Subdermal liposuction

Aesth. Plast. Surg. 14:137-142, 1990

Aesthetic _ Plasuc Surgery

�9 1990 Springer-Verlag New York Inc.

Subdermal Liposuction

Carlo Gasperoni , M.D., Marzia Salgarello, M.D., Paola Emiliozzi, M.D., and Gabriele Gargani, M.D.

Rome, Italy

A b s t r a c t . Liposuction is a widely used technique today and indications are that it is becoming even more popular due to new technical refinements. The use of cannulae with a smaller diameter allows suction of the fat immedi- ately under the dermis. The cannula we use to perform this new kind of fat suction is straight and has an external diameter of less than 2 ram. This cannula, the so-called Mercedes cannula, has a bullet tip and a three-hole head. Moreover, the holes are not round but are slit-shaped and oriented in the same plane at 120 ~ This cannula is specifi- cally designed to produce less trauma. The cannula with one downward-facing orifice is not suitable for suction of the subdermal layer and an upward-facing orifice would be too traumatic. The advantage of this new technique, apart from the possibility of treating patients with very slight adiposity, is to allow an effective skin retraction. When a large amount of fat has already been aspirated, residual deformities can occur. These skin irregularities represent the lack of an effective cutaneous retraction mostly due to the permanence of the subdermal fat. In fact, the presence of a thick subdermal adipose layer de- creases the possibility of skin retraction. Therefore, indi- cations for liposuction of the subdermal fat are mainly the slight adiposities and the remnant deformities of a pre- vious liposuction operation. Moreover, this technique is applied to every lipoplasty whenever better skin retrac- tion is needed.

Key words: Lipectomy - - Lipoplasty - - Subdermal fat - - Skin elasticity

Suction l ipectomy has become increasingly popular in the last few years. Its amazing success is attribut-

Address reprint requests to Carlo Gasperoni, M.D., Cen- tro di Chirurgia Estetica, Via G.G. Porro, 1, 00197 Rome, Italy

able to the good results and inconspicuous scars. The technique of l iposuction has greatly evolved since it was first described.

The pioneer for " c l o s e d " removal of fat was Schrudde, who described in the early 1970s [13] a new procedure named " l ipexeres i s . " His technique consisted of creating with scissors a subcutaneous tunnel and then removing the fat with curettes and suctioning the remaining fatty particles after irriga- tion. In 1977 Fischer and Fischer [3] described a new instrument connected to a vacuum system, the cel lulosuctiontome, to cut the fat tissue before aspi- ration. Thereaf ter , in 1978, Kesselring [10, 11] pro- posed another curet te with at tached suction, the as- piradeps, whose application after undermining above the muscle fascia permit ted the surgeon to cut and to aspirate at the same time.

All these techniques utilize sharp instruments and have the drawback that the vessels and lymphatics of the adipose tissue are cut creating a cavity be- tween the skin and the deep planes. Consequently, several complicat ions may occur. I l louz 's innova- tive technique introduces a blunt cannula that cre- ates many tunnels and preserves the vessel and lymphat ic connect ions with the skin. Illouz uses straight and curved cannulae (the so-called hypos- padia-like cannula for rounded surfaces) whose di- ameters range be tween 0.4 and ! cm. Illouz recom- mends going deep into the adipose tissue, 1-2 cm below the dermis, in order to respect the integrity of the superficial fat and to avoid adhesions that may cause unaesthet ic dimples or furrows [6-9].

Fur ther technical refinements presented in the lit- erature are concerned with the size and shape of the cannulae and the p roper selection of the patient [1, 2]. Moreover , the role of l iposuction as an adjunc- tive procedure in many aesthetic operations has been widely discussed [12]. With respect to the

138 Subdermal Liposuction

method itself, it has not changed since Illouz first described it and it still follows the general guidelines of Illouz's procedure.

The subdermal liposuction described in this ar- ticle applies the same principles of the suction-as- sisted l ipectomy of Illouz with new guidelines for its use immediately under the dermal layer. The advan- tages of this new procedure are also discussed.

Description of the Technique

Straight cannulae with diameters ranging from 1.8 to 3 mm and a bullet tip are used. There are two basic cannulae. Graze r -Grams Mercedes cannulae with a three-hole head, and cavnulae showing two lateral openings. In the former the holes are not round but are slit-shaped and are oriented in the same plane at 120 ~ The diameters range from ! .8 mm to 2 cm. In the second kind of cannula the holes are round and lie at 180~ the diameters range from 2 to 3 mm. The length of the shaft of both types of cannula varies from 16 to 30 cm. in addition, a " s cavenge r " cannula with a 3- or 4-ram diameter and a shaft 30 cm in length and with three round orifices oriented at 360 ~ in a helicoidal fashion is used.

The procedure may be performed on an outpa- tient basis with local anesthesia when the amount of fat to be removed is expected to be around 1000 mL or less and the area to be infiltrated is not too wide (limited to the abdomen, "saddle bags ," hips, me- dial thighs, knees, or ankles or a possible combina- tion treatment of several areas in the same opera- tion, for example, hips and knees or saddle bags and knees). The patient is infiltrated with cold normal saline plus 0.2% or 013% xylocaine and 1:500,000 adrenalin. Therefore, a cold compress is applied lo- cally using gauze soaked in cold sterile water. When general anesthesia is indicated, the patient is widely infiltrated with a solution comprising cold normal saline plus adrenalin (1 : 500,000). Cold compresses are also applied locally.

In a primary suction l ipectomy the superficial adi- pose tissue is suctioned first followed by the deep layer of fat. The procedure differs in the way con- tour deformities of various areas of the body are treated. When facing a "saddle bag" adiposity, the procedure is performed with the patient in the ven- tral decubitus position. It starts with the subdermal liposuction using the thin Mercedes cannula. This surgical step is carried out before treating the deep fat in order to work in a firm layer. Next , the deep subcutaneous layer is worked on with the same thin Mercedes cannula. This guarantees uniform results. Suction is then performed on the deep layer by us-

ing a thicker cannula with two orifices in order to remove more fat. If facing a conspicuous adiposity, the " scavange r" cannula is used at the end of the procedure. This three-hole cannula is thicker and suitable for removing some fat particles that have been crushed but not suctioned out with the smaller cannulae. I f the amount of fat to be removed is very small, the thicker cannulae are not used.

The same method is suitable for treating the knees while the patient is in the dorsal decubitus position. For abdomen, hips, and medial thighs, the lateral opening cannulae are used to perform a deep suction. In secondary procedures the residual de- formity usually is caused by an untreated and thick superficial fat layer which prevents an effective cu- taneous retraction; subdermal suction alone is the appropriate treatment.

Discussion

We have been performing liposuction since 1982. Before the introduction of the Mercedes cannula, we followed Illouz's blunt method and had experi- ence with both dry [4, 5] and wet [1, 6-9] tech- niques using the one-downward-facing-orifice can- nulae 0.4-1 cm in diameter. Illouz's technique removes deep subcutaneous fat. The tunnels are created at different levels but never in the superfi- cial layer, and the holes of the cannula are always directed downward away from the skin. The healing of each subcutaneous tunnel produces a concentric retraction [9]: The cicatricial fibrosis of all the tun- nels together with the reduced volume of fat modi- fies the contour of the body and consequently causes skin retraction. The existence of a residual, untouched, superficial layer of fat reduces the effect of the skin retraction.

In our experience this technique gives good results but presents a few drawbacks. It is very diffi- cult to treat slight adiposities. Moreover , when fac- ing major adiposities, we experience the frequent inconvenience of residual deformities, especially in the "saddle bag" area.

The introduction of the Grazer -Grams Mercedes three-hole cannula ranging in diameter from 1.8 to 2 mm gave us the possibility to operate in a superficial plane with less trauma. The three-hole head guaran- tees a 360 ~ oriented liposuction which means that it is possible to perform a uniform and less traumatic procedure. The small diameter allows its superficial use: The cannula can be maneuvered to produce tunnels in the subdermal layer of adipose tissue. Its progression is made easier by the bullet tip. The cannula with one downward-facing orifice is not suitable for suctioning of the subdermal fat, and it

C. Gasperoni et al. 139

Fig. I(A,B). Preoperative view of a 27-year-old patient presenting a slight saddle bag adiposity. (C) Preoperative view; note the protuberant fat accumulation located under the undergluteal crease. (D,E): Four months postoperative view after performing subdermal liposuction. (F) Postoperative view; note the disappearance of the undergluteal adiposity

would be too traumatic if it is used with the orifice facing upward. The lateral-opening cannula is suit- able for more conspicuous removal of deep fat, avoiding the subdermal adipose layer. It works in lateral directions bilaterally, i.e., on both sides of the cannula.

The liposuction of the subdermal fat layer allows effective skin retraction because of the "shaving" of the dermal layer. Therefore, proper patient selec- tion is mandatory: Good skin tone is essential to

achieve good skin retraction. Subdermal fat layer liposuction enables operation on very slight adiposi- ties (Fig. 1). Moreover, it avoids or reduces the residual deformity that occurs after treating con- spicuous saddle bags that are due to the perma- nence of an untreated superficial layer of adipose tissue. This tissue prevents a complete cicatricial retraction of the cutaneous layer, in the same way that the second layer of brick supports the vault of the roman arc and prevents its collapse.

140 Subdermal Liposuction

Fig. 2(A-C). Preoperative view of a 20-year-old patient presenting conspicuous adiposity located on hips, abdomen, medial and anterior areas of both thighs, and knees. (D-F) Postoperative aspect after 6 months. The suction has been carried out both superficially and deeply in each area

Conclusion

Based on seven years of experience, the authors believe the quality of liposuction results depends either on the characteristics of the cannulae used (size and diameter, number, position, and shape of the holes) or on the levels where the work is per- formed (superficial or deep fat). The whole liposuc-

tion procedure is performed with cannulae that are less than 3 mm in diameter, starting with the thinner 1.8-mm cannula and increasing in gauge during the procedure. The authors perform subdermal liposuc- tion in primary (Fig. 2) and secondary (Fig. 3) pro- cedures in order to obtain a more uniform and accu- rate results and to reduce the evidence of remnant adipose deformity.

C. Gasperoni et al. 141

Fig. 3(A,B). Preoperative view of a 25-year-old patient presenting the result of a liposuction performed two years before. Note the bilateral conspicuous saddle bag remnants. (C,D) Ten months after performing subdermal liposuction

R e f e r e n c e s

1. Cohen S: Lipolysis: pitfalIs and problems in a series of 1,246 procedures. Aesth Plast Surg 9(3):207-214, 1985

2. Ersek RA, Zambrano J, Surak GS, Denton DR Suc- tion-assisted lipectomy for corrections of 202 figure faults in 101 patients: indications, limitations, and applications. Plast Reconstr Surg 78(5):615-626, 1986

3. Fischer A, Fischer GM: Revised technique for cellu- litis fat reduction in riding breeches deformity. Bull Int Acad Cosmet Surg 2:40, 1977

4. Fournier PF, Otteni M: Lipodissection in body sculpturing: the dry procedure. Plast Reconstr Surg 72(5):598-609, 1983

5. Goddio AS, Delbet JP: Liposuccion: techniques et mat6riel utilis6s depuis 1979. Resultats sur 388 cas. Ann Chir Plast Esth 31(3):232-240, 1986

6. lllouz YG: Body contouring by lipolysis: a 5-year experience with over 3000 cases. Plast Reconstr Surg 72(5):592-597, 1983

7. lllouz YG: Remodelage chirurgicaI de ta silhouette par lipolyse-aspiration ou lipectomie s~lective Ann Chit Plast Esth 29(2):162-179, 1984

8. Illouz YG: Surgical remodeling of the silhouette by

142 Subdermal Liposuction

9.

10.

aspiration lipolysis or selective lipectomy. Aesth Plast Surg 9(1):7-21, 1985 Illouz YG: Les s6quelles esthdtiques ou les r6sultats ind6sirables de la lipoaspiration. Ann Chir Plast Esth 32(3):229-245, 1987 Kesselring UK, Meyer R: A suction curette for re- moval of excessive local deposits of subcutaneous fat. Plast Reconstr Surg 62"305, 1978

11.

12.

13.

Kesselring UK: Regional fat aspiration for body con- touring. Plast Reconstr Surg 72(5):610-626, 1983

Madick RA: Lipopolasty as an adjunctive procedure. Perspect Plast Surg 3(1):21-52, 1989

Schrudde J: Lipexeresis as a means of eliminating local adiposities. Aesth Plast Surg 4"215-226, 1980