Liposuction

• What is it?
• Why is it performed and who is it suitable for?
• What are the risks and complications associated with the procedure?
• How are patients prepared for the surgery?
• How is it performed?
• What happens after the surgery?

What is it?

Liposuction is a cosmetic surgery procedure which involves the removal of excess body fat from under the skin from various parts of the body using a cannula and a suction device. The most common areas that are treated are the abdomen, thighs, buttocks, arms and neck. Liposuction is the most popular cosmetic surgery performed worldwide and is usually done to improve the appearance of distorted body shapes and remove pockets of fat that are difficult to eliminate with diet and exercise. It is also known as body contouring as it can be used to contour the chin, neck, cheeks, ankles, calves, and breasts. It should not be considered as a method of weight loss.

The first liposuction procedures were performed in the early 1980s and were done under general anaesthesia, however they were often associated with serious complications and a high risk of death. New treatments have revolutionised liposuction and it is now considered to be a very safe procedure that can be performed in an office environment with minimal recovery time.

There are a number of liposuction techniques that may be used depending on the site and how much fat is to be removed. They include:

• tumescent liposuction
• wet liposuction
• superwet liposuction
• ultrasound assisted liposuction
• power assisted liposuction
• laser assisted liposuction

Tumescent liposuction is the most common type of liposuction. It involves injecting a large amount of fluid (3-4 times the volume of the fat being removed) made up of a salt solution containing a mix of local anaesthetic and epinephrine into the areas before the fat is removed. The anaesthetic numbs the area and the purpose of the epinephrine is to minimise bruising, swelling and blood loss. Injection of the fluid creates space between the muscle and fatty tissue for the cannula. This form of liposuction usually takes longer than others as the fluid must be injected slowly. However it has the fastest recovery time and least amount of complications.

The super-wet technique is similar to tumescent liposuction except that not as much fluid is used, the amount of fluid injected is about equal to the amount of fat to be removed. This technique takes less time however it usually requires sedation with general anaesthesia.

Ultrasound or ultrasonic-assisted liposuction (UAL) is a fairly recent technique introduced in 1996. It involves exposing fat cells to ultrasonic vibrations which supposedly liquefy fat cells, thereby facilitating aspiration.  This can be done internally through the cannula which transmits ultrasound vibrations under the skin, or by external exposure. This technique may be useful in the removal of fat from dense or fibrous areas of the body such as the upper back or male breast tissue. UAL is often used in conjunction with the tumescent technique or in follow-up procedures. Little benefit is achieved from this procedure and it has been associated with cutaneous burns and higher risk of seroma formation.

Power-assisted liposuction (PAL) is a new technology which utilises a motor-driven, reciprocating cannula attached to a standard aspirator. This reduces the workload on the surgeon as it limits the physical movements that must be made. In addition, it allows the surgeon to remove fat more completely in tight areas where forceful cannula movements are difficult because of physical space constraints. This new technology has been shown to have significant benefits over traditional cannulas.

The newest liposuction technique is Laser-assisted liposuction which works by focusing low energy waves from a laser onto the parts of the body that require treatment. This causes the fat cells to weaken and burst. Like UAL this technique can be used in conjunction to other liposuction procedures. This technique has the advantage of producing much less swelling and bruising and hence a faster recovery time.

Why is it performed and who is a suitable candidate?

Liposuction is a cosmetic surgery used to remove localised accumulations of fat that are resistant to diet and exercise. Liposuction is not a weight loss strategy, substitute for exercise or cure for obesity. It also does not have any effect on cellulite or stretch marks.

Generally anyone with good health physically and mentally can have the procedure done however a patient must go through extensive counselling prior to undergoing surgery to ensure they are suitable.

An ideal candidate for liposuction would have:

• normal-weight or slightly-overweight with localised pockets of excess fat in certain areas
• generally healthy and doe not have significant medical problems
• elastic skin
• realistic expectations
• is over 18
• age is not a major factor, although older persons with diminished skin elasticity may not have the same results as persons with tighter skin
• has tried diet and exercise
• has a stable weight and has a regular exercise routine
• does not suffer from diabetes, coagulation disorders, cardiovascular disease or any infectious disease
• is not pregnant

These are only a guide; however patients that fill these criteria will have a more optimal result.

Liposuction is also suitable for the treatment of other conditions such as breast reduction in men, gynecomastia, removal of lipomas and angiolipoma, hematoma evacuation and improving hyperhidrosis of axillae.

How are patients prepared for the surgery?

Prior to admitting a patient for a liposuction procedure, a medical history, physical examination and psychological assessment must be undertaken.

Liposuction is contraindicated in patients with severe cardiovascular disease, severe coagulation disorders including thrombophilia, and during pregnancy.Patients with any history of the following conditions must receive medical clearance before undergoing liposuction:

• bleeding diathesis
• emboli
• thrombophlebitis
• infectious diseases
• poor wound healing
• diabetes mellitus
• heart problems
• high blood pressure
• Diabetes
• Allergic reactions to medications
• Pulmonary problems
• Smoking, alcohol, or drug use

What is involved in the procedure?

Surgery may be performed in an office, an outpatient facility, or a hospital. Usually liposuction of smaller volumes are done as an outpatient while larger volumes require a stay in hospital to monitor fluid levels and if patients are suffering from any other medical conditions. Depending on how many sites will be treated, the surgery time may range from 1-4 hours.

Markings are made on the skin as a guide to where fat is to be removed. Depending on which procedure is used a general anaesthetic is administered, or for the tumescent technique, a fluid consisting of a salt solution or local anaesthetic and epinephrine is injected into the area being liposuctioned. Small incisions are made in the skin through which a cannula is inserted. The cannula is attached to vacuum pump which can suction out the fat cells as the surgeon moves it back and forth. After the fat is removed, small drainage tubes may be inserted which remove any blood and fluid which has accumulated. If a lot of fluid is lost then a blood transfusion or IV fluid replacement may be needed.

Volumes of fat removed should not exceed five litres especially in patients with comorbidities. Generally, removal of larger volumes is associated with a higher risk of complications mainly due to the fact that this requires general anaesthesia as opposed to local anaesthesia.

Following surgery, bandages are applied to stop any bleeding and keep pressure on the area. These usually are left on for about two weeks. Depending on the extent of the surgery and how much fat was removed the patient may be required to stay overnight in hospital.

It must also be determined whether any previous abdominal surgery has been performed and any problems from past surgical procedures that may influence complications.

Medications that affect blood clotting such as aspirin, anti-coagulants, non-steroidal anti-inflammatory agents and vitamin E, as well as other vitamins and herbs must be ceased two weeks prior to surgery. Depending on the extent of the liposuction to be done, the contraceptive pill may have to be ceased as well.

Physical evaluation

An assessment of general physical health is necessary to determine whether a patient is a suitable candidate for surgery. The specific sites that are being considered for liposuction are examined for potential problems. Skin tone and elasticity is assessed as well as the presence of hernias, scarring, cellulite and stretch marks. If patients have poor skin elasticity they are informed that following surgery they may have skin draping which may need further surgical correction.

Psychological assessment

Inquires are made about diet and exercise habits and any history of weight gain and loss as this can affect the long term success of the procedure. Patients are counselled on the limitations and risks associated liposuction. Their expectations are determined to ensure they are realistic and are aware that full results may take up to 12 weeks to be seen. Liposuction does not result in any significant weight loss and patients should also be aware that fat removed may return if excess weight is put on.

Blood tests

Some general blood tests are carried out to ensure potential candidates are in good health. Selection blood tests to be performed depends on the type and extent of the liposuction procedure and the conditions revealed in the history and physical examination. Usually a complete blood cell count with quantitative platelet assessment, prothrombin time, partial thromboplastintime, liver function tests, pregnancy test for women of child bearing age are performed.

What are the risks and complications associated with liposuction?

Some common minor side effects that can occur which are usually not permanent or life threatening and are a normal consequence of the surgery include:

• Bruising which should fade after a few weeks
• Swelling which should subside gradually over a month or two
• Scars varying in size depending on the particular procedure but should fade over the weeks. Scarring depends on the individual as it is partly dependent on heredity. In some people it may take up to a year to heal.
• Pain which should be temporary and can be ontrolled by either over-the-counter medication
• Numbness which may persists for a few weeks
• Limited mobility

Liposuction is associated with several risks and complications, many of which are rare and are dependant on the extent and type of procedure. As there is no central registry for reporting of these it is difficult to ascertain the likelihoood or frequency of them. It appears that prolonged procedures and aspirate volumes greater than five litres seem to be associated with higher complication rates. Limiting the volume of aspirate and using local rather than general anesthesia can reduce the risk of some of the major complications such as embolism and death.

A national survey of plastic surgeons found that the most common complications were:

• contour irregularities
• unplanned hospital admissions
• prolonged swelling

Other complications include:

• patient dissatisfaction
• unfavorable aesthetic results- irregularities in the skin surface following excessive or subdermal liposuction asymmetry, dimpling, lumpiness and waviness and skin laxity
• hyperpigmentation
• scarring- incisions usually heal however patient can develop hypertrophic scarring following inadvertent injury to overlying skin through superficial liposuction or UAL
• hematomas
• seromas
• infections
• skin burns, particularly in the use of UAL devices
• Skin necrosis- superficial liposuction, overzealous subdermal fat thinning, liposuction in areas of prior incision scars, and UAL can result in partial-thickness and full-thickness skin necrosis
• necrotizing fasciitis
• cerebrovascular accident or transient ischemic attack
• pulmonary thromboembolism
• pulmonary fat embolism
• bleeding, especially if large amounts of fat are removed
• Shock if not enough fluid is replaced during the surgery
• Fluid overload
• transfusion complication
• deep vein thrombosis
• Drug toxicity, the patient can react to the anaesthetic or epinephrine
• toxic shock syndrome
• Nerve damage
• thoracic and abdominal cavity perforation
• aortic perforation
• acute renal failure

Overall revision or re-operative rates range from 5-15%. Rates of serious or fatal complications are in the range of 0.02% to 0.3% and are predominantly attributed to pulmonary embolus, fat embolus, abdominal perforation, anesthesia.

What happens after the surgery?

Following surgery compression garments are applied to the areas that have been treated to reduce swelling and support the skin as it readjusts to the new contour. These usually need to be left on for 2-3 weeks. There is likely to be swelling, bruising, pain and numbness for a few weeks after surgery. Pain medication can be prescribed as well as antibiotics to prevent infection.

Patients can return to work and resume their normal activities within a few days after the procedure. Strenuous excercise should be avoided however walking soon after surgery is advised to prevent blood clots. It may take up to 3-6 months to see the final result of the surgery as swelling subsides and skin contraction occurs. The final outcome generally depends on age, skin elasticity, volume of fat removed and the area it is removed from, with the best results are generally seen in younger patients of normal weight and who have had a small volume of fat removed. Maintaining a healthy lifestyle with regular excersise all aid in improving the final outcome.

More information

For more information on obesity, health and social issues, and methods of weight loss, as well as some useful tools, see Obesity and Weight Loss.

References

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3. http://www.plasticsurgery.org.au/procedures/liposuction.html
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6. Guidelines for Liposuction Surgery. 2006. The American Academy of Cosmetic Surgery.
   Available from: http://www.cosmeticsurgery.org/Media/2006%20Liposuction%20Guidelines.pdf
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9. Matarasso A and Hutchinson OHZ. Liposuction. JAMA. 2001; 285(3); p. 266-268.
10. Flynn TC and Narins S. Preoperative evaluation of the liposuction patient. Dermatologic Clinics. 1999; 17(4); p.729-734.
11. Cowles RA. Liposuction. Updated 5/3/2007 http://www.nlm.nih.gov/medlineplus/ency/article/002985.htm updated 5/3/07