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Ziya Saylan,MD; Düsseldorf Germany

Abstract: According to the German Liposuction Society1 many unsatisfactory results were reported due to the rapid growing popularity of liposuction. According to their statistics almost 20% of liposuctions needed to be corrected again. Pittmann2 claimed 15% to be minor touch ups or lipofillings as a local treatment in the office, the other 9% needed to undergo a proper liposuction using lipofilling or re-liposuction. The lipofilling in large quantities as we have performed up to now didn't last and were not a good solution to this particular problem. The Author proceeds to shift the fatty tissue under the skin without incorporating any liposuction and he doesn't remove the loose fat out of the body during this procedure. A special type of taping and fixation is necessary directly afterwards.
Keywords: , shifting under the skin, fat damage survival, Post - Liposuction Irregularities
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Iin Europe approximately 200.000 liposuctions are performed annually, and this number is rapidly increasing. Due to the amount of increased Liposuctions, the number of unsatisfactory results are also rising. Cosmetic surgeons are not being trained to the proper standards required of liposuction . Untrained physicians, after reading a few articles and visiting one or two congresses (not even workshops), are beginning to practice liposuction and cause the majority of unsatisfactory results.

My personal experience up to now is that the lipofilling of small post liposuction irregularities may be helpful, but lipofilling of larger irregularities has not been satisfactory enough forcing me to develop a new method. After studying fat transfer and damage over the years, I came up with the idea of shifting fat under the skin without suctioning (damaging) and without removing it from the body (no pressure, and no air contact). This is safest way not to damage fatty tissue and enable it to survive.
This new technique which I developed has been applied on 27 patients since August 1996. The results have so satisfactory that I want to introduce and share this method with my colleagues for further development.

Technique:
The procedure consists of the following stages:
1. Marking the skin while standing
2. Local anesthesia
3. Tumescent technique
4. Loosening the fat (Becker cannula)
5. Shifting
6. Fixation (taping and Reston Foam fixation)

Marking the skin:
The marking of the skin is extremely important. The marking has to be done while the patient is standing allowing the physician to localize the correct places for liposhifting and giving him the possibility of controlling his results. An Orthostatic table like Dr. Giorgio Fischer's is not necessary because the patient needs to stand many times during this procedure. The molds on the skin should be marked with different colors so that the sites can be recognized during the shifting. Before starting the procedure the amount of fat to be shifted has to be decided. The places where large amounts are required should be marked with a third color or it has to be written on the skin which makes the whole procedure easier. A form of documentation by means of photographing the area is very important for future comparison. We also make a drawing on a piece of paper to give us more orientation.

Anesthesia:
If the patient wishes to have a total sedation it is done with general anesthesia. Normally iv sedation with a local anesthesia (tumescent technique) or a tumescent local anesthesia without any iv sedation is all that is required. The sites of the incisions are infiltrated with local anesthesia (we generally prefer lidocaine because of it's known safety).
Tumescent technique:
To loosen the fatty tissue and to also provide an anesthesia a tumescent solution is used . After infiltration of the tumescent solution some time is required to allow it to work and achieve an optimal fat loosening and vasoconstriction. A molding of the tissue (as described by Dr. Giorgio Fischer) is in my opinion very helpful in obtaining better results. In our study we have seen very good results after molding the place to be treated. I believe that the fatty tissue is set free by means of molding so that a larger amount of fat can be shifted.

Loosening fat:
Tumescent technique has now diluted the fatty tissue and loosened it a little bit, but now something has to be done in order to free the fatty tissue from the connective tissue. For this purpose I'm using a 26 cm long 3mm Becker cannula from Byron medical Co. which will be pushed under the skin and has to be moved in criss-cross technique (figure 1) in order to set the fat free. Many incisions are required to achieve better results, windshieldwiper movements has to be avoided, otherwise the subcutaneous connective tissue will be damaged and skin will also be loosened which is not our goal.

Shifting:
Pushing or shifting the fat under the skin can now be done. An old thick cannula (6-9 mm) which is not used any more can be helpful for this purpose (figure 2). The cannula is held in both hands and the fatty tissue under the skin will be shifted towards the defect which has to be filled (abbr. 1). The place to be filled has to be observed very closely and when the dent is filled and has the same level as the surrounding skin further shifting is required to obtain an overcorrection of 20-30%, which is the amount of the tumescent solution that will be absorbed in a few hours.

Infiltration & Looseningthe skin

Shifting & Fixation

Fixation:
After shifting the fatty tissue and placing it in the dent a tape dressing (same technique as the orthopedic surgeons) is required in order to keep the fat in situ. This kind of taping is called water melon slice formed taping which applies pressure from upper and lower parts in direction to the middle of the tape dressing (abbr. 2, figure 3). We usually apply a Reston® Foam (3M Company) dressing over the tape in order to stabilize the whole dressing. This foam applies a kind of massage to the tissue as the patient moves which will reduce the bruising and oedema4. The taping and fixation has to be taken off and renewed after 3 or 4 days which enables a control of the operation site ( looking for hematoma and infection) and gets rid of the loosened dressing. The fixation is removed after 7 days.

Results:
I have applied this technique on 17 patients in a time of one year. All patients were female with an average age of 34. The rate of satisfaction was 88% (15 patients). Some cases with huge defects had to be liposhifted more than once (5 cases, 24%). This will be explained to the patient before the Surgery so that we plan a strategy and a schedule with them before the treatment. A time of 3-4 months is needed between two treatments. If they know that they need 2 or 3 sessions, they are more cooperative and satisfied with the result. In 3 cases (18%) the result was not that satisfactory even if it was a small lesion and 2 cases (12%) didn't answer to this treatment.

Complications:
The most common complication was the hematoma due to fat loosening. This problem was reduced after using the taping and the Reston Foam and also leaving the incisions unsutured. There were no infections. A hypersensibility of the liposhifted part of the body is longer than the liposuctioned parts of the body. Also the hyposensibility is seen more often but disappears after a few weeks. A hemosiderin pigmentation ( pigmentation of the skin due to iron in the blood) was seen in 2 cases who had hematomas and which was still there after 6 and 9 months.

Conclusion:
Liposhifting is the only method to eliminate larger irregularities of the skin and the underlying tissue caused by liposuction. It is only helpful in the extremities and in the abdominal wall. It is almost safe because a contamination of the fat transplant via air contact is not possible and needs no training or special instruments. The fixation of the liposhifted part of the body for one week is very important which stabilizes the shifted fat and makes it possible for the fat to survive. More research has to be done to study my technique which would also make it possible to compare the results of other surgeons. The irregularities due to liposuction are still a main problem.

References:
1. German Liposuction Society, Annual Meeting 1996 in Düsseldorf. Saylan, Ziya, MD. Presentation on Liposuction Complications about a questionary of the members.
2. Pittman, Gerald, MD; Liposuction and Aesthetic Medicine, QMP Inc. St. Louis, Missouri, 1993
3. Fischer Giorgio, Personal Conversation, April 1997 Annual Meeting of the European Academy of Cosmetic Surgery.
4. Saylan, Personal Conversation with 3M "Reston Foam"