Liposuction and Liposculpture

Introduction

Liposuction and liposculpture represent the evolution of minimally invasive plastic surgery techniques developed in an attempt at restoring shape and form. Liposuction was first described in the 1920s but it was not until the 1970s that the technique was popularized in Europe by Illouz, Fournier, and Otteni whereby fat was harvested using a blunt cannula and aspirated using negative pressure. Prior to liposuction, fat was directly excised leaving unsightly scars and increased morbidity. The effect of liposuction on the body has been extensively studied and it has been shown to be safe and effective. Other than producing improved contour cosmesis, liposuction was shown to reduce body weight, BMI, waist circumference, body fat, plasma leptin, and insulin levels. Although fat grafting was first described back in 1893 by Neuber, it was Coleman who popularized free fat transfer in a minimally traumatic fashion leading to a consistently higher graft retention compared to prior techniques. As research in the field increased, the indications and quoted graft retention rates also increased (20%–90%). Part of the reason for the wide variation in the results is the sheer amount of factors involved in graft survival. Though the Coleman technique is often accepted as the standard, in the nascent field of fat grafting, multiple strategies for liposuction, fat processing, and grafting have evolved, which makes standardization and optimization challenging. This chapter critically appraises each step in the process of liposuction and fat grafting, from harvesting to processing to injecting, to provide a detailed overview for the plastic surgeon of the 21st century.

Harvest Site

Liposuction for body sculpting or for fat harvesting purposes can be performed anywhere around the body as long as there is sufficient adiposity. The most common sites include the abdomen, flanks, and thighs. However, both animal and human studies have shown that donor site does not influence the quality of the lipoaspirate and the graft survival. In fact, in a murine model Ullmann et al found no significant differences based on thigh, abdomen, and breast donor sites in graft retention or histology after 16 weeks. Li et al repeated and expanded upon these animal findings, finding no difference in retention from five separate donor sites (flank, upper and lower abdomen, and lateral and inner thigh) after 12 weeks. Human studies have also found no difference based on comparative symmetry scores of craniofacial patients grafted with fat from the abdomen versus other areas (medial thigh, suprapubic). Similarly, in breast reconstruction Small et al found no significant difference in graft retention after 140 days in fat harvested from the abdomen versus the thighs. There is currently no evidence to support that harvest site independently influences graft survival. However, this parity has not been proven with higher-level prospective cohorts or randomized control trials, and further research is needed.

Donor Site Preparation

Liposuction can be performed dry (no wetting solution), wet (200 mL/area), superwet (1 mL infiltrate per 1 mL of aspirate), or tumescent (2–3 mL infiltrate per 1 mL of aspirate). The wetting solution may contain lidocaine, epinephrine, and/or sodium bicarbonate depending on surgeon’s preference. The benefit of using a superwet or tumescent solution is the significant decrease in blood loss down to 1%. Other benefits of using a wetting solution is the analgesic effect provided by lidocaine, volume replacement, and enhanced cavitation and heat dissipation in ultrasound-assisted liposuction. The concern of the use of wetting solutions in the setting of fat grafting is the potential effect on adipocyte viability and blood flow reduction to grafts. However, as early as 2005 Shoshani et al demonstrated no significant difference in weight and volume retention at 15 weeks between xenografts harvested with lidocaine and epinephrine versus a control of saline. Livaoğlu et al further proved the safety of local anesthesia showing no significant difference in retention at 180 days between control, lidocaine plus epinephrine, or prilocaine groups in an autologous murine model. Lastly, Rohrich et al found no significant differences in adipocyte viability among four donor sites (abdomen, flank, thigh, knee) determined on an in vitro colorimetric assay of cell proliferation. Overall, despite theoretical concerns for the use of local anesthesia, graft survival does not seem to be greatly affected by its use in animal models. This finding should be further investigated in human studies.

Harvest Technique