eMedicine Specialties > Plastic Surgery > Body Contouring

Liposuction, Techniques

Author: Charles Chalekson, MD, FACS, Chief of Plastics, Twin Cities Community Hospital
Coauthor(s): Bradon J Wilhelmi, MD, Professor and Endowed Leonard J Weiner, MD, Chair of Plastic Surgery, Residency Program Director, University of Louisville School of Medicine; Michael Neumeister, MD, FRCSC, Professor & Chairman - FACS - Director Hand/Microsurgery Fellowship - Division of Plastic Surgery, Southern Illinois University School of Medicine
Contributor Information and Disclosures

Updated: Nov 11, 2009

Introduction

The Illouz technique of cannula liposuction has been used for almost a quarter of a century. First originated in 1977, the new tunneling technique allows for removal of localized fat collections without long incisions and prolonged recovery. The current technique of suction-assisted liposuction (SAL) represents removal of fat using blunt-tipped hollow cannulas connected to a closed suction system. Over the years, many alterations and modifications have been employed to minimize risk and improve cosmetic outcome of the contouring procedure of liposuction.

Etiology

Anatomy and pathophysiology

Most adipose tissue is composed of white fat, which serves to store triglycerides and fatty acids for the body's energy needs. Obesity results from an increase in fat content and can be either hypertrophic or hyperplastic. Traditionally, theories stated that increases in fat could originate only from an increase in fat cell content volume. However, more recent research has supported the finding of increases in total fat cell numbers (ie, hyperplastic obesity) that become more prevalent as body fat levels exceed 40 kg. Hyperplastic obesity also appears relatively more resistant to dieting and exercise regimens.

Research on obesity and fat accumulation and hunger has focused on the hormones ghrelin, leptin, and adiponectin. These proteins appear to have potential significance on food intake, obesity, and weight changes in humans. Liposuction research in animals appears to decrease ghrelin and increase leptin, decreasing appetite and improving lean body mass.¹ The implications regarding liposuction and its after affects on humans continue to be defined.

The structural organization of fat in the trunk and extremities has been characterized as having both a superficial and deep fatty layer. The superficial layer is composed of small dense pockets of fat separated by vertical well-organized fibrous septa. The deeper fat layer is organized more loosely, with looser areolar fatty tissue interspersed with less regular fascial septae intervening between the pockets. The vertical septa originate from the fascia and extend upward toward the dermis. These layers become important in avoiding potential complications during liposuction.

Cellulite is a commonly used lay term referring to skin surface irregularities and dimpling of skin, predominantly in the thighs and buttocks. Etiologic sources have been attributed, but not necessarily proved, to be secondary to differences in connective tissue structure and adipose tissue biochemistry. Research has confirmed the frequent layperson observation of increased incidence in women. Illouz has attributed the defect as secondary to enlargement in fat cells in the superficial adipose layer, resulting in compartmental bulging between the organized and relatively more rigid septa. Since the well-developed and organized septa do not give way to the increased volume in a limited space, this becomes transmitted as surface irregularity between the deeper pockets of fat.

Others have suggesting similar findings of expansion of adiposity toward the superficial layer and less regular and structured septa in women than in men. To date, no significant differences in biochemistry, physiology, or blood and/or lymph flow of the tissue and structure organization in cellulite tissue have been demonstrated scientifically.

Fat distribution differences between men and women have been established and characterized in previous research studies. On average, women are more likely to demonstrate gynoid pattern collections, which are characterized by increased deposits over the outer thigh, buttock, hips, and truncal region. Alternatively, men more frequently exhibit android pattern collections that center around the truncal and abdominal regions. However, accumulation patterns vary by race and age patterns as well as by sex. As age increases, a significant decrease in the subcutaneous fatty layer and elevations in intra-abdominal fat contents occur.

Increased obesity results in an increased complication rate and comorbidity, as documented throughout the literature. Aesthetic outcomes are also impaired in patients with a higher BMI. Recent study has attempted to document improvement in cardiovascular risk profile with large-volume liposuction. Initial study has preliminarily demonstrated improved weight, body fat mass, lowered blood pressure, and decreased fasting insulin levels.² Further study is required to determine whether these results translate into long-term decrease in comorbidity from obesity.

Pathophysiology

See Etiology.

Presentation

Patient selection

Proper liposuction planning commences with a thorough and detailed history and examination. Previous medical and surgical history with close focus on cardiovascular and pulmonary status is critical. Current medications and allergies can play a significant role in the decision to proceed, thus are important to examine and explore in depth with the patient. Previous anesthetic history also can provide useful information in minimizing patient risk.

The assessment of the amount and thickness of the adipose layer in areas that concern the patient are appraised critically. If the abdomen is being considered for treatment, the amount of intra-abdominal fat must be considered along with careful assessment for hernias. In males, most of the abdominal protuberance frequently can be internal, with only smaller amounts of subcutaneous tissue. The skin should have an appropriate inherent elasticity to recoil and contract after removal of fat. Stretch marks are a strong indication of poor elasticity, as is delayed rebound after manual stretching. Significant skin overhang is also a prime indicator of the need for adjunctive procedures (eg, abdominoplasty, thigh lift), because the removed fat accentuates the redundant skin, forming an unsightly pannus. These adjunctive procedures decrease the risk of contour deformities and possible skin irregularities.

Document areas of cellulite and point them out to the patient so that he or she understands that these areas are not altered significantly by the procedure and in fact may be accentuated postoperatively. The pinch test is a relatively simple estimate to check for the amount of fat that can be removed. Gently pinching the subcutaneous tissue between the thumb and index finger provides a width between the two fingers that should be at least 1 inch before improvement can be expected (except in the neck and face area). If too little subcutaneous fat is left postprocedure, contour deformities and difficulties with skin elasticity can result.

Several areas need to be treated with extreme caution and liposuction should be avoided in these areas due to increased risk of complications. Such areas include the gluteal crease, lateral gluteal depression, distal posterior thigh, middle medial thigh, and the inferolateral iliotibial band. These areas have increased susceptibility to superficial contour deformities due to minimal amounts of deep fat and adherence of the more superficial layer to the underlying fascia of the muscle.

Also discuss and evaluate proposed port sites with the patient. To minimize risk of contour abnormalities with liposuction, multiple port sites are required to approach each problem area. For the medial thigh, the authors use the medial inguinal area for one of the port access sites. The saddlebag, infragluteal region (banana fold), and posterior thigh are accessed best with gluteal crease and lateral trochanteric port sites. Lateral flank, hip roll, and saddlebag sites also can be accessed through lateral trochanteric, flank, and midline back sites. Abdominal access can be achieved through umbilical port sites with inguinal and subcostal sites if necessary.

Relevant Anatomy

See Etiology.

Contraindications

Liposuction is reserved for patients who are healthy and without significant illnesses. Although difficult to determine absolute contraindications, the authors believe that significant medical history should necessitate discussion with the patient's primary physician and/or anesthesiologist prior to approval of any procedure. Anticoagulants (including aspirin) should be stopped 2 weeks prior to surgery to avoid risks of hematoma and excessive bleeding. Physicians must be particularly attentive to herbal supplements that may affect anesthetic risks and bleeding. Obviously, patients who are unable to stop these medicines should not be considered for surgery, as in patients with cardiac valve replacement, atrial fibrillation, and those undergoing therapy for deep vein thrombosis or pulmonary embolism.

Patients also must understand and discuss at length with the physician the potential risks and sequelae. Surgeons also should document all discussions with the patient regarding the potential surgery and potential risks. Port site scars also should be appreciated by the patient and occasionally can be modified to address specific needs of the patient.

Hemodynamic responses to liposuction have been recently characterized and have been found to not be insignificant. In a small study of healthy women, increases in cardiac index (57%), heart rate (47%), and mean pulmonary arterial pressure (44%), and decreased intraoperative body temperatures (35.5°C) were noted.³ Maximum elevation of epinephrine was found to be increased at 5-6 hours after surgery. Although hemodynamic numbers were found to be within the safe ranges, these data reinforce the need to screen patients, as required, for cardiovascular disease and to prevent hypothermia during surgery.

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