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28 Renuvion-Assisted Body Contouring Surgery
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References
A.C. Markey, St. John’s Institute of Dermatology, St. Thomas’ Hospital, London U.Liposuction
in cosmetic dermatology. Vol. 26, Clinical and Experimental Dermatology. 2001. p.3–5.
Wu S, Coombs DM, Gurunian R.Liposuction: Concepts, safety, and techniques in body- contouring
surgery. Cleve Clin J Med. 2020 Jun;87(6):367–75.
Bellini E, Grieco MP, Raposio E.A journey through liposuction and liposculture: Review. Ann
Med Surg. 2017;24(August):53–60.
Garcia cano Margarita. Subjetividades femeninas en las cirugias estéticas de la ciudad de cali.
Tesis [Internet]. 2016;(May):31–48. Available from: http://bibliotecadigital.univalle.edu.co/
bitstream/10893/9313/1/0534169- P- S- 2016- 1.pdf
Černauskis K, Kružyk S, Šukytė G, Venclauskas L, Sakalauskas M.Saugi liposukcija: klinikinis
atvejis ir literatūros apžvalga. 2020;19:145–50.
Renuvion cosmetic tecnology. Renuvion cosmetic tecnology. 2018. p.1–28.
Gentile RD.Plasma atmosférico frío ( J-Plasma ) y nuevas opciones para el contorno facial y el
rejuvenecimiento de la piel del Rostro y cuello pesados. 2018;1(212):66–74.
Tabbal GN, Ahmad J, Lista F, Rohrich RJ. Advances in liposuction: Five key principles with
emphasis on patient safety and outcomes. Plast Reconstr Surg. 2013;1(8):1–9.
Broughton G 2nd, Crosby MA, Coleman J, Rohrich RJ.Use of herbal supplements and vitamins in
plastic surgery: a practical review. Plast Reconstr Surg. 2007 Mar;119(3):48e-66e.
Part IV
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Importance of Liposuction Improving
Body Contouring
Chapter 29
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Critical Analysis andtheFuture
ofLiposuction forBody Contouring
LuizS.Toledo
Abstract The date of 28 November 1980 is an especially important landmark for
Brazilian plastic surgeons. It was then, in a small side room of a hotel in the city of
Fortaleza, in the northeast of Brazil, that a French surgeon showed a technique with
a 16mm black-and-white lm. The patient was an African woman with very large
thighs. More than 40 years has passed since that rst presentation. Liposuction
underwent many changes. Many were only a change of name by the machine manufacturers for their marketing purposes. Some of the modications were good and
improved the technique, some were bad, and others were catastrophic. Soon we
would see many doctors without plastic surgery training performing the technique,
believing liposuction to be an easy procedure. It is not. It may be simple in theory,
but it is not an easy surgery.
Introduction
The date of 28 November 1980 is an especially important landmark for Brazilian
plastic surgeons. It was then, in a small side room of a hotel in the city of Fortaleza,
in the northeast of Brazil, that a French surgeon showed a technique with a 16mm
black-and-white lm. The patient was an African woman with very large thighs.
About 6 months before, I had helped my professor, Dr. William Callia, in São
Paulo perform surgery to treat a similar problem, lipodystrophy, on a 16-year-old
girl. The girl had a beautiful gure, but her thighs were thick and out of proportion
to the rest of her body. She couldn’t buy clothes that t. Dr. Callia proposed a radical
surgery, a dermolipectomy, making a vertical incision on the outside of the thighs,
L. S. Toledo (*)
Dubai, United Arab Emirates
Lisbon, Portugal
Switzerland AG 2023
J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_29
435© The Author(s), under exclusive license to Springer Nature
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from the hips to the knees. He removed a fuse of fat about 50cm long by 15cm
wide at the widest part, weighing more than 1kg on each side. The scar, despite
having been sutured with very ne threads and being practically invisible, remained
forever. The result was good, and the girl was satised, as there was no other solution. But I already knew that I would never perform this technique.
When the French surgeon’s lm started, we were about 50 attendees in a small
side room, while the other 500 were in the main room, watching other presentations
of the Brazilian Congress of Plastic Surgery. It was a magical moment, in which all
the plastic surgeons present were able to see for the rst time Dr. Yves-Gèrard Illouz
demonstrate a technique that would later become known as liposuction. When we
watched fat being aspirated from the patient’s thighs through a 1cm incision, passing through a clear plastic tube, and being deposited in a glass vial, the audience
could not believe what they were seeing. Here was the solution to a series of previously insoluble problems. Illouz was widely applauded and became the congress
sensation, having to explain his technique several times. I felt I was witnessing a
change in all elds of plastic surgery, which after that day splits into before and after
liposuction.
More than 40 years has passed since that rst presentation. Liposuction underwent many changes. Many were only a change of name by the machine manufacturers for their marketing purposes. Some of the modications were good and improved
the technique, some were bad, and others were catastrophic. Soon we would see
many doctors without plastic surgery training performing the technique, believing
liposuction to be an easy procedure. It is not. It may be simple in theory, but it is not
an easy surgery. And I heard Illouz many times say in his heavy French-accented
English “It is not easy to make simple!”
L. S. Toledo
History
The rst closed lipectomy was shown by Joseph Schrudde (Schrudde 1972), a
German plastic surgeon in 1972 at the rst ISAPS Congress in Rio de Janeiro. He
used a curette to remove fat through a small incision. The technique caused many
problems, such as delayed healing, seromas, and hematomas, and was abandoned.
In Italy, in 1977 (Fischer and Fischer 1977), Arpad and Giorgio Fischer, father and
son, devised what they called the planatome, a suction cannula with an internal cutting mechanism inside, connected to an aspirator. In 1975, Raymond Vilain (Vilain
1975) in France started using a curette to remove fat from the medial knee through
a small incision. The next technique for the removal of excessive local deposits and
subcutaneous fat using the curette was in 1978, by Ulrich “Uri” Kesselring and
Rudolph “Rudy” Meyer from Switzerland (Kesselring and Meyer 1978). Bahman
“Buck” Teimourian was the rst American to use suction curettage in 1981 to
remove excess fat for body contouring (Temourian and Fisher 1981). All these early
attempts were unsuccessful, and it was only when Illouz developed the aspiration of
29 Critical Analysis andtheFuture ofLiposuction forBody Contouring
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fat with a blunt cannula that the technique became reproducible. Illouz’s rst publication was in 1980in a French journal (Illouz 1980a).
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Liposuction
I had witnessed something very important that would change many techniques.
Realizing the impact of Illouz’s discovery, I quickly bought the aspirator and cannulas, becoming one of the pioneers in the use of this technique in Brazil. At this
time, I started working on the board of the Brazilian Society of Plastic Surgery,
whose dynamic young president, Juarez Avelar, decided to organize symposia with
live surgery, with Illouz (Illouz 1983a) and another pioneering French surgeon,
Pierre Fournier (Fournier and Illouz 1984). In addition to helping organize the
events, I took the opportunity to learn and discuss the details of the surgery with
them both. But France would have even more surprises, with the fat grafting technique. In 1986, Juarez Avelar published together with Illouz the rst Brazilian textbook on liposuction, emphasizing the pinch test to avoid abdominal perforation
(Avelar 1986).
Illouz presented his technique for the rst time in the United States at the end of
1982, at the ASPS Congress in Hawaii. The Americans were so impressed that they
formed a “Blue Ribbon” Committee, with Simon Fredericks as president, to go to
Paris, watch Illouz operate, and investigate the validity of the technique. Many
members of this committee immediately bought the equipment in Paris and became
advocates of the technique when they returned to the United States. A new society
was formed by Gregory Hetter to teach liposuction to the American surgeons, the
LSNA, the Lipoplasty Society of North America.
Nomenclature
Lipoplasty is the generic term for surgical correction of lipodystrophy. There are
two types of lipoplasty: Liposuction is the surgical procedure in which fat excess is
aspirated manually or mechanically with aesthetic purposes. Liposculpture is the
aesthetic procedure to improve the facial and body contour through aspiration and
injection of fat obtained from the same individual.
Anesthesia
Illouz in the early 1980s used local inltration, a hypotonic solution alone or combined with epidural or general anesthesia (Illouz 1980b). In 1983, Fournier introduced the dry technique for lipoplasty, aspiration without any inltration, under
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L. S. Toledo
epidural or general anesthesia. The dry technique had no uids injected into the
tissues and resulted in 20–45% blood loss (Drake etal. 1991). Hetter was the rst to
add epinephrine to the Illouz formula in 1984 to decrease bleeding (Hetter 1984).
In January 1998, the ASAPS Lipoplasty Task Force showed the main factors that
increase risk in lipoplasty. There was no mention of the potential problems caused
by hypothermia, so we published a review of the effects of hypothermia during
liposuction (Toledo etal. 2001). Hypothermia is responsible for a series of harmful
effects to the patient, trembling and shivering, provoking an excessive consumption
of oxygen, hypoxemia and intense discomfort, and signicant alterations of
hemostasis.
In 1984, Fournier had started using external cryoanesthesia (Fournier 1984), by
placing ice bags on the skin surface, combined with sedation. In 1991, Fournier
used internal cryoanesthesia (Fournier 1991), injecting the tumescent uid at 4
°C.The use of a 4 °C solution aggravates the hypothermia normally associated with
this procedure. Possible complications can be arrhythmia, heart attack and hypertension, prolongation of the effect of several anesthetic drugs, trembling and shivering, excessive consumption of oxygen, hypoxemia and intense discomfort, acidosis
and hydro-electrolytic alterations, and alteration of coagulation. There is also evidence that intra-operative hypothermia is associated with the higher incidence of
infection of the surgical wound. When we increased the temperature of inltrated
uid to body temperature, we noticed an improvement in the safety of the procedure
and a better postoperative recovery. Just by using a combination of tumescent technique with adrenaline at 37 °C, there is practically no bleeding. There is no need for
hypothermia.
In 1987, Klein introduced the tumescent anesthesia (Klein 1987), with small
doses of lidocaine, adrenaline, and saline. The tumescent technique produced a dramatic reduction in blood loss due to vasoconstriction of the area to be treated. In
1992, I felt the Klein formula was not strong enough to ensure a painless procedure,
so I doubled the lidocaine. Since I injected most of the fat I aspirated, I changed
saline to Ringer’s lactate to better preserve the fat cells. I changed the formula to
Ringer’s lactate 500 ml, lidocaine 2% 20 ml, adrenaline 1:1000 1 ml, and sodium
bicarbonate 3% 5 ml, injected at body temperature, in the proportion 1:1 (Toledo
1992a), i.e., 1 cc of uid injected per 1 cc of aspirated fat, to avoid pulmonary
edema and lidocaine overdoses. The tumescent state is reached when palpation
shows a typical tension of the injected area. The injection at body temperature, circa
37 °C, avoids hypothermia and postoperative shivering. All measures that maintain
physiologic temperature should be encouraged: the use of intravenous solutions
warmed at 37 °C, the use of local inltration uids warmed at 37 °C, maintenance
of the operating room temperature at acceptable levels, and the use of skin surface
air warming systems intra-operatively and immediate postoperatively (Hohn etal.
1998). In 2001, we published our study on the effect of hypothermia on coagulation
and its implications for inltration in lipoplasty.
I always worked with an anesthesiologist present who would administer either
sedation or general anesthesia, combined with the tumescence (Toledo 1990a). The
patient is monitored, and the anesthesiologist starts the sedation with midazolam
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Fig. 29.1 DVT prevention
with sequential
compression boots and
stockings
439
and fentanyl. Midazolam is used in the initial doses of 0.1 mg/kg IV up to a total
dose of 0.3 mg/kg, according to the surgical procedure. Fentanyl is used at 50 μg/
kg, slowly. Although the respiratory depression is very low with midazolam, it is
necessary to have all the conditions to ventilate the patient, especially when fentanyl
is utilized. Midazolam’s action is antagonized with Lanexate (umazenil) in variable doses from 0.2 to 1.0mg IV.Propofol is used in sub-doses of 15–30 mcg/kg/min.
The advent of the tumescent technique increased the safety in lipoplasty, not only
due to the decrease of peak plasma lidocaine concentrations and, consequently, drug
toxicity but also to the reduction of blood loss. Studies show that for each 1000ml
of fat removed, 9.7ml of whole blood was suctioned (Klein 1993). The tumescent
technique is an exceptionally safe method of liposuction, which eliminates the
necessity of blood transfusions. It is safer than liposuction under only general anesthesia, or epidural alone, and results in fewer complications (Hanke etal. 1995). To
avoid the risk of DVT, we use sequential compression massaging boots intra-operatively (Fig.29.1). Drug prevention of DVT is done with Fraxiparine (7500 UI/day)
or Clexane (enoxaparin) (20–40 mg/day).
Instruments
Many companies produce aspirators today. Byron was one of the rst companies in
the United States and Richter in Brazil. Illouz’s rst cannulas were 1cm gauge
(Fig.29.2), very thick for any rened work. We soon had cannulas of various lengths
and gauges, according to the areas to be treated. The cannula tips, which initially
were blunt, with one lateral hole started being modied. Grazer designed what he
called the Mercedes tip, with three holes, and Hilton Becker designed a modication of the Mercedes, with a small “cage” at the tip, to aspirate brous tissue
(Fig.29.3). In 1988, I realized we needed an instrument to break the retinacula cutis
and improve cellulite, release scars, and break brous adherences from previous
liposuction. I designed the V-tip cannula, which became known as the Toledo cannula (Toledo 1992b). It was produced by many companies, in various lengths and
gauges, depending on the area to be used (Fig.29.4).
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Fig. 29.2 Yves-Gèrard
Illouz with one of the rst
liposuction 10mm gauge
cannulas
L. S. Toledo
Fig. 29.3 Cannulas were
modied. (Left) An
anesthesia inltration
3mm gauge with multiple
holes. (Center) A “pyramid
tip” cannula with three
holes. (Right) The Hilton
Becker “basket” cannula to
aspirate difcult brotic
areas
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Fig. 29.4 The Toledo
V-tip cannula to treat
“cellulite” and scars and
liposuction sequelae. The
tips of the V are blunt, and
the inside is cutting
441
Although working with the syringe was a simple and cheap method, many surgeons decided to continue using the aspirator. This posed a problem when aspirated
fat had to be reinjected. It was easy with the syringe. You could just decant it for
10min or centrifuge for 1min at 1500rpm. Together with Alberto Hodara, a plastic
surgeon from Porto Alegre in Brazil, we designed a simple manual centrifuge to use
with different size syringes, up to 60ml (Fig.29.5). I showed this simple device in
my teaching courses, but soon it was forbidden to be used in the United States,
because safety measures needed it to be totally covered. Today, I see many variations of that machine produced by many different international companies. But if
you were using an aspirator to obtain fat, the only way to avoid fat contamination
was to attach a sterile second vial to collect fat for reinjection. So, the industry kept
producing new devices to aspirate, collect, decant, centrifuge, and inject fat.
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Fig. 29.5 The manual
centrifuge. It can hold
10–60ml syringes. It
should be used at 1500rpm
for 1 minute to separate the
fat from the anesthesia
uid without breaking the
fat cell membrane
L. S. Toledo
Fat Grafting
In 1983, Illouz (Illouz 1983b) and Fournier (Fournier 1985) began to graft the aspirated fat. Fournier called the new technique liposculpture. By aspirating and injecting fat, it was now possible to “sculpt” the patient’s body. Between 1985 and 1986,
I operated, with my associate Paulo Matsudo, over 200 cases of liposuction with fat
grafting. Our results were presented in 1987 (Matsudo and Toledo 1987) and published in 1988 (Matsudo and Toledo 1988). We were aspirating and injecting fat
from several areas of the body and face. We would also reduce breasts with a combination of liposuction and periareolar incision (Toledo and Matsudo 1989).
Syringe Liposculpture
Pierre Fournier demonstrated for the rst time that it was possible to aspirate fat
with a syringe (Fournier 1987). He discovered this by accident, when giving himself
an injection and when he pulled the plunger, fat entered the syringe. In 1985, we
were using only 10ml syringes and 3mm gauge cannulas to aspirate the neck and
the face and reinjecting fat into depressions and folds. In 1988, the next step was to
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