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June 2019 Issue

About saddlebags, love handles, muffin tops, spare tyres and buffalo humps

If you think you are reading the title of a new Dr Zeuss book, I don’t blame you. For the less initiated amongst you, let me help: These all refer to body contour deformities:
  • Saddlebags refer to the extra fat on the thigh area;
  • Love handles to extra fat of the flanks;
  • Muffin tops and spare tyres refer to excess fat pockets over abdomen and back area across the hips; and
  • Buffalo humps to the excess fat, most often due to the use of HIV or AIDS medication, over the upper part of the neck.
These are not the only areas that might concern you – the loss of neck contour due to excess fat under the chin (double chin, turkey neck, gizzard neck); man boobs – enlarged male breasts, due to excess fat in the chest area; the loss of a thigh gap, causing friction, sweating and rashes between your legs; the lack of leg contour, due to excess fat on the knee area; the inability to fit into shirts, because of excess fat of the arms; frustration about the “extra boob” in your axillary area, or the bulges straining out of your bra straps on the back, because of excess deposits of fat in these areas, might all be unwanted body parts.

And although “fat” is the common denominator - this fat does not necessarily belong to overweight people, but very often belongs to people who have lost weight through stringent diets, who have done all exercises possible, but are still left with pockets of fat that will not disappear.

If you recognise yourself in the descriptions above, you might be an ideal candidate for a procedure with many names: liposuction, liposculpture, suction-assisted body contouring; lipo-contouring, lipoplasty, suction-assisted lipectomy; suction lipectomy.

This procedure is not only used for cosmetic reasons. I also remove fat to use for fat grafting – using fat in one part of the body to replace loss of fat in another, and I also use liposuction techniques to remove benign fat tumours called lipomas.

Even if you are not considering liposuction, I hope you will find the information shared in this newsletter interesting. I will briefly discuss:
  1. The history of liposuction – a procedure with a short history
  2. How liposuction works
  3. The different types of fat in the body and why you should know about them
  4. The ideal candidate for liposuction surgery
The final success of liposuction surgery depends on the quality of skin of the patient. My skin care diagnostic technician, Amori, will discuss the components that determines your skin quality.

Follow my social media links (Facebook, Instagram, Twitter, Pinterest and You Tube) for more information about liposuction and other plastic surgery procedures and plastic surgery news.

The history of liposuction

“Natural History”, the famous book by Pliny the Elder, covering all ancient knowledge of the natural world, describes the first primitive liposuction procedure. It is said that the young Apronius, grandson of the Roman military commander Lucius Apronius (39AD), was so obese, that he was unable to move. He was cured in that “Fat was withdrawn from Apronius, and his body was relieved of the weight that made it impossible for him to move.”

Another source tells of a third-century Jewish Sage, Rabbi Eleazer ben Simon, who had been hired as a detective by the Roman government to help with police investigations. The rabbi was confident that all the criminals he had helped catch were guilty but was nevertheless concerned that he might have handed over innocent Jews to the Romans. To clear his conscience, he devised a test to prove that he did not make any mistakes as a detective: He swallowed an anaesthetic, and had a doctor surgically remove the fat from his stomach. The removed fat was left in the sun, and after some time left there (said time not stipulated), there was no noticeable disintegration. His idea was based on the words of Psalm 16:9: “My flesh too shall rest and confidently dwell in safety.” Now the rabbi was convinced that everyone he had caught, was guilty as charged.

Fast forward to the 28th of February 1928, and you will read about the French surgeon, Charles Dujarier. Suzanne Geoffre, a model of the couturier Paul Poiret, in the process of starting his own fashion house, begs the French surgeon (even threatening suicide), to perform surgery on her “unbecoming legs”. French haute couture is promoting skirts stopping at the knee, and said lady is convinced her legs are not “becoming”. Dujarier, who has never performed this kind of surgery, agrees. He removes fat with a curette, removes too much skin, leaving a skin defect which cannot be sutured. He then bandages the legs too tight, causing gangrene, and eventual amputation of both legs.

Dujarier was sued and required to pay compensation of 200 000 francs. Cosmetic surgery paid a heavy price, as all procedures for cosmetic reasons were outlawed. Two years later Dujarier’s sentence was confirmed, but cosmetic surgery was cleared, provided that the patient’s informed consent be obtained – a principle that remains paramount in plastic surgery today. Dujarier died shortly after the second ruling. No one would perform the procedure again until 1974.

In 1974 two Italian gynaecologists, Dr Giorgio Fischer and Dr Arpad Fischer (father and son) removed internal fat tissue using an electric-powered rotating scalpel inserted through small incisions. They focused their work on the outer thighs only. Their blunt-tunnelling technique remains the basis of modern liposuction.

It was, however, the work of two French surgeons, Dr Yves-Gerard Illouz and Dr Pierre Fournier, which catapulted liposuction onto the world stage, and made the procedure easier, safer and applicable to many areas of the body.

As I wrote my Matric in 1982, Dr Illouz invented the “Illouz-method” of liposuction, by improving the methods used by Fischer and Fischer, making results more predictable and the procedure safer. Dr Illouz modified the equipment needed for liposuction and extended the procedure to include liposuction of the whole body. He started using the “wet technique”, which involved infusing fluid into the tissues to break up the fat deposits, ensuring less nerve and blood vessel damage during the procedure. A suction-device was used to remove the fat.

Dr Pierre Fournier pioneered the use of lidocaine as a local anaesthetic during liposuction. Together with advances in using conscious sedation, general anaesthetic was no longer necessary to perform the procedure. Dr Pierre Fournier travelled extensively, introducing the new technique to the rest of the world, and spreading the popularity of the procedure.

In 1987, Dr Jeffrey Klein probably made the biggest contribution to the science of liposuction. He invented a recipe, still used today, whereby a combination of saline, local anaesthetic and a blood vessel constrictor, could be safely infused prior to liposuction. This allowed larger areas to be safely operated on at the same time, and larger volumes of fat removed, without causing local anaesthetic toxicity. At the same time, blood loss was significantly reduced by the addition of the blood vessel constrictor. This introduced the world to the so-called “tumescent technique” of performing liposuction.

Since then, many refinements have been made, and today liposuction is the second most popular cosmetic surgery procedure in the world, increasing in popularity every year.

How liposuction works

Although the procedure might sound simple, you need to remember that this remains a surgical procedure, and as with any surgical procedure, risks and complications exist. You must be carefully selected, as not everyone makes an ideal candidate, and you need to adhere to post-surgical recovery guidelines.

The procedure can be safely performed on an outpatient-basis, and not necessarily in a hospital theatre, provided that the plastic surgeon performing the procedure has a fully equipped procedure room, with all the necessary safety equipment in place, and the ability to admit you to hospital for post-operative complications if necessary. Your plastic surgeon should be available after surgery to attend to your health if required.

I recommend conscious sedation to be administered for this surgery – you will be more comfortable, my anaesthetist will attend to your vital signs, and I can focus on ensuring that you have the best possible results after the procedure.

All the areas that you want to improve will be marked prior to the procedure. It is important that you stand and move naturally and that I mark the areas that should be sculpted, so that we achieve a natural looking result.

Once the conscious sedation has been administered, the procedure starts with the infusion of the tumescent solution. This numbs the area where fat is to be removed and constricts the blood vessels in the area to minimise bleeding. The tumescent solution is infused through a blunt infusion cannula after puncture holes were made in the skin, to gain access. These same puncture holes are used to insert the aspiration cannula, which is connected with a pipe to the suction machine. The unwanted pockets of fat are removed. After the procedure the puncture holes are either left open or sutured closed.

Although the procedure sounds rather uncomplicated, it takes a long period of time, as the tumescent mixture must first be infused, and the local anaesthetic be allowed to take effect. Then the tedious process of removing the fat starts. In the procedure room we refer to the aspiration of fat as “playing the violin”. The aspiration cannula is gently moved in and out between the tissues where fat is to be removed, taking meticulous care not to damage important structures, accidentally puncturing the bowel, or removing too much fat. The technique requires experience and skill to ensure that there are no dents and bulges after the procedure. “Playing the violin” is quite an exercise, and the most physical procedure I perform.

The amount of fat removed during a procedure differs from patient to patient. The more fat that is removed at one surgical sitting, the higher the risks involved with the procedure. It is generally accepted, for safety reasons, that no more than 6 litres of fat and tumescent solution should be removed at one surgical sitting.

Through many years of experience, I have refined my liposuction technique. My technique introduces an additional step both before and after fat aspiration. Before fat aspiration a specialised cannula is used to first loosen the fat from underlying structures, prior to aspiration. After the aspiration, the same cannula is used to redistribute the remaining fat. This leads to less revision procedures and improved retraction of the skin after the liposuction procedure.

Different types of fat, and why you should know about them

In order to understand liposuction and what it can do for you, you need to understand the anatomy of the skin and body fat, and the structure of fat cells.

Fat, or adipose tissue as it is also known, consists of about 25 to 30 billion fat cells (or adipocytes). Each fat cell stores lipids, which are necessary to provide energy to the body. Whether you are thin or fat – we all have the same number of fat cells. Our fat cells shrink (making us thinner) or plump up (making us fatter). The number of fat cells remain the same.

Human skin consists of three main layers: the epidermis, the dermis and the hypodermis. The hypodermis is important in liposuction. The hypodermis is also called subcutaneous fat (“fat under the skin”).

Fifty percent of body fat is stored in the hypodermis, and the rest is stored in the abdominal cavity around the internal organs. The fat stored around the internal organs we call visceral fat.

The purpose of the subcutaneous fat is to offer padding and a gliding plane for your skin to move over the underlying structures. Without fat, you would literally be a “bag of bones”. Fat also offers insulation and energy storage.

Subcutaneous fat is divided in two layers – the deep layer and the superficial layer. The superficial subcutaneous fat is denser and contains more nerves and blood vessels. It is in this layer that cellulite is located. Some of the superficial fatty tissue is inadvertently removed during liposuction, however, this is not the target level of fat to be removed. Removing too much subcutaneous fat is dangerous, as it can lead to skin necrosis (dead skin), permanent irregularities and discoloration. Cellulite can therefore not be improved with liposuction.

The target fat for liposuction is the deep subcutaneous fat.

Liposuction removes some fat cells, which are gone for good, but the remaining fat cells can still shrink or expand – therefore liposuction should never be considered a weight-loss option.

It is very important to understand what visceral fat is, as this cannot be removed during liposuction or during a tummy tuck (abdominoplasty). Many patients requesting these procedures, are not ideal candidates, specifically because they have a lot of visceral fat.

Visceral fat or intra-abdominal fat covers the intestines and other organs in the abdomen. The so- called beer belly is a sure sign of excess visceral fat. This is most commonly caused by poor diet and exercise, hormonal disorders and fluctuations (and not necessarily by beer consumption.) It is extremely dangerous to remove visceral fat.

Visceral fat can be successfully reduced by means of diet and exercise only. I recommend that you visit a specialist dietician to assist you with a diet plan and a biokineticist to develop a professional exercise plan specifically dedicated to reducing visceral fat. Once this has been completed, you will be an ideal candidate for liposuction surgery.

The ideal candidate for liposuction surgery

The ideal candidate follows a healthy diet, exercises regularly and has a steady and healthy body weight. You need to be within 20% of your ideal body weight with limited visceral fat. Apart from this, skin elasticity is probably the most important criteria for successful results.

If you can “pinch an inch” of skin and fat (and no more), you are probably an ideal candidate for liposuction surgery.

Cosmetic surgery candidates should always have realistic expectations, be psychologically stable, healthy and well-informed about the risks and complications of the surgery they plan to undergo.

Contra-indications for liposuction include the use of Accutane in the last six months; collagen, scarring and connective tissue problems; significant stretch marks, blood clotting disorders, Lupus Erythematosis, diabetes, heart or lung disease, vascular problems, endocrine disorders, hypertension, tissue disorders, depression, active diseases, morbid obesity, wound healing disorders, smoking, recreational drug use, excessive drinking and pregnancy.

Risks and complications of liposuction surgery include all the risks associated with anaesthesia, emboli and pulmonary thromboemboli, fat emboli, fat and tissue necrosis, pulmonary edema, fluid shifts and blood loss, irregular contour deformities and general dissatisfaction or disappointment with the results.

The success of liposuction surgery depends on the plastic surgeon’s “tricks of the trade”. Each plastic surgeon develops their own skill set of customised techniques. This will include choosing the ideal candidate for liposuction surgery, the choice of liposuction technique and the post-operative care prescribed for each patient.

The final key ingredient in determining whether you are an ideal candidate for liposuction surgery, is the quality of your skin. A healthy skin, with good elasticity, that will bounce back to its former tightness after fat has been removed, is essential. Without this, you will need surgery to remove excess skin after your liposuction procedure.

What determines skin quality – Amori explains

As the largest organ in the human body, skin plays an important role in determining whether you are the ideal candidate for plastic surgery, especially liposuction surgery.

Because the plastic surgeon removes some of the fat that supports skin, the overlying skin will sag over the areas where fat was removed. If your skin is not elastic enough to retract, further surgery might be required to remove the excess skin, or you will be left with empty bags of skin.

Liposuction does not improve areas where skin irregularities are present, such as stretch marks. As a matter of fact, the prevalence of stretch marks gives the plastic surgeon a pretty good idea that your skin is not elastic, and that it will probably not retract after liposuction.

There is an easy test we use to determine how thick your skin is: pinch the skin over the fullest part of your cheek – one centimetre or more, and you are truly “thick skinned”, anything less, and your skin is either medium or thin.

The same test can be used elsewhere. Thin skin, typically prevalent in older patients, is fragile, easily damaged and bruised. These skins typically need their barrier strengthened, with moisture retention the first step in this process. Patients with thin skins do not make ideal candidates for any type of cosmetic surgery, as their skins do not retract, and sag very quickly after surgery.

Two proteins play an important role in skin quality: elastin and collagen.

Elastin fibres are like elastic bands or coils and are an integral part of the connective tissue in our body. It can move and stretch without breaking or tearing and makes the skin smooth and even in colour. It allows the skin to return to its original shape after stretching or contraction. Think of the abdominal skin in a pregnant woman – it stretches to unimaginable dimensions, and contracts back to its normal shape after the baby was born. Elastin makes the skin resilient and is also present in the lungs and the aorta. It is a thousand times more flexible than collagen.

Collagen is the most abundant protein in the body and is found mostly in the connective tissue. Collagen gives skin rigidity and strength.

When we refer to the elasticity of the skin, we therefore refer to the ability to stretch the skin without it being damaged, and the ability of the skin to snap back to its original shape and how long it takes to do this. When plastic surgeons perform eyelid surgery, they would typically perform the “snap” test. You can do it yourself: pull the skin of your upper eyelid gently away from the eye and see how quickly it snaps back to its original shape. In younger people it will snap back almost immediately. In older people it will remain pulled away for a while. The same can be done with skin on the hands, arms and elsewhere to determine elasticity.

Many factors play a role to determine the elasticity of our skin, including genetics, medical conditions and weight loss.

From the mid to late twenties our skin starts losing elastin and does not produce as much elastin as before. Other causes of loss of elasticity include sun exposure, which causes the over production of elastin, which causes the breakdown of collagen; smoking; dehydrated skin and hormonal changes. A diet with a high glycaemic index causes glycation – essentially the sugar in the diet attacks collagen and elastin, making the fibres hard and brittle, which leads to wrinkling and sagging. It is for this reason that people with diabetes take longer to heal, and age faster.

Exercise can help to build muscle to offer a better support structure to skin, while a diet rich in healthy protein, with foods with a low glycaemic index, rich in fruits and vegetables with antioxidants and Omega 3 supplements all play an important role in preserving collagen and elastin.

To prepare your skin adequately before and after liposuction, we recommend very good moisturising to the deep levels of the skin. Combinations of products containing Alpha Hydroxy Acids and Vitamin A should be used at least four to six weeks before and after the procedure to assist with adequate moisturising to the deeper level of the skin.

Medical grade microneedling, a clinically proven treatment modality that increases and modulates collagen and elastin in the skin, both before and after liposuction could assist with retraction of the skin, however, the improvement will not be enough in patients with severe collagen and elastin deficiencies.

It is best to be informed of this prior to liposuction, so that you will not be disappointed with the excess skin you are left with.

Remember that I offer a free Advanced Skin Analysis  and Visia Complexion Analysis consultation.

June and July are perfect months to have chemical peels done – ensuring you will have a vibrant, healthy skin for the summer season. All chemical peels cost R650.00 in June and July. Many patients have an irrational fear of chemical peels, based on horror stories they read on social media. Chemical peels do not need to be harsh, burning and leaving you shedding skin like a snake. Many medical grade chemical peels are effective, even if they are mild. Come in for a free consultation to find out more, and determine whether your fear is based on fact or fiction.
Copyright © 2019 Dr Dehan Struwig, Plastic and Reconstructive Surgeon, All rights reserved.

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