Case Report
Modern Liposuction has evolved from humble beginnings as a rather
experimental procedure 40 or so years ago, to being one of the most popular
procedures in aesthetic surgerytoday. It was the second most popular aesthetic procedure
globally (1,453,340 cases)[1] in 2016(up
4%) as well as most popular procedure in the United States (414,335cases),
up 4.6% from 2015[2].
Subsequent
toIllouz’s presentation of a technique for removing subcutaneous fat with a
blunt cannula attached to a suction generating device at the 1982 Annual
Meeting of the American Society of Plastic and Reconstructive Surgeons, the
procedure has undergone many refinements and evolved with improvement in
techniques and technology[3].
My endeavour in
this article is to briefly discuss current evidence based best practice principles
and highlight future trends.
Potential
liposuction patients who strive to improve their appearance through diet,
exercise, and a healthy lifestyle are more likely to be satisfied with their
long-term postoperative results[4].It is
paramountfor both the patient and the surgeon to remember that liposuction is not a weight-loss technique; it is a
body reshaping (contouring)
technique.
A consensus
statement onlarge-volume liposuction (defined as >5 litters oftotal
aspirate), regardless of anaesthetic method, has underscored the recommendation
for operatingin either an acute-care hospital or in an accredited or licensed
facility when removing large volumes[5].
Depending on
patient characteristics liposuction can be done either in a hospital or office
based setting, but the American Society ofPlastic Surgeons Practice Advisory recommends
avoidingneuraxial anaesthesia (i.e., spinal, epidural)in office-based settings
because of potential hypotension and volume overload issues[6].
The super wet (infiltration of 1 mL per estimatedmL
of expected aspirate) and the tumescent (3 to 4 mL of wetting solution per mL
aspirated) are the most widely used wetting techniques in operation. The
maximum recommended safe dose of lidocaine is 55mg/kg and that of epinephrine 50mcg/kg
in the solution[7,8].Recent data suggest that,
for patientsundergoing generalanaesthesia with the super wet technique, the
lidocainecomponent may be reduced and/or eliminated withoutpostoperative sequel
of increased pain[9,10].This is important in
view of the well-known toxicity issues associated. Wetting fluids should be
warmed to room temperature and the patient should be maintained at normothermic
temperatures to decrease postoperative complications.
Fluid management guidelines for liposuction state
that for small volume aspirations (less than 5 litters) maintenance fluid along
with correction of preoperative losses as well as the subcutaneous infiltrate
is adequate, whereas large volume liposuction (above 5 litters) in addition to
the above, requires 0.25 ml of crystalloid per millilitre of aspirate above 5 litters[11,12].
New devices
continue to emerge for use in this procedure, most of them with little evidence
to support their claims of superiority. It isa formidable task for surgeons to
stay abreast ofall the latest techniques, technologies and, more importantly,
evidence surrounding their uses. The common technologies in use are Suction
Assisted Liposuction (SAL), Power Assisted Liposuction (PAL), Ultrasound
Assisted Liposuction (UAL), Laser Assisted Liposuction (LAL) and the more
recent Radio Frequency Assisted Liposuction (RFAL).
Though UAL and
its current avatar VASER has been found to have some benefit in treating
fibrotic areas and in limiting blood loss, larger incisions required, concerns
with burns, cost, long learning curve and slow procedure times have seen its
popularity on the decline,with erstwhile advocates now employing it in only 7-10%
cases[13,14].
LAL has shown in
a randomized, blinded study to result in up to 17% skin contraction and 25%
improvement in skin elasticity[15].On the
contrary Prado et al. conducted a
randomized,double-blind, controlled study examiningLAL and SALthat showed no
clinical differencein aesthetic outcomes between these techniques. Cost, slow
operative time, multiple stages, potential for skin injury and the learning
curve limits its usage[16].PALfared well in a
three-way comparison (SAL vs. UAL vs. PAL) foroverall efficiency, reduced
vascular injury and most favourablecost-benefit ratio[17].More
recently, PAL was quantified as being 17% more efficient than SAL and less
influenced bythe region of fat distribution, the reciprocating motion
aidingcannula penetration into ‘difficult’ and fibrous areas[18]. This technique has been found tocause less
trauma, swelling andecchymosis in addition to shorter recovery and
diminishedoperator fatigue, particularly in large volume liposuction[19]. The early drawbacks of machine noise and
excessive vibrations to operator have been overcome with the newer devices.
Currently PAL is the author’s preferred technique.
RFAL is an
emerging technology that produces controlled thermal injury at the sub dermal
surface to enhancecoetaneous contraction as it heals. There appears to be a
biphasic skin contraction,with 14% and 24% noted at 6 and 12 weeks
respectively;explained by a stimulation of neocollagenesis[20].This technique has to be used in conjunction with
SAL and though increasing operative time, it has shown promise.
At the end of the day it’s not the type of device used but the surgeon’s
skill and patient characteristics that determine the final result(Figure 1-3).
All plastic
surgeons that perform liposuction should be familiar with the risks, unto wards
equelae, and complications associated with the procedure. Fortunately, most
complications of liposuction are minor in nature and tend to resolve
spontaneously. Venous thromboembolism following surgicalprocedures,
particularly liposuction continues to generate a great deal ofattention in the
professional and lay media.
A recent article
cited the incidence of deep vein thrombosis to be less than 1 percent in
liposuction[21]. Newall et al.reported a 0
percent deep vein thrombosis rate in a retrospective series of patients who underwent
large-volume liposuction and received chemoprophylaxis with
low-molecular-weight heparin[22]. In 2011 the
ASPS Venous ThromboembolismTask Force recommended risk stratification based on
the 2005 Caprini scale for patients undergoing liposuction and the need for low
molecular weight prophylaxis[23].These
guidelines should be incorporated by all plastic surgeons in their practice.
Although indirectly
related to liposuction,the topic of fat transfer is among the most currentand
still debated topics in plastic surgery,despite initial investigations going
back morethan 25 years. Fat transfer may be performed as a primaryprocedure
(e.g., breast or buttock augmentation),as an adjunct (e.g., face-lift surgery
or breast reconstruction), or for the potential of “stem cell” therapy[24].Adiposestem cell pluripotentiality and unlimited
capacity forself-renewal, represents a great promise fortissue engineering.
Cell-assisted lipotransferis a novel approach to autologousfat transplantation
in which adipose-derived stem cells are attached to the aspirated fat[25] (Figure 4).
The “holy grail”
for body-sculpting technology is non-invasive technologies that minimize tissue
morbidity, decrease downtime, and increase skin contraction/tightening, which
lessens the need for skin excision by way of surgical intervention. This has
led to a new industry: non-invasive body contouring[26].In
this regard are non-invasive technologies as cryolipolysis (e.gZeronaTM,Coolsculpt™), high-intensity focused ultrasound -HIFU (e.gLiposonix™) and radiofrequency
devices (e.gBodyFXTM) for fat cell disruption and lysis.
The proven
benefit of liposuction as an adjunct in procedures such as
abdominoplasty,breast reduction, face-neck lifting andbody lifts cannot be
stressed enough. It is an essential tool for the three-dimensional composite
sculpting/remodelling of body structures(Figure 5,6).When liposuction
was first introduced andpopularized in the early 1980s, it indelibly alteredthe
field of body contouring surgery and redefined plastic surgery for future
generations ofsurgeons.Unless a “cure” for obesity is discovered, or a tectonic
shift in human nature, lifestyle, or fashion trends occurs, it is likely than
our concerns withlipodystrophy will persist unabated. Moreover, asmore
practitioners and manufacturers becomeinvolved in this area and research
continues intothe understanding of adipocyte physiology, the fields
ofliposuction, lipolysis, obesity, and fat cell metabolismwill continue to gain
more interest and realizemore advancement[24].
case report 
