Liposuction

• Liposuction is a surgical procedure that removes excess fat from areas of the body via small, hollow instruments called cannulas.
• These instruments are inserted into tiny cuts (incisions) generally no bigger than one-quarter inch in diameter, where the fat will be removed. A medical-grade vacuum suctions tiny, broken up globules of fat into a canister. In tumescent liposuction, local anesthetic and other medications are injected into the fatty layer before suctioning excess fat.
• Additionally, laser-assisted liposuction is available. While there are many forms of lasers, most combine one or two types of lasers that melt the fat before the tumescent portion of the liposuction. "Smart Lipo" was the first laser-assisted liposuction, but there are many others now available. Invariably, these are used alongside other methods, such as tumescent liposuction.
• Methods of laser-assisted liposuction are named by the laser used in conjunction with the liposuction, such as Smart Lipo, Vaser, Laser Lipolysis, and other newer forms.
• Laser-assisted liposuction is not the same as LipoDissolve, or mesotherapy, which are non-FDA approved procedures that consist of materials injected into the areas of the fat with the hope that these areas will dissolve. Any laser used in addition to liposuction should be FDA-approved for just that task.

There is an initial consultation before the procedure, at which time the surgeon will evaluate the areas to be suctioned. These may be the chin, abdomen, chest (both male and female), hips, thighs (both inner and outer), knees, calves, and arms. Initial photographs are taken, and results of the surgeon's prior work or illustrative examples of the procedure may be shown to the patient. Additionally, many offices can show prospective patients their own pictures on a computer and manipulating the picture (or drawing on the computerized picture) to illustrate the expected results.

During this consultation, information on the procedure is given, and the risks are explained. Questions the prospective patient has are answered. If the patient is deemed a good candidate for tumescent liposuction, they then will be scheduled for a pre-liposuction evaluation. Laser-assisted liposuction may be recommended to accompany the tumescent method as well.

The patient who undergoes this procedure is typically evaluated at least one to two weeks before the procedure and, at that time, blood tests, medical history and physical, measurements, and photographs are taken. Depending on results of the history and physical examination, the patient may need further evaluation, medical clearance from a primary physician, EKG, and/or other tests performed before the procedure.

At the time of the preoperative evaluation, an informed consent is given if it is close to the time of the procedure. This may include a written and, in some practices, a computer-generated, informed consent form with examples of potential complications and expectations of the surgery.

Before surgery, the patient is advised of which, if any, medications they will be taking before, during, and after the surgery. Additionally, if there are any medications that need to be stopped before surgery, this is communicated as well. Certain pain relievers, such as aspirin and non-steroidal anti-inflammatory agents (such as ibuprofen [Advil] or naproxen [Aleve]) are to be avoided for at least seven days before the surgery. Some surgeons may advise the patient to stop other medications, such as thyroid medications, antidepressants, and various antibiotics in preparation for the surgery.

On the day of the procedure, the patient typically has an initial opportunity to ask questions to the nurse and surgeon, after which a final consent form is signed. At this time, the surgeon marks the areas to be suctioned and an intravenous line (IV) is placed to deliver fluids and medications as necessary. If tumescent liposuction is planned, the patient will be given an oral mild sedative pill and is taken to the operating room. In the operating room, a nurse will then inject approximately four to 20 tiny areas with numbing solution and start to inject the tumescent fluid with a small needle.

Depending on the area to be suctioned, the process of numbing an area can take from 30 minutes (chin or knees) to several hours (most other areas). To get good anesthesia to the area, it is important to perform the numbing slowly, as this can make the experience more pleasant. Most patients have very little, if any, discomfort during this part of the process. Additionally, they may fall asleep, watch TV, or listen to music at this time.

If the surgeon is performing the non-tumescent method (without injecting the solution into the area to be suctioned), anesthesia ranging from intramuscular-only to general anesthesia may be given. Both the tumescent liposuction procedure and the non-tumescent procedure yield excellent results; however, the former avoids the risks of injected anesthesia. Additional benefits of tumescent liposuction include the use of smaller cannulas, less bleeding, less need for post-procedure pain control, less bruising, and quicker recovery.

After the area is anesthetized (if performing tumescent liposuction) or the patient is sedated, the surgeon will suction the area(s). Before the tumescent method or suction, the laser-assisted liposuction portion may be used to help melt the fat and seems to result in larger amounts of fat being suctioned, with potentially more retraction of the areas as well.

In tumescent liposuction, generally less areas can be suctioned at one time as the fluid that tumesces, or anesthetizes, the area contains lidocaine and several other ingredients. The total amount that can be used is based on the weight of the patient. Typically, this means that no more than one large area or two smaller areas can be done at one time except in unusual cases.

On the other hand, in the traditional method, many areas are typically able to be suctioned at once. However, a large amount of fat suctioning at one time may increase risks to the patient.

The entire procedure may last an hour or less, depending on the areas to be suctioned. It may be necessary to give a little more numbing material during the procedure. Additionally, some surgeons may use an intravenous relaxant medication, such as Versed, during the procedure.

After the procedure, the patient is brought into a postoperative recovery area (some offices may use the same surgical area as a postoperative area), and dressings are applied. Dressings may consist of gauze pads, tape, a special absorbent draping, or even a diaper. Lastly, a specialized garment is fit to the patient, which should be worn for about a month. For chin liposuctions, the garment is worn for three days. This helps the area to be firmly bound down, but not so firmly that blood cannot circulate normally. There are many different types of garments, and the surgeon may send the patient to a medical supply house to pick them up before surgery. The author favors the HK garments and uses two garments on top of each other (one smaller than the other) to keep the area comfortable but tight.

Usually, the patient will be observed for at least an hour or longer and then discharged with a friend or family member to be observed for the rest of the day and evening. Although many patients have asked to go home alone, it is quite possible to have minor issues that arise and, for that reason, careful observation for the next 12 to 24 hours is recommended. Pain medication need varies by procedure type. Patients who undergo the tumescent liposuction procedure usually require acetaminophen (Extra Strength Tylenol), but oral narcotics are often necessary for patients who undergo the non-tumescent procedure.

The most common time for possible dizziness to occur after the procedure is the first time the patient uses the restroom or when the garments are initially removed. For this reason, it is always a good idea to have a friend or family member available, or within calling distance, when doing these activities.

Follow-up care is typically the morning after the procedure. Further follow-up care may vary from practice to practice. The majority of improvement occurs within one to two months after a procedure, but, in some areas, such as the chin, results may be incomplete until six months.

If the tumescent liposuction method is performed, most surgeons will not need to suture the area closed (studies have shown that suturing the area closed prolongs recovery and leads to more scarring at the cannula entrances). If the surgeon has sutured the area, another visit is necessary to remove the sutures.

During the recovery process, patients are urged to keep their garments on for the full time recommended by their surgeon and to report any problems or issues to their surgeon. Additionally, it is very important that the patient not wear tight or constrictive clothes during the recovery phase, as these may act to push fat away from certain areas, eventually causing a groove in the area. Usually, it is advisable to wear looser fitting clothing for the first couple of months after the procedure.

The tumescent liposuction method, when performed as described, has not resulted in reported deaths, but the traditional liposuction method has a death rate of approximately one in 5000. Other complications may include pulmonary embolus (with the traditional method), allergy to one of the medications used, fluid collection after surgery called a seroma or a hematoma, a puncture of either the lung or the abdominal cavity, and an overdose of the medication used to numb the area (lidocaine). Less serious complications include worsening of cellulite in the area treated; dimpling or lumpiness in the area treated; infections; and reactions to the tape, bandages, or salves used in the recovery period.

If laser-assisted liposuction is performed, there is a slight risk of damage to the tissue, especially if the surgeon is unversed in the potential dangers of laser treatments. The laser can result in burns to the tissue, especially if it is introduced too closely to the skin. For this reason, it is imperative that the procedure be performed by an expert in lasers and liposuction. In general, the risks of the tumescent liposuction method are much less than the risks from the laser-assisted method. When performed by a skilled surgeon, however, the risks of the laser can be minimized.

The recovery time varies from a few days with the tumescent liposuction method to two weeks with the traditional procedure. The patient should ask their surgeon to estimate the recovery period. Laser-assisted methods result in recovery in roughly the same time, depending on which method is used. Because many surgeons tend to use the tumescent method along with the laser, they claim that the laser method results in less recovery time, but this is actually a result of the use of the tumescent method, which has a shortened recovery time when compared with the traditional method.

Results can vary from minor to significant improvement. This type of improvement varies with the type of procedure performed, the skill of the surgeon, and the overall laxity of the area before the surgery. Most patients find this surgery to be very helpful, and most results are anticipated to be either good or excellent.

It is worthy to note that surgeon's skills vary greatly, and it is always best to check how many of these procedures your surgeon has performed, look at pictures of previous patients, and even ask for references from previous patients who might be willing to discuss their experience if necessary.

While many surgeons claim the laser method to be vastly superior, in this surgeon's experience it is somewhat better, but not significant enough to claim it to be a revolutionary method. In the cases of this surgeon, it tends to result in about 100 cc more fat being suctioned per area and a small amount more retraction, all of which tend to be appreciated by the patient.

If there is any potentially infected area (an area of spreading redness and/or pus drainage), around the incision area, it is important contact your surgeon. Additionally, if the patient feels faint (feeling tired is OK, fainting or swooning is not) after the procedure, call the surgeon. Other more severe problems are shortness of breath or severe pain after the procedure, extreme bleeding, or chest pain.

One point to note is that with the tumescent liposuction method, the patient may have swelling initially, and the fluid used to anesthetize the area will leak out over the next day or so after surgery, appearing bloody. This is entirely normal in this procedure, but very abnormal in the traditional (non-tumescent) type of liposuction. It is always best to check with the surgeon at the time of the procedure to see if there are any other reasons for which he or she should be contacted. Many surgeons will call the patient the night of the procedure to check how he or she is feeling.

Technically, any part of the body is able to be suctioned, but there are varying degrees of improvement depending upon the area treated. The best way to tell if a particular area will be successful is the ability to see a difference of shape in the area to be liposuctioned. If the area is not dramatically different than the surrounding areas, liposuction will probably not be as effective as diet and exercise. Additionally, certain areas are less responsive to liposuction and/or more likely to have complications. This is not to say that there can't be excellent results, but the possibility of less-than-outstanding results is magnified in these areas:

• The arms (skin can hang after the procedure)
• Calves (may have significant swelling after the procedure, higher risk of blood clots)
• Inner thighs (may be uneven and asymmetric after the procedure)
• Chin (may have a slight nerve problem in the lip area after the procedure which lasts up to two to three months). Additionally, fluid and fat can remain in cases in which the chin was very fatty before the procedure, resulting in a need for re-doing the procedure.
• Female and male breasts (These can pose the problem of minimal improvement. Given the male breast fat makeup, there may be minimal fat obtained during the procedure. The female breast can be liposuctioned, but the candidate needs to be aware of the possibility that reduction of only one breast size may occur. Typically, liposuction can be done but is limited to mildly affected breasts rather than severe cases.)

Every method has its pros and cons, and many types of surgeons perform liposuction. The most important qualification to check is actual photographic results or via speaking with previous patients. This will inform you if the surgeon does a good job consistently, stands by his or her results, cares for the patient well (both before and after the surgery), and handles any complications in a prompt and thorough manner.

Many variations of liposuction have been devised over the years, including ultrasonic liposuction, laser liposuction, the "wet" method, and the "super-wet" method of liposuction. Currently, data doesn't show any significant difference when these results are compared with the traditional and tumescent liposuction procedures. The newer laser-assisted methods do add some benefits from the standpoint of larger amounts of fat being obtained and more retraction after the procedure, but there are also risks from this method if performed by unqualified or "learning" surgeons.

American Society for Dermatologic Surgery

American Academy of Cosmetic Surgery