LIPOSUCTION

At the turn of the 1970s a new method of liposculpture with a suction device was developed and popularised in subsequent years. Initially, the use of liposuction (LS) was limited to excess fat deposits typically located over the trochanteric area, on arms and abdomen. Nevertheless, over the years new applications have been reported, accompanied by detailed surgical guidelines for managing deformities of various body areas.

At the turn of the 1970s a new method of liposculpture with a suction device was developed and popularised in subsequent years. Initially, the use of liposuction (LS) was limited to excess fat deposits typically located over the trochanteric area, on arms and abdomen. Nevertheless, over the years new applications have been reported, accompanied by detailed surgical guidelines for managing deformities of various body areas.

Currently, LS is used in the majority of procedures involving body contouring, according to actual needs resulting from an  individual body fat distribution pattern. At the beginning, extraction of relatively small amounts of tissue (up to 1500 ml) was recommended but in the course of time due to the increased demands of patients, a growing number of surgeons have been inclined towards  the more extensive procedures.

The amount and distribution of adipose tissue depend on genes, environmental factors and aging effects. Diet, exercise, lifestyle – these are the factors influencing the individual body proportions, which can be modulated within the genetic pattern. The aging process is characterized by a decrease in muscle mass, which is mostly replaced by fat tissue, and a loss of tissue elasticity; each of the abovementioned factors affects localised fat deposits and the extension of the integuments.

It is known that some areas of fat deposition, e.g. abdomen deposit, are more susceptible to weight gain or loss than others, such as hips and buttocks deposits, which are less prone to volume fluctuations. As it turned out, these processes (lipolysis) are regulated by tissue-specific receptors -  alpha 2, which inhibit lipolysis and beta 1, which accelerate lipolysis. These receptors are located in various proportions at the particular areas of adipose tissue. Following the liposuction procedure, the areas of tissue where alpha 2 receptor prevail do not relapse to previous condition even after weight gain, whereas the areas with predominant beta 1 receptors are susceptible to hypertrophic obesity if the dietary recommendations are not followed.

Typical equipment necessary to carry out the procedure consist of the following components: 1. a vacuum pump with tanks of various capacity; 2. a thick-walled hose; 3. cannulae of various lengths, diameters and types of end tips, interchanged depending on the procedure site and the surgeon's preference. It is always recommended to use the end tips of the smallest possible diameter to cause as minimum trauma to adipose tissue as feasible. Usually, cannulae of  3 - 6 mm in diameter are used. Thicker cannulae are usually selected for more extensive procedures.

A basic prerequisite for carrying out the LS, as well as any other elective surgery performed for non-medical reasons, is good health. Another requirement is good elasticity and firmness of the integuments in the LP site  which facilitate the removal of substantial amounts of fat without the risk of excessive skin sagging after the surgery. Moreover, it is necessary to perform a thorough examination of the abdomen for hernias, postoperative and posttraumatic scars.

Preoperative planning involves precise delineation of excess fat deposits while the patient is in a standing position. Areas with the thickest fat layer, together with the surrounding areas of thinner deposits and, finally, the areas of smooth transition to the surrounding tissue, are marked by means of contour lines as used in terrain cartography. The procedure is performed under local or general anaesthesia, depending on the extent of the procedure. Local anaesthesia is used in less extensive procedures (up to 2500ml) and it consists of dilute solution of lidocaine (0.05% - 0.1%)  and epinephrine (1:1000000) according to the tumescent technique. In more extensive procedures, however, general anaesthesia is preferred as it facilitates shorter operation time, is more convenient for the surgeon and reduces patients’ discomfort. Regardless of the type of anaesthesia, tissues are infiltrated with solutions containing epinephrine in order to reduce the bleeding from the surgical site, which seems to be an effective method.  Tissues are injected with the solutions of epinephrine and lidocaine in saline containing sodium bicarbonate. After sufficient tissue swelling,  an incision with a knife no. 11 is made, and a cannula is introduced through the adit. Prior to aspiration, it is necessary to break down fat cells by moving the cannula back and forth in all directions. During the extraction the tip of cannula should always be under manual control. A conventional liposuction should be performed with preserving a 1-1.5 cm layer of fat adjacent to the skin. Relatively wide experience is required for proper evaluation of adipose tissue through the skin over the operative site. When the desired thinning and smoothing of the subcutaneous tissue is obtained, it is necessary to even out the disparities between the operated and adjacent areas. Adits are left open under the absorbent dressing. An important factor in the prevention of haematomas and tissue exudates is the use of tight compression garment. In our clinic we recommend to wear it for a month, day and night, only with necessary breaks for a shower. Moderate exercise is advised in order to prevent thrombotic complications.

In the 1980s liposuction has become one of the most commonly performed surgical procedures. Just as with any other surgery, LP is associated with some risks. The most frequent complications include: infections, haematomas, the accumulation of serous exudate, cutaneous nerve damage, thrombotic complications, uneven skin surface. Sometimes readjustment is unavoidable, especially in the cases of  more extensive procedures. Nevertheless, it does not happen frequently and the correction produces favourable final results. There have been reported exceptionally rare thromboembolic complications leading to death.

Liposuction is most frequently performed in the following areas:

Face - elimination of a double chin.
Arms – elimination of the flabbiness in the triceps area.
Breast – used as a complementary procedure in a conventional breast reduction, which often leaves a characteristic bulge in the axillary breast area, and as a stand-alone treatment in some cases of gynaecomastia.
Abdomen - used as a complementary procedure in abdominoplasty or as a stand-alone procedure, depending on the firmness of the skin.
Hips and thighs - there are seven basic types of contour distortion in the hips and thighs area. Grazer’s Classification was developed on the basis of anatomical differences in the skin, subcutaneous tissue, muscles and bones, which reflect a genetic pattern, nutritional state, the influence of aging process and congenital deformations.

Type 1 - deposition of fat in the medial thigh area, occurs spontaneously or as an isolated entity;
Type 2 - deformation of the ‘riding breeches’ or ‘saddlebags’ type - excess subcutaneous tissue in the trochanteric area;
Type 3 – recess in the medial buttock area   with accompanying ‘riding breeches’ deformation;
Type 4 – ‘violin’ or ‘cello’ deformation - an excess of subcutaneous tissue around the iliac crest and the trochanteric region;
Type 5 - obesity, particularly in the cases of disproportion: small chest - large pelvis and thighs, may also be subject to surgical treatment;
Type 6 - traumatic and congenital contour asymmetries,
Type 7 – atrophy and sagging tissue resulting from aging process or a significant weight loss (e.g. following operations excluding a part of the gastrointestinal tract).

In patients with satisfactory skin firmness, body sculpting by liposuction is usually sufficient (mainly types 2,3,4,5,6) whereas types 1 and 7, and sometimes 4 and 6, require a skin reduction procedure.


References

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