Indications and techniques of liposuction

Dry technique

In 1983, Fournier introduced the no infiltration (dry) liposuction method; however, the method has lost favor as a result of the considerable amount of blood loss in the lipoaspirate, which can range from 20% to 40%.^[2]

Moist technique

Illouz’s method entailed injecting 200–300 cc of infusate fluid, regardless of the amount that needed to be aspirated. About 8–10% of less blood loss was reported during lipoaspiration than previously reported wet technique advanced by adding epinephrine which further lowers the blood loss to 4–8% in the infranatant of the lipoaspirate due to vasoconstriction of the vessels.^[3]

Superwet technique

The superwet approach, as described by Fodor in 1986, includes infusing 1 cc of infusion fluid for 1.5 cc of lipoaspiration. Due to this approach, only 1% of blood loss was reported during lipoaspiration.^[4]

Tumescent technique

The tumescent technique was introduced by dermatologist Klein and achieved significant improvements in the day-care surgery for liposuction and liposculpture, including high-definition body sculpture. The tumescent approach became more popularized in the 1990s. The tumescent infiltration method, which uses the skin’s turgor and its change to white as end points on the volume injected in the area of liposculpture, allows for more volumes to be eliminated than with conventional wetting agents. The ratio of infusate to lipoaspirate is typically 2–3:1. It is prepared by combining 50 cc of 1% of lidocaine injected added to 1 l of normal saline with 1 cc of 1:1000 adrenaline and 10 cc of 8.4% of sodium bicarbonate solution (which lowers the discomfort). Normal saline has a pH of 5, but by adding bicarbonate, it lessens the acidity and reduces the amount of lidocaine that is available for absorption.^[4] As a result, large amounts of diluted lidocaine with a concentration up to 35 mg/kg can be injected into the site of liposuction with maximum dose of 7 mg/kg avoiding the complication due to drug toxicity. The additional benefit is reduction in intravenous fluid replacement.^[5] It is crucial to consider the anticipated volume when aspirating fat. Overall, tumescent technique reduces the fluid burden, lowers the danger of local anesthetic toxicity, and limits the infusate to not more than 4–5 l for 4 l of lipoaspiration. For every milliliter of aspirated fat, one must replace with 2 ml of fluid within the first 24 h when infusing or aspirating significant volumes, such as 3 l or more. For instance, it is expected that 20% of the injected fluid will be eliminated with the lipoaspirate in a scenario where 3 l of fluid are injected and 3 l are aspirated. This will leave 2.4 l in the extracellular space, necessitating a 3.6 l replenishment of fluid volume over the course of the 1^st day.

Mechanical liposuction (SAL)

In the 1980s and 1990s, three distinct types of mechanical liposuction were first developed. A typical procedure for liposuction that uses a blunt and small cannula attached to a pressured vacuum pump is known as suction assisted liposuction (SAL). Cannulas of different sizes and diameter available for liposuction are shown in [Figure 1]. A tiny incision is used to inject fluids and a cannula is subsequently placed to collect fat using a high-pressure vacuum connected with silicone or polyvinyl chloride suction tubing.^[6] The suction pump has two distinct values: Maximum vacuum and maximum flow rate. The canisters can be reused or discarded and they come in several sizes ranging from 250 ml to 3000 ml. There are several different types of reusable suction cannulas available.^[6] The type of anesthesia used will depend on the area that needs to be treated. Compared to SaL, the surgeon can remove fat more rapidly and with less effort, but there is a danger that blood vessels and nerves could be harmed. Although SaL can get rid of surface fat, the risk to the skin’s blood supply is greater. The risks associated with this surgery include the potential for bruising and a longer recovery period.

Close

Figure 1:

Liposuction cannulas for mechanical liposuction.

Export to PPT

Syringe assisted liposuction

Blunt cannulas and syringe-generated negative pressure are used in the operation known as SaL to remove fat [Figure 2].

Close

Figure 2:

Syringe suction-assisted liposuction.

Export to PPT

The surgeon can use the syringe method to treat large areas slowly and laboriously. It is advisable to use it in treating small areas as a result.^[7] One of its advantages is that it can be done under local anesthesia as an outpatient surgery or as a day case. The syringe method has a number of shortcomings while being a safe operation. These challenges include the inability to remove surface fat as well as the challenge of managing post-liposuction resistance brought on by scar tissue.

PAL

PAL aspirates fat using cannulas that move either in circles or quickly back and forth. Due to the mechanical cannula’s small incision and expedited fat extraction, less effort is needed during surgery.^[8] PAL was becoming more and more popular for body contouring and fat removal procedures [Figure 3]. The vibrating cannula used in the fat extraction process makes it easier and less difficult to extract more fibrous fat.^[9] Power aided liposuction has increased the surgeon’s skill, particularly in huge volume liposuction, fibrous areas, and secondary treatments utilizing more superficial tissue planes. Reduced fatigue and time spent by the surgeons during the procedure expedites the removal of fat and yields remarkable outcomes for patients seeking body contouring. Other advantages of PAL include less edema, a quicker recovery, and decreased intraoperative pain. Compared to SaL and suction-assisted liposuction, fat harvesting is 45% faster.^[10] Another advantage of PAL is the use of the self-contained tank and the tubing system, which guarantees cleanliness. The method as a whole is latex-free, and the fat retrieved is practically colorless and less bloody than that obtained through manual liposuction, making it suitable for fat transfer.^[11] In conclusion, aspirating fat from diverse body parts using the PAL system is practical, completely sterile, and time-efficient. Other body parts may also receive this fat. In addition, donor site morbidity is reduced, making the procedure safer for the patient and less taxing on the surgeon.

Close

Figure 3:

Power-assisted liposuction machine.

Export to PPT

EDL

Both the life of the surgeon and the patient has been altered by the power-assisted liposculpture revolution. Two energy delivery technologies have been created and put on the market in the past 20 years.

VL

VASER energy delivery technology, the surgeon was able to melt and remove a significant quantity of fat, even the superficial fat layer, leaving the body with finely defined muscles throughout abdomen, back, arms, and legs by ultrasound [Figure 4]. It is crucial to refrain from over-removing fat and leave 1 cm of fat thickness in the deep dermis to avoid deep tissue scarring and anomalies.^[17,18] By presenting a novel method for body contouring, Colombian cosmetic surgeon Alferdo Hoyos significantly enhanced the VASER liposculpture procedure. The technique’s name was HDL. In contrast to basic liposuction or fat removal, Dr. Hoyos’ treatment is an esthetic approach to contouring the body and defining the surface anatomy. VASER body sculpture technology gives the doctor the ability to use it as a sculpting tool to produce the ideal profile,^[19] going much beyond the straightforward fat removal of fatty bulges. Excellent cosmetic outcomes are made possible with less injury to the blood vessels and soft tissue with VASER-assisted liposuction. HDL breaks down the fat and makes it ready for the surgeon to delicately sculpt the muscle structure using aspiration, which is not possible with conventional liposuction.^[20-22] Compared to normal liposuction, the VASER technique may be more challenging and time-consuming. It is important to keep in mind that VASER technology or laser technology adds one extra stage to traditional liposuction that is emulsification of fat. However, another phase that is included in three-dimensional sculpting is the elimination of the superficial fat.^[23] The fat is debulked with less trauma when VASER is combined with power aided liposculpture devices. The VASER and HDL approach may be more difficult and time-consuming than standard liposuction.^[24,25] However, the removal of the superficial fat is a further stage of three-dimensional sculpting.

Close

Figure 4:

Ultrasonic liposuction machine.

Export to PPT

As a result, we advise that it be carried out by an experienced team or, if possible, by multiple teams working together. An experienced team or team’s increases safety, shortens surgery, lessens surgeon fatigue, and improves patient outcomes. To get the best results from any of the approaches mentioned in the sections above, it is essential to remember that the patient’s choice is just as important as the surgeon’s training and experience.