Liposuction

Liposuction
Intervention

Suction-assisted lipectomy of bilateral outer thighs
ICD-9-CM 86.83
MedlinePlus 002985

Liposuction, also known as lipoplasty ("fat modeling"), liposculpture suction lipectomy ("suction-assisted fat removal") or simply lipo, is a cosmetic surgery operation that removes fat from many different sites on the human body. Areas affected can range from the abdomen, thighs and buttocks, to the neck, backs of the arms and elsewhere.

Several factors limit the amount of fat that can be safely removed in one session. Ultimately, the operating physician and the patient make the decision. There are negative aspects to removing too much fat. Unusual "lumpiness" and/or "dents" in the skin can be seen in those patients "over-suctioned". The more fat removed, the higher the surgical risk.

While reports of people removing 50 pounds (20 kg or around 4 stone) of fat have been claimed, the contouring possible with liposuction may cause the appearance of weight loss to be greater than the actual amount of fat removed. The procedure may be performed under general, regional, or local anesthesia. The safety of the technique relates not only to the amount of tissue removed, but to the choice of anesthetic and the patient's overall health. It is ideal for the patient to be as fit as possible before the procedure and not to have smoked for several months. 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 to follow.[1]

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[2] 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.

Popularity

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. According to the American Society for Aesthetic Plastic Surgery and ISAPS 2011 Statistics, 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.

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.

Approaches

The basic surgical challenge of any liposuction procedure is:

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.

Areas of the body where liposuction is performed

An obese woman with excessive arm fat

Techniques

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.

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.[3] Third-generation UAL devices address this problem by using pulsed energy delivery and a specialized probe that allows physicians to safely remove excess fat.[4]

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

Main article: Tumescent liposuction

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.[5][6] 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.

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.

Procedure

Liposuction aspirate

In all liposuction methods, there are certain things that should be done when having the procedure:

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.

Health benefits

Whether or not liposuction provides the health benefits commonly associated with achieving weight loss through other means is a matter of debate in scientific circles. Mainstream doctors agree that liposuction does not help to combat obesity related metabolic disorders like insulin resistance.[7][8]

Side effects

Side effects of the procedure, as opposed to complications, are medically minor, although they can be uncomfortable, annoying, or even painful.

There could be various factors limiting movement for a short while, such as:

The surgeon should advise on how soon the patient can resume normal activity.

Complications

As with any surgery, there are certain risks, beyond the temporary and minor adverse effects. The surgeon should mention them during a consultation. Careful patient selection minimizes their occurrence. Their likelihood is somewhat increased when treated areas are very large or numerous and a large amount of fat is removed.[9]

During the 1990s there were some deaths as a result of liposuction, as well as alarmingly high rates of complication. By studying more and educating themselves further, surgeons have reduced complication rates. A study published in Dermatologic Surgery (July 2004, pp. 967–978), found that "The overall clinical complication rate [for liposuction] ... was 0.7% (5 out of 702)", the minor complication rate was 0.57%, and the major complication rate was 0.14% with one patient requiring hospitalization.[10]

The more serious possible complications include:

The cosmetic surgeon should give the participant a written list of symptoms to watch for, along with instructions for post-operative self-care.

Combined with other procedures

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.

Non-surgical alternatives

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.

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.

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.

See also

Notes

  1. ↑ Dujarier's case from the US National Library of Medicine and the National Institute of Health
  2. ↑ "Coleman III, William. P.: The History of Liposculpture". Retrieved 2013-08-25.
  3. ↑ Mark Laurence Jewell. Lipoplasty. In: M. Eisenmann-Klein, Constance Neuhann-Lorenz, eds. Innovations in Plastic and Aesthetic Surgery. Springer, Berlin Germany; 2006:439-444
  4. ↑ Pinto et al. Liposuction and VASER. Ibid, 108-110
  5. ↑ MedlinePlus Medical Encyclopedia: Liposuction
  6. ↑ Site Map on Yahoo! Health
  7. ↑ Gottlieb, S. (2004). "Liposuction does not achieve metabolic benefits of weight loss". BMJ 328 (7454): 1457–1450. doi:10.1136/bmj.328.7454.1457-a. PMC 428545.
  8. ↑ Stacy A Porter; et al. (2009). "Abdominal Subcutaneous Adipose Tissue: A Protective Fat Depot?" (PDF). Diabetes Care 32: 1068–1075. doi:10.2337/dc08-2280.
  9. ↑ Weill Cornell Physicians - Liposuction
  10. ↑ Hanke, William; Sue Ellen Cox MD, Naomi Kuznets PhD, William P. Coleman III MD (July 2004). "Tumescent Liposuction Report Performance Measurement Initiative: National Survey Results". Dermatologic Surgery 30 (7): 967–978. doi:10.1111/j.1524-4725.2004.30300.x. PMID 15209785. Retrieved 20 October 2011. Cite uses deprecated parameter |coauthors= (help)
  11. ↑ Liposuction Information from the FDA

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