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Part II
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Lipo-contouring
Liposuction: Principles andTechniques
https://t.me/medicina_free
MartinJugenburg andWaqqasJalil
4
Liposuction is a cosmetic procedure to remove unwanted fat,
which may be performed under local or general anesthesia. It
requires three-dimensional (3D) understanding of the anatomy, of the adipose tissue, precision, skill, and artistry that is
attained only with hands-on experience. There are many
terms used to refer to this procedure, such as suction-assisted
lipectomy, suction lipoplasty, liposculpting, and liposculpture. The concept of liposuction, suctioning out unwanted
fat, traces its origins back to the early 1900s, but it was not
until the 1970s that Illouz really popularized liposuction as
we know it today (Table 4.1) [1, 2]. With the constantly
growing worldwide body mass index (BMI), and given the
fact that aside from using implants, fat contouring is the only
way to really sculpt the body, it is not surprising that liposuction continues to grow and slowly become a major component, or an add-on to most procedures cosmetic plastic
surgeons perform today. It is the second most common surgical procedures performed by board-certied plastic surgeons
in the USA and is performed by 92% of all plastic surgeons.
Overall, 289,261 liposuction procedures were performed by
American Society of Aesthetic Plastic Surgeons (ASAPS)
member surgeons in 2018 [10]. If we add to it liposuctions
performed by dermatologists and other cosmetic physicians,
liposuction is likely the most commonly performed cosmetic
procedure worldwide. These numbers as evidenced by the
last decade will only continue to increase every year.
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 981- 19- 4997- 5_4].
M. Jugenburg (*) · W. Jalil
Toronto Cosmetic Surgery Institute, Toronto, Ontario, Canada
Table 4.1 Liposuction history
1921 French surgeon Charles Dujarier introduces concept of body
contouring and fat removal, although the result of his
attempt at body contouring resulted in gangrene and set
back body contouring for years [1, 2]
1974 Drs. Arpad Fisher and Giorgio Fisher in Italy develop blunt
tunneling technique on which liposuction is based [3]
1977 Dr. Illouz in France introduces wetting solution and
develops modern suction-assisted liposuction [4]. Fournier
then later added lidocaine to the wetting solution
1987 Klein published “tumescent” technique introducing
epinephrine to help control bleeding via vasoconstriction
(Klein solution: 0.05% lidocaine, 1:1,000,000 epinephrine,
10mL sodium bicarbonate per 1L of saline) [5]
1992 Hunstad formula (lactated ringers, 0.05–0.0125% lidocaine,
1:1,000,000 epinephrine) [6]
1992 Zocchi introduced ultrasonic-assisted liposuction [7]
1992 Apfelberg introduced laser-lipolysis [8]
1998 Power-assisted lipoplasty approved for use [9]
4.1 Preoperative Assessment
The most important aspect of the preoperative assessment,
which applies to all cosmetic procedures, not just liposuction, is to understand the patient’s goals and ensure these
goals are realistic and achievable. We now live in the age of
social media, where virtually everyone “tunes” their photos
and videos, leading to a distorted perception of beauty and
expectations. It is common practice for “inuencers” to use
various apps to adjust their bodies, and create illusion of
muscular anatomy leading to anatomically impossible body
shapes. As a result, even though most people understand that
the photos they are looking at are not “authentic,” the result
is still a warped sense of normalcy. Often patients bring in
“wish pics” of what they want their desired results to be; this
can be helpful for a surgeon because it can set the table for
their expectations and allow one to have a frank discussion
about what is achievable. Teasing out expectations and concerns from a patient is also helpful in identifying risk factors
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_4
49
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M. Jugenburg and W. Jalil
consistent with body dysmorphic disorder (BDD), which has
a reported prevalence of 6–15% in patients seeking out cosmetic surgery procedures [11].
In general, patients who attempt to improve their appearance through not only surgery, but also diet, exercise, and
healthy lifestyle, are more likely to be satised with their
surgical results [12].
4.1.1 Past Medical History
4.1.1.1 Medical Conditions
Beyond psycho-social issues, the other important factor in
the assessment of patient eligibility is their general medical
health. This is the one aspect that varies the most in the literature as every surgeon has different tolerances for various
medical conditions. In general, it is of our opinion to turn
away patients who are ASA (American Society of
Anesthesiologists rating) >3 or 4. In addition to this if a
patient is a smoker or on oral contraceptives, it is asked that
they stop at least 2 weeks prior to surgical date.
A complete medical history should be obtained from the
patient, with focus on conditions that may affect safety of the
procedure, or the quality of outcome (Table4.2).
4.1.1.2 Previous Surgeries
Previous surgical history is relevant, specically abdominal
procedures as they may predispose the patient to hernias and
increase brosis and anatomic anomalies that increase the risk
of abdominal perforation. In our experience, nonsurgical fat
reduction treatments also increased brosis in treated areas.
4.1.1.3 Medications
Patients should have their prescription drugs, nonprescription
drugs, and various dietary supplements reviewed. Various medications (e.g., Selective Serotonin Reuptake Inhibitor (SSRIs))
can interfere with lidocaine metabolism in the liver and thus
increase the risk of lidocaine toxicity [13], and these too should
be discontinued 2 weeks prior to surgery. Other medications
Table 4.2 Conditions affecting safety as well as quality of outcome
Conditions affecting safety Conditions affecting quality of outcome
• Cardiac history • Polycystic Ovarian Syndrome
(PCOS)
• History of embolism • Ehlers-Danlos syndrome
• Implants in the surgical
area
• Immunosuppressive
conditions
• Coagulopathies – Injectable
• Previous surgeries in the area
(scarring/brosis)
• Previous nonsurgical treatments
– Nonsurgical fat reduction
that can impact the risk of bleeding and should be stopped at
least 2 weeks prior to surgery include: Non-steroidal antiinammatory drugs (NSAIDs), anti-coagulants, Vitamin E,
glucosamine, ginseng, ginkgo biloba, omega-3 fatty acids, and
high sh diet. Patients with autoimmune or gastrointestinal
(GI) disorders may be on medications that suppress the immune
system, and these should be discontinued prior to surgery.
Patients should be instructed in general to stop all nonprescription medications, vitamins, and supplements at least 2
weeks prior to surgery.
4.1.2 Physical Examination
A thorough physical examination is crucial prior to planning
the surgical procedure. Understanding the underlying anatomy (skeletal anatomy and fat distribution) allows the surgeon to plan the surgical procedure. A review of the surgical
area for any abnormalities, such as prominent skeletal features, presence of a hernia, previous scars (which may make
the surgical area more brotic, increase the risk of abdominal
wall defects or hernias), will allow the surgeon to recognize
potential danger zones early on. Skin contour and irregularities should be noted and discussed with the patient as they
may be unaware of their presence and will not understand
why they are there after surgery.
In our practice it is routine to always have the patient take
an in-ofce height and weight measurement during ofce
visits and prior to surgery, which is then used to calculate
their body mass index (BMI), and document it in the electronic medical records (EMR). If their BMI is above the
value of 30, it is our opinion to turn the patient away and
suggest that they continue to lose weight. It is routine in the
practice to cancel patients on day of surgery if their BMI
ratio is found to be above 30.
Once the issue of weight is settled, the surgeon then must
assess the quality of the skin for the area in question for its
elasticity/laxity, previous scars, and dermal thickness. If the
patient has extremely poor elasticity and thin dermis, it is
usually recommended that they look into excisional-based
procedures.
However, in the scenario where they fall in the “inbetween” category of laxity (i.e., some laxity just not enough
for excisional-based surgery), adjunct treatments may be discussed that may help with the skin laxity. However, we
always stress that these adjunct treatments will not generate
the same skin-tightening effect as excisional surgery.
In summary, there is no consistent evidence about preoperative assessment but the authors tend to generally agree with
Araco etal. [14] in excluding patients with body mass indexes
greater than 30 or those with inelastic or redundant skin.
4 Liposuction: Principles andTechniques
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4.1.3 Preoperative Investigations
While a patient undergoing a very minor liposuction does
not require any preoperative bloodwork, it is our practice to
obtain a complete blood count (CBC) on all liposuction
patients where we estimate aspiration volume to be over
1L.Hemoglobin (Hgb) level indicates whether the patient is
able to tolerate possible drop in hemoglobin as a result of a
larger volume of liposuction. Additional bloodwork is
obtained if past medical history raises any questions.
4.2 Wetting Solution
Wetting solution can contain several medical ingredients and
each surgeon can make their individual recipe. There is no one
standard formulation for the wetting solution with surgeons
adding individual medications in dosages that they are satised
with. The effect of uid inltration into the tissue aids in swelling of the tissue that then allows the passage of cannulas and
other devices through the tissue in a safe effective manner.
Klein solution
• 1L normal saline
• 50cc of 1% lidocaine (500mg)
• 0.5–1.0mg epinephrine
• 10cc of 8.4% NaHCO3 (10mEq)
4.2.1 Wetting Solvents
Table 4.4 Effects of epinephrine in wetting solution
• Prolongs the anesthetic effect
• Slows the absorption of lidocaine allowing higher dosage
• Capillary vasoconstriction to reduce surgical blood loss
4.2.2 Epinephrine
Epinephrine is an alpha and beta agonist that plays a key role
in minimizing blood loss, lowering peak lidocaine levels,
and prolonging the effect of the lidocaine.
In the wetting solution, 1 mg/L provides consistently
good vasoconstriction with low incidence of tachycardia,
and requires 3–6min for onset of action and 10–15min for
maximal effect. In our practice, we have increased our formulation to include 2mg/L to shorten wait time for onset of
action and to further minimize blood loss, without any negative systemic effect on the patients (Table4.4).
Areas of increased brous tissue tend to be associated
with increased surgical bleeding, and these tissues require
more wetting solution, more epinephrine, and longer time to
set in.
The most common adverse reaction to epinephrine is
when a rapid absorption leads to supraventricular tachycardia. There may also be allergic reaction to bisulte, which is
an antioxidant often added to commercial epinephrine. There
are other clinically relevant conditions where epinephrine
may be contra-indicated such as: signicant cardiovascular
or peripheral vascular disease, hyperthyroidism, and others.
Solvent in the wetting solution initially used was normal saline
(NS). Later, Ringer’s solution was developed where potassium
chloride was added to the normal saline, and nally Hartmann’s
solution (lactated Ringer’s [LR] solution) was developed where
lactate was added to the Ringer’s solution. NS, Ringer’s, and
LR are similar when used as wetting solution. Of these solutions, normal saline (0.9% NaCl) is most commonly used. LR
has been associated with perioperative complications, such as
deep venous thrombosis (DVT) [15] and alkalosis. Table4.3
compares the constitution of the various wetting solutions.
Table 4.3 Wetting solutions
Lactated Ringer’s
(Hartmann
Normal saline Ringer’s solution
• 0.9% NaCl
154mEq/L of
sodium and
chloride
• It is the most
commonly used
solvent
• Ringer’s solution is a
solution of various salts
dissolved in water in
order to create an
isotonic solution
• Usually contains NaCl,
KCl, CaCl, and NaHCO
solution)
• Ringer’s
3
solution,
where lactate
replaces
NaHCO
3
4.2.3 Anesthetic
Local anesthetic can be added in various dosages to help
anesthetize inltrated areas, and thus avoid the need for general anesthesia. Lidocaine is the most commonly used anesthetic, and the dosage varies from surgeon to surgeon.
Lidocaine, when injected intravenously, has a maximal
safe dose of 5mg/kg (7mg/kg with epinephrine). However,
because lidocaine toxicity is related to its plasma concentrations, and absorption from subcutaneous tissues is slow,
maximum safe dose in liposuction is debated, and doses of
up to 35 mg/kg of lidocaine in subcutaneous tissues have
been shown to be safe [16, 17]. Ostad and colleagues [18]
demonstrated lidocaine up to 55 mg/kg as being safe.
Table4.5 enumerates Klein’s recommendation and Table4.6
mentions safety features regarding use of lidocaine in tumescent uid.
Because of potential lidocaine toxicity, however, some
surgeons (including our clinic) avoid the use of lidocaine in
their wetting solution all together without increased postoperative pain when the procedure is performed under general
anesthesia [19].
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4.2.4 Tranexamic Acid
Tranexamic acid is anti-brinolytic agent that inhibits the
activation of plasminogen, and is used to reduce perioperative blood loss without increasing the risk of thromboembolism. As a result, it has gained popularity as an effective and
safe adjunct to many surgical procedures [20, 21]. Cansancao
etal. have shown a 43.8% decrease in blood component of
the lipoaspirate, and blood loss was decreased by 56.2% in
patients who received 10 mg/kg tranexamic acid intravenously preoperatively and postoperatively, compared to a
placebo group [22–24].
4.2.5 Sodium Bicarbonate
Sodium bicarbonate neutralizes the acidic pH of the local
anesthetic, to make the inltration in an awake patient less
painful [25]. Adding 10cc of 8.4% NaHCO3 (1mEg/mL) to
Table 4.5 Klein’s recommendations
• 45mg/kg in a thin patient
• 50mg/kg in a heavier patient
• Maximal dose should be reduced 30% in patients taking drugs
that may interfere with lidocaine metabolism (e.g., SSRIs)
Table 4.6 Lidocaine in wetting solutions
Lidocaine injected into subcutaneous tissues as part of a wetting
solution has a higher toxic dose because of slower plasma
absorption:
• Subcutaneous fat is less vascularized
• Presence of epinephrine causes vasoconstriction
• Tumescent solution volume compresses blood vessels
• Dilution of lidocaine in the wetting solution keeps the gradient
for absorption low
• Lidocaine is lipophilic and is sequestered by the fat
• Unknown amount of lidocaine is removed from the patient during
aspiration
• Absorption half-life of lidocaine in wetting solution is 8–14h,
thus little of the total dose is in the systemic circulation at any
given time
Plasma lidocaine peaks at 12–14h after injections, and local
anesthesia effect can last up to 18h, negating the need for
long-lasting anesthetics such as bupivacaine and marcaine
1L of NS results in 10mEq/L of wetting solution, which
signicantly reduces the pain of inltration and the burning
of the acidic lidocaine. Please note adding NaHCO3 to solution containing bupivacaine results in precipitation of bupivacaine and should be avoided.
4.2.6 End Points ofWetting Solution
The wetting solution is inltrated to various end points, with
increasing inltrate volume leading to decreasing blood loss
(Table4.7) [26, 27].
Following the injection of the wetting solution, it is recommended to wait 5–20min to allow for maximal vasoconstriction, thus minimizing blood loss during surgery. Patients
with “soft” non-brotic fat are ready 5min after inltration,
while brotic areas and areas with previous liposuction benet from 20min wait period. A variation on the inltration
technique is the simultaneous separation tumescence (SST)
introduced by Del Vecchio [28] in which Del Vecchio demonstrated to have a more rapid onset of vasoconstriction.
4.3 Liposuction Surgery
There are various surgical techniques surgeons can use to
perform the liposuction procedure [29, 30]. The basic concept of aspirating fat can be achieved by simple syringebased suction, or with a suction pump-assisted suction. A
simple set of instruments can allow a surgeon to perform
liposuction safely and effectively (Fig. 4.1). Liposuction
cannulas can be attached to a syringe, or via suction tubing to
a suction machine. The fat is aspirated into a simple container (Fig. 4.2) or, when fat grafting is performed, into a
canister that allows for the uid to be drained and fat to be
re-injected (Figs.4.3 and 4.4). Additionally, there are various
instruments that can be used to pretreat the fat to facilitate
aspiration. A more “sophisticated” set of instruments
includes variety of tools to pretreat the fat, variety of cannulas to achieve different sculpting goals, and tools to post-treat
the liposuction area (Fig.4.5). Although most manufacturers
would like to promote their tools as benecial to patients in
terms of lower blood loss, less bruising, and quicker recov-
Table 4.7 Estimated blood loss during the various techniques of liposuction
Technique Amount of wetting solution inltrated Estimated blood loss as % of aspirate volume
Dry No wetting solution 20–45
Wet 200–300cc of wetting solution per area 4–30
Superwet 1cc of wetting solution per 1cc of fat to be removed 1
Tumescent 3–4cc of wetting solution for each 1cc of fat to be
1
removed or until tissue becomes rm
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Fig. 4.1 Typical liposuction instrument setup: aspiration canister and a
stand, basic instruments to create liposuction port and for sutures;
pitcher, bowl, and funnel
Fig. 4.3 Simple reusable liposuction canister with a luer lock: allows
easy drainage of the separated tumescent uid as well as aspiration of
ne fat for fat grafting
Fig. 4.2 Simple reusable liposuction canister: autoclavable canister
can be reused many times, and can be sterilized to allow placement on
the instrument table if needed
Fig. 4.4 Reusable liposuction canister with a suction tubing adapter:
allows larger-diameter suction and fat injection tubing to be connected,
for large-volume fat grafting
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Fig. 4.5 A typical liposuction setup (left to right): an instrument tray
used to sterilize liposuction canister and its stand is used as a container
to hold and protect instruments and cannulas during a procedure. Sterile
green towels for draping and gauze. Pitcher and a funnel for transferring harvested fat between canisters. Various liposuction cannulas are
laid out for demonstration (during surgery, they would be in the instrument tray covered to protect them from contamination while not in use).
Basic instruments are used to create liposuction ports and later to suture
them, close, and xate drains if needed. Piercing towel clips are used
intraoperatively to close liposuction ports to avoid tumescent uid leaking while the port is not being used. A small bowl contains liposuction
ery, there are few independent studies to support these benets. The undisputed benet that these machines have is that
they make the actual liposuction less physically straining on
the surgeon.
4.3.1 Pretreatment Technologies
4.3.1.1 Power-Assisted Liposuction (PAL)
The concept of power-assisted liposuction (PAL) vibration to
break up fat was introduced by Dr. Malak and Rebelo [31].
MicroAire (MicroAire Surgical Instruments, Charlottesville,
Virginia) system was rst introduced in 1998 and is probably
the best-known PAL where the cannula vibrates back and
forth 3mm at 2000–4000cycles/min. The speed of cannula
movement can be adjusted according to the surgeon’s preference. The mobilized subcutaneous fat is aspirated with
conventional suction machines simultaneously while the
PAL cannula vibrates. Since PAL’s introduction, many plastic surgeons across the world have quickly adapted their
port protectors. These are essential for vibration application of sound
energy at resonance (VASER), and can be used for standard suctionassisted lipoplasty (SAL) as well. Aspiration tubing with appropriate
diameter is seen (MicroAire-compatible tubing displayed). VASER
handpiece and VASER probes (and skin ports) are seen on the top, with
MicroAire (power-assisted liposuction) PAL handpiece and power cord
seen below. VASER is used to pretreat the fat and MicroAire is used to
aspirate (VASER is used to pretreat fat in some patients; in others,
MicroAire PAL with a basket cannula is used for the separation pretreatment of fat prior to aspiration). Bottom right shows an autoclavable
canister with a stand, and tubing to connect it to a suction machine
Table 4.8 Power-assisted liposuction
Advantages Disadvantages
• Less tiring • Added cost of the
equipment
• Decreased OR time when
compared to manual liposuction
and other modalities
• More versatile • Noise associated with the
• Easy to learn
• Easy to perform
• Breaks up brous fat easier than
SAL
• Pretreatment and aspiration with
same tool and may be performed at
the same time
• Vibration transmitted to
the surgeon’s upper
extremity
device
practices to now incorporate PAL as the predominate method
of liposuction (Table4.8).
Initial studies by Fodor etal. [32] found PAL was equal to
SAL in safety, speed of recovery, and the aesthetic quality of
4 Liposuction: Principles andTechniques
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Fig. 4.6 PAL—Authors’ preferred liposuction tool. We use PAL in virtually all but the simplest liposuction case. Relative low cost, speed, and
efciency of PAL make liposuction signicantly less manually exhausting than simple manual liposuction. (1) Power generator, (2) power
cord, (3) PAL handle, (4) bent basket cannula used to get around curved
surfaces such as when liposuctioning anks and lower back from a
supine position, and (5) straight basket cannula used on at surfaces
the results. The authors further mentioned that it was considerably superior in terms of “ease of fat extraction.” Therefore,
treatment of brotic areas and speed of fat removal were
found to be faster with PAL than with SAL [32]. This fact
has been conrmed as many surgeons have noted the process
of PAL to be less labor intensive than traditional SAL (especially in terms of fatigue reduction and time savings). PAL is
our preferred liposuction tool in all cases except for very
minor liposuction cases where manual liposuction is sufcient (Fig.4.6).
4.3.1.2 Ultrasound-Assisted Liposuction (UAL)
Ultrasound-assisted liposuction (UAL) was rst introduced
by Zocchi in 1992 [7] who employed ultrasonic energy to
pretreat fat. Early machines used the ultrasonic probe to create oscillating sound waves leading to cavitation and cellular
fragmentation. While early machines resulted in lipolysis,
emulsication, and liquefaction of fat, modern machines use
lower power to cavitate air bubbles in the wetting solution to
separate fat cells while preserving their viability for fat transfer [33] (Fig.4.7).
The UAL probe may be either a hollow cannula through
which low-pressure suction can pretreat and aspirate
lipoaspirates, or more commonly a solid probe that requires
subsequent aspiration of emulsied fat through a separate
hollow cannula, as per SAL.The probe contains a piezoelectric crystal that converts incoming electrical energy into a
mechanical vibration at an ultrasonic frequency of 20–30kHz
with a cyclical displacement of around 100μm.
When applied to adipose tissue, these alternating waves
cause compression and rarefaction resulting in microcavities
or bubbles that can expand with each cycle until a critical
Fig. 4.7 VASER instruments: (1) probe cover, (2) VASER handpiece,
(3) skin port protectors, and (4) probes of various diameters, lengths,
and various numbers of groove (more grooves mean more energy distribution, while fewer grooves result in more energy concentration at the
tip for brous tissues)
diameter is reached beyond which they implode. This results
in disruption of cells and/or generation of high levels of
energy in various forms such as heat and light [34].
Adipocytes are thus lysed into an emulsion. When sufcient
wetting solution is inltrated, this ultrasonic energy instead
induces cavitation of air bubbles in that solution, which are
then responsible for very ne mechanical separation of fat
without destroying adipocytes themselves. Schafer etal. [33]
demonstrated 88.7% adipocyte viability after harvest of fat
for autologous fat grafts, with third-generation UAL.
Because heat can build up at the UAL probe if it remains
in one place too long, there is a well-known risk of thermal
injury with UAL.Sufcient amount of wetting solution (to
absorb the thermal energy) and constant movement (to avoid
overheating any one area) are needed to avoid thermal injury.
Risk of dermal injury and seromas is also increased with
UAL (Table4.9).
The seroma rates were overall higher with UAL, which
can be up to 21% [36] versus less than 1% in
SAL.Interestingly, when the authors analyzed to see if the
benets of UAL translated into improving overall patient satisfaction, swelling, or bruising, the data were inconclusive.
UAL is most useful when treating brous tissue and secondary liposuction [35, 37, 38] and compared to SAL, UAL
may have increased skin contraction and lower blood loss
[39]. Even though there are studies that support the use of
UAL, there are some studies that did not nd any additional
benets and did not recommend UAL for routine use
[40–42].
4.3.1.3 Laser-Assisted Liposuction (LAL)
Laser-assisted liposuction (LAL) utilizes selective photothermolysis to disrupt adipocytes while leaving other tissues
undamaged [43]. Apfelberg [8, 44, 45] was rst to describe
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Table 4.9 Ultrasound-assisted liposuction
Advantages Disadvantages
• Less tiring than SAL and PAL in
brous tissues
• Finer aspirate • Risk of thermal injury
• Ideal for brotic areas such as
back, bra rolls, male chest, or
previously liposuctioned areas
• Lower blood loss • More likely to require
• Less ecchymoses • Signicant cost associated
• Improved skin contraction • Hyperpigmentation
• Further benets remain
controversial in the literature
Table 4.10 Laser-assisted liposuction
Advantage Disadvantages
• Allows for use of smaller
cannula
• Less physical strain • Increased risk of seromas
• Small incisions • Additional cost of
• Quicker recovery • Risk of thermal injury
• More time-consuming to
pretreat the liposuction
areas
• Increased risk of seroma
drains
with the ultrasound
machine
• Sensory alteration
• Longer learning curve [35]
• Prolonged pretreatment
time
equipment
the use of YAG laser but found no clear benet to the use of
laser. Later, Blugerman [46] and others introduced
Nd:yttrium aluminum garnet (Nd:YAG) laser, which they
found lysed adipocytes, resulting in an oily aspirate containing free fatty acids, ruptured cellular debris, and the tumescent solution. They also found less intraoperative blood loss
and less postoperative ecchymoses [47, 48].
The wavelengths currently used by laser lipolysis machines
(pulsed 1440 nm, pulsed 1064 nm, pulsed 1320 nm, and
CW980nm diode) generate energy, which is absorbed by adipocytes and converted to heat resulting in cell rupture.
Complications specic to laser-assisted liposuction are
related to thermal injury, as damaging energy level at the
treatment area can build up quickly. The other potential
downside to laser lipolysis is that they require more time to
remove same amount of fat than a PAL would (Table4.10).
4.3.1.4 Radiofrequency-Assisted Liposuction
(RFAL)
Radiofrequency (RF) is another modality to deliver energy to
the tissues during liposuction. RF energy is high-frequency
oscillating electrical current applied to tissues to create a
thermal effect to dissolve fat, contract collage, and induce
subdermal remodeling and neocollagen formation [49–51].
Radiofrequency-assisted liposuction (RFAL) devices simultaneously coagulate fat, aspirate it, and contract the residual
broseptal tissue.
4.3.1.5 Water-Assisted Liposuction
Water-jet-assisted liposuction is a method for fat harvesting
that relies on a fan-shaped water jet to assist liposuction. In
this method, the liposuction tube is connected to a negativepressure pump and the water pump so that the fan-shaped
water can jet at a specied frequency during liposuction.
With the assistance of water-jet force, adipocytes can be gently detached from the tissue and the mechanical injury to
lipoaspirates thereby reduced. Thus, pulsating jets of wetting
solution and simultaneous liposuction to anesthetize the surgical eld, break up and aspirate adipocytes [52]. Because
water-jet assistance was proved to improve the survival of
grafted lipoaspirates, its mechanisms are quite important for
investigators [53]; they did an in vitro study specically
looking at water-jet liposuction’s ability to improve lipoaspirate viability. Their invitro study revealed that cultured stromal vascular fraction cells in the group with water- jet- assisted
liposuction have a greater capacity for adipogenic differentiation and endothelial differentiation, therefore showing
convincing evidence that the fate of grafted fat was affected
by water-jet force. With the assistance of water-jet force during the harvesting procedure, they could obtain lipoaspirate
that was more viable and achieve a better survival result.
There is some controversy regarding adipose- derived stem
cells (ADSCs) and their presence in certain liposuction techniques. Murphy etal. (2012) showed that harvesting ADSCs
using BodyJet and BodyJet with SmartLipo lipoplasty technique produces a high yield/clinically useful ADSCs.
Conversely, another study showed that when assessing
water-assisted liposuction (WAL) alone, both with and without stem-cell enrichment, in cosmetic fat transplantation to
the breast they saw no difference. The research on ADSCs
(adipose-derived stem cells) and water- assisted liposuction
is still in its infancy; although there are some promising early
results, its safety and clinical applications need further
exploration.
4.3.2 Liposuction
4.3.2.1 Liposuction Technique
Liposuction is a blind procedure, where the surgeon does not
see what is being liposuctioned; rather the surgeon must use
his or her hands to feel tissues to “see” what is being done.
This procedure, probably more than any other in plastic surgery, is highly dependent on the surgeon’s experience. No
amount of reading and watching replaces the experience of
feeling of how liposuction is done. The operative hand holds
and guides the cannula, while feeling for resistance (Fig.4.8).
The other hand serves to feel the surgical area, guiding the
cannula, and should always provide tip feedback to the surgeon. The surgeon should at all times be aware of where the
cannula tip is, to guide the procedure and to prevent perfora-
Liposuction Steps
4 Liposuction: Principles andTechniques
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tion injury. This hand also helps to stabilize fatty pockets,
and if needed guides or pushes the fat toward the cannula.
This is the art of liposuction, feeling what the surgeon is
doing, because otherwise this is a “blind” procedure: the surgeon does not see where exactly the instrument is located
and what tissue layers are being addressed. The stepwise
process of liposuction is summarized in Fig.4.9.
4.3.2.2 Inltration
Prior to aspiration, the target area should be inltrated with
the wetting solution. Small areas or touch-ups may be inltrated up to a wet endpoint. Any more signicant liposuction
should be inltrated to a superwet or tumescent endpoint,
and time should be given to allow the skin turn pale, indicating the epinephrine effect has set in. During the inltration,
the inltration cannula should be moving back and forth to
Fig. 4.8 The operative hand is guiding the cannula into place while the
non-operative hand provides the feedback about the spatial position of
the tip of the cannula
allow the wetting solution to spread widely and rapidly. Del
Vecchio’s SST takes that principle a step further, using the
vibration of PAL to help spread the wetting solution.
Inltration of wetting solution is through sites that will
then be converted to liposuction ports. As such, the selection
of these sites is an important step (Fig. 4.10). These sites
should allow easy access to the target area, while being hidden in natural body contour—areas known to be covered by
clothes, within tattoos, or other lesions that may camouage
the subsequent scar. The attempt to hide scar should however
not sacrice the ability to easily and effectively reach the
target area. Understand that liposuction may result in linear
tunnels that may result in contour deformity or a fold. That
understanding should help guide the placement of the liposuction ports. In cases of HiDef liposuction where the goal is
an intentional, controlled contour deformity, the incision
port can be placed in line with the desired contour. In other
cases, such as in the lower abdomen, which is prone to horizontal folds, the liposuction ports should be placed such that
liposuction will be performed as perpendicular as possible to
the potential folds one wants to avoid.
4.3.2.3 Separation
While some surgeons will proceed from inltration directly
to fat aspiration, pretreatment of the surgical areas with fat
separation is an option. Separation, a pretreatment step
described by Wall [54], has gained popularity among liposuction surgeons. Using a basket cannula with PAL without
suction breaks up fatty deposit, breaks up or loosens the
broseptous network, and allows the wetting solution to
spread widely. The benet of this pretreatment is better vasoconstriction in shorter amount of time, looser fat globules for
Infiltration
Infiltration:
• Wetting solution
• large volume liposuction or fat
harvest
• no lidocaine added
• NS with 2amp epi/L
• routine liposuction
• NS 40cc 2% Xylocaine w
Epi, and 2 amp Epi/L
• 1g TXA/L may be added
• Allow for sufficient time (>5min) for
epinephrine to act. Typically by the
time all the liposuction areas have been
infiltrated, the first area is ready for
separation
• SST may allow for shorter time before
aspiration can take place.
Fig. 4.9 Stepwise process of a liposuction procedure
Separation
Separation:
• Basket cannula pre-tunneling
• single basket cannula with PAL
• up to triple basket large diameter
cannula with PAL for more
aggressive separation
• Ultrasound - assisted separation
• tools such as VASER emulsify fat
with a theoretical advantage of
less bleeding and smaller/finer fat
fragments
• When PAL/UAL is unavailable, simple
infiltration cannula pre-tunneling can be
used
• Separation performed until no tissue
resistance felt
Aspiration
Aspiration:
• Cannula selection based on the
liposuction need
• Fine cannulas vs large bore
cannulas
• up to triple basket large diameter
cannula with PAL for more
aggressive separation
• Ultrasound - assisted separation
• tools such as VASER emulsify fat
with a theoretical advantage of
less bleeding and smaller/finer fat
fragments
• When PAL/UAL is unavailable, simple
infiltration cannula pre-tunneling can be
used
• Separation performed until no tissue
resistance felt
Fat Equalization
Fat Equalization:
• Basket cannula with PAL used to break
up and separate any residual adipose
lumps
• Wet/lubricate the skin to facilitate
manual massage to feel for irregular
residual fat and to re-distribute lose fat
globules
• 3mm basket cannula PAL or infiltration
cannula are effective in assisting with
this step
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