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Nowadays, liposuction is the most frequently performed aesthetic surgery procedure Huang S.H., Wu S.H., Chang K.P. Contour refinements of free flaps for. Atlas of Liposuction: Medicine & Health Science Books @ Free Two-Day Shipping for College Students with Amazon Student. amazon s3 - save this book to read atlas of liposuction pdf ebook at our online download book atlas of free download, atlas of.

Not in United States? Choose your country's store to see books available for purchase. See if you have enough points for this item. Sign in. From fat grafts and liposuction through total body lift following massive weight loss surgery, full-color photos and procedural videos show you exactly how to proceed, step by step, and achieve gratifying results. Pearls of Wisdom, Third Edition. Michael Zevitz.

The first attempt to remodel the body silhouette dates back to , when Dr. Charles Dujarrier wanted to improve the shape of the ankles and knees to a dancer patient. He removed a large part of skin and soft tissue, with a broad subcutaneous dissection and long skin incision. The result was tragic because of an excessive removal of tissue and suture too tight and live. This caused necrosis and amputation [1] , [2]. After that, many other attempts are followed with less tragic results, with en bloc resection of both fat and skin to recontour outer thigh adiposity.

Several complications such as hematoma, long-term seroma, necrosis, infections, and many post-operative body deformities burdened this technique [3] , [4]. Several other surgeons used this technique through the mid 's: Kesserling and Meyer [5] , in , used a large, double blade cutting curette connected to a low-power aspirator to suck the fat, previously separated from the deep plane by scissors.

Bibliographic Information

In , Arpad and Giorgio Fischer [8] , father and son cosmetic surgeons, developed the modern technique of liposuction. They was the first to introduce blunt hollow cannula attached to a suction source and the criss-cross suctioning technique from multiple incision sites. The Fischer applied their method only to outer thigh adiposity [9]. Illouz and Fournier, two Parisian surgeons, modified and popularized the Fischer's technique.

In , Illouz [10] developed modified equipment for performing liposuction and extended technique to the whole body. He introduced blunt cannulas of smaller diameter to reduce the section of nerves, lymphatic vessels and blood vessels.

He used three different size of blunt-tipped cannulas depending on the area to be aspirated: The hydrotomy allowed preserving the neurovascular bundles, the enlargement of the deep adipose layer that needs to be aspirated. This make easer for the surgeon preserving the superficial flap and removing only the deep layer [11]. However, experience has led it to abandon this approach in favor of local lidocaine infiltration and eventually the tumescent technique, recognizing the bleeding advantages.

He has also strongly supported the need for taped compression to support and shape the suctioned tissue, during the post-operative period. However, the greatest merit of Fournier was to travel the world teaching others this technique and inspiring those [12].

Lawrence Field, a Californian based dermatological surgeon, visited and studied this evolving technique in He was probably the first American to visit France and learn the new technique of liposuction from the Italian and French pioneers [13] , [14].

After that, in the early s, many other surgeons traveled to France to study this procedure. The blunt cannula technique came to be the accepted liposurgical method in this country and around the world, and in , the American Society of Lipo-Suction was formed to bring surgeons from both the United States and foreign countries into one group to establish a teaching program [15] , [16].

Furthermore, by , liposuction training was available in some dermatology and plastic surgery residency program [17] , [18]. Throughout this period, liposuction surgery was mostly performed under general anesthesia. Dermatologists were very interested in performing the process in local anesthesia. Therefore, they started to combine a slight preoperative sedation with local lidocaine infiltration.

However, the possible applications were limited by the maximum recommended local anesthetic dosage to few cases with small areas to be treated. In Jeffrey Klein, a Californian dermatologist, first reported on the use of large volumes of very dilute anesthesia which allowed liposuction to be performed in larger volumes completely under local anesthesia without the need of sedation or general anesthesia.

Klein invented a recipe consisting of 0. Klein also demonstrated that the same dosage of lidocaine diluted in a large volume of fluid allowed obtaining a good degree of anesthesia even on large areas, without evidence of systemic toxicity.

Moreover, the presence of epinephrine produced an important vasoconstriction which greatly reduces bleeding during the procedure, which was a major liposuction problem prior to Klein's development [20] , [21]. Lillis demonstrated that the Klein's tumescent technique offered significant reduction in blood loss, even in suction case of over 3L. He verified, also, that Klein's work demonstrating minimal plasma absorption of lidocaine when low concentration solutions were infused [22] , [23].

Furthermore, performing liposuction without general anesthesia offered other different advantages like reduction of hospitalization, costs and risks of anesthesia. The main disadvantage of this method is that infiltration of the anesthetic takes a significant length of time. In addition, the cannulas used to extract the fat need to be somewhat finer in diameter to be tolerated by the patient and hence the time to remove a given volume of fat is lengthened compared with general anesthesia [24].

Liposuction was born as a suction technique by means a vacuum pump [25]. However, the Brazilian Luiz Toledo, in [26] , experienced the use of disposable syringes of different gauges and size for aspiration of adipose tissue.

The main advantage was a wider freedom of movement for the operator during the procedure, making surgery simpler and easier. In addition, the syringes allow you to know precisely the amount of local anesthetic that has been infiltrated before the procedure and the exact amount of fat removed from each area, all data which are just approximate with the use of the lipoaspirator.

Toledo also proposed creating a patient's body map to ensure symmetry as much as possible. A nurse marked exactly the amount of injected local anesthetic and fat tissue removed from each body area to improve as much as possible the aesthetic result and symmetry [27].

The main advantage of syringe liposuction is, therefore, the precision and accuracy in measurement of adipose harvested volumes, in addition to the possibility of injecting fat. The vacuum-pump assisted liposuction makes the surgical procedure more comfortable and less tiring for the surgeon, especially in case of large amounts of fat to be removed.

Therefore, the vacuum pump assisted liposuction was usually chosen for major lipoplasty procedures, in which quantity of fat to be removed is a priority over the topographic, symmetric, precise distribution of fat harvest [28]. Ultrasonic liposuction was introduced by Zocchi, in Italy, in [29] as an alternative to conventional blunt cannula suction.

Zocchi credits Scuderi for the original concept of lipo-exeresis [30]. This technique is based on the application of ultrasounds to the fatty tissue to be aspirated, resulting in both thermal effects and mechanical effects to the surrounding adipocytes.

These mechanical oscillations pass through the cannula that emits the waves from its tip. The thermal effects play a role in fat dissolution and must be dissipated by tissue infiltration [31] , [32]. In this way, Zucchi tried to make aspiration easier and to preserve the neurovascular structures, which can be destroyed by the cannulas.

Zocchi detailed what he believed were the advantages of Ultrasonic technique over traditional liposuction: Ultrasonic liposuction was embraced initially in South American and Europe and then largely rejected after experience with skin sloughs, burns, and seromas [34]. Laser-lipolysis began to spread after the publication of the studies about the interaction between laser and adipose tissue, conducted by Apfelberg [35] and Apfelberg et al.

Laser-assisted liposuction represents a relatively recent advancement in the treatment of lipodystrophies and irregularities of adipose tissue. The laser beam is directly propagated to adipose tissue with which it keeps a direct contact.

The action of the laser causes the rupture of the adipocyte membrane and consequent release of oily content into the extracellular fluid. Complications and results of laser-assisted liposuction are similar to those obtained with the majority of liposuction techniques. In addition to the cytolitic effects on adipocytes, the laser can cause neoformations and remodeling of the collagen and reorganization of the reticular dermis. It is particularly indicated for localized areas of lipodystrophy in the body or face [2] , [38].

Liposuction is the most performed aesthetic surgery in the world. It is mainly used to correct deep and superficial fat accumulations and remodel the body contour. It has become an essential complementary technique to enhance the aesthetic result of many other aesthetic procedures such as cervicoplasty, reduction or augmentation mammoplasty, abdominoplasty, brachioplasty thigh lift and postbariatric body contouring. It now seems to have enormous potential for its application in ablative and reconstructive surgery, far from the most common aesthetic processes [39] Table 1.

One of the first non-cosmetic clinical applications of liposuction was the aspiration of a large lipoma without leaving a visible scar [10]. Lipomas are the most common benign tumor of soft tissues and have very variable dimensions.

Simple surgical excision remains the main and most effective treatment, however, removal of large or multiple lesions may be problematic and result in significant objectionable scars [40].

However, the removal of bulky lipomas or multiple lipomas through liposuction has been described in the literature [40] , [41] , [42]. The disadvantage of this technique lies in the frequent incomplete resection and at a high recurrence rate associated with it [41]. The small liposuction incision can also be located in a less visible area than the area affected by the lipoma, so you can choose the less visible region where to position the scar.

Furthermore, in the case of multiple lipomatosis, it is possible to remove more injuries with a single incision, the healing of the small incision is rapid, and there is a minimal postoperative discomfort [43]. Liposuction can also be a useful solution for the treatment of the multiple-lipoma syndromes and familiar multiple lipomatosis associated with some genetic pathology [44] , [45]. Lipedema is characterized by bilateral symmetrical and localized subcutaneous fat deposits of the buttocks and lower limbs.

It causes significant physical disability, fatigability, pain, difficulty in wearing shoes and boots [46]. Diet and exercise, even if performed correctly, are not enough to reduce the disproportion between the upper and lower body.

Indeed, sometimes, they make the anesthetic dispensation more noticeable, as the patient slides only in the upper body of the body [47] , [48].

Skin and subcutaneous excision significantly improve the size and shape of the limbs; however, it may be associated with severe complications.

Suction-assisted lipectomy may be a good surgical option given the diffuse nature of lipedema adipose hypertrophy and it may be combined with limited skin and subcutaneous tissue excision in cases of persistent redundant skin [48] , [9].

In these patients, liposuction provides good aesthetic results, improving the proportion between the upper and lower body and, also, it reduces painful symptoms, especially at the lower limb articulations, ensuring better mobility [50]. Lipodystrophies are usually associated with insulin resistance, type 2 diabetes, dyslipidemia, liver steatosis, polycystic ovaries, acanthosis nigricans, and cardiovascular complications [46] , [50].

Treatment of lipodystrophies is difficult. Lifestyle is generally very helpful in controlling the disease but not enough. Aesthetic surgery is essential to improve the body contouring, especially in areas where there has been loss of adipose tissue [51].

The only therapeutic options for controlling the metabolic disorder are insulin sensitizers, insulin, and lipid-lowering drugs. Autologous adipose tissue transplantation or implantation of dermal fillers can improve facial appearance and excess adipose tissue from the chin, buffalo hump, and vulvar region can be surgically excised or removed by liposuction [46] , [52].

In addition, hypertrophic insulin lipodystrophy may benefit from suction-associated lipectomy. It occurs frequently in the sites of multiple insulin injections in diabetic patients causing functional and aesthetic disorders including pain, reduction of treatment efficiency, hematoma and edema [53] , [54].

Cervicodorsal lipodystrophy is another secondary lipodystrophy in which liposuction is needed to achieve satisfactory results. It is a side effect of some drugs including the corticosteroids Cushing's syndrome and human immunodeficiency virus HIV medications [55] , [56]. Liposuction subcutaneous mastectomy is the initial surgical approach of choice for pneudogynecomastia and gynecomastia.

In pseudogynecomastia, there is an increased development of the fatty component in the male breast region. In true gynecomastia, however, there is an increase in volume of the male breast gland with a dense fibrous and vascular stroma, which makes suction more difficult. The gynecomastia liposuction treatment is usually associated to a resection under direct vision of the glandular tissue through a periareolar or transareolar incision.

After that, compression dressing and limited activity are necessary for several days to minimize bruising and hematoma formation allowing the skin to adhere to the chest in a favorable position [57] , [58] , [59]. In female macromastia and gigantomastia, there is an important increase in breast fat component. Bulky and heavy breasts often cause significant symptoms such as neck and back pain, dermatitis and skin irritations. Liposuction combined with traditional resection mammoplasty allows volume reduction before excision and refining the results after the reconstruction with an easier surgical procedure and better aesthetic results [60] , [61] , [62].

Lymphedema is a condition with a wide range of etiologies; the most common cause is the removal of one or more lymph nodes stations for neoplastic disease.

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Consists in the accumulation of lymphatic fluid in the dermis and subcutaneous tissues, due to a blockage of the lymphatic flow. Chronically accumulated lymphatic fluid causes cutaneous dermal thickening, hypercellularity, and progressive fibrosis. Secondary to restricted lipid transport from limited lymph flow, lipids accumulate in adipocytes and macrophages, resulting in increased adipose tissue [49] , [63] , [64] , [65].

In chronic lymphedema, the increase in volume of the area is mainly due to the accumulation of adipose tissue and not fluid. For this reason, conservative therapies and lymphatic flow regeneration are not effective at this stage.

Before it is necessary to surgically remove the bulky subcutaneous tissues. Traditional surgical excision, however, causes unacceptable complications and scar and often the result is unsatisfactory, liposuction provides good aesthetic and functional long-term results with a minimum complications rate [66] , [67] , [68].

It is important to emphasize that liposuction alone cannot eliminate the tendency to accumulate fluids and fat tissue, therefore it must always be associated with conservative therapies and lymphatic flow regeneration [64] , [66] , [67] , [68]. Muscocutaneous or fasciocutaneous flaps are widely used successfully for the reconstruction of a wide variety of defects.

In many cases, the flaps are set up to a greater extent than necessary, in the sense of having enough tissue for the recoating, resulting in unsatisfactory aesthetic results. Surgical review in a second time is needed to remodel the flap, especially at certain body areas such as the ankles, knees, feet and breast, to obtain a better aesthetic result and to improve the functionality of that area. Liposuction allows thinning the subcutaneous tissue usually without the risk of flap necrosis and reduces the number of revision procedures required to achieve optimal aesthetic and functional result [69] , [70].

Other less common clinical applications include axillary hyperhidrosis [71] , [72] , [73] , revision of surgical scars [74] , [75] , [76] , sexual dysfunctions and genital area e. Liposuction is also used to facilitate tracheostomy, colostomy and urostomy in great obese patients, in which the stoma could be occluded by excessive fatty tissue surrounding [79] , [80] , [81]. Before the surgery it is important preparing for surgery by marking. Areas to be suctioned are typically marked with a circle in a topographic pattern.

Zones of adherence and areas to avoid are marked with hash marks [82]. Areas that can be suctioned effectively include the face, chin, neck, anterior and posterior axillary areas, arms, breasts, abdomen, waist, hips, buttocks, thighs, knees and ankles. The current options for anesthesia are dry, wet, superwet, and tumescent. The essential differences between these techniques focus on the amount of infiltrating solution injected into the tissues and the resultant blood loss as a percentage of aspirated fluid.


The dry technique involves no infused fluid and results in approximately 25—40 percent blood loss of the volume removed. Blood loss has been estimated to represent approximately 1 percent of the liposuction aspirate volume for both tumescent and superwet techniques [83] , [84]. Klein's tumescent technique has been gradually embraced by all medical specialties [4] , because of the advantages including especially bleeding reduction [20] , [21].

With awake tumescent liposuction, the patient is able to drink normally the night before and the day of surgery, eliminating the need to replace deficits after important bleeding, avoiding the risks of postoperative overhydration or underhydration [85].

The Klein's solution, consisting of 0. This helps avoid damage to the surrounding tissues, and this means less postoperative edema and ecchymoses [39]. Tissue blanching and moderate tension are considered clinical endpoints of infiltrate [84]. Small incisions are performed in different places depending on the area to be treated, but always designed to hide the small surgical scar [16].

For example, the chin and neck can be approached through a small incision placed in the submental crease, posterior lobular crease, or in the nasal vestibule.

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They are well hidden and allow excellent access to the cervicofacial region [39]. An abdominal procedure could be approached through three or four incisions. Two incisions are suprapubic, at the lower abdominal fold and another incision is placed over the umbilicus. Other incisions can be placed under the breast or through an existing scar.

Of course, different situations require different incisions [16] , [39]. The cannula is inserted with the opening away from the skin, and the adipose tissue is broken loose from the fibrous stroma with multiple crisscross movements.

These movements create tunnels in the subcutaneous flap of the area [16] Fig. Harvesting fat collected in the syringe. This allows to precisely knowing the exact quantity of adipose tissue aspirated. In this picture is possible to note the different between the right abdomen, in which the liposuction has already been performed, and the left abdomen. These are areas with relatively dense fibrous attachments running to the underlying deep fascia where they help define the natural shape and curve of the body.

These areas are not to be suctioned because of the high potential for contour deformities [85] , [86] , [87] , [88]. For the body 2—4. The dominant hand directs the cannula, with the other hand used as a guide for this blind procedure [16]. Liposuction is generally performed by two methods: Small volume procedures or procedures primarily for harvesting fat can be performed with syringe liposuction. The syringe technique used blunt-tip suction cannulas connected to a syringe. Drawing back the syringe plunger generates the negative pressures needed to remove fat during liposuction and replaces the electric vacuum pump and connecting tubing traditionally used for this procedure [26] , [27] , [89] , [90].

Pressure bandages occlude the tunnels by collapsing the remaining fat into the spaces of the honeycomb [12]. With appropriate patient selection and minimally traumatic techniques, many complications can be avoided. True complications that are possible include contour defects, permanent skin color changes, infection, emboli, hematomas, or seromas.

The presence of ecchymosis depends on the localization and size of the treated area, the length of the procedure and individual factors. It will be of high value for experienced plastic and cosmetic surgeons and also for residents and fellows.

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Clearly describes high-quality liposuction techniques applicable to different parts of the body Includes coverage of liposuction treatment of osmidrosis and fat injection techniques Presents novel approaches developed by the author during the course of his very extensive experience see more benefits.

Buy eBook. Buy Hardcover. Copyright Liposuction - All Rights Reserved. Download the full book NOW. Chapter 22 — Bupivacaine, Prilocaine, and Ropivacaine. Chapter 2 — Two Standards of Care for Liposuction. Chapter 23 — Tumescent Formulations. Chapter 3 — Ethical Considerations. Chapter 24 — Ancillary Pharmacology.

Chapter 4 — Educational and Clinical Qualifications. Anatomy and Histology. Chapter 5 — Problems in Reporting Liposuction Deaths. Chapter 26 — Tumescent Infiltration Technique.

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Chapter 27 — Microcannulas. Chapter 7 — Risks of Systemic Anesthesia.