Liposuction

What is liposuction?

Liposuction is a surgical body contouring technique that removes localized fat deposits that are often resistant to diet or exercise. The thighs, hips, knees, and abdomen are the most frequently treated areas in women (Figure 1). The neck, arms, breasts, back, calves, and ankles are other sites less commonly treated. Liposuction is not intended for generalized weight reduction. Other terms such as liposculpture, micro-liposuction, and lipoplasty are synonymous with liposuction.

Is liposuction safe?

Liposuction is a safe. Sporadic media reports to the contrary have involved personnel who either are not properly trained to perform this surgery, have operated on poor candidates, have exceeded the safe limit of fat removal, or have included too many other procedures simultaneously.

Who is a candidate for liposuction?

The best candidates have the following characteristics: they are young, are of normal weight for their height, have firm skin, and have just a few areas to treat. While younger patients do best, those over forty are also good candidates provided that their skin tone is still favorable. Those who are significantly overweight at any age achieve more modest results.

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Figure 1
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Table 1

What is body mass index (BMI) and why is it important?

Body mass index is a measure that correlates height and weight to categorize weight health. Those with a BMI over 30 are considered obese (Table 1). Medical studies have shown that obese individuals are more prone to surgical complications such as infection and wound healing problems that may require additional surgery. They are also at greater risk from anesthesia. Patients with a BMI over 30 are therefore higher risk candidates for surgery. Weight loss is strongly recommended prior to surgery to reduce this risk.

What about liposuction in men?

The abdomen and waist are the most commonly treated areas in men. As with women, the best candidates are of normal weight for their height. Overweight men often have high fat content inside the abdomen that is responsible for a large girth. Liposuction of the fat layer between the skin and muscles does not improve overall abdominal contour enough to justify doing it in these individuals.

Liposuction is typically combined with surgical excision of breast tissue in order to effectively flatten protruding male breasts, a condition called gynecomastia. Liposuction of the neck is usually combined with a muscle tightening procedure to achieve optimal neck contour in those who are good candidates.

How is liposuction performed?

The first step is marking each of the areas to be treated. Concentric circles are drawn much like a topographic map: the innermost circle defines the highest point of fat protuberance, and the outermost circle represents the transition point to normal contour (Figure 2). These markings are critical references because body contour changes when lying down or positioned on the side during the procedure.

All methods of liposuction accomplish fat removal by very similar means despite differences in technology. Hollow metal tubes called cannulas are passed back and forth through small skin incisions to dislodge and remove fat that lies between the muscles and skin. Cannulas come in various diameters. Larger sizes remove fat in bulk whereas smaller ones are used for final shaping and finishing touches (Figure 3). They typically have several openings at the tip (Figure 4). Cannulas are attached by a hose at the handle end to a canister on the vacuum machine (Figure 5).

There are usually at least two incisions next to each area to be treated, each no more than ¼ of an inch in length. They are placed in body creases and other inconspicuous locations as much as possible. They are positioned in relation to one another so that the surgeon can pass the cannulas in perpendicular directions parallel to the body surface. This contributes to a smoother result and helps to prevent grooves and irregularities that can be otherwise caused by suctioning in one direction only. Although the scars are permanent, they are usually quite inconspicuous after a year.

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Figure 2

After making the incisions the areas to be treated are filled with fluid containing dilute local anesthetic and adrenaline. This fluid is administered under pressure through a specialized injection cannula. This process is called tumescent technique. It minimizes bleeding, bruising, and postoperative discomfort. Tumescent technique is integral to all methods of liposuction.

What are the different options available?

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Figure 3

Traditional tumescent liposuction as described remains the gold standard. One variation adds an electric motor to the cannula to reduce manual effort (power assisted liposuction or PAL). This method lessens surgeon fatigue and appears to cause less swelling and bruising.

Ultrasound assisted liposuction (UAL) is another variation on standard liposuction. It adds sound waves internally through the cannula to emulsify fat cells prior to their removal by suction. It was originally claimed to be more effective in certain areas of the body where fibrous tissue makes fat removal more difficult. Although it can cause skin burns and abnormal fluid collections called seromas, this is unusual. This method is useful today for "love handles" in men and for areas that have been previously treated with liposuction where deep scar tissue may be present.

The most recent variation on traditional tumescent liposuction adds laser energy to the process. It has been marketed under the brand name SmartLipo. Laser energy is introduced under the skin through a cannula to break up fat cells. The laser also heats up surrounding tissues as a side effect and can cause skin burns. This equipment has been widely marketed prior to proof of efficacy in clinical trials. There has been only one reputable scientific study so far that compares SmartLipo with traditional tumescent liposuction. No difference in results was found between the two types.

What nonsurgical techniques are available to eliminate excess fat?

CoolSculpting is most popular method for nonsurgical fat removal today.  It accomplishes this through a series of office visits where fat just under the skin in the treated areas is frozen by a machine.  The process, called “cryolipolysis”, kills the fat cells which are then slowly broken down and removed by the body.  Up to six treatment visits are needed and the final result may not be evident for as long as three months.

The most common areas suitable for treatment include the abdomen, flanks, arms, and under the chin.  The best candidates have small volumes to remove and tight skin.  While this nonsurgical method avoids anesthesia and downtime, the results are generally modest.  Surgical liposuction is a much more powerful tool by comparison.  Problems that can occur with CoolSculpting include inadequate result, dimples and irregularities, and, rarely, paradoxical fat growth in treated areas.

Mesotherapy, also called lipodissolve, is an invasive but nonsurgical method where substances are injected directly into the fat to chemically dissolve it. The most common ingredients are phosphatidylcholine and deoxycholate. Neither has been approved by the FDA for this purpose. Vitamins, hormones, and enzymes are often included in the injections. Problems including rashes, ulcers, infections, and contour deformities from uneven fat removal have been reported with this technique.

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Figure 4

What about liposuction for breast or buttock enhancement?

Breast and buttock enhancement by fat grafting is a newly emerging technique growing in popularity.  Large volumes of fat are needed for both procedures.  Liposuction of the hips, flanks, abdomen and thighs, as well as other donor sites, is first performed.  The fat is then concentrated and injected into the breasts or abdomen.  It can be challenging to harvest enough fat for use given that most patients interested in these procedures tend to be thin.

Fat grafting is not a powerful tool for breast augmentation compared to breast implants. Adding fat alone (no implant) usually achieves only a half cup size increase in breast volume.  Although it can produce a permanent result without implants, additional fat grafting sessions are sometimes needed because not all of the transplanted fat survives the first time.  

Buttock augmentation with fat is a better concept than using silicone implants because long-term implant problems are common when used for this purpose.  Fat grafting of the buttock requires expertise so that fat is not inadvertently injected into the underlying buttock muscle.  Doing so is dangerous and may cause death due to fat embolism in the lungs.

How long do the benefits of surgery last?

Liposuction results are permanent because the body does not manufacture new fat cells after puberty. However, liposuction is not a substitute for weight control. Significant weight gain after liposuction may not impact the treated zones much but other areas such as the breasts and arms may enlarge noticeably. Modest weight gain following surgery is usually evenly distributed throughout the body. Most patients have only one liposuction procedure and remain pleased.

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Figure 5

Where is the surgery performed and how long does it take?

Liposuction is performed in the office as an outpatient procedure. Surgery time ranges from thirty minutes to as long as three hours depending on the number and size of the areas treated. The procedure is performed in its entirety by Dr. Hidalgo.

Can other procedures be done at the same time?

Liposuction may be combined with other procedures such as breast augmentation, blepharoplasty (eyelid surgery), or rhinoplasty, for example. Liposuction of the abdomen is sometimes conveniently combined with a breast reduction. Liposuction limited to a few areas can be safely combined with an abdominoplasty too.

What type of anesthesia is used?

General anesthesia is required. A board certified anesthesiologist is present for the entire procedure and uses state-of-the-art monitoring equipment.

Performing liposuction under local anesthesia with the patient standing is practiced by some physicians as an alternative approach. However, this method causes greater patient discomfort, limits the scope of the procedure possible, and often compromises sterile technique. It is not recommended except for minor touch-up procedures.

What are the risks associated with liposuction?

Bleeding or infection rarely occurs from liposuction. Fat embolism syndrome can occur when fat droplets enter the bloodstream and become trapped in the lungs. Toxicity from the local anesthetic agent infused into the tissues can occur in large volume cases. Any of these problems may require additional treatment that includes hospitalization. Despite these possibilities, complications from liposuction are rare.

Why is smoking so harmful for surgery?

Smoking severely reduces blood supply to body tissues and delays healing. It can contribute to infection, bad scars, and other complications. It is therefore essential to stop smoking completely for at least three weeks before surgery and six weeks after. Simply cutting back is not enough. Nicotine containing patches and gum are equally harmful.

Do I need a nurse after surgery?

Private duty nurses are not typically necessary for liposuction. However, a nurse may be required if there are many areas being treated, large volumes of fat removed, or if a breast procedure, abdominoplasty, or facelift is performed at the same time. The nurse meets our patients at the office and escorts them either home or to the hotel for overnight observation. They are arranged through our office but charge separately for their services.

What is the recovery like?

A support garment is placed at the time of surgery and is worn for two weeks. The small sutures placed at each incision dissolve after a few weeks and do not require removal.

After surgery there is generalized soreness that lasts for about 48 hours. Oral pain medication is helpful during this period. Walking is encouraged as soon as possible, preferably on the day of surgery. Generalized stiffness lasts for as long as one week. Bruising usually lasts for two weeks although complete resolution can take a month or more. Patchy numbness in the treated areas is typical and generally lasts for months.

Return to work is usually possible after one week. Vigorous exercise should generally be avoided for three weeks and thereafter gradually resumed.

What is lymphatic drainage?

Lymphatic drainage is a specialized form of massage performed after surgery to encourage the reduction of swelling. Some patients believe it speeds recovery and optimizes results but neither premise has been proven. Lymphatic drainage may provide a soothing effect but is not necessary and is therefore not routinely recommended.

What are some of the limitations associated with liposuction?

Liposuction is not a substitute for weight loss. As mentioned previously, the results of liposuction are less impressive in overweight patients. Losing weight after liposuction, on the other hand, will enhance the results of surgery.

Liposuction improves body contour but not surface texture. The term “cellulite” describes patchy skin dimpling and other surface irregularities frequently seen in the thighs and buttocks. It usually increases with age and its cause is poorly understood. Cellulite is not improved by liposuction and often becomes more evident by fat removal. There is no effective remedy for cellulite by any means presently.

Loose skin frequently develops with aging. It commonly occurs in the abdomen, inner thighs, and the front of the thighs, sometimes extending as far as the knees. Liposuction does not improve loose skin and may make it worse. The only effective remedy for loose skin is surgical excision, a process that creates long scars that are only partially concealed.

Results following liposuction are also influenced by body type and age. Tall, thin patients usually exhibit the best results. Younger patients do better than older ones. Results are often more subtle in those having a wide waist or pelvis, or having a large frame in general.

Liposuction is an inherently less precise technique compared to most other plastic surgery procedures. Minor imperfections can occur such as an area of residual fullness or the opposite: a small depression of irregularity. Fortunately, such problems can usually be improved by means of a short touch-up procedure. More extensive postsurgical defects, commonly the result of over aggressive treatment, may require fat grafting to restore normal contour.

What are the costs involved in having surgery?

There are separate fees for surgery, anesthesia, and operating room use. Costs also include preoperative lab tests, medical grade photographs, and support garments.

What are the steps involved in proceeding with surgery?

At the initial consultation the specific areas of interest on the body will be evaluated for suitability to liposuction. If you are a good candidate anatomically and are at a reasonable weight, a surgical date can be scheduled. Photographs and preoperative laboratory studies follow. Patients with significant medical conditions will need to obtain clearance from their internist or other specialist beforehand.

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