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Lipoplasty (Liposuction): Then and Now   by ASAPS There was a time when men and women unhappy with their body contours, particularly individuals with diet- and exercise-resistant fat "pockets," had few options. For decades, surgeons sought a safe and effective method of removing fat.

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NEW YORK, NY (September 30, 2003) - There was a time when men and women unhappy with their body contours, particularly individuals with diet- and exercise-resistant fat "pockets," had few options. For decades, surgeons sought a safe and effective method of removing fat. In the early 1970s, "suction lipectomy," (SAL) or lipoplasty (liposuction) first appeared in the peer-reviewed literature. The procedure was originally used to remove lipomas (fatty tumors), defat flaps and remove fatty deposits in various reconstructive procedures; however, it was soon found to have a much wider application as a cosmetic surgery technique. The American Society for Aesthetic Plastic Surgery (ASAPS) has played a major role in the development of lipoplasty, which today is the most popular cosmetic surgery in the United States, with more than 370,000 procedures performed in 2002, according to ASAPS statistics.

The Appeal of Lipoplasty
The most revolutionary aspect of lipoplasty was that it could remove fat using small incisions (usually less than ½ inch in length), placed inconspicuously, and leaving only minimal scars. A long, hollow tube, called a cannula, with an opening at one end was inserted through the incision. The other end of the cannula was attached to a vacuum pressure unit that suctioned away the unwanted fat.

Several doctors are credited with being the first to develop this popular cosmetic technique, which originated in Europe. Names such as Yves-Gerard Illouz, MD, (Paris, France) and Giorgio Fischer, MD, (Rome, Italy) are often cited. Joseph Schrudde, MD, of Cologne, Germany, however, has been called the "Father of Lipoplasty" for work published as early as 1972.

According to an article on the development of lipoplasty authored by Eugene Courtiss, MD, ("Liposuction: Some Memories and Thoughts," Aesthetic Surgery Journal, March/April, 1997), "Suction Curette Removal of Excessive Local Deposits of Subcutaneous Fat" by V.K. Kesselring, MD, (Lausanne, Swtizerland), was the first published English-language paper on lipoplasty. At the 1980 ASAPS Annual Meeting, plastic surgeon Bahman Teimourian, MD, presented, "A Different Approach to Lipodystrophies: Suction and Curettage," recognized as the first paper on suction surgery presented at a national meeting in the United States. There was initial skepticism, but wide interest among American surgeons soon followed, and before long lipoplasty was a frequent subject in the popular media.

ASAPS Responds to FDA
In 1984, the U.S. Food and Drug Administration (FDA) requested clinical proof of the safety and efficacy of lipoplasty equipment and devices. That same year, ASAPS funded research to demonstrate that the equipment was safe and warranted a more favorable device classification. In 1988, ASAPS petitioned the FDA to reclassify suction lipoplasty systems for use in aesthetic body contouring. The request was considered by the FDA's advisory panel and, in 1989, the panel recommended reclassification to a lower risk category, a significant recognition of the procedure's safety.

Lipoplasty Techniques Expand to Meet Patient Demands
In the early years of lipoplasty, the procedure was primarily used to treat localized fat collections in young, active patients. The introduction of smaller instrumentation that gave surgeons greater control and precision also increased the safety of the procedure. Over time, with further advances in instrumentation, anesthesia techniques, and postoperative recovery, the range of patients who could be considered as suitable candidates for lipoplasty became much broader. Soon patients began asking for treatment of diffusely large thighs, hips or abdomens in addition to localized fat deposits, and "circumferential lipoplasty" involving larger volumes of aspirated fat became an accepted technique.

In these more extensive procedures, blood loss was frequently sufficient to require transfusion. The tumescent technique was developed to virtually eliminate the need for blood replacement. It involves the infusion of wetting solution - often a sterile fluid containing a salt solution, low concentrations of lidocaine (a local anesthetic) and adrenaline (a naturally-occurring hormone) - into the areas of localized fatty deposits. This technique, however, has the potential for creating a serious imbalance of body fluids, and problems attributable to over-injection of wetting solution eventually would mar the good safety record of lipoplasty procedures.

To address the potential problems associated with the tumescent technique, the "superwet" technique was developed, and some surgeons began using this new method as early as 1986. With the superwet technique, instead of the very large volume of wetting solution used in the tumescent technique, a small-volume dilute solution of local anesthetic and a vasoconstrictor is infiltrated into the surgical areas. Pre-injection of fluids in a volume equal to the volume of fat to be removed decreased blood loss, swelling, bruising and discomfort, and significantly increased the overall safety of lipoplasty.

In 1995, the introduction of Ultrasound-assisted Lipoplasty (UAL) heralded a new era of high technology in lipoplasty surgery. ASAPS was instrumental in organizing accredited educational programs for board-certified plastic surgeons to learn proper use of UAL technology, which was felt to offer certain advantages in removing fat from fibrous tissues as well as possibly reducing tissue trauma. Other technologies, such as External Ultrasound-assisted Lipoplasty, followed.

In 1998, Power-assisted Lipoplasty (PAL) appeared on the scene, with a major advantage of reducing surgeon fatigue associated with traditional techniques.

VASER®-assisted Lipoplasty (VAL), a more advanced version of the original Ultrasound-assisted Lipoplasty (UAL) technology, was among other new methods that began to be investigated during the latter part of the decade.

Lipoplasty Safety Becomes an Issue
As new instrumentation and techniques were introduced, and physicians found they could satisfy patient desires for removal of greater amounts of fat, the incidence of complications began to rise. In addition, patient demand for cosmetic surgery, coupled with financial incentives, had encouraged many doctors to venture outside their specialty training and begin performing lipoplasty - with or without any surgical training. The results were, in some cases, disastrous.

By 1997, according to ASAPS statistics, there were more than 175,000 lipoplasty procedures being performed annually. (Consult the ASAPS statistics section for past and current statistics.) At the same time that lipoplasty was increasing in popularity, however, the safety of lipoplasty was being questioned by many physicians, state medical boards and the media. Published reports of a growing number of patient deaths associated with lipoplasty procedures were inconsistent with the previous safety record of lipoplasty established over more than a decade of experience.

Plastic Surgeons Form Lipoplasty Task Force
Board-certified plastic surgeons were concerned and, in 1997, formed a task force to investigate the current state of lipoplasty safety. Their research led to increased efforts by ASAPS and other plastic surgery organizations to re-educate plastic surgeons about risk reduction in lipoplasty procedures. Several measures were identified as ways to increase patient safety, including: 1) using stricter patient selection criteria, 2) limiting the length of surgery, 3) avoiding pre-injection of excessive amounts of fluid and local anesthetic, 4) removing a smaller volume of fat, 5) avoiding the combination of lipoplasty and certain other procedures, and 6) careful postoperative monitoring.

Beginning in mid-1998, the safety record of lipoplasty performed by board-certified plastic surgeons appears to have improved dramatically. In May 2001, a major survey on lipoplasty safety was published in Aesthetic Surgery Journal, the peer-reviewed journal of the American Society for Aesthetic Plastic Surgery. The survey, covering many thousands of lipoplasty procedures performed by ASAPS members from September 1998 through August 2000, showed that the risk of death from lipoplasty performed as an isolated procedure (not in combination with any other surgeries) was 1 per 47,415 procedures, a nearly 10-fold decrease from rates suggested by earlier published surveys.

ASAPS Urges Regulatory Action
During the past several years, ASAPS representatives have testified before various state medical boards reviewing lipoplasty safety issues, urging these boards to adopt stricter standards for physician credentials and surgical facility accreditation. Any physician can legally perform lipoplasty, and other cosmetic surgical operations, regardless of the appropriateness of his or her specialty training.

ASAPS continues to recommend certification by the American Board of Plastic Surgery (ABPS) as a credential to perform lipoplasty. ABPS-certified surgeons have received at least five years of surgical and plastic surgical training after medical school, and are well qualified to perform lipoplasty procedures.

Lipoplasty can be safely performed in a hospital, outpatient surgical facility or office surgical facility. However, ASAPS has urged states to require accreditation of any surgical facility in which lipoplasty, or other major cosmetic procedures, are performed. Patients undergoing office-based lipoplasty are urged to verify that their surgeon has privileges to perform lipoplasty in an accredited hospital.

Lipoplasty Now
The generally more conservative approach to lipoplasty adopted by board-certified plastic surgeons since 1998, and the subsequent drop in mortality suggested by new research, has helped to reassure the public that they can again feel confident about the safety of lipoplasty. As medical technology continues to advance, there will be new developments in lipoplasty techniques. Computer-assisted surgery may someday enable plastic surgeons to achieve even greater precision in fat removal. With the strictest patient selection and in the hands of a qualified plastic surgeon trained in the proper technique, large volume lipoplasty (LVL) may prove to be a valuable tool for reducing some of the co-morbid conditions associated with being overweight. Fat tissue removed by lipoplasty may prove to be an ideal source for stem cells that can potentially be "engineered" for use in reconstructive surgery and cosmetic enhancements such as breast augmentation.

Whatever advances lie ahead, it is ASAPS' position that lipoplasty technology is secondary to the skill of the surgeon. Every surgery has risks, but selecting a qualified, board-certified plastic surgeon can help to ensure both patient safety and satisfaction.

Glossary of Lipoplasty Terms:

• Suction-assisted Lipoplasty (SAL): The traditional method, by which the surgeon removes fat by inserting a small, hollow tube (cannula) connected to a vacuum pressure unit, directing the cannula into areas to be suctioned through tiny incisions.
• Ultrasound-assisted Lipoplasty (UAL): Sound waves are transmitted to the tip of the cannula to liquefy fat before it is removed by suction.
• External Ultrasound-assisted Lipoplasty (E-UAL): External ultrasound waves alter fat cells. The area is injected with fluid containing local anesthetic to transmit ultrasonic energy and liquefied fat is removed by suction.
• Power-assisted Lipoplasty (PAL): A cannula with a back and forth motion of the tip passes through tissue to suction out fat and fibrous or scarred tissue with reduced effort.
• VASER®-assisted Lipoplasty (VAL): Intermittent, or continuous bursts of ultrasonic energy can be used to break up fat cells which are then removed by suction.

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