Basic Principles of Liposuction
‘Patient is more vital than surgical gimmicks’
Liposuction has been one of the commonly performed procedures in cosmetic surgery since its proposition by Dr Yves-Gerard Illouz in 1978. Over years, technical modifications of the type of instrument used have undergone metamorphosis. But the basic principles of liposuction remain the same since its safe practice.
With evolution of the speciality many accessory uses of it have been proposed. Some have found their way in everyday practice, while others have met its inevitable death. Those that survived, were based on adhering to the basic principles. Those that died its natural death were disregarding them. In that light, with the ongoing evolution, it is imperative to take a closer look at its basic principles.
Before implementation of any technique in medical practice it is essential to analyse its safety before embarking on it. More so, to remember it, in the process of evolution. No technique, however modern it may seem, is worth, if it compromises the safety of the patient.
In any cosmetic procedure, the first and foremost is clarity of communication. This can be achieved only by proper evaluation, indication and valuation of the expectations of the patient. If the doctor can envisage the expectations of the patient, deal with it realistically, then only can patient satisfaction be attained. Unrealistic hopes should be dealt with sternly than commercially. Most litigations occur when the cosmetic surgeon fails to live up to patient expectations. If it is beyond realistic limits, it is better not to operate. At the same time the doctors must ensure the patient is committed to lifelong healthy eating and exercising.
I prefer to carry out the procedure under general anaesthesia. A pre-operative anaesthetic evaluation is mandatory with appropriate intra-operative monitoring. Some prefer to carry it out under local anaesthesia. My British mentor humorously remarked “Local anaesthesia involves all the components of general anaesthesia without intubation”. On a serious note, if that path is chosen, patient positioning, intra-operative monitoring is vital for safety of the patient. An operating surgeon is not the best person to play a dual role. The presence of an anaesthetist or intensivist decreases the intra-operative risk.
Fluid monitoring is of utmost importance, both intra-operatively as well as post-operatively. Both dry and wet technique can be used. Dr Yves-Gerard Illouz, one of the pioneers of wet liposuction while teaching us, sarcastically said “Either you make the patient sweat or you sweat”. I prefer the former. Where wetting solutions are used and especially on large areas, fluid monitoring and management is mandatory. In such cases, the patient should never be operated as a day case. Overnight fluid monitoring is a must for safety of the patient.
Expertise in the technique is mandatory for a satisfactory outcome. The depth of cannula insertion is vital to keep a layer of padding between the skin and the cannula. Failure to do so may result in irregularities in contour. I use my left-hand fingers to palpate the depth between the two, while the right hand performs the procedure. This depth must be uniformly maintained to prevent irregularities. It is pointless losing the plane, overdoing it and then supplanting it with fat injection. All to prove the inexperience of the surgeon. Failure to maintain the depth may lead to catastrophes as skin necrosis, a very rare complication of the procedure. It happens when the surgeon is less experienced.
The success of liposuction does not end with sending home the patient safely. The surgeon must ensure post-operative instructions are meticulously followed especially the use of pressure garments. If the dead space is not obliterated, chances of haematoma, fluid collection, seromas, contour irregularities may lead to less satisfactory result. Patient must understand the success of a procedure is on conjoint effort than a solitary one.
No matter what other’s views might be, let me emphasise, liposuction is a procedure of localised removal of fat and not for correction of obesity. The chart below highlights the areas of liposuction.
Liposuction also does not correct obesity due to metabolic disorders as well. I maintain 3 litres to be the maximum amount of fat, the patient can have removed at one go. If there is error of judgement and more fat removal is warranted, it can be done at a second sitting 4-5 days later, but never at one go. It may be used as an adjuvant to some other procedure, but in no way a replacement for it. People have used liposuction for correction of gynaecomastia. Breast is a fibro fatty glandular organ. Liposuction removes only the fat, not the fibrous and glandular component. Hence, in spite of success claims, it is not scientific and does not replace the correction of gynaecomastia.
Whatever instrument is used for liposuction, primary safety is vital. This involves the use of the right cannula, whether it is adequate to cover the area desired. If any accessory punctures are essential they should be in concealed areas if possible. You never know, which scar will turn hypertrophic! The elastic recoil of the skin should be carefully assessed. In older patients or those with elastic skin, liposuction can leave sagging skin even after correct techniques. For them, skin correction should be advised along with the procedure. The incisions can be closed by non-absorbable suture. Some surgeons prefer to leave it open for the excess fluid to drain out. My anaesthetist uses this solution for infiltration in wet liposuction.
1 litre of Normal Saline
2 ml of Adrenaline
50 ml of Sodium Bicarbonate
The problems arise when lidocaine is used as a part of local anaesthesia. In super-wet or tumescent technique under local anaesthesia, to keep the patient at ease, sometimes mistakenly high concentration of lidocaine is inadvertently injected. Maximum permissible dose is 35mg/kg body weight. It may be too much for the patient’s system leading to tingling and numbness, followed by seizures, ultimately leading to unconsciousness and cardio-respiratory arrest. I prefer to carry it under general anaesthesia to avoid these catastrophes. It also gives additional comfort to patient which gives me the mental peace of carrying out the procedure without disturbance.
I use the wet technique. The insertion of cannula at the appropriate level, breaking the locules of fat bluntly by it and subsequently carrying out the liposuction is the procedure of my choice. The aspirate should only contain sucked fat. If there is reddish tinge or blood admixed, the causes could be inadequate infiltration or suction in non-fatty areas. When confronted with it, the inadequacies must be immediately evaluated and appropriate steps taken to correct it.
Some areas of liposuction are difficult. A lovely diagram from one of my teachers Dr. Gottfried Lemperle in Asthetische Chirurge highlights those difficult zones in the chart:
As you see from this figure buttocks are a very difficult zone. Careful pre-operative planning is mandatory for correction of this zone. Before embarking on liposuction, it is worthwhile to assess the degree of ptosis. A lovely chart by Gonzalez classifies it beautifully.
To determine the degree of ptosis the marking is done with the patient in standing position, with straight hips, and facing backwards. The ischial tuberosity is identified by palpation, and from there a vertical line (Line T) is drawn and a second parallel to the first one (Line M) corresponding to the midpoint of the posterior thigh.
Degree 0 No ptosis.
1st Degree Minimal pre-ptosis: Sub-gluteal groove lies between the line T and M.
2nd Degree Moderate pre-ptosis: Sub-gluteal groove reaches the M-line and there is ptotic tissue at line T.
3rd Degree Borderline Ptosis: Sub-gluteal groove goes beyond the M-line, but without ptotic tissue.
4th Degree Real ptosis: Adipose tissue is projected on the thigh. From here on the excess of ptotic tissue is measured in centimetres.
The “Banana Fold” or the so called to the deposit of adipose tissue in the posterior thigh below and parallel to the inferior gluteal groove is not easy place to deal with. This fat deposit is a result of buttocks pressure on the sub-gluteal groove, transmitting that pressure on the posterior thigh fat layer thus creating this fold deformity. This is a major problem. Though different techniques are advised, none have produced satisfactory results.
Beside is a picture of The Bermuda Short Triangle. Its corners are the level of the ischial tuberosities and the upper edge of the inter-gluteal crease.
The patient is pre-operatively marked in standing position. The marking is extended to the adjoining of inter-gluteal and sub-gluteal groove like an L. It is divided into two zones:
- A vertical one parallel to the inter-gluteal groove. Here the liposuction is carried out both in superficial and deep planes. in which the liposuction is done in both deep planes.
- Horizontal one to sub-gluteal groove where the liposuction is done only in the deeper pane to avoid flaccidity and wrinkling of skin.
Two incisions, one located over the sacrum and another one on the trochanteric area at the end of the sub-gluteal groove. Here the tumescent technique is used. A treatment with bipolar Nd: YAG laser or radiofrequency may help in the skin correction. MAST (Manual Assisted Stabilization Tissue) is a very helpful manoeuvre in the procedure. Here the assistant presses the buttock preventing its movement, while the surgeon carries out the liposuction.
The competence of the surgeon is put to test, in liposuction of the Absolute Taboo Zone. There is no alternative to surgical training to master the art of liposuction. The surgeon should undertake to perform the procedure depending on his/her expertise. It is wise to refer to Dr. Gottfried Lemperle’s chart to follow the zones he/she is comfortable with. Mishaps occur when the surgeon crosses his expertise. However, if the basic guidelines are adhered, risk is minimised.
Redo’s of unsatisfactory liposuction, aren’t easy. Especially dealing with the irregularities. Often additional liposuction with autologous fat graft is needed. Often skin tightening reduces the visibility of the defect.
The success of liposuction does not end with performing the procedure. Eventually it is the result obtained and satisfaction of the patient. The choice of the patient for liposuction is vital. Those with body dysmorphic disorder or eating disorders should be avoided even if other indications indicate to a success of the procedure. Surely the surgeon doesn’t deserve to be crucified for a successful surgery leaving an unhappy patient to moan because of unrealistic expectations or dissatisfaction. Liposuction is a team work. In that team, all are equally important. Right from a safe surgeon, a competent anaesthetist, the assistant, appropriate operating milieu, the staff in the operation theatre and above all the patient and his/her safety.
If the basic principles are adhered, which includes adequate pre-operative patient evaluation and planning, intraoperative monitoring and safety, appropriate wetting solutions, intraoperative monitoring, expertise and correct technique, following the guidelines of safe to difficult zones depending on the expertise, prevention of complications, assessment of postoperative results, liposuction is a safe procedure.
Finally, it is better to have a satisfied patient than an ailing one. The surgeon must remember that the patient is prime, not his heroism either for commercial or ego reasons. The eternal quest for perfection is an elusive entity. In liposuction both the patient and the surgeon need to be on the same platform to accept that safety is the key even it slightly compromises on the final outcome.
‘Give me the wisdom to understand the limits without gimmicks’