Liposuction (Spot Fat Removal)

In the late 1970’s, liposuction or suction lipolysis was developed so that localized fat could be surgically removed without leaving a significant scar. Since that time the procedure has been refined and developed to a degree of sophistication that provides consistently reliable results. The most recent innovation is referred to as the tumescent or wet technique. Older techniques will be referred to as dry techniques.

Most aesthetic surgeons would agree that tumescent technique is the procedure of choice because it is safer and provides a more satisfactory cosmetic result.

Who are the candidate for liposuction?

An ideal candidate for liposuction can be characterized as having:

• Good elasticity of the skin so it will shrink adequately after the underlying fat has been removed.
• Stable weight for 6 months prior to that surgery.
• Good health
• A regular exercise program
• Normal blood clotting
• A tendency to heal well after injury &
• Realistic expectations.

Although the results of liposuction may contribute to an improvement in an individual’s body image and self- esteem, it will not change or improve relationships or solve psychological problems.

Before	After

The bulk of the solutions is made up of saline which is similar to the make up of the body’s fluids. Four medications are added to the saline: lidocaine, epinephrine, bicarbonate and cortisone. Each contribute to a less traumatic form of surgery than the dry technique and ensures a faster, more comfortable healing time. Lidocaine is a local anesthetic which numbs the area to be treated such as general anesthetics, intravenous sedatives or narcotic analgesics are not necessary. The later are generally used to some extent with the dry techniques. Post operative discomfort is also minimized since the local anesthesia remains in the surgically treated areas for approximately 18 hours after surgery. Any further discomfort can be managed comfortably with an analgesic such as Morphine.

Epinephrine, which temporarily shrinks capillaries, dramatically reduces both the bleeding during surgery and bruising after surgery. In fact, there is so little blood loss with the tumescent technique that often more blood loss is experienced from the pre – operative laboratory tests than during the actual liposuction surgery.

Minimal bleeding shortens the post –operative recovery time. Most patients can return to work and begin exercise again within a day or two after surgery.

The mild cortisone controls inflammation which in turn results in less post- operative swelling and discomfort.

The tumescent technique also dictates the use of very small circular cannulas to suck out the fat as compared to large cannulas employed with the dry technique. The smaller cannulas allow the surgeon better control over the direction, depth and amount of fat removed during surgery. This reduces the risk of irregularities.

Because smaller cannulas are used, only small incisions are required. The incisions are so small that sutures are not necessary. The open incisions allow any excess tumescent solutions to drain which helps to minimize bruising and soreness. An added benefit is that a smaller incision will heal faster.

• A waiting period of 30 to 90 minutes takes place after the area has been well in filtered with a large volume of tumescent solution. This allows the local anesthetic and blood vessel constrictor to take effect to ensure the area is completely numb and the bleeding will be minimal.
• A suction cannula is inserted into the targeted layer of fat through the small incisions. The cannula is connected to a machine, via a tube, that provides a gentle suction force. As the cannula is pushed back and forth in several directions through the saline engorged fat, the fat is sucked into a reservoir bottle. This succession of forward and backward motions of the cannula through the incisions creates numerous tunnels throughout the layer of fat. The surrounding collapses into empty tunnels. The more tunnels created, the greater the fat reduction. The use of small cannulas with the tumescent technique offers better control over the direction and depth of the tunnels within the fat. It is important that the surgeon leaves a small layer of fat under the skin to avoid puckering and to maintain a soft, supple feel to the skin.
• Once an adequate amount of fat has been removed, absorbent pads are placed over the tiny incisions and held in place by a pressure garment. The incisions are not sutured in order that the remaining solution can drain off into the pads. This helps minimize swelling, bruising and soreness.

After the procedure a custom made elasticated garment is applied to give compression to the treated area.

• Eighty percent of the tumescent solutions is absorbed into the body and excreted in the urine and 20% is either sucked out with the fat drained out through the tiny incision sites. The solution that drains from the incisions is 98% saline solution and 2% blood. The blood gives the solutions a red appearance. Drainage is greatest immediately after the procedure and gradually subside over 2 to 4 days for larger areas and in 1 to 4 days for smaller areas such as under the chin. The absorbent pads are changed and worn until the drainage is complete then it is only necessary to wear the compression garment for a few more days. The compression garments may be worn longer, although the lengths of time they are worn dopes not affect the outcome of the procedure. Wearing it longer helps it to resolve the swelling faster. Most patients wear their garments for 4 to 5 days. The compression headband used after liposuction to the neck and chin is worn for the first 24 hours then is only required at night for a day period.

Swelling, bruising, inflammation and soreness are to be expected with the tumescent technique but not to the extent that it occurs with the dry technique. The more fat that has been removed the longer the duration of post- operative swelling. Temporary subcutaneous lumpiness and firmness are also common during the healing process. This may persist to some degree for 2 to 6 months.

Bruising is usually minimal because there is less bleeding due to the presence of epinephrine in the tumescent solution. Factors which contribute to bruising include the extent of the area treated and an individual’s unique tendency to bruise. If bruising occurs, it gradually subsides over a 10 to 15 day period.

It is common for a patient to feel sore and be easily fatigued for a few days after tumescent liposuction. However, it is possible to return to all normal activities within 48 hrs of the procedure.

In 90% of cases an improvement can be seen one week after tumescent liposuction. However because of the slow resolution of post- surgical swelling, the ultimate results are realized in 12 to 24 weeks.

Dry Technique
When the dry technique is used the suctioned area is always bruises extensively. The bruising often extends well beyond the areas treated, and takes up to 3 weeks to disappear. For the first 3 to 6 weeks after the procedure, the area swells considerably. Massage and ultrasound therapy are often advised, and usually begin one week after the procedure for a period of 3 to 4 weeks. Massage seems to speed up the resolution of bruising and swelling and decreases the amount of fibrous tissue that might develop under the skin. Wearing supporting garments for 3 to 6 weeks following surgery also helps to diminish the bruising and swelling. The dry technique is almost obsolete today.

Fatigue may set in during the first few weeks following surgery. This may be due to a drop in hemoglobin as a result of bruising and iron supplements may be recommended. The amount of fat removed at the time of surgery is controlled to ensure that the red blood cell count does not drop to dangerously low levels which would necessitate a blood transfusion.

Two weeks off work is recommended and no exercise should be done for 6 weeks.

• What is Ultrasonic Liposuction?
  It is a relatively new technique where sound waves are passed along the cannula causing emulsification of the fat prior to aspiration. This allows the surgeon to get closer to the skin surface while reducing the risk of troughing and wrinkling. Many surgeons feel the ultrasonic technique provides an added dimension of safety in high volume fat removal, particularly when combined with the tumescent technique. It also provides an added advantage over the other techniques in areas of the body that are fibrous such as ankles upper back and breasts in men(Gynecomastia) and areas of the body that are poorly supported by underlying muscles such as the inner thighs.
  
  One of the disadvantages of this technique in the past was the overheating of the cannula which in some cases burned the skin. The latest equipment has a device which wraps around the cannula circulating water to keep it cool. It also has a pressure monitoring system to control for excess vibration and potential heat build up which could damage the skin.
  
  The technique is performed under local or general anesthetic at the discretion of the surgeon and patient. The ultrasonic instrumentation is tenfold the cost of traditional liposuction equipment and this as well as lengthy nature of the procedure escalates the costs of the surgery.
  
  The technique does not have significant advantage over the regular liposuction procedure and because of possible complications this is not a favored in routine liposuction cases.

By magnifying the fatty compartment the tumescent technique permits more accurate removal of fat with greater assurance that the liposuction cannula will not approach the undersurface of the skin which could cause waves, dents, or dimples in the skin. If irregularities do occur they tend to subside within 6 months to a year.

Cellulite is a contour deformity which may or may not lessen with liposuction. In fact, in some cases cellulite may become worse.

Asymmetry may also occur when more fat is removed from one side of the body than the other. This can easily be corrected by taking a bit fatter from the heavier side. If too much fat is removed, a droopy appearance in such areas as the buttocks might result.

Excessive bleeding and dehydration are risks associated with the dry liposuction technique. The wet or tumescent technique significantly reduces these risks.

Other potential complications include:

• Slight flushing of the face due to prostaglandin release from the fat, which usually occurs the day after the procedure,
• A slight temperature elevation shortly after the procedure,
• Irregular or premature onset of menstruation which is presumed to be related to prostaglandin release,
• Inflammation of the incision sites,
• Collections of the blood vessels on the skin,
• Sensory nerve damage resulting in persistent discomfort or numbness,
• Lymph channel interruption and varicose veins.

Mild speeding of heart may result from the effects of the epinephrine in the tumescent solution. Some drugs such as thyroids supplement, appetite suppressants and the like may interact with the epinephrine to cause a faster heart rate.

FAQs

• Can dieting /exercise eliminate the need for liposuction?
  
  Although exceptions exist, liposuction is designed for people who are close to their normal weight and have found that through and exercise they are unable to get rid themselves of unwanted fat deposits. A typical example is the saddlebag or "riding breech" deformity on the upper outer thigh. This is often an inherited problem that persists despite vigorous exercise and dieting.

• What are the areas suitable for liposuction?
  
  The fat deposits collect in the hip, buttocks, and thigh areas creating a silhouette in the shape of a violin. This problem can be corrected with liposuction.
  
  A more shapely leg can be created with liposuction by removing fat on the inner and outer thigh, the inside of the knee, the upper portion of the calf and ankle. Liposuction is not limited to buttocks and limbs.
  
  As discussed earlier fat may be removed from the abdomen of individuals who have good muscle tone and skin elasticity without the necessity of tummy tuck. Similarly, liposuction of the neck, jowls, and cheeks gives a better profile without the need for more extensive surgery. The procedure can also be used for reduction of excess fat in the arms and in the lateral portion of the breasts. Men appreciate the benefits of liposuction of reducing their love handles and pot bellies.

• What involves in a tumescent liposuction procedure?
  
  First, a pre- operative consultation, during this initial visit the cosmetic surgeon will want to determine through discussion the outcome. A physical examination and body analysis will determine whether it is possible to achieve the results through liposuction. The physician will evaluate the fat deposits and underlying muscle tone. They will also note any pre- existing scars, hernias, or asymmetry which may affect the outcome. To avoid disappointment this is the time for the patient and the physician to be totally honest. If a person’s expectations are unrealistic it is better not to proceed.
  
  Second a pre- operative visit. During the pre-operative visit the patient is given all the necessary details related to the procedure including the pre-operative and post- operative instructions. A complete medical history and physical examination is performed. For the safety of the patient and the medical staff, pre- operative blood tests are done which include tests for HIV, hepatitis B, hepatitis C and blood stability.
  
  Finally, on the day of the procedure:

1. Prior to beginning the procedure, the locations of the fat to be removed are mapped out on the skin with a permanent ink pen while the patient is standing so the effects of gravity can be noted. The effect is that of a topographical map on the skin and the ink takes a while to wash off after the procedure. A photograph is than taken.
2. At the discretion of the surgeon an anesthetist may be present to monitor the patient’s vital signs but not to give an anesthetic. This is important when extensive procedures are performed. A needle is inserted into the vein of one arm. It would be used as a vehicle to give fluids or medication if it were ever necessary. A blood pressure cuff is placed on the opposite arm. The analogy can be drawn that these precautions are like wearing a seat belt in the car. You wear the seat belt everyday but you rarely need it. When and if you do need it you are glad you had the foresight to use it routinely because you cannot predict when it might be required.

• Will the surgery hurt?
  The anesthetic in the solution numbs the area to be treated so little or no pain is felt during the procedure. Due to the residual local anesthetic and mild cortisone absorbed into the tissue, most patients do not experience any significant soreness for 6 to 18 hours after the procedure. An aching sensation similar to what might be felt after rigorous exercise may be experienced for 24 to 48 hours after the surgery. Maximum discomfort is generally experienced 5 days after surgery once the anti- inflammatory effect of the cortisone has worn off. Tylenol helps to control the inflammation thereby reducing this temporary discomfort.
  
  
  
• Will there be a scar?
  The wet or tumescent technique employs many 4mm entry sites that heal rapidly and are not noticeable 6 months after the procedure. With the dry technique, one or several incisions 1 cm (1/2 inch) in length is made. After healing they leave a fine pink scar which gradually fades into a white line within 6 months.

• Could more than one area be treated at the same time?
  Many areas may be treated at one time, although the limiting factor is the hemoglobin level. The more fat removed, the greater the drop in the red blood cell level. If a large amount of fat removal is anticipated, the procedure is often scheduled over a series of appointments in order to avoid the necessity of a blood transfusion.

• When may the normal activities be resumed?
  Body movement and physical activity is encouraged after tumescent liposuction because it facilitates drainage of the residual solution.
  
  Normal activities may be resumed within 48 hours of tumescent liposuction but activities should be restricted to 25% of that which would normally takes place, then gradually build up to a full routine by the end of one or two weeks. This is compared to a recommended 2 weeks off work and 6 weeks off exercise when the dry technique is used.

Twenty four hours after tumescent liposuction a person may begin:

• Driving a car
• Shopping
• Work and
• Exercise, including bicycling, golf, low impact aerobics, tennis, and walking. High impact sports should be delayed for a few weeks and integrated slowly into a daily routine of activities.

• What are limitations of liposuction?
  Liposuction is not used for the generalized obesity. It is only effective in correcting unwanted fat in the specific areas of the body. People who are generally overweight first need to commit to a lifestyle change which will encompass a proper diet and an exercise program. This for many is easier said than done and we recommend that the expert assistance with this process is sought. Once a person reaches a reasonable weight and the remaining fat deposits are stable, liposuction may be considered for certain areas of the body.

• Will liposuction get rid of stretch marks and cellulite?
  Liposuction will not improve the appearance of stretch marks although treatments with topical tretinoin or laser resurfacing may be helpful.
  In some cases liposuction may improve the appearance of cellulite. Creating a criss cross of tunnels through the fat with the very small cannulas used in tumescent liposuction causes mild inflammation of the fibrous pillars that hold the skin to the underlying muscular structure. As the inflammation subsides, the entire area contracts down pulling the skin with it, much like a layer of spandex. The more elasticity in the skin the greater the positive benefit of this contraction. Although liposuction is not used to treat cellulite, the effect of this tethering may help to improve the appearance of this condition .

• Should weight be lost before liposuction?
  A person’s body weight should remain stable for 6 months prior to surgery and should be maintained by weight management and exercise after the procedure is complete. Any excessive post- surgical weight gain will lay down a uniform layer of fat over the entire body. It will not accumulate in those areas treated as the number of fat cells in these areas has been reduced with liposuction and they don’t grow back.
  Nevertheless, excessive weight gain is unattractive and to a certain extent will undo the results of the procedure. Weight loss after liposuction will, on the other hand, simply improve the esthetics results.

• What are the alternatives to Liposuction?
  Dieting to obtain an ideal weight, in combination with a regular exercise program, is the cornerstone to maintaining a healthy and attractive physical form. For many individuals, however, the ideal is not possible because of persistent deposits of fat that detract from their physical appearance. For these victims of fat liposuction is a potential solution.

• What is micro lipid transfer?
  It is the process by which the fat is injected into areas of fat deficiency. This fat is harvested from the products of liposuction, cleansed, and then, reinjected. The short term results are quite satisfactory, but in the long-term, relocated fat are almost always progressively metabolized.

• Who performs Liposuction ?
  Plastic surgeons trained in liposuction techniques perform these procedures. In some centers, specialists other than plastic surgeons or will also perform liposuction. It is up to the individual to ensure that the surgeon is qualified, , well trained, and experienced in any procedure being considered.