Advances in Liposuction and Fat Transfer

Liposuction is the surgical procedure of removing fat cells with specially designed suction devices. Using stiff hollow cannulas, the subcutaneous fat can be removed through tiny incisions. By minimizing the total number of adipocytes, fat cannot be stored in the treated body areas any longer. Since its first description in 1975, the method has constantly been improved. Today liposuction should be called “liposculpturing” as the precise forming of body areas (body contouring) is possible. It is the most commonly performed procedure in cosmetic surgery worldwide. But besides the cosmetic indications, liposuction has been established as an effective treatment in noncosmetic indications as well. By setting up internationally accepted guidelines for liposuction, renowned medical societies try to establish high-quality standards to achieve predictable operative outcomes and minimal surgical risk.

In 1975, Georgio and Arpad Fischer from Rome were the first who gave a description of removing fat using cannulas inserted through tiny incisions (Fischer & Fischer, 1977). They invented a machine to suction unprepared fat through hollow needles under general anesthesia. The fat was fragmented by a motorized cutting blade. This procedure suffered from high intraoperative risks such as severe blood loss and poor aesthetic results as well as a high rate of postoperative complications (for example, dents and seromas). Yves-Gerard Illouz, a surgeon from Paris, introduced the so-called “wet technique.” To facilitate aspiration of the adipose tissue and reduce blood loss, he instilled physiologic saline solution mixed with hyaluronidase into the operation site (Illouz, 1983). In 1987 Jeffrey Klein, a dermatologist and pharmacologist from San Juan Capistrano, California first described the tumescent technique, a combination of the wet technique and a local anesthetic procedure. He instilled large volumes of physiologic saline (tumescere = to swell) with added lidocaine anesthetic solution. His idea revolutionized liposuction as tumescent liposuction minimized the operative and anesthetic risks, and turned the operation into an outpatient procedure (Klein, 1987).

The tumescent solution is infiltrated subcutaneously into the surgery field. The solution stabilizes the subcutaneous connective tissue which is consequently less traumatized. This also makes the procedure less painful for the patient and physically less strenuous for the surgeon. The awake patient is able to cooperate: he can shift the position on the operating table when required or even get up during operation to control the already achieved result in a standing position.

Further advantages of tumescent liposuction are (Lillis, 1988):

* No need for general anesthesia.

* Significantly reduced blood loss.

* Immediate patient mobilization.

* Significantly shorter convalescence.

* Long-lasting postoperative analgesia.

All these advantages make tumescent liposuction an ideal outpatient procedure and the method of choice. In a survey performed by Hanke, Bernstein, and Bullock (1996), the high safety profile of liposuction with tumescent local anesthesia was dramatically demonstrated: from 15,336 patients undergoing liposuction with tumescent anesthesia, no severe complications such as blood transfusions or hospitalization were reported. New developments during the last decade have further helped to facilitate the procedure and improve the aesthetic outcome (Sattler, Sommer, Bergfeld, & Sattler, 1999).

New Developments in Liposuction During the Last Decade

New cannulas and liposuction-assisted techniques changed the technical side of the procedure. Improvement and changes in the tumescent solution made the use of greater volumes possible and safer. On the basis of growing clinical experience and findings, the concept of physiodynamic tumescent liposuction as well as wound healing also developed, which has consequences in the planning and technique of liposuction (Sattler et al., 1999).

Current Concept of Physiodynamic and Wound Healing After Tumescent Liposuction

During and after infiltration of the tumescent solution the distribution takes place in certain stages. Initially there is a suprafascial hydrodissection along the septa of the fibrous tissue. The solution then starts to gather around the fat lobules in the paralobular space. Allowing a penetration time of 30 to 60 minutes, the solution will lead to an intralobular infiltration which will, as a result of the interstitional pressure and diffusion forces, finally lead to a homogenization of the adipose tissue. This effect is important to facilitate the suction process and to achieve regular postoperative results. The softened, prepared fat can be aspirated with small non-traumatic cannulas, thus reducing tissue traumatization and destruction of subcutaneous connective tissue, blood, and lymph vessels. These structures are essential for wound healing and skin retraction and help create a predictable cosmetic outcome. When all tumescent solution is drained from the surgery site, a process of continuous adherence and shrinking of the subcutaneous wound is initiated which results in a global three- dimensional wound contraction and finally a horizontal subcutaneous scar. Maximum shrinking is normally seen after 4 months, total time of wound healing continues for up to 18 months. In the same process, the shrinking of the connective tissue fibers leads to a skin retraction. A liposuction in tumescent technique with correct suction process in all layers of the subcutaneous tissue causes an “interstitial skin reduction flap.”

Current Concept of Planning and Carrying Out Tumescent Liposuction

A patient undergoing a typical tumescent liposuction case should be healthy! Beyond that any medications such as hormonal contraception or derivatives of salicylic acids (aspirin) should be discontinued. Other drugs, such as those for blood pressure treatment, are not affected and can be continued. A standardized preoperative laboratory test should be carried out just before surgery.

To achieve an ideal healing process with corresponding ideal results, the use of a standardized operation technique is recommended which is the least vulnerable for the patient. Thin, blunt-tipped atraumatic cannulas or vibrating cannulas should be preferred to save the subcutaneous fibrous and connective tissue and vessels. To achieve the necessary interstitial tissue pressure, a “super-tumescence” with building up of high tissue turgors should be reached. Infiltration of the tumescent solution should be done slowly; to save time infiltration can be done parallel with multiple needles at different sites. The solution must be allowed to soak in for at least 30 to 60 minutes. Suction must be done at all layers of the subcutaneous space. The correct use of tumescent local anesthesia in combination with atraumatic cannulas reduces friction as much as possible. After 20% to 30% of tumescent fluid is removed, manual assisted skin stabilization technique (MASST) performed by an assistant compensates the developing laxity of the skin turgor. Postoperatively, a thorough drainage of tumescent solution must be achieved by leaving the incision sites open and the wearing of compression garments.

Technical Developments

To obtain an atraumatic suction technique, technical developments led to an improvement of cannulas and liposuction assisting devices.

Manual liposuction, 24-hole cannulas. If a correct tumescent local anesthesia is performed, suction can be done with thin, blunt- tipped cannulas. The connective tissue can further be spared when cannulas with multiple suction holes are used (24-hole cannulas). After building up the suction force, a number of holes will get occluded by fibrous tissue. The remaining holes stay effective in liposuctioning so the cannula cannot build up a higher suction force due to occlusion of the holes. As the suction force decreases, the holes that were blocked before will reopen. When using a 2 or 3- hole cannula, all holes can become occluded simultaneously. In this case the suction force is increasing rapidly thus reinforcing the occlusion. Liposuction can only be continued after cleaning the cannula or destruction of the blocking tissue. The developed suction force in 24-hole cannulas is strong enough to remove the fat cells but too weak to suck in and destroy fibrous tissue or vessels. This way blockage of the cannula and destruction of the connective tissue is prevented; the treatment is more subtle.

Ultrasound-assisted liposuction. To facilitate fat aspiration in difficult areas such as the male breast or back or in secondary sites, a number of new suction devices were developed starting in the late 1980s. In 1987 Scuderi and DeVita first described a method of homogenizing the fat with ultrasound waves. The suction cannulas were attached to an ultrasound generator. The ultrasound waves that were sent into the tissue are supposed to destroy the adipocytes. There are some severe disadvantages when using this technique. The cannulas must have a comparatively large volume. A raised number of seromas and skin burns occurred, and as a result of destruction of the myelin sheath of peripheral nerves, persisting hypo or hyperasthesias were reported (Lillis, 1988). There was even speculation about a potential cancerogenic risk. The American Society of Dermatology rates ultrasound-assisted liposuction as an experimental method \with no extended clinical use (American Society of Dermatology, 1998; Topaz, 1998; Zocchi, 1992).

Powered liposuction/vibrating cannulas. In 1995 Charles Gross, an E NT-surgeon at the University of Virginia, described a new technique he used in liposuction of the neck called “liposhaving” (Gross, Becker, Lindsey, Park, & Marschall, 199,5). An engine- powered cannula with an integrated rotating blade was used to destroy adipocytes under direct visual or endoscopie control. This concept started the invention of a new generation of cannulas, primarily with rotating blades, but soon with oscillating blades. The latest development is cannulas without blades but a vibrating grip that leads to vibration of the cannula when passing through the tissue. The rationale of vibrating cannulas is the different inertness of the various materials in connection with the different velocity of the vibration frequence and the building up of suction force. If the vibration speed is higher than the speed of building up a certain suction force, the suction is just strong enough to only withdraw the loose, homogenized fat. The cannula will escape and spare the tissue structures which have tight attachments.

Table 1.

Sattler’s Tumescent Solution With Reduced Prilocaine

Table 2.

Volumes of Tumescent Solution Recommended 1992 and 2001

Vibrating cannulas facilitate the treatment of fibrous or pretreated areas. As they pass easily through the tissue and do not tangle with the fibers, the procedure is more comfortable for the patient and the surgeon. Severe complications have not been reported. Further improvements of the cannulas and grips are expected and will lead to widespread use of this suction device as it shows great benefits in achieving good operative outcome (Coleman, 2000).

Endoscopie liposuction. Liposuction is an operation without direct visual control. Endoscopie liposuction can be used to visualize the subcutaneous space during liposuction. The method helps to control technique and quality of liposuction and gives a further understanding of physiodynamic processes in the adipose tissue. It is not routinely used clinically but helps in the development of new, useful liposuction devices.

Refinements of the Tumescent Solution

In the course of time the original Klein tumescent solution was modified by various working groups. Lidocaine was replaced as local anesthetic with prilocaine because of its lower systemic plasma levels which is relevant when using large volumes (Sattler, Rapprich, & Hagcdorn, 19!)7). As a result of clinical observations the prilocaine could be reduced by 20% from initially .50 ml/1 to 40 ml/1 which resulted in a reduced local anesthetic concentration of 0.088% (see Table 1).

As a consequence of reduced local anesthetic concentration and the growing knowledge of the delayed absorption, the quantities of tumescent solution used in one session could be raised. The possibility to use more tumescent solution widens the therapeutic range. Clinical experience showed the better effects of “supertumescence” when using large volumes. Because of reduced tissue traumatization, the complication rate is also reduced. Table 2 provides a comparison of initially recommended amounts of solution and the amounts used today.

Over the past years the tumescent technique has evolved from a mainly anesthetic procedure to an essential part of successful liposuction as it is crucial for the described processes of physiodynamic and wound healing, and determines the course of the surgery and postoperative outcome.

Figure 1.

Manual Assisted Skin Stabilization Technique (MASST) during Liposuction

Figure 2a.

Autologous fat augmentation: Before treatment in 1995.

Figure 2b.

Same patient in 2002 after augmentation of cheeks, forehead, glabella, and perioral area. Patient received six treatments during 1995 to 1999. There has been no change in the patient’s body weight.

Figure 3.

MicroGraftCutter. Small fat micrografts are created at the tip of the cannula and redistributed into the tissue at the end of the cannula while a suctionless liposuction maneuver is performed.

Improved Operating Techniques And Positioning of Patient

Besides technical and pharmacological improvements, clinical experience led to improvements in the procedure. The operative outcome can be improved mainly through active cooperation of the awake patient. It improves the suction process if the patient can contract the underlying muscles to build a firm base and change positions if necessary. The operative outcome can be improved significantly by a correct positioning of the patient on the operating table and an easy access to the surgery site. Experience has shown that it is better to treat the medial thighs, not with the patient lying on his or her back, but on the side with the leg to be treated stretched out on the operating table and the other leg in a 90 degree angle to stabilize the position. With this positioning there is better access to the fat deposits. When treating the back or flanks it is better to position the patient on the side with overstretched back. With this improved positioning the overlying skin as well as the underlying muscles are stretched, which makes aspiration of the subcutaneous fat easier.

Manual Assisted Skin Stabilization Technique (MASST)

During liposuction surgery using the tumescent technique the stabilizing effect of the tumescent solution on the tissue decreases constantly because it is removed along with the fat by the suctioning process. Thus, liposuctioning becomes more difficult as shearing forces on the tissue become stronger. This can be counteracted efficiently when the tissue is bimanually stabilized by an assisting person (nurse) by stretching it (see Figure 1).

Fat Transfer

Experiments in the field of correction of soft tissue defects with autologous fat have been performed since the beginning of the 20th century. Pierre Fournier, a French surgeon, who had already contributed to refinements in liposuction technique, revitalized the idea of fat transfer in the mid-1980s. He set new standards by inventing a special technique using microcannulas for the fat harvesting (Fournier, 1987a; 1987b; 1990; 1985).

Since then many different procedures of fat harvesting and reinjection have been described (Schuller-Petrovic, 1997; Sommer & Sattler, 2000). One of the main advantages when using fat as augmentation material is the lack of an immunogenic risk. There is ongoing discussion about the correlation of harvesting technique, donor, and injection site on the long-term outcome. The harvesting procedure should be minimally traumatizing for the adipocytes although there is no proof that adipocytes must be vital to achieve good augmentation results. The main augmentation effect is caused by a secondary fibrosis rather than by surviving adipocytes (Sommer & Saltier, 2000). Using the fat gained with a reduction liposuction performed with microcannulas in tumescent technique has proven safe with excellent long-lasting results. One working group has coined the term “liporecycling” for this procedure (Saltier & Sommer, 1997). The fat that is gained during a liposuction in tumescent technique is gathered in sterile plastic containers by the use of an aspirator machine. To separate the fraction of graft material that will be reused from the tumescent solution, the harvested material is poured into a sterile bowl which is covered by two unfolded sterile cotton sheets. This material is then spread onto additional cotton sheets and “dried” further, since residual tumescent fluid is evacuated by the cotton material. Before drawing the fat for re- injection into sterile 5-cc disposable plastic syringes, remaining fibrous tissue threads can be removed by visual inspection with the help of forceps.

Figure 4a.

Example of a liposuction result in a patient with a saddle-bag deformity. Before treatment.

Figure 4b.

Three months after liposuction.

Figure 4c.

Before liposuction.

Figure 4d.

Three months after liposuction.

Figure 5a.

Before lipoplasty.

Figure 5b.

After lipoplasty.

Figure 5c.

Before lipoplasty.

Figure 5d.

After lipoplasty.

The fat that is not used for direct re-injection can be stored by deep freezing it with temperatures between -20 to -70 C. It is safe to keep the fat for re-injection for up to 2 years. Thawing should be done carefully and slowly by simply leaving the material at room temperature. Liporecycling can be used for all sorts of soft-tissue augmentation, including treatment of scars, local lipodystrophy (for example, after steroid injection), coup-de-sabre defects in collagenosis, and facial hemiatrophy. Liporecycling is also effective as a rejuvenating technique in facial recontouring. Fine wrinkles as well as deep folds (for example, naso-labial) can be treated. The technique for tissue augmentation depends on the targeted area. For scars or other deep defects, the fat is injected subcutaneously. For facial recontouring, the injection is done subdermally (see Figures 2a & 2b).

A new development in the field of fat transfer is the repair of postlipoplasty irregularities or other irregularities of the subcutaneous fat by moving adipocytes without extracting them. This procedure is named “liposhifting” (Saylan, 2001). Dents and other irregularities are marked preoperatively. Then the area is infiltrated with tumescent solution to achieve anesthesia and to loosen the fatty tissue. The fat tissue is mobilized by cannulas and moved internally by external pressure. To facilitate and improve the method, Blugerman (2002) has developed a special operating set. A MicroGraftCutter (MGFC) is inserted into the prepared tissue. The MGFC cuts little fat grafts from the tissue that can be shifted internally to the receptor sites (see Figure 3).

Conclusion

Today liposuction in tumescent local anesthesia is the most commonly performed cosmetic procedure worldwide (see Figures 4a, b, c, & d; Figures 5a, b, c, \& d). Due to improved operative techniques as well as refinements in the tumescent solution and cannulas, a substantial reduction of risks and side effects can be achieved. Thanks to all these improvements we have reached a point today where this operative technique can offer a predictable, cosmetically highly satisfactory result combined with minimal risk. Fat transfer for soft tissue augmentation is a well-established method. By introducing the method of liporecycling fat that is gained by reduction, liposuction in large quantities can be reused. The technique has proven safe and effective over the last 15 years. Liposhifting is a new, promising method of internally shifting subcutaneous fat to repair irregularities.

References

American Society of Dermatology. (1998). Statement on ultrasonic liposuction. Task force on ultrasonic liposuction of the American Society of Dermatology. Dermatologie Surgery, 24(9), 1035.

Blugerman, G. (2002). Liposhifling. Vortrag auf dem Kongress der Deutschen Gesellschaft fur Asthetische Chirurgie, Heidelberg.

Coleman, III, W.P. (2000). Powered liposuction. Dermatologie Surgery, 26(4), 315-318.

Fischer, A., & Fischer, G. (1977). Revised technique for cellulitis fat reduction in riding breeches deformity. Bulletin of the International Academy Cosmetic Surgery, 2, 40-41

Fournier, P.F. (1985). Microlipoextraction et microlipoinjection. Rev Chir Esthet Long Franc, W, 3(i-38.

Fournier, P. (1987a). Body sculpturing through syringe liposuction and autologous fat re-injection. Paris: Samuel Rolf International.

Fournier, P. (li)87b). Body sculpturing through syringe liposuction and autologous fat transplantation. Paris: Samuel Rolf International.

Fournier, P.F. (1990). Facial recontouring with fat grafting. Dermatologie Clinics, 5(3), 523-537

Gross, C.W., Becker, D.G., Lindsey, W.H, Park, S.S., & Marschall, D.D. (1995). The soft tissue shaving procedure for remove of adipose tissue. Archives of Ololaryngology-Head & Neck Surgery, 121(10), 1117-1120.

Hanke, C.W., Bernstein, G., & Bullock, B.S. (1996) Safety of tumescent liposuction in 15,336 patients: National survey results. Dermatologie Surgery, 27(5), 459-462

Illouz, Y. (1983). Body contouring by lipolysis: A 5-year experience with over 3000 cases. Plastic and Reconstructive Surgery, 72(5), 511-524

Klein, J.A. (1987). The tumescent technique for liposuction surgery. Americanjournal of Cosmetic Surgery, 4, 236-267.

Lillis, PJ. (1988). Liposuction surgery under local anesthesia: Limited blood loss and minimal lidocaine absorption. Journal of Dermatologie Surgery and Oncology, 74(W), 1145-1148.

Saltier, G., Rapprich, S., & Hagedorn, M. (1997). Tumeszenz- lokalanasthesic: Untcrsuchung zur pharmakokinctik von prilocain. Z Hautkr, 7,522-525

Sattler, G., & Sommer, B. (1!)!)7). Ijporcrycling: Immediate;md delayed. American Journal of Cosmetic Surgery, 14, 311-316.

Sattler, G., Sommer, B., Bergfeld, D., & Sattler, S. (1999). Tumescent liposuction in Germany: History and new trends and techniques. Dermatologie Surgery, 25(3), 221-223

Saylan, Z. (2001, Mach/April). Liposhifting instead of lipofilling: Treatment of postlipoplasty irregularities. Aesthetic Surgery Journal, 137-141.

Schuller-Petrovic, S. (1997). Improving the aesthetic aspect of soft tissue defects on the face using autologous fat transplantation. Facial & Plastic Surgery, 73(2), 119-124.

Scuderi, N., & DeVita, R. (1987). Nuove prospettivo nella liposuzione: La lipoemulsificazione. Giorn.Chir.Plast.Ricostr. Este. J, 33.

Sommer, B., & Sattler, G. (2000). Current concepts of fat graft survival: Histology of aspirated adipose tissue and review if literature. Dermatologie Surgery, 26, 1159-1 Kin’.

Topaz, M. (1998). Possible long-term complications in ultrasoundassisted lipoplasty induced by sonolumiscence, sonochemistry and thermal effect. Aesthetic Surgery, 18, 19-24.

Zocchi, M.L. (1992). Ultrasonic liposculpturing. Aesthetic & Plastic Surgery, 16, 287-298.

Additional Reading

American Society of Liposuction Surgery and American Academy of Cosmetic Surgery. (2001) Guidelines for liposuction surgery. Chicago: American Academy of Cosmetic Surgery

Gerhard Sattler, MD, is a Clinical Director, Rosenparkklinik, Darmstadt, Germany.

Copyright Anthony J. Jannetti, Inc. Apr 2005