Author: Jay Burns, MD FACS
The roots of liposuction date back approximately 30 years to France and were introduced by Dr. Yves-Gerard Illouz. What was initially met with great skepticism by the medical community has progressed over the past 30 years to be the most popular invasive plastic surgery procedure performed over the last 5 years.
Liposuction was originally designed for a patient who has a stable weight, who exercises regularly, and watches their diet, but has small to moderate pockets of fat that persist. The most popular areas to be treated are the abdomen and love handle areas, the outer/inner thigh, inner knee, back, upper arms, and the area under the chin.
Indications for liposuction have been expanded over the years as the techniques have been refined. Clearly, many patients now have greater volumes of fat liposuctioned. However, when volumes greater than 5 liters are removed, the complication rate begins to rise. Even though indications have expanded, there are limitations to what liposuction can achieve. Liposuction is not performed to achieve weight loss and is not an indication for the obese patient.
Obese patients are not candidates for liposuction. Some physicians use BMI (body mass index) as an objective criteria while others utilize more subjective criteria such as a simple physical exam.
In my experience the patient who has a widely fluctuating weight problem is not a candidate for liposuction, as weight gain after liposuction can cause body shape changes that are often unsightly.
Also, patients with medical problems that make them not good candidates for surgery in general, are not good candidates for liposuction. Such conditions include but are not exclusive to cardiac disease, emphysema (chronic obstructive pulmonary disease), and a history of blood clots or pulmonary embolus.
If the patient is determined to be a good candidate, then surgery is scheduled, and the areas to be liposuctioned are marked precisely by the surgeon. These areas are marked much as one would mark a contour map to determine the high and low points on the body. The marked areas are instilled with varying amounts and types of fluid depending on the surgeon’s preference. Most surgeons use a wet or a super-wet technique currently.
A cannula (suctioning instrument) is used to remove the fat in a uniform fashion until the endpoint is reached. This is determined by pinching the skin and feeling how much fat is left behind. This is compared to the opposite side to check for symmetry. In most instances a pressure dressing in the form of a girdle or binder is applied after the procedure so as to minimize swelling.
A general guideline of wearing the girdle for one week per decade of life lived is a good general rule. For example, a 40-year-old patient would wear the girdle for 4 weeks, and a 60 year old might wear the girdle for 6 weeks.
If the patient’s weight is maintained, the contour improvement will be maintained for the reminder of one’s life. The only thing that negatively affects the result with regard to contour would be recurrent weight gain.
As the swelling diminishes over the next several weeks after surgery, pressure on the skin from the binding garment causes the skin to reattach to the muscle underneath. If no girdle pressure is applied to the wound, maximum swelling and stretching of the skin is seen after surgery. If this occurs, the skin can droop as the swelling abates. Even in optimal conditions, the skin can be a little more lax after liposuction.
There are some general truths about recovery that are consistent. Bruising typically persists for approximately 2-3 weeks post operatively. Most patients report soreness that feels as if they had worked out for the first time in several months. Therefore, when the patient is stationary they do not report undue amounts of pain in most cases. It is only upon movement that the soreness is felt. Again, this discomfort is the most intense in the first three days and lessens over the following week. After ten days to two weeks, a steady recovery is seen of gaining strength and decreasing discomfort. Numbness may remain for several weeks to several months. As the swelling diminishes, lumps and bumps can be seen and are usually minor. One must wait a full 6 months to determine the final result after liposuction.
Side effects and risk would include an unsatisfactory cosmetic result in which longstanding contour irregularities are seen. Minor lumps and bumps may be seen after liposuction, and this must be expected to some degree. For example, the fat that is left behind has been bruised in a 2-4 hour procedure, and therefore bruising of this fat may lead to long term reduction in volume in that area, and hence a small depression. Also, when fat has been injured there can be inflammation and calcification within the fat, which can leave a long term elevation in skin contour. These are usually minor, and the overall result is not significantly impacted by these irregularities. Abdominal perforations have been reported in rare instances. These complications are more common with patients who have a larger body mass index and have more fat to be removed.
Other complications usually occur with larger volume liposuction and involve stresses on the cardio/pulmonary system. In addition, blood clots can arise in the lower legs and migrate to the lungs causing what is called a pulmonary embolus. In extremely rare cases, death can occur. These severe complications are fortunately very rare and are usually seen after very large volume liposuction. Large volume liposuction should be done as a stand-alone procedure and not in combination with other surgeries.
Alternatives to liposuction include diet and weight loss and are always the first choice for fat reduction. Other treatment choices include non-invasive fat removal treatments.
Laser assisted liposuction
Laser assisted liposuction has become increasingly popular in the last 2-3 years. Though claims have been made that with laser assisted liposuction there is greater tightening of the skin, less bleeding, faster recovery time, and less pain, no prospective study comparing standard techniques to laser assisted liposuction has been performed.