Liposuction

Liposuction, also known as lipoplasty ("fat modeling"), liposculpture suction lipectomy or simply lipo ("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 and buttocks, to the neck, backs of the arms and elsewhere.

Suction-assisted lipectomy of bilateral outer thighs

Several factors 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.

While reports of people removing 50 pounds (22.7 kg or around 3.6 stone) of fat has been claimed, 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 not to have smoked for several months.

History

Doctors Giorgio and Arpad Fischer, two Italian-American surgeons working in Rome, Italy, invented the liposuction procedure in 1974.^[1] The roots of liposuction, however, date back to the 1920s.^[1] Relatively modern techniques for body contouring and removal of fat were first performed by a 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.^[2]

Liposuction evolved from work in the late 1960s from surgeons in Europe and was pioneered in the United States by the European surgeon Leon Forrester Tcheupdjian using primitive curettage 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 after infusing fluid into tissues using blunt cannulas and high-vacuum suction and demonstrated both reproducible good results and low morbidity. During the 1980s, many United States surgeons experimented with liposuction, developing some variations, and achieving mixed results.

In 1985, Klein and Lillis 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.

Technologies involving the use of laser tipped probes (which induce a thermal lipoysis) have been introduced in recent years and are being evaluated to examine any potential benefit over traditional techniques.

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. In addition, fat can also be used as a natural filler. This is sometimes referred to as "autologous fat transfer" and in general, for these procedures, fat is removed from one area of the patient's body (for example, the stomach), cleaned, and then re-injected into an area of the body where contouring is desired, for example, to reduce or eliminate wrinkles.

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 (around 8 1/2 pints). Most often, liposuction is performed on the abdomen and thighs in women, and the abdomen and flanks in men. According to the American Society for Aesthetic Plastic Surgery, liposuction was the most common plastic surgery procedure performed in 2006 with 403,684 patients.

Candidacy

Not everyone is a good candidate for liposuction. It is not a good alternative to dieting or exercising. To be a good candidate, one must usually be over 18 and in good general health, have tried a diet and exercise regime, and have found that the last 10 or 15 pounds persist in certain pockets on the body. Diabetes, any infection, heart or circulation problems, generally nullify one's eligibility for the procedure. In older people, the skin is usually less elastic, limiting the ability of the skin to readily tighten around the new shape. Liposuction of the abdominal fat should not be combined with simultaneous tummy tuck procedures due to higher risk of complications and mortality. Laws in Florida prevent practitioners combining liposuction of the upper abdomen and simultaneous abdominoplasty because of higher risks.

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.

Areas of the body where liposuction is performed^[3]

• Abdomen
• Hips
• Outer thighs (saddlebags)
• Flanks (love handles)
• Back
• Inner thighs
• Inner knees
• Upper arms
• Submental (chin)
• Gynecomastia (male breast tissue)

Techniques

Power-assisted liposuction Cannula.

In general, fat is removed via a cannula (a hollow tube) and aspirator (a suction device). Liposuction techniques can be categorized by the amount of fluid injection and by the mechanism in which the cannula works.

Amount of fluid injection

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 lidocaine as a local anesthetic, adrenaline to contract the blood vessels and thus minimize bleeding, and a salt solution to make it saline, like bodily fluids. This fluid helps to loosen the fat cells and reduce bruising. The fat cells are then suctioned out as in the basic procedure.

Super-wet liposuction

Liposuction procedure using the Super-wet technique being performed on female patient by Vishal Kapoor, MD.

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 homeostasis and potential fluid overload (as with the tumescent technique). It takes one to three hours, depending on the size of the treated area/ areas. It may require either IV sedation as well as the local lidocaine, or complete anesthesia.

Tumescent liposuction

Tumescent liposuction is the precursor of wet liposuction. The surgeon injects a solution containing a local anesthetic and vasoconstrictor (often lidocaine and epinephrine respectively) directly into the subcutaneous fat to be removed. The volume of fluid creates a space between the muscle and the fatty tissue allowing more room for the cannula. Despite a potentially large total volume of local anaesthetic injected into the tissue, absorption by the body is spread over 12–36 hours because of the vasoconstrive effect, and systemic toxicity from lidocaine is rare.

Laser assisted liposuction (LAL)

Laser assisted liposuction uses thermal and photomechanical energy to affect the lipolysis. The addition of a laser to traditional liposuction procedures results in skin tightening effects through tissue coagulation, which makes it a highly efficacious and less traumatic solution for permanently eliminating fat cells. The procedure involves either the use of the Erchonia or Nd:YAG powered devices. The first FDA-approvals came for Smartlipo in 2006, but FDA-approved studies using Nd:YAG date back as early as 1994.^[4] Although the initial study in 1994, which compared conventional and laser thigh surgery, only showed small clinical benefits for laser assisted liposuction, more recent studies have shown laser assisted lipolysis is ideal for treating localized fat deposits and skin laxity on various areas of the body and face.

Mechanism of liposuction

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 in a forwards and backwards motion, carefully through the fat layer, breaking up the fat cells and drawing them out of the body by suction.

Ultrasound-assisted liposuction (UAL)

In ultrasound-assisted or 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 than traditional liposuction, but not longer than tumescent liposuction. There is slightly less blood loss. 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. Ultrasound-assisted liposuction techniques used in the 1980s and 1990s were associated with cases of tissue damage, usually from excessive exposure to ultrasound energy.^[5] The Vaser Lipo system, a third-generation UAL device, prevents this problem by using pulsed energy delivery and a specialized probe that allows physicians to safely remove excess fat.^[6]

A 40-year old woman undergoing a combination liposuction and abdominoplasty. Power-assisted liposuction: the cannula is inserted to about 80% of its full length.

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.

Twin-cannula (assisted) liposuction (TCAL or TCL)

Twin cannula (assisted) liposuction uses a tube-within-a-tube specialized cannula pair, so that the cannula which aspirates fat, the mechanically reciprocated inner cannula, does not impact the patient's tissue or the surgeon's joints with each and every forward stroke. The aspirating inner cannula reciprocates within the slotted outer cannula to simulate a surgeon's stroke of up to 5 cm (2 in) rather than merely vibrating 1–2 mm (1/4 in) as other power assisted devices, removing most of the labor from the procedure. Superficial or subdermal liposuction is facilitated by the spacing effect of the outer cannula and the fact that the cannulas do not get hot, eliminating the potential for friction burns.

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; and 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 produces less edema from the tumescent fluid. The utility of this technology is under study and is currently not widely used.

Sutures

Since the incisions are small, and 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. Others suture them only partially, leaving space for the fluid to drain out.^[7][8] Others delay suturing until most of the fluid has drained out, about 1 or 2 days. In any 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, no anticoagulants should be taken for two weeks before the surgery. If general anesthesia or sedation will be used, 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, as 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 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 would need someone else to drive them.

Recovery

Depending on the extent of the liposuction, patients are generally able to return to work between two days and two weeks. A compression garment which can easily be removed by the patient is worn for two to four weeks, this garment must have elasticity and allow for use of bandages.^[9] 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. Bruising will fade after a few days or maybe as long as two weeks later. Swelling will subside in anywhere from two weeks to two months, while 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.

The suctioned fat cells are permanently gone. However, if the patient does not maintain a proper diet and exercise regimen, 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.

• 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 should 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.^[10]

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 out of 702)", the minor complication rate was 0.57%, and 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.^[11]
• 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

Liposuction and tightening / lifting skin

Liposuction can be a good tool for tightening the skin. The removal of quantities of fat from under the skin allows the elastic skin to retract to its genetically predetermined position and sometimes even smaller. Good examples of this effect are seen after liposuction to the arms, stomach areas and breasts. The level of skin retraction following liposuction is also determined by the age of the patient, quality of skin, presence of underlying disease or smoking and the presence of previous skin damage such as caused by childbirth and surgery. Liposuction techniques such as subdermal undermining using fine cannulas can stimulate further skin retraction. While subdermal undermining may help the skin contract, patients with severe elasticity loss and heavy stretch marks prior to liposculpture may require removal of redundant skin by surgical means after liposculpture. Usually this can be performed after 6 months.

Surgical lifts such as a rhytidectomy (facelift), mastopexy (breast lift), abdominoplasty (tummy tuck), or lower body lift, thigh lift, or buttock lift can be utilised when sagging skin alone is the issue or after massive weight loss when the combination of large amounts of skin and shrunken fat cause significant skin droop.

Large volume Liposuction (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, however a new techniques in tummytuck surgery involves vigorous liposuction first before excising the redundant skin.

Non-surgical alternatives

Shapewear

One non-surgical alternative that has gained in popularity is the use of shapewear garments^[12]. Although shapewear cannot provide patients with the same level of results as liposuction, body scans have shown that they can remove bulges and slim the waist, hips, and thighs^[13]. Most shapewear products are similar to the post-surgical compression garments but unlike the post-surgical garments, shapewear is designed for long-term daily use.

Diet and exercise

Healthy eating habits combined with regular exercise has also been proven to cause weight loss. However, the process can take much longer compared to liposuction. However, losing weight via exercise and eating a healthy diet carries much less risk than liposuction, and can provide general health benefits (such as increased cardiovascular health) that liposuction will not.

See also

• Abdominal etching
• Bariatrics - branch of medicine that deals with the causes, prevention, and treatment of obesity
• Gastric bypass surgery
• Spot reduction

References

External links

• How Liposuction Works from howstuffworks
• Liposuction at the Open Directory Project
• FDA liposuction information
• Youtube video documentary on liposuction surgery patient