added strong suction to sharp curettage – reports of seroma, skin necrosis
  • 1980 – Illouz , and Fournier and Otteni (1983) replaced curette with rigid blunt cannula inserted subcutaneously, connected to vacuum pump to aspirate fatty tissue
History of Suction Lipectomy

  • 1984 – Illouz also proposed irrigation of subcutaneous space with hypertonic Suction Assisted Lipectomyine solution
  • Belief that adipocytes would swell and rupture – never confirmed clinically
  • 1984 – Hetter recommended adequate suction pressures to achieve lipolysis Standardization of the vacuum pump
  • 1982 – Teimourian proposed small – diameter suction cannulas to limit amount of fat removed, minimized postoperative depressions
Indications for Liposuction

  • Localized fat deposits unmanageable by diet and exercise
  • Ultrasound Assisted Liposucion: Applications to generalized lipodystrophy or deformities
  • General good health
  • Moderate skin tone
  • Reasonable body weight
Contraindications to Liposuction

  • Morbid obesity
  • Cellulite the primary concern
Techniques of Suction Lipectomy

  • Traditional suction – assisted lipectomy
  • Ultrasound – assisted liposuction
  • Power – assisted liposuction
Suction Lipectomy – Preoperative Evaluation

  • Patient’s concerns, goals, expectations
  • Surgeon’s evaluation
  • Standard preoperative photographs
  • Informed consent
Traditional Suction Lipectomy – Instrumentation

  • Suction cannulas
    • Poiseuille’s Law: For each unit increase in radius of a tube, flow rises exponentially; the longer the tube, the smaller the flow
    • Mercedes cannula is most popular
  • Vacuum pump
    • Maximum vacuum any pump can produce at a given time and location is equivalent to the current atmospheric pressure (Hetter, 1984)
Traditional Suction Lipectomy – Objectives

  • Utilizes mechanical disruption (force of moving cannula) to break up subcutaneous fat lobules
  • Fat removed with mechanically induced negative pressure ( suction vacuum )
    • Maximum vacuum any pump can produce at a given time and location = current atmospheric pressure (Hetter, 1984)
  • Final contour is determined by not what is removed, but what is left behind Traditional Suction Assisted Lipectomy Technique
  • Local anaesthesia + sedation or GA
  • Infiltration of subcutaneous solution
  • Stab incisions made along relaxed skin tension lines or natural creases
  • Larger cannulas tunnel deeper areas first
  • Smaller cannulas next intermediate areas
    • Criss – cross pattern of tunnelling
Traditional Suction Assisted Lipectomy Technique

  • Cessation when less then 2 cm of tissue can be pinched from suctioned areas (Rohrich, 1998)
  • Closure of incisions with absorbable suture
  • Compression garments / Reston foam (Schlesinger and Kaczynski, 1993)
    • Not recommended by 3M
Subcutaneous Infiltration (‘Wetting Solution’)

  • Dry Technique: Popularized by Fournier and Otteni in 1983 – largely out of favour due to excessive blood loss. Blood loss mean 25% – 35% in some series. This technique is associated with no infiltrate and the Estimated Loss as percent Volume of Aspirate is 20%-40%
  • Wet technique: Pioneered by Illouz – infusion of 100-300 cc into each treatment site regardless of amount of fat to be removed – aspiration with blunt cannulas, aided by hydrotomy – blood loss 20-25% total aspirate. Hetter added EPI in 1:400,000 concentration and 0.25% lidocaine – reported smaller postop drop in hematocrit. Most studies thereafter used wetting solution containing some EPI and local anaesthetic– blood loss averaged less than 15% of aspirate. Infiltrate 200–300 cc / area. Estimated Loss as % Volume of Aspirate 4%-30%
  • Superwet technique: First advocated by Fodor – involves injecting dilute solution of local anaesthetic and EPI into SC tissues in approximately equal volume of fat to be removed. Blood loss ranged 1-4%. 1 mL infiltrate : 1 mL aspirate. Estimated Loss as % Volume of Aspirate 1%.
  • Tumescent technique: Late 1980s, Klein (Dermatologist wishing to perform lipo without GA in an outpatient setting) reported tumescent technique. Reported increased safely, decreased blood loss (1%), under local anaesthesia in office. Skin & SC tissues anaesthetized by direct infiltration of large volumes of dilute solution of 0.1% or 0.05% lidocaine with 1:1,000,000 EPI in physiologic Suction Assisted Lipectomyine. Fluid engorges targeted areas – easier removal. Infiltration to skin turgor (2-3 mL infiltrate : 1 mL aspirate). Estimated Loss as % Volume of Aspirate 1%
Tumescent vs Superwet – Techniques

  • Tumescent technique
    • Improved safety
    • Improved aesthetic results
    • Decreased postoperative pain
    • Shortened convalescence
    • Minimal time of physician follow-up care
  • Superwet technique
    • Low blood loss, equivalent to tumescent
    • Low complication rate
    • Theoretically improved control of fluid, epinephrine, lidocaine administration
Concerns with Subcutaneous – Infiltration

  • Concerns with tumescence centre around fluid delivery and dosages of lidocaine and epinephrine
  • Trott et al., 1998 suggest guidelines for fluid resuscitation using superwet technique:
    • Aspirates less than 4 L – Wetting solution and maintenance IV alone
      • Adjusted according to vital signs and urine output
    • Aspirates over 4 L – 0.25 cc IV fluid : 1 cc aspirate over 4 L
  • Matarasso (1997)
    • Patients absorb ~ 1 mL of injectate per mL fat aspirate
    • Approximately 20% injectate is removed by suction
        • Recommended supplementation of total fluid given to equal 2 – 3 mL : 1 mL aspirate
  • Both Trott and Matarasso advocate close clinical monitoring of fluid status and urine output, good communication between Surgeon and Anaesthesiologist
  • Dose of epinephrine received with wetting solution varies with technique
  • Normal resting serum EPI levels 0 – 133 pg/mL
  • Supine, at rest for 10 min, CL specimen
  • In pheochromocytoma, levels range 200 – 12,700 pg/mL
  • No reported ‘toxic dose’ or dosing limitation (WRW!)
  • Peak plasma levels 3 hours (intraoperative; silent)
  • Safety demonstrated with up to 10 mg using tumescent technique (Burk et al., 1996)
  • Injectate containing 1:1,000,00 epinephrine provides hemostasis and safety (Trott et al.,1998)
  • Lidocaine thought to absorbed slowly by subcutaneous tissues when mixed with epinephrine in solution
  • Safe dose of lidocaine using dilute subcutaneous infiltration reported as 35 mg/kg body weight (Klein, 1990)
  • Peak plasma levels at 12 hours, did not reach toxic levels
  • Dosages up to 55 mg/kg reported without consequence (Ostad et al., 1997)
  • Only reported case of toxicity with tumescence believed to involve drug interaction between sertraline, flurazepam and lidocaine (Klein, 1995)
  • Reported complications with tumescence:
    • Pulmonary edema (Gilliland and Coates, 1997)
    • Acute median nerve compression from injection in the arm (Lombardi et al., 1998, Grazer and Meister, 1997)
  • ASPRS Task Force on Lipoplasty has defined ‘large volume liposuction’ as > 5 L aspirate removed
    • Recommends physicians performing liposuction be properly trained in techniques, fluid resuscitation and physiology of fluid diffusion
Suction Lipectomy – Complications

  • Undesired sequelae
    • Surface contour irregularities
    • Hypoesthesia – normal sensation usually returns in 3 – 6 months
    • Edema
    • Ecchymosis
    • Hyperpigmentation
  • Potential complications
    • Excessive blood loss
    • Hematoma
    • Seroma
    • Infection
    • Skin necrosis
    • Venous thrombosis
    • Fat emboli
    • Pulmonary edema
    • and in rare cases – Death
  • Contour irregularities
    • Related to surgeon’s (in)experience
      • Keep to minimum by proper patient selection, thorough preoperative evaluation, small cannulas, multiple incisions, cross – radial tunneling, combined superficial/deep suction, ‘feathering’
    • Treat conservatively for 6 months
    • Corrected using liposuction of protuberance or around depression, fat grafting, dermolipectomy (Chang, 1994)
  • Survey of Canadian and US Plastic Surgeons revealed an overall complication rate of 9.3% following suction lipectomy (Pitman and Teimourian, 1985)
    • 20.7% of patients had an unfavourable result
      • Superficial waviness or asymmetry from over – or under – suction
  • 1987 ASPRS report by Commission on Surgical Suction Lipectomy of >100,000 procedures over 5 years:
    • 11 deaths – 2 nec fasc, 2 hypovolemic shock/fat embolism, 4 PE, 1 infection/DIC, 1 pulmonary fat embolism syndrome, 1 probable fat embolism
      • 4 deaths Suction Assisted Lipectomy alone, 7 with other procedures (often abdominoplasty)
    • 9 cases of major morbidity – 3 PE, 3 pulmonary fat emboli, 2 massive infections, 1 intraperitoneal/bowel perforation
  • Other reported complications (Beran and Rohrich, 1998) :
    • Toxic shock syndrome
    • Acute respiratory distress
    • Hypersensitivity to metal cannula
    • Pulmonary edema from tumescence
    • Intestinal perforation
Liposuction – Outcomes
  • Dillerud (1991) analyzed complications and undesired results in >2000 patients:
    • Healthy or stable diabetics, moderately obese patients accepted; BMI >35 contraindicated
    • Overall complication rate 1.2%
    • Undesired results in 10.8%
      • Asymmetry, underresection, skin irregularities
  • Long – term patient satisfaction found to be 76% overall according to Dillerudin 1993
    • Buttock area caused greatest dissatisfaction
    • Most pleased with gynecomastia and submental region