Atlas of Liposuction Adrien E Aiache, Melvin A Shiffman
INDEX
×
Chapter Notes

Save Clear

History of Liposuction1

Melvin A Shiffman

ABSTRACT

The history of how liposuction developed and progressed allows the surgeon to see what the problems were and understand how they were solved. This is necessary to be able to develop further improvements in the future. The author will follow the changes in fat removal, step by step, so that the liposuction surgeons can understand how to avoid the problems that have been resolved by improved instruments and techniques.
 
Introduction
The liposuction surgeon should be able to adjust to new developments and improve his/her own technique.
 
History
Dujarrier (1921)1 reported a case of using a sharp curette to remove fat of calves and knees that resulted in blood vessel injury, and necessitated amputation. Pangman2 performed curettement of the submental fat using a small uterine curette in 1940s.3 Schrudde used a sharp curette to remove fat through small incisions.4 The technique resulted in complications including bleeding and seromas.5,6 Vilain curetted fat in the medial knee through a small incision with good results.7,8 Kesselring developed a metal suction cannula designed like a ski that was attached to a low vacuum pump (0.5 atm) and was used only for the trochanteric area.9 The fat was shaved out in a modified curette fashion. Teimourian and Fisher (1981)10 produced an instrument from a fascia lata stripper that was similar to the curette used by Kesselring. Early removal of abnormal fat deposits was performed by surgical excision trying to keep the resultant scar in a line or fold of the body.11
 
Liposuction
The concept of reducing fat deposits without leaving large scars was started by Arpad and Giorgio Fischer in 1972, and by 1974, a prototype machine called the cellusuctiotome (Fischer G, personal communication, September 13, 2008) (Figures 1-1A to D) was developed. This device was a motor-driven cannula with a rotating cylinder inside which was used to cut fat and was connected to a suction machine.
The cutting cylinder inside the cannula could be used by pressing a lever. Fischer, in 1975 and 1976, reported utilizing a 5 mm incision to remove fat with suction using a blunt hollow cannula to aspirate subcutaneous fat.13,14 The cellusuctiotome was produced in a portable and a nonportable form.15 There were complications such as hematoma, seroma and pseudobursa, reported in 1977.16 The Fischers can be credited with other developments such as tunneling and the use of cross-tunneling technique, in which the fat is aspirated from multiple entry sites.
2
zoom view
FIGURES 1-1A TO D: (A) First prototype suction machine with a motor-driven cannula; (B) Second prototype motor suction machine; (C) Motor-driven cannula with cutting and rotating cylinder inside; (D) When thumb released there is no aspiration(Courtesy: Giorgio Fischer)
The planatome was brought into use in 1977 for trying to solve the problem of skin irregularities due to blunt liposculpturing (Figure 1-2).17 The planatome dissector created a layer of adipose tissue 8–13 mm thick under the skin and regular liposuction was used for the deeper layers using a guide.15 In 1982, a guided cannula was produced with a second overlying slide that moved over the surface of the skin, while the suction cannula worked at a depth of 1.5 cm.12 At the same time, the swan-neck cannula was developed to make it easier for the surgeon to maintain a constant depth in the fatty layer12 (Figure 1-3).
Fischer introduced liposuction at Fournier's clinic in 1977 (Figure 1-4). Illouz, having seen the technique at Dr Fournier's clinic, favored a “wet technique”, in which hypotonic saline combined with hyaluronidase was infiltrated into the adipose tissue prior to suction removal.18
zoom view
FIGURE 1-2: The planatome(Courtesy: Giorgio Fischer)
He felt this would reduce trauma and decrease bleeding. He mistakenly thought that the solution ruptured the fat cells. His techniques also included the use of the Karman cannula and abortion suction machine.
3
zoom view
FIGURE 1-3: Swan-neck cannula and guided cannula (first prototype)(Courtesy: Giorgio Fischer)
zoom view
FIGURE 1-4: Clinic where the first liposuction operation was performed with Fournier in 1977(Courtesy: Giorgio Fischer)
Fournier developed the syringe technique of liposuction19,20 that reduced bleeding and prevented indentations.
Gasparotti and Toledo21-24 championed the technique of superficial liposuction to smooth out excess fat and to improve skin retraction.
Orthostatic liposuction was originated in 1990s by Fischer; in order to perform liposuction more accurately with the patient in a standing position.25 He developed a table, that could bring the patient from supine position to an upright position. This allowed reversing the table to supine position, if the patient became dizzy or fainted.
Variations in instrumentation have also been developed. Ultrasonic liposuction was introduced by Zocchi.26 The concept was that adipose cells could be treated with ultrasound energy, presumably breaking up their cell walls and facilitating fat aspiration. The American Society of Plastic and Reconstructive Surgery quickly adopted ultrasonic liposuction; however, over time, problems were found with this technique. Internal ultrasound (ultrasound tips contained within cannulas) increased the risk of cutaneous burns and seroma formation.
Newer powered liposuction devices have been developed using reciprocating cannulas that facilitate the fat removal and decrease the work of the surgeon. Powered liposuction devices are largely electrically operated but some air-driven devices are also available.27 There is an increase in the rate of fat harvesting and the ease of use. Powered liposuction is particularly useful for difficult fibro-fatty areas such as male pseudogynecomastia or male love handles.
Elam proposed lower vacuum pressure that is successful in preventing or reducing bleeding during liposuction.28
External percussion massage-assisted liposuction was reported in 2005,29 as a substitute for expensive devices for emulsifying fat and making liposuction easier. The $30.00 double-headed massager caused emulsification of the fat.
The earliest book on liposuction was written by Morgan and Berkowitz (1984),29 and this was followed by later books.19,20,24,30-39
Guidelines of care for liposuction were approved by the American Academy of Dermatology in 1989 and were published in 1991.40 Additional guidelines of care for liposuction were published by the American Academy of Cosmetic Surgery, the American Society for Dermatologic Surgery in 2000,41 the American Academy of Dermatology in 200142 and the Indian Academy of Dermatology, Venereology and Leprology in 2008.43
 
Tumescent Technique
In the early days of liposuction, the dry technique was used with general anesthesia. The technique used had no fluids injected into the tissues and resulted in 20% to 45% blood loss.40,43-47 Liposuction was limited to 2,000–3,000 ml because of the blood loss and patients were frequently given transfusions.44
The wet technique relies on infusions of 100–300 ml of normal saline into each site but has blood loss of 15% to 30%.48-52 With epinephrine added to the fluid, the blood loss is reduced to 20% to 25%.
4The tumescent technique has improved the problem of blood loss reducing it to 1% to 7.8%.53-55 The term “superwet anesthesia” has been used to describe the same fluid injection as with the tumescent technique.56 This technique consists of an infusion of saline with epinephrine and an aspirate removal of approximately 1:1. Local tumescent anesthesia usually has a fluid infusion to aspirate ratio of 2:1 or 3:1.
 
Local Tumescent Anesthesia
There appears to be much confusion in the medical literature concerning Klein's solution. No one is certain as to what the so-called Klein's solution contains and what a modification of Klein's solution is.
Klein first reported the use of local tumescent anesthesia in 1987.57 The report described solutions used that consisted of:
  • For general anesthesia:
    • Normal saline: 1,000 ml
    • Epinephrine: 1 mg
  • For local tumescent anesthesia:
    • Normal saline: 1,000 ml
    • Epinephrine: 1 mg
    • Lidocaine: 1,000 mg
The amount of tumescent solution compared to removal of aspirate was 1:1. This is Klein's solution and all the rest are modifications.
Klein, in 1990,58 showed that 35 mg/kg was a safe amount of lidocaine to be used for local tumescent anesthesia. The solution utilized at that time consisted of:
  • Normal saline: 1,000 ml
  • Epinephrine: 1 mg
  • Lidocaine: 500 mg
  • Sodium bicarbonate: 12.5 mEq
Klein, in 1993,54 had changed the local tumescent anesthesia solution to:
  • Normal saline: 1,000 ml
  • Epinephrine: 0.5 to 0.75 mg
  • Lidocaine: 500 to 1,000 mg
  • Sodium bicarbonate: 10 mEq
  • Triamcinolone: 10 mg (optional)
The mean tumescent solution compared to total aspirate was 4609 ml: 2657 ml or almost 2:1.
By 1995, Klein59 had changed the tumescent formula to:
  • Normal saline: 1,000 ml
  • Epinephrine: 0.5 to 0.65 mg
  • Lidocaine: 500 to 1,000 mg
  • Sodium bicarbonate: 10 mEq
  • Triamcinolone: 10 mg
In 2000, Klein60 described a variation of drugs, in the local tumescent solution, according to the area being liposuctioned. The basic solution to be changed after checking for anesthesia completeness was:
  • Normal saline: 1,000 ml
  • Lidocaine: 500 mg
  • Epinephrine: 0.5 mg
  • Sodium bicarbonate: 19 mEq
If the anesthesia was not adequate then a variety of formulations were proposed for each area of the body and ranged from lidocaine of 750 mg to 1,500 mg, epinephrine from 0.5 mg to 1.5 mg,54,56-65 and sodium bicarbonate of 10 mEq.
Local tumescent anesthesia is used as the anesthetic for performing liposuction, especially with small cannulas (microcannulas). The same fluid can be used with conscious sedation to provide the necessary local anesthesia.
Ostad (1991)66 proposed that the maximum safe tumescent lidocaine dosage was 55 mg/kg.
Gross et al (1995)67 introduced a soft tissue shaving cannula that shaves the fat in an open fashion under direct vision.
References
  1. Grazer FM. Historical perspective. In: Grazer FM (Ed). Atlas of Suction-assisted Lipectomy in Body Contouring. Churchill Livingstone;  New York:  1992. pp. 1-4.
  1. Pangman WJ 2nd, Wallace RM. Cosmetic surgery of the face and neck. Plast Reconstr Surg Transplant Bull. 1961;27:544-50.
  1. Gurdin M. Personal communication. In: Grazer FM (Ed). Atlas of Suction-assisted Lipectomy in Body Contouring. Churchill Livingstone;  New York:  1992.
  1. Schrudde J. Lipexeresis in the correction of local adiposity. Rio de Janeiro: Proceedings of the First Congress of the International Society of Aesthetic Plastic Surgery; 1972.
  1. Flynn TC, Coleman WP 2nd, Field LM, et al. History of liposuction. Dermatol Surg. 2000;26:515-20.
  1. Dolsky RL, Newman J, Fetzek JR, et al. Liposuction history, techniques, and complications. Dermatol Clin. 1987;5:313-33.
  1. Vilain R. Surgical correction of steatomeries. Clin Plast Surg. 1975;2:467-70.
  1. Vilain R. In: Illouz YG, DeVillers YT (Eds). Body Sculpturing by Lipoplasty. Churchill Livingstone;  Edinburgh:  1989. pp. 9-17.
  1. Kesselring UK, Meyer R. A suction curette for removal of excessive local deposits of subcutaneous fat. Plast Reconstr Surg. 1978;62:305-6.
  1. Teimourian B, Fisher JB. Suction curettage to remove excess fat for body contouring. Plast Reconstr Surg. 1981;68:50-8.
  1. Pitanguy I. Trochanteric lipodystrophy. Plast Reconstr Surg. 1964;34;280-6.5
  1. Fischer G. Personal communication September 13, 2008.
  1. Fischer G. Surgical treatment of cellulitis. Rome, Italy; Third Congress International Academy of Cosmetic Surgery; 1975.
  1. Fischer G. First surgical treatment for modeling body's cellulite with three 5 mm incisions. Bull Int Acad Cosm Surg. 1976;2:35-7.
  1. Fischer G. History of my procedure, the harpstring technique and the sterile fat safety box. In: Fournier PF (Ed). Liposculpture: The Syringe Technique. Arnette;  Paris:  1991. pp. 9-21.
  1. Fischer A, Maurice GM. Revised technique for cellulitis fat reduction in riding breeches deformity. Bull Int Acad Cosm Surg. 1977;2:40.
  1. Fischer A, Fischer G. Revised technique for cellulitis fat reduction in riding breeches deformity. Bull Int Acad Cosm Surg. 1977;2:40-3.
  1. Illouz YG. Une nouvelle technique pour les lipodystrophies localisées. Rev Chir Esthet. 1980;4:19.
  1. Fournier P. Body Sculpturing Through Syringe Liposuction and Autologous Fat Reinjection. Samuel Rolf International.  US:  1987.
  1. Fournier PF. Liposculpture: The Syringe Technique. Arnette;  Paris:  1991.
  1. Toledo LS. Superficial syringe liposculpture for the treatment of “cellulite” and liposuction sequelae. Buenos Aires, Argentina; Presented at the International Symposium: Recent Advances in Plastic Surgery; June 1989.
  1. Gasparotti M. Superficial liposuction for flaccid skin patients. In: Toledo LS (Ed). Sao Paulo, Brazil: Annals of the II International Symposium: Recent Advances in Plastic Surgery; March 1990. p. 443.
  1. Gasparotti M. Superficial liposuction: a new application of the technique for aged and flaccid skin. Aesth Plast Surg. 1992;16:141-53.
  1. Gasparotti M, Lewis CM, Toledo LS. Superficial Liposculpture: Manual of Technique, Springer-Verlag;  New York:  1993.
  1. Fischer G. Orthostatic liposculpture. In: Shiffman MA, Di Giuseppe A (Eds). Liposuction: Principles and Practice. Springer;  Berlin:  2006. pp. 217-21.
  1. Zocchi M. Ultrasonic liposculpturing. Aesthetic Plast Surg. 1992;16:287-98.
  1. Coleman WP 3rd. Powered liposuction. Dermatol Surg. 2000;26:315-8.
  1. Elam MV, Packer D, Schwab J. Reduced negative pressure liposuction (RNPL): Could less be more? Int J Aesthetic Restor Surg. 1997;5:101-4.
  1. Mirrafati S: Vibrotumescent liposuction of the abdominal wall. In: Shiffman MA, Mirrafati S (Eds). Aesthetic Surgery of the Abdominal Wall. Springer-Verlag;  Berlin:  2005. pp. 177-81.
  1. Morgan WR, Berkowitz F. Body Sculpture: A Guide to Permanent Fat Removal, Premier Publishing Co.;  Anaheim, California;  1984.
  1. Illouz YG, deVillers YT. Body Sculpting by Lipoplasty. Churchill Livingstone;  Edinburg;  1989.
  1. Grazer FM. Atlas of Suction Assisted Lipectomy in Body Contouring. Churchill Livingstone;  New York;  1992.
  1. Pitman GH. Liposuction & Aesthetic Surgery. Quality Medical Publishing Inc.;  St. Louis;  1993.
  1. Cook WR Jr, Cook KK. Manual of Tumescent Liposculpture and Laser Cosmetic Surgery. Lippincott Williams & Wilkins;  Philadelphia:  1999.
  1. Klein JA. Tumescent Technique: Tumescent Anesthesia & Microcannular Liposuction. Mosby;  St. Louis:  2000.
  1. Narins RS. Safe Liposuction and Fat Transfer. Marcel Dekker Inc.;  New York:  2003.
  1. Wilkinson TS, Paradise LA. Atlas of Liposuction. Elsevier Saunders;  Philadelphia:  2005.
  1. Hanke CW, Sattler G. Liposuction. Elsevier Saunders;  Philadelphia:  2005.
  1. Shiffman MA, Di Giuseppe A. Liposuction: Principles and Practice. Springer;  Berlin:  2006.
  1. Drake LA, Ceilley RI, Cornelison RL, et al. Guidelines of care for liposuction. Committee on Guidelines of Care. J Am Acad Dermatol. 1991;24:489-94.
  1. Lawrence N, Clark RE, Flynn TC, et al. American Society for Dermatologic Surgery Guidelines of Care for Liposuction. Dermatol Surg. 2000;26:265-9.
  1. Coleman WP 3rd, Glogau RG, Klein JA, et al. American Academy of Dermatology Guidelines/Outcomes Committee. J Am Acad Dermatol. 2001;45:438-47.
  1. Mysore V. IADVL Dermatosurgery Task Force. Tumescent liposuction: standard guidelines of care. Indian J Dermatol Venereol Leprol. 2008;74 Suppl:S54-60.
  1. Dillerud E. Suction lipoplasty: a report on complications, undesired results, and patient satisfaction based on 3511 procedures. Plast Reconstr Surg. 1991;88:239-46.
  1. Courtiss EH, Choucair RJ, Donelan MB. Large-volume suction lipectomy: an analysis of 108 patients. Plast Reconstr Surg. 1992;89:1068-79.
  1. Ersek RA. Severe and mortal complications. In: Hetter GP (Ed). Lipoplasty: The Theory and Practice of Blunt Suction Lipectomy, 2nd edition. Little Brown;  Boston:  1990. pp. 223-5.
  1. Hetter GP. Blood and fluid replacement for lipoplasty procedures. Clin Plast Surg. 1989;16:245-8.
  1. Courtiss EH, Kanter MA, Kanter WR, et al. The effect of epinephrine on blood loss during suction lipectomy. Plast Reconstr Surg. 1991;88:801-3.
  1. Goodpasture JC, Bunkis J. Quantitative analysis of blood and fat in suction lipectomy aspirates. Plast Reconstr Surg. 1986;78:765-72.
  1. Gargan TJ, Courtiss EH. The risks of suction lipectomy: Their prevention and treatment. Clin Plast Surg. 1984;11:457-63.
  1. Clayton DN, Clayton JN, Lindley TS, et al. Large volume lipoplasty. Clin Plast Surg. 1989;16:305-12.
  1. Dolsky RL. Blood loss during liposuction. Dermatol Clin. 1990;8:463-8.
  1. Hetter GP. Blood and fluid replacement. In: Hetter GP (Ed). Lipoplasty: The Theory and Practice of Blunt Suction Lipectomy, 2nd edition. Little Brown;  Boston:  1990. pp. 191-5.
  1. Klein JA. Tumescent technique for local anesthesia improves safety in large-volume liposuction. Plast Reconstr Surg. 1993;92:1085-98.
  1. Pitman GH. Tumescent liposuction: operative technique. Oper Tech Plast Reconstr Surg. 1996;3:88-93.
  1. Matarasso A. Superwet anesthesia defines large-volume liposuction. Aesthet Surg J. 1997;17:358-64.
  1. Klein JA. The tumescent technique for liposuction. Am J Cosm Surg. 1987;4:263-7.6
  1. Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol 1990;16(3):248-63.
  1. Klein JA. Tumescent technique chronicles: Local anesthesia, liposuction, and beyond. Dermatol Surg. 1995;21:449-57.
  1. Klein JA. Tumescent formulation. In: Klein JA (Ed). Tumescent Technique: Tumescent Anesthesia & Microcannular Liposuction. Mosby;  St. Louis:  2000. pp. 187-95.
  1. Greco RJ. Massive liposuction in the moderately obese patients: a preliminary study. Aesthet Surg J. 1997;17:87-90.
  1. Hanke CW, Bernstein G, Bullock S. Safety of tumescent liposuction in 15,336 patients. National survey results. Dermatol Surg. 1995;21:459-62.
  1. Kaplan B, Moy RL. Comparison of room temperature and warmed local anesthetic solution for tumescent liposuction: A randomized double-blind study. Dermatol Surg. 1996;22:707-9.
  1. Lillis PJ. Tumescent technique for liposuction surgery. Dermatol Clin. 1990;8:439-50.
  1. Matarasso A. Superwet anesthesia redefines large-volume liposuction. Aesthet Surg J. 1997;17:358-64.
  1. Ostad A, Kageyama N, Moy RL. Tumescent anesthesia with a lidocaine dose of 55 mg/kg is safe for liposuction. Dermatol Surg. 1996;22:921-7.
  1. Gross CW, Becker DG, Lindsey WH, et al. The soft-tissue shaving procedure for removal of adipose tissue. A new, less traumatic approach than liposuction. Arch Otolaryngol Head Neck Surg. 1995;121:1117-20.