THE ART OF LIPOSUCTION
By Robert Caridi, M.D.
Westlake Plastic Surgery
Introduction
Liposuction is one the most common cosmetic surgical procedures performed today by plastic surgeons. In 2005, more than 324,000 cases of liposuction were performed by board certified plastic surgeons. I have extensive experience in liposuction, as I have performed thousands of procedures that have included large volume liposuction (the removal of greater than 5 liters of fat and fluid). It is popular because the procedure is comparatively safe, the recovery time is short, and patient satisfaction is extremely high. Liposuction is a surgical procedure for removing subcutaneous fat anywhere on the body. Liposuction is as much art as a surgical procedure. It involves the practical application of scientific knowledge with the precision, artistry, and skill obtained from significant clinical experience. Liposuction is not just “removing fat,” it is a surgical procedure that requires the utmost respect and should only be performed by experienced surgeons.
The benefits of liposuction are impressive. Diet, exercise, weight loss, and careful selection of clothing can only do so much to improve your appearance. If you’re not happy with the way you look, if you want to feel more comfortable in a bathing suit, or if you’d like greater freedom in the clothes you wear, you may benefit from liposuction. This surgical technique can provide you with an improved body contour with negligible scarring. As with any cosmetic surgery, it’s important to have clear objectives and realistic expectations.
Technique
Tiny incisions are made near the area from which the fat is to be removed and a specially designed surgical cannula (tube) is placed through the incision into the fat. The vacuum pump removes the fat by suction as the cannula is manipulated beneath the skin.
Liposuction can be utilized to remove fat deposits from virtually anywhere on the body. Commonly treated areas include the legs, buttocks, abdomen, face, neck, and back. During an initial consultation, patients discuss the areas of most concern; then the plastic surgeon may suggest other areas that if treated would optimize your result.
The most common way to perform liposuction is the “tumescent technique.” With tumescent liposuction, large amounts of fluid are injected into the fatty areas prior to treatment. This allows for greater removal of fat, decreases the amount of bruising, and speeds recovery time. The fluid infiltrated into the fat is what drains from the incision sites after your surgery. Small cannulas are used as they limit potential contour irregularities. Microcannulas, (those with an external diameter of 4mm or less) are ideal for contouring fat as the use of such a fine cannula results in smoother liposuction, less bruising, and less potential for contour abnormalities.
There are many “tools” available on the market to facilitate fat removal. Examples include UAL or “ultrasonic liposuction,” VASER, Laser, and Power Assisted Liposuction. I have been fortunate to have used most machines and I have observed how well they perform in actually removing the fat as well as how they have impacted the final results. My honest assessment is that these machines increase the risks of liposuction while providing no additional benefit over standard liposuction. Indeed, the standard procedure is often longer, the incision larger, and the potential for irregularities greater, and as it may be easier for the surgeon to perform liposuction when using one of the “power devices,” in the end, the ultimate measure of the benefit of these machines in terms of the quality of the result has not been observed, nor proven. After many years of performing liposuction on thousands of patients, I have come to the simple conclusion that the quality of the results is determined by the quality of your surgeon and not the device he/she utilizes.
All patients need to be aware of Smart Liposuction. This is a laser-based liposuction technique that has been marketed heavily. Unfortunately, there are many patients who have been lured into thinking that this was the best procedure for them and have learned to regret it. This machine has found itself in the hands of non-surgeons who are inexperienced at best, dangerous at worst. The number of patients I have seen in my office with complications from this device has increased tremendously. Endermology technicians have reported a huge rise in post Smart Lipo contour irregularities that are impossible to correct. Please understand that liposuction is a real procedure requiring real expertise and should not be taken lightly.
Mesotherapy is a non-surgical cosmetic medical treatment that involves multiple injections of pharmaceutical and homeopathic preparations, plant extracts, vitamins, and other ingredients into the subcutaneous tissue. It has been marketed as a liposuction alternative. There is no science supporting mesotherapy as a legitimate technique. A patient of mine who had mesotherapy elsewhere and then had conventional liposuction with me described it well: “It hurt like hell, lots of bruising, and no results.” I don’t recommend mesotherapy except for maybe small areas of lipodystrophy and only if provided by a Board Certified Plastic Surgeon.
The media has contributed significantly to patient’s confusion regarding liposuction. Statements indicating less bruising, less downtime, and improved results are just marketing tools to entice you into thinking you will obtain better results with little to no downtime. This is patently false in my opinion. Don’t make your decision based on a particular type of liposuction. Choose to have liposuction from an experienced and reputable surgeon who is known for his/her record of safe and expected results.
More than 50% of the adult population is overweight. Although liposuction is not considered a treatment for obesity, it is not surprising that it is frequently used to treat obesity. Advances in the removal of larger and larger volumes of fat with less blood loss have lead to what we call “large volume liposuction.” This is generally considered the removal of 5 liters of total aspirate from a patient. Large volume liposuction must be left in the hands of only the most experienced plastic surgeons for your safety.
Post-Liposuction Benefits
Fat distribution is determined by two factors: heredity and diet. Heredity determines the location and number of individual fat cells, which are fixed and unchanging after puberty. Diet can increase or decrease the amount of fat in each cell but will not affect the total number of cells or their distribution. For example, if you have inherited large numbers of fat cells on your thighs and small numbers of fat cells on the chest, then strenuous attempts at weight loss can leave you with a thin upper body and persistently bulky thighs. Localization of fat deposits is different in men and women. Women tend to have contour irregularities about the hips (saddle bags), thighs, and knees. Men tend to concentrate fat about the abdomen and flanks (love handles). Some patients have a genetically programmed distribution of fat (apple or pear shape). One example is patients who may be thin about the waist but have large volumes of fat about their hips, thighs, and legs. Their parents oftentimes had the same shape. This fat distribution is not amenable to treatment with diet and exercise and is ideal for liposuction. Fat distribution also changes as we get older (we tend to “spread” with age).
Your appearance after liposuction will be influenced by the general state of your health, the overall condition of your skin, age, weight, hormonal influences, and other factors. Each patient is unique, and during a consultation, your plastic surgeon should discuss in detail how these general factors are likely to apply to you in particular. Liposuction is not a substitute for a healthy diet, nor is it useful for generalized weight reduction. While the foregoing may seem obvious, I mention it because some patients may expect localized fat removal to affect a dramatic weight loss. This is not possible. Patients commonly ask how much weight they will lose after the procedure. Surprisingly, it is not dramatic—a few pounds at most. I have discovered that for every 1000cc of fat removed you can expect about a one-pound weight loss. The real benefit from the procedure is the new shape of your body and the dramatic effect is has on your self-esteem and motivation for exercise and a healthy lifestyle. I don’t offer liposuction to about one third of the patients that I see in consultation for liposuction because I don’t think it is in their best interest.
Liposuction selectively removes fat from those areas in which the patient desires reduction. Since the actual fat cells are removed, the procedure is permanent, and following liposuction the body will always have less fat in the treated areas. The fat does not come back. If you gain weight following your liposuction, your remaining fat cells can increase in size. However, you will not grow new ones. It is important therefore to monitor your weight by using a scale on a regular basis. This is particularly important for those people whose weight tends to increase and decrease frequently. For example, many men use their waistline as the indicator of weight gain or loss. If your waist is made smaller through liposuction, it can be easy to put on pounds because of the lack of feedback after your liposuction. Since your “alarm” has been altered, you may be unaware of subtle weight gain. Frequently my patients lose weight and exercise more after body contouring because they feel better about themselves and are no longer plagued with fat in their “trouble” areas. It is remarkable to witness this transformation.
Many patients are aware of the concept of “fat traveling.” They may know a friend who had liposuction and then gained considerable weight afterwards. They look different, almost as if they actually got larger in the areas that were not treated by liposuction. This is so because weight gain after a liposuction will go to untreated areas as well as treated areas, and sometimes this appears as a shape imbalance. This is why liposuction is not ideal for individuals whose weight fluctuates, and those who have little self control. Know yourself and be honest to your surgeon; if you struggle with your weight, liposuction probably isn’t in your best interest and there is no “quick fix.”
The quality of your skin has the greatest impact on your results! Good elasticity is a desirable attribute in all patients because it yields a smooth surface contour. Elasticity refers to skin that is tight and will quickly retract after stretching. Tight skin is universally seen in our youth and is gradually lost as we age. Even through middle age, however, we retain some elasticity. Clinically, the skin should have sufficient inherent elasticity to recoil and contract after removal of fat. Stretch marks are a strong indication of poor elasticity, as is delayed rebound after manual stretching. The skin always shrinks to adjust to the reduced contour following an appropriate liposuction. Significant skin overhang may indicate a need for skin removal. An experienced liposuction surgeon can always analyze your skin and render his/her opinion regarding how well your skin will respond to liposuction and what areas, if any, are potential trouble spots that may require differential treatment, usually consisting of less removal of fat so that the skin does not become wrinkled or irregular.
Appearance of the Skin, Cellulite and Endermologie
The word “cellulite” has no precise medical meaning. Most people use the word to refer to dimpling and irregularities that occur on the surface of the skin. It is seen most frequently over the lower torso and thighs, worsens with age, and is often associated with loose skin. Cellulite is due to laxity of the underlying skin supporting structures. While liposuction will not cure cellulite, it will remove fat and reduce contour. It has been my experience that most cellulite actually improves after liposuction unless the cellulite is extremely advanced. Endermologie services after my liposuction procedures are almost mandatory in cases of cellulite.
Many of my patients receive Endermologie treatments after liposuction. Endermologie is a non invasive treatment to help condition the soft tissue deep below the skin. It’s a machine used by an experienced operator. The technique involves the use of a special hand held device with rollers and a vacuum that is passed over the skin in the treatment areas. Because liposuction causes scarring and swelling deep beneath the skin, this treatment is a excellent way to soften the scar tissue, reduce swelling and edema, and facilitate a smooth skin contour. Treatments start about two weeks after your procedure and most patients elect to have one or two treatments a week for about four to ten weeks.
In addition to Endermologie Services, I also recommend that you use a “dough roller” device to roll over your treatment areas. This will reduce swelling and help to ensure an even, bump-free result. This can be done in the comfort of your own home and can be performed when it is convenient for you. Press the roller against your tissue with medium intensity and try to roll towards areas of lymphatic drainage (such as your armpit or groin area.)
Anesthesia and Procedure
During the procedure you are administered an anesthetic and there is no discomfort. Afterwards, you will feel sore but not particularly pained unless a large volume liposuction was performed, in which case the level of discomfort is greater. It feels similar to the deep muscle ache you experience after a particularly strenuous workout. When only one or two small areas are treated, particularly on the face and neck, the patient is given a local anesthetic. When multiple or large areas are treated, general or regional anesthetics are administered by my anesthesiologist. I suggest general anesthesia to most of my patients because I feel it offers the patient the most comfort and safety and is associated with less pain and anxiety. It is always safer to have my anesthesiologist present during your surgery. The additional fee for her service is money well spent. Your safety is my primary concern. Liposuction performed under local or “tumescent anesthesia” is typically offered by non plastic surgeons who have little experience working with an anesthesiologist. I can tell you that I personally would never have multiple areas of liposuction performed on myself without the help of an anesthesiologist—it would be very stressful, painful and even barbaric!
Routine liposuction lasts from 30 minutes to 4 hours, depending on how many areas are treated. Most of the procedures performed in my fully accredited office operating facility are outpatient (the patient is discharged to their home afterwards). I don’t admit patients to a hospital after liposuction because as a general rule, if I anticipate a patient can’t be safely discharged home after a liposuction, I will not offer them the procedure based on safety concerns.
My patients are placed in a support garment (girdle) immediately after their surgery. This should be worn for up to five weeks afterward surgery. I suggest using sanitary pads placed over the incisions to manage the drainage. In addition, placing some kind of water repellent cover over your bedding to prevent soiling of your mattress is suggested. It’s appropriate to shower soon after your procedure, but I suggest that you wear your compression garment in the shower for the first few days so that you do not become lightheaded upon garment removal.
Recovery
Patients experience some soreness and bruising that disappears within a few weeks. We have you take a regimen of Arnica and Bromelain (homeopathic supplements) which helps to reduce bruising and swelling. Many patients may return to work several days after surgery. Vigorous sports are prohibited for about two weeks or slightly longer in a large volume liposuction. Office visits are at one week, one month and four months after surgery. You are always smaller immediately after liposuction despite the fact that you are also swollen. Resolution of swelling occurs rapidly after the first week, but your final improvement may not be apparent until as long as three months or longer (it’s a gift that keeps giving!) During the early healing phase you may be able to feel some irregularities beneath the surface of the skin, particularly along the lateral ribs and lower abdomen. This is part of the normal healing process and will resolve within several weeks. It is also not uncommon for treated areas to be numb for weeks to months after the liposuction.
Liposuction scars are generally tiny and are placed in natural body creases. In most patients these areas remain red or pigmented for six months, and then gradually fade. There will be a permanent scar, albeit small and inconspicuous.
Potential Complications
Serious complications are uncommon with liposuction. All patients have some bruising which lasts two weeks. A certain amount of numbness or reduced sensation in the treated area is also to be expected. This is particularly common when liposuction is performed around the knees and about the lower back. Patients can expect lower extremity swelling to persist for a longer time when suctioning is done on the distal legs (ankles and calves).
As with any surgery, bleeding, infection, and other complications are possible. Patients may experience temporary contour irregularities in the treated areas following surgery. Perfect symmetry is the goal, although small side-to-side differences can occur. I will make every effort to give you as smooth and symmetric a result as possible. Some waviness of the skin can occur after large suctioning in individuals with marginal skin quality. Please note that small irregularities after a large procedure can be treated in my office operating room under local anesthesia or IV sedation at minimal cost. All liposuction patients will have some contour irregularities. The measure of your surgeon’s expertise is how he/she limits the amount of skin irregularities. Safety is paramount with any surgical procedure. Teamwork and the judicious and appropriate selection of a surgically and medically fit patient are of utmost importance.
The amount of patients that I see for contour irregularities has increased significantly over the past few years (they were treated by others and I have been asked for help regarding unwanted outcomes). My experience in consulting with many patients who have had previous liposuction is that most of the problems arose from over-resection of fat, poorly performed liposuction, or an inartistic approach to liposuction. Transferring fat to those areas that have been over treated is difficult at best. Fat transfer tends to be very unpredictable and fat resorption (loss of transferred fat) is the rule rather than the exception. Endermology services may be beneficial. Skin resection or lifting procedures may be used to remove areas of loose and irregular tissue. It’s always advisable to not over treat fat because you can always go back to remove more. However, it’s difficult, or impossible to offer help to those patients who have been over suctioned. Unless an adequate layer of fat is maintained under the skin (particularly the upper abdomen, upper medial thighs and the posterior arms), the normal look and feel of the soft tissues can be lost. All liposuction cases should be performed in about three hours or less. Make sure your surgeon adheres to the five pillars of safety: safe surgeon, safe anesthesiologist, safe facility, safe coworkers, and a properly selected patient.
There is a reason why liposuction is such a popular procedure. When well-selected patients are provided outstanding surgical care, the liposuction experience can be very rewarding and even life changing. Ultimately, the long-term results following a liposuction depend on the preoperative condition of the patient’s skin, the patient’s overall health and expectations, and the ability of the patient to maintain a healthy weight and lifestyle postoperatively. I hope that the information that I have provided to you will be beneficial in ensuring your safety and excellent results!
Robert Caridi, M.D.
