SAUFLEY, C.J., and ALEXANDER, LEVY, SILVER, MEAD, GORMAN, and JABAR, JJ. [¶1] Christopher H. appeals from a judgment entered in the Superior Court (Cumberland County, Cole, J .) affirming the judgment of the District Court (Portland, Eggert, J .) ordering his involuntary commitment pursuant to 34-B M.R.S. § 3864 (2009). Christopher H. contends that his due process rights were violated bec
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UntitledActa chir belg, 2006, 106, 647-653
Liposuction : Review of the Techniques, Innovations and Applications
O. Heymans, P. Castus, F. X. Grandjean, D. Van Zele Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital Sart-Tilman Liège, Belgium Key words. Liposuction ; lipoplasty ; aesthetic surgery.
Abstract. Liposuction is currently the most frequently performed aesthetic operation in the world. Despite its wide-
spread popularity, it should nevertheless be stated that it is not trivial surgery, not always benign and not as safe as inti-
mated in the glossy office brochures. Since the initial description of liposuction, numerous changes have taken place.
Today, surgical indications are well defined and the liposuction procedure is well codified. However, several surgeons
and manufacturers have developed new equipment and techniques. We propose to survey all the techniques showing
the real place of each of them. Their advantages and disadvantages will be discussed. The various techniques dealt with
are : the wetting solution techniques, standard liposuction or Suction-Assisted Lipoplasty (SAL), internal Ultrasound-
Assisted Liposuction (iUAL), VASSER assisted liposuction, external Ultrasound-Assisted Liposuction (eUAL), Laser-
Assisted Liposuction (LAL), Power-Assisted Liposuction (PAL) and Vibroliposuction (VL). On the basis of this review
of the literature and of our clinical experience, we conclude that VL is the safest, most effective and precise surgery that
can be used in any of the modern indications for liposuction. We concluded that VL seems to have all the advantages
and none of the disadvantages associated with iUAL.
Indications and Patient Selection
Liposuction is currently the most frequently performed The best results are still obtained when treating moder- aesthetic operation in the world. Despite its widespread ate localized fat deposits in a normal-weight patient popularity, it should nevertheless be stated that it is not which cannot be managed by diet and exercise (Fig. 1).
trivial surgery, not always benign and not quite as safe as At the present moment, the key to success is the capaci- intimated in the glossy office brochures. Mortality and ty of the skin to redrape on the new adipose tissue shape, morbidity related to liposuction procedures still exist in order to avoid surface irregularities and wrinkles due to skin excess. This important property has to be evalu- The first surgical procedure was performed, by DUJARRIER in 1921. He used a uterine curette to remove Although a smooth, young and tight skin is a desir- fat from the knees of a well-known ballerina, with a dis- able criterion in patient selection, patients with less elas- astrous outcome. In the 1960s SCHRUDDE removed sub- tic or older skin, skin wrinkling or multiple fine irregu- cutaneous fat deposits through stab incisions by sharp larities (cellulite) may also benefit from liposuction and curettage (3). In 1978 KESSELRING added strong suction more specifically from superficial liposuction inducing to this sharp curettage method (4). Shortly after, ILLOUZ replaced the curette by a blunt cannula inserted subcuta- Good health is a basic requirement for aesthetic body neously and connected to a vacuum pump to aspirate the contouring procedures. Failure to screen out patients fatty tissue (5). He also proposed irrigation of the sub- whose health is suboptimal is one of the important con- cutaneous space with a hypotonic saline solution in the tributing factors to serious morbidity following liposuc- belief that the fat cells would swell and rupture, but this tion. Most surgeons agree that liposuction is NOT a process has never been confirmed clinically.
weight loss technique (7). However, it can be used for In the past decade, many innovations have been made patients who far exceed ideal body weight, but the results and the anatomy and physiology of the fatty tissue have are less dramatic, although very helpful in improving the been studied in ever greater depth. Modern innovations fit of clothing in problem areas, such as the hips.
in suction lipectomy include the superwet and thetumescent wetting techniques, Ultrasound–Assisted General Aspects
Aspiration (UAL), VASSER, Laser-Assisted Lipo-suction (LAL), Power Assisted Liposuction (PAL) and Numerous changes have taken place in the original tech- nique of suction lipectomy. The original large, sharp, with less danger of penetration or neurovascular bundledamages. The distal aperture should be positionedbehind the tip ; this has the advantage that skin can belifted by the tip of the cannula without direct subcuta-neous fat removal. Multiple holes increase the efficien-cy of fat removal, resulting in fewer passes of the can-nula and less tissue trauma. As regards the diameter of the cannula, no single diameter suits all anatomic areas. Originally, traditionalliposuction was performed using very large cannulas(10 mm) which had to be kept in the deep fat to avoidsurface irregularities. With the advent of smaller cannu-las (2-3 mm) and different tip configurations, surgeonscan work closer to the skin without creating noticeable irregularities and perform liposuction of areas of sparsefat deposits. After superficial liposuction treatment of 2,500 patients, Gasperoni describes good aesthetic A. This is an excellent case for limited liposuction of fat results on patients with “old and less elastic skin”. A deposits located at the top of the thighs and on the hips, with skin retraction, following the superficial removal of fat excellent skin quality ; B. At 6 months post-operativesmoother curves can be observed with excellent skin retraction deposits would be responsible for these results (8).
However, most authors agree on the fact that cellulitis isnot a good indication for liposuction. As a general rule,large, deep fat deposits should be treated with large- single-hole cannulas were replaced by smaller cannulas diameter cannulas (5-6 mm), and small, superficial fat with blunt tips and multiple holes (Fig. 3). Sharp tips are deposits should be treated with small-diameter cannulas more likely to penetrate the fascia or skin, whereas a (3-4 mm). Facial suction requires cannulas of only 1.5- rounded tip permits easy movement through the tissues A. This is not a good candidate for liposuction. The skin is of poor quality, aged, hardened, striated with wrinkles and poor retrac-tion capacity ; B-C. When the patient is young, with a skin of excellent quality, an good cutaneous covering retraction can be expect-ed and significant liposuction can be carried out with no risk.
The cannula most often used with the Lipomatic® is size 4,with a foam end and multiple holes. The nutation movementsof the head and the multiple holes make for optimum fatremoval during a cannula pass.
This is a perioperative view of the subcutaneous tissue being The stab incisions into the skin are placed adjacent to lipoaspirated with the Lipomatic®. The cannula pass removesthe fat while respecting the fascio-neuro-vascular structures.
the area to be treated, concealed in a natural fold. Theincisions should be slightly longer than the cannuladiameter to avoid skin trauma and burns. Liposuctioncreates a discontinuous cavity or multiple small cavities.
attempted to induce swelling and hydrolysis of in vivo More accurately the treated area is characterized by a fat cells, i.e., “lypolysis” (5). There remains no clinical fascia-neurovascular-lymphatic framework from which evidence to support this action mechanism, and the use of hypotonic saline has fallen into disfavour. The use of After infiltration, the cannula is inserted for suction- saline infiltration, however, gained popularity, and by ing. Keeping the tip in the central deep fat permits con- the early 1980s the majority of surgeons were using the tour reduction, leaving the superficial fat undisturbed to wet technique. They infiltrated 200 to 300 cc of saline, provide smooth, soft cover above the treated area. If with or without additives (Lidocaine and Adrenaline), superficial liposuction is planned, it will be performed into a surgical area. These two techniques were both after the deep fat liposuction. However, some anatomic abandoned because of excessive blood loss, the suction areas may only have a single, thin fatty layer, so the sur- aspirate containing 20-45% of blood in the dry tech- geon has to direct the tip immediately below the skin nique (9-11) and 4-30% in the wet technique (12). New solutions appeared with the superwet tech- Before concluding the procedure, the edges have to nique (13, 14) and the tumescent technique (15), which be palpated in the search for lumps and abrupt steps dramatically improved the safety of liposuction. The from treated to untreated areas. If present, smoothing superwet technique is defined as 1ml of infiltrate per can be performed by removing small amounts of fat in 1 ml of aspirate. The tumescent technique is defined as the transition zone using a fine-diameter cannula.
2-3 cc of infiltrate per 1cc of aspirate. In these methods, General guidelines call for a halt when skin flaccidity the subcutaneous fat is infiltrated with large volumes of precludes secondary shrinkage. The final contour will a mixture of lidocaine, adrenaline, sodium bicarbonate not be determined by the amount of fat removed, but and normal saline before fat removal. Blood loss rather by how much is still in place at the end of the dropped to 1 percent of the aspirate, which allows a larg- er volume of fat to be safely aspirated (14). Anotheradvantage is the reduced need for intravenous adminis- Wetting solution techniques
Lidocaine may be used at dosages higher than those The terminology relating to infiltration of the subcuta- listed in the standard references (7 mg/kg or 500 mg neous fat before liposuction includes : the dry, the wet, maximum doses). Several studies have shown that much the superwet and the tumescent technique. The dry and larger doses can be used safely. PITMAN has injected up to wet techniques are now of historical interest only. In the 2000 mg of dilute lidocaine and epinephrine over 10 min- dry technique, liposuction was performed without the utes without any problems (16), KLEIN used doses of addition of subcutaneous solution injection (9). The wet 35 mg/kg with the tumescent technique (17) and BURK technique was introduced by ILLOUZ in 1984 and 28 mg/kg (18). Rohrich believes that 35 mg/kg is the safe consisted of injecting hypotonic saline solution. He limit for liposuction with the tumescent technique (14).
Epinephrine induces vasoconstriction, improving that this technique causes enhanced contraction of the haemostasis, delays absorption of the anaesthetic agent, prolongs its effect to four times as long, decreases the At the present time this technique is suffering from amount needed and reduces the risk of lidocaine toxici- increased operating time with similar volume fat ty. It is recommended that 0.7 mg/kg not be exceeded, removal compared with conventional lipoplasty (21). A although doses as high as 10 mg already have been used number of complications are also associated with this technique : skin loss (19, 22), seroma with rates as high There is still no consensus regarding the optimal as 50% in the initial experience in the USA (23), and composition and amount of subcutaneous infiltration peripheral nerve injury (24). KARMO et al. showed that solution for safety or for optimal aesthetic results. With blood loss using the iUAL is slightly higher even if sub- these techniques, the focus has shifted from hypovo- clinical (25). IGRA et al. were unable to show a difference lemia prevention to the prevention of fluid over- in the postoperative course or the final cosmetic result load (15). The risk of fluid overload and congestive heart when comparing the SAL and iUAL techniques (26).
failure seems to be lower with the superwet technique.
After initial enthusiasm for iUAL, many surgeons have There are no proofs in the literature supporting advan- now rejected this technique. They asserted that the poten- tages, with respect to safety and efficacy, when ratios tial benefits do not outweigh its greater cost, need for training, and increased risk of complications. The longterm consequences of iUAL are also unknown.
Internal Ultrasound-assisted lipoplasty (iUAL)
Fodor stated that the operating time is longer (+ 40%) and longer incisions are needed (21). Moreover, rigid Some additional pieces of equipment are required for cannulas are needed (making for difficulty in passing iUAL, compared with the SAL (19). As a minimum, around the body curves) which are expensive due to the these devices include an ultrasonic generator that con- need for frequent replacement (one single cannula : 20 h verts the standard electricity supply into high-frequency life, 1,000 USD !). Skin protection is essential, in the electrical energy. The generator is connected to a surgi- cal handpiece, which contains a piezoelectric crystal that The incidence of skin slough or necrosis has been converts electrical energy into a mechanical vibration. A reported to be as high as 4%-6% (19). While some titanium probe (solid or hollow) attached to the hand- authors like ZOCCHI (20) advocate a superficial iUAL to piece amplifies these vibrations and transmits it to its tip, stimulate the dermis and enhance skin retraction, others which produces alternately reduced and increased pres- like Maxwell abandoned aggressive iUAL because of sure in the surrounding fluid of the adipose tissue. This process causes a “cavitation process” which induces adi- The incidence of seroma is definitely higher after pose cell wall rupture. The triglyceride released com- iUAL, compared with the negligible rate associated with bined with the tumescent solution and the interstitial fluid form a stable fatty emulsion in the subcutaneous HOWARD et al. (24) examined the sensory changes space. This emulsion can be removed with low-vacuum after iUAL. Their analysis showed that recovery time suction and small diameter cannulas.
appeared to be longer (10 weeks) compared with SAL The iUAL is a three-step process (19). First the sub- (6 weeks). Indeed, the neurosurgical literature has docu- cutaneous fat is infused. The second step consists of fat mented the injurious effects of ultrasound energy on emulsification with the probe vibrating at ultrasound fre- peripheral nerves (27, 28). The potential for ultrasound quency. The third step is the evacuation of emulsified fat energy causing damage to peripheral nerves suggests by lipoaspiration. An aspiration function can be incor- that the risks of using iUAL in arms, legs, neck and face porated in the probe (hollow) to remove as much aspi- may outweigh any potential benefits. HOWARD et al. (24) rate as possible while energy is being applied to emulsi- recommend caution when considering iUAL in the ex- fied fat (19). The two cardinal rules of utmost impor- tremities and in anatomic areas containing nerves. They tance in iUAL to prevent thermal injury are that the found a direct correlation between the amplitude (gener- ultrasound energy must be applied in a wet environment ator setting), number of passes made, and degree of and the probe must always be kept in motion.
injury, noted both grossly and by walking track analysis. This technique, conceived by Zocchi in the late Fortunately, the frequency of these complications 1980s (20), has been promoted as an ideal method for associated with iUAL has steadily decreased thanks to the extraction of large volumes of fat with minimal greater operator experience and the use of lower ultra- fatigue to the surgeon, minimal blood loss, little or no sonic energy levels for shorter periods of time. Many bruising, and exceptional control of contour (19, 20).
surgeons believe that it produces results superior to Difficult fibrous areas such as the male breast and back those obtained with SAL for large-volume removals, are especially well treated (19). It has been suggested fibrous areas, and repeat operations (19, 20, 21, 29, 30).
VASSER (Sound Surgical, Denver, Colo.)
off bloodlessly. APFELBERG et al. concluded in their mul-ticentre study that there was no clear and significant The search for an improved iUAL device has led to the benefit to be gained from LAL over conventional lipo- introduction onto the market of the VASSER–Assisted suction (35). The disadvantages are the slightly cumber- Liposuction (21). Adjustments have been made to render some and awkward equipment, and the fact that experi- the device safer. Only small-diameter solid probes (2.9 ence in laser use is essential. Safety glasses are neces- and 3.7 mm) are used and require much less ultrasound sary, the procedure is noisy and constant cooling is energy than the traditional iUAL systems currently used.
required. The only advantages are greater ease and less Grooves near the tip are added to increase fragmentation efficacy. The VASSER still liquefies fat, but the risk of Neira used the Low-Level Laser-Assisted Lipoplasty thermal injury (from end blows and at the insertion site) (LLLAL) in 2000 (36). Low-level laser therapy is is reduced. In many ways, this new technology is more defined as treatment with a dose rate that causes no like power-assisted lipoplasty than traditional internal immediate detectable temperature rise in the treated tis- ultrasound-assisted lipoplasty. However, skin protection sue and no macroscopically visible changes in tissue (ports and wet towels) is still needed.
structure (36). The LLLAL consists of the tumescentliposuction technique with the external application of a External-UAL (eUAL)
cold laser (635 nm and 10 mW intensity for a 6-minuteperiod) through the skin. They demonstrated that exter- External ultrasound application was introduced by nal lower-level laser associated with tumescent infiltra- Silberg in 1998 (31). Immediately after injecting the tion of the subcutaneous tissue produces a transitory tumescent fluid, the ultrasonic energy transducer is pore in the adipocyte membrane (99% of the adipocytes placed on the area. Moderate pressure is used to help after 6 minutes of laser exposition), preserving the inter- energy delivery to the deeper fat and a slow continuous stitium and the capillaries in particular. This allows fat to motion of the transducer must be maintained (31).
move from inside to outside the cell, placing it in the According to his preliminary report, the advantages of interstitial space. The release of fat by suction is facili- this technique were that more fat could be removed in a tated, surgical trauma is diminished, ecchymosis or significantly shorter period of time, and the fat was hematoma is reduced and patient recovery is fasten- whiter and of a looser consistency. There was less resis- ed (36). However in 2004, BROWN et al. analyzed the tance to the movement of the canula, less bruising, and effect of low-level laser therapy on abdominal less post-operative swelling and discomfort (31). These adipocytes before lipoplasty procedures and their results results have been confirmed by other investigators (7, did not bear out the effect of low-level laser therapy on Nearly all the complications associated with iUAL A third innovative laser technique is the use of a are avoided. Silberg reported one case of post-operative pulsed Nd-YAG laser beam (1064 nm) delivered via an seroma, but otherwise no skin slough or nerve lesions optical fibre of only 300 micrometers inserted in a 1 mm (which are induced by direct contact of the probe in the cannula. After lipolysis, the liquid fat is suctioned by a iUAL) were reported (7, 31-33). The large incisions 3 mm cannula. Proposed indications are flaccid areas, required for internal ultrasound liposuction were no small areas, secondary liposuction and difficult longer necessary (33) and good skin retraction was also cases (38). KUWAHARA showed that the ultra short stress observed (33, 34). Gasperoni considers external ultra- waves generated can mechanically cavitate fat in vitro sound as an ideal complementary procedure to superfi- without significant damage to adjacent structures (39).
cial subdermal liposuction, since the eUAL permits amore uniform aspiration of the subdermal fat layer, mak- Powered Assisted Liposuction
ing skin retraction even more effective (33). The notion of PAL was first introduced by Charles Laser-Assisted Liposuction (LAL)
Gross, an American surgeon (40). The original motordesign provided for a rotating blade within the cannula. Different kinds of LAL have recently been developed Recently, several manufacturers have introduced sys- and some are still at the experimental stage. An initial tems that drive the cannula using a power source. These type of LAL has been tested by Apfelberg (35). The systems rely on electricity or are gas-driven. A small, operator inserts the cannula (special design, single- variable-speed motor generates a reciprocating motion holed, 4-6mm diameter), activates the suction, and then (forward and backward) in the cannula to produce a depresses the foot pedal to activate the laser. The nega- 2 mm to 4 mm excursion at the tip. The mechanism tive suction draws the fat globule into the hole of the action is due to a jackhammer-type movement of the cannula where the laser beam (YAG laser 40W) shears it cannula tip which breaks up fat, and the fat aspirated into the cannula openings is avulsed by the reciprocating insulin lipodystrophy, lymphedema and axillary hyper- motion. FODOR and VOGT (41) found that the two proce- dures were comparable with respect to complications, It is also used in open procedures. As shown in the speed of recovery, and aesthetic results, and PAL was figure 4, removal of the fatty tissue around the neu- superior in terms of ease of fat removal. In addition, the rovascular bundles creates a pseudo-plane facilitating aspirate from suction-assisted and power assisted tissue mobilisation with maximal safety. This allows lipoplasty are similar, and powered cannulas do not pro- improved healing and faster sensitivity recovery than duce more bleeding than SAL when the tumescent tech- with the usual undermining. This property, combining nique is used (41, 42). According to COLEMAN (42), PAL defatting and respect for the neurovascular structures, is has all the advantages and none of the disadvantages used in abdominoplasty (46), bodylift (47), concentric associated with iUAL. Vibration and noise are the only medial thigh lift (48), breast reduction (49, 50) and bra- disadvantages of this technique. SCUDERI et al. (43) com- pared iUAL, PAL and SAL. PAL is said to be a handy Extravasation injuries, which may induce important technique, with the most favourable cost-benefit ratio, sequelae, can be managed by liposuction. Contrast solu- and seems to be the best option for busy liposuction tion or chemotherapeutic drugs in the subcutaneous practices or fast office procedures.
tissue lead to necrosis and retraction. Performed imme-diately after the accident, soft tissue necrosis rarely Vibroliposuction (VL)
Vibroliposuction represents a development of the PAL Conclusion
concept. In this system, the cannula is activated by airpressure, producing a complex movement of the tip.
Liposuction is currently the most frequently performed This movement, combining antero-posterior, supero- aesthetic operation in the world. Despite its widespread inferior and parasaggital displacement is called “nuta- popularity, it must be practiced with maximum care and tion”. The amplitude of this movement depends on the safety. Over time, many changes have taken place in the cannula length and diameter as well as the pressure instrumentation and new techniques have been intro- entering the handpiece. A recent publication by duced. A number liposuction techniques are currently in REBELO (44) describes this technique.
use but our preference is for vibroliposuction. Fat A study conducted in our department showed that extraction is easier, even in fibrous region or in sec- vibroliposuction is more efficient than SAL. It removed ondary operations and the lymphatic and neurovascular 40% more fat than SAL under the same conditions.
structures encountered are respected. Thanks to the After centrifugation of the aspirated fat, the pure fat more efficient fat extraction, less cannula passes are nec- fraction was 70% greater than in the SAL. essary, reducing morbidity. Local traumas and surgeon The use of VL in our daily practice has shown that fatigue are diminished. This results in safe, effective and this procedure is safe. Complications were even fewer precise surgery that can be used in any of the modern than with our previous use of SAL. We had no seromas indications for liposuction, from precise and superficial and local hematomas were reduced. This technique is aspiration in extravasation injury to massive fat aspira- less traumatic because fat extraction is more efficient needing fewer passes of the cannula. VL respects thelymphatic vessels and neurovascular bundles. The com-bination of VL and open procedures showed the neuro- References
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Contributors: Liz Bradbury, Binay Cahn, Ros Catt, Laurie Crocker, Steve Dudley, Ann Ghiorso, Gael Goldsack, Sherry Hartung, Ina Olsen, Sue Sanvido, Martha Millas Senécal, Chuck & Dorothy Turley, Teresa Vigil, Nell Ward, Susan Williams, Kathryn Yost This article is about osteoarthritis, OA, rather than immune mediated forms of arthritis such as inflammatory or rheumatoid arthritis. OA is not