Suction Lipectomy & Liposuction Toronto

Suction lipectomy liposuction toronto

Superficial SAL

  • 1992 – Gasparotti presented suction of the superficial layer in 2500 patients following traditional deeper SAL
    • Thin cannula, multiple closely spaced tunnels, undermining first without aspiration in neighbouring areas
    • Remaining irregularities smoothed manually
    • Claimed thin cutaneous adipose flap underwent controlled scar retraction
  • 1994 – Gasperoni and Salgarello published massive all – layer aspiration and subdermal defatting ( MALL ) technique
    • Subdermal fat suctioned using 2 mm, 3 – hole Mercedes cannulas
    • Believed to reduce as much thickness as possible and promote effective skin retraction
  • Recommended for treatment of flaccid skin, rippling irregularities following deep aspiration, ‘peau d’orange’ or ‘cottage cheese’ skin deformity (cellulite) according to De Souza Pinto et al., in 1996
    • Favourable sites – posterior neck, jowls, dorsal back rolls, outer thighs, banana roll, abdomen, flanks, lumbar roll, breasts
    • Unfavourable sites – buttocks, inner and outer thighs
  • Degree of skin retraction determined by treatment site, patient age, volume of fat removed, according to Goddio in 1991
  • Matarasso (1995) classified types of lax skin amenable to superficial SAL into groups:
  • Type A: Pseudoptotic – obtain maximum benefit from superficial SAL of neck, dorsal rolls, outer thighs
  • Type B: Cellulitic – respond best to superficial SAL of outer/anterior thighs

Syringe vs Vacuum Aspiration

  • Fournier (1989) and Toledo (1989) independently reported fat aspiration using manual syringe :
    • Correction of superficial contour deformities after SAL
    • Treatment of cellulite or flaccid skin
  • Comparison of syringe to vacuum technique on 6 patients serving as their own control (Lewis, 1991) :
    • Less blood in aspirate, less bruising/morbidity, less trauma with syringe
    • Reduced dead space without vaporizing tissue
  • Mandel (1993) discussed syringe aspiration:
    • Advantages – accurate removal of precise quantities of superficial fat, less blood loss, no vaporization, accelerated patient recovery, less pain, less Surgeon fatigue, quieter O.R. environment
  • Disadvantage – prolonged operating time

Ultrasound – Assisted Liposuction (UAL)

  • What is UAL?
    • Conventional liposuction utilizes mechanical disruption (by the force of moving the cannula) to break up fat lobules, which are then removed with a significant vacuum. In contrast, in ultrasound-assisted liposuction the ultrasonic sound waves are transmitted to the end of a probe (similar in size to a conventional cannula), which cavitates the fat cells, releasing liquid fat that can then be aspired under low pressure.
    • The power to disrupt the fat is provided by the machine, and, therefore, the forces needed to move the cannula become minimal. The movement through tissue becomes a fingertip and fine motor control, in contrast to conventional liposuction in which large muscle forces are necessary. This is a particular advantage when operating in more fibrous areas such as the hip, back, upper abdomen or male chest. Fat cells are more susceptible to the cavitating forces, so that the fat can be selectively removed from fibrous areas with minimal damage to surrounding tissues. Blood vessels are less susceptible as well, so there appears to be less blood loss and bruising.
  • Physics
    • Electrical energy is converted to ultrasonic sound waves through a piezoelectric crystal (which is contained within the handpiece of this instrument). Ultrasound is sound waves above the human audible spectrum (up to 10,000 to 12,000 cycles per second). UAL machines utilize sound waves at 22,000 cycles. These waves are transmitted from the piezoelectric crystal down the probe–or cannula– which is very precisely machined so that the waves form a harmonic and produce a motion at the top of the probe with an amplitude of a few microns, at 22,000 times/second. The surrounding tissue is alternatively compressed and then expanded. The latter produces a localized vacuum which results in dissolved gases producing small bubbles which cavitate or explode the fat cells, which then release the emulsified fat. Other cells that do not contain fat are much more resistant, and fibrous structures (i.e., collagen) are quite resistant. The emulsified fat can easily be removed, and minimal suction is required.
  • Ultrasound = sound waves above the human audible spectrum (10,000 – 22,000 cycles / second)
  • Waves transmitted from piezoelectric crystal in a handpiece down a cannula into subcutaneous tissues
  • Subcutaneous tissue alternately compressed and expanded
    • Expansion produces localized vacuum → dissolved gases cause cavitation ( implosion ) of adipocytes → release of emulsified fat → aspirated
  • Followed by traditional SAL for contouring
  • 1993 – Zocchi published research on ultrasonic energy used to liquefy excess body fat: Solid probe emulsified fat, aspirated with syringe
  • First hollow UAL cannula for applying ultrasound developed by Maxwell (1998), adopted by Fodor (1998) and Rohrich (1998)
  • Kenkel et al. (1998) compared effects of ultrasound to traditional SAL on tissue with a porcine model: UAL aspirate with external protective sheath contained less blood, caused less vascular disruption of treated areas
  • Useful in certain anatomic areas difficult to treat with SAL: Tissue more fibrous,
    • Upper abdomen, back, male flanks, gynecomastia (Tissue more fibrous, compact thus U/S assist in break up)
  • Zocchi (1996) has reported over 1000 cases, with essential precepts:
    • Never apply to dry tissue
    • Never apply energy without motion of probe
  • Superwet technique produces a low – density environment for ultrasound action (Beran and Rohrich, 1998)
  • Different endpoints of complementary procedures:
    • UAL = loss of tissue resistance, blood – tinged aspirate
    • SAL = final contour, pinch test
  • Scheflan and Tazi (1996) and Kloehn (1996) report improved skin contraction with UAL but provide cautions: Steep learning curve !
    • Unique disadvantages / risks – dysesthesias, thermal injury, seromas, contour deformities
    • Common mistake is overtreating – using UAL to final contour
  • UAL procedure is described in 3 stages (Rohrich et al., 1998) :
    • 1. Subcutaneous infiltration of fluids (superwet)
    • 2. Ultrasound emulsification of subcutaneous fat
    • 3. Evacuation of emulsified fat, final contouring (w SAL)
  • Complications avoided by adopting 3 – stage technique, avoid areas prone to hyperpigmentation (medial thigh), treat with UAL < 10 minutes
  • UAL is a complement to traditional SAL, not a replacement
  • ASPS has provided an online resource guide for Surgeons considering practicing UAL
  • Advantages of UAL (Ultrasound Assisted Liposuction ) Compared to Traditional Liposuction:
    • Possible less blood loss in obese patients
    • Less surgeon fatigue in very large fat volume removals
    • Fibrous areas such as the male breast and back are easier to perform with UAL than with a blunt – tipped cannula
  • Disadvantages of UAL (Ultrasound Assisted Liposuction) Compared to Traditional Liposuction:
    • Burns of the skin, hyperpigmentation, seromas more common
    • Longer incisions needed to accommodate skin protection sleeve
    • Longer operating time
    • Greater expense – longer operating time, high cost of equipment, limited life of cannula
  • No Proven Difference Between UAL and Traditional Liposuction:
    • Blood loss in non – obese patients
    • Post – operative bruising / swelling
    • Recovery time
    • Amount of fat that can be removed
    • Shrinkage of skin
    • Surgeon’s ability to contour
    • Smoothness of result
  • Unknown Long – Term Effects of UAL:
    • Ultrasonic energy on the breast gland
    • Fat cell breakdown products

Power – Assisted Liposuction (PAL)

  • Recently introduced technique using traditional cannulas coupled to a power source (compressed nitrogen or electric motor)
  • 600 – 4000 oscillations / minute of cannula, range of motion 2 – 3 mm
  • Advantages of PAL:
    • Cannulas cold (unlike UAL) – small incisions needed
    • Can be bent to shape to contour the area suctioned
    • Reciprocating motion reduces surgeon fatigue in difficult areas of gynecomastia, flanks, back, previously suctioned areas, epigastrium
    • Suction time less than or equal to traditional SAL
  • Disadvantages of PAL:
    • Vibration of handle, slightly increased noise, high equipment costs

Liposuction – Combination Procedures

  • SAL + abdominoplasty Toronto
    • Increased risk of thrombotic and fat embolic complications
    • Concurrent SAL of epigastrium or saddlebags discouraged by Vogt (1989) ; SAL of hip rolls safe
  • Safe zones for SAL with abdominoplasty described by Matarasso (1995) based on remaining blood supply to abdominal wall
    • Lateral and superior areas unrestricted
    • Central medial flap suctioned cautiously
  • Risk factor index proposed for combined abdominoplasty and liposuction (Matarasso, 1995)
  • Illouz (1992) avoids surgical complications by en bloc resection of fatty tissues with no extensive undermining during combined lipoplasty / abdominoplasty Toronto

Liposuction – Specific Applications

  • SAL in Men
    • Abdomen
      • Assess for intraabdominal adipose tissue (SAL ineffective), periumbilical hernias
      • Differential SAL (‘ etching ’) described by Mentz et al. (1993) to enhance male muscular definition
  • Gynecomastia
    • Traditional SAL with 7 mm cannula for adipose, 2.4 mm for glandular and ductal tissue (Rosenberg, 1994)
    • UAL as the sole technique (Zocchi, 1996; Maxwell, 1998)
      • Disruption of inframammary fold
      • Tapering boundaries of treated area
      • Periaerolar excision of fibrotic core beneath nipple
    • Axillary approach possible using long cannula +/ – periaerolar excision (Abramo, 1994)
  • Face
    • Adjunct to rhytidectomy, before or after flap elevation
      • Smallest cannulas, no extension above zygoma (facial nerve)
      • Access via nasolabial crease, postauricular, submental, nasal vestibule or intraoral incisions (Beran and Rohrich, 1998)
    • Grooving and surface irregularities common with SAL alone
  • Neck
    • Neck skin highly retractable, improves up to 2 years postoperatively
      • Retraction better than elsewhere in body (Samdal, 1995; Hughes, 1998)
      • SAL itself may induce formation of elastic fibres during healing (Goddio, 1992)
    • Formation of new platysmal bands reported following SAL (Kamer and Minoli, 1993)
      • Caution advised with redundant cervical skin, mild preop bands, submental obesity, nondecussation of platysma)
  • Upper arms
    • 4 – cannula technique described for SAL through a single incision (Schlesinger, 1990)
    • 3 mm diameter cannulas, different lengths
    • Best candidates <35 years, good skin elasticity, excessive fat in upper arms
    • Circumferential para – axillary superficial tumescent liposuction ( CAST ) technique (Gilliland, 1997)
      • Circumferential treatment enhances skin retraction without brachioplasty scar
  • Breasts
    • Traditional SAL often used to improve lateral contour of breast followin reduction mammaplasty
    • Used preoperatively to complement vertical pedicle technique (Lejour, 1990, 1994)
  • SAL alone for reduction mammaplasty described by Courtiss (1993)
    • Small scars, minimal interference with sensation
    • No need to reposition or reduce diameter of NAC
    • Adjunct to pedicled or free TRAM flap reconstruction (Drever, 1990)
      • Improvement of symmetry or contour, IMF correction as second stage
    • UAL alone for reduction (Zocchi, 1996; Maxwell and White, 1996)
      • Current US recommendations are avoidance in cancer – prone organs until safety proven
  • Thighs and knees
    • Correction of ‘ saddlebags ’ in lateral trochanteric regions is most common
      • Riskier in midthigh region (deep and superficial adipose layers merge)
    • Mladick (1994)
      • Goal is to thin the thigh circumferentially in intermediate layer, rather than limit the correction to defined bulges
    • Small – diameter cannulas through 3 incisions around the knee (Fodor, 1989)
  • Legs
    • Schrudde (1964) was the first to treat fat ankles using sharp curette
    • Field (1984) and Kesselring (1984) warned skin necrosis at the ankle
      • Beware of edema, deep venous incompetency
      • Other complications – peroneal nerve injury, pronounced foot drop
    • Mladick (1990, 1994) describes fat accumulation and incisions for circumferential treatment
  • Other applications (Beran and Rohrich, 1998)
    • Lipomas
      • Benign symmetric lipomatosis (Madelung’s disease) (Apesos and Chami, 1991)
    • Hematomas, fat necrosis
      • Following other surgical procedures, trauma
    • Axillary hyperhidrosis
      • +/ – Endoscopic shave
    • Buffalo humps
    • Lymphedema
    • Flap debulking / defatting

Innovations in Suction Lipectomy

  • Syringe liposculpture
  • Suspension of superficial fascia
  • Combination with excisional procedures
  • Combination with autologous fat grafting

Body Contouring – Suction Lipoplasty References

  • American Society of Plastic Surgery website [www.plasticsurgery.org]
  • Beran SJ and Rohrich RJ, eds, Selected Readings in Plastic Surgery: Body Contouring , 8(38), 1998.
  • Grazer FM, ed. Clinics in Plastic Surgery: Body Contouring , 23(4), 1996.
  • Grazer FM, Grazer JM and Sorensen CL, “Suction – Assisted Lipectomy”, In: Plastic Surgery: Indications, Operations and Outcomes , Volume 5, 2000.
  • Health Canada, Canadian Community Health Survey , 2000/2001.
  • Additional references detailed throughout text of presentation

Other Techniques in Abdominoplasty

  • Reverse Abdominoplasty
  • ‘Downstaging’
  • ‘Access’ Incisions
  • Secondary Abdominoplasty
  • Adjunctive Procedures
  • SAL
  • UAL
  • PAL

Advances in Abdominoplasty in Toronto

  • Research is ongoing regarding:
    • Gender – specific and long – term metabolic effects of abdominal lipectomy
      • Effect of abdominoplasty on weight, glucose metabolism, cholesterol/TG levels
    • Impact of lipectomy on other body systems
    • Functional impact of abdominoplasty
    • Effect on body image, self – image, self esteem, quality of life

Arms, Thighs and Trunk Treatment Strategies

  • High lateral tension abdominoplasty
  • Transverse flank/thigh/buttock life
  • Lower body lift
  • Medial thigh lift
  • Brachioplasty
body contouring assessment

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