■ After thorough disinfection, again an incision is made with a size 11 scalpel. This incision is not sutured later and cannot be seen. This process is completely free of pain because of tumescence. The liposuc-tion cannulas can be inserted without much pressure, and the openings should point towards the subcutis. At the beginning of the procedure the cannula should not be more than 4.0 mm. At the end of the procedure, after the majority of the fat has been removed, a 2.0-3.0 mm cannula is used for delicate modeling. The tumescence technique allows the procedure to be carried out with almost no bleeding.

■ Tumescence allows the tissue to be tunneled without much effort. Novices should not initially use the assisted system, but should carry out liposuction manually in order to get a feel for the tissue. In order to achieve an even result, the same amount must be removed from all sides at angles of 90,180 and 360°. The fat should be removed using smooth, constant, forward and backward movements, similar to the movement of a violin bow. The fat should always be removed from within the predetermined level and in a fan shape. Several incisions are necessary to reach the problem zones well, and one of these should always be at the lowest point of the problem area to allow the tumescence to drain. As long as io tic o p pure fat appears the procedure can be continued without risk. When the fat becomes mixed with tumescence solution and then only tumescence solution appears, the procedure should be ended in order to avoid skeletonization and the formation of dimples. Ideally, a "fat film" should be left directly under the skin during liposuction. Liposuction should therefore always be carried out from the deepest layers to the upper ones.

■ Because the procedure is carried out under local anesthesia it is possible for the patient to roll over; therefore, all areas can be reached easily and evenly. This is a particular advantage for achieving homogeneous liposuction, as it brings about a tightening effect without the formation of dimples.

■ Because the patient is mobile all problem areas on the face and the body can be treated. It should be ensured that suction is carried out evenly and in one plane in order to avoid contour irregularities. This is harder to even out than residual persistent deposits, which can be corrected without any problems.

■ To make sure the wound is well drained, an incision must be positioned at the lower pole of the area to be removed during liposuction. Contouring can also be carried out from here. If the patient experiences pain, a strong, fast-acting analgesic can be given via the venous cannula. Synthetic opioids, e.g., piritramide (Dipidolor®), have proved effective in these circumstances.

■ Liposuction should be carried out on an inpatient basis and requires a lot of experience. An experienced surgeon will preserve a thin layer of fat below the skin.

■ When using the aspirator it is important that there is a constant vacuum of about 0.8 (Atmos Medizintechnik aspirator*).

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