Office Setting Liposuction: Techniques & Tricks
According to Tumescent Liposuction: A Review by Jayashree Venkataram (2008) Liposuction is one of the most commonly performed cosmetic procedure today. Dermatologists now perform about one third of these procedures in the United States and have pioneered many of the advances in liposuction, especially in the fields of ambulatory surgery and local anaesthesia. Tumescent liposuction using microcannuale under local anaesthesia, is regarded as safe and effective.
LIPOSUCTION
Liposuction was initially developed in the late seventies in Italy and France.
At that time, liposuction was performed under general anaesthesia without any introduction of fluid, hence, called “dry liposuction”. Later, a small amount of fluid was introduced into the fat (the “wet technique”).
These methods were associated with much blood loss, and patients frequently required blood transfusions. In 1985, Dr. Jeffrey A. Klein, a dermatologist in California, revolutionised liposuction surgery when he developed the tumescent technique, which permits liposuction totally by local anaesthesia and with minimal surgical blood loss.
Further modifications such as power liposuction and ultrasonic liposuction have been introduced with variable results. Despite these advances, the tumescent technique remains the worldwide standard of care for liposuction.
INDICATIONS FOR LIPOSUCTION
Liposuction can be used on fat that is resistant to diet or exercise, located in any area of the body such as the abdomen, thighs, hips, neck, face, and under the chin.
It can be used for breast reduction.
In men, gynaecomastia is an important indication for liposuction. Liposuction has been found to be useful for noncosmetic indications also, such as hyperhidrosis of axillae and lipomas.
In women, with age and a genetic predisposition, may accumulate fat over the arms to a degree that many consider to be disproportionate and unattractive. Exercise does not reduce the volume of fat located on the arms. Microcannular tumescent liposuction of female arms easily and consistently yields results that are well proportioned and without visible surgical scars.
STRUCTURE OF FAT
Subcutaneous fat is arranged in the form of lobules separated from each other by septae.
Except in obesity, the typical female arm has a distribution of fat that encompasses approximately three quarters of the arm’s circumference. The deep subcutaneous fat compartment of the arm extends over the biceps and triceps. The volar aspect of the female arm overlying the biceps has relatively little deep subcutaneous fat.
The fibrous septae consist of blood vessels, nerves, and lymphatics. Each lobule consists of fat cells, which consist mostly of triglycerides and fill up the cell almost entirely, pushing the nucleus to one side. It has been shown that during initial weight gain in any person, there is an increase in the size of the fat cell.
The medial or volar aspect of the arm is relatively devoid of significant subcutaneous fat deposits. Because most of the important subcutaneous neurovascular structures of the arm are found in the medial compartment, liposuction surgery in this quadrant should be done with caution.
The largest mass of soft subcutaneous fat in the arm is found in the posterior or extensor compartment, overlying the triceps muscle. On careful palpation, however, it is evident that a significant amount of subcutaneous fat can be found extending anteriorly, overlying the biceps muscle. This fat is more fibrous than the fat of the triceps area.
With continued weight gain, there is, in addition, an increase in the fat cell number as mesenchymal stem cells get converted to fat cells. Diet and exercise have been shown to decrease the fat cell size, but not the fat cell number, which is referred to as “resistant fat”.
Liposuction is a method of reducing the fat cell number and thereby, the resistant fat. Liposuction removes the resistant fat by two mechanisms: 1 Removal of fat cells during suction & 2 Damaging the fat cells by the to-and-fro motion of the cannula. These remaining damaged fat cells get absorbed slowly over 6–12 weeks and hence, the final result after liposuction is seen after 6–12 weeks, a fact which needs to be emphasised during counselling.
OFFICE SETTING MICRO-CANNULAR TUMESCENT LIPOSUCTION
The word “tumescent” means swollen and firm.
This technique involves subcutaneous infiltration of large volumes of crystalloid fluid called Klein’s solution, which contains low concentrations of lignocaine and epinephrine, followed by suction-assisted aspiration of fat by using small aspiration cannulae called microcannuale.
The term tumescent liposuction specifically excludes the use of any additional anaesthesia, either intravenous or gaseous, and by definition, is a method for performing liposuction surgery with the patient totally under local anaesthesia.
The procedure of microcannular tumescent liposuction consists of:
Induction of anaesthesia by tumescent anaesthesia:
Making 4–8 small incisions called adits (1–3 mm in size)
Introduction of a large amount (1–4 L) of Klein’s solution into the fat. Klein’s solution contains lignocaine, epinephrine, and large amounts of saline. The saline balloons the fat tissue, epinephrine causes vasoconstriction, thus, decreasing bleeding, and lignocaine induces local anaesthesia. This procedure usually lasts 45–60 minutes.
Allowing the fluid to percolate uniformly through all layers, a process called detumescence, lasts 30 minutes.
Aspiration of fat by microcannular liposuction:
Sucking the fat out through microcannuale which are 1.5–3 mm in diameter. This is a slow process lasting 1–1½ hours.
Leaving the incision wounds of cannulae open to drain out fluid. A small amount of fluid is left back in the tissue and is allowed to drain slowly over two days. This residual fluid provides analgesia in the immediate postoperative period.
Applying compression bandages and sending the patient home without any hospital admission.
PRINCIPLE OF TUMESCENT ANAESTHESIA
The most important aspect of tumescent liposuction is that a local anaesthetic is used over a wide area to provide anaesthesia and analgesia, using a sufficient quantity of lignocaine far in excess of the conventional dosage.
Conventional teaching has widely regarded, without adequate pharmacological proof, that the safe upper limit for lignocaine administration is 6 mg/kg body weight. In a radical departure from this conventionally accepted fact, Klein showed that in tumescent anaesthesia, much higher doses, even up to 45–55 mg/kg weight can safely be administered.
This is because in tumescent anaesthesia, the rate of absorption of lignocaine is slow, leading to smaller peak values and hence, lesser toxicity. The reasons for the slow absorption of lignocaine are that subcutaneous fat has a low volume of blood flow, lignocaine is lipophillic and is easily sequestered in fat, diluted epinephrine in saline solution ensures vasoconstriction, thus, minimizing systemic absorption and bleeding, large volume of tumescent solution itself compresses blood vessels by hydrostatic pressure, very low dilution of lignocaine in Klein’s solution does not achieve the gradient required for systemic absorption & most of the solution is removed during aspiration, minimizing the duration for absorption.
This slow absorption from subcutaneous fat has been likened to a slow release capsule, with the fat itself acting as the capsule.
CONCLUSION
Office Setting liposuction is a safe and effective procedure when performed in trained hands in a proper setting. The lack of need for hospital admission and rapid postoperative recovery time also contributed to its popularity.
Experience and training of surgeon, proper selection of cases, and proper technique in anaesthesia and aspiration are all important to get optimal results.
It is important to keep in mind that, as in any cosmetic procedure including liposuction, a final safe and satisfactory result is far more important than quick results.
Techniques for Tumescent Infiltration, Various Suction Equipment (VASER & Laser Lipolysis) and Techniques.
REFERENCE
Tumescent Liposuction: A Review by Jayashree Venkataram (2008)
5 Questions you should be asking about Liposuction. by Dr Beverly Fischer (2022)
Liposuction for Men or Male Breast Reduction? by NuBody Concepts (2023)
What are the Benefits of Tumescent Liposuction? by Kleinlipo (2017)
Liposuction Textbook, The Tumescent Technique By Jeffrey A. Klein (2015)
High Definition Arms By High Definition Liposuction Centers (2022)
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IFAAS Mini Fellowship (Hands-On)
Liposuction & Fat Transfer for
Face & Body Under local Anaesthesia
May 11-12, 2023 - Seoul, South Korea - [Register Now]
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