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INTRODUCTION

Today many people complain about extra fat deposits and overweight.

While exercise and dieting may be useful for losing unwanted weight and fat, some fat deposits may not respond to efforts at weight loss. Applying liposuction techniques may be an option in these situations. Liposuction is not a low-effort alternative to exercise and diet. It is a form of body contouring with significant attendant risks and is not a weight loss method. The amount of fat removed varies by doctor, method, and patient, but the average amount is typically less than 10 pounds (5 kg).

There are several factors that limit the amount of fat that can be safely removed in one session. Ultimately, the operating physician and the patient make the decision. There are negative aspects to removing too much fat. Unusual “lumpiness” and/or “dents” in the skin can be seen in those patients “over-suctioned”. The more fat removed the higher the surgical risk.

Reports of people removing 50 pounds (22.7 kg) of fat are often exaggerated. However, the contouring possible with liposuction may cause the appearance of weight loss to be greater than the actual amount of fat removed. The procedure may be performed under general or local (“tumescent”) anesthesia. The safety of the technique relates not only to the amount of tissue removed, but to the choice of anesthetic and the patient’s overall health. It is ideal for the patient to be as fit as possible before the procedure and to have given up smoking for several months.

HISTORY

Relatively modern techniques for body contouring and removal of fat date back to French surgeon, Charles Dujarier. A tragic case that resulted in gangrene in the leg of a French model in a procedure performed by Dr. Dujarier in 1926 set back interest in body contouring for decades to follow.

Liposuction evolved from work in the late 1960s from surgeons in Europe using primitive curettage techniques which were largely ignored, as they achieved irregular results with significant morbidity and bleeding. Modern liposuction first burst on the scene in a presentation by the French surgeon, Dr Yves-Gerard Illouz, in 1982. The Illouz Method featured a technique of suction-assisted lipolysis using blunt cannulas and high-vacuum suction and demonstrated both reproducible good results and low morbidity. During the 1980s, many U.S. surgeons experimented with liposuction, developing some variations, and achieving mixed results.

In 1985, two U.S. dermatologists developed the tumescent technique, which enhances effectiveness and safety in office-based procedures, partly by avoiding the use of general anesthesia. The patient is instead given twilight anesthesia in which they remain partly conscious.

In the late 1990s, ultrasound was introduced to facilitate the fat removal by first liquefying it using ultrasonic energy. After a flurry of initial interest, an increase in reported complications tempered the enthusiasm of many practitioners.

Overall, the advantages of 30 years of improvements have been that more fat cells can more easily be removed, with less blood loss, less discomfort, and less risk. A great deal has been written about it as practitioners and advocates wrestle with the alternatives and controversies

ANATOMY AND PHYSIOLOGY OF ADIPOSE TISSUE

Adipose tissue consists of fat storage cells in a fibro cellular matrix. Adipocytes are an important source of energy and also serve as effective insulators. Fat accumulation in a normal adult occurs by increase in fat cell size (hypertrophy), while fat cell number remains constant. If fat accumulation becomes become severe (as in cases of obesity) the number of fat cells will increase (hyperplasia) to accommodate the excess lipid storage requirement. Hyperplasic obesity is relatively resistant to diet and exercise and is fortunately less common than hypertrophic obesity.

There are variations in fat distributions based on age, sex and race. Women generally have a higher percentage of total body fat than men, manifested by thicker adipose tissue throughout the body. The pattern of fat accumulation in women tends to be in the lower trunk,hips,upper thighs and buttocks(gynoid pattern).In contrast, fat tends to accumulate around the trunk in men, reflected by an increase in abdominal girth with a thick torso in the upper abdomen (android pattern).

The proportion of truncal fat generally increases with age, with a progressive internalization of fat and a tendency for subcutaneous fat in the extremities to shift to an intramuscular and intermuscular pattern of fat deposition over time. There are also racial depositions in the buttock area in African Americans, the upper torso in Asians, the hips and thighs of Latin people and the lower abdomen and hips in Nordic people. All of these differences of fat disposition related to sex, age and race should be taken into account when patients are evaluated for liposuction.

WHAT IS LIPOSUCTION?

Liposuction is defined as the removal of fat from deposits beneath the skin with the use of a hollow stainless tube called cannula and the assistance of powerful vacuum called the aspirator. It is also known as “lipoplasty”, “liposculpture” or “lipectomy”. It can be accomplished with either general anaesthesia or mild or heavy sedation or, most frequently, local anaesthesia.

AREAS FOR LIPOSUCTION

1. Abdomen
2. Hips
3. Outer thighs (saddlebags)
4. Flanks (love handles)
5. Back
6. Inner thighs
7. Inner knees
8. Upper arms
9. Submental (chin)
10. Gynecomastia (male breast tissue )

BEST CANDIDATES FOR LIPOSUCTION

To be a good candidate for liposuction, you must have realistic expectations about what the procedure can do for you. It is important for you to understand liposuction can enhance your appearance and self confidence, but it will not necessarily change your looks to match your ideal or cause other people to treat you differently.

The best candidates for liposuction are normal weight people with firm, elastic skin who have pockets of excess fat in certain areas. You should be physically healthy psychologically stable and realistic in your expectations. Diabetes, any infection, or heart or circulation problems usually nullify one’s eligibility for the procedure. Also a person suffering from thromboembolism disorders is contraindicated.

Age is not a major consideration but should be above 18 years. However, older patients may have diminished skin elasticity and may not achieve the same results as a younger patient with tighter skin.

Also liposuction should not be a substitute for dieting and exercise or used to treat cellulite.Cellulite is actually a dimpling effect of fat caused by the way fat cells lie in or between connective tissue in the body, primarily in the hips, thighs, buttocks region. Connective tissue extends from the skin to the muscle below. Fat cells when they get bigger push up against the tissue to create dimpling.

PATIENT EVALUATION AND PREOPERATIVE PREPARATION

At the point of consultation, the patient’s desires, needs expectations and concerns are discussed. A history about prior surgery history is obtained. The nurses offer the patient general information concerning the procedure, including but not limited to what to expect from the consultation, how to prepare themselves for surgery and how they may look and feel following surgery. The physician will discuss these topics in greater detail with the patient.Pre and post operative photos are shown and questions are answered.

Patient should refrain from smoking for a minimum of two weeks prior to surgery and two weeks following surgery. Aside from the potential pulmonary complications after surgery, patients who smoke should be made aware that nicotine-induced vasoconstriction from smoking can cause skin breakdown, skin loss, and delayed healing even years later. Refusal to change smoking habits should alert physicians and staff to possible non compliance with other postoperative regimens as well.

Some medications may interfere with anesthesia and cause undesirable side effects. Although the drug Ephedra should be advised to discontinue the drug due to intraoperative catecholamine surges. Physicians should be sensitive to diet supplements and other weight loss medications that contain ephedrine and anything stimulating catecholamine release. The old version of ephedra (xanadrine) and the Chinese herb, Ma Huang should also be considered.Ma Huang was used for many years in Chinese herbal remedies to treat asthma and is used now by many people for weight loss and energy enhancement. Patients who are taking the Chinese herb should be advised to discontinue it since the plant contains ephedrine.

The patient is given a list of drugs to avoid two weeks prior to surgery that may have undesirable side effects such as abnormal bleeding or bruising. Aspirin, Non-steroidal Anti-inflammatory agents and vitamin E are all included in this list cause they interfere with blood clotting mechanisms. The physician may choose to introduce the patient to a homeopathic therapy regimen such as Arnica Montana to be use pre and post operatively to reduce pain and bruising, lessen scar tissue and promote better overall healing.

Once the decision has been made to proceed with surgery, informed consent is obtained from all patients, and appropriate lab work is performed. The patient is given a packet of information including the general surgical risks, anesthesia risks, tips on how to care for themselves after surgery and drugs to avoid prior to surgery. Photographs are taken of patients using standard views, taking care to keep distances and leg and arm stance consistent in order to allow better comparisons between preoperative and postoperative photographs. Preoperative photographs are mandatory for medical legal chart documentation and also a good ‘reminder’ for patients of their preoperative appearance. Patients are often not aware of preexisting asymmetries and irregularities, but tend to have a heightened awareness of such imperfections after surgery.

INTRAOPERATIVE CARE

Surgical Markings:

It is important to mark the patient in the standing position before surgery. Topographical maps are drawn with permanent markers, carefully noting the asymmetries, cellulite and “danger” zones to be avoided (Fig e). Typically a black marker is used to delineate bulges and a red marker to delineate areas of depression to be avoided with suction. Access incisions for the liposuction cannulas are also marked. Some physicians choose to keep a Polaroid camera in the holding area to take photographs of the markings and allow patients to make a final approval of the areas to be treated.

Anaesthesia:

The majority of patients undergoing lipoplasty are given local anesthesia. However the patients are also given choices of local, local with IV sedation, epidural or general anesthesia. The final decision is based upon patient desire and physician preference. The volume of fat to be suctioned is taken into account as well as whether or not the patient is to have additional procedures performed at the same time. For example, patients undergoing simultaneous procedures that require general anesthesia, such as abdominoplasty or breast augmentation, would most likely have liposuction performed under general anesthesia. If the patient is to be placed in the prone position and is having general anesthesia, the patient is intubated supine on the stretcher and then turned over to the prone position on the operating table. Prophylactic antibiotics are prescribed preoperatively.

Intraoperative Positioning

Patient positioning depends primarily on the surgeons preference and secondly on the areas to be treated. The patient is placed prone with a blanket roll to treat flanks, hips, lateral and posterior aspect of the medial part of the thighs. This position is also ideal if a patient’s buttock or back is to be addressed. The arms are secured on the arm boards and positioned with the shoulders abducted, the elbows flexed with the hands held above the head, and the palms facing down. Care is also taken during the positioning of the arms to ensure that there is no traction on the brachial plexus. Saline filled bags are placed under the arm pits to prevent pressure effects. Any other potential pressure points, such as the knees and the dorsum of the feet, are adequately padded. Once positioning is complete, the patient is prepped and draped in the standard fashion.

The supine position is used to address the anterior and medical aspects of the thighs, medial knee area, abdomen, breasts and arms. The patient is reprepped and draped.

Patients are routinely prepared with a five minute povidone-iodine (BETADIENE) scrub and then Betadiene paint. Circumferential preparation of the arms and legs is done when appropriate. When liposuction is used to treat Gynecomastia, the patients arm should be firmly secured on arm boards and positioned away from the body. The back of the operating table is raised intermittently to a sitting position during the procedure to better evaluation symmetry and adequacy of the lipoplasty.

SURGICAL TECHNIQUE

Infiltration of Wetting Solution

A small stab incision is made with a scalpel, and the wetting solution is infiltrated into the targeted subcutaneous tissues. A dilute solution of lactated Ringers (LR), lidocaine and epinephrine are instilled with the infusion cannula and pump to evenly expand the subcutaneous space. Some surgeons do not use the lidocaine when the patient is under general anesthesia. The wetting solution is prepared prior to the beginning of the surgery and is kept at the ambient temperature of the operating room. The patient’s body temperature is maintained with Bear Hugger warming blankets on all unprepared portions of the body. Warmed IV fluids are used in large volume aspirations.

Constituents of wetting solution depending on the type of anesthesia:

GENERAL ANESTHESIA

1 litre lactated Ringer solution

1 ampule 1:1000 epinephrine

25 cc 1% lidocaine

LOCAL ANESTHESIA

1 litre lactated Ringer solution

1 ampule 1:1000 epinephrine

50 cc 1% lidocaine

100 cc of sodium bicarbonate

LARGE VOLUME LIPOSUCTION

Lidocaine amounts are reduced so as not to exceed the maximum recommended dose of 35 mg/kg

Peak plasma lidocaine levels occur between 6 and 12 hours post infusion. Prevention of lidocaine toxicity starts with strict adherence to the currently accepted maximal recommended dose of 35mg/kg and early recognition of symptoms should they occur.

The instillation of wetting solution is complete when the tissue is firm to touch (“tumescent state”); this endpoint will vary among surgeons. Surgeons consistently infuse about the same volume of wetting solution of the total volume of fluid that is eventually removed. The epinephrine in the solution helps to decrease the amount of bleeding and the lidocaine provides local anesthesia for the patient that is awake.

Depending on the amount of fluid injected, the techniques are classified as:

1. Dry Liposuction- The dry method does not use any fluid injection at all. This method is seldom used today.
2. Wet Liposuction- In this method the amount of fluid injected is less than the amount of fat to be removed.
3. Super wet liposuction- In this method the amount of fluid injected is equal to the amount of fat to be removed. In this technique there are less chances of lidocaine toxicity.
4. Tumescent liposuction- In this technique the amount of fluid injected is two times or more than that than the amount of fat to be removed.

The fluid injected creates space between the muscle and the fatty tissue, which creates more room for the cannula to remove the fat cells. Also it is easier for the surgeon to make the back and forth movements that break up the fat cells. An hour or so must be allowed for it to percolate and enlarge the area before any work is started.

Insertion of Cannula

Based on the type of cannula used there are five different techniques of liposuction:

1. Suction assisted liposuction
2. Ultrasound assisted liposuction
3. External ultrasound assisted liposuction
4. Power assisted liposuction
5. Laser liposuction

REFERENCES

• Advances in liposuction and fat transfer. (Procedures in Therapeutics) Gerhard Sattler. Dermatology Nursing. April 2005 v17 i2 p133(7).
• Wikipedia: http://en.wikipedia.org/wiki/Liposuction (accessed on March 12, 2011)
• Ultrasound-assisted lipoplasty Joy L Pine; Lisa J Smith; Melinda J Haws; Mary K Gingrass Plastic Surgical Nursing; Fall 2003; 23, 3; Health Module pg. 101
• http://health.howstuffworks.com/liposuction.htm (accessed on March 12, 2011)
• http://www.liposuction.com (accessed on March 12, 2011)
• http://www.tuckthattummy.com/abdominoplasty.htm (accessed on March 12, 2011)