**4. Progressing from mechanical liposuction to energy delivery liposculpture**

Liposuction in a large number of countries in the world is the most popular cosmetic surgical procedure. It is safe with pleasing cosmetic immediate visible results, which improve with the passage of time. In our experience in all liposuction and liposculpture techniques although results are immediate; however, they continue to improve for 6 months following the procedure, and the patients are counselled accordingly.

The evolution of liposuction into liposculpture was facilitated by advancement in technology from the early manual devices using vacuum and blunt cannulas into energy delivery machines including Laser and VASER.

#### **4.1 Mechanical liposuction (SAL)**

The 1980s and 1990s saw the introduction of three types of mechanical liposuction. Suction assisted liposuction is a traditional method of liposuction using a blunt small cannula connected to a pressurised vacuum machine. Through a small incision the fluids infiltrated and the cannula inserted to extract the fat by high-pressure vacuum connected through suction tubing made of either polyvinylchloride or silicone [22].

The suction pump has two different performance diameters, maximum vacuum and maximum flow rate. The canisters come in different sizes from 250 ml to 3000 ml and can be reusable or disposable. Big choice of suction cannulas with different sizes, different function and all are reusable [22].

The procedure can be done under local anaesthetic depending on the area treated. It is less tiring than the syringe liposuction and faster for the surgeon to remove fat, however, it risks trauma to blood vessels and nerves.

Although (SAL) can remove the superficial fat, this comes at higher risks to the skin and its blood supply. Bruising and potential of longer recovery are also risks that have to be considered in this technique.

### **4.2 Syringe assisted liposuction (SaL)**

Syringe liposuction technique (SaL) with blunt cannulas to extract the fat by syringe generated negative pressure and the syringe is single use [23].

The syringe technique can be slow and tiring for the surgeon to treat large areas. That is why it is recommended in treating small areas [23]. One of its advantages; it can be done under local anaesthetic as a day case or even an outpatient surgery.

The syringe technique is safe procedure; however, it has limitations. These include difficulty extracting superficial fat in addition to being challenging in treating secondary liposuction because of the resistance as a result of scar tissue [23].

#### **4.3 Power assisted liposuction (PAL)**

PAL implements either circular or reciprocating quick movements cannulas to aspirate fat. Mechanical cannula extracts the fat with small incision and shorter surgical time making it less tiring [24].

The power assisted liposuction technology was getting very popular for fat extraction and body contouring procedures. The vibrating cannula during the fat extraction makes it easier and less challenging in extracting more fibrous fat [24].

The power assisted liposuction technology has improved the surgeon's experience especially in large volume liposuction, fibrous areas, secondary work including in more superficial tissue planes. Surgeons fatigue and time is decreased during the procedure thus speeding the rate of fat extraction delivering good results for patients wishing body contouring [25].

Added benefits of PAL include intraoperative pain reduction, less swelling, and faster recovery. Fat harvested is 45% faster compared to suction assisted liposuction and syringe liposuction [26].

Another advantage of PAL is using the medinorm self-contained tank and the tubing system that guarantees the sterility. The whole system is latex free, and the harvested fat is less bloody than the manual liposuction and almost pure yellow colour making it useful for fat transfer [27].

In summary the PAL system is a convenient, fully sterile, time saving method to aspirate fat in various part of the body. This fat can also be used to transfer in other parts of the body. Furthermore donor site morbidity is minimised; and as time is saved it becomes less tiring for the surgeon and safer for the patient.
