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6.10 Liposuction Devices
Over the years, several modalities of liposuction have
evolved. These include:
1. Syringe liposuction (SL).
2. Standard suction-assisted liposuction (SAL).
3. Power-assisted liposuction (PAL).
4. Ultrasonic liposuction (UAL).
5. Vibration amplication and sound energy at resonance
(VAL) or (VASER).
6. Laser-assisted liposuction (LAL).
7. Water-assisted liposuction (WAL).
6.10.1 Syringe Liposuction—SL
This technique was popularized by Pierre Fournier of France.
[21, 22] In this technique, a cannula is attached to a 20–50cc
syringe which has a locking device at the proximal end of the
syringe which maintains a negative pressure (Fig.6.26). This
procedure can be used under local anesthesia for small areas.
It is cost effective but it is time consuming and laborious.
[23] It is not appropriate for large volume aspirations.
Fig. 6.24 Less bloody aspirate with wetting solution
Fig. 6.25 Bloodless aspirate
with superwet solution
6.10.2 Standard Liposuction Technique—SAL
The standard liposuction technique, which was initiated in
the 1980s, consists of blunt cannulas of different diameters
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Fig. 6.26 Syringe
liposuction
K. Bhangoo
Fig. 6.27 Standard liposuction (SAL) showing cannulas and tubing
ranging from 3 to 6mm, attached to a vacuum pump through
a tubing (Fig. 6.27). This technique was commonly used
until the advent of power-assisted liposuction. This modality is strenuous, particularly in brous tissues, in areas of
secondary liposuction and in cases of large lipoaspirates
because it requires a lot of physical work in order to aspirate
the fat. Its advantage is that it is safe, and the equipment is
cheaper than other modalities (Fig.6.28).
Fig. 6.28 Suction machine
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6.10.3 Power-Assisted Liposuction—PAL
Power-assisted liposuction was introduced by Robette in
1990 (Fig.6.29). This technique uses an electric power source
to drive the liposuction cannula in a handpiece (Figs.6.30,
and 6.31). The cannula oscillates in a reciprocating manner in
a 2mm back and forth motion at 4000cycles per minute. This
emulsies the fat, which is then suctioned through a tube
attached to a vacuum pump. The advantage of PAL includes
Fig. 6.29 Power-assisted liposuction handpiece
decreased surgical time, less operator fatigue and it also
allows to transverse brous tissue and is very good for secondary liposuction cases. [24] This technique is less strenuous, requiring less physical stress and thus allowing the
surgeon to use the non-operating hand for palpation and evaluation of the treatment areas. This technique is the one that is
most frequently used by most surgeons, including the author.
6.10.4 Ultrasonic-Assisted Liposuction—UAL
Ultrasonic-assisted liposuction uses ultrasonic energy which
implodes and emulsies fat cells (Figs.6.32 and 6.33). This is
then aspirated by a tube attached to a vacuum pump. This technique is used in dense brous areas of fat in male patients and
in treatment of gynecomastia, but it does not have signicant
advantages in the liposuction of lower extremity [25]. The dis-
advantage is that the equipment is expensive, there is a steep
Fig. 6.30 PAL handpiece and cannulas
Fig. 6.31 PAL electric console
Fig. 6.32 Ultrasonic liposuction
Fig. 6.33 Solid cannula for ultrasonic liposuction
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K. Bhangoo
learning curve and it generates heat which can cause tissue
damage resulting in contour deformities, causes hyperpigmentation, paresthesia, and higher incidence of seroma. [26]
The standard suction-assisted lipectomy is frequently
used in combination with UAL in order to evacuate the emulsied and imploded fat cells and shorten the ultrasound
exposure. [27]
It is necessary to maintain constant motion of the cannula
in order to prevent heat damage. Skin protectors are used at
the entry points, requiring larger incisions and resultant longer scars.
6.10.5 Vaser Liposuction—VAL
Another modality of liposuction incorporates vibration
amplication of sound energy at resonance, so-called pulse
ultrasound [28, 29].
This technique uses solid probes of small diameter which
emit pulse energy causing thermal tissue injury. The proposed advantage of this technique is that it induces skin
retraction and is used in older patients where there is skin
laxity. It is also claimed that it reduces blood loss and there
are fewer complications from thermal energy, such as contour irregularities, seromas, and skin injury. [30] In spite of
much hype, VAL has not gained much popularity in the
United States, and less than 3% of plastic surgeons use this
liposuction modality.
6.10.6 Laser-Assisted Liposuction—LAL
Laser-assisted liposuction involves the use of the laser bers
that emit energy that emulsies and disrupts fat cells. These
are then evacuated using SAL or PAL.This is said to result
in subdermal skin stimulation. Advocates of LAL indicate
that it reduces post-operative pain and enhances skin tightening effect due to collagen reorganization. However, double
blind randomized studies comparing SAL and LAL have
found that there is no signicant difference in the outcomes.
6.10.7 Water-Assisted Liposuction—WAL
Water-assisted liposuction involves a dual lumen cannula
that injects a wetting solution through one cannula at high
pressure and simultaneously aspirates emulsied fat cells
through a separate channel. [31–33] WAL uses fan-shaped
jets to inject uid in a pulsied manner with the object of
loosening fat cells and also minimizing soft tissue injury during liposuction. This technique was introduced in 2009. The
technology has been shown to be safe; however, it has not
gained much popularity.
6.11 Cannulas
Since abandoning the original sharp curettes and sharp edged
cannulas, the modern cannulas have evolved to be blunt
tipped. Many designs have been developed with single or
multiple holes. The holes can be either on one side only for
supercial liposuction or circumferential for liposuction in
deep tissue planes (Fig. 6.34a, b). The blunt tip cannulas
minimize tissue injury, particularly to blood vessels and
nerves and decrease blood loss. They also decrease the incidence of inadvertent penetration of tissue planes, such as
deep fascia. The cannulas can be either hollow or solid
depending on the technology utilized. Hollow cannulas are
used for SAL, PAL, and WAL.Technologies which use ultrasound, radiofrequency, and laser use solid cannulas for fat
emulsication and hollow cannulas for suctioning the emulsied fat.
a
Fig. 6.34 (a, b) Blunt cannulas with holes on one side only and multiple circumferential holes
b
a
b
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Fig. 6.35 (a) Large cannulas result in waviness. (b) Small cannulas are
preferable and prevent waviness
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mechanical compression devices can be used for large volume inltration which infuses the uid with force and in a
measured way. The amount of uid inltrated becomes
important in assuring volumetric symmetry when doing the
procedure bilaterally.
An appropriate period of time should be allowed for vasoconstriction. Although the author has used ultrasonic modality in the past, he is currently using power-assisted
liposuction. In fact, the majority of plastic surgeons in the
United States use power-assisted liposuction as it is less
strenuous (Fig.6.36). The cannula oscillates at high speed
and the emulsied fat is aspirated with a vacuum pump into
a container (Fig.6.37). The video shows the liposuction in
progress. The aspirate is white in color because there is minimal blood in the aspirate. The end point is determined by
palpation and when the aspirate becomes bloody. The aspiration is monitored with the left hand or non-dominant hand
constantly which also determines the position of the tip of
The cannulas come with different diameters ranging from
2 to 8mm. The larger cannulas should be avoided as they can
cause unevenness and waviness (Fig. 6.35a). Smaller cannulas prevent this complication but take longer operating
time (Fig.6.35b). For most purposes, in the lower extremity
a 4mm cannula is most frequently used. This prevents contour irregularities; however, for large volume aspiration a
5mm cannula can be used for the deeper layers and a 4mm
cannula can be used for the more supercial liposuction.
Cannula lengths can vary from 10 to 30cm. The length of
the cannula will depend on the site of the proposed treatment
area and the incision site.
Fig. 6.36 Liposuction with PAL is less strenuous
Cannulas which are somewhat curved at the distal extremity can be used when dealing with curved areas, such as
around the hips, in order to prevent end hits and dimpling.
6.12 Operative Techniques andCaveats
The procedure is commenced by making an incision at the
proposed site. The wetting solution is then inltrated into the
areas to be treated. There are several ways of injecting the
wetting solution. For small areas, the uid can be injected
with a 50cc syringe and a 22 gauge spinal needle.
Large volume inltration can be done by putting the solution in an IV bottle and hanging it high on an IV stand and
using gravity to force the uid into the tissues. Alternatively,
the plastic IV bottle can be compressed by surrounding it
with a sphygmomanometer cuff and inating it. Calibrated
Fig. 6.37 Liposuction of hips
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the cannula to prevent end hits (Fig.6.38). A Lukens trap can
be incorporated into the tubing to harvest fat for grafting if
needed (Fig. 6.39). Unlike ultrasonic liposuction, fat aspirated during PAL can be used for grafting (Fig.6.40).
The cannula should be kept in constant motion as keeping
it in one area can result in overaspiration and dimpling or
depressions.
The pinch test as demonstrated in the photograph is done
to demonstrate the difference between the treated and
untreated area and to determine the endpoint (Fig.6.41).
Figure 6.42 shows patient undergoing liposuction of multiple areas.
Figure 6.43 shows liposuction of lateral thigh done systematically from anterior to posterior.
Figure 6.44 shows liposuction complete on one side.
Site specic areas of treatment in the lower extremity.
K. Bhangoo
Fig. 6.40 Fat aspirate with PAL can be used for grafting
Fig. 6.38 Liposuction of lateral thighs with the non-dominant hand
used to monitor the procedure
Fig. 6.39 Liposuction of medial thighs and note the Lukens trap
attachment for harvesting fat for grafting
Fig. 6.41 Pinch test used intra-operatively
Fig. 6.42 Pre-op of patient undergoing liposuction of multiple areas
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Fig. 6.44 Liposuction right side completed
Fig. 6.43 Liposuction of lateral thighs done systematically from ante-
rior to posterior
a
Fig. 6.45 (a, b) Areas of liposuction in the lower extremity
Figure 6.45a, b show multiple sites of liposuction in the
lower extremities.
In the lower extremity, the following sites are the targets
for liposuction:
b
6. Gluteal region (banana rolls).
7. Medial knees.
8. Calves.
9. Ankles.
1. Lateral hips.
2. Lateral trochanteric areas (saddle bags).
3. Medial thighs.
4. Anterior thighs.
5. Circumferential thighs.
1. Lateral Hip: The photograph shows lipodystrophy of the
lateral hips. This is approached through an incision along
the lateral extremity of the inguinal crease. The incision
should be placed below the anterior superior iliac spine in
order to prevent trauma to this structure which will result
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K. Bhangoo
in post-operative pain. The operating table can be tilted in
order to gain access to the posterior aspect of the lateral
hip lipodystrophy (Figs.6.46, 6.47, and 6.48).
2. Lateral Trochanteric Areas (So-Called Saddle Bag
Deformity)
This is the most commonly requested area for liposuc-
tion by female patients (Fig.6.49).
Figure 6.50 shows markings.
Figure 6.51 shows direction of cannula movement.
This area is approached with the patient in a supine position. The lateral trochanteric area is approached through a
lateral incision in the inguinal crease. Again, the operating
table can be tilted in order to access the posterior aspect of
the saddle bag deformity. Usually a 4mm cannula should be
used for the supercial layer of the fat in order to prevent
irregularities. The deeper layer can be aspirated through a
5mm cannula depending on the severity of the deformity. It
is usually necessary to use a longer cannula measuring
approximately 30cm for treating the saddle bag areas. For
the supercial areas, cannulas with holes on one side only
should be used with the holes facing the deeper surface to
prevent irregularities and puckering. Cannulas with circumferential holes can be used for the deeper layer.
Figures 6.52, 6.53, and 6.54 shows pre- and post-operative.
Fig. 6.46 Lipodystrophy of hips
Fig. 6.47 Markings for
liposuction of hips
3. Anterior Thigh Area
Figure 6.55 shows markings for anterior thigh.
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Fig. 6.48 Pre- and postoperative lipodystrophy of
hips
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Fig. 6.49 Lipodystrophy of lateral trochanteric areas or “saddle bags”
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Fig. 6.50 Markings for
lipodystrophy lateral thighs
K. Bhangoo
The anterior thigh area can be approached through an
incision in the lateral area of the inguinal crease which is also
used for the lateral hip and lateral trochanteric areas. Again,
two layers of fat are addressed using a 4mm cannula for the
supercial layer and a 5mm cannula for the deeper layer. For
the supercial layer, a cannula with the holes on one side
only is used, making sure that the holes are on the deeper
aspect to prevent puckering or dimpling of skin. For the
deeper layer, a cannula with circumferential holes can be
used.
Figures 6.56, 6.57, and 6.58 show pre- and post-operative
pictures of anterior thighs.
4. Medial Thigh Area
Lipodystrophy of the medial thighs is performed through
an incision along the medial aspect of the inguinal crease.
Although lipodystrophy of the medial thighs is a common
deformity of the lower extremities, it rarely occurs as an isolated deformity. Most commonly, it occurs in combination
with lateral and anterior thigh lipodystrophy as a component
of circumferential thigh lipodystrophy. It can also occur after
massive weight loss.
The fat in this location is soft and can be easily aspirated.
This location is good for harvesting fat for small volume fat
grafting.
Care should be exercised in not injuring the long saphenous vein and the femoral vessels.
Fig. 6.51 Direction of cannula movement
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