liposuction

1. Liposuction: its various method

2. Introduction
• Definition:
 Liposuction is the surgical aspiration of subcutaneous
fat by use of a cannula attached to a vacuum pump.
• Lipoplasty, liposculpture, suction-assisted lipectomy.
• Originally introduced by Illouz in the early 1980s,
continues to be one of the most popular means of
body contouring.
• The essence of liposuction is removal of fat by blunt,
discontinuous dissection without interruption of the
larger neurovascular bundles coursing to the skin from
the deep fascia.

3. • Volume reduction of the subcutaneous fat
compartment
tissue collapse
Healing
contracture.
• Blood supply and innervation to the overlying
skin are preserved.
• Permanent weight loss requires modification of
diet and permanent change in eating habits.

4. Basic science and
anatomic considerations
• Divide subcutaneous fat
throughout the body into
superficial and deep layers or
compartments separated by
Scarpa’s fascia, or the
superficial fascial.
• Subcutaneous fat is arbitrarily
divided into three layers:
superficial, intermediate, and
deep.
• superficial layer is rarely
violated. vascular compromise
and/or a significantly
increased risk for contour
irregularities.

5. • Anatomic “zones of adherence,”
• These are areas of relative dense
fibrous attachments to underlying
deep fascia, which help define the
natural shape and curve of the
body.
• It is important to recognize these
zones, high-risk areas for contour
irregularities after surgical
intervention.
• Intermediate and deep layer.
allows uniform reduction without
risk of injury to the subdermal
plexus and unwanted skin injury.

6. Classification
(Based on the three types of lipodystrophy and skin redundancy )
• Type I: Localized lipodystrophy. Often younger patients
with good skin tone and minimal skin irregularities.
• Type II: Generalized lipodystrophy. These patients tend
to have slightly diminished skin tone with some skin
irregularities and circumferential lipodystrophy
throughout their trunk and extremities.
• Type III: Skin redundancy and lipodystrophy. Patients
displaying significant skin redundancy that would be
more amenable to excisional surgical techniques to
improve shape and contour. If necessary, liposuction
may be a useful adjunct in order to achieve an optimal
result.

7. Evaluation and assesment of patient
1. Selection of the patient.
2. Complete history including medical history.
3. The physical examination addresses the
entire body.

8. History
• The history begins with the initial telephone call from the prospective
patient. height and weight. body mass index (BMI) chart.
• If BMI is 30 or more. Referrals are offered to nutritionists, bariatric
physicians, and Weight Watchers.
• At the office consultation, the patient is asked to fill out a complete medical
history form before seeing the surgeon. A nurse reviews the form and the
surgeon reviews the history before seeing the patient.
• Medical impairments such as diabetes, hypertension, or coronary vascular
disease, optimize the patient's care before surgery.
• A history of bulimia or anorexia nervosa may prompt referral for a
psychiatric evaluation.

9. Physical Examination
• Physical examination of the opposite sex is always performed
with attendant who works for the surgeon and is the same sex
as the patient.
• The examination starts with height and weight and a
calculation of BMI. Weight is also recorded at all subsequent
visits.
• Measured circumferences of selected body areas.
• Even if patients inquire about treatment of only one or two
areas, they are encouraged to undergo a comprehensive
examination.
• Observed first from the back to note posture, body
proportions, and asymmetries. The relative heights of the right
and left shoulders and iliac crests are recorded.

10. • Starting with the upper
posterior torso, pinch
thickness and estimates
of fat volume to be
aspirated are recorded
for the various body
areas.
• The elasticity and laxity
of the skin are
evaluated.

11. 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.

12. Fig. 24.5 Patient examination in
front of a mirror.
Fig. 24.6 Patient examination in the
supine position confirming integrity of the
abdominal wall.

13. Operative consideration
• In the erect position. patients for
total body liposuction with
excisional surgery, marking can
be done in the office day before
surgery.
• Marking is done in front of a
mirror.
• Areas to be suctioned are marked
with a circle.
• Access incisions are also marked.
• Cosmetically, preferable stagger
incisions in an asymmetric
fashion to camouflage their
appearance.
Fig.Patient has been marked prior to surgery.
Markings demonstrate the contours of the
areas to be suctioned as well as the planned
incision sites.

14. Maintenance core body temperature
and immediate preoperative care
• The patient is placed in a forced air, warming blanket 30–60
min prior to the procedure.
• Additionally, pedal or calf compression devices are also
applied in the holding area.
• During the procedure, all areas not being treated should be
covered by the forced warm air blanket.
• The wetting solutions should be warmed and not administered
cold

15. Cannulas and probes
• Suction of fat is achieved.
• Come in a wide variety of size,tip
configuration and length of
cannula
• Tip configuration
 Blunt or sharp, speed, efficacy
and safety of liposuction.
• Cannula diameter
 The most common sizes between
2.5 and 5.0 mm.
 Sizes are available down to 1.8
mm and up to 1 cm in size.
 Size increases, the amount and
speed of tissue removal and tissue
damage increases.
• In general large cannulas are used
for deeper fat deposits and the
smaller cannulas are utilized 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 more
limited but more areas can be
suctioned with fewer access
incisions.

16. Wetting solutions and perioperative
fluid management
• When first described, liposuction was performed without the use of any
infiltrated wetting solution which resulted in blood loss of up to 45% of
aspirate in some areas.
• Liposuction with wetting solution provide hydro-dissection, improve
hemostasis, and potentially provide some perioperative analgesia.
• There are four different terms used to describe the types of wetting
solution:
 Dry,
 wet,
 superwet, and
 tumescent.

19. Lidocaine
• Most wetting solutions utilize lidocaine as the local anesthetic
component.
• The traditional recommended maximum dose of lidocaine with
epinephrine is 7 mg/kg.
• Liposuction setting, numerous studies have documented the
safety of lidocaine in concentrations >35 mg/kg and as high as
55 mg/kg in large volume cases.
• Dilute nature of lidocaine solutions used in liposuction, slow
infiltration, the avascular plane injected and a high lipid
solubility of lidocaine.
• Toxicity: CNS and CVS.

20. Epinephrine
• Vasoconstrictive properties is the key to minimal blood loss
during liposuction.
• This effect also decreases the rate of vascular absorption of
lidocaine, potentiating the local anesthetic effect.
• Most commonly, epinephrine in 1 mg with 1/1000 dilution is
injected into a 1 L bag of infiltrate either NS/LR.
• To maximize its effect, the infiltrate should be allowed to set
for a minimum of 7 min and no longer than 30 min.
• Epinephrine toxicity can result in tachycardia, hypertension,
and arrhythmias.

21. Fluid management
• Body contouring procedures can result in significant fluid
shifts and intravascular volume changes for the patient.
• Attention to maintenance intravenous fluids, third-space
losses, wetting solution infiltration, and lipoaspirate.
• 3–5 mg/kg per hour of crystalloid solution is adequate volume
for maintenance replacement and third-space losses.
• Additional, ratio of 0.25 mL of crystalloid solution for each
aspirated milliliter over 5 L is considered.

22. Preparation and Draping
• While standing on an absorbent
pad, the patient is
circumferentially painted with a
warmed, germicidal solution.
• Lie supine on a sterile-draped
operating room table with arms
out at 90 degrees.
• The feet are wrapped in sterile
towels.
• A sterile barrier sheet is placed
between the anesthesiologist and
the sterile field.
• The patient will be repositioned
several times.
Figure 123-16 Patient is painted
circumferentially from neck to feet with warm
povidone-iodine (Betadine) solution.

23. Infiltration
• All areas to be treated are infiltrated with large volumes of
dilute lidocaine 0.04% with epinephrine 1:1,000,000 before
the start of liposuction.
• The first areas infiltrated will be the first areas aspirated.

24. Patients positioning
Prone:
• A soft hip roll is placed beneath
the iliac crests, and pillows or
longitudinal rolls are used to
support the upper chest.
• Arms are extended on padded arm
boards at <90° from the long axis
of the table.
• The face must be appropriately
padded.
• In the prone position, up to 70%
of the contouring can be
performed and may include
liposuction of the arms, back,
hips/flanks, lateral, posterior, and
medial thighs.

25. Supine position:
• treatment of the arms, abdomen, anterior medial thighs, and knees.
• This position does not have significant effects on the cardiopulmonary
systems.
Lateral decubitus:
• Although rarely used in our hands, the lateral decubitus position can access
the flanks, lateral back, buttocks, thighs, and lower legs.
• A disadvantage of this method is that a side-by side comparison to the
contralateral area is not available to assess symmetry.

26. Treatment options
• Factors that influence the selection of a particular
type of treatment include surgeon preference,
target area, expected aspirate, and history of
previous liposuction.
1. suction-assisted liposuction (SAL);
2. power-assisted liposuction (PAL);
3. ultrasound-assisted liposuction (UAL);
4. Vaser assisted liposuction; and
5. laser-assisted liposuction (LAL).

27. Suction-assisted liposuction (SAL)
• SAL: Most common and
popular modality.
• Uses a two-stage technique.
• The site is infiltrated with a
predetermined wetting
solution and then evacuated.
• Patients are marked and
incisions 3–4 mm in size are
made for access.
• Advantages:
 ease of use
 Malleable cannulas
 Wide variety of cannulas,
and
 Decades of experience.
• Disadvantages:
 Difficult to use in fibrous
areas and secondary
liposuction.
 More physical work
involved to break up and
remove fat.

28. Power-assisted liposuction (PAL)
• Used since 1999.
• The cannula reciprocate 2-mm
magnitude at the rates of 4000–
6000 cycles/ min.
• Best used for large volumes,
fibrous areas, and revision
liposuction.
• Both the power source, and the
suction are attached to the
proximal end of the handpiece.
• PAL systems have multiple power
settings; they can be programmed
for a variety of areas, tissue types
and according to the preferences
of performing surgeon.
Figure: Electric power-
assisted liposuction device.

29. 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)
• Ultrasound-assisted liposuction
devise 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.
• Tip of probe break down fat by
cavitation and facilitate
suction-assisted removal.
Figure: Handpiece of an ultrasonic device. The handpiece converts electrical energy from a generator to kinetic energy, which is transmitted to a probe as
ultrarapid vibrations. The handpiece is connected to a generator by a flexible cord. The probe attaches to the handpiece by a screw mount. B, Hollow
ultrasonic liposuction probe tips. Ultrarapid vibration at the probe tip implodes fat cells. Openings at the tip permit suction evacuation of liquefied fat.

31. • The treatment is begun at
a depth of approximately
1–2 cm, depending on the
body area.
• The plane is treated
uniformly, beginning at
one side of the area and
moving in a radial fashion
to the contralateral side.
• When the last plane is
completed, evacuation
begins in the deeper plane
to remove the emulsified
fat.

32. 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,
3. longer operative times
4. possibility of thermal
injury.

33. VASER-assisted liposuction
• Newer generation of ultrasound-
assisted liposuction device that
incorporates less energy with
more efficient, solid probes.
• Continuous or intermitten burst of
energy can be produced.
• The grooves on the end of probes
allow better lateral fragmentation
of tissue with lower energy.
• The probes come in an array of
sizes and grooving, depending on
tissues in which they will be used.
• Advocates the use of VASER in
large volume liposuction to
reduce blood loss especially in
fibrous fatty areas
Figure:A, The VASER ultrasonic device . The
handpiece is attached to the generator by the power
cord. The probe screws into the distal end of the
handpiece (right). B, The VASER ultrasonic probes. The
tips of the probes are grooved to facilitate
fragmentation in a lateral direction.

34. Laser-assisted liposuction(LAL)
• LAL has been at the forefront of marketing hype at present.
• The treatment involves insertion of a laser fiber via a small
skin incision.
• Depending on the manufacturer, the fiber may either be housed
within a cannula or as a separate fiber.
• There are several commercially available lasers.
• The most common available wavelengths in the United States
are 924/975 nm, 1064 nm, 1319/1320, and 1450 nm.
• Many of these devices utilize more than one wavelength
during treatment.

35. Four-stage technique:
I. infiltration,
II. application of energy to the subcutaneous
tissues,
III. evacuation, and
IV.subdermal skin stimulation.
• The laser fiber purportedly acts to disrupt fat
cell membranes and emulsify fat.
• These devices have been marketed for
purported skin-tightening effects.

36. Surgical endpoints
• Skin pinch, final contour, and volume of aspirate.
• Final contour irregularities can be treated with
autologous fat grafting immediately.

37. Treatment of specific areas
Back
• The anatomy of the subcutaneous
fat and skin is unique. very thick
dermis and a dense fibrous.
• UAL and PAL extremely useful
for this area.
• Access incisions will depend on
the distribution of fat and/or skin.
• Suctioning from areas off of the
thoracic cage (hip region) towards
the posterior back should not be
performed to obviate intra-
abdominal and intra-thoracic
penetration of the cannula.

38. Abdomen
• Amenable to all of the various modalities of liposuction.
• Suctioning the deep two-thirds of the fat is safe and effective.
• The operating surgeon should reserve superficial liposuction
for correction of secondary deformities.
• Access through an umbilical incision, bilateral lower
abdominal incisions, suprapubic incisions.
• Manual palpation, pinch, and symmetry assessment helps
decrease the likelihood of contour irregularities.

39. Hips/flanks
• Prefer prone position, allows for
simultaneous treatment of both
sides and for comparison.
• access through bilateral or single
midline paraspinous region and/or
lateral gluteal fold.
• Differ aesthetic consideration of
the hips and flanks in males and
females is crucial.
• In general, males tend to have
fullness in the superior and lateral
region, while females usually
exhibit prominence more
inferiorly and posteriorly.

40. Buttocks
• There are widely varying
aesthetically pleasing buttock.
• These change with time and vary
across age groups, ethnicity, and
geography.
• Access incisions are placed
asymmetrically, to avoid an
operated look.
• Avoiding deep, aggressive
suctioning and ensuring the
length, position, and integrity of
the inferior gluteal crease is of
critical importance.
• Accessed via paraspinous or
gluteal access incisions.

41. Thighs• Women tend to accumulate fat either
in a diffuse, circumferential manner
or in significant amounts medial and
lateral.
• In general, men tend to accumulate
more compact fat in the proximal
thighs.
• saddlebag (a trochanteric bulge
lateral to gluteal crease); banana roll
(roll inferior to the gluteal fold), and
violin deformity (female contour of
narrow waist, full hips, full lateral
thighs, and depression in the zone of
adherence between the hips and
thighs).
• The adherent areas: the gluteal
crease; the lateral gluteal depression;
the posterior, inferior, and distal
lateral thigh; and the area of the mid-
inner thigh

42. Neck
• Patients with minimal to mild skin
laxity and lipodystrophy of the
neck.
• All liposuction devices may be
used
• neck hyper-extended with a
shoulder roll or pill beneath the
upper back.
• submental access incision for
central and lobular incision for
lateral access.
• Direct subdermal suctioning
should be avoided.
• key pinch is the critical endpoint
allowing for symmetry.

44. Postoperative care
• At the conclusion of surgery, placed in a compression garment
which is customized based on surgeon preference and
procedure performed.
• Antibiotics and analgesics.
• Large-volume procedure (>5000 mL aspirate), liposuction of
multiple areas, or liposuction in addition to abdominoplasty
are kept overnight for observation.
• Patients are asked to ambulate the day of the surgery.
• Patients are allowed to shower as early as 1 or 2 days
postoperatively.
• Instructed to keep the compression garment on 24hours a day
for 2 weeks.

45. • The patient may remove the compression garments for bathing.
• Initial postoperative visits are scheduled for 5–7 days postoperatively.
• Return to activity/work can occur as early as 3–4 days or at 2 weeks,
depending on the procedure.
• Walking is encouraged immediately, and light activity is allowed 2 weeks
after surgery, unless the patient has undergone an associated
abdominoplasty or other invasive procedure.
• Edema tends to peak from 3 to 5 days after surgery.
• Bruising should be minimal and dissipate by 7–10 days after surgery.
• Patients should begin to see contour changes in their waist by 2 weeks and
at 6 weeks, be able to appreciate significant changes in their shape.
• The final aesthetic result can be seen 3–6 months after surgery, depending
on the patient.
• Postoperative lymphatic massage is encouraged to help with swelling and
induration and is often started prior to surgery and resumed shortly after the
procedure.

46. Complications
• Complications can vary from mild postoperative nausea and
vomiting to deep venous thrombosis (DVT)/pulmonary
embolism (PE) and even death.
• Perioperative period (0–48 h): anesthesia and cardiac
complications, cannula trauma to skin and/or internal organs,
and volume loss/overload from bleeding or excess fluid
administration.
• Early postoperative period (days 1–7): venous
thromboembolism, infection, and skin necrosis.
• Late postoperative period (1 week to 3 months ): delayed
seroma formation, edema and ecchymosis, paresthesias,
hyperpigmentation, and contour irregularities.

47. Emerging technology
• The noninvasive dissolution of fat is an extremely attractive
concept for patients.
• The earliest version was “mesotherapy” or “lipolysis”, an
evolving technology, the goal of which is a reduction in fat by
dissolution.
• The concept dates back to 1952 and involves injection of
phosphatidylcholine, deoxycholate, and/or other agents which
are purported to dissolve fat.
• It is the injection of a standardized solution into the
subcutaneous fat, rather than the mesoderm.

48. • Due to lack of scientific data and adequate studies and
outcome results, the use of mesotherapy or its variants is not
currently recommended.
• ‘Low level laser therapy’ has recently emerged as a treatment
for lipodystrophy. The application is percutaneous and
reportedly painless.
• Non invasive focused external ultrasound therapy is one of the
most popular fat reducing technologies currently being
evaluated and has considerable popularity in Israel, Spain, and
Japan.

49. • The ‘UltraShape’ device is a nonthermally mediated
(cavitation) mechanism and is currently being marketed
outside of the United States.
• UltraShape device was target specific for the adipocyte,
preserving the surrounding neurovasculature.

50. • ‘LipoSonix’ technology uses high-intensity focused
ultrasound(HIFU) to disrupt fat in a thermally mediated
mechanism.
• LipoSonix disrupts fat via a thermocoagulation mediated
mechanism (versus UltraShape, which acts via cavitation,
causing disruption of fat cell membrane).
• Liposuction combined with radiofrequency ablation of fat cells
is currently being investigated under the trade name
‘BodyTite’ (New York).

51. • ‘Cryolipolysis’ is a new and vastly different technology
currently being evaluated for fat destruction under the trade
name ‘Zeltiq’.
• The concept is a controlled cooling of the subcutaneous fat,
with destruction of selective fat cells without epidermal or
dermal injury.
• Nonsurgical body contouring will be validated and ultimately
approved in many different forms in the upcoming years.

52. Conclusion
• Over the past three decades, the procedure of liposuction has
evolved and become consistently one of the most popular
cosmetic procedures performed around the world.
• The process of liposuction/liposculpture is as much an art as
science.
• Must understand the pathophysiology of both the patient and
disease process in order to effectively treat the patient and
achieve safe and aesthetically pleasing results.
• Liposuction will likely remain one of the most popular
aesthetic procedures performed in the years to come.

53. Thank you