All About Liposuction: Part 2

by

ALL ABOUT LIPOSUCTION: PART 2

The surgical removal of subcutaneous fat utilizing a blunt cannula attached to a suction device is termed liposuction. Synonymous terms include suction lipectomy and suction-assisted lipectomy (SAL). Lipoplasty, a broader term, defines any procedure that alters the contours of subcutaneous fat deposits by either the removal or addition of fat (liposuction and autologous fat transfer are both examples of lipoplasty). Lipolysis reflects the direct ablation of adipocytes by any method.

PERIOPERATIVE CARE
Since liposuction involves extensive manipulation of skin structures, broad spectrum antibiotic prophylaxis targeting common skin pathogens is employed immediately prior to surgery.

After surgery, absorbent dressings are placed over all incision sites; drainage of fluid typically ceases in 2 to 3 days. Compression garments are applied over the wound dressings and over the complete span of each surgical site. High-compression garments (aka “phase one” garments) are worn continuously until drainage from the incision sites ceases. Lower-compression (“phase two”) garments are worn continuously thereafter for 4 to 6 weeks. Rarely is postoperative discomfort severe. Most patients describe varying degrees of a burning soreness over the muscle layer at the treatment sites that responds well to nonsteroidal anti-inflammatory medications.

Massage of the treatment sites is frequently employed as a means of expediting the resolution of varying degrees of soft tissue swelling common after this type of surgery. There are no established standards for post-liposuction massage, but most regimens begin a minimum of two weeks after surgery at which time the patient’s discomfort level from this type of therapy is low. Complete healing and tissue remodeling require approximately six months. Within this time frame induration of the treatment sites develops and resolves.

COMPLICATIONS OF LIPOSUCTION
Complications may relate to either anesthesia or surgery. Anesthetic complications of general and regional anesthesia are no different for liposuction than for other types of surgery. However, the addition of large volumes of superwet or tumescent fluids into the fat layers creates the potential added risk of fluid overload if the patient is receiving significant amounts of intravenous fluid simultaneously. When liposuction is performed totally by local tumescent anesthesia, intravenous access is established only for the purpose of administering medications; fluids are administered orally, intermittently and in small volumes.

Lidocaine overdose is rare with tumescent liposuction when toxicity thresholds are assessed and respected, but patients taking medications that interfere with lidocaine metabolism are at increased risk. Allergic reactions to the components of tumescent and superwet solutions have been described in their undiluted states and are most commonly attributed to preservatives. Allergies to lidocaine hydrochloride, an amide anesthetic, are exceedingly rare (13).

Organ and vascular perforation injuries by liposuction instrumentation ares rare. They have been reported in association with surgery in the presence of abdominal scars or hernias as well as with large volume cases with all types of liposuction in all types of surgical settings by all types of surgeons (14, 15).
Surgically-related blood clots are dangerous, but thankfully rare. These conditions are more characteristic of prolonged procedures performed under general anesthesia or deep sedation than tumescent local anesthesia, but nonsurgical factors such as oral contraceptive use, inherited coagulation disorders, a history of smoking, or a long trip spent sitting in a car or an airplane perioperatively can increase the risk regardless of the type of anesthesia employed.

Fat embolism, and fat embolism syndrome (FES) are rarer still in relation to liposuction (14, 15). FES is a delayed biochemical inflammatory condition which, when severe, is marked by respiratory distress, cerebral dysfunction and a spotted skin rash 24 to 48 hours after surgery. Emboli of fat may also provoke mechanical blockage of the pulmonary capillaries resulting in tachycardia (rapid heart rate), tachypnea (rapid shallow breathing), elevated temperature, hypoxemia (reduced blood oxygen levels), and mild neurologic symptoms among other symptoms (16).

Hemorrhage due to direct vascular injury within the surgical field is not typically seen with either tumescent or superwet liposuction because of the vasoconstriction which both of these modalities produce. Low-level intraoperative bleeding is sometimes provoked by venturing beyond the zone of vasoconstriction either by inadvertently venturing into fat outside the treatment zone or by grazing the underlying superficial layers of muscle and fascia with the cannula. The latter respond well to compression and targeted infiltrations of dilute epinephrine. Case reports of significant bleeding necessitating blood transfusion during liposuction indicate deep tissue lacerations and perforations.

Bruising, typically mild, is common after liposuction, but less so when small caliber cannulas, pure tumescent techniques and drainage are employed. Not infrequently, bruising will appear in areas dependent to the surgical field. More extensive bruising accompanies the use of systemic anesthesia, larger instrumentation and the treatment of highly vascular regions such as the submandibular fat pad and the breast. Hypertensive patients are at higher risk for bruising.

Hematomas and seromas are uncommon in liposuction, but when seen are usually related to the treatment of richly vascularized areas such as the breast or the submental (beneath the chin) fat pad and may be associated with extensive bruising. Sonography is a useful assessment tool for these conditions. Primary treatment in both instances is drainage and compression. Hematomas left undrained subcutaneously provoke wrinkling of the overlying skin.

Infection is rare with this type of surgery probably owing to the selection of exclusively healthy patients, the common use of dedicated clean operating rooms, antibiotic prophylaxis and the routine use of drainage postoperatively. The common method of post-liposuction drainage is via the egress of fluid from unsutured cannula sites rather than by the placement of indwelling drains. Necrotizing fasciitis, the most dangerous type of tissue infection has been reported with liposuction, is most commonly due to streptococcus pyogenes and is extremely rare (17).

Partial or full-thickness skin necrosis can occur when the vascular supply to the skin is injured by various means. Damage may be provoked by excessively superficial liposuction, by pressure from improperly worn compression garments, by ice packs, by infection and by dermal atrophy which is common with obesity, advancing age, and chronic cigarette smoking. Prompt and regular debridement and appropriate antibiotic coverage until healthy granulation tissue develops are the mainstays of management. Lesser degrees of vascular injury to the dermis manifest as areas of erythematous skin discoloration.

Contour irregularities subsequent to liposuction may range from mild to severe. Proper positioning and surgical technique minimize these defects, but when they occur can be managed with either autologous fat transfer (sometimes referred to as lipofilling) or liposhifting. Autologous fat transfer involves the harvest of fat by liposuction from area(s) usually remote from the intended recipient site, separation of the fat from the anesthetic fluids, and fine, incremental injection of the purified fat in layers into the targeted region using small syringes and blunt-tipped fat transfer cannulas. There are numerous techniques for separating and preparing the harvested fat. Liposhifting is a technique through which the fat peripheral to an iatrogenic concavity is loosened by mechanical disruption by means of specialized cannulas surrounding and then massaged vigorously into the target area (18).

LIPOSUCTION ASSISTED BY TECHNOLOGY
Liposuction is most commonly performed manually and generally produces excellent results in properly selected patients. Nonetheless, the process is tedious and requires prolonged repetitive motion by surgeon. Consequently, one of the major stimuli for technological innovation has been an effort to facilitate the liposuction process.

Liposuction has been found to require less time and effort when the integrity of the targeted fat layers has been partially disrupted especially in the presence of fibrous tissue, scar tissue or a previously liposuctioned field. There are presently three methods of achieving this goal with FDA-approved equipment: mechanical disruption, internal ultrasound, and external laser therapy. All of them require preliminary tumescent or superwet infiltration of the fat layers.

Slow mechanical disruption of the fat layers utilizing smooth cannulas without suction was originally described as a means of softening the transition between the treatment site and the surrounding tissues at the time of wet liposuction and was termed mesh undermining in the early 1980s (19). The process was subsequently adopted as a pre-treatment of the targeted fat at the time of wet liposuction and found to facilitate both cannula motion and the achievement of smooth contours and dubbed pretunneling (20). Pretunneling re-emerged as “fat disruption” in 2003 - a pre-treatment to tumescent liposuction with the goal of speeding the surgical process (21). Unlike its predecessor, fat disruption utilizes cannulas with flared apertures originally designed for liposhifting which are more effective at softening the tissues of the SFS than are smooth cannulas.

Internal ultrasonic emulsification of the targeted fat layers was introduced in 1987 (22). Termed ultrasound-assisted liposuction (UAL), this technology utilizes metallic probes to deliver mechanical vibrations at frequencies in the range of 20 t0 60 kHz which interact with the targeted tissues via direct thermal effects, cavitation and direct mechanical effects. The emulsified fat is then removed by conventional liposuction. Burn injuries continue to plague this modality because ultrasonic energy can easily turn into heat energy (i.e. the widely used harmonic scalpel utilizes the same basic principles exclusively for their thermal effects). An external version of this technology utilizing skin paddles and a gel interface was introduced in the 1990s, but there is no present device on the market (23). Other adaptions of external ultrasound technology which bypass the need to employ liposuction are marketed outside the United States, but remain a topic of continued investigation (24).

A technique of external laser assisted liposuction was introduced in 2000 (25). The procedure, termed low-level laser-assisted lipoplasty utilized a 635-nm, 10mW diode laser applied in conjunction with tumescent anesthesia prior to conventional liposuction. The authors demonstrated microscopically that the laser action caused transient pores to open in the adipocytes cell membrane allowing its contents to move into the interstitial space. They commented that the latter effect resulted in easier fat extraction and less surgical trauma and bruising. An attempt to to duplicate these microscopic findings by another group utilizing superwet rather than tumescent solution was unsuccessful (26).

Powered liposuction cannulas offer a more direct alternative for reducing surgical fatigue, but do not reduce operating time to any perceivable degree. Power-assisted liposuction (PAL) devices became available in 2000 (27). A variety of designs include electric motors, pneumatic motors, axial motion, rotational motion and oscillation. Patients typically perceive less discomfort with PAL cannulas due to their inherent vibration when activated. PAL is sometimes referred to as vibroliposuction.

Aside from facilitating the liposuction process, various technologies have focused on augmenting the benefits of the procedure. Internal laser devices for assisting conventional liposuction surgery were first described in 1992 (28) with the implication that laser-mediated coagulation of blood vessels, collagen and adipocytes would result less blood loss, bruising and tissue reorganization. First-generation devices were low-energy 1065-nm neodymium:yttrium-aluminum-garnet lasers and were heavily marketed in South America and subsequently in North America, but clinical studies, including a prospective randomized trial versus standard liposuction failed to find any major cosmetic or convalescent differences (29). Laserscontinue to flood the liposuction market touting “unique” combinations of wavelengths and wattages each promising the ultimate cosmetic results with little more than than the anecdotal blessing of a handful of industry-friendly surgeons. Water-assisted liposuction was introduced in Europe in 2005 with the promise of less tissue trauma utilizing a powered cannula that delivers a pulsatile flow of fluid and aspirates simultaneously (30), but there is not yet sufficient data to substantiate whether the procedure offers any advantages over existing methods in terms of complications or cosmesis.

SUMMARY
Liposuction provides effective contouring of the torso, extremities and jawline in properly selected patients. There are effective established techniques for performing liposuction under local anesthesia and general anesthesia. Both methods share many similarities with regard to the surgical craft of fat removal, but have distinct elements of anesthetic precaution which must be respected to optimize safety. No technology to date appears to give superior results over conventional methods.

REFERENCES
  • 1.Cosmetic Surgery National Data Bank. 2008 Statistics. American Society for Aesthetic Plastic Surgery 2009. P. 3.
  • 2.Comiskey C. Cosmetic surgery in Paris in 1926: the case of the amputated leg. J Women’s History 2004;16(3):30-54.
  • 3.Fischer A, Fischer GM. Revised technique for cellulitis fat reduction in riding breeches deformity. Bull Int Acad Cosmetic Surg 1977;2:40.
  • 4.Illouz YG. Une nouvelle technique pour les lipodystrophies localisées. La Revue de Chirurgie Esthétique de Langue Française 1980;6(19):10-2.
  • 5.Fournier P. Liposculpture: Ma technique. Paris: Librairie Arnette 1990.
  • 6.Hetter GP. The effect of low-dose epinephrine on the hematocrit drop following lipolysis. Aesthetic Plast Surg 1984;8(1):19-21.
  • 7.Klein JA. Tumescent technique for liposuction surgery. Am J Cosm Surg 1987;4:263-7.
  • 8.Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol 1990;16:248-63.
  • 9.Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: A new concept. Plast Reconstr Surg 1991;87(6):1009-18.
  • 10.Avelar J. Regional distribution and behavior of the subcutaneous tissue concerning selection and indication for liposuction. Aesthetic Plast Surg 1989;13(3):155-65.
  • 11.Klein JA. Subcutaneous fat: Anatomy and histology. In: Tumescent technique: Tumescent anesthesia and microcannular liposuction. Philadelphia: Mosby; 2000. P. 213-21.
  • 12.Kaminski M, Lopez deVaughn RM. The anatomy and physiology metabolism/nutrition of subcutaneous fat. In: Shiffman MA, DiGiuseppe A, editors. Liposuction: Principles and practice. Berlin: Springer; 2006. P. 17-25.
  • 13.Gonzalez-Delgado P, et al. Cross-reactivity among amide-type local anesthetics in a case of allergy to mepivacaine. J Investig Allergol Clin Immunol 2006;16:311-3.
  • 14.Talmor M, Hoffman IA, Lieberman M. Intestinal perforation after suction lipoplasty: A case report and review of the literature. Aesthetic Plast Surg 1997;38:169-72.
  • 15.Shiffman MA. Prevention and treatment of liposuction complications. In: Liposuction: Principles and practice. Berlin: Springer; 2006. P. 333-41.
  • 16.Levy D. The fat embolism syndrome: a review. Clin Orthop 1990;261:281-6.
  • 17.Wang HD, et al. Fat embolism syndromes following liposuction. Aesthetic Plast Surg 2008;32:731-6.
  • 18.Haeck PC, et als. Evidence-based patient safety advisory: Liposuction. Plast Reconstr Surg 2009;124:28S-44S.
  • 19.Heitman C, Czermak C, German G. Rapidly fatal necrotizing fasciitis after aesthetic liposuction. Aesthetic Plast Surg 2000;24:344-7.
  • 20.Saylan Z. Liposhifting instead of lipofilling: Treatment of postlipoplasty irregularities. Aesthetic Surg J 2001;21:137-41.
  • 21.Hetter GP. Surgical technique. In Hetter GP, ed: Lipoplasty: The theory and practice of blunt suction lipectomy. Boston: Little, Brown and Co. P.137-54.
  • 22.Mladick RA, Morris RL. Alternative patient positioning and pretunneling. In Hetter GP, ed: Lipoplasty: The theory and practice of blunt suction lipectomy. Boston: Little, Brown and Co. P.137-54.
  • 23.Mangubat EA. Fat disruption using the Blugerman liposhifting instrument. American Academy of Cosmetic Surgery Fall Symposium on Body Augmentation and Contouring 2003. Philadelphia.
  • 24.Scuderi, N., de Vita, R., d'Andrea, F., and Vonella, M. Nuove prospettive nella liposuzione: la lipoemulsificazione. Giorn. Chir. Plast. Ricostr. Estet. 2: 1, 1987.
  • 25.Rosenberg GJ, Cabrera RC. External ultrasonic lipoplasty: An effective method of fat removal and skin shrinkage. Plast Reconstr Surg 2000;105:785-91.
  • 26.Brown SA et al. Characterization of nonthermal focused ultrasound for noninvasive selective fat cell destruction (lysis). Plast Reconstr Surg 2009;124:92-101.
  • 27.Neira R, Arroyave J, et al. Fat liquefaction: Effect of low-level laser energy on adipose tissue. Plast Reconstr Surg 2000;110:912-22.
  • 28.Brown SA, et al. Effect of low-level laser therapy on abdominal adipocytes before lipoplasty procedures. Plast Reconstr Surg 2004;113:1796-1804.
  • 29.Coleman WP 3rd. Powered liposuction. Dermatol Surg 2000;26:315-8.
  • 30.Apfelberg D. Laser-assisted liposuction may benefit surgeons and subjects. Clin Laser Mon 1992;10:259.
  • 31.Prado A, Andrades P, et al. A prospective, randomized, double-blind, controlled clinical trial comparing laser-assisted lipoplasty with suction-assisted lipoplasty. Plast Reconstr Surg 2006;118:1032-45.
  • 32.Araco A, et al. Comparison of power water-assisted and traditional liposuction: a prospective randomized trial of postoperative pain. Aesthetic Plast Surg 2007;31:259-65.
Article by
Jersey City OB/GYN