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发表时间:2015-12-08 浏览次数:555次
Introduction
Five thousand years ago, the ancient Egyptian mummification methods were
based on removal of all internal organs and subcutaneous fat except the
heart, they used the liposuction technique via a small hole to aspirate
the whole body contents. [1]
The traditional dry liposuction technique was introduced more than 50
years ago. The term liposculpture was introduced by Teimouria and Fisher [2] and Fournier and Otteni [3] who advocated also the criss-cross technique.
Illouz [4] developed the wet tumescent liposuction that helped in standardization and refinement of this technique in 1977. Field, [5]
an American dermatologist, started the procedure in USA using the
Fischer's suction machine. The first American liposuction course was
taught 1982 by Dolsky et al.[6]
In 1987, Klein [7]
developed a formula of 0.05% lidocaine, 1:1,000,000 epinephrine, and 10
mL of bicarbonate and a liter of normal saline. The Klein formula
allowed large liposuction to be done under local anesthesia and provided
patient a painless 24 h postoperatively.
Zocchi in 1992, [8]
presented a revolutionary body contouring technique based using
ultrasound energy. This allows selective destruction of lipocytes by
means of cavitation and elimination of the fluid fraction (fatty acids).
The ultrasound waves stimulate the collagen in deep dermis and initiate
lifting of the skin.
In 1992, Apfelberg [9]
described the use of laser assisted lipolysis. Laser-assisted
liposuction uses laser energy lasers heat the fat, turning it semi-soft
and making it easier to remove via liposuction, and helps to tighten the
skin. There is no scientific evidence demonstrating the advantage of
this technique over the ultrasound assisted liposuction or the
traditional liposuction.
Blugerman et al.[10]
described a novel technique using radiofrequency assisted liposuction.
Radio frequency is a form electro-magnetic energy similar to microwave.
The process involves passing radio frequency energy through tissue to
heat up fat cell and making it easier to remove via liposuction and
helps to tighten the skin. This procedure was well-tolerated, safe, and
efficient in the removal of a moderate volume of fat. Paul et al.[11] reported three-dimensional skin tightening with this procedure and proposed a mechanism of tissue tightening.
The
Water-Jet assisted liposuction is a new technique that uses fan-shaped
jet of tumescent solution to anaesthetize the area for liposuction.
Sasaki [12]
used this technique in 2011 on 41 patients. The amount of instilled
tumescent fluid, lidocaine dosage, and aspiration volumes appeared to be
safe, with minimal blood loss in small and moderate volume liposuction
cases, and have emphasized on efficacy and safety of the technique.
Adipose tissue diseases
El-Khatib [13] has used the wet technique to treat the lower part of the body with unusual fat distribution that is clinically characterized by massive symmetric and diffuse fat deposition in the trochanters, groins, buttocks, hips, and lower extremities; it contrasts sharply with the normal fat distribution in the upper part of the body. The massive lipomatoses of the lower body can be classified into 3 types: type 1, the familial symmetric lipomatosis (Simon's syndrome) that affects the groins, trochanters, hips, buttocks, and thighs [Figure 1]; type 2, the bilateral peritrochanteric familial lipomatoses [Figure 2]; and type 3, the unilateral peritrochanteric lipomatosis. The adipose tissue diseases are often accompanied by psychological depression due to their disturbed body image. The traditional liposuction is the treatment of choice for these esthetic deformities. The surgical removal of the localized fatty deposit results in unacceptable cosmetic outcome.
Multiple Symmetrical Lipomatosis, also known as benign symmetric lipomatosis or Madelung's disease and Lanois-Bensaude syndrome are metabolic conditions characterized by the growth of fatty masses around the face, back of the head, neck, upper arms, abdomen, back and upper leg in a very specific distribution [Figure 3]. Unlike the usual lipoma, these benign fatty masses are not enclosed in a membranous. Due to this characteristic and symmetrical appearance, these conditions are often dismissed as simple obesity.
Bassetto et al.[14] used the ultrasound-assisted liposuction to treat multiple systemic lipomatosis. He compared the traditional lipectomy and the ultrasound-assisted liposuction and concluded that the ultrasound liposuction is preferable due to a reduction of blood loss and reduction of effort produced by surgeon.
DERCUM'S DISEASE
Decrum's disease is characterized by the presence of the painful condition, sleep disturbance, memory impairment, shortness of breath, constipation, and fatigue. As reported by Hansson et al., Dercum's disease is classified into: generalized diffuse adiposity, generalized nodular adiposity [Figure 4], localized nodular adiposity, and juxta-articular adiposity. [15],[16]
Hansson traditional treated 53 patients with Dercum's disease that had
been operated on with liposuction. As controls, 58 nonoperated subjects
with Dercum's disease and 41 obese abdominoplasty patients were followed
for 5 years. Hansson suggested that liposuction might alleviate pain in
patients with Dercum's disease. However, it is difficult to determine
whether the effect is due to the actual surgery or to other factors.
Women
are more affected by this condition and, it usually presents in ages
between of 30 and 50 years. The differential diagnosis for this
condition includes: familial lipomatosis, multiple symmetric
lipomatosis, adipose tissue tumors, panniculitis, lipedema, and
fibromyalgia. Dercum's disease is diagnosed based on patient's history
and the physical findings. There are no specific laboratory tests for
this disease.
The treatment strategies for this condition are
mostly based on case reports. Treatment of Dercum's disease is usually
targeted towards pain relief rather than lipoma removal. [17]
Currently, there is a lack of scientific data on the use of integrative
therapies for the treatment or prevention of Dercum's disease.
De Silva and Earley [18]
used liposuction in the treatment of two patients with juxta-articular
adiposis dolorosa (Dercum's disease), and recommended liposuction as an
effective, has a low morbidity and is well-tolerated by the elderly.
Subcutaneus lipomas
A lipoma is a benign tumor composed of adipose tissue. It is the most
common benign soft tissue tumor. Lipomas are often soft to the touch,
mobile, and painless. Many lipomas are small (under 1 cm diameter) but
can enlarge to sizes greater than 6 cm. They are commonly found in
adults from 40 to 60 years of age, but can also be found in younger
adults and children.
Al-basti and El-Khatib [19]
successfully reported the treatment of subcutaneous capsulated giant
(more than 10 cm diameter) and moderate (5 cm to 10 cm diameter) sized
lipomas by traditional liposuction. The capsule was extracted surgically
by the end of the procedure from the same small incision used for
liposuction. There was no recurrence, and the cosmetic outcome was
highly satisfactory.
Posttraumatic lipomas
The pathogenetic link between soft tissue trauma and formation of
lipomas remains controversial. A proposed mechanism is the prolapse of
adipose tissue through the fascia defect resulting from direct impact.
An alternate explanation is the formation of adipose tissue as a result
of preadipocyte differentiation and proliferation mediated by cytokine
release following trauma and hematoma formation.
Aust et al.[20] used the simple excision method in 22 cases and used the liposuction method in 1 case and recommend both techniques.
Chronic lymphedema
In chronic lymphedema, there is a physiological imbalance of blood flow
and lymphatic drainage. The decreased lymphatic drainage results in
impaired clearance of lipids and deposition of fat in subcutaneous
tissue.
Lymphedema may be inherited (primary) or caused by injury
to the lymphatic vessels (secondary). It is most frequently seen after
lymph node dissection, surgery, and/or radiation therapy, most notably
in the treatment for breast cancer. In many patients with cancer, this
condition does not develop until months or even years after therapy have
concluded. Lymphedema may also be associated with trauma or conditions
that inhibit the lymphatic system function. In tropical areas, a common
cause of secondary lymphedema is filariasis, a parasitic infection. It
can also be caused by cellulitis as it compromises lymphatic drainage.
While
the exact cause of primary lymphedema is still unknown, it occurs due
to poorly developed or missing lymph nodes or channels. Lymphedema may
be present at birth, develop at the onset of puberty (praecox), or in
adulthood (tarda). Lower-limb primary lymphedema is most common in men,
occurring in one or both legs. Secondary lymphedema affects both men and
women. In women, it is most prevalent in upper limb after breast cancer
surgery and lymph node dissection. It occurs on the same side as
surgery. Cancer treatment is the most common cause of secondary
lymphedema in western countries. Between 38% and 89% of breast cancer
patients suffer from lymphedema due to axillary lymph node dissection
and/or radiation, [21],[22],[23] Unilateral lymphedema occurs in up to 41% of patients after gynecologic cancer. [24] For men, a 5-66% incidence of lymphedema has been reported in patients treated with radical removal of lymph glands.
The first report of use of liposuction to reduce the size of lymphedema of the extremity was published by O'Brien et al.[25] and Brorson. [26]
Developed a pressure-measuring device to optimize compression treatment
of lymphedema and evaluation of change in garment pressure with
simulated wear and tear, was added to the liposuction technique in order
to enhance the outcome.
In 2008, National Institute for Health
and Clinical Excellence published guideline on indications and patients'
selection for liposuction.
Brorson et al.[27]
used absence of pitting, failure of conservative treatment, absence of
wounds and cancer as criteria for liposuction for treatment of
lymphedema of upper extremity due to ablative surgery for breast cancer.
Literatures
review concluded that liposuction demonstrated significant and stable
reduction of both upper and lower limbs lymphedema. The technique is
also reliable in the treatment of both the acquired and congenital
lymphedema.
Axillary hyperhidrosis
Axillary hyperhidrosis, also known as underarm sweating, involves
extreme sweat production in the axillary region. This condition is not
controlled by deodorants and other odor controlling medication. Axillary
hyperhidrosis can occur by itself or associated with hyperhidrosis of
other regions of the body.
Over-stimulating of sympathetic
nervous system is the main cause of this condition. This has a direct
relation to the emotional well-being of the person and environmental
stimuli such as stress and anxiety.
Traditional surgical
procedure has many disadvantages such as scarring, longer wound healing,
complex wound dressing, and limited range of motion for shoulders after
surgery.
Seo et al.[28]
studied 43 patients who underwent superficial liposuction with
curettage for axillary hyperhidrosis and found that 31 patients (72.1%)
showed excellent to good results. The most common postoperative
complication was transient ecchymosis that spontaneously regressed in
1-2 weeks. Focal skin necrosis, induration, and hematoma or seroma were
each noted in 4, 3 and 1 patient, respectively. All these conditions
resolved with proper dressing. The preoperative histological findings
included increase in size and number of apocrine glands in cross-section
view, and the postoperative specimen showed absence of subcutaneous
tissue, including apocrine and eccrine glands, and destruction of sweat
glands.
Seo et al.[28]
used the tumescent superficial liposuction with curettage of the
subdermal tissues for treatment of axillary bromhidrosis and concluded
that this technique is an effective and safe.
Ottomann et al.[29]
studied reported a total of 88 patients, 47 patients underwent a
tumescent liposuction curettage (TLC) (liposuction combined with
curettage), and 41 patients received intradermal Botox injections. The
effect of both treatments on the quality-of-life was assessed using a
specific hyperhidrosis questionnaire and was correlated with sweat
volumes measured by gravimetry. Follow-up after 6 months showed
significantly improved sweat volumes of 52 ± 41 mg/min of TLC patients
versus 78 ± 87 mg/min in the Botox group. Ninety-one percent of TLC
group and 98% of Botox group were satisfied with the result. Both
methods were superior to the traditional surgical methods in terms of
efficacy and complication rates. Both Botox and TLC improved the
quality-of-life.
Postablative surgery
Use of autologous fat grafting for reconstruction is still controversial because of its safety and efficacy. Liposuction is considered an ideal harvesting method for fat graft [Figure 5].
Coleman [30]
advocated a unique method for harvesting fat graft. General anesthesia
can be used for removal of large volume of fat although local anesthesia
is most commonly used. The preferred donor sites are the abdomen, the
inner thigh, the lateral thigh, and the lower back.
Fifteen or
twenty-six centimetre two hole Coleman harvesting cannula with a blunt
tip and dull distal openings is placed near the end of the cannula, and
it is twisted onto a 10 mL Luer-Lok syringe. The combination of negative
pressure and the cannula motion through the fatty tissue allows
aspiration of adipose tissue. The recommended centrifugation of the
lipoaspirate is 3,000 revolutions per minute for 3 min. The middle layer
contains fat cells that can be used as a fat graft.
Another technique is "The one-step harvesting modification" described by Lazzeri et al.[31]
It is a useful and time-saving method for high-volume replacement fat
graft. This is an atraumatic, low-negative-pressure drain method that
helps to preserves any viable lipocytes for transfer. The manual method
using a Luer-Lok syringe is also similar and better than the continuous
active suction machine liposuction.
Claro et al.[32]
studied articles regarding autologous liposuctioned fat grafting of
female breast, with a description of clinical complications,
radiographic changes, and local breast cancer recurrence.
Claro
found that there were few complications reported in the literature;
there was no evidence of interference with follow-up for breast cancer
posttreatment although oncologic safety remains unclear.
Postirradiated skin
Radiation dermatitis results from prolonged exposure of skin to ionizing radiation. [33] It can be seen in patients receiving radiation therapy, with or without adjuvant chemotherapy. [34]
Inflammation
of the skin after exposure to the radiotherapy (radiodermatitis) can be
classified to three specific types of radiodermatitis: acute
radiodermatitis, chronic radiodermatitis, and eosinophilic, polymorphic,
and pruritic eruption associated with radiotherapy. Radiation therapy
can also cause radiation skin cancer.
Radiodermatitis can be
successfully treated by implantation of fat graft harvested from
liposuction. The lipofilling procedure was first performed by Coleman. [35],[36],[37]
After
radiation treatment, breast reconstruction with an implant carries a
high risk of failure and complication. Clinical and experimental studies
have demonstrated that adipose tissue graft (lipofilling) in the
irradiated area enhances skin atrophy. Sarfati et al.[38],[39]
reported the use of lipofilling to the irradiated skin before the
implant breast reconstruction. Safarai claimed that the lipofilling will
decrease the risk of breast Implant exposure.
Debulking of flaps
Patients often complain about an enlarged or bulky appearance after fasciocutaneus and myocutaneus flap reconstruction.
Conventional liposuction can be used to debulk the skin flap without fear of tissue necrosis [Figure 6].
Single-stage debulking of flaps using suction-assisted lipectomy
combined with skin excision is a safe and reliable procedure with
results comparable to conventional multistaged surgical techniques. In
2010, Reuben et al.[40]
reported on the efficacy and safety of power assisted suction lipectomy
for debulking fasciocutaneus flaps in upper and lower extremity. Reuben
operated on 16 lower extremity flaps of 15 patients and recommended the
use of liposuction as an adjunct in debulking and contouring skin
flaps.
Hallock [41],[42],[43] reported successful use of traditional liposuction for debulking perforator muscle flaps, and free flaps elsewhere.
Overall, literature review [Table 1]
showed good outcomes for suction-assisted lipectomy as an adjuvant
procedure for recontouring bulky skin flaps. Most papers recommend
debulking three months after initial procedure.
Complications of liposuction
Severe complications have been reported and include necrotizing fasciitis, [44] toxic shock syndrome, [45] perforation of inner organs, [46] and pulmonary embolism. [47]
These complications were mostly due to inappropriate patient selection,
use of excessive local anesthesia during mega-liposuction (tumescent
technique) and inadequate postoperative surveillance based on literature
review, the complication rate usually reflects a lack of medical
experience.
Liposuction has gained popularity and has become the
most frequent esthetic procedure for adipose tissue reduction and
treatment of lipedema. Liposuction is also a suitable treatment for
chronic medical conditions like lymphedema, benign adipose tissue
diseases, radiodermatitis, re-contouring skin flaps from previous
procedures and breast reconstruction. This intervention is not without
risks and requires extensive knowledge and training to prevent
irreversible medical or esthetic complications.
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