Liposuction Practices among Brazilian Surgeons
Condutas em lipoaspiração entre cirurgiões brasileiros

INTRODUCTION

Charles Dujarier first performed liposuction in the 1920s by curettage of adipose tissues¹. At the time, it presented a great number of complications.

In 1982, Illouz² revolutionized the procedure by using a rhombus instrument connected to a suction device. This technique gained considerable popularity for drastically reducing complications. Today, it is the best treatment for adipose tissue. In the 1990s, Klein³ introduced the tumescent liposuction method, and Zocchi⁴ reported the use of ultrasound-assisted liposuction.

In 2015, it was the second most commonly performed plastic surgery in the world, with 1,394,588 cases according to the International Society for Aesthetic Plastic Surgery (ISAPS). In Brazil, it was the most commonly performed plastic surgery, with 182,765 cases⁵.

The Brazilian Society of Plastic Surgery exhibits similar numbers, with liposuction accounting for one-third (32%) of all procedures performed by surgical specialists in the country⁶. Nearly 16.07% of the legal cases in plastic surgery are due to liposuction⁶.

Despite its importance, a standard for conducting the procedure⁷ still does not exist, much less a uniformity in teaching surgeons in training.

Liposuction has potentially lethal complications. Grazer and Jong⁸ reported that the cause in 23% of the deaths was pulmonary thromboembolism, followed by abdominal perforation in 14.6% of cases.

A study on standardization may reduce these complications and increase the patients’ safety.

ObjeCtivE

To provide a sample of liposuction practices by different plastic surgeons from Brazil.

METHODS

A questionnaire (Annex 1) was given to surgeons of different age groups and from regions of Brazil who were registered and present at the 52^nd Brazilian Conference for Plastic Surgery, which took place on November 12-15, 2015 in Belo Horizonte, Minas Gerais. The study followed the principles of the Declaration of Helsinki during its elaboration, and the participants authorized publication of the results.

RESULTS

A total of two hundred forty-three (n = 243) questionnaires were filled out and received.

Each interviewee was asked to perform a liposuction procedure on the anterior and posterior torso (Figure 1). The number of incisions varied from 2 to 16, with an average of 9 incisions per surgery (Figure 2). Two hundred twenty-eight (94%) surgeons preferred to position the incisions in locations covered by underwear or swimwear. One hundred eighty-five (76%) made incisions on the umbilical scar. One hundred ninety-four (80%) surgeons positioned the scar on the median/paramedian line and 18 (7.5%) made an incision on the lateral region between the anterior and posterior axillary lines.

Figure 1 - Back of questionnaire with diagram for positioning incisions.

Figure 1 - Back of questionnaire with diagram for positioning incisions.

Figure 2 - Graph demonstrating the number of incisions made by each surgeon.

Figure 2 - Graph demonstrating the number of incisions made by each surgeon.

Regarding movement vectors, most of the surgeons conduct movements in the medial region to both the anterior and posterior lateral regions (99% and 97%, respectively). Movement of the lateral areas to the medial region was performed by 5% and 11% of the surgeons, respectively.

Given that a large volume of fat was to be removed, 219 (90%) surgeons affirmed that they performed deep liposuction under Scarpa’s fascia. At the same time, 143 (59%) surgeons advocated superficial liposuction for better body contours (Figure 3).

Figure 3 - Graph demonstrating the depth of the liposuction procedures performed by the surgeons.

Figure 3 - Graph demonstrating the depth of the liposuction procedures performed by the surgeons.

Nearly half of the interviewees administered general anesthesia to perform the procedure. One hundred seven (44%) surgeons used epidural anesthesia, and 15 (6%) used spinal anesthesia.

Two hundred nine (86%) surgeons changed the patient’s position during surgery using both the prone and supine positions. Just 34 (14%) surgeons performed liposuction only in the supine position (Figure 4).

Figure 4 - Graph showing the patient’s position during the liposuction procedure.

Figure 4 - Graph showing the patient’s position during the liposuction procedure.

One hundred twenty-six (52%) surgeons observed the pressure on the liposuction apparatus; 87 (36%) surgeons performed the procedure under controlled pressure.

DISCUSSION

A large quantitative and qualitative variation in incisions was observed. The number varied nearly by 800%. The literature defends performing the least amount of incisions possible that can allow appropriate liposuction of the desired area and the perpendicular crisscross subcutaneous tunnels⁹. Correct positioning of the incisions also means reducing the exposure of the resulting scars⁹, which has been observed in 94% of the cases.

Most surgeons provide access for the liposuction from the median/paramedian line, both in the anterior and posterior regions (99% and 97% respectively). This median/paramedian access might explain why a significant number of professionals (86%) need to change the patient’s position for dorsal liposuction.

Liposuction with the patient in the prone position must be performed with an emphasis on adequate monitoring of the patient, in order to avoid potential complications such as cervical lesions, ocular lesions, air embolism, venous thromboembolism¹⁰, bradycardia, and cardiac arrest^10,11. In this questionnaire, complications related to position change were 5%; however, they were all systemic and potentially serious.

Most of the interviewees (90%) performed deep liposuction, in order words, under Scarpa’s fascia. Although the literature argues that superficial liposuction increases the chances of local complications such as scar contractures, skin dyschromia, and abrasions¹², nearly 60% of the specialists still utilize this technique. A small portion (9%) of surgeons defended superficial liposuction only due to apprehensions regarding cavity perforation.

No anesthetic technique was predominant. The anesthesia technique administered depended on the preference of the surgeon or that of the center where the procedure was performed. However, in large-volume liposuctions, the use of general anesthesia was advised due to the important risks of vasodilation and hypertension¹¹. General anesthesia allows more control over the utilization of drugs, the patient’s movements, and the handling of air passageways¹³. In Brazil, we verified that the majority of the procedures were performed with general anesthesia, followed by the use of epidural anesthesia, with a considerable portion of the procedures utilizing it.

The surgeons demonstrated little preoccupation (35%) with observing and/or controlling the pressure on the liposuction apparatus. The lack of a definition of an ideal pressure in the literature to this very day leaves an important variable open. There are already authors that defend low-pressure liposuction, which would reduce blood loss and local trauma¹⁴. This fact was recently corroborated in works on lipografting that demonstrates cellular damage at elevated negative pressures (≥13.5 PSI)¹⁵. If there is a correlation among negative pressure, tissue damage, and systemic inflammatory response in the postoperative phase, controlling the pressure must be considered a routine part of the surgeons’ practice.

CONCLUSION

In conclusion, liposuction practice in Brazil presents a great diversity of techniques and little standardization.

There is a need for further studies on the most performed plastic surgery procedure in Brazil. Further studies are required to improve knowledge and standardize its practice, as well as identify ideal methods of teaching it, with the objective of reducing the number of intercurrences and increasing patient safety.