Thinking About Liposuction? Part I | Dermatology, Laser & Vein Specialists of the Carolinas

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By Gilly S. Munavalli, MD, MHS
Charlotte HEALTH&FITNESS magazine, May 2006

What can you do about those stubborn love handles, the “turkey gobbler” under the neck, or that little bit of “junk in the trunk”? There’s plenty you can do about it. Liposuction is an incredibly safe, in-office procedure that can jump start a new healthy and fit lifestyle or fine tune the finest figure. In this two part series on liposuction, I will attempt to demystify the past, present, and future of one of this country’s most popular cosmetic procedures….

WHEN WAS LIPOSUCTION INVENTED?

Well, the modern procedure known as liposuction has been around since the mid 1970’s when it was practiced by a pair of Italian physicians in Rome. They were the first to develop and report on the use of blunt hollow cannulas for fat extraction. Why is this important? The cannula is a long cylindrical, tapered, surgical instrument, which is primarily used to suction adipose tissue, AKA fat or subcutaneous tissue of the skin, which lies below the epidermis and dermis of the skin. It has several openings or ports along the sides of the tip. The blunt nature of the cannula tip allows for movement back and forth through the subcutaneous tissue without risk of cutting or damaging any important structures such as arteries. This technique was picked up and modified by Drs’ Fornier and Illouz in Paris who refined the use of the cannula. Dr Illouz, in particular, modified the technique by injecting saline and enzymes into the fat prior to extraction. This so called “wet technique” made for a much less traumatic procedure. However, general anesthesia was still required for the procedure to be performed. The first American physician, a Dermatologist / Dermatologic surgeon, traveled to France in 1977 to learn about liposuction.

HOW DOES LIPOSUCTION REALLY WORK?

In a nutshell, liposuction is a very straightforward and well-defined procedure. The thickness of the adipose layer varies from person to person and from one location of the body to the other; for example the cheeks or the scalp of a healthy person are usually much thinner than the abdomen or thighs. Prior to the surgery, the physician marks out the areas for fat removal. During the surgery, he/she creates entry points in the skin using a small blade or needle and passes the cannula through the skin and back and forth in a criss-cross pattern in the adipose layer, removing fat with each pass. Great care is taken to stay within the same level of adipose, not going too deep or too superficial. The entry points are later either sewn shut after the procedure or left open to heal in by themselves. In any event, they usually heal imperceptibly.
The oscillating movements of the cannula break up the fat and adhering connective tissue into smaller particles that can pass through the hollow space in the cannula. Back in the 1970’s, the cannulas were huge, almost 1 cm (2.5 inches) in diameter. This created wide tunnels in the adipose and may have caused damage to neurovascular bundles and occasionally may have led to uneven contours, large bruising and fluid collection under the skin in some patients. Today’s cannulas are usually 6 mm or less and provide the liposuction surgeon with much more control, leading to very narrow tunnels in the fat layer, efficient fat removal, and very even contours. An aspirator, or suction machine is attached the hand piece of the cannula (opposite the tip) and provides constant suction to draw the fat out of the hollows of the cannula and into the collecting jar for measurement and ultimately, for biohazard disposal.

DO I FEEL ANYTHING DURING THE PROCEDURE? AM I SEDATED OR KNOCKED OUT WITH GENERAL ANESTHESIA?

Of course, the goals of any surgical procedure are to: A) be safe for the patient, B) be comfortable for the patient, C) be effective for the patients. One of the biggest revolutions in liposuction in the past 15 years has really been in the way that anesthesia in administered prior to and during the surgery, to numb the treatment area. Traditionally, liposuction was done under general anesthesia in the operating room of a hospital-based setting, with the assistance of an anesthesiologist. In 1987, dermatologist Jeffery Klein, MD reported on his development of tumescent anesthesia. This innovation involved the infusion or infiltration of a dilute solution of lidocaine with epinephrine to allow more extensive liposuction totally by local anesthesia, significantly reducing bleeding. Patients no longer needed general anesthesia. This truly has revolutionized the field of liposuction for all specialties. Complex calculations of fluid and blood loss were no longer required. Peri- and postoperative monitoring was simplified. Patients avoided the inherent risks of “going under”.

Klein demonstrated that very dilute concentrations of lidocaine with epinephrine are not absorbed to the same degree as standard “out of the bottle” commercial solutions of lidocaine. This pharmacologic discovery allowed large volumes of fat to be removed using only local anesthesia. The tumescent technique has been the key to the safety and accuracy of modern liposuction, and has been recognized throughout the world for its importance.

While some specialties continue to perform liposuction in a hospital-based setting, dermatologic surgeons have clearly shown that tumescent liposuction is safe as an office-based outpatient surgical procedure. To date, there have been NO fatalities and very few complications when the tumescent anesthesia technique is employed as a local anesthetic approach without excess intravenous fluids or general anesthesia.

Gilly Munavalli, MD, MHS is medical director of the Goslen Aesthetic and Skin Center in Charlotte, NC. He has been performing in-office liposuction for 5 years and speaks internationally on liposuction, skin cancer surgery, and laser surgery.