basics of liposuction and instruments

1. LIPOSUCTION
Dr. S.Satish Kumar

2. INTRODUCTION
• Liposuction is the surgical aspiration of subcutaneous fat by use of a
cannula attached to a vacuum pump.
• Originally introduced by Illouz in the early 1980s, one of the most
popular means of body contouring
• Permanent weight loss requires modification of diet and permanent
change in eating habits.
• Based on the principle – Number of adipocytes in the body is constant.

3. BASIC SCIENCE AND ANATOMIC
CONSIDERATIONS
• Subcutaneous fat
- superficial
- intermediate
- deep
• most common areas treated - intermediate and deep layer.
• Superficial layer - vascular compromise / significantly increased risk
for contour irregularities.

4. ZONES OF ADHERENCE
• Areas of dense fibrous
attachments to underlying deep
fascia.
• Define natural shape and curve
of body.
• High risk for contour
irregularities.

5. CLASSIFICATION OF PATIENTS
• Type I: Localized
lipodystrophy
• Good skin tone and
minimal skin
irregularities.

6. • Type II: Generalized
lipodystrophy
• slightly diminished skin tone
with some skin irregularities
and circumferential
lipodystrophy.

7. • Type III: Skin
redundancy and
lipodystrophy
• significant skin
redundancy
• more amenable to
excisional surgical
techniques to improve
shape and contour.
• Liposuction may be a
useful adjunct procedure

8. PATIENT SELECTION
• A successful liposuction patient must satisfy four key elements
1. Lifestyle change
2. Regular exercise
3. Well-balanced diet
4. Stable weight (not morbidly obese)

10. PRE-OPASSESSMENT
Six key elements are documented
1. Evaluation of areas of lipodystrophy and contour deformities
2. Skin tone and quality
3. Asymmetries
4. Dimpling and cellulite
5. Myofascial support
6. Zones of adherence.

11. • Patient examination in front
of a mirror.
Patient examination in the
supine position confirming
integrity of the
abdominal wall.

12. • High-quality medical
images should be obtained.
• Anterior, posterior, lateral,
and oblique views.
• Documentation of results
• Objective evaluation of
outcomes by both patient
and physician.

13. • Patient education and Informed consent
• Preoperative marking
• Pt in erect position - in front of mirror
• Areas to be suctioned – circles
• Zones of adherence , areas to be avoided
– hash mark

14. • Assymetries, cellulite,
dimpling marked
• Access sites marked
• Reviewed with patient
• Lesser the oncisions – better
• Away from adherence zones

15. MAINTENANCE CORE BODY TEMPERATURE
AND IMMEDIATE PREOPERATIVE CARE
• Patient is placed in a forced air, warming blanket 30–60 min prior to
the procedure.
• All areas not being treated should be covered by the forced warm air
blanket.
• Wetting solutions should be warmed prior to administration.
• Pedal or calf compression devices are also applied.

16. PATIENT POSITIONING
Hip roll - beneath the iliac crests
Longitudinal rolls - support the upper chest
Breasts placed medially and nipples protected.
Arms - extended on padded arm boards at <90°
Face appropriately padded, including placing the cervical
spine in a neutral position and protecting the globes.
Liposuction of arms, back, hip, flanks, lat. pos. med.
thighs.

17. • In supine position, arms, abdomen, anterior medial thighs, and knees
are approached.
• In lateral decubitus position, flanks, lateral back, buttocks, thighs,
and lower legs are approached.

18. WETTING SOLUTIONS
• Initially, liposuction -without the use of wetting solution resulted in
blood loss of up to 45% of aspirate.
• Wetting solution provide hydro-dissection, improve hemostasis and
perioperative analgesia effect.
Wetting techniques
• Dry
• Wet
• Superwet
• Tumescent

21. LIDOCAINE
• Provide analgesia for up to 18 h postoperatively
• Traditional recommended maximum dose lidocaine + epinephrine -
7mg/kg.
• Liposuction, safety of lidocaine in concentrations >35 mg/kg and as
high as 55 mg/kg in large volume cases
Toxicity effects
• Initial signs and symptoms - circumoral numbness, tinnitus, and
lightheadedness.
• Increasing levels- tremors, seizures, and eventually cardiopulmonary
arrest.
• Intraoperative findings include arrhythmias and cardiac irregularities

22. EPINEPHRINE
• Vasoconstrictive properties - key to minimal blood loss
• Decreases the rate of vascular absorption of lidocaine, potentiating the
local anesthetic effect
• Upper safety limit of 15 mg per surgical procedure
• Toxicity can result in tachycardia, hypertension and arrhythmias

23. FLUID MANAGEMENT
• 4 key elements guide intraoperative fluid management –
• Intravenous fluid maintenance (body weight dependent)
• third-space losses
• volume of wetting solution infiltrated
• total lipoaspirate volume

24. FLUID MANAGEMENT
• Rohrich et al. in 1998 (updated in 2006), the following formula aids in
fluid management
1. Replace losses from preoperative oral intake loss as needed.
2. Maintain fluid throughout the procedure and manage it based on vital
signs and urine output.
3. Employ the superwet infiltration technique.
4. Administer crystalloid replacements, 0.25 mL for each mL of
lipoaspirate over 5 L

25. TREATMENT OPTIONS
• Modes of treatment
1. Suction-assisted liposuction (SAL)
2. Power-assisted liposuction (PAL)
3. Ultrasound-assisted liposuction (UAL)
4. VASER assisted liposuction
5. LASER-assisted liposuction (LAL)

26. SUCTION-ASSISTED LIPOSUCTION (SAL)
• Most common and popular
modality.
• Two-stage technique.
• Site infiltrated with wetting
solution and then evacuated.
• Access incisions 3–4 mm in
size

27. SUCTION-ASSISTED LIPOSUCTION (SAL)
Advantages:
• Ease of use
• Malleable cannulas
• Wide variety of cannulas
Disadvantages:
• Difficult to use in fibrous areas and secondary liposuction.
• More physical work involved to break up fat.

28. POWER-ASSISTED LIPOSUCTION (PAL)
• Uses an externally powered
cannula - flex and oscillates
in a 2–3-mm reciprocating
motion at rates of 4000–
6000 cycles/ min.
• Used for large volumes,
fibrous areas and revision
liposuction.

29. POWER-ASSISTED LIPOSUCTION (PAL)
• Advantages:
1. Breaks up fibrous fat much more readily
2. the procedure is significantly faster.
3. less labor intensive for the surgeon than traditional SAL.
• Disadvantages:
1. Noise generation
2. Mechanical vibration experienced by the operating surgeon.

30. ULTRASOUND-ASSISTED LIPOSUCTION
(UAL)
• Utilizes ultrasonic energy to break down fat and facilitate suction-
assisted removal.
• MOA - cavitation of fat and thermal effect of ultrasonic energy
• 3 stages:
(1) Infiltration
(2) Emulsification
(3) Evacuation and Contouring
• solid ultrasound probes and hollow probes

31. ULTRASOUND-ASSISTED LIPOSUCTION
(UAL)
• Consist of handpiece that convert electrical energy to ultrasonic
energy.
• Transmit the energy through a titanium probe.
• The tip of the ultrasound device reciprocate at 20000- 35000 cycles
per second over an amplitude of 100 micron.

33. ULTRASOUND-ASSISTED LIPOSUCTION
(UAL)
• Treatment starts at a depth of
approximately 1–2 cm
• The plane is treated uniformly,
beginning at one side of the area
and moving in a radial fashion to
the contralateral side
• Probe moved to a deeper plane.
• When the last plane is completed,
evacuation begins in the deeper
plane to superficial plane to
remove the emulsified fat

34. ULTRASOUND-ASSISTED LIPOSUCTION
(UAL)
Advantages:
1. Less surgeon fatigue
2. Improved results in fibrous areas and in secondary procedures.
3. More uniform treatment of fat layers and improved contour with less
revision.
Disadvantages:
1. Increased equipment cost
2. slightly larger incisions (5-6 mm)
3. longer operative times
4. possibility of thermal injury
5. cannot be done without wetting solution

35. VASER ASSISTED LIPOSUCTION
• Newer generation of ultrasound-assisted liposuction device that
incorporates less energy with more efficient, solid probes.
• Continuous or intermittent burst of energy can be produced.
• The grooves on the end of probes allow better lateral fragmentation of
tissue with lower energy.
• In large volume liposuction to reduce blood loss especially in fibrous
fatty areas
• Lesser energy ~ lesser thermal effect

37. LASER-ASSISTED LIPOSUCTION (LAL)
• The treatment involves insertion of a
laser fiber via a small skin incision.
• most common available wavelengths are
924/975 nm, 1064 nm, 1319/1320 nm
and 1450 nm.
• The laser fiber disrupts fat cell
membranes and emulsify fat.
• Evacuation via traditional liposuction
cannulas.

38. LASER-ASSISTED LIPOSUCTION (LAL)
Four-stage technique:
I. infiltration,
II. application of energy to the
subcutaneous tissues,
III. evacuation
IV. subdermal skin stimulation.
• Subdermal stimulation has skin
tightening effect

39. SURGICAL ENDPOINTS
• Primary and secondary endpoints
• Skin pinch and final contour are the most critical endpoints
• A reduction in convexity to a smooth contour is the ultimate goal.

40. CANNULAS AND PROBES
• Come in a wide variety of
size,tip configuration and length
Tip configuration
• Blunt or sharp
• Determines speed, efficacy and
safety of liposuction.
Cannula diameter
• The most common sizes between
2.5 and 5.0 mm.
• 1.8 mm and to 1 cm available.
• Size increases, the amount and
speed of tissue removal and
tissue damage increases.
• Large cannulas for deeper fat
deposits and smaller cannulas for
superficial deposits and final
contouring.
Cannula length
• Length of the cannula can vary
from 10 cm to 30 cm.
• Length increases, the ability to
finely control evacuation is limited
but more areas can be suctioned.

41. CANNULAS UTILIZED IN TRADITIONAL
SAL
• rounded and somewhat tapered
tips to allow easier movement
through the tissues.
• Multiple openings allow
improved efficiency in fat
removal
• Most common type is the
Mercedes type which has three
apertures set back from the tip
to allow efficient
circumferential fat removal

43. TREATMENT OF
SPECIFIC AREAS
• BACK
• Very thick dermis and a dense
fibrous fat.
• Prone posn
• UAL and PAL extremely useful
for this area.
• Access incisions in bra/bathing
suit line.
• Women – fat rolls and
lipodystrophy
• Care taken to avoid
intraabdominal and intra-thoracic
penetration of the cannula.

44. ABDOMEN
• Amenable to all modalities of liposuction.
• Suctioning the deep two-thirds of the fat is safe and effective.
• Superficial liposuction for linea alba and correction of secondary
deformities.
• Access - umbilical incision, bilateral lower abdominal incisions,
suprapubic incisions.
• Inframammary incision – subcostal region
• Manual palpation, pinch, and symmetry assessment helps
decrease the likelihood of contour irregularities.

45. HIPS/FLANKS
• Prone position, allows for
simultaneous treatment of both
sides and for comparison.
• Access - bilateral or single midline
paraspinous region and/or lateral
gluteal fold incision.
• Males - fullness in the superior and
lateral region.
• Females - prominence more
inferiorly and posteriorly.

46. HIPS/FLANKS
• Lateral gluteal depression –
important landmark.
• Violation can lead to
persistent or exacerbated
contour irregularity.
• Violin deformity - female
contour of narrow waist,
full hips, full lateral thighs,
and depression in the zone
of adherence between the
hips and thighs

47. BUTTOCKS
• Paraspinous or gluteal access
incisions.
• Ensuring the length, position, and
integrity of the inferior gluteal
crease is of critical importance
• Overzealous treatment in deep or
superficial > buttock ptosis
• Treatment of the intermediate layer
> decrease in buttock projection in
an anterior/posterior dimension

48. BUTTOCKS
• Excessive contouring of
lateral proximal posterior
thigh > extension of
gluteal fold in the female
patient and
masculinization of
gluteal area

49. THIGHS
• Women tend to accumulate fat in a
diffuse, circumferential manner or
in significant amounts medial and
lateral.
• Men have more compact, fibrous
fat in the proximal thighs.
• Saddlebag (a trochanteric bulge
lateral to gluteal crease) banana
roll (roll inferior to the gluteal
fold), violin deformity, cellulite
• Circumferential approach – prone
and supine

50. THIGHS
• The adherent areas of thigh
• the gluteal crease
• the lateral gluteal depression
• the posterior, inferior, and
distal lateral thigh
• area of the mid-inner thigh

51. KNEES/ANKLES
• Lipodystrophy around the knees confined to areas of medial and
anterior leg.
• Small stab incisions used.
• The posterior knee avoided.
• supine position
• Ankles and calf - increased morbidity
• doubles the recovery time of liposuction (from 3 to 6 months).
• avoided

52. NECK
• Patients with minimal to mild skin
laxity and lipodystrophy of the neck.
• Prone for contour irregularities, skin
injury and nerve injuries.
• Neck hyper-extended with shoulder
roll beneath upper back.
• Submental access incision for central
and lobular incision for lateral
access.
• Key pinch is the critical endpoint

53. NECK
• Overzealous treatment >
hollowing and
skeletonizing of neck ,
neuropraxia of marginal
mandibular nerve

54. POSTOPERATIVE CARE
• Compression garment on 24 h a day for 2 weeks PO
• Return to activity/work - 3–4 days or at 2 weeks PO, depending on the
procedure.
• Walking is encouraged immediately
• Light activity - 2 weeks PO
• Edema reduces 3 to 5 days PO
• Bruising dissipate by 7–10 PO
• Contour changes in their waist - 2 weeks
• Significant changes – 6 weeks
• Final aesthetic result 3–6 months PO

55. COMPLICATIONS
• Perioperative complications
• anesthesia and cardiac complications, cannula trauma to skin and/or
internal organs, volume loss/overload from bleeding or excess fluid
administration, hypothermia
• Early postoperative complications
• Venous thromboembolism, infection, and skin necrosis
• Late postoperative complications
• Delayed seroma formation, edema and ecchymosis, paresthesias,
hyperpigmentation, and contour irregularities.

56. EMERGING TECHNOLOGY
• Injection lipolysis
• Kybella (Allergan Inc., Irvine, CA) or deoxycholic acid, cytolytic
agent that physically destroys the adipocyte cell membrane when
injected.
• FDA approved for submental fat
• Injection administered midway into the preplatysmal fat layer 1–1.5
cm below the inferior border of the mandible

57. NON-INVASIVE DEVICES
• Devices deliver transcutaneous energy to the subcutaneous fat layer
either by ultrasound, radiofrequency, tissue cooling (cryotherapy),
low-level laser therapy.
• Lack evacuation phase
• Fat clearance is accomplished by a physiologic macrophage-mediated
phagocytic process

58. Low-level laser therapy
• Mechanism of lipolysis is
creation of transitory pores
in the adipocyte membrane,
from which intracellular
lipids egress.

59. Focused external ultrasound therapy
• UltraShape device delivers
low-frequency non-thermally
mediated (cavitation) acoustic
energy.
• Cleared by the FDA for
circumferential reduction of
the abdomen.
• Three 40–60 min sessions
every other week

60. Focused external ultrasound therapy
• LipoSonix is the second FDA-
cleared ultrasound technology
for fat reduction
• Uses highintensity focused
ultrasound (HIFU) to disrupt
fat with a thermally mediated
mechanism
• For waist circumference
reduction

61. Radiofrequency (RF) ablation
• An oscillating
electromagnetic current
delivering energy to the fat
cells, in turn, creating heat
and causing destruction of
the cells and subsequent
phagocytosis.

62. Cryolipolysis
• Controlled cooling of the
subcutaneous fat, with
selective destruction of fat
cells without epidermal or
dermal injury
• Based on adipose tissue’s
relative sensitivity to cold.
• Approved for fat reduction
in the thigh, abdomen and
flanks in patients with BMI
less than 30

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