**2. The history of liposuction**

Liposuction is defined as a technique in cosmetic surgery for removing excess fat from under the skin by suction. In this section we have focused on the history of evolution of this procedure since its inception, however, we excluded all the techniques, which originated early in the 20th century including excision or curating of adipose tissue [1, 2].

More than 4 decades elapsed when in 1975 a father and son cosmetic surgery team developed the technique of liposuction by introducing a cannula attached to a suction machine. In so doing they produced consistent results with lower risks [3].

Illouz in 1977 innovated modified liposuction blunt end cannulas of smaller diameter. He used cannulas of varied sizes thus extending the technique to the entire body. He injected saline and hyaluronidase into the fat prior to suctioning, allowing for hydro-dissection; hence reducing trauma to other tissues. This was the advent of the wet technique [4, 5].

Although initially the evolution in liposuction was related to the refinement of the blunt end cannulas the surgery was performed under general anaesthetic and in some instance without injecting fluid to hydro-dissect, which lead to significant blood loss in the lipo-aspirate.

The main evolution in the last 4 decades, however, has been with the anaesthesia and the composition of the fluid injected allowing the surgery to be performed under local anaesthetic with sedation and later also excluding sedation. This was popularised by Klein in 1987 using large volumes of very dilute local anaesthetic allowing for larger volume of lipo-aspirate and under local anaesthetic only [1, 2, 6–8].

Klein's infusion mixture included 0.05% Lidocaine, 1:1000,000 epinephrine and 10 mls of 8.4% bicarbonate per litre of saline. He also demonstrated that a large volume of this diluted mixture was safe, however, it also significantly reduced bleeding. Bleeding was a problem when using other techniques [6–8]. The tumescent technique meant less hospitalisation, reduced costs and risks to the patient even for large volumes of lipo-aspirate [9].

Liposuction uses a vacuum pump (a suction machine), however, in 1988 Toledo in Brazil used disposable syringes on which can be fitted blunt end cannulas. This technique allowed for more precision and refinement in liposuction in addition to usability of the fat to transfer. This gave the cosmetic surgeon choice; the vacuum pump assisted liposuction was used for large volumes and for more refined liposuction the syringe system was used [10, 11].

In 2006 laser assisted liposuction using coherent light to deliver energy preferentially targeting fat cells was a new advancement in liposuction surgery. The laser caused rupture of the adipocyte membrane releasing oily content into the extracellular matrix. The laser energy also leads to neocollagen formation and remodelling with reorganisation of the dermis. The fluid produced in this process was then aspirated using blunt end cannulas and a vacuum pump [12, 13].

Ultrasonic liposuction was first introduced in 1992 by Zochhi; it created an alternative to conventional blunt cannulas suction. The aim was to ease the surgeon workload, shorten surgical time, improve results of liposuction, and use smaller cannula, thus reducing tissue trauma and protecting important structures like the neurovascular bundles [14].

The ultrasonic technology required the tumescent technique to combine with the technology for safer outcomes. Titanium probes were used to deliver ultrasonic energy, followed by liposuction.

Refinement of ultrasound energy delivery using VASER technology (vibration amplification of sound energy at resonance), was first reported by Jewell on the clinical application of a third generation ultrasound device that deliver utilised

*The Safe Evolution of Liposuction into Liposculpture DOI: http://dx.doi.org/10.5772/intechopen.97351*

pulsed low power ultrasound with high efficiency using different size small diameter strong titanium probes [15].

The energy applied to the tissues was approximately one-quarter that of previous devices, while the pulsed mode reduced heat generation. Expanded applications of VASER lipolysis and liposculpture include treatment of the male and female breast, face and neck; fibrous body areas (trunk and back), in addition to combined excisional body contouring procedures of all types [16].

Colombian plastic surgeon Alfredo Hoyos presented a vast improvement in technique in 2003 at a national Colombian meeting. Hoyos innovated the high definition liposcultpure HDL [17].

Hoyos elaborated that the nomenclature liposcultpure is not simple fat removal, but an artistic approach designed to sharpen the anatomy of the muscles through the skin. VASER high definition liposcultpure combines technology and technique unlike mechanical liposuction it reduces trauma to blood vessels, achieve better result, and removes superficial and deep fat. This allows for high levels of finesse in sculpting the human-form three-dimensional anatomy thus sharpening the body muscles details at the same time [17].
