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The liposuction cannula, or tube, has to be placed through the skin in order to reach the fat that needs to be removed. Therefore, holes are necessary for the cannula to reach the unwanted fat. The holes through which the suction tube will enter the skin are called cannula entrance wounds. These holes can be made in your skin with a special small surgical knife called a scalpel or even with a small cookie-cutter–like instrument called a punch biopsy. The larger the diameter of cannula chosen by a particular surgeon, the larger the hole must be in order for the cannula to enter the skin to reach the unwanted fat. The Web site author has much experience with patients who have had liposuction performed by another doctor and who have large unwanted scars in the areas where the liposuction cannulae entered their skin. Why is this so? The standard liposuction cannula used by many plastic surgeons is between 4 and 5 mm in diameter (roughly 1-1/2 times the width of a pencil eraser). A cut (incision) in the skin of roughly 7 mm in length (about 1/3 inch) is needed to allow a 4- to 5-mm cannula to fit into the body. This might seem like a small incision to remove a large amount of fat, but there may be between ten and twenty of these cuts. Remember that all cuts scar. Although most scars created using the traditional liposuction method are small, even these scars can be improved upon relatively easily. The author feels that scar size is very important in models, ballerinas, and professional cheerleaders, and is still important in the rest of the patients. The Web site author is convinced by many years of experience and many patients that liposuction cannula entrance wounds can usually be kept to less than 3 to 4 mm in length, and that those wounds can be further minimized with the use of stitching. Most liposuction surgeons do not like to stitch the entrance wounds. The reasons are probably at least threefold. First, it takes extra time to stitch at the end of the liposuction surgical procedure. Second, most surgeons cannot sew quickly enough with fine enough thread, even when using special magnifying goggles, so as not to leave "train tracks" or other stitch marks at the cannula entrance wounds. Third, the wounds made by doctors who have previously performed other good works, like those of Dr. Klein, are not stitched. Dr. Klein currently holds a view that following liposuction surgery, stitching does not allow for drainage of fluids that have been pumped into the body as part of the tumescent technique. Dr. Klein is well respected in many circles for his early contributions to tumescent liposuction. However, when it comes to his opinion on "entrance-wound stitching," it appears that Dr. Klein may have overlooked several important facts. When he conducted studies to determine whether or not fluid was draining from the holes after surgery, Dr. Klein, as shown in his own photos (which he presented at lectures), did stitch with one solitary stitch across the cannula entrance wound. The stitches were apparently relatively tight. The relatively tight single stitch applies the greatest amount of pressure in the center of the hole; this completely seals off the holes, preventing proper drainage of fluids. It appears that Dr. Klein has not studied the use of a "double throw" single crisscross stitch, with which the cannula entrance wound is lightly sewn closed at points one-third of the way across the wound. When performed properly, a "double throw" single crisscross stitch is not drawn or tied tightly, and it allows plenty of fluid to escape from special beveled-entrance wounds (used by the author). This special stitching condition likely mimics very closely the amount of fluid leakage that would have escaped if Dr. Klein had not sewn his wounds. Additionally, Dr. Klein uses extremely small cannulae, in which case it may take many additional hours to perform a single liposuction. The performance of liposuction over a period of many hours allows for a dissipation of the effect of the tumescent solution in some patients. Additionally, the use of small cannula necessitates many, many small entrance wounds. Although Dr. Klein's entrance wounds are usually small because he uses many small cannulae, it is likely that newer technology will allow cannulae of relatively small diameter to move safely for longer distances within the human body, therefore minimizing the number of entrance wounds placed on a patient. The Web site author prefers to put fewer entrance wounds on a patient's body. Dr. Klein has championed the use of a skin-punch biopsy knife to make the entrance wounds. The punch biopsy is similar to a cookie cutter and makes a 2-mm hole into the bodies of Dr. Klein’s patients. Fashion models, ballerinas, professional cheerleaders, and the like do not wish to have any obvious holes in their bodies, even if they are only 2 mm in diameter (roughly twice the width of a pencil lead). The author agrees with Dr. Klein in that fluid should have free access to flow out of the patient’s skin immediately following tumescent liposuction for a day or two. The bulk of the fluid that will flow out the entrance wounds is the injected tumescent fluid, however some wound fluid and blood will flow out as well. The author differs in the way in which free drainage is allowed. The author makes many fewer entrance wounds (limited) than Dr. Klein. The author stitches the cannula entrance wounds in a special way that still allows for leakage but reduces marks. The lower on the body a drainage path is, the more effect gravity will have in aiding drainage. Since not all of the limited cannula entrance wounds the author makes are at the bottom of a suctioned area it is helpful to make some additional drainage paths (to allow fluid to escape) that are even smaller than the unstitched entrance wounds that Dr. Klein prefers. Tiny specialized instruments are used by the author to make 1 to 1 ½ millimeter (1/16 inch) skin drainage paths in the lowest, most hidden suctioned areas so that gravity and motion and compression garments will milk excess fluids to escape. These tiny holes used by the author are not irritated or stretched by the motion of any liposuction cannulas and remain small. The tiny drainage holes are connected with only a few passes of a specialized instrument to connect with the suctioned areas. They heal with marks that are very difficult for the naked eye to detect, even in special skin types of African-American, Mediterranean, etc. In summary, loose stitching of the larger liposuction cannula entrance wounds accompanied by several additional 1 to 1 ½ millimeter drainage paths provides ample opportunity for fluids to escape the skin’s surface. This aids and allows for stitching to reduce the larger liposuction cannula entrance wounds. We could agree with Dr. Klein’s policy if a particular surgeon was not capable of putting proper stitches in place using ultra-fine monofilament polypropylene stitch. In that case, it may be best to avoid stitching. However, if the surgeon is capable of delicate stitching or is able to use special eye magnifiers, then the Web site author believes it is best to place the double-cross stitch, which allows for adequate fluid drainage. The benefit of having closed an open wound is obvious. The Web site author has seen many patients who have come to him for consultation after having liposuction performed by another surgeon who left cannula wounds unstitched (open to heal on their own) and festered or did not completely heal after many months. For example, if a doctor made ten to fifteen wounds on a patient and all but one healed, that one open (non-healing) wound could become a problem. It could easily become infected. It could result in a larger scar. It could itch and chronically fester. The author has not had a single wound site that failed to completely seal after double throw stitching. Doctors of African-American or Hispanic patients may wish to consider sewing cannula entrance wounds. The longer a wound stays open in such a patient, the greater the chance that a chronic dark color will develop through the wound site. It is reasonable for surgeons to inform their patients of this possibility, especially if they are of Hispanic, dark Italian, or African-American heritage. Such patients should ask their surgeons how they usually deal with open liposuction cannula entrance wounds
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