Tumescent liposuction - how do you achieve evenness?

[platypus768]

Hello Doctors,
   I have a question about tumescent liposuction.
   As far as I understand it a solution is injected into an area and then fat/solution is sucked out through a thin liposuction cannula. How does a surgeon know that he/she is removing the fat evenly? What if the solution is not injected evenly, or if there are areas with higher lymphatic drainage that might affect whether the liquid stays or is removed quickly, or areas with scaring ...etc. What if some areas have a tendency to swell more then others, .... wouldn't that lead to uneven results?
   Is the solution injected through a cannula? How is that done to ensure even distribution of the solution? And does that matter?

   Thank you for your answers.
   Regards,
      David

[DrBermant]

Hello Doctors,
   I have a question about tumescent liposuction.
   As far as I understand it a solution is injected into an area and then fat/solution is sucked out through a thin liposuction cannula. How does a surgeon know that he/she is removing the fat evenly? What if the solution is not injected evenly, or if there are areas with higher lymphatic drainage that might affect whether the liquid stays or is removed quickly, or areas with scaring ...etc. What if some areas have a tendency to swell more then others, .... wouldn't that lead to uneven results?
   Is the solution injected through a cannula? How is that done to ensure even distribution of the solution? And does that matter?

   Thank you for your answers.
   Regards,
      David

This is surgical sculpture, an art based on technique, skill, and experience. Each doctor has his or her own methods. Even sculpture results is not the only thing at risk. Even placement of the Tumescent Technique Solution and then meticulous contouring of remaining tissue are critical not only for sculpting, but also for Patient Comfort, swelling and bruising after gynecomastia surgery.

Over the years I evolved my techniques to achieve these goals. Methods I have used include using less tumescent fluid and getting the fluid absorbed first so that residual contour issues and not the distortion of the fluid reveal themselves during the operation. I use micro infiltration cannula at a low flow rate to better disperse the tumescence. At the extremely dense juncture of gland and areola, I use a very fine injection needle to get my local anesthesia into that critical plane for my technique of going after the gland first. I use time to permit the fluid to disperse and equilibrate before starting my work. Both for the infiltration and the sculpture, the variation of tissue density defines the task at hand. There is soft fat, firm fat, soft gland, firm gland, scars, adhesion, and other issues that make this work the art form I have described. Choice of sculpting tool needs to evolve during the operation. Beyond targeting gland first, the Dynamic Technique selects from my artist's pallet of surgical options and tools based on what is happening during surgery. One cannula just does not fit all. I will vary my Liposuction Cannula based both upon feel and what the suction is producing. Too aggressive a tool can deplete an area too fast beyond repair. I then progress with finer and finer sizes to refine the sculpture. Choice of tool also impacts on the damage to the tissue left behind. That is why I avoid cell bursting or exploding ultrasonic and other variations of that format.

Evaluation of how successful any particular sculptor in this case must also take into consideration how the tissue moves after surgery and by what path they had to take to get there. The body should look good more than just a single still view. The male chest should look good living lift, raising arms up overhead, flexing, playing sports, and activities with the shirt off. Movies are even more critical than flexing photos. Scars, uneven tissue, defects, adhesion, and other factors can otherwise ruin a result that looks good on a still picture with the arms at the side. Each bruise and additional swelling means potentially slower healing, longer recovery, and less comfort. That is why checking out progression after surgery photographs can have value in assessing a particular method. In the optimal situation, peak swelling occurs at surgery and progressively decreases after then.

Over my life, I have sculpted wood, plastic, clay, stone, metal, light, and even sound for artistic achievement. It is the above aspects of sculpting the human body that began my fascination with the subject. Beyond that I have been trying to capture the emotion behind the deformity and adding healing the emotional scars as well. That is what my work on videos of my patient experiences has moved towards. It used to be just the healing and movement of the body. Now it is documenting the emotion component as well. Trying to help people to heal those scars as well and move on with their lives is just as critical mission as restoring a contour.

So, even results are a staring point for the sculpture process. The success of surgery goes way beyond that.

Hope this helps,

Michael Bermant, MD
Learn More About Gynecomastia and Male Breast Reduction

[Dr. Elliot Jacobs]

To answer your question simply and directly:  ALL surgeons use tumescent solution for liposuction.  The usual ingredients are lidocaine (a local anesthetic), epinephrine (adrenaline -- to help constrict tiny blood vessels and minimize bleeding) and saline (salt water -- which softens the tissues and makes them mushy and easier to be removed).

Tumescent solution is evenly injected with a micro-cannula in all areas to be suctioned and then some time is given for the medications to work.  Then liposuction is performed. 

This all occurs in a relatively brief period of time so there is really no influence by adjacent lymphatics.

Even removal of tissue is done by feel, by pinch and of course, is dependent on the surgeon's skill and experience.

Dr Jacobs

[platypus768]

Thank you to both doctors.
Does tumescent liposuction remove or damage also connective tissue (superficial fascia) or muscle fascia or is it very selective in removing only fat?
Thank you,
    David

[Dr. Elliot Jacobs]

The purpose of tumescent lipo is to tighten the blood vessels (to limit bleeding during/after surgery) and to make the tissues softer and easier to remove.  The actual removal of any tissue is in the hands of the surgeon through the use of his instruments.

Dr Jacobs

[platypus768]

The purpose of tumescent lipo is to tighten the blood vessels (to limit bleeding during/after surgery) and to make the tissues softer and easier to remove.  The actual removal of any tissue is in the hands of the surgeon through the use of his instruments.

Dr Jacobs

Thank you Dr. Jacobs.
To clarify my question: Does the movement of a liposuction cannula remove all tissues indiscriminately? Or does it tend to remove only fat and leave connective tissues undamaged? The cannulas have suction holes in it, does it suck out the connective tissues also or only the softer fat?
As far as I know the cannulas are blunt, but can they damage fascia?

    David

[Dr. Elliot Jacobs]

Any instrument, if wielded improperly, can result in unwanted damage to adjacent tissues.  That is what I meant when I said it was "in the hands of the surgeon."

Blunt liposuction cannulas can indeed injure tissues other than fat -- it is up to the experience and expertise of the surgeon using the instrument to make sure that it doesn't happen.

Dr Jacobs

[DrBermant]

Thank you to both doctors.
Does tumescent liposuction remove or damage also connective tissue (superficial fascia) or muscle fascia or is it very selective in removing only fat?
Thank you,
    David

Different liposuction cannula tend to injure tissue to different degrees. The earliest liposuction cannula had a sharp cutting opening which cut through everything when new. The damage, bruising, and swelling was terrible and this was quickly abandoned by those using it (I never tried that aggressive a cannula). Other cannula designs incorporated varying degrees of sharp edges that could still damage the tissues to different degrees. However even a nonaggressive cannula can be put where it does not belong. I have reviewed disasters where inept surgeons put their liposuction cannula through the stomach wall injuring intestines and other structures inside. I have seen patients from other surgeons with disrupted muscle fascia and muscle torn from attachments from liposuction. I have had to incorporate the repair of other surgeons' muscle and fascia injury into my contouring of that patient's chest to get results that looked good on animation.

Again this is part of the skill and art of this surgery and why picking the surgeon for gynecomastia is like picking a sculptor for your chest.

Hope this helps,

Michael Bermant, MD
Learn More About Gynecomastia and Male Breast Reduction