History of Liposuction
The idea of removing excess fats from localized body sites is not new. In 1921, Charles Dujarrier, in France, attempted to remove subcutaneous fat using a uterine curette on a dancer's calves and knees. A tragic result occurred due to injury of the femoral artery leading to amputation of one of the dancer's legs. In 1964, Schrudde extracted fat from the lower leg through a small incision with a curette. Hematomas and seromas resulted from this technique. Pitanguy favored an en bloc removal of both fat and skin to remove excess thigh adiposities. Significant noticeable incisions diminished the popularity of this technique.
The field of modern liposuction began with the technique and instruments of Arpad and Giorgio Fischer. Working in Rome, the Fischers developed a blunt hollow cannula equipped with suction. Some of their early cannulas also contained a cutting blade within them. The Fischers published their results in 1976. They also developed the technique of crisscross tunnel formation from multiple incision sites. Good results were obtained with the new instruments. Fewer complications such as hematomas and seromas were seen than with sharp curettage. In 1978, Kesselring and Meyer published results of sharp curettage aided by suction, but this technique was not widely accepted.
Pierre Fournier,William Coleman, Giorgio Fischer, Lawrence Field and Geoge Felman together in Rome for a symposium on liposuction during the ISDS annual meeting in 1985.
Pierre Fournier, working in Paris, showed an early interest in the Fischers' liposculpture technique. Fournier was an initial advocate of the "dry technique" in which no fluids were infiltrated into the patient prior to liposuction. Fournier subsequently became a world leader in liposuction and fat transplantation, eventually recognizing the benefits of tumescent anesthesia and contributing greatly to teaching liposuction to surgeons throughout the world.
Illouz, of Paris, became interested in the Fishers' developments. He favored a "wet technique" in which a solution of hypotonic saline and hyaluronidase was infiltrated into the adipose tissue prior to aspiration. Illouz felt the solution was a "dissecting hydrotomy" which would facilitate the removal of fat and reduce trauma with less bleeding. Illouz was responsible for creating worldwide publicity for the new procedure.
The first American to visit France and learn the new field of liposuction was Lawrence Field, in 1977, a California dermatologic surgeon (Figure 1). Other Americans, attending scientific meetings and reading about the new technique in the literature, also developed an early interest. Norman Martin, an otolaryngologist, visited Illouz in 1980 and began performing liposuction in Los Angeles in 1981. In mid-1982, a group of physicians from different specialties received instruction from Illouz and Fournier. Dermatologists Claude Caver and Arthur Sumrall were among the group. Rhoda Narins, a dermatologist from New York, also visited France in 1982 to learn the techniques. In the meantime, a task force from the American Society of Plastic and Reconstructive Surgeons visited Europe to investigate this new procedure. Excited by its potential, they attempted to monopolize the field by having Illouz sign a contract to exclusively teach plastic surgeons. Fournier refused to sign the contract, and continued to teach physicians from many different fields. Julius Newman, an otolaryngologist and cosmetic surgeon, and his associate Richard Dolsky, a plastic surgeon, taught the first American course on liposuction in Philadelphia in 1982. The first live surgery workshop was held in Hollywood, California, in June 1983 under the direction of the American Society of Cosmetic Surgeons and the American Society of Liposuction Surgery. Ten dermatologists attended the course.
Cover of the special issue on liposuction published by the Journal of Dermatologic Surgery and Cutaneous Oncology, 1988
Interest in liposuction continued to expand in the United States. In 1983 and 1984, several interspecialty courses were sponsored by the American Academy of Cosmetic Surgery. Newman first used the term "Lipo Suction" and established the American Society of Liposuction Surgery. The first articles on liposuction appeared in the dermatologic literature in July 1984.
As early as 1984, training was available in some residency programs. The dermatology department at the Tulane University School of Medicine was among the first to teach liposuction to residents as a basic part of their training. Liposuction became a portion of the "Core Surgical Curriculum in Dermatology" in 1987. Dermatologic surgeons also took the lead in postgraduate training in liposuction establishing hands-on training courses. Patrick Lillis, Rhoda Narins, and Jeffery Klein directed numerous popular workshops.
The dermatologic literature of the 1980s contained many important articles and chapters about liposuction techniques. Jeffery Klein developed the tumescent technique, allowing nearly bloodless liposuction using only local anesthesia. This innovation dramatically altered the future of liposuction. The first dermatologic textbook to contain a chapter on liposuction was Cosmetic Dermatologic Surgery, published by Year Book in 1984, authored by Samuel Stegman and Theodore Tromovitch.
William Coleman, Patrick Lillis, Timothy Flynn and Rhoda Narins at a Tulane University tumescent liposuction course, 1997
The American Academy of Dermatology (AAD), the American Society for Dermatologic Surgery (ASDS), and the International Society of Dermatologic Surgery (ISDS) featured extensive educational curricula on liposuction at their annual meetings beginning in 1984. Coleman and Fournier served as guest editors of a special issue on liposuction for the Journal of Dermatologic Surgery and Oncology in 1988 with articles contributed by Saul Asken, Gerald Bernstein, Bruce Chrisman, Paul Collins, Leonard Dzubow, Lawrence Field, C. William Hanke, Christine Jaworsky, Jeffrey Klein, Patrick Lillis, Rhoda Narins, John Skouge, Paul Weber, and Allan Wulc. Lillis and Coleman were guest editors for a special issue of Dermatology Clinics on liposuction in 1990 and again in 1999. Articles in these two issues included contributions by Harvey Abrams, Saul Asken, Gerald Bernstein, Bruce Chrisman, David Clark, Paul Collins, William Cook, Richard Dolsky, Lawrence Field, Timothy Flynn, Pierre Fournier, William Hanke, Jeffrey Klein, Edward Lack, Jeffery Lauber, Naomi Lawrence, Seth Matarasso, Rhoda Narins, Julius Newman, Kevin Pinski, Sheldon Pollack, Henry Roenigk Jr., John Skouge, Alan Spinowitz and Samuel Stegman. William Coleman and Naomi Lawrence were guest editors for a special issue of Dermatologic Surgery in 1997. Articles were authored by Patrick Lillis, William Hanke, Rhoda Narins, William Cook, Alan and Seth Matarasso, Jeffrey Klein, Norma Kassarjidian, Zoe Draelos, Giorgio Fischer, Pierre Fournier, Richard Dolsky, Helena Igra, Nancy Satur, Ronald Moy, Greg Menaker and Debra Luftman.
Jeffery Klein, the inventor of the tumescent technique, in the operating room.
The first guidelines of care for liposuction by any specialty were approved by the American Academy of Dermatology in 1989 and published in 1991. The Tumescent Liposuction Council was formed in 1992 for the purpose of increasing awareness of the tumescent technique for liposuction and its first newsletter was published in 1993. Numerous postgraduate courses helped to instruct dermatologists in this technique.
Dermatologists continued to make many important contributions to the field during the 1980s. Among them were the use of liposuction for the face alone or in combination with micro-lipo-injection, face-lifting, and liposuction for axillary hyperhidrosis, lipomas, gynecomastia, and reconstructive surgery.
Initially, large cannulas were employed for liposuction, some up to 1 cm in diameter. These large instruments may have caused damage to neurovascular bundles and occasionally may have led to uneven contours and seromas or hematomas in some patients. The use of local anesthesia, favored by dermatologic surgeons, required a gentle touch. A variety of smaller cannulas were developed by dermatologic surgeons. Cannulas used today are extremely small, some with an inside diameter of less than 0.6 mm. Blunt-tipped cannulas are now standard, as they decrease injury to blood vessels and reduce subsequent bleeding. The use of multiple side ports allows for efficient removal of adipocytes. Manual systems consisting of syringes and cannula tips were also developed. Some surgeons preferred the use of these quiet, disposable instruments, and they also became popular as a back-up system. Aspiration units developed by manufacturers in consultation with dermatologic surgeons have gradually become more powerful and quieter, allowing for an efficient, pleasant surgical environment.
The Key to Modern Liposuction: Tumescent Anesthesia
In 1987, dermatologist Jeffery Klein, MD reported on his development of tumescent anesthesia. This innovation involved infiltration of a dilute solution of lidocaine with epinephrine to allow more extensive liposuction totally by local anesthesia, significantly reducing bleeding. This has revolutionized the field of liposuction for all specialties. Klein and Lillis demonstrated that the hematocrit of the aspirated fat was minimal. The common complications of hematoma and seroma formation became uncommon. Complex calculations of fluid and blood loss or autologous transfusion were no longer required. Peri- and postoperative monitoring was simplified.
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. Klein confirmed that when tumescent liposuction was performed after infiltration of 0.05% lidocaine and 1:1,000,000 epinephrine, dosages up to 35 mg of lidocaine per kilogram of body weight were safe and effective. This pharmacologic discovery allowed large volumes of fat to be removed using only local anesthesia.
This development of tumescent anesthesia eventually tempted some surgeons to progressively explore the boundaries of lidocaine dosage. Lillis verbally reported no complications with tumescent lidocaine dosages of greater than 70 mg/kg. Ostad et al. proposed the maximum tumescent safe lidocaine dosage to be 55 mg/kg body weight. The rate of infusion of the tumescent anesthesia was shown to be independent of plasma lidocaine levels. 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 few complications and no fatalities when the tumescent anesthesia technique is employed as a local anesthetic approach without excess intravenous fluids or general anesthesia. Complications and fatalities have been reported in patients who have had liposuction performed under general anesthesia and deep intravenous sedation after infiltration of tumescent fluids. These aberrations of the tumescent technique have been criticized by dermatologic surgeons. Dermatologic surgeons have also shown that limiting the amount of fat aspirated contributes to the safety of the procedure.
The record of safety in liposuction performed by dermatologic surgeons has been carefully documented. The potential for lawsuits has been shown to be dramatically decreased when liposuction is performed using the tumescent technique in an outpatient facility by a dermatologic surgeon. Hospital-based liposuction, which usually involves general anesthesia, results in 3.5 times as many malpractice claims.
Liposuction has been a procedure practiced by several specialties, and interspecialty rivalries have arisen and continue. Personal economic interests have led to attempts to restrict who should be allowed to perform liposuction and in what setting. Several states have had legislation introduced to limit the physical location in which liposuction can be performed. Liposuction is safest as an outpatient procedure. Mandating the performance of liposuction in a hospital setting may increase the risks and complications for patients. It is likely that these politically motivated and restrictive activities will continue.
Variations of Liposuction
Ultrasonic liposuction was developed in Europe in the early 1990s, being introduced by Zocchi. The procedure involves exposing fat cells to ultrasound energy, presumably facilitating fat aspiration. Ultrasonic techniques are both cannula-based (internal) and by external application. Although the American Society of Plastic and Reconstructive Surgeons has promoted ultrasonic liposuction, dermatologic surgeons have largely abandoned this technique. Internal ultrasound increases the risk for cutaneous burns and seroma formation, and provides little, if any, additional benefit over standard liposuction. Several scientific studies by dermatologists studying external ultrasonic liposuction have found little benefit when used either before, during, or after a procedure. Unnecessary complications have resulted from both forms of ultrasound.
A shaving instrument with suction to remove fat has been reported for use in submental resection. A full-body version of this technology as well as new powered liposuction cannulas have been developed and used by dermatologic surgeons. The shaving devices use a rotary internal blade built into the cannula and are designed to facilitate tunneling through fibrous adipose tissue. Newer powered liposuction devices employ a reciprocating cannula that facilitates fat removal and may decrease the physical work of the surgeon.
Non-cosmetic applications of liposuction were pioneered or developed by dermatologic surgeons. Dermatologic surgeons demonstrated that liposuction could be used to remove lipomas, angiolipomas, and improve hyperhidrosis. Liposuction techniques can assist in hematoma evacuation. Klein demonstrated liposuction techniques for breast reduction. Field pioneered liposuction to facilitate flap movement in cutaneous reconstruction. Gynecomastia, benign symmetrical lipomatosis (Madelung's disease), Dercum's disease, Cushing's disease, and insulin-induced lipohypertrophy have been treated with liposuction. Lymphedema, particularly following breast cancer treatment, has been improved with liposuction and controlled compression therapy. Liposuction has also been used to improve stomal dysfunction.
Dermatologic surgeons have played a critical role in the evolution of liposuction in the USA. Dermatology training programs mandate resident education in this procedure, and future developments in liposuction are yet to come.