Liposuction Techniques: A Guide to Surgical Fat Reduction Methods

Surgical Techniques
• The newer liposuction methods aim to
disrupt the fatty cell membrane –
liquefaction – to enable more efficient fat
removal.
• Outcomes may be further enhanced by a
degree of dermal injury, which promotes
cutaneous retraction.
• However, one should remember that any
trauma under the skin risks collateral
damage with the subcutaneous layer richly
supplied by delicate vascular, neural, and
fibrous supporting systems.
10/21/2022 email: askprof@moawadskininstitute.com 1

email:
askprof@moawadskininstitute.com
10/21/2022 2
Fat Reduction
Surgical Techniques
Syringe vs.
machine
Superficial vs.
deep
Liposculpture
vs. high
definition
SAFElipo
Standard vs
energy-assistant
cannulas
Power or
mechanical
Ultrasound and
VASER
Laser Radiofrequency Water-power
Liposuction techniques can be classified as superficial vs. deep, syringe vs. machine, and standard vs.
energy assistant cannula. I will mention these techniques emphasizing syringe reduction liposuction and
a technique I call it external ultrasound-power assistant liposuction (U-PAL).

Syringe-assisted
liposuction
(large vs. small)
• The syringe is another small machine
that can create a high vacuum power
device when attached to various cannulas.
• The power vacuum is generated by
withdrawing its plunger depending on the
purpose of fat removal (reduction vs.
extraction) and the sizes of syringes (10-60
ml).
• For example, a sixty ml syringe attached
to a 3-4 mm cannula can cause the
significant removal of deep fatty tissues for
volume reduction (liposuction.

Syringe-assisted
liposuction
(large vs. small)
• Small syringe-assisted liposculpture has tremendous precision and control
for surgeons who remove superficial fat in artistic, three-dimensional body
contouring.
• Therefore, I use the syringe reduction technique as a first step in
liposuction of any area prone to skin irregularities (abdomen, arms, and
medial thighs), revision, and touch-ups to create a smooth transition
between body contours.

Syringe-assisted
liposuction
(large vs. small)
• Multiple access incisions are placed at various
points to allow a cross-hatched pattern of the
cannula to pass at multiple depths to avoid contour
irregularities.
• The operating hand moves forwards and
backward radially like the spokes of a wheel while
the other hand stabilizes the skin over the tip of the
cannula.
• As fat extraction continues, the pinch test is
performed intermittently to assess symmetry and
reduction in the thickness of the fat layer.
10/21/2022 5

Syringe-assisted
liposuction
(large vs. small)
• When a 10 ml syringe is
attached to microcannulas
(2mm or less), a lesser vacuum is
generated, a prerequisite to
successful fat grafting.

Machine Assisted
Liposuction
• Suction-assisted lipoplasty, otherwise known as
S.A.L., is the workhorse of liposuction.
• The suction machine must achieve a vacuum of
at least 700 mmHg.
• The cannulas come in a wide variety of sizes
(diameter of the tube), tip configurations
(number and location of holes at the tip), and
cannula lengths attached to the liposuction
pump through silicone tubing.
• Advantages of this technique include ease of use
and decades of experience and results.
Sterile container
Vacuum machine
Silicone tube containing fat extracted

Liposuction vs.
Liposculpture
• There are two types of fat removal with a vacuum; one removes deep fat
with the help of large cannulas attached to vacuum producing syringe or a
machine called "liposuction."
• The other removes the superficial fatty tissue using microcannulas called
"liposculpture."

Liposculpture
• During the learning process, I started with liposculpture, a technique closer to fat
extraction of grafting.
• . One should carefully know how to thin the superficial fatty layer, respect the
subdermal vascular plexus, and leave 3–4 mm of subdermal fat intact to avoid
irregularities and complications.
• The endpoint is accomplished when there is a small uniform amount of fat and a
livid appearance on the skin.

Liposuction vs.
Liposculpture
email: askprof@moawadskininstitute.com
• Later, I used the same
technique on the body for those
presented with cellulitis, skin
irregularities and localized fat.
• Like treating depressed,
atrophic scars, one should do
subcision followed by filling.
10/21/2022 10

Liposculpture
• In cellulite, the thinned skin flap will lessen the load on the vertically
oriented superficial fascia, immediately allowing it to contract its elastic
fibers and dynamically re-wrapping over deeply located fat

Liposuction vs.
Liposculpture
• With experience, I used liposculpture
thoroughly at the end of liposuction to
even out the overlying skin flap.
• I was scratching under the skin with a
cannula (as in the axilla to scrape out
eccrine glands).
• The maneuver creates additional scar
tissue followed by contractions, as is true
for any surgery on or below the skin.
• A further contraction related to fibrous
scar tissue during the wound-healing
phase will happen.
• As the fat extraction necessitates
peripheral mesh undermining, it will
ensure a homogeneous contraction of
scar tissue.
10/21/2022 12

Liposculpture
• The liposculpture technique
was an obvious and logical
solution to the limitation
presented with traditional
liposuction (deep fat removal)
without addressing the
superficial fatty layer.
• The result is an immediate
improvement in skin
irregularities and better final
aesthetic results.
• The results are better in lean
or average BMI patients.
• However, there are a few
indications for liposculpture;
improving dimpling, face and
neck contouring, body etching,
and the creation of the buttock
crease.
13
10/21/2022

Liposuction/
liposculpture
• The patient is usually an ASA
class III, obese or more, has
multiple sites, and is not
committing to healthy lifestyle
changes
• The target is a volume
reduction.
• Marking is concentric rings.
• Lipoaspiration is mainly the
deep plane.
• Cannulas are large 4mm- 5mm.
To summarize, the difference between liposuction and liposculpture is as follows:

Liposuction vs Liposculpture
• Patient is usually ASA class II, average or
slightly an overweight, localized deposits and
is committed to healthy lifestyle.
• It need artistic analysis and geometric
markings.
• The target is shape and profile.
• Lipoaspiration is mainly superficially.
• Small cannulas are 2 mm- 3mm.
• May need fat Grafting.
• Immobilization of the treated area.

High Definition Liposculpture
• Since I do not have the clientele for that technique, I am simply not
doing it. However, I will mention high-definition liposculpture to complete
different liposuction surgical techniques.
• The typical candidate works out regularly and may be at or near ideal
body weight but not with an ideal body shape.
• High-definition liposculpture involves creating a harmonious, optimized
body shape.
• It is a complex and time-consuming procedure with a high learning
curve appropriate only for experienced surgeons.
• Therefore, patients must prioritize the body regions they are most
concerned with while focusing on specific complaints within these areas.

High Definition
Liposculpture
• The superficial body anatomy is formed mainly by its muscles, so the
perfect body would be the one with visible muscle structures, giving the
desired shape.
• Muscles such as the gluteus maximus, pectoralis major, deltoid,
rectus abdominis, serratus, and latissimus dorsi are critical muscles that
should be sculpted. They are the predominant mass in their anatomical
zones.

High Definition Liposculpture
• Preoperative marking is accomplished with a keen
understanding of underlying musculoskeletal anatomy and
how this anatomy affects outward topographic appearance,
both in the static state and through a range of motion for
each of the individual muscles that affect the superficial
human figure topography.
• Smooth areas of transition between muscles are done in
women, while sharp ends are preferred in men.
• The harvested fat is used to enhance, contour, and reshape
zones. Some surgeons advocate injecting fat into muscles
(movable sites) to improve grafting success.

High Definition
Liposculpture
• Fat injection emphasizes convexity, while liposculpture
emphasizes concavities between these muscles.
• Some surgeons advocate injecting fat into muscles to
emphasize convexity, while liposculpture emphasizes
concavity.
• Absorbable pads are placed over incisions; the patient is
dressed in foam vests and compression garments.
• Foams must be used at least 2 to 4 weeks after the procedure,
while compression garments must be used from 4 to 8 weeks.

Liposuction vs.
Lipoextration
• In fat grafting, what is essential is
the quality of the fat extracted and
not the fat left.
• In contrast, in liposuction, the
most important is the amount of
fat removed, not the quality, as we
will be discarded.
• Unlike fat extraction, the most
important is what you leave (fat
blanket), which prevents
adhesions and evenly disguises
underlying musculature.

Power-assisted
Liposuction
• Power-assisted liposuction uses an externally
powered cannula, oscillating in a 2–3-mm
reciprocating motion at four thousand–six
thousand cycles/ min.
• It uses mechanical energy to break up fibrous
fat much more readily; the procedure is
significantly faster and less labor-intensive for
the surgeon than traditional S.A.L.
• Disadvantages include the instrumentation
expense. Instruments can range from a few
thousand to up to US $10,000.
• I always combine power-assisted, suction-
assisted, and syringe-reduction liposuction.

Ultrasound-assisted
Liposuction
• Two types of ultrasound energies can be used in
liposuction: external and internal ultrasound energy.
• External ultrasound can be continuous and pulsed.
The constant mode heats the tissue, and the pulsed
variety does not.
• Both techniques (internal and external) cause acoustic
microstreaming in the tissues, resulting in cell
membrane alterations.
• The adipocyte cell membranes become more
permeable, thus increasing intracellular volume and
rupturing the cellular membrane of fatty cells.
• Ultrasound selectively destroys the liquid
fraction of adipocytes, which accounts for 90% of
the fat volume through thermal and mechanical
effects.

External Ultrasound –
assisted Liposuction
• Transdermal ultrasound is used in liposculpture both
operatively and postoperatively, particularly in fibrous areas.
• The hand-held transducer is slowly moved on the marked area
with slow circular or up-and-down movements for about 15
minutes per site.
• External ultrasound can be used as a fat reduction device (see
non-invasive devices) if volumes are less than 300 ml.
• For volumes (more than 300ml), I combine it with either
syringe liposculpture in small cases or power-assisted in large
ones.
• I used it while waiting for the wetting solution to reach its
maximum effect.
TLA of the back reach its
endpoints (firm and blanched)

External
Ultrasound
• Postoperatively, it improves skin
dimpling, decreases swelling and
bruises, and fastens the healing
process.
• Furthermore, it stimulates fibroblasts
to increase collagen production and
enhance the outcome.

External Ultrasound
Lipoaspiration
• The lipoaspiration after using external ultrasound is milky,
with less blood, compared with SAL or PAL techniques.
• The syringe technique yield better pure fat collection with the
least amount of blood in true TLA.

VASER
• VASER-assisted liposuction employs
newer ultrasound solid probes producing
less power but more efficiency.
• Disadvantages include equipment cost,
more extensive incisions, longer operative
times, thermal skin injury, and limiting
the availability of good fat for grafting.

Laser-Assisted Liposuction
• Like ultrasound energy, the use of tumescent infiltrate solutions is required for
proper laser operation and to minimize blood loss and potential complications.
• The treatment involves the insertion of a laser fiber via a small skin incision
followed by a traditional S.A.L. There are several commercially available lasers on
the market under different trade names.
• The longer wavelength has 20 times more absorption in adipose tissue than
the 1064-nm/1320-nm and 40 times more absorption than 924-nm/980-nm
wavelengths.
• Depending on the manufacturer, the fiber may be housed within a cannula or
as a separate fiber.
• The belief is that laser heats subdermal tissue that will provide a skin-
tightening effect. I am not convinced, at least in my patients (large volume), that I
need this tiny diameter laser energy to help me achieve better skin contraction.
• As ultrasound energy, laser energy has similar disadvantages and even worse.

Radiofrequency
Assisted
Liposuction
• Utilizes diathermy-like bipolar
radiofrequency energy to disrupt fatty
cells
• A beneficial secondary effect on skin
contraction is also claimed, and much
like LAL, it causes a thermal injury at
the subdermal surface.

Thermal –Assistant
Liposuction
Laser / UAL /
RF creates
thermal injury
Cell death,
inflammatory
response
Fibrosis and
scar formation
Dermis
adheres to the
fascia
Contour
deformities

IMPORTANT
NOTES FOR
THOSE WHO
ADVOCATE THE
USAGE OF
THERMAL
INJURY TO
REMOVE FAT
• The mechanical effect of the tumescent
solution and mechanical energy exerted by
the surgeon alone or with power-assisted
cannulas is enough to extract the fat we
need even in challenging, fibrous areas of
a male patient.
• The thermal energy is introduced with
ultrasound, laser, and radiofrequency-
assisted liposuction to impart the thermal
load of additional fibrosis, scarring, and
contour irregularities.
10/21/2022 30

IMPORTANT NOTES
FOR THOSE WHO
ADVOCATE THE
USAGE OF THERMAL
INJURY TO REMOVE
FAT
• Using thermal devices designed to
eliminate fat increases liposuction
complications.

Power Water-Assisted
Liposuction 32
• This investigational liposuction
technique is an almost painless
procedure that uses a fine high-
pressure jet of water to detach fat
cells while sparing anatomical
structures such as blood vessels
and nerves.
• Studies show that power
water-assisted liposuction
produces significantly less tissue
trauma than traditional
tumescent liposuction.
email: askprof@moawadskininstitute.com 10/21/2022

Surgical
Endpoints
• Longstanding endpoints have
been divided into primary and
secondary.
• Skin pinch and final contour are
the most critical endpoints in
traditional liposuction and
account for the best
determination of the result.
• Other indicators such as
operation time, amount of
aspirate, and the blood in aspirate
are essential factors to consider.

Surgical
Endpoints
• Measured volume aspirated is a good
indicator for bilateral procedures to
judge symmetry and contour,
comparing each side to the opposite.
• However, with the advent of innovative
technology, the operating surgeon must
be aware of the differences in surgical
endpoints for different technology.
• Ultrasound-assisted liposuction
endpoint is reached when one
encounters a loss of tissue resistance by
the non-dominant guiding hand.

Multiple vs. single procedures
• Liposuction, in combination with multiple unrelated procedures,
has been the topic of many debates, mainly because the volume of
liposuction aspirate that can be safely removed is yet unknown.
• Severe complications have been reported when large-volume
liposuction is combined with abdominoplasty.
• I believe that the cumulative effect of multiple procedures
performed during a single operation may increase the potential
likelihood that complications may develop.
• Therefore, I am crystal clear from the beginning with the patient
that I do not recommend combining unrelated surgical procedures in
a single operation.
• However, I encourage new approaches in body and breast surgery,
such as lipo-abdominoplasty and lipo-brachioplasty.

Staging vs. single
Body contouring
• Decision-making in body contouring, especially for massive-weight-
loss patients, must consider the balance between the quality of the
results and safety issues.
• Many factors go into single session versus multistage procedure,
which is a surgeon's most critical decision. It has a steep learning
curve.

Immediate
Post-operative
Period
• I prefer to leave all the
access sites open for
better drainage and to
hasten healing in the
recovery period.
• In males, with large
volume liposuction, a
drain may be lift.

Post-
Operative
Liposuction
• Assistants use the hand-made
roller to gently remove the
remaining wetting solution and
further break down fat cells.
• Also, we massage the area to
liposhifting existing local fatty
tissues.

Immediate
Post-operative
Period
• A final look at what has been done is essential; when contour
irregularities are recognized intraoperative, we treat them with fat
collected at the beginning of the procedure.
Final Look

Immediate
Post-operative
Period
• Evenly dispersed gentle postoperative compression is the goal
achieved through dressing postoperatively.
• I must emphasize that dressing should be done by the surgeon
or his well-trained medical team artistically.
• We apply bulky absorbent dressings for the first 24 to 48 hours
to allow the excess remnant fluid and serous reaction to flow out.
Fat grafting

Immediate Post-
operative Period
• In liposculpture, silicone foam should be added to
distribute the pressure more evenly, particularly at the
flexion points and areas of creasing.
• Finally, the patients are placed in a compression garment.
• In selected patients, a high degree of compression is
maintained for as long as drainage persists, followed by
lighter compress 24 hours after all drainage (bimodal).
• The general rule of thumb is for patients to wear the
garment for one week every decade of life (40-year-old
patients would wear garments for four weeks.
• The patient will wear the garment 24 h per day, removing it
only to shower for a few days.

Immediate Post-
operative Period
• In large volume liposuction, vital signs and urinary output
should be monitored overnight in an appropriate facility by
qualified and competent staff members familiar with the
liposuction patient's perioperative care.
• Immediate postoperative care should include an assessment
of fluid and electrolyte balance and administering replacement
fluids as needed.
• In addition, red blood cell loss needs to be assessed, and
replacement transfusions should be given if required.
• The patient must fulfill the ambulatory discharge criterion.

Ambulatory Discharge Criterion
• All life-preserving protective reflexes, i.e., airway, cough, and gag, must be returned to normal
• The vital signs must be stable without orthostatic changes
• There must be no evidence of hypoxemia 20 min after the discontinuation of supplemental oxygen
• Patients must be oriented to person, place, time, and situation (times 4)
• Nausea and vomiting must be controlled, and patients should tolerate p.o. fluids
• There must be no evidence of postoperative hemorrhage or expanding ecchymosis
• Incisional pain should be reasonably controlled
• The patient should be able to sit up without support and walk with assistance
• Patients should be discharged in the care of a responsible adult
• Patients should not drive for at least 24 h if sedatives or analgesics were used
Modified from Mecca. Reproduced from Bennett

Immediate Postoperative Period
• Patients are asked to ambulate on the day of the surgery
• The patient may be sent home with oral pain medication, which may be needed for several days.
• The patient is advised to immediately report any worsening pain to the physician, as it may indicate infection or
other complications.

Immediate Post-operative Period
• Shower is permitted after the first follow up visit, but baths, swimming in the pool, using the Jacuzzi, or
submerging the body under the water must be avoided because the liposuction incisions are left open.
• Walking is encouraged immediately, and light exercise is allowed two weeks after surgery.
• The patient is scheduled for his first follow-up visit, 2-5 days postoperatively.

First Follow
up Visit
I see all patients on the
first postoperative visit
• The area is examined for
seroma, infection, skin
ulceration, hematoma, and
swelling.
• Making sure that there is
no kink or pleating in the
garment or the padding

First Follow
up Visit
• The padding is changed, and the
compression garment is placed,
making sure that there is no kink
or pleating in the garment or the
padding.
• Patients should expect to gain
weight initially.
• Weight gain is due to volume
shifts and postoperative swelling
that peak from 3 to 5 days after
surgery.
MSI
MSI
MSI MSI

Postoperative Follow up Visits
• Patients should begin to see
contour changes in their results
by two weeks, and at six weeks,
they should be able to appreciate
significant changes in their shape.
• As patients' activity levels
improve and necessary lifestyle
changes proceed, further changes
may be noticed.
• Depending on the patient, the
final aesthetic result can be seen
3–6 months after surgery.

Postoperative
Follow up Visits
• Postoperative lymphatic massage or external ultrasound are
encouraged to help with swelling and induration.
• The following office visits are at six weeks and six months after
surgery.
• Height and weight with calculating body mass index (B.M.I.)
are paramount for long-term trends during follow-up.

Revision vs.
Secondary
Liposuction
• Revision is a repeat operation typically
performed by the same surgeon to improve
the initial result or deal with something not
or sub-optimally addressed in the primary
procedure (skin waviness, divots, and
asymmetry).
• Many patients request repeat
procedures for further reduction of an area
already treated, having either gained
weight or simply wanting additional
contouring of the area.

Revision vs. Secondary
Liposuction
• A detailed explanation of the limits to the liposuction
procedure, the risks and complications, or the presence
of already irregularities or asymmetries is essential for
the patient to understand preoperatively and is that
further refinements (touch-ups or another surgery) are
possible.
• The surgeon advises the patient to do an under-
correction rather than an overcorrection, as fat removal
is much easier than putting it back.
• The financial considerations for touch-up procedures
are individualized yet should be spelled out ahead of
time and agreed to by the patient.

Revision vs. Secondary
Liposuction
• On the contrary, secondary liposuction is frequently
performed by a different surgeon and is far more extensive
than a revision.
• Secondary procedures are usually performed more than a
year after the initial procedure, whereas revision
procedures may fall within a year.
• Many surgeons avoid secondary liposuction altogether.
• However, when considering repeat liposuction, surgeons
must accept that :
• (1) the result will never be as good as achieved from an
optimally performed primary liposuction,
• (2) the risk of serious injury is more.

Liposuction Techniques: A Guide to Surgical Fat Reduction Methods

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