Liposuction

Liposuction
Intervention
Suction-assisted lipectomy of bilateral outer thighs
Synonyms	lipoplasty, fat modeling, liposculpture, suction lipectomy, suction-assisted fat removal, lipo
ICD-9-CM	86.83
MedlinePlus	002985

Liposuction or simply lipo, is a type of cosmetic surgery that removes fat from the human body in an attempt to change its shape.^[1] Evidence does not support an effect on weight beyond a couple of months and it does not appear to affect obesity related problems.^[2][3]

Serious complications include deep vein thrombosis, organ perforation, bleeding, and infection.^[4] Death occurs in about one per ten thousand cases.^[5] The safety of the technique relates not only to the amount of tissue removed, but to the choice of anesthetic and the person's overall health. Several factors limit the amount of fat that can be removed in one session. Negative aspects to removing too much fat include "lumpiness" in the skin.

Areas operated on can include the abdomen, thighs, buttocks, and backs of the arms. The procedure may be performed under general, regional, or local anesthesia. It then involves using a cannulae and negative pressure to suck out fat.^[6] People operated on should generally have a normal weight and good skin elasticity.^[6]

In the United States it is the most commonly done cosmetic surgery.^[6][7] Relatively modern techniques for body contouring and removal of fat were first performed by a French surgeon, Charles Dujarier. A 1926 case that resulted in gangrene in the leg of a French model in a procedure performed by Dr. Dujarier set back interest in body contouring for decades.^[8]

Uses

Liposuction is generally used in an attempt to change the body's shape.^[1] Weight loss from liposuction appears to be of a short term nature with little long term effect.^[2] After a few months fat typically returns and redistributes.^[2] Liposuction does not help obesity related metabolic disorders like insulin resistance.^[3]

Side effects

• 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.
• Post-operative weight gain
• 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

Complications

As with any surgery, there are certain risks, beyond the temporary and minor adverse effects. Their likelihood is somewhat increased when treated areas are very large or numerous and a large amount of fat is removed.^[9]

When done using local anesthesia the risk of side effects appear less than with general anesthesia.^[4] In Europe between 1998 and 2002, 23 deaths mostly from infection occurred.^[4]

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.
• Seromas: Sometimes the entrapped liquified fat may get accumulated beneath the subcutaneous plain as a seroma. Small seromas get absorbed spontaneously,but larger seromas need aspiration to avoid secondary infection.
• 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 cannot 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 cannot be ignored.^[10]
• 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-operative self-care.

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 an ongoing diet and exercise regimen, and have fatty pockets of tissue available in certain body areas. Significant disease limiting risk (e.g. diabetes, any infection, heart or circulation problems) weigh against the eligibility of a person 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.

Techniques

Liposuction aspirate

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.

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 he or she 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 he or she did not receive general anesthesia, although they would need someone else to drive them

The basic surgical challenge of any liposuction procedure is:

• To extract 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 the patient

As techniques have been refined, many ideas have emerged that have brought liposuction closer to being safe, easy, less uncomfortable, and effective. The marketing that goes on makes it hard for the consumer to determine truth from exaggeration however.

Suction-assisted liposuction

Suction-assisted liposuction (SAL) 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

In ultrasound-assisted or ultrasonic liposuction (UAL), 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, or to deposit additional fat cells, used in high definition liposuction, to create more volume where it is needed. Ultrasound-assisted liposuction techniques used in the 1980s and 1990s were associated with cases of tissue damage, usually from excessive exposure to ultrasound energy.^[11] Third-generation UAL devices address this problem by using pulsed energy delivery and a specialized probe that allows physicians to safely remove excess fat.^[12]

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

Power-assisted liposuction (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 SAL.

Twin-cannula (assisted) liposuction

Twin cannula (assisted) liposuction (TCAL or TCL) 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

External ultrasound-assisted liposuction (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

Water-assisted liposuction (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 immediate edema from the tumescent fluid.

Laser assisted

A laser is used to melt the fat in the target area, making it easier to remove. This laser is administered through a fibre threaded through a microcannula. The premise is similar to UAL. It is believed that these techniques, such as SmartLipo or SlimLipo, can also reduce bruising and bleeding, as it also cauterizes to a certain extent.

Tumescent technique

Tumescent liposuction is a technique that provides local anesthesia to large volumes of subcutaneous fat and thus permits liposuction totally by local anesthesia. In the past, liposuction surgery required blood transfusions because of significant blood loss in the liposuction aspirate. The tumescent liposuction technique eliminates both the need for general anesthesia and intravenous narcotics and sedatives while minimizing blood loss.

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.^[13][14] 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. Doctors disagree on the issues of scarring with not suturing versus resolution of the swelling allowed by leaving the wounds open to drain fluid.

Liposuction and tightening / lifting skin

The removal of quantities of fat from under the skin allows the elastic skin to potentially retract after SAL. Good examples of this effect are seen after liposuction to the arms, stomach areas and breasts. The level of skin retraction following liposuction is affected 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 but are more frequently associated with contour irregularity. 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), Lipotuck (combination abdominoplasty and liposuction), or lower body lift, thigh lift, or buttock lift can be utilized 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 technique in tummytuck surgery involves vigorous liposuction first before excising the redundant skin.

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 of tobacco must be avoided for about two months prior to surgery, as nicotine interferes with circulation and can result in loss of tissue. Bruising can be seen in people who smoke post surgery.

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. 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.

Usage

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 10½ pints). Most often, liposuction is performed on the arms, abdomen, buttocks, and thighs in women, and the chest, abdomen, and flanks in men. Liposuction was the most common plastic surgery procedure performed in 2006 with 403,684 patients and in the year 2011 with 1,268,287 patients.^[15]

History

Liposuction evolved from work in the late 1960s from surgeons in Europe using primitive curettage techniques which were largely ignored, as they achieved irregular results with significant morbidity and bleeding . The invention of modern liposuction procedure is linked to the name of two Italian gynecologists, Arpad and Giorgio Fischer, who created the blunt tunneling^[16] method in 1974. Then, 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 tumesing or infusing fluid into tissues using blunt cannulas and high-vacuum suction and demonstrated both reproducible good results and low morbidity. Another French surgeon, Pierre Fournier used lidocaine as local anesthetic, modified the incision technique, and began to use compression after the operation. During the 1980s, many United States surgeons experimented with liposuction, developing some variation 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 the fat using ultrasonic energy. However, after a flurry of initial interest, there was an increase in traditional techniques. Practitioners often report that many of the modern technologies touted to improve liposuction are simply advertising hooks and that the choice of a quality surgeon is the primary determinant of a quality result. 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 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.

Non-surgical alternatives

Diet and exercise

Healthy eating habits combined with regular exercise also help people lose weight. This natural process, however, takes more time and determination than liposuction. Weight loss via exercise and healthy eating carries little risk compared to liposuction. Some authors argue that weight loss from liposuction is inconsistent at best and make light of those guaranteeing weight loss to liposuction clients. With diet and exercise fat loss is achieved through breakup of fat (triglycerides) within the cells, which the body uses for energy. The fat cells remain intact, and can easily store fat again if the diet and exercise regime changes. With liposuction the fat cells themselves are removed from the body.

Cryolipolysis

Cryolipolysis is the non-invasive cooling of adipose tissue to induce lipolysis—the breaking down of fat cells—to reduce body fat without damage to other tissues. Evidence for its use is promising.^[17]

High-intensity focused ultrasound

The cosmetic use of high-intensity focused ultrasound (HIFU) for treating subcutaneous adipose tissue has been approved for use in some countries.

See also

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

Notes

1. Dixit, VV; Wagh, MS (May 2013). "Unfavourable outcomes of liposuction and their management.". Indian Journal of Plastic Surgery. 46 (2): 377–92. doi:10.4103/0970-0358.118617. PMC 3901919. PMID 24501474.
2. Seretis, K; Goulis, DG; Koliakos, G; Demiri, E (October 2015). "Short- and Long-Term Effects of Abdominal Lipectomy on Weight and Fat Mass in Females: a Systematic Review.". Obesity Surgery. 25 (10): 1950–8. doi:10.1007/s11695-015-1797-1. PMID 26210190.
3. Seretis, K; Goulis, DG; Koliakos, G; Demiri, E (December 2015). "The effects of abdominal lipectomy in metabolic syndrome components and insulin sensitivity in females: A systematic review and meta-analysis.". Metabolism: clinical and experimental. 64 (12): 1640–9. doi:10.1016/j.metabol.2015.09.015. PMID 26475176.
4. Tierney, EP; Kouba, DJ; Hanke, CW (December 2011). "Safety of tumescent and laser-assisted liposuction: review of the literature.". Journal of drugs in dermatology : JDD. 10 (12): 1363–9. PMID 22134559.
5. Draelos, Zoe (2011). Cosmetic Dermatology: Products and Procedures. John Wiley & Sons. p. Chapter 56. ISBN 9781444359510.
6. Norton, Jeffrey A. (2012). Surgery Basic Science and Clinical Evidence. Berlin, Heidelberg: Springer Berlin Heidelberg. p. 2014. ISBN 9783642572821.
7. Khan, MH (November 2012). "Update on liposuction: clinical pearls.". Cutis. 90 (5): 259–65. PMID 23270199.
8. Dujarier's case from the US National Library of Medicine and the National Institute of Health
9. Weill Cornell Physicians - Liposuction
10. Liposuction Information from the FDA
11. Mark Laurence Jewell. Lipoplasty. In: M. Eisenmann-Klein, Constance Neuhann-Lorenz, eds. Innovations in Plastic and Aesthetic Surgery. Springer, Berlin Germany; 2006:439-444
12. Pinto et al. Liposuction and VASER. Ibid, 108-110
13. MedlinePlus Medical Encyclopedia: Liposuction
14. Site Map on Yahoo! Health
15. http://www.isaps.org/Media/Default/global-statistics/ISAPS-Results-Procedures-2011.pdf
16. "Coleman III, William. P.: The History of Liposculpture". Retrieved 2013-08-25.
17. Ingargiola, MJ; Motakef, S; Chung, MT; Vasconez, HC; Sasaki, GH (June 2015). "Cryolipolysis for fat reduction and body contouring: safety and efficacy of current treatment paradigms.". Plastic and Reconstructive Surgery. 135 (6): 1581–90. doi:10.1097/PRS.0000000000001236. PMC 4444424. PMID 26017594.

External links

• Liposuction at DMOZ
• FDA liposuction information