Liposuction or lipoplasty, slims and reshapes areas of the body by removing excess fat and improving body contours.
The first real liposuction was probably performed by Dujarrier in 1921. His patient was a ballerina with some fat excess on her knees... Unfortunately, a serious complication led to an outright failure. This has certainly tempered the surgeons' enthusiasm for a few years.
The modern liposuction was developed in 1977 by a Frenchman, Y.G. Illouz, who eventually found the ideal instrument: a thin metal cannula, with a foam tip, connected with a powerful suction device. This prevented extensive skin detachment and reduced the risk of damaging the vascular and nerve structures. The technique was further improved by preceeding liposuction with a hydrotomy, which means the infiltration of the adipose tissues with an adrenaline solution. In this way, bleeding was reduced. Depending on the use and extent of this prior infiltration, we speak of a dry, wet, super-wet or tumescent technique. This was later followed by the external ultrasound assisted liposuction. The principle is to use the energy of ultrasound to destroy fat cells by "cavitation". The fat is emulsified and then removed by suction. After a great enthusiasm for this seductive new technique, the surgeons have tempered their enthusiasm. The indications for an ultrasonic liposuction are still much more limited.
The current trend is to use high-frequency vibrating cannulas in some cases, which emulsify the fat and thus make it easier to remove fat cells in denser and more fibrous areas.
Principles and goals
The aim is aesthetic and all the costs associated with this operation are therefore entirely at the patient's expense. It is common practice to limit the indications to a local excess of fat deposits.
Obese people with a general fat overload are no good candidates for liposuction. Plastic surgery does not make these patients lose weight, the procedure is dangerous and the chance of success is not certain.
Localized lipodystrophies are steatomas, located under the fascia superficialis, a fibrous anatomical surface that separates it from the subcutaneous fat. Their own metabolism makes them resistant to weight loss. According to Illouz, to lose 1 kg of this "blocked" fat, you have to lose 6 kg elsewhere. In addition, the slightest weight gain is first placed on the steatomas and the former deformity is back. These steatomas are mainly present in women. They are located at the hips - the classic "saddlebags" -, the "love handles", on the inside of the knees and at the level of the lower abdomen. So liposuction mainly targets these steatomas. Other places are less suitable, at least if the technique is used alone: a chin liposuction will generally only be effective in combination with cervico-facial lifting, a liposuction of the abdominal wall and the flanks should generally be combined with a tummy tuck. This procedure corrects a possible diastasis of the abdominal muscles and the excess of the skin, which cannot be achieved by a liposuction alone.
In general, the inside of the thighs is considered to be a taboo area. The skin there is very thin and not very elastic with a risk of skin irregularities, not to mention the presence of vena saphena magna (large superficial vein that runs on the inside of the leg), the perforation of which would cause a large hematoma. The legs (calves and ankles) rarely qualify for the technique, as the fat is denser and the skin shows the least irregularities. Often, abnormalities in the shape of the legs and ankles are related to insufficiency in the veinous and/or lymphatic circulation that need to be diagnosed.
Once removed, fat cells will not be replaced. The number of adipocytes is normally determined after puberty. Except in pathological conditions, adipocytes do not multiply once you are an adult. Of course it is always possible to increase the volume of the remaining fat cells, in proportion to the weight gain.
Cellulite is not corrected by liposuction. It is the superficial fat, located under the dermis and above the superficial fascia. This layer of fat must be respected by the surgeon, otherwise there will be a risk of necrosis or skin irregularities. In fact, the term "cellulite" is not correct because it is neither an infection nor an inflammation of the skin. Let's talk about an aspect of "orange peel skin" or "dimples". This subcutaneous fat consists of fat cells separated by connective tissue: retinaculum cutis. These fibrous partitions combine the vertical dermis with the superficial fascia. In this way, we can understand the aspect of the skin that reflects the obstruction of these fat cells. This superficial excess can be treated by endermology.
The aim of preoperative consultations is to examine the patient, listen to the patient's expectations, and provide clear and appropriate information. Preoperative examinations, if any, are common in all operations (coagulation tests, etc.).
In addition to the excess fat, it is essential to assess the quality of the skin. Skin that is too thin and/or not elastic enough can limit the amount of aspirated fat, with the risk of skin irregularities.
The surgeon will have to detect possible contraindications: obesity, obvious venous insufficiency, lack of skin elasticity,... A general poor state of health does not allow you to take careless anaesthetic or surgical risks before an aesthetic procedure.
Finally, as with all aesthetic procedures, care must be taken to avoid surgery in patients with unrealistic expectations.
Most liposuctions are performed under general or regional anaesthesia (spinal or epidural) via an one day procedure. Only in case of a very limited fat excess, such as the treatment of the inside of the knees or very discreet riding breeches, can an operation under local anaesthesia be considered. Liposuction of several litres, on the other hand, requires a longer postoperative follow-up because of possible hydro-electrolytic disturbances.
Incisions and scars
Incisions of a few millimetres are made in the skin in the desired places (skin folds, hidden places in the underwear, ...), close to the area to be treated, but always at a sufficient distance from the perineum, in order to avoid septic contamination.
Usually, the dressings are waterproof and do not need to be changed until the next check-up.
Liposculpture, liposuction, lipoaspiration,... All these terms refer to the same principle: aspiration by means of a thin metal tube or cannula inserted under the skin and connected to an aspirator, which allows to loosen and remove excess fat.
Drawings of the areas to be treated are made just before the operation, with the patient standing upright, in the form of contour lines. Once the patient lies down, and even more so after the infiltration of the tissues, the location of skin and fat defects becomes more difficult to determine.
Infiltration is performed and patience is required to achieve the desired vasoconstriction effect. The cannula - 15 to 35 cm long with a diameter of 2 to 5 mm - is then inserted. They are connected to the surgical vacuum and the surgeon "tunnels" the fat tissue with back and forth movements. While the fat is being suctioned out of the body, the surgeon checks the remaining fat thickness with his or her free hand. The aspirated area must come from at least two separate locations in order to obtain a crossing of the tunnels, the only guarantee for a harmonious result, with a certain retraction of the scar tissue.
This operation is generally not very painful. The use of an elastic compression garment, a lipopanty, is recommended day and night for the first few weeks after surgery. During the same period, the patient avoids intense physical activity, but is encouraged to move. The end result will only be achieved in a few months. Indeed, the haematomas and postoperative oedema precede the expected result. It is not desirable to have a significant weight fluctuation later on. Sometimes an endermology prescription is useful. This technique, proposed by physiotherapists, complements the liposuction procedure. It is a superficial lymphatic drainage that treats the skin oedema that is responsible for the development of damaged skin. After the last prescribed session, maintenance sessions are sometimes proposed.
To begin with, there are the complications as with any surgical procedure: bleeding, hematomas, infections, deep thrombophlebitis (blood clot in a leg vein) and pulmonary embolism (migration of this clot to the lungs) .... When we talk about hematoma, we mean the collected hematoma under tension. It is not the diffuse hematoma with its typical skin discoloration that inevitably follows after this procedure. It should be noted that an infection can be dangerous because the fat defends itself particularly badly against an infection and the infection spreads through the tunnels created by the cannula. The hygiene regulations must therefore be strict: a reliable operating room, careful sterilization and meticulous surgical technique. To reduce the risk of venous thrombosis, the patient should be asked to temporarily stop any oral contraception and the patient should also be advised to stop smoking during the period of the procedure. Preventive subcutaneous injections with low molecular weight heparin are more cautious. Rapid mobilization after the procedure is recommended.
Specific complications with infiltration and aspiration, especially with large liposuction: cardiac decompensation, hydroelectrolytic disorders, toxicity of an excessive dose of local anesthesia (Xylocaine). This justifies why not wanting a local anesthesia at all costs when liposuction is significant and that the procedure is performed in a medical environment with the presence of an anesthesiologist.
Technical complications: excessive skin irregularities and asymmetries, Morel-Lavallée-laesi ("seromas" or fluid retention in the space between the skin and subcutis and the underlying muscle fascia), perforation of anatomical structures. Transient hypoesthesia or reduced sensitivity of the treated areas is classic.
Liposuction is one of the most commonly performed procedures in aesthetic surgery. In the vast majority of cases, it will give the patient and her surgeon full satisfaction with a minimum of care, but under certain conditions. It is important to ensure that the correct surgical indications are given and that this operation is performed under the best conditions. There is no doubt that, despite its apparent simplicity, it is a surgical technique in itself that requires sufficient training and experience. It cannot be practiced anywhere, nor by anyone. If this operation is performed under poor conditions, the complications can be terrible. It is imperative that this operation be performed by a surgeon or, better still, by a plastic surgeon. Not only is the technique not as simple as it seems, but setting the correct indication, correctly detecting and managing the complication also requires appropriate surgical training.