2. History of suction-assisted lipectomy (SAL)

Patient and physician interest in limiting incisions and complications led to the development of liposuction in the late 1970s [1]. While Illouz [2] has commonly been given credit for coming up with liposuction as a new procedure, other surgeons before him used a combination of sharp cannulas without tumescent fluid to remove fat. German surgeons Schrudde, Meyer, and Kesselring performed liposuction in the early to the mid-1970s in such a manner [3]. Blood loss was significant, and clinical outcomes were not ideal.

The Fischers, a father and son team, developed a blunt liposuction cannula in the mid-1970s [4].

They treated only the thigh area. Frenchmen Illouz and Fournier spread the technique to other body regions and to other esthetic surgeons [5]. During the late 1970s, they began combining injection of intravenous fluid and hyaluronidase for the purpose of improving the ease of dissection. The term they used was "wet technique." Klein [6] is credited with the concept of tumescent fluid, which differs from the French wet technique by adding both epinephrine (to reduce intraoperative blood loss) and lidocaine (for pain reduction during the procedure, so that it could be performed while the patient was awake). Sodium bicarbonate was added to the injectable fluid in order to reduce burning on injection when general anesthesia was not used. The safety of infusing large volumes of this solution was documented in studies performed by the dermatologic surgery contingent, who focused on lidocaine toxicity [7]. The complication rate with liposuction was significant though [8], and the ASAPS recommended limiting large volumes of infusion and lipoaspirate over 5 L to the hospital setting [9].

Liposuction rapidly gained popularity but did not replace dermolipectomy, as limited skin surface area contraction was noted with SAL alone [10]. The development of energy-assisted liposuction was rapid and included ultrasound, laser, power, water-jet, shock wave, and radiofrequency-assisted liposuction [11–16].

While many new devices have been utilized during the past 20 years, few have attained the simultaneous goal of significant and esthetically acceptable skin contraction in the treatment region.

For decades, practitioners and patients alike have been focused on treating "skin laxity" without considering the true cause of the problem. Recent publications [17] show that the adipose/stromal framework of the skin may be a better treatment target. Rubin noted [18] that skin follows the substructure. If the scaffold or framework that the skin rests upon is weak or ptotic, the skin will follow, as it has no ability to hold a fixed shape on its own. If a practitioner chooses a device or treatment that does not target the framework, also known as the fibroseptal network (FSN), the goal of improving a pendulous structure will not be met without an excisional approach.

How does the skin become lax? Facial aging studies show that the average person loses 235 cc of bony mass during a lifetime [19]. Certainly, there is associated muscle and fat atrophy with aging [20, 21]. While fat loss in the face and neck is a normal part of the aging process, these factors do not explain the loss of soft tissue tone. Serial scanning electron micrographs were taken from volunteers of various ages and similar skin types [22]. These show that with age, weight gain and loss, and genetic predilection, the stromal portion of the adipose framework for the overlying skin becomes weak, due to loss of the fibrocollagenous matrix and involution of the vascular network.

While mechanical stimulation of the FSN with liposuction can create an 8% skin surface area contraction at 1 year posttreatment [23], the firm tone and defined shape of youthful body contours are not re-established. A thermal regenerative solution for this dilemma has been the focus of my energy-based device studies over the last decade.
