History of Liposuction

Darwinian natural selection theory dictates that individuals who choose mates with biological/survival advantages will be rewarded with children likely carrying those same advantages.

And for the great majority of human history, you could demonstrate biological advantage by being *fat*.

  • Fat meant not being hungry, at a time when most were hungry.
  • Fat meant generous harvests and a generous table, when most were scrounging for a living.
  • Fat meant being an employer, or a merchant, or a member of the nobility…..
  • Fat meant modelling for Peter Paul Rubens.

Today, fat no longer indicates wealth and status and, rightly or wrongly, suggests the opposite. Therefore, its removal for aesthetic reasons is more of a concern today than it would have been in centuries past, even if they’d had the capacity to do so back then.

It is generally held that the first reported case of an attempt being made to remove undesired fat, by subcutaneous approach, for cosmetic purposes, was that of Dr Charles Dujarrier, a French obstetrician who in 1921 was seeking to help a young dancer wanting thinner ankles and knees. His approach was to use a uterine curette (essentially a tiny sterile spoon on a long handle) to remove the undesired fat. No doubt the attempt was noble, but the results were unfavourable, as it happened.

Then in the 1960s the favoured approach was that of plastic surgery’s great pioneer, Dr Ivo Pitanguy of Brazil. His technique (then) was “dermolipectomy”, involving the en bloc excision of skin together with underlying fat. This gave results that were considered good by the standards of the time (i.e. this result or nothing) and patients looked improved whilst in clothes, but the price was paid in the form of long unsightly scars.

Attempts were made in the 1960s to remove fat by suctioning using sharp cannulas, the idea being to cut then aspirate the fat, but such an approach could not avoid cutting vessels and nerves along with the fat. Unacceptable vessel and nerve damage resulted, and no such technique gained any favour, despite attempts being made to sharp-cut fat as late as 1978 by Kesselring and Meyer.

Dr Giorgio Fischer

I cannot tell you how, in 1976, father-and-son Italian gynaecologists Arpad and Giorgio Fischer hit upon the idea of using blunt cannulas instead, but it was a “eureka’ moment. They must have observed that fat globules are relatively loosely attached to surrounding structures and supported by very fine vessels that would easily give way. They would have observed that more critical structures such as larger vessels and nerves were somewhat stouter and, by virtue of their shapes, less likely to be easily sucked away. Or, perhaps they were just using old cannulas that had become blunt with use, and the discovery was serendipitous. Either way, these revered liposuction pioneers were then able to offer a technique for fat removal that exceeded the results of Pitanguy’s dermolipectomy.

The Fischers contributed in two more important ways.

They recognised that if a fatty area was subject to liposuction from one access point only, a streaky result would ensue, with ridges and valleys parallel to the movement line of the aspirating cannula. So, quite simply, they pioneered liposuctioning a site along two perpendicular lines, from two (or more) access points. This is quite simply called “criss-crossing” (as non-obscure a medical term as you will ever likely find), and their inspiration may have been as banal as observing a five-year-old colouring in.

Secondly, they coined the term “liposculpture”.

And their work attracted the attention of Drs Yves Illouz and Dr Pierre Fournier, both considered further co-pioneers of liposuction (Success, as we know, always has many fathers, whilst failure is inevitably an orphan). Their contribution was to introduce the so-called “wet technique” of liposuction. The idea (again quite simple in retrospect) was to introduce watery fluid (saline) into the area being proposed for treatment. This extra fluid had the effect of separating out the lobules of fat, compressing blood vessels (to further reduce bleeding) and making the aspiration process more efficient. Results were better again and the technique was a success.

At this time, all but the smallest liposuction procedures were being performed in a hospital environment under general anaesthesia. Performing liposuction under local anaesthetic may have been considered often, but every doctor “knew” the maximum allowable dose of local anaesthetic (lignocaine/lidocaine) was only 7mg per kg body weight, and that wasn’t enough to do very much.

Dr Jeffrey Klein

Enter to our story Dr Jeffrey Klein, a Californian dermatologist. Considering subcutaneous fat to be so closely related to skin as to be the territory of the dermatologist, Dr Klein was keen to treat subcutanous fat in the office setting familiar to all dermatologists. And, as a dermatological surgeon daily cutting bumps and what-not out of skin, he was as familiar as anyone with lignocaine.

He knew that adding adrenaline (“epinephrine”, if you prefer) to lignocaine made it last much longer in its effect on skin – might this mean it was thence distributed more slowly into the blood stream? Might this slower redistribution allow a larger dose to be used with equivalent safety?

He also knew that lignocaine was often used in concentrations unnecessarily high, increasing risk without increasing anaesthesia. After all, numb is numb – once sensation is fully lost, adding more lignocaine can’t make it any loster.

So he started experimenting with the “wet technique” of Illouz and Fournier, adding adrenaline and lignocaine to the saline being used to expand the fatty tissue for best-practice liposuction at the time. First he used standard concentrations, then increasingly smaller concentrations, looking for the minimum concentration that would deliver the anaesthesia he needed to perform liposuction.

This turned out to be 0.05% lignocaine (buffered with sodium bicarbonate) and 1:1,000,000 adrenaline.

Using such a dilute anaesthetic solution allowed Dr Klein to safely administer larger volumes of this solution into sites for liposuction, and this became known as his “tumescent technique”. It was 1987 and liposuction was thence able to break out of the confines of the hospitals, free itself from the need for general anaesthetic, and develop as the office-based procedure it is today.

And armed with anaesthetic fluid of this concentration, the next question became – how much of this solution can be used safely? in 1990 Dr Klein demonstrated that by using his formula lignocaine could be administered at a total body dose of 35mg per kg body weight without leading to any problematic blood levels of lignocaine arising. This was fully seven times as high as the previously “known” limit, and allowed quite significant areas of fat to be treated safely in an office environment. And more research established the safe upper limit even further: a 1996 research paper demonstrated the safety of 55mg lignocaine per kg body weight when using Klein’s formula.

Tumescent technique, office-based liposuction using blunt cannulas and a criss-cross approach: the basic principles of modern liposuction were established now 33 years ago.

But that’s not to say other novelties have not been introduced….

Other surgeons have looked at further improving the technique of liposuction in other ways.

In 1992 a Dr Zocchi published on the idea of using ultrasound-generated heat to help reduce the workload of liposuction and to induce better skin contraction after such procedures. At first ultrasound was applied externally, and later via the aspirating cannula, but, either way, ultrasound-assisted liposuction proved no better than regular liposuction, and even caused skin burns. So not all apparent technological novelties end up being real advances.

Then in 2006 Kim and Geronemus published on laser assisted lipolysis: so-called “SmartLipo”. The idea was that that by shooting a fine laser beam through fat that at globules and cells would be broken up and thence removed more easily. As with ultrasound-assisted liposuction, it is conjectured that the added heat would assist with skin contraction to produce a smoother final outcome.

Subsequent studies (Katz 2008) (Regula and Lawrence 2014 : “Ultimately, while laser lipolysis is effective for localized fat reduction, data is lacking to show its superiority to tumescent liposuction.”) have not convincingly demonstrated that the addition of laser devices to regular liposuction is worth the additional expense.

2012 saw the introduction of the VASER device as the latest in a long line of devices hoping to offer a marginal advantage. Time will tell whether this device becomes standard, although one must think history is against it. Certainly, the added steps implicit in introducing such technologies bring added complication potential.

In conclusion, there is no safer way to perform liposuction than by the now-long-established method we employ at Peach ūüôā

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