Thirtyfour years of liposuction: past, present and future.

Initial, variably successful attempts of fat sculpting date back to the beginning of the 20th Century, but Gerard Illouz was the first to introduce the modern, safe, widespread method of liposuction. Preoperative injection of local anaesthesia, saline, distilled water, adrenaline and hyaluronidase, defined wet technique, established as a safe and effective adjunct to lipoaspiration. This procedure was initially based on an automatic pump system, but then the accuracy of syringe aspiration was popularized by Toledo in the eighties. Liposuction in the subcutaneous tissue, just 3-4 mm deep to dermis, also called superficial liposuction, is a modern effective evolution of the technique, but requires a good mastery in order to avoid disfiguring outcomes. Ultrasound and laser lipoplasty methods have provided further advancement in the range of technical choices offered to the plastic surgeon. Liposuction is a purely surgical procedure, and as such, carries risks of minor and major complications. In the nineties, an interplay between abdominoplasty and abdominal liposuction as simultaneous procedures, also called lipoabdominoplasty, has become more and more popular. Reinjection of the harvested fat with the purpose of liposculpture for both reconstructive and cosmetic indications is a relatively recent development which has established as a successful, world-wide accepted procedure. Adipose stem cells, extracted from the unlimited source represented by human adipose tissue, are a great promise for future tissue-engineering. Liposuction has nowadays become a safe, effective, popular procedure for contouring adipose tissue and human body in general, in many reconstructive and cosmetic indications.

The value of a new filler material in corrective and cosmetic surgery: DermaLive and DermaDeep.

DermaLive is a long-term wrinkle reduction product including two types of components: pure hyaluronic acid, produced in cell culture, and an acrylic hydrogel. The product was first marketed in France and the rest of Europe in 1998. We have over three years of experience with this product. Several studies have been conducted simultaneously, mainly in Germany and in France. At present, DermaLive is used in the long-term correction of natural or acquired skin depressions (caused by aging, trauma) or the creation of volume (lips, sunken cheekbones). It provides a worthwhile alternative to good-quality bioresorbable materials (pure hyaluronic acid or collagen)--materials that are so resorbable, in fact, that most patients are ultimately dissatisfied with the results--and to other so-called permanent materials that patients do not tolerate well. Filling involving the use of autologous fat transplantations, which yields satisfactory results, is not appropriate for ambulatory injection and, therefore, will not be examined in detail. The tolerance experienced with DermaLive three years on is, at present, considered highly satisfactory. The wrinkle reduction effect obtained after the first injection is long-lasting with 60% resorption of the initial material. Two or three injections, with an interval of at least three months between each, may be required to bring about the reduction of some wrinkles or the correction of post-scar depressions. Side effects occurring long after the injection are rare (1.2 for 1,000). They appear mainly as palpable nodules occurring about six months after injection. They are treated by intralesional injection of corticoids. DermaLive and DermaDeep are both filler implants with a long-lasting effect designed for corrective and aesthetic surgery. Instruction of use and intervals between injection sessions must be respected. After DermaLive or DermaDeep injection, injections of pure hyaluronic acid (Juvederm or Restylane) for treatment of fine lines and superficial defects yield safe and excellent aesthetic results.

[Liposuction of the abdomen]. / La lipoaspiration au niveau de l'abdomen.

The abdomen is a difficult region for liposuction which can be responsible for serious systemic complications and local sequelae, which are difficult to correct. However, spectacular results can also be obtained in the abdomen, provided a very rigorous approach is observed at to each step: indications, technique, postoperative care. In most cases, when well conducted, abdominal liposuction can even avoid abdominoplasty, with all of the risks that it comprises.

[Isolated cervico-facial liposuction applied to the treatment of aging]. / Lipoaspiration cervico-faciale isolée appliquée au traitement du vieillissement.

Almost 20 years after its first application, liposuction is today a procedure commonly used on the cervicofacial region. This article emphasizes the importance of the isolated liposuction in the rejuvenating treatment of the face. Liposuction allows the correction of the fattening of the contours, but also of the sagging of the teguments thanks to the skin retraction. The reconstruction of a tridimensional image shows the importance and the constancy of the adipose tissue in the whole face, even in thin ones. The limits of this method are related to the existence of a skin with a sufficient elasticity of a not too important skin excess, and of a sufficient subcutaneous adipose tissue. In selecting the orientation of the tunnels according to the lines of skin tension, we are determining the concept of an orientated skin retraction. In the conclusions, the isolated tunnelization of the face, with or without liposuction seems to be a solution allowing either to delay for several years the time for facelift, or to suggest an alternative choice for patients who refuse or fear the principle of a facelift.

History and current concepts of lipoplasty.

Lipoplasty accomplishes the opposite of classic plastic surgery results. Instead of a long incision, there is a tiny one; instead of undermining, tunneling is performed; instead of redraping and resection of the skin, lipoplasty uses skin retraction. Retraction versus traction is the key principle of liposuction. The history and principles of lipoplasty are presented.

A new safe and aesthetic approach to suction abdominoplasty.

Suction abdominoplasties are associated with a number of surgical complications, mainly in obese people and diabetic patients. The aesthetic result is often spoiled by poor balance caused by improper distance between the "guide points" of an harmonious abdomen (e.g., minimum of 10 cm between the pubic scar and the umbilicus). Almost all surgical complications are caused by extensive undermining and can be avoided by an en bloc resection without any undermining (the suction lipectomy of the upper flat creates a "mesh undermining" which is almost as efficient). A new neo-umbilicoplasty, described here, can be situated in the "right position" with good aesthetic results.

Study of subcutaneous fat.

The main goal of this article is to demonstrate that biochemically, metabolically, histologically, embryologically, and anatomically there are two totally different types of subcutaneous fat. This fact has clinical and surgical consequences including the concept of dynamic and surface anatomy.

[A plea for a non-hemorrhagic aspiration lipectomy]. / Plaidoyer pour une aspiration non sanglante.

Lipoplasty is and must be an atraumatic procedure. The surgeon must aspirate fat but not blood. The main goals of this technical note are: to show the interest of a "white procedure", to describe the "tricks" to avoid bleeding, to summarise "how to do it".

[En bloc abdominoplasty: a new, safer and more esthetic technique]. / L'abdominoplastie en bloc: une nouvelle technique moins risquée et plus esthétique.

Suction abdominoplasties are associated with a number of surgical complications, mainly in obese people and diabetic patients. The aesthetic results is often spoiled by a poor equilibrium due to an incorrect distance between the "guide points" of an harmonious abdomen (e.g. min 10 cm between the pubic scar and the umbilicus). The author thinks that almost all surgical complications are induced by the extensive undermining and can be avoided by a "en bloc" resection without any undermining (the suction lipectomy of the upper flap creates a "Mesh Undermining" which is almost as efficient). A new neoumbilicoplasty described by the author can be situated in the "right position" with a good aesthetic result.

Refinements in the lipoplasty technique.

Careful attention to the proper indications, technique, and the traps of lipoplasty will decrease the incidence of complications and reward the surgeon with better results. The aesthetic complications of lipoplasty are multiple and varied and they may at times be disastrous. A thorough understanding of all the steps is the best way to avoid problems.

[Subcutaneous fatty tissue]. / Etudes du tissu graisseux sous-cutané.

Up until now, subcutaneous fat has been considered to be a distinct entity. Recent studies have demonstrated chemical and metabolic differences between 2 kinds of fat, mobile fat and fixed fat. The main aim of this article is to show that these differences also have histological, embryological and anatomical implications. Their surgical consequences are important for plastic surgery and lipoplasty procedures.

Discrepancy between glucose transport and transporters in human femoral adipocytes.

Obesity is known to be associated with insulin resistance in human and rat adipocytes. However, it is not known what are the perturbations in insulin action that contribute to disproportional femoral obesity. Thus femoral subcutaneous adipose tissue was obtained from lean women with various degrees of disproportional obesity, by liposuction. 3-O-methylglucose (3-O-methyl-D-glucopyranose) transport was measured in intact cells, and glucose transporter levels in plasma and low-density microsomal membranes were assessed using the cytochalasin B binding assay. A sixfold cellular enlargement was associated with increase in both basal and insulin-stimulated glucose transport activity in the intact cell, and a 300-600% increase in insulin stimulating effect per se. However, when glucose transporter levels were assessed, this cellular enlargement was accompanied by a 40-70% transporter depletion (in largest cells compared with smallest ones) in both subcellular fractions examined, from either basal or insulin-stimulated cells. This discrepancy, between increasing cellular glucose transport rates and relative depletion of transporter levels, suggests that these cells are not insulin resistant, as could be expected from their large size. A role for other factor(s), additional to glucose transporter levels, in the regulation of cellular glucose uptake rate is thus suggested.

Surgical implications of "fixed points": a new concept in plastic surgery.

The dynamic study of surface anatomy brings to light the existence of "fixed points." This new concept allows us to better understand the difficult problem of skin excess and the "crumpled" appearance sometimes seen after liposuction. Understanding this phenomenon will avoid unaesthetic or nonfunctional results of plastic surgery.

Present results of fat injection.

Long-term results for 167 cases of the fat injection technique performed between June 1983 and June 1987 are presented. During this four-year period, stable results appear to have been obtained in only a few cases. This report also includes the disappointing preliminary findings of attempts to use fat to fill wrinkles in the face. Although these preliminary long-term results may not be encouraging, various laboratory studies seem to demonstrate the hypothetical possibility of fat cell survival and tend to encourage continued research in this field.