Liposuction

Fat Removal by Liposuction
           Though it is a fact that the body tends to put on weight after forty years of age, in today’s health-conscious society, many people, young and old, are maintaining a slender form. Though many times leanness is not uniform over all parts of the body; many patients have problems with unwanted fat deposits that persist in spite of dieting and exercise. Liposuction may be a solution.
           Until the 1980s surgical fat removal was primarily surgical excision of fat. The procedure involved making large, conspicuous incisions in areas of the body that resulted in obvious, often unfavorable, scars. Liposuction is a more recent procedure that requires only small incisions, a few millimeters in length, to enter the area under the skin where fat deposits bulge in the body. It was a procedure introduced in Europe by French surgeons during the mid-1970s and taught around the world by the mid-1980s. At first the procedure was popularly called "lipolysis," and in some quarters it still is. Now its most common name is a term called "liposuction or body contouring."
          The procedure has swept the world as one solution to getting rid of unwanted fat deposits. It is now among the most frequently performed cosmetic procedure in the nation. Even with all the hype, it is not a means of weight reduction, but, rather, a way to permanently change the shape of the body and the body’s fat distribution.

Cross Section View

          Liposuction involves removal of fat cells by suction through a metal tube—no bigger around than a narrow pencil—called a cannula. Fat cells can be removed quickly by suction. The newest internal ultrasonic liposuction procedures involve the liquefaction of the fat with sound waves prior to their removal. When fatty tissue under the skin is removed, their needs to be sufficient elasticity of the skin for it to smoothly contract into place, rather than wrinkling and sagging. A support garment may be worn to support the skin for several weeks. For most patients this is not a serious consideration, though surgeons look for potential lack of skin elasticity and warn against removing too much fat. Superficial fat removal, although more risky and requiring more training for excellent results can lead to a small amount of tightening of the skin coupled with the fat removal. Lasers may be available for this purpose in the near future.
           The same is true of weight loss in older patients. Too much fat removal either by diet or lipoplasty may result in redundancy or wrinkling of skin, whereas the skin of younger patients will usually tighten without sagging. However, older patients with less elasticity are often good candidates since their improved appearance in clothing and their sense of wellbeing offsets any local skin irregularities. Even those with sagging skin around the middle enjoy slipping into smaller dresses and pants. Tummy tuck types of procedures (removing excess skin) can of course, correct sagging skin. These surgeries are larger and require long incisions. Recovery is also longer and may not be desired by the patient. If the underlying structure supporting the skin is loose and there is little fat present, there is no choice but to perform a tummy tuck or similar procedure since there will be little effect from simply removing a small amount of fat from under the skin.
         Liposuction can be performed on many areas of the body, including fat deposits under the chin, in the neck, the abdomen, the chest and upper arms, the hips, thighs, knees, calves, and ankles. In some cases liposuction may be combined with customary surgical procedures that stretch and remove excess skin and fatty tissue, such as a tummy tuck (abdominoplasty). This method often permits achievement of improved results in face-lift surgery by combining safe removal of fatty tissue with skin tightening. Suction of the neck can also be helpful. However, suction of the face is performed minimally and very carefully.
          Liposuction surgery can be performed on any person in reasonably good physical condition who may have localized, unwanted fat. It may have a role in the removal of fat from the obese patient, though full investigation of this area of the field is not complete. Large volumes of fat removal can be very dangerous and these types of procedures are performed only in the hospital and, often, as staged procedures.
           Questions frequently asked are "Will the fat return again if I put on weight after surgery?" and "Will I look out of proportion to the rest of my body?" It appears that in children fat cells increase in number until they reach puberty, and thereafter the number of fat cells in the body remains fixed or constant throughout life. With weight gain or loss, the fat cells change size only. This is true for all except massive weight gain of hundreds of pounds where the body can be forced into making more fat cells. The cells store fat and expand or contract like a balloon. With liposuction, fat cells are removed, thereby permanently decreasing the number of cells and excess fatty deposits in the surgically suctioned area. Weight can still be gained and just as easily but the distribution of the fat is more even throughout the body rather in just a few "problem areas."
             Since most patients are generally "post pubertal," the return of fat cells does not occur, and fat deposits should therefore not return in the treated area. This is not to say that the remaining fat cells will not enlarge if the patient gains weight. Researchers know that fat cells can dramatically increase in size if the body takes in too many calories.
             Unlike for many procedures, it is best for the patient to be on the heavy side prior to the liposuction procedure. This largely has to do with the technique of fat removal. It is far better to leave a slightly thicker fat layer just beneath the skin than to try to skeletonize it and risk the chance of puckering and adherence of the skin to underlying structures. After the liposuction, weight loss is a wonderful idea and many people find the procedure a springboard to a fitter more attractive body and lifestyle.

Surgical Procedure
          The surgeon marks the patient preoperatively using marking pen to indicate the areas of the body where he wishes to reduce fat deposits prior to administering anesthetic. Fat deposits are best observed with the patient in a standing position. These deposits may shift somewhat when the patient lies down. They are marked topographically to indicate the high and low points. The procedure involves the use of a tumescent solution that makes the liposuction procedure safer, more even and easier on the patient by providing slight numbness for a few days following the procedure. Obviously, when this solution is infiltrated under the skin, all contours change. Although the procedure of liposuction itself is very simple and safe, it is the surgical judgments and planning that require a great deal of training.

          The cannula can be inserted into tiny incision near the arm pit and reach the entire side of the breast to remove the fat and slenderize the area.
          Through a tiny incision the cannula can reach the extreme regions of the trunk and calves of the body and remove fat located near the surface of the body.

Region of Breast

Region of Arms

Hips Before      Hips After

Ribs to Calf's-After                        Ribs to Calf's-After

           A general anesthetic is commonly administered, although small or localized areas of fat can be treated with local anesthetic with or without IV sedation.
Near the fat deposits, either in a skin fold or under the bikini line, the surgeon makes a small incision, approximately a quarter inch in length. In removing fat from the abdominal area, the incision is often placed in the navel or in the pubic area. Fat removal from the thighs is accomplished through small incisions in the buttock creases, lateral hip area, and inner thigh.

          The first step of the procedure, after the tiny incision may be made, is the infiltration of tumescent solution. This is a special sterile solution that wets the area and allows for the closure of small blood vessels to minimize bruising and bleeding. An offshoot is that it allows the area to be numb for a couple of days after the procedure thereby making the procedure much easier on the patient. Having fluid in an area of the body where it is needed allows for less solution to be given intravenously and thereby reduce the anesthetic risks. It is very important to infiltrate the area evenly. Different surgeons will use different solutions and different volumes depending upon their experience and judgment as well as the total volume of fat expected to be suctioned. A small, hollow tube or cannula is then inserted through the small incision. Then, with a vacuum-assisted pump that allows for high-pressure suction, the fat is suctioned from the body through the cannula into the tube and collects in a special receptacle. Some surgeons use this special vacuum pump; others employ syringe suction. Both techniques are acceptable. Different sizes and shapes of cannula are available to treat different body areas.
          The newest advance in liposuction surgery is the use of ultrasonic energy to liquefy the fat prior to removal. This internal ultrasonic-assisted liposuction is not to be confused with external ultrasound where a wand is used on the skin to make heat. This has been shown to do nothing to liquefy the fat under the skin. It can be used as a marketing ploy and you should investigate the type of ultrasound prior to the surgery.
          No surgeon attempts to remove all of the fat in a deposit. If this were to happen, the result could very well cause skin depression, contour irregularities, and an unnatural appearance. The direction of cannula movement is in a plane parallel to the muscle and skin; therefore, removal of the deeper portion of the fat layer is accomplished with minimal risk. Liposuction is an artistic procedure, often referred to as "body sculpturing" or "body contouring" and should preferably be done by qualified, legitimate, surgeons that are experienced in this technique.
         A good deal of the success of this procedure depends on the surgeon’s artistic judgment and skill. Surgeons must plan carefully in marking the areas of fat to be removed and during surgery may readjust their plan and modify it to suit the goal. In addition to careful planning, the surgeon achieves excellent results based on the "feel" of the skin and the underlying fatty tissue. Surgeons use their hands to judge the remaining amount of fat in a given area. Many of us prefer to err on the side of leaving slightly too much fat rather than over thinning the tissue under the skin. The reason for this is simple. The fat cannot be put back. Fat grafts largely don’t work or their take is irregular. It is very hard to correct an area that has been over suctioned but it is relatively easy to go back and take out slightly more fat if greater contouring is desired. I return about 10% of my patients to the operating room for "touch up" procedures to take out slightly more fat in a given area.

Postoperative
          Upon completion of the procedure, the tiny incisions are sutured. Rarely, but if warranted, a drain is placed in the area of incision to drain any extra fluid build-up. Pressure dressings, girdles, or contouring garments may be worn for several weeks following surgery to help the skin contract to the new shape and thereby adhere properly.
          Usually, little discomfort is felt for the first two days following surgery. After that, there is a slight tenderness in the area. Slight discomfort is usually readily managed with Tylenol. For extensive areas of liposuction, the recovery is slightly more uncomfortable and extended. Narcotic analgesics may be necessary for control of discomfort; especially after the first few days.
         Swelling, bruising, and some temporary numbness are common in the treated areas. This may vary with the amount of fat removed and the area treated.
           The eager patient will not be able to appreciate the end result for at least several months after surgery due to swelling that slowly dissipates. Yet, in spite of swelling, most patients notice an immediate change in body contour shortly after surgery.
           The patient must avoid strenuous physical activity for at least one to two weeks postoperatively. Nevertheless, patients are encouraged to be up and about and to resume some light physical activity within the first week.
          The surgeon will usually have patients begin to massage the areas of liposuction after a few weeks in order to stimulate blood flow and lymphatic drainage, which in turn helps to speed the decrease in swelling. Other adjunctive measures such as external ultrasound may be used to help with prolonged swelling, however this is rarely necessary.

Risks
          Infection is a risk of any surgery, though this is rare. As with any surgical procedure, complications are possible, though considering the number of liposuction procedures performed each year, the number of serious complications is very small. Bruising and swelling, as noted previously, are common and are not considered complications. In rare instances, fluid collection under the skin may persist for several weeks postoperatively, and require simple aspiration. Fluid tends to reabsorb with no long-term, adverse effects. Contour irregularities can occur with this type of surgery but are kept to a minimum by conservative fat removal. Any irregularities in the skin itself present before surgery may not be corrected by surgery. This is not a treatment for so called cellulite, although improvement in cellulite areas has been often noted.
          Your surgeon will discuss with you the risks and benefits. The purpose is to assist you in achieving an aesthetically pleasing body image when conservative measures have proven ineffective.
          The duration of the surgical improvement is long lasting even permanent if the patient heeds a sensible diet and exercise.

Innovations in Liposuction Surgery
           The word "tumescent" means swollen or firm. This technique, mentioned earlier in the chapter, is accomplished by injecting a large volume of a dilute solution of lidocaine, a local anesthetic, and epinephrine, (a vasoconstrictive drug which shrinks small blood vessels), into the fatty tissue. Patients find that anesthesia injected locally is effective in reducing pain post operatively.
          As mentioned, blood loss is reduced with the tumescent method of liposuction. The epinephrine in the anesthetic solution causes small blood vessel constriction that results in minimal blood loss during and after surgery. Not only is recovery time reduced (i.e., your oxygen-carrying capacity is preserved), but blood transfusions are virtually unnecessary.
         With the tumescent technique, as we mentioned, the doctor injects a solution into the fatty tissue. Because the solution anesthetizes the area, it also causes the area to become firm and swollen (tumescent), which enables the surgeon to extract fat more accurately and uniformly, and thereby produce smoother, improved results.

         With the tumescent method there is a quick return to normal activities. Home rest is advised for the first twenty-four to forty-eight hours; then a light work schedule may be resumed. If the sculpting is extensive and performed in several areas of the body, then several days of recuperation may be necessary. Special elastic garments must be worn for two to six weeks after the surgery. The rate of healing is accelerated as a result of the drainage of blood-tinged anesthetic solution. This drainage minimizes bruising, reduces inflammation, and significantly accelerates healing. The elastic garments help promote healing by reducing swelling and bruising.
          Exercise appropriate for the individual may be initiated after consulting with the surgeon, generally in two to three weeks.
         Because the tumescent technique uses very small cannulas, minimal incisions can often be concealed in natural body creases, such as the end of the buttock fold, the umbilicus, under the chin, or in the pubic hair. Sutures, when used, will dissolve on their own or be removed in the surgeon’s office following surgery.

Risks
          General anesthesia and IV sedation have some inherent risks , but with modern techniques, in a controlled , operating room environment, these risks are almost nonexistent.

Benefits of the Tumescent Technique
          When used, general anesthesia is very light dose. Some patients may choose to have an alternative to general anesthesia. Many of these patients receive only minor sedation to help them relax and are quite comfortable during surgery. Postoperative discomfort is significantly reduced since the local anesthesia is effective for eight to sixteen hours after surgery.
The suction tubes used in this technique are very thin and minimize the amount of trauma produced. The incisions usually heal nicely with few, if any sutures. There is minimal scarring.
          After surgery patients can get up and leave the office and usually are back to their regular routine in a few days.

Before                            After

Before                After

Before                After