Liposuction

Editors-In-Chief: Martin I. Newman, M.D., FACS, Cleveland Clinic Florida, [mailto:Newmanm@ccf.org]; Michel C. Samson, M.D., FRCSC, FACS [mailto:samsonm1@ccf.org]

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

Liposuction is not a low-effort alternative to exercise and diet. It is a form of body contouring with significant attendant risks and is 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". The more fat removed the higher the surgical risk.

As shown previously, 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 not only to the amount of tissue removed, but to the choice of anesthetic and the patient's overall health. It is ideal for the patient to be as fit as possible before the procedure and to have given up smoking for several months.

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 leg of a French model 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 1960s from surgeons in Europe using primitive curetage techniques which were largely ignored, as they achieved irregular results with significant 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 described the tumescent technique, which added high volumes of fluid containing a local anesthetic allowing the procedure to be done in an office setting under intravenous sedation rather than general anesthesia. Concerns over the high volume of fluid and potential toxicity of lidocaine with tumescent techniques eventually led to the concept of lower volume "super wet" tumescence.

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 practitioners.

In 2005-6, two new, FDA-approved technologies introduced laser-assisted liposuction. One technology employs a laser at high frequency, the other, a cold laser at low frequency. What the two laser technologies have in common is a refinement in the preparation of fat cells for removal that allows for a less invasive procedure. For patients, this can mean a smaller incision, and easier, more precise use of the cannula. The patient benefit, according to clinical trials and studies conducted by the medical technology firms and by surgeons employing the new technologies, is less tissue trauma and abbreviated wearing of the compression garment or girdle worn compared to other methods of liposuction. 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. Recent developments suggest that the recovery period can be shortened as well.

Popularity
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:


 * The abdomen and thighs in women
 * The abdomen and flanks in men

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 persist 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 an abdominoplasty (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
Liposuction techniques can be further categorized by the amount of fluid injection and by the mechanism in which the cannula works.

Dry liposuction
The dry method does not use any fluid injection at all. This method is seldom used today.

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

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

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

Tumescent liposuction
In the classic tumescent technique, 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. It is the same saline fluid as the super wet technique, 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. Depending on the size of the area(s) being worked, this procedure takes longer than other techniques must as the large amount of infiltrate must be introduced slowly.

The high volumes of fluid and local anesthetic required for this technique have limited its use with larger people.

Laser assisted liposuction
Laser assisted liposuction may involve either of two technologies, both of which received FDA approval in 2006. These technologies have been adopted by physicians seeking an advance in liposculpture procedures.

The Erchonia Neira 4L laser produces a low-level, or cold, output that has no thermal effect on the body's tissue. According to Erchonia, this technology is currently in use at a handful of cosmetic plastic surgery practices in the US. Specifically calibrated to destabilize or liquefy the fat, without affecting surrounding tissue, the patient feels neither heat nor sensation from the laser's application. The cosmetic surgeon then uses a small cannula to remove the destabilized fat cells. According to Erchonia, the liquefaction of the fat cells allows for a substantially less invasive procedure, with less trauma to surrounding tissue.

Laser assisted liposuction may also refer to a laser technology, known in the US as SmartLipo, that employs a cannula tipped with a diode laser emitter. According to Cynosure, the cold laser's US maker and marketer, a small cannula threaded and tipped with a 1064-nm Nd:YAG laser fiber is inserted through a small incision. It delivers energy directly to subcutaneous fat cells-causing them to rupture. The emitted fat melting energy also coagulates surrounding tissue, thus inducing collagen retraction and tissue tightening.

The surgeon monitors cannula placement by following a visible red light that shines through the skin and tissue. This is from a “guide” optical fibre in the cannula. Typically, when SmartLipo is used, fat is not removed by a suction device, but rather, dissipates through the body’s natural processes,

Laser assisted liposuction of either type is considered to be minimally invasive when compared to traditional liposuction techniques.

Suction-assisted liposuction (SAL)
Suction-assisted liposuction is the standard method of liposuction. In this 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.

Microcannula liposuction
Microcannula or very small liposuction cannula that makes possible fine, close to surface contouring, sometimes through much smaller incisions.

Ultrasound-assisted liposuction (UAL)
Also referred to as ultrasonic 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

After ultrasonic liposuction, it is necessary to perform suction-assisted liposuction to remove the liquified fat.

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.

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.

Water-assisted liposuction (WAL)
WAL uses a thin fan-shaped water beam, which loosens the structure of the fat tissue, so that it can be removed by a special cannula. During the liposuction the water is continually added and almost immediately aspirated via the same cannula. WAL requires less infiltration solution and much less intraoperative swelling. This allows the surgeon to better realize the target result. The cannula movements are very subtle, helped by the water beam. This is a new technique that there is not much published yet in the medical literature.
 * Not approved by the FDA in the US.

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


 * Some surgeons opt to leave the incisions open, the better to clear the patient's body of excess fluid. They find that the unimpeded departure of that fluid allows the incisions to heal more quickly by themselves.
 * Others stitch them only partially, leaving space for the fluid to drain out
 * 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.

Preparation
Before receiving any of the procedures described above:
 * No anticoagulants should be taken for two weeks before the surgery.
 * If receiving general anesthesia or sedation, 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. Nicotine interferes with circulation and can result in loss of tissue.

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
Depending on the extent of the liposuction, patients are generally able to return to work or school between two days and two weeks. A compression garment or bandage is worn for two to four weeks. If non-absorbable sutures are placed, they will be removed after five to ten days.


 * 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 using ice packs or heating pads on the treated areas
 * Postpone soaking the wounds until they are sealed (usually 48 hours for sutured wounds and a little longer for unsutured ones).
 * 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 irregularities.

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

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


 * 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.

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 medications or material used during surgery.
 * 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, that can vary in size depending on the technique.
 * 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 (dead skin) is a rare complication, in which the skin falls off in the necrotic area. The problem can vary in degree.  The resulting wound then needs to heal typically requiring extended wound care.
 * 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. Not all patients heal in the same way, 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.
 * 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.

Liposuction and tightening / lifting skin
Liposuction is not a good tool for tightening the skin. The removal of quantities of fat from under the skin can leave the skin even more loose. When drooping skin and fat are the issue, then lift such as a Rhytidectomy Facelift, Mastopexy Breast Lift, Abdominoplasty Tummy Tuck, or Lower body lift, Thigh Lift, or Buttock Lift are better tools and may include liposuction during surgery to refine the sculpture. SAL in combination with other surgery is common, but may have higher complication rates. When done simultaneously, SAL is done minimally in the areas of the undermined tissues to minimize further insult to the blood supply.