**4. Evolution of liposuction**

Describing the evolution of body contouring procedures would be entirely inadequate without presenting the chronologic events in the development of closed liposuction techniques. For certain, the most significant advancement in body contouring WITH OR WITHOUT concomitant excision of skIn and subcutaneous fat was the development of closed liposuction.

Removing excess fat from localized body sites is not a new idea [11]. In 1921, in France, Charles Dujarrier tried to remove subcutaneous fat using a uterine curette on a dancer's calves and knees [12]. Unfortunately, he damaged the femoral artery, and the patient has lost her leg. One of the original and creative initiatives came from Schrudde in 1964, when he extracted fat from lower areas of the limb, through a visibly small incision, utilizing a curette. The unfortunate results from this surgical initiative were unpleasant hematomas and seromas [13]. Pitanguy, on the other hand, was in favor of a removal of both fat and skin in a block, in order to remove excess thigh adiposities in one act [14]. Of course, this was an excisional procedure, not closed liposuction. Significant visible incisions made this method quite unpopular and made closed, non-excisional, procedures preferred, but, at that time, not discovered. The field of modern liposuction began with the technique and new instruments developed by Arpad and Fischer [15, 16]. During their work in Rome, Italy, they managed to develop a blunt hollow cannula, with additional function of suction. Some of the previous cannula designs contained a cutting blade also. They made their results public in 1976 [17] Fischer also started the crisscross tunnel formation method, from several incision sites. The new instruments brought very promising results avoiding the above complications.

#### *History of Body Contouring DOI: http://dx.doi.org/10.5772/intechopen.99098*

Kesselring and Meyer [18] published their surgery results of sharp curettage aided by a suction device in 1978, but their method did not receive a wide acceptance. Fournier, in Paris, showed an early interest in the Fischer's liposculpture technique [19]. He was an initial enthusiast of the "dry technique" in which no fluids were infiltrated into the patient prior to liposuction. Fournier would become a world leader in liposuction and fat transplantation, eventually insisting on the benefits of tumescent anesthesia and making a great contribution in opening new horizons and ideas to surgeons from different parts of the world. Illouz, a French gynecologist, was quite attracted by the Fishers' work. His preferred method was the"wet technique", which consisted of a solution of hypotonic saline together with hyaluronidase inserted into the adipose tissue before the aspiration. Lllouz thought that the solution itself was a "dissecting hydrotomy" which would catalyze the removal of fat and thus reduce trauma, as there was smaller amount of bleeding. Lllouz received worldwide publicity and promoted this method. The first US surgeon to visit France to learn the new area of liposuction was Lawrence Field in 1977, a Californian dermatologic surgeon. Other surgeons from the States, coming to conferences and educating themselves about new methods in the literature, also showed an interest in the area. One of them was Norman Martin, an otolaryngologist. He visited Illouz in 1980 and quickly started with liposuction surgeries in Los Angeles in 1981 [20, 21]. It was 1982 when a group of physicians from various specialty disciplines received lectures from Illouz and Fournier. At the annual meeting of the American Society of Plastic Surgeons (known at that time as The American Society of Plastic and Reconstructive Surgeons) in 1982, Dr. Illouz, for the first time in front of an audience of Board Certified Plastic Surgeons presented his technique of closed liposuction utilizing hollow cannulas of 1 cm in diameter connected to a suction pump with one atmosphere of negative pressure to extract fat that was pretreated with his wetting solution. The photographs (presented in carousel slide format) showed pre and pos-op photos of women who underwent liposuction of their "saddle bags" with only one cm. scars. This was remarkable in light of the existing treatment option which required large incisions (as published by Pitanguy) for the performance of dermo-lipectomies of this area. After this meeting, a task group formed by the American Society of Plastic and Reconstructive Surgeons visited Europe to learn and form opinions about this new procedure. Several pioneers in the closed technique of liposuction visited Dr. Fred Grazer after the national presentation in 1982 and I had the privilege of attending this small group course. Dr. Frank Ashley, former Chairman of the Division of Plastic Surgery at the University of California attended as well to learn this revolutionary technique. Dr. Grazer named this new procedure Suction Assisted Lipectomy. Important pioneers in the closed liposuction technique had developed cannulas which were quite aggressive when compared to the 5 mm and smaller cannulas in widespread use today. Schrudde, Kesselring, and Ilouz left their cannulas in Dr. Grazer's office and they are of historical importance as one studies the refinement in the performance of liposuction (**Figures 6–9**). Julius Newman, otolaryngologist and cosmetic surgeon, together with his associate Richard Dolsky, who was a plastic surgeon, together taught the first American course on liposuction, held in Philadelphia in 1982. The five live surgery workshops were held in Hollywood, California, in June 1983, under the authority of the American Society of Cosmetic Surgeons and the American Society of Liposuction Surgery. There were altogether 10 dermatologists in attendance. The American Society of Plastic Surgeons and The American Society for Esthetic Plastic Surgery subsequently developed teaching courses and symposia to teach closed liposuction to fully trained, Board Eligible and Board Certified Plastic Surgeons. Subsequently, the core curriculum in accredited Plastic Surgery Resident Training Programs included didactic and hands-on training in liposuction.

#### **Figure 6.**

The development of the Tumescent (from Latin meaning swollen or being swollen) Technique for performing Liposuction, described in publications by Dr. Jeffrey Klein [22–26], a Dermatologist, had an enormous impact in the safe and more easily performed liposuction procedure. The formula currently includes Lidocaine 2%, Sodium Bicarbonate, and Epinephrine (1–1,000,000), added to 1 liter of Sodium Chloride (if Ringers Lactate is substituted for Normal Saline, sodium bicarbonate is not added to the solution). The tumescent technique was modified such that only a 1:1 or 1.5:1 ratio of tumescent fluid to expected aspiration volume is injected rather than a 2 or 3:1 ratio which was the initial ratio in the Klein tumescent solution. The introduction of the tumescent liposuction technique allowed for the office- based removal of fatty deposits under no sedation, minimal Class 1 sedation, intravenous sedation, or general anesthesia. (Safe guidelines and other safety considerations are described below).

As the number of cases increased dramatically over the years, important additions to the options in body contouring occurred. Lockwood's observance and, perhaps the discovery, of the SFS (superficial fascial system) [27–29] resulted in his landmark publications wherein he utilized this fascial system for important

**Figure 7.** *Examples of first generation suction cannulas.*

**Figure 8.** *Examples of first generation suction cannulas.*

support of elevated soft tissue flaps including abdominal and lower extremity flaps that were elevated and repositioned to correct soft tissue ptosis. Liposuction was a component of his body contouring procedures. Certainly, liposuction allowed remodeling of the abdomen and lower extremities combined with, based upon the clinical anatomical findings, surgical excision of excess skin and subcutaneous tissues. Prior to Lockwood's description of the SFS, lower extremity medial thigh lifts were accompanied by migrating, unattractive scars. He also utilized the SFS in his High Lateral Tension Abdominoplasty to obtain improved contours and favorable scars as a trade-off for important excision of redundant soft tissues.

**Figure 9.** *Examples of first generation suction cannulas.*

Prior to liposuction, upper extremity unwanted fatty deposits with or without accompanying excess skin required large excisions of skin and subcutaneous tissue with resultant unfavorable scars. Liposuction has allowed fatty deposits to be removed through small access incisions and the incisions needed for skin and subcutaneous tissue removal have decreased in length.

Combined with available energy-based devices, soft tissue retraction can be an important component to body contouring of the head and neck, extremities and anterior and posterior trunk.

Fat grafting, although introduced by Gustav Neuber (1850–1932) late in the 19th century [30], was authenticated and refined with the landmark work of Sydney Coleman [31]. He introduced structural fat grafting which required small amounts (macrografts) of fat carefully placed in parallel tunnels, separated by adjacent blood vessels which nourish the grafted fat. Without a doubt, his contribution brought fat grafting to the armamentarium of cosmetic physicians and surgeons with a method that proved that grafted fat, when obtained, processed, and carefully injected in tiny amounts (0.1 cc or less) survived. He also showed how the stem cell component of fat grafts rejuvenate the skin, improve dermatologic skin conditions, with improved texture, etc. Fat grafting has evolved to include soft tissue augmentation of the face and breast, revision of breast reconstruction, treatment of post-augmentation mammoplasty contour deformities (including capsular contracture), contour deformities from prior liposuction and/or skin and subcutaneous fat excisions, and treatment of depressed scars. It is included in High Definition Liposuction further defining the underlying abdominal wall musculature. Fat grafting has evolved to the production of smaller particles including nanofat introduced by Tonnard [32].

Recently, cosmetic surgeons have injected Tranexemic Acid (TXA) and have observed an impressive decrease in blood loss. It has been used intravenously and topically as well, but the addition of tranexemic acid to the liposuction infusion has seen its' application in closed liposuction. TXA is safe and its' application has been studied in other cosmetic procedures with a notable decrease in blood loss [33].

When one looks at the statistics regarding obesity and morbid obesity with 40% of Americans considered obese and 18% considered severely obese as of 2019 with severe obesity defined as a BMI greater than 35 (Research performed at the Harvard T.H. Chan School of Public Health) it is clear as to why liposuction which is consistently listed in position 1 or 2 of the 5 most frequently performed cosmetic

#### *History of Body Contouring DOI: http://dx.doi.org/10.5772/intechopen.99098*

surgical procedures in the U.S. and dermolipectomies (270,670 liposuction and 140,381 abdominoplasties performed by Board Certified Plastic Surgeons) are so popular, increasing in numbers yearly (American Society of Plastic Surgeons Annual Statistics, 2019). Moreover, bariatric procedures to treat morbid obesity have evolved in tandem with body contouring procedures to address excess skin throughout the body after significant weight loss.

In summary, Liposuction has evolved from the removal of fatty deposits in the neck, upper and lower extremities, and anterior and posterior trunk to artistic remodeling of the shape of the face, neck, extremities, and trunk, performed alone or in combined treatment with various energy based devices.
