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THE HISTORY OF LIPOSUCTION AND FAT TRANSPLANTATION IN AMERICA
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LIPOSUCTION
+ .OO
THE HISTORY OF LIPOSUCTION AND FAT TRANSPLANTATION IN AMERICA William I? Coleman, 111, MD
In 1975, Arpad and Giorgio Fischer, father and son Italian cosmetic surgeons, developed the modem technique of liposuction.” Prior to this, many physicians had attempted to sculpt hereditary deposits of excess fat using a curette subcutaneouslyz1The results were quite variable, with hematomas, seromas, skin unevenness, and frequent complications. 0thers favored en bloc resection of both fat and skin to recontour outer thigh adiposities. This resulted in a significant incision, and with time, reaccumulation of fat around the incision site leading to an unnatural deformity? The Fischer’s invention was a blunt hollow cannula attached to a suction source. Some of the prototypes of this device contained sharp blades within the cannulas. The Fischer’s developed a technique of criss-cross suctioning from multiple incision sites.l* As opposed to the curette, this new suction technique resulted in fewer hematomas and seromas and the final aesthetic result was smoother and more predictable. Illouz, in Paris, became interested in the Fischer’s work and developed modified equipment for performing liposuction. He recognized the impact of this new procedure and popularized it throughout France and later the world. Illouz gradually developed the “wet technique” in which a solution of saline and hyaluronidase was injected into the fat before suctioning. Illouz felt that this
approach decreased bleeding and made suctioning easier.I9 Fournier, who also worked in Paris, was an early proponent of a ”dry technique” in which no fluids were injected prior to the pr0~edure.l~ He felt that this approach was more accurate. He later abandoned this technique in favor of local infiltration of lidocaine, and eventually the tumescent technique, once he recognized the vasoconstriction afforded by this approach. Fournier refined the Fischer ’s technique based on criss-cross liposuction from several incision sites in order to give more even contouring. He also believed in taped compression to help support and mold the suctioned tissue postoperatively. Perhaps Fournier ’s greatest contribution, however, was his generous attitude toward teaching liposuction. He traveled the world teaching others this technique and inspiring them. In 1977, Larry Field, a California dermatologic surgeon, was probably the first American to visit France and leam the new technique of liposuction from the Italian and French pioneers.1° Other Americans gradually became aware of this new type of surgery. It was not until 1982, however, that a strong interest developed. A variety of medical specialists visited France that year. Rhoda Narins, a dermatologist from New York, probably became the first American woman to learn
From the Department of Dermatology, Tulane University School of Medicine, New Orleans, Louisiana
DERMATOLOGIC CLINICS VOLUME 17 * NUMBER 4 * OCTOBER 1999
723
724
COLEMAN
liposuction in 1982. Julius Newman, an otolaryngologist cosmetic surgeon, and his associate, Richard Dolsky, a plastic surgeon, directed a liposuction course in Philadelphia in late 1982.30Meanwhile, a ”Blue kbbon” committee from the American Society of Plastic and Reconstructive Surgeons visited France and returned to the United States to develop an official policy toward this new surgery. Interspecialty rivalry over liposuction began to intensify immediately8 Plastic surgeons insisted that they were the only surgeons qualified to perform this new type of surgery. Meanwhile, the American Academy of Cosmetic Surgery under the leadership of Richard Webster and Julius Newman developed live interspecialty liposuction teaching courses that were open to physicians from many different specialties. Newman coined the term ”Lip0 Suction” and founded the American Society of Liposuction From these early efforts, liposuction continued to evolve in the United States as more surgeons adopted the new technique. Liposuction education was initially based on live weekend training courses; however, by 1984, liposuction training was available in some dermatology and plastic surgery residency program^.^ Educational opportunities continued to grow as an increasing number of American surgeons were trained in this technique. The American Academy of Dermatology and the American Society for Dermatologic Surgery took a lead role in teaching liposuction. Liposuction became part of the Core Surgical Curriculum in Dermatology in 1987. The American Academy of Dermatology was the first specialty organization to approve Guidelines of Care for Liposuction in 1989.’ Dermatologists were interested in performing liposuction under local anesthesia. Comfortable in their office operating rooms and skilled in outpatient surgery, early liposuction procedures performed by dermatologists were small-volume cases of several hundred mL using local anesthesia with mild preoperative sedation; however, the size of these cases was limited by the recommended maximum dosage of lidocaine. The maximum dosage of lidocaine was thought to be 7 mg/ kg since 1947.28In 1985, dermatologist Jeffrey Klein introduced the tumescent technique for liposuction, which completely revolutionized thinking about local anesthetic infiltration into fat.22Klein was able to demonstrate that dilute concentrations of lidocaine were not ab-
sorbed systemically to the degree more concentrated solutions were, even when the total dosage was the same. Klein invented a recipe consisting of 0.05% lidocaine, 1:1,000,000 epinephrine, and 10 mL sodium bicarbonate per liter of saline, which could be infused into tissue prior to liposuction. He subsequently demonstrated that this solution could be used safely in dosages of up to 35 mg/kg when infiltrated into fat prior to l i p o s u ~ t i o nThe .~~ dilute epinephrine solution also vastly decreased blood loss during liposuction, which was a major problem prior to Klein’s development.5 Klein’s new concept allowed liposuction to be performed in larger volumes completely under local anesthesia without the need for sedation or general anesthesia. Dermatologic surgeons enthusiastically embraced Klein’s new approach for liposuction. Lillis demonstrated minimal blood loss when cases of over 3000 mL extracted were performed using the tumescent technique.25He verified Klein’s work demonstrating minimal plasma absorption of lidocaine when low concentration solutions were infused.26 The tumescent technique allowed dermatologic surgeons, who had formerly been performing liposuction in hospitals or using intravenous sedation, to develop office-based liposuction facilities where local anesthesia liposuction could be performed. Many plastic surgeons, on the other hand, continued to perform liposuction using general anesthesia with minimal infiltration of lidocaine. Autotransfusion of blood was required in many cases and patients experienced significant bruising and slow recovery from their proced u r e ~Gradually, .~ however, the tumescent technique came to be recognized throughout the world and was gradually embraced by all medical specialties. More recently, however, some surgeons have been employing the advantage of decreased blood loss from the tumescent technique to push the envelope on the size of procedures that they perform. It has become apparent, however, that when tumescent infiltration of large volumes of dilute lidocaine and epinephrine are combined with intravenous fluid replacement and general anesthesia, there are significantly increased risks of fluid overload, pulmonary edema, and drug interaction^.'^ Some plastic surgeons have blamed these problems on the tumescent technique itself17; however, Klein and others have pointed out that this altered use of the tumescent technique is the problem.24When
THE HISTORY OF LIPOSUCTION AND FAT TRANSPLANTATION IN AMERICA
the tumescent technique is used as local anesthetic approach for liposuction with minimal or no preoperative sedation and no intravenous fluids, there have been minimal complications and no documented fatalities.18 Also, malpractice data indicate that the potential for lawsuits is dramatically decreased when liposuction is performed in an office facility by dermatologists. Hospital-based liposuction, usually involving general anesthesia, results in 3.5 times as many laws~its.3~ Ultrasonic liposuction was introduced by Zocchi in 1992 as an alternative to conventional blunt cannula sucti0n.3~This technique involves the application of ultrasonic energy to fat cells prior to suctioning them. Zocchi hoped that this new technology would facilitate liposuction and preserve small neural and vascular structures that could be destroyed through blunt cannula liposuction. Ultrasonic liposuction was embraced initially in South American and Europe and then largely rejected after experience with skin sloughs, burns, ~ e r o m a s .35~ ~In, 1997, the American Society of Plastic and Reconstructive Surgeons made a dramatic commitment to ultrasonic liposuction and developed a series of educational courses for teaching their members about this new technology. This had the effect of promoting the use of these new devices among plastic surgeons. Dermatologic surgeons, on the other hand, after experimenting with ultrasonic liposuction, largely rejected this new technology. The consensus was that increased complications over-shadowed the minor benefit of less work for the surgeon. Interestingly, however, the need for a wet environment for ultrasonic liposuction to be properly performed inadvertently introduced many plastic surgeons to the tumescent technique. Those who were not using tumescent anesthesia for their standard liposuction cases were impressed with the dramatic decrease in bleeding afforded by tumescent anesthesia. Originally this decrease in blood loss was attributed to ultrasonic liposuction itself but it became quite clear after dermatologists began to use the new technique that there was no improvement in blood loss over standard blunt cannula liposuction using the tumescent technique. As of the time of publication of this article, the American Society for Dermatologic Surgery considers ultrasonic liposuction to be an experimental technique.37 Interspecialty rivalries over liposuction have been rekindled during the 1990s. As in-
725
creased numbers of physicians have begun to perform this technique, economic pressures have motivated some to attempt to restrict who should be allowed to do liposuction. There have been attempts in California, Florida, and other states to legislate the training required for liposuction and to limit the physical location in which it can be performed. Some of these legal maneuvers appear on the surface to be for the public good. Forcing liposuction out of the office environment and into the hospital, however, may well have the effect of increasing complications. Dermatologic surgeons have demonstrated that office liposuction units in which the tumescent technique is employed are the safest milieu for performing liposuction. Staffed with personnel who are experienced in dealing with liposuction and outfitted with the latest liposuction instrumentation, these office facilities are superior to a hospital or ambulatory surgery center where liposuction is performed only occasionally. Twenty-five years after the development of liposuction, it is clear that this is an interspecialty procedure. It is a technique that continues to evolve, becoming simpler, safer, and producing consistent results. Certainly, it will evolve further in the next 25 years as physicians and their patients continue to attempt to overcome hereditary fat distribution problems. FAT TRANSPLANTATION
Autologous fat transplantation has been performed for at least 100 years. In the later part of the 19th century, Neuber transplanted small fat grafts from the arm to soft tissue defects of the face.29During the first half of the 20th century fat transplantation became popular among many medical specialties. Neurosurgeons, orthopedists, thoracic surgeons, opthalmologists, and breast surgeons all employed fat transplants for a variety of indications. These procedures involved en bloc transplantation of fat harvested through an incision in the donor region. Transplantation to cutaneous and subcutaneous defects also involved an incision in the recipient site through which to implant the fat. Survival of the transplanted fat grafts was variable. Pee132studied fat transplantation extensively in the middle of the 20th century and hypothesized a 50% weight and volume loss of the fat graft after 1 year. Frustration
726
COLEMAN
with variable survival and the cosmetic problems of both donor and recipient incisions lead to physician disappointment with fat grafting by the 1950s. Dermal-fat grafts briefly became popular for soft tissue reconstruction3;however, the popularity of silicone lead to a loss of interest in autologous tissue grafts. With the onset of liposuction in the late 1970s, patients and physicians both began to question whether the extracted fat could somehow be used for soft tissue augmentation in other parts of the body. Illouz reawoke dormant interest in fat transplantation by demonstrating that the suctioned fat could be successfully reinjected into a distant recipient site.20Therefore, fat could now be transplanted without donor or recipient incisions. Interestingly, in 1911, Brunning had briefly demonstrated the feasibility of injecting fat grafts during rhinoplasty procedures4; however, there is no evidence that his work stimulated additional interest. Fournier worked to simplify the process of autologous fat transplantation. He demonstrated that using only local anesthesia or even chilled saline infiltration, fat could be extracted using a 13-gauge needle and then reinjected into a distant recipient defect.I3 Fournier typically harvested large volumes of fat using 50 mL syringes. Manual negative pressure developed by retracting the plunger was sufficient for rapid harvesting of fat. Others experimented with ”fat traps”, small containers spaced between two sections of sterile liposuction tubing, one attached to a standard cannula and the other to the aspiration machine. This enabled fat to be harvested during liposuction. In the US, Asken, Skouge et al, and Glogau pioneered refinements in fat transplantation techniques.2,16, 36 Meanwhile, Fournier, followed by Zocchi in Italy, began experimenting with ”autologous collagen” derived from After suction harvesting of fat he added distilled water and froze the suspension. Upon reheating, he discovered that many of the fat cells had ruptured, releasing their triglyceride contents. After centrifugation he discarded an oil infranate leaving only the cell walls of the adiposites. He hypothesized that these walls contained autologous collagen, which could then be used to reinject into dermal defects. Coleman and others subsequently demonstrated that the benefits of this dermal augmentation using ruptured fat cells occured primarily from stimulation of collagen at the recipient
site. They suggested the term ”lipocytic dermal augmentation” was more appr~priate.~ Sidney Coleman evolved the concept of lipostructure in the 199Os.‘jUsing large volumes of fat he was able to demonstrate significant improvement in facial contours, injecting very small amounts at various levels in the subcutaneous space. He felt this lead to better survival of the transplanted fat. Currently, fat transplantation appears to be increasingly popular among dermatologic surgeons. Perhaps in the future pharmacologic manipulation will allow even more long-lasting results. Fat remains the most easily accessible autologous tissue for soft tissue augmentation.
References 1. American Academy of Dermatology: Guidelines of care for liposuction. American Academy of Dermatology, revised. J Am Acad Dermatol 24289, 1991 2. Asken S Autologous fat transplantation: Micro and macro techniques. Am J Cosmet Surg 4:111-120,1987 3. Boering G, Huffstadt AJ: The use of derma-fat grafts in the face. Br J Plast Surg 20:172, 9165 4. Brunning P, cited by Broeckaert TJ: Contribution a l’etude des greffes adipeueses. Bull Acad Roy Med Belgique 2 8 4 0 , 1914 5. Chrisman €3, Coleman WP: Determining the maximum volume of liposuction before transfusion is required. J Dermatol Surg Oncol 141095-1102, 1988 6. Coleman SR Facial recontouring with lipostructure. Clin Plast Surg 24:347-367, 1997 7. Coleman WP I11 The dermatologist as a liposuction surgeon. J Dermatol Surg Oncol 141057, 1988 8. Coleman WP 111: The history of dermatologic liposuction. Dermatol Clin 8:381, 1990 9. Coleman WP 111, Lawrence N, Sherman RN, et a 1 Autologous collagen: Lipocytic dermal augmentation-A histopathologic study. J Dermatol Surg Oncol 19:1032, 1993 10. Field L: The dermatologist and liposuction-a history. J Dermatol Surg Oncol 13:1040,1987 11. Fischer A, Fischer G: First surgical treatment for molding body’s cellulite with three 5 mm incisions. Bull Int Acad Cosmet Surg 3:35, 1976 12. Fischer G: Liposculpture: The correct history of liposuction: Part I. J Dermatol Surg Oncol 16:1087, 1990 13. Fournier P:Facial recontouring with fat grafting. Dermatol Clin 8:523, 1989 14. Fournier P, Otten F: Lipodissection in body sculpturing: The dry procedure. Plast Reconstr Surg 75:598, 1983 15. Gilliland MD, Coctes N Tumescent liposuction complicated by pulmonary edema. Plast Reconstr Surg 99:215-219, 1997 16. Glogau R Microlipoinjection: Autologous fat grafting. Arch Dermatol 1241340-1343, 1988 17. Grazer FM, Meister F L Complications of the tumescent formula for liposuction. Plast Reconstr Surg 100:1893-1896, 1997 18. Hanke CW, Bemstein G, Bullock S: Safety of tumes-
THE HISTORY OF LIPOSUCTION AND FAT TRANSPLANTATION IN AMERICA cent liposuction in 15,336 patients: National Survey results. Dermatol Surg 21:459, 1995 19. Illouz Y Body contouring by lipolysis: A 5 year experience with over 3000 cases. Plast Reconstr Surg 72511, 1983 20. Illouz Y The fat cell ”graft” a new technique to fill depressions Plast Reconstr Surg 78:122, 1986 21. Kesselring LK, Meyer R A suction curette for removal of excessive local deposits of subcutaneous fat. Plast Reconstr Surg 62305, 1978 22. Klein JA: The tumescent technique for liposuction surgery. Am J Cosmetic Surg 4263-267,1987 23. Klein JA: Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction: Peak plasma levels are diminished and delayed 12 hours. J Dermatol Surg Oncol 16:248263,1990 24. Klein JA: The two standards of care for tumescent liposuction. Dermatol Surg 231194-1195,1997 25. Lillis PJ: Liposuction surgery under local anesthesia: Limited blood loss and minimal lidocaine absorption. J Dermatol Surg Oncol 1411451148, 1988 26. Lillis PJ: The tumescent technique for liposuction surgery. Dermatol Clin 8:439, 1990 27. Maxwell GP, Gingrass MK: Ultrasound-assisted lipoplasty: A clinical study of 250 consecutivepatients. Plast Reconstr Surg 101:189-204, 1998 28. Moore DC, Bridenbaugh DL, Thompson GE, et al: Factors determining dosages of amide-type anesthetic drugs. Anesthesiology 47263-268, 1977
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29. Neuber F: Fettransplantation. Chir Kongr Verhandl Dsch Gesellsch Chir 2266, 1893 30. Newman J: Liposuction surgery: Past, present, future. Am J Cosmet Surg 1:1, 1984 31. Newman J: Training in liposuction for dermatologists. Dermatol Clin 8851, 1990 32. Peer LA: Loss of weight and volume in human fat grafts with postulation of ”cell survival theory.” Plast Reconstr Surg 5:217,1950 33. Coleman WP III, Hanke CW, Lillis P, et al: Does the location of surgery or the specialty of the physician affect malpractice claims in liposuction? Dermatol Surg 25343,1999 34. Pitanguy I: Trochanteric dystrophy. Plast Reconstr Surg 34:280, 1964 35. Scheflan M, Tazi H Ultrasonically assisted body contouring Aesthetic Surg Quarterly 16117-122, 1996 Canning DA, Jefs RD Long-term survival 36. Skouge JW, of perivesical fat harvested and injected by microlipo injection techniques in a rabbit model. Presented at the 16th Annual American Society for Dermatologic Surgery Meeting, Fort Lauderdale, FL March 1989 37. Statement on ultrasonic liuosuction. The American society for dermatologic-surgery. Dermatol Surg 241035.1998 38. Zocchi M: Methode de production de collagene autologue par traitment du tissu graisseax. J de Medecine Esthetique et Chirurgie Dermatologique 17105,1990 39. Zocchi M: Ultrasonic liposculpturing. Aesth Plast Surg 16:287-298, 1992
Address reprint requests to William P. Coleman, III, MD 4425 Conlin Street Metairie, LA 70006
LIPOSUCTION
+ .OO
THE HISTORY OF LIPOSUCTION AND FAT TRANSPLANTATION IN AMERICA William I? Coleman, 111, MD
In 1975, Arpad and Giorgio Fischer, father and son Italian cosmetic surgeons, developed the modem technique of liposuction.” Prior to this, many physicians had attempted to sculpt hereditary deposits of excess fat using a curette subcutaneouslyz1The results were quite variable, with hematomas, seromas, skin unevenness, and frequent complications. 0thers favored en bloc resection of both fat and skin to recontour outer thigh adiposities. This resulted in a significant incision, and with time, reaccumulation of fat around the incision site leading to an unnatural deformity? The Fischer’s invention was a blunt hollow cannula attached to a suction source. Some of the prototypes of this device contained sharp blades within the cannulas. The Fischer’s developed a technique of criss-cross suctioning from multiple incision sites.l* As opposed to the curette, this new suction technique resulted in fewer hematomas and seromas and the final aesthetic result was smoother and more predictable. Illouz, in Paris, became interested in the Fischer’s work and developed modified equipment for performing liposuction. He recognized the impact of this new procedure and popularized it throughout France and later the world. Illouz gradually developed the “wet technique” in which a solution of saline and hyaluronidase was injected into the fat before suctioning. Illouz felt that this
approach decreased bleeding and made suctioning easier.I9 Fournier, who also worked in Paris, was an early proponent of a ”dry technique” in which no fluids were injected prior to the pr0~edure.l~ He felt that this approach was more accurate. He later abandoned this technique in favor of local infiltration of lidocaine, and eventually the tumescent technique, once he recognized the vasoconstriction afforded by this approach. Fournier refined the Fischer ’s technique based on criss-cross liposuction from several incision sites in order to give more even contouring. He also believed in taped compression to help support and mold the suctioned tissue postoperatively. Perhaps Fournier ’s greatest contribution, however, was his generous attitude toward teaching liposuction. He traveled the world teaching others this technique and inspiring them. In 1977, Larry Field, a California dermatologic surgeon, was probably the first American to visit France and leam the new technique of liposuction from the Italian and French pioneers.1° Other Americans gradually became aware of this new type of surgery. It was not until 1982, however, that a strong interest developed. A variety of medical specialists visited France that year. Rhoda Narins, a dermatologist from New York, probably became the first American woman to learn
From the Department of Dermatology, Tulane University School of Medicine, New Orleans, Louisiana
DERMATOLOGIC CLINICS VOLUME 17 * NUMBER 4 * OCTOBER 1999
723
724
COLEMAN
liposuction in 1982. Julius Newman, an otolaryngologist cosmetic surgeon, and his associate, Richard Dolsky, a plastic surgeon, directed a liposuction course in Philadelphia in late 1982.30Meanwhile, a ”Blue kbbon” committee from the American Society of Plastic and Reconstructive Surgeons visited France and returned to the United States to develop an official policy toward this new surgery. Interspecialty rivalry over liposuction began to intensify immediately8 Plastic surgeons insisted that they were the only surgeons qualified to perform this new type of surgery. Meanwhile, the American Academy of Cosmetic Surgery under the leadership of Richard Webster and Julius Newman developed live interspecialty liposuction teaching courses that were open to physicians from many different specialties. Newman coined the term ”Lip0 Suction” and founded the American Society of Liposuction From these early efforts, liposuction continued to evolve in the United States as more surgeons adopted the new technique. Liposuction education was initially based on live weekend training courses; however, by 1984, liposuction training was available in some dermatology and plastic surgery residency program^.^ Educational opportunities continued to grow as an increasing number of American surgeons were trained in this technique. The American Academy of Dermatology and the American Society for Dermatologic Surgery took a lead role in teaching liposuction. Liposuction became part of the Core Surgical Curriculum in Dermatology in 1987. The American Academy of Dermatology was the first specialty organization to approve Guidelines of Care for Liposuction in 1989.’ Dermatologists were interested in performing liposuction under local anesthesia. Comfortable in their office operating rooms and skilled in outpatient surgery, early liposuction procedures performed by dermatologists were small-volume cases of several hundred mL using local anesthesia with mild preoperative sedation; however, the size of these cases was limited by the recommended maximum dosage of lidocaine. The maximum dosage of lidocaine was thought to be 7 mg/ kg since 1947.28In 1985, dermatologist Jeffrey Klein introduced the tumescent technique for liposuction, which completely revolutionized thinking about local anesthetic infiltration into fat.22Klein was able to demonstrate that dilute concentrations of lidocaine were not ab-
sorbed systemically to the degree more concentrated solutions were, even when the total dosage was the same. Klein invented a recipe consisting of 0.05% lidocaine, 1:1,000,000 epinephrine, and 10 mL sodium bicarbonate per liter of saline, which could be infused into tissue prior to liposuction. He subsequently demonstrated that this solution could be used safely in dosages of up to 35 mg/kg when infiltrated into fat prior to l i p o s u ~ t i o nThe .~~ dilute epinephrine solution also vastly decreased blood loss during liposuction, which was a major problem prior to Klein’s development.5 Klein’s new concept allowed liposuction to be performed in larger volumes completely under local anesthesia without the need for sedation or general anesthesia. Dermatologic surgeons enthusiastically embraced Klein’s new approach for liposuction. Lillis demonstrated minimal blood loss when cases of over 3000 mL extracted were performed using the tumescent technique.25He verified Klein’s work demonstrating minimal plasma absorption of lidocaine when low concentration solutions were infused.26 The tumescent technique allowed dermatologic surgeons, who had formerly been performing liposuction in hospitals or using intravenous sedation, to develop office-based liposuction facilities where local anesthesia liposuction could be performed. Many plastic surgeons, on the other hand, continued to perform liposuction using general anesthesia with minimal infiltration of lidocaine. Autotransfusion of blood was required in many cases and patients experienced significant bruising and slow recovery from their proced u r e ~Gradually, .~ however, the tumescent technique came to be recognized throughout the world and was gradually embraced by all medical specialties. More recently, however, some surgeons have been employing the advantage of decreased blood loss from the tumescent technique to push the envelope on the size of procedures that they perform. It has become apparent, however, that when tumescent infiltration of large volumes of dilute lidocaine and epinephrine are combined with intravenous fluid replacement and general anesthesia, there are significantly increased risks of fluid overload, pulmonary edema, and drug interaction^.'^ Some plastic surgeons have blamed these problems on the tumescent technique itself17; however, Klein and others have pointed out that this altered use of the tumescent technique is the problem.24When
THE HISTORY OF LIPOSUCTION AND FAT TRANSPLANTATION IN AMERICA
the tumescent technique is used as local anesthetic approach for liposuction with minimal or no preoperative sedation and no intravenous fluids, there have been minimal complications and no documented fatalities.18 Also, malpractice data indicate that the potential for lawsuits is dramatically decreased when liposuction is performed in an office facility by dermatologists. Hospital-based liposuction, usually involving general anesthesia, results in 3.5 times as many laws~its.3~ Ultrasonic liposuction was introduced by Zocchi in 1992 as an alternative to conventional blunt cannula sucti0n.3~This technique involves the application of ultrasonic energy to fat cells prior to suctioning them. Zocchi hoped that this new technology would facilitate liposuction and preserve small neural and vascular structures that could be destroyed through blunt cannula liposuction. Ultrasonic liposuction was embraced initially in South American and Europe and then largely rejected after experience with skin sloughs, burns, ~ e r o m a s .35~ ~In, 1997, the American Society of Plastic and Reconstructive Surgeons made a dramatic commitment to ultrasonic liposuction and developed a series of educational courses for teaching their members about this new technology. This had the effect of promoting the use of these new devices among plastic surgeons. Dermatologic surgeons, on the other hand, after experimenting with ultrasonic liposuction, largely rejected this new technology. The consensus was that increased complications over-shadowed the minor benefit of less work for the surgeon. Interestingly, however, the need for a wet environment for ultrasonic liposuction to be properly performed inadvertently introduced many plastic surgeons to the tumescent technique. Those who were not using tumescent anesthesia for their standard liposuction cases were impressed with the dramatic decrease in bleeding afforded by tumescent anesthesia. Originally this decrease in blood loss was attributed to ultrasonic liposuction itself but it became quite clear after dermatologists began to use the new technique that there was no improvement in blood loss over standard blunt cannula liposuction using the tumescent technique. As of the time of publication of this article, the American Society for Dermatologic Surgery considers ultrasonic liposuction to be an experimental technique.37 Interspecialty rivalries over liposuction have been rekindled during the 1990s. As in-
725
creased numbers of physicians have begun to perform this technique, economic pressures have motivated some to attempt to restrict who should be allowed to do liposuction. There have been attempts in California, Florida, and other states to legislate the training required for liposuction and to limit the physical location in which it can be performed. Some of these legal maneuvers appear on the surface to be for the public good. Forcing liposuction out of the office environment and into the hospital, however, may well have the effect of increasing complications. Dermatologic surgeons have demonstrated that office liposuction units in which the tumescent technique is employed are the safest milieu for performing liposuction. Staffed with personnel who are experienced in dealing with liposuction and outfitted with the latest liposuction instrumentation, these office facilities are superior to a hospital or ambulatory surgery center where liposuction is performed only occasionally. Twenty-five years after the development of liposuction, it is clear that this is an interspecialty procedure. It is a technique that continues to evolve, becoming simpler, safer, and producing consistent results. Certainly, it will evolve further in the next 25 years as physicians and their patients continue to attempt to overcome hereditary fat distribution problems. FAT TRANSPLANTATION
Autologous fat transplantation has been performed for at least 100 years. In the later part of the 19th century, Neuber transplanted small fat grafts from the arm to soft tissue defects of the face.29During the first half of the 20th century fat transplantation became popular among many medical specialties. Neurosurgeons, orthopedists, thoracic surgeons, opthalmologists, and breast surgeons all employed fat transplants for a variety of indications. These procedures involved en bloc transplantation of fat harvested through an incision in the donor region. Transplantation to cutaneous and subcutaneous defects also involved an incision in the recipient site through which to implant the fat. Survival of the transplanted fat grafts was variable. Pee132studied fat transplantation extensively in the middle of the 20th century and hypothesized a 50% weight and volume loss of the fat graft after 1 year. Frustration
726
COLEMAN
with variable survival and the cosmetic problems of both donor and recipient incisions lead to physician disappointment with fat grafting by the 1950s. Dermal-fat grafts briefly became popular for soft tissue reconstruction3;however, the popularity of silicone lead to a loss of interest in autologous tissue grafts. With the onset of liposuction in the late 1970s, patients and physicians both began to question whether the extracted fat could somehow be used for soft tissue augmentation in other parts of the body. Illouz reawoke dormant interest in fat transplantation by demonstrating that the suctioned fat could be successfully reinjected into a distant recipient site.20Therefore, fat could now be transplanted without donor or recipient incisions. Interestingly, in 1911, Brunning had briefly demonstrated the feasibility of injecting fat grafts during rhinoplasty procedures4; however, there is no evidence that his work stimulated additional interest. Fournier worked to simplify the process of autologous fat transplantation. He demonstrated that using only local anesthesia or even chilled saline infiltration, fat could be extracted using a 13-gauge needle and then reinjected into a distant recipient defect.I3 Fournier typically harvested large volumes of fat using 50 mL syringes. Manual negative pressure developed by retracting the plunger was sufficient for rapid harvesting of fat. Others experimented with ”fat traps”, small containers spaced between two sections of sterile liposuction tubing, one attached to a standard cannula and the other to the aspiration machine. This enabled fat to be harvested during liposuction. In the US, Asken, Skouge et al, and Glogau pioneered refinements in fat transplantation techniques.2,16, 36 Meanwhile, Fournier, followed by Zocchi in Italy, began experimenting with ”autologous collagen” derived from After suction harvesting of fat he added distilled water and froze the suspension. Upon reheating, he discovered that many of the fat cells had ruptured, releasing their triglyceride contents. After centrifugation he discarded an oil infranate leaving only the cell walls of the adiposites. He hypothesized that these walls contained autologous collagen, which could then be used to reinject into dermal defects. Coleman and others subsequently demonstrated that the benefits of this dermal augmentation using ruptured fat cells occured primarily from stimulation of collagen at the recipient
site. They suggested the term ”lipocytic dermal augmentation” was more appr~priate.~ Sidney Coleman evolved the concept of lipostructure in the 199Os.‘jUsing large volumes of fat he was able to demonstrate significant improvement in facial contours, injecting very small amounts at various levels in the subcutaneous space. He felt this lead to better survival of the transplanted fat. Currently, fat transplantation appears to be increasingly popular among dermatologic surgeons. Perhaps in the future pharmacologic manipulation will allow even more long-lasting results. Fat remains the most easily accessible autologous tissue for soft tissue augmentation.
References 1. American Academy of Dermatology: Guidelines of care for liposuction. American Academy of Dermatology, revised. J Am Acad Dermatol 24289, 1991 2. Asken S Autologous fat transplantation: Micro and macro techniques. Am J Cosmet Surg 4:111-120,1987 3. Boering G, Huffstadt AJ: The use of derma-fat grafts in the face. Br J Plast Surg 20:172, 9165 4. Brunning P, cited by Broeckaert TJ: Contribution a l’etude des greffes adipeueses. Bull Acad Roy Med Belgique 2 8 4 0 , 1914 5. Chrisman €3, Coleman WP: Determining the maximum volume of liposuction before transfusion is required. J Dermatol Surg Oncol 141095-1102, 1988 6. Coleman SR Facial recontouring with lipostructure. Clin Plast Surg 24:347-367, 1997 7. Coleman WP I11 The dermatologist as a liposuction surgeon. J Dermatol Surg Oncol 141057, 1988 8. Coleman WP 111: The history of dermatologic liposuction. Dermatol Clin 8:381, 1990 9. Coleman WP 111, Lawrence N, Sherman RN, et a 1 Autologous collagen: Lipocytic dermal augmentation-A histopathologic study. J Dermatol Surg Oncol 19:1032, 1993 10. Field L: The dermatologist and liposuction-a history. J Dermatol Surg Oncol 13:1040,1987 11. Fischer A, Fischer G: First surgical treatment for molding body’s cellulite with three 5 mm incisions. Bull Int Acad Cosmet Surg 3:35, 1976 12. Fischer G: Liposculpture: The correct history of liposuction: Part I. J Dermatol Surg Oncol 16:1087, 1990 13. Fournier P:Facial recontouring with fat grafting. Dermatol Clin 8:523, 1989 14. Fournier P, Otten F: Lipodissection in body sculpturing: The dry procedure. Plast Reconstr Surg 75:598, 1983 15. Gilliland MD, Coctes N Tumescent liposuction complicated by pulmonary edema. Plast Reconstr Surg 99:215-219, 1997 16. Glogau R Microlipoinjection: Autologous fat grafting. Arch Dermatol 1241340-1343, 1988 17. Grazer FM, Meister F L Complications of the tumescent formula for liposuction. Plast Reconstr Surg 100:1893-1896, 1997 18. Hanke CW, Bemstein G, Bullock S: Safety of tumes-
THE HISTORY OF LIPOSUCTION AND FAT TRANSPLANTATION IN AMERICA cent liposuction in 15,336 patients: National Survey results. Dermatol Surg 21:459, 1995 19. Illouz Y Body contouring by lipolysis: A 5 year experience with over 3000 cases. Plast Reconstr Surg 72511, 1983 20. Illouz Y The fat cell ”graft” a new technique to fill depressions Plast Reconstr Surg 78:122, 1986 21. Kesselring LK, Meyer R A suction curette for removal of excessive local deposits of subcutaneous fat. Plast Reconstr Surg 62305, 1978 22. Klein JA: The tumescent technique for liposuction surgery. Am J Cosmetic Surg 4263-267,1987 23. Klein JA: Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction: Peak plasma levels are diminished and delayed 12 hours. J Dermatol Surg Oncol 16:248263,1990 24. Klein JA: The two standards of care for tumescent liposuction. Dermatol Surg 231194-1195,1997 25. Lillis PJ: Liposuction surgery under local anesthesia: Limited blood loss and minimal lidocaine absorption. J Dermatol Surg Oncol 1411451148, 1988 26. Lillis PJ: The tumescent technique for liposuction surgery. Dermatol Clin 8:439, 1990 27. Maxwell GP, Gingrass MK: Ultrasound-assisted lipoplasty: A clinical study of 250 consecutivepatients. Plast Reconstr Surg 101:189-204, 1998 28. Moore DC, Bridenbaugh DL, Thompson GE, et al: Factors determining dosages of amide-type anesthetic drugs. Anesthesiology 47263-268, 1977
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29. Neuber F: Fettransplantation. Chir Kongr Verhandl Dsch Gesellsch Chir 2266, 1893 30. Newman J: Liposuction surgery: Past, present, future. Am J Cosmet Surg 1:1, 1984 31. Newman J: Training in liposuction for dermatologists. Dermatol Clin 8851, 1990 32. Peer LA: Loss of weight and volume in human fat grafts with postulation of ”cell survival theory.” Plast Reconstr Surg 5:217,1950 33. Coleman WP III, Hanke CW, Lillis P, et al: Does the location of surgery or the specialty of the physician affect malpractice claims in liposuction? Dermatol Surg 25343,1999 34. Pitanguy I: Trochanteric dystrophy. Plast Reconstr Surg 34:280, 1964 35. Scheflan M, Tazi H Ultrasonically assisted body contouring Aesthetic Surg Quarterly 16117-122, 1996 Canning DA, Jefs RD Long-term survival 36. Skouge JW, of perivesical fat harvested and injected by microlipo injection techniques in a rabbit model. Presented at the 16th Annual American Society for Dermatologic Surgery Meeting, Fort Lauderdale, FL March 1989 37. Statement on ultrasonic liuosuction. The American society for dermatologic-surgery. Dermatol Surg 241035.1998 38. Zocchi M: Methode de production de collagene autologue par traitment du tissu graisseax. J de Medecine Esthetique et Chirurgie Dermatologique 17105,1990 39. Zocchi M: Ultrasonic liposculpturing. Aesth Plast Surg 16:287-298, 1992
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