Liposuction

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Liposuction. Aspirate with suctioned fatty tissue and tumescent solution
Liposuction in the abdominal area

Liposuction ( liposuction , more rarely: aspiration lipectomy ) is an operation in which fat cells are sucked off with cannulas at certain points under the skin. It is mostly performed as a cosmetic operation , the technical term "aesthetic surgical intervention", but increasingly also because of the disease in lipedema. In general, interventions in aesthetic surgery are interventions that change shape, the indication of which is reduced at the request of the patient (elective intervention). In the event of illness, painful deposits of fat cells are removed.

Aesthetic-surgical interventions take place across disciplines and are therefore carried out by doctors from different backgrounds (including general surgeons, oral and maxillofacial surgeons, dermatologists, plastic surgeons, gynecologists, ENT specialists, general practitioners). The term “cosmetic surgeon” is often used in this context, but does not represent a specialist title.

history

Aesthetic surgery is not a reinvention of the 20th century, but has been known for at least 1400 years. One of the earliest Central European records comes from the Petersberg Chronicle, completed in 1230 , according to which the obese Margrave Dedo III. died on a campaign in Italy on August 16, 1190 as a result of surgical fat removal. However, it did not experience its boom until the 19th century. Since the beginning of the 20th century, there have been first attempts to reduce excess fat with medical aids, initially primarily through surgical measures that involved large incisions and thus, according to the hygienic circumstances prevailing at the time, with a high risk of wound healing disorders. The first attempts at liposuction are attributed to the French Charles Dujarrier, who injured the leg artery of a tabloid dancer in attempts with sharp cannulas, which ultimately led to a leg amputation. In the 1960s and 1970s, Josef Schrudde , a German surgeon, and the Swiss surgeons Meyer and Kesselring in particular tried to combine their sharp instruments with a suction function, but this was not very successful and was accompanied by a high rate of complications, such as high blood loss, risk of injury to neighboring organs, etc.

It was not until the French Yves-Gerard Illouz succeeded in 1977 with his pioneering work using thinner blunt cannulas and the preoperative introduction of a larger amount of fluid to achieve significant progress. Nevertheless, the breakthrough came with the so-called tumescent technique, which was coined by the French Fournier and the American Klein.

technology

The method most frequently used at present is tumescent anesthesia . It was developed by the Californian dermatologist Jeffrey A. Klein. In a first step, ½ to several liters of a mixture of sterile , isotonic water, an anesthetic (similar to that used in dental treatments), sodium bicarbonate and usually a little cortisone are injected into the subcutaneous fatty tissue. This mixture causes two main effects there: An anesthesia lasting up to 18 hours, which is also safe when used properly, and the soaking of the individual fat cells with the mixture, which can then be more easily removed from the connective tissue , which stabilizes the fatty tissue and the skin. This procedure is followed by a waiting period of at least 30–60 minutes, during which the applied liquid is evenly distributed in the fatty tissue and the anesthetic becomes effective. A kind of emulsion is formed from fat cells and tumescent solution. The connective tissue structures that stabilize the fatty tissue, but also the veins, vessels and nerves that run through the fatty tissue are not changed. Then the emulsion is removed from the fatty tissue with a slight suction and special cannulas . Depending on the cannulas used, the places at which the cannula penetrates the skin must be sutured or not. As a result, a compression girdle must be put on, which must be worn for a period of a few days up to six weeks.

Mechanical suction pumps, which generate a continuous, medium to strong suction, are mostly used for suction. A more elaborate method is used in liposculpture , in which manually operated suction syringes of 20 to 60 cm³ are used instead. The proponents of this suction method claim that the weaker and degressive suction of the syringes makes it possible to work in a more tissue-friendly manner, which means less stress on the patient and less follow-up effort. If the extracted fat is to be used for fat transfer , the use of suction syringes is the standard.

Conventional cannulas for liposuction have a diameter of 3 to 8 mm. These cannulas enable quick work. A more complex method is the use of microcannulas with a diameter of 1–2.5 mm.

Proponents of the microcannulas point out that they enable suction that is much more precise and gentle on the tissue than thicker suction cannulas. Also, no tissue incisions are necessary, minimal skin incisions are sufficient. B. can be made with a 1.5 mm puncher and do not have to be sewn. It is particularly gentle to suction if the liposculpture is linked to microcannulas . The time after the procedure, during which compression must be worn, can be shortened from four to six weeks to a few days. Klein is a proponent of the microcannula method. A number of patents exist for microcannulas . B. von Klein and Heinrich.

Liposuction must be distinguished from methods of so-called lipolysis, in which energy (ultrasound / cavitation / radio frequency / negative pressure) or cold is introduced into the tissue non-invasively from the outside via the skin in order to have effects on cells located under the skin and a. to unfold the fat cells that are to be "emptied". The actual mechanism of action of the individual methods has not been clarified with certainty. A further distinction must be made between the so-called injection lipolysis , in which a substance that is forbidden in Germany for this procedure is injected into the tissue to be reduced, which causes the affected cells to die. The method comes from a. used in very localized processes and has come under criticism due to the possible side effects.

There are several modifications to the technique of liposuction. These consist of a. in the handpiece to which the cannula is attached:

  • a pure handpiece, for better grip of the cannula.
  • a vibrating adapter - vibration assisted liposuction (VAL) also called PAL (power assisted liposuction).
  • an adapter that generates ultrasound - ultrasound-assisted liposuction (UAL or VASER), which is supposed to help liquefy fat cells before the actual suction. X-UAL uses externally applied ultrasonic energy.
  • an adapter that allows the tissue to be "watered" and "suctioned off" in quick succession and via the same cannula - water jet assisted liposuction (WAL).
  • or an adapter that, after the liposuction process, also brings laser-mediated thermal energy into the tissue via a fiber. Various laser systems are used, whereby the wavelength of a Nd: YAG laser is mainly used - laser -assisted liposuction (LPL).

Each method is characterized by its own advantages and disadvantages, whereby no method can make a scientifically proven claim to superiority in terms of the aesthetic result or effectiveness, but can make the work of the surgeon easier.

Liposuction is often used as a complementary measure at the same time as other cosmetic operations (e.g. tummy tuck , breast reduction, etc.) to improve the results.

A distinction must be made between the injection lipolysis method (so-called "fat-away-syringe"), which is only an alternative for localized fat accumulations. The chemical agents used (phosphatidylcholine) are, however, not approved for this application and therefore represent "off-label use". The method is banned in some countries.

Costs and risks

According to the German Society for Aesthetic Plastic Surgery (DGÄPC), smaller interventions cost around 1,000 euros; if fat is sucked off at several points at the same time, costs of 10,000 euros and more can be incurred, plus anesthesia and clinic costs. Small interventions take around 20 minutes, larger ones up to three hours and can then be performed under general anesthesia.

In addition to suitable equipment, the skill and experience of the surgeon are decisive for the success of the operation. They should have a certain feeling for adipose tissue that cannot be learned at school, as the technique of liposuction is hardly required in the training regulations in any specialist doctorate. The quality of treatment depends above all on the individual medical experience and talent. When assessing the risk of liposuction, one should bear in mind that liposuction is relatively safe given the number of operations performed each year (250,000 in Germany, at least 750,000 in the USA), but five deaths per year are expected in Germany alone. In general, interventions under inpatient conditions, i.e. in hospitals, have a statistically higher risk of complications due to nosocomial infections . As with any other procedure, pain, infection, bleeding and the like may occur after the operation . a. come. In this case, immediate hospitalization is urgently recommended, as a large number of the serious incidents described in the literature are due to - in these cases dangerous - hesitation and efforts of the suction doctors to "solve the problem themselves". Liposuction in lipedema is associated with increased risks.

From 2020, the German health insurances will cover the costs of liposuction for the treatment of severe lipedema (grade 3) as a benefit in kind.

restrictions

With liposuction, it is possible to remove fatty tissue - but it may not be permanent. Recent research suggests that certain structures in the hypothalamus strive to restore the original amount of total body fat after the procedure. Apparently the fat is initially deposited in other fat deposits . With the above Investigations had already reached the initial value after twelve weeks, the total body fat amount and z. T. exceeded. It has not been investigated whether this situation has changed in the subsequent period. Even so, some studies have shown that liposuction can be used safely to treat obese patients.

In practice, this means that if you are overweight, professional nutritional advice , exercise , lifestyle changes, etc. a. should take place simultaneously or better before This is especially true for men, in whom, depending on the sex, fat accumulates more easily than visceral fat (i.e. not visually visible in the free abdominal cavity ), which cannot be sucked off. Compared to subcutaneous fat, this fat apparently has an increased endocrinological activity, i.e. it produces more messenger substances than subcutaneous fat, which in turn influence processes such as atherosclerosis, diabetes, blood pressure, etc. The effects of liposuction for these processes have been examined in several studies with partly contradicting results. Newer approaches assume a cumulative health risk of the visceral and subcutaneous adipose tissue (total body fat amount).

The following conclusions can be drawn from what is already known:

  1. Liposuction is not a substitute for a healthy diet or other measures to treat the causes of excessive fat deposits .
  2. Rapid weight loss through liposuction alone is not possible. However, reducing the number of fat cells in the body can lead to weight loss. So are z. B. Fat cells are able to use the enzyme aromatase to convert part of the testosterone into estrogens , which promote fat accumulation in the body. In addition, clinical experience shows that weight loss through diet and other measures is easier immediately after liposuction than without it. Whether psychological factors or physiological factors (initiation of lipolytic processes by liposuction) are decisive is discussed.
  3. The total amount of body fat can be reduced through liposuction. The longevity of the success depends - like every measure for health-effective weight loss - on whether the lifestyle is adapted to the advantage: calorie reduction and physical activity.
  4. With the help of liposuction, a disproportionality can be permanently proportioned, i.e. the body can be shaped. However, if you gain weight again, fat will also be stored again. This is not stored disproportionately in the treated area, but rather evenly in both treated and untreated areas.

Liposculpture and fat transfer

Washboard abdominal liposculpture in a woman

While liposuction is mostly associated with the removal of unwanted "cushions", it is increasingly used to improve the body contours of people of normal weight. The most common method of surgically creating a washboard abs is modeling with liposuction.

By means of fat transfer (fat grafting), the extracted fat from one region of the body is newly deposited in other fat deposits (e.g. in the subcutaneous fat tissue). The best known is the so-called "Brazilian Butt Lift", in which belly fat is transferred to the bottom. More recently, muscles with fat deposits have also been shown to better advantage in men, such as the pectoral muscles and biceps.

Individual evidence

  1. Jan Keupp: The table of glory - table joys in the Middle Ages . In: Kitchen - Cooking - Nutrition (=  communications of the German Society for Archeology of the Middle Ages and Modern Times . No. 19 ). 2007, ISSN  1619-1439 , pp. 51–62, here: p. 51 ( PDF [accessed February 25, 2020]).
  2. JA Klein: The tumescent technique for liposuction surgery . In: AM J Cosmetic Surg . No. 4, 1987, pp. 263-267. 1124-1132.
  3. ^ Patent Klein
  4. Austrian Patent Office, patent number 408722
  5. Ästhetik Magazin Critical presentation of cavitation techniques
  6. FDA prohibition of injection lipolysis or fat-away-syringe
  7. Aesthetic Plast Surg. 2012 Mar 24. 1,000 Consecutive Cases of Laser-Assisted Liposuction and Suction-Assisted Lipectomy Managed With Local Anesthesia. Chia CT, Theodorou SJ.
  8. FDA prohibition of substances for injection lipolysis
  9. Patient guide on liposuction from the German Society for Aesthetic Plastic Surgery (DGÄPC)
  10. Philipp Neumann: Liposuction: Health insurance companies must pay women liposuction from 2020. January 29, 2019, accessed on December 23, 2019 (German).
  11. https://www.g-ba.de/presse/pressemitteilungen/811/
  12. Dissertation thesis by Dr. U. Janert
  13. Aesthetic Plast Surg. 2006 Sep-Oct; 30 (5): 574-88. Safe total corporal contouring with large-volume liposuction for the obese patient.Dhami LD, Agarwal M. Liposuction for obesity
  14. ^ Plast Reconstr Surg . 2001 Nov; 108 (6): 1753-63; discussion 1764-7. Large-volume liposuction: a review of 631 consecutive cases over 12 years. Commons GW, Halperin B, Chang CC Liposuction for Obesity
  15. Tunc Tiryaki: Inverse Abdominoplasty: An Illustrated Guide, page 46 ff.
  16. ^ Joseph C Blessing: The Doctors' Dictionary, 2nd edition: A medical dictionary, 2nd edition 2011, letter B.
  17. Melvin A. Shiffman: Autologous Fat Transfer: Art, Science, and Clinical Practice, p. 15

Web links

Commons : Liposuction  - collection of images, videos and audio files