Article: Liposuction

Liposuction, also known as lipoplasty ("fat modeling") or suction lipectomy ("suction-assisted fat removal") is a cosmetic surgery operation which removes fat from many different sites on the human body. Areas affected can range from the abdomen, thighs, buttocks, neck, arms and elsewhere. The fat is usually removed via a cannula and aspirator.

While exercise and dieting may be useful for losing unwanted weight and fat, some fat deposits may not respond to efforts at weight loss. Applying liposuction techniques may be an option in these situations. Liposuction is not a low-effort alternative to exercise and diet. It is a form of body contouring and not a weight loss method. The amount of fat removed varies by doctor, method, and patient, but the average amount is typically less than 10 pounds (5 kg).

There are several factors that limit the amount of fat that can be safely removed in one session. Ultimately, the operating physician and the patient make the decision. There are negative aspects to removing too much fat. Unusual "lumpiness" and/or "dents" in the skin can be seen in those patients "over suctioned".

Reports of people removing 50 pounds (22.7 kg) of fat are exaggerated. However, the contouring possible with liposuction may cause the appearance of weight loss to be greater than the actual amount of fat removed. The procedure may be performed under general or local ("tumescent") anesthesia. The safety of the technique relates to the amount of tissue removed, the choice of anesthetic, and the patient's overall health.

History

Relatively modern techniques for body contouring and removal of fat date back to French Surgeon, Charles Dujarier. A tragic case that resulted in gangrene in the legs of a French model[1]in a procedure performed by Dr. Dujarier in 1926 set back interest in body contouring for decades to follow.

Liposuction evolved from work in the late 1960's from surgeons in Europe using primitive curetage techniques which were largely ignored, as they achieved irregular results with signifigant morbidity and bleeding. Modern liposuction first burst on the scene in a presentation by the French surgeon, Dr Yves-Gerard Illouz, in 1982. The Illouz Method featured a technique of suction-assisted lipolysis using blunt cannulas and high-vacuum suction and demonstrated both reproducible good results and low morbidity. During the 1980s, many U.S. surgeons experimented with liposuction, developing some variations, and achieving mixed results.

In 1985, two U.S. dermatologists developed the tumescent technique, which enhances effectiveness and safety in office-based procedures, partly by avoiding the use of general anesthesia.

In the late 1990s, ultrasound was introduced to facilitate the fat removal by first liquefying it using ultrasonic energy. After a flurry of initial interest, an increase in reported complications tempered the enthusiasm of many practicioners.

Overall, the advantages of 30 years of improvements have been that more fat cells can more easily be removed, with less blood loss, less discomfort, and less risk. A great deal has been written about it as practitioners and advocates wrestle with the alternatives and controversies.

Popularity

In the U.S., more than 50% of the population is overweight. So it should not be surprising that liposuction is now the most often performed surgery in the country. Usually it is done to remove about 10 to 15 pounds of fat.

Removal of very large volumes of fat is a complex and potentially life-threatening procedure. The American Society of Plastic Surgeons defines "large" in this context as being more than 5 liters.

Most often, liposuction is performed on:

Candidacy

Not everybody is a good candidate for liposuction. As stated earlier, it is not a good alternative to dieting or exercising. To be a good candidate, one must be:

  • Over 18
  • In good general health
  • Have tried a diet and exercise regime, and find that the last 10 or 15 pounds insists on remaining in certain pockets on the body

Diabetes, any infection, or heart or circulation problems usually nullify one's eligibility for the procedure.

In older people, the skin is usually less elastic, so it does not tighten so readily around the new shape. In this case, other procedures can be added to the liposuction, such as a tummy tuck.

Approaches

The basic surgical challenge of any liposuction procedure is:

  • To remove the right amount of fat
  • To cause the least disturbance of neighboring tissue, such as blood vessels and connective tissue
  • To leave the person’s fluid balance undisturbed
  • To cause the least discomfort to both patient and surgeon

As techniques have been refined, many ideas have emerged that have brought liposuction closer to being safe, easy, painless, and effective.

Techniques

In the basic approach, a small cannula (like a straw) is inserted through a small incision. It is attached to a vacuum device. The surgeon pushes and pulls it carefully through the fat layer, breaking up the fat cells and drawing them out of the body by suction.

This method is seldom used today. Instead, the surgeon will incorporate some of the various improvements that have been made since liposuction's inception.

Basic liposuction with fluid injection

A small amount of fluid, less in volume than the amount of fat to be removed, is injected into the area. It contains:

  • Lidocaine: as a local anesthetic
  • Epinephrine: to contract the blood vessels and thus minimize bleeding
  • A salt solution: to make it saline, like our body fluids

This fluid helps to loosen the fat cells and reduce bruising. The fat cells are then suctioned out as in the basic procedure.

Tumescent liposuction

This is a major improvement on basic liposuction. Not just a small amount, but a large amount of fluid is injected into the area, perhaps as much as 3 or 4 times the volume of fat to be removed. "Tumescent" means swollen.

It is the same saline fluid as used in basic liposuction, but its increased quantity creates space between the muscle and the fatty tissue, which creates more room for the suction tube (cannula) that the surgeon uses to remove the fat cells. It is easier for the surgeon to make the back and forth movements that break up the fat cells and allow them to be suctioned out.

Depending on the size of the area(s) being worked, this procedure takes perhaps four hours or so, longer than basic liposuction. This is because the fluid must be introduced carefully and about an hour must be allowed for it to percolate and enlarge the area before any work is started.

Stitches

To stitch or not to stitch is the surgeon's decision. Since the incisions are small, and since the amount of fluid which must drain out is large:

  • Some surgeons opt to leave the incisions open, the better to clear your body of excess fluid. They find that the unimpeded departure of that fluid allows the incisions to heal more quickly by themselves. [2] [3]
  • Others stitch them only partially, leaving space for the fluid to drain out [4] [5] [6] [7]
  • Others delay stitching until most of the fluid has drained out, about 1 or 2 days

In either case, while the fluid is draining, dressings need to be changed often. After one to three days, small self-adhesive bandages are sufficient.

Super-wet liposuction

In this method, the infusate volume is in about the same amount as the volume of fat expected to be removed. This is the preferred technique for high-volume liposuction by many plastic surgeons as it better balances hemostasis and potential fluid overload (as with the tumescent technique). It takes one to three hours, depending on the size of the treated area(s). It may require either:

  • IV sedation as well as the local lidocaine, or
  • Complete anesthesia

Ultrasound-assisted liposuction (UAL)

Also referred to as ultrasonic liposuction, this is a type of tumescent liposuction. A specialized cannula is used which transmits ultrasound vibrations within the body. This vibration bursts the walls of the fat cells, emulsifying the fat, i.e., liquefying it, and making it easier to suction out.

  • UAL is a good choice for working on more fibrous areas, like the upper back, or male breast area
  • It takes longer to do than traditional liposuction, but not longer than tumescent liposuction
  • There is slightly less blood loss
  • So far, there appears to be slightly more risk of seromas forming (pockets of fluid) which may have to be drained with a needle

Power-assisted liposuction (PAL)

PAL uses a specialized cannula with mechanized movement, so that the surgeon does not need to make as many manual movements. Otherwise it is similar to traditional UAL.

  • The cannula movement is more subtle, which creates less discomfort for the patient
  • So far, there appears to be less risk of puncturing internal organs, because of the more controlled cannula movement.

External ultrasound-assisted liposuction (XUAL or EUAL)

XUAL is a type of UAL where the ultrasonic energy is applied from outside the body, through the skin, making the specialized cannula of the UAL procedure unnecessary.

It was developed because surgeons found that in some cases, the UAL method caused skin necrosis (death) and seromas, which are pockets of a pale yellowish fluid from the body, analogous to hematomas (pockets of red blood cells).

XUAL is a possible way to avoid such complications by having the ultrasound applied externally. It can also potentially:

  • Cause less discomfort for the patient, both during the procedure and afterwards
  • Decrease blood loss
  • Allow better access through scar tissue
  • Treat larger areas

At this time however, it is not widely used and studies are not conclusive as to its effectiveness.

Candidate preparation

Before receiving any of the procedures described above:

  • No anticoagulants should be taken for two weeks before the surgery.
  • If receiving general anesthesia, and the surgery will be in the morning, fasting from midnight the night before is required. If only local anesthesia will be used, fasting is not required.
  • Smoking must be avoided for about two months prior to surgery. Smoking interferes with circulation and in the context of surgery, may increase the risk of blood clots.

The procedure

In all liposuction methods, there are certain things that should be done when having the procedure.

  • The candidate and the surgeon will agree ahead of time on exactly which area(s) will be treated and both will discuss what outcome to expect
  • A consent form is signed on the day of surgery
  • An antibiotic will be given either about an hour beforehand, or afterwards
  • The targeted areas are marked on the body while the candidate is in a standing position
  • Sometimes photos will be taken of the area to be treated, so the patient will have before and after photos
  • In the operating room, a sterilizing solution such as Betadine, is applied to the relevant areas
  • Local anesthetic is injected and the patient may be given a sedative, either orally, or through an IV injection
  • Incisions are small, about a quarter to a third of an inch
  • The patient will probably have an IV fluid line, since they will be losing fluid with the fat, and the fluid balance must be kept intact
  • There will be some monitoring devices attached to the body to keep track of the blood pressure, heart rate, and blood oxygen level
  • The patient will feel only a scraping or rasping sensation from the cannula movement
  • Usually the patient can get up, walk around, and go home the same day if they did not receive general anesthesia, although they’ll need someone else to drive

Recovery

  • Afterwards, a compression garment or Ace bandage will be worn until drainage has stopped, perhaps days, or perhaps for two to four weeks, depending on the specific case
  • Bandages will be changed after one or two days
  • Drains and sutures will be removed after five to ten days, or whenever the drainage is finished
  • Any pain is controlled by a prescription or over-the-counter medication, and may last as long as two weeks, depending on the particular procedure
  • Swelling will subside in anywhere from two weeks to two months
  • Bruising will fade after a few days or maybe as long as two weeks later
  • Numbness may last for several weeks
  • Normal activity can be resumed anywhere from several days to several weeks afterwards, depending on the procedure
  • The final result will be evident anywhere from one to six months after surgery, although the patient will see noticeable difference within days or weeks, as swelling subsides

Expediting recovery

The patient should:

  • Drink enough water to prevent dehydration
  • Avoid alcohol for a couple of days, both before and after surgery
  • Avoid using ice packs or heating pads on the treated areas
  • Postpone any submersion in water for at least a week (bathtub, swimming pool, river, etc.)
  • If any dizziness is experienced, the patient should take it easy: stand up slowly, get some help for the shower, remove the compression garment slowly, etc.

The suctioned fat cells are permanently gone. However, if the patient does not diet and exercise properly, the remaining fat cell neighbors could still enlarge, creating assorted bulges.

Side effects

A side effect, as opposed to a complication, is medically minor, although it can be uncomfortable, annoying, and even painful.

  • Bruising: can be painful in the short term, and should fade after a few weeks.
  • Swelling: should subside gradually over a month or two.
  • Scars: will vary in size depending on the particular procedure, and should fade over the weeks. Scarring is an individual thing, partly dependent on heredity. For some, scar healing may take as long as a year.
  • Pain: should be temporary and controlled by either over-the-counter medication, or by a prescription.
  • Numbness: sometimes persists for a few weeks.
  • Limited mobility: will depend on the exact procedure.

There could be various factors limiting movement for a short while, such as:

  • Wearing a compression garment
  • Keeping the head elevated
  • Temporary swelling or pain

The surgeon should advise on how soon the patient can resume normal activity.

Possible complications

As with any surgery, there are certain risks, beyond the temporary and minor side effects. The surgeon may mention them during a consultation. Careful patient selection minimizes their occurrence. Their likelihood is somewhat increased when treated areas are very large or numerous and a large amount of fat is removed. [8]

During the 1990s there were some deaths as a result of liposuction, as well as alarmingly high rates of complication. By studying more and educating themselves further, surgeons have reduced complication rates.

A study published in Dermatologic Surgery (July 2004, pp. 967-978), found that:

  • “The overall clinical complication rate [for liposuction] ... was 0.7% (5 of 702)”
  • The minor complication rate was 0.57%
  • The major complication rate was 0.14% with one patient requiring hospitalization

The more serious possible complications include:

  • Allergic reaction to anesthetic: most liposuction is done with local anesthetic, so the risks of general anesthesia are avoided.
  • Infection: any time the body is incised or punctured, bacteria can get in and cause an infection. During liposuction, multiple small puncture wounds are made for inserting the cannula, typically about 1/3 inch wide.
  • Damage to the skin: most surgeons work on the deeper levels of fat, so as to avoid wounding the skin any more than they must for the insertion of the cannula.
  • Sometimes the cannula can damage tissue beneath the skin, which may show up as a spotted appearance on the skin surface.
  • Skin necrosis (death) is a rare complication, in which the skin falls off in the necrotic area. Bacteria can then invade.
  • Puncture of an internal organ: since the surgeon can't see the cannula, sometimes it damages an internal organ, such as the intestines during abdominal liposuction. Such damage can be corrected surgically, although in rare cases it can be fatal. An experienced cosmetic surgeon is unlikely to puncture any internal organ.
  • Contour irregularities: sometimes the skin may look bumpy and/or withered, because of uneven fat removal, or poor skin elasticity. We all heal differently, and with older patients the healing may be slower and a bit imperfect. Sometimes a small touch-up procedure can help.
  • Thromboembolism and fat embolisation: although liposuction is a low-risk procedure for thromboembolism including pulmonary embolism, the risk can't be ignored.[9] [10] [11] [12]
  • Burns: sometimes the cannula movement can cause friction burns to skin or nerves. Also, in UAL, the heat from the ultrasound device can cause injury to the skin or deeper tissue.
  • Lidocaine toxicity: when the super-wet or tumescent methods are used, too much saline fluid may be injected, or the fluid may contain too high a concentration of lidocaine. Then the lidocaine may become too much for that particular person’s system. Lidocaine poisoning at first causes tingling and numbness and eventually seizures, followed by unconsciousness and respiratory or cardiac arrest.
  • Fluid imbalance: since fat contains a lot of fluid and is removed in liposuction, and since the surgeon injects fluid for the procedure, even a very large amount of it for tumescent liposuction, there is a danger of the body’s fluid balance being disturbed. This could happen afterwards, after the patient is at home. If too much fluid remains in the body, the heart, lungs and kidneys could be badly affected.

The cosmetic surgeon should give the participant a written list of symptoms to watch for, along with instructions for post-op self-care.

Combined with other procedures

In general, it is regarded as less than optimally safe to have other procedures done at the same time as liposuction. But it can be done, and some combinations are:

Liposuction with a tummy tuck (abdominoplasty)

The removal of quantities of fat from under the skin leaves the skin loose. If the person’s skin is less elastic than it used to be, it might remain loose and never quite tighten up around the new, slimmer contour. In older people, the muscle can also be somewhat lax and need tightening. So a tummy tuck is a way of addressing this situation.

Liposuction with a hip, thigh or buttock lift

For some people, excess fat stubbornly remains in the buttocks, hips and thighs. When the skin is not loose, liposuction alone can remedy the problem.

But if the skin is loose and hanging in folds, then the liposuction can be combined with a hip, thigh or buttock lift. The skin will be tightened, the excess removed, and the remainder re-positioned over the newly liposuctioned areas.

Liposuction and wrinkle removal

Tumescent liposuction is often used to slim down the jaw and neck area. In younger people, this produces very good results. In older people, a facelift can often do the job nicely.

But if the skin there is becoming too wrinkled or sagging, the best alternative is sometimes a combination of liposuction and laser resurfacing or chemical peel.

Choosing a surgeon

There is no standardized training specifically required for a surgeon to perform liposuction. Any surgeon can do it, and in view of the increasing demand, many do.

Therefore:

  • In the US, one should choose a surgeon who belongs to the Association of Plastic Surgeons (AAPS), at the very least, and preferably some of the other national associations as well such as:
  • One should choose a surgeon who is experienced in doing liposuction in the way that he/she proposes it for the candidate.
  • The facility where it will be done should be certified and accredited by a nationally recognized surgery accreditation body. It should have the ability to handle complications.
  • The surgeon should have privileges in at least one local hospital. This is a back-up in case of any emergency that turns out to be more than the surgeon’s facility can handle.
  • The anesthesiologist should be as qualified and experienced as the performing surgeon.
  • The surgeon’s support staff in the operating and recovery rooms should be experienced with the procedure.
  • With a list of possible surgeons, the candidate should set up initial consultations with them.
  • The candidate should have a list of questions and should be sure that they understand the answers. If the surgeon seems impatient or unwilling to take time to answer the questions, move on.
  • The surgeon should be one with whom the candidate feels personally comfortable, as well as confident in their professional qualifications.

Cost

The price of liposuction varies depending on the number of areas treated, the body site treated and the amount of fat removed. The price may also vary with different clinics and areas. Usually, the total cost is from USD$2000 to $3000 per body area.

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