Liposuction

Overview

What Is It?

Liposuction, also called lipoplasty, suction lipectomy or liposculpture, is a cosmetic surgical procedure that vacuums out fat from beneath the skin's surface to reduce fullness in areas such as the abdomen, hips, thighs, knees, buttocks, upper arms, chin, cheeks and neck.

If no amount of diet or exercise removes those stubborn saddlebags on your hips or that paunchy spot on your stomach, you may be able to get rid of that localized area of fat through surgery. Liposuction, also called lipoplasty, suction lipectomy or liposculpture, is a cosmetic surgical procedure that vacuums out fat from beneath the skin's surface to reduce fullness in areas such as the abdomen, hips, thighs, knees, buttocks, upper arms, chin, cheeks and neck.

Liposuction is the most popular form of cosmetic surgery among both men and women in the United States, with 283,735 procedures performed in 2009, according to the American Society for Aesthetic Plastic Surgery. Introduced in the United States in 1982, liposuction's popularity increased as refinements to the technique improved results and reduced recovery times. Thirty-eight percent more women had liposuction in 2009 than in 1997.

Although liposuction can produce permanent changes in body contour, it is not a substitute for a healthy low-fat diet and exercise. It will not tighten loose skin or eliminate the shallow surface fat irregularities called cellulite. It is a sculpting technique that can improve body proportions and help clothing fit better.

Liposuction recontours the body by removing some of the body's finite number of fat cells. It's a myth that when you gain weight, you're adding new fat cells to your body. In fact, each person has a fixed number of fat cells. When you gain weight, those fat cells grow larger but don't increase in number. When you lose weight, the fat cells shrink. Your genes determine how many and where fat cells are distributed, and some people tend to have more fat cells in some body areas than others. For example, some women have more fat cells in their thighs and hips, instead of a uniform fat distribution.

Liposuction can permanently remove some fat cells from such areas. But, the fat cells that remain in the area treated still can grow larger if you gain weight. Many liposuction patients find, however, that newly added weight will not accumulate in the specific areas as it did before and instead distributes more evenly or in different areas. This is why weight gain is inadvisable after liposuction. People who do best are the ones who come as close as possible to their ideal weight before the procedure.

There are several variations on the liposuction technique, but those most commonly used involve first infusing the area to be treated with a solution of saline, a local anesthesia and a drug that constricts blood vessels. Then, a hollow tube attached to a vacuum is inserted into the fat layer beneath the skin. The tube, called a cannula, is moved through the fat layer in a push-and-pull motion to break up the fat. Then, the dislodged fat is sucked out of the body either via a syringe attached to the cannula or a surgical vacuum. In the tumescent technique, the solution used is two to three times the amount of fat to be removed. In the super-wet technique, the amount of fluid infused is the same as the amount of fat slated for removal. In ultrasound-assisted liposuction, ultrasonic energy that liquefies the fat is applied through the cannula, which also suctions out the fat. Similarly, a new technique as of 2007—laser-assisted liposuction—uses a laser beam to liquefy the fat. And another fairly new method called power or power-assisted liposuction uses a motorized cannula that pushes and pulls itself while suctioning out the fat.

The choice of technique depends on the patient and the surgeon's skill and preference. According to the American Academy of Dermatology, not only does the tumescent technique offer improved safety, it offers the fastest recovery time and few significant side effects.

Liposuction of small areas can be performed in an outpatient office surgical setting under the local anesthetic that is included in the infusion solution. It is often combined with sedation to keep the patient more relaxed during the procedure. If large amounts of fat are to be removed, the procedure is likely to be performed on an outpatient basis in a hospital or an accredited, ambulatory outpatient surgical center, using a general or regional anesthesia, such as an epidural block commonly used in childbirth, which may be combined with intravenous sedation. General anesthesia is used when the patient must be put to sleep. In cases involving general anesthesia and large areas of fat removal, patients may be hospitalized overnight.

Most liposuction patients are able to return to work in a few days. Normal activities can usually be resumed within 10 days or less after liposuction, depending on the extent of the procedure. Patients must wear compression garments for one to six weeks after surgery to help the skin smoothly adhere to the underlying tissue and remaining fat and to help control swelling in the treated area. Compression garments appear to be most effective in the first seven days following surgery. Follow your surgeon's instructions, and attend all scheduled follow-up visits. Temporary bruising, numbness of the skin and swelling are common postoperative side effects.

As with any surgery, liposuction carries risks, including death. A controversial study published in the journal Plastic Reconstructive Surgery in January 2000 found a death rate of about 20 in every 100,000 patients who underwent liposuction from 1994 to 1998. According to the American Society for Aesthetic Plastic Surgery (ASAPS), a task force of plastic surgeons in 1998 determined that the factors that increase the risk of death from liposuction include:

• poor patient health
• excessive fat removal
• too much fluid and local anesthesia used during the procedure
• performing multiple procedures along with liposuction in a single surgical session, especially under general anesthesia

However, in skilled surgical hands, life-threatening complications from anesthetics, blood clots and even perforation of the organs near the area being treated are extremely rare. Bleeding, excessive bruising and infection are possible but uncommon. Seromas, or pockets of fluid that have collected under the skin, also can occur when large amounts of fat are removed, but can be treated in an office setting by draining with a needle and syringe.

More common complications that usually require additional liposuction surgery include irregularities in contour, such as lumps or divots where the surgeon has removed too little or too much fat, and asymmetry, where the contour differs on each side of the body. These kinds of complications can be the result of poor surgical technique, lack of experience in the procedure or performing a liposuction technique on a patient who is not appropriate for the procedure. That's why it's important to carefully select your surgeon and ask questions about the surgeon's experience with liposuction. Various studies in the medical literature have reported revision rates ranging from five to 20 percent, depending on the type of patient, the number of areas treated at one time and how much fat was removed. A small amount of fat is considered less than 1.5 liters, while a large amount is four to five liters. Removing more than five liters of fat in a single liposuction treatment is considered too risky by most surgeons unless performed in a hospital with an overnight stay.

In addition to carefully choosing your surgeon, it's important that you have realistic expectations of your liposuction surgery. Liposuction can improve your body contour, but it will not make you fit or thin. The only way to get in shape is to eat a healthy diet and exercise. The best candidates for liposuction are healthy, normal-weight people with firm, elastic skin who have localized pockets of fat that do not respond to diet and exercise. Although there are no absolute age limits for liposuction, older women who have lost skin elasticity may not achieve as good results from the procedure as younger women with elastic skin. Skin imperfections can occur after any liposuction. The skin surface may be irregular, asymmetric or baggy, and these problems tend to occur more often in women whose skin is no longer elastic enough to smooth out and tighten after the underlying fat is removed.

Diagnosis

To determine if you are a candidate for liposuction (a surgical procedure that vacuums out fat from beneath the skin's surface to reduce fullness in certain areas), you first should consult with the health care professional who would perform the procedure. That health care professional may be a plastic surgeon, cosmetic surgeon or dermatologist.

The physician will conduct a physical examination and ask you questions about your medical history, what medications you are taking, your diet and exercise history and what you hope to achieve by having this elective surgical procedure. It's important that you provide an accurate medical history, including any past or present medical conditions, and what medications, including prescriptions, over-the-counter drugs and dietary and herbal supplements, you are taking. Some types of drugs, such as steroidal medications, aspirin, ibuprofen and vitamin E, thin the blood and can interfere with clotting, and your health care professional most likely will want you to stop taking such drugs about two weeks before surgery.

You may be an ideal candidate for liposuction if you are within 30 percent of your ideal weight, physically fit and healthy and have good skin elasticity, but have pockets of fat in a specific area, such as the hips, thighs, buttocks, arms, neck or chin, that don't respond to diet and exercise programs. If you have localized fat deposits in specific areas, such as saddlebags on the thighs or extremely wide hips, and good skin elasticity, you may be a candidate for liposuction of those areas to help improve your body proportions. If you are significantly overweight (more than 30 percent over ideal body weight for your height), appear heavy everywhere with no specific area fatter than others and have loose skin from weight fluctuations, liposuction is unlikely to benefit you. Liposuction is a body contouring procedure; it cannot remove a layer of fat from the entire body.

Additionally, patients with serious medical problems, such as uncontrolled diabetes, heart disease, circulatory problems or lung disease, generally are not candidates for any type of elective surgery, including liposuction. If you have a medical condition, your surgeon will seek medical clearance from your primary health care professional before considering you as a candidate for liposuction surgery. In addition, liposuction is not recommended for patients who are or may be pregnant.

In evaluating whether liposuction is for you, your surgeon may conduct a "pinch test" to assess how much fat is under the skin in the area considered for treatment and to check the elasticity of your skin. During this test, the health care professional simply pinches the skin between the thumb and forefinger to see how much fat is in the area and see how the skin springs back after releasing the pinch. If an inch or more of fat can be pinched, the area may be reduced through liposuction. At least a half-inch of fat needs to remain after the procedure to ensure a smooth result. Otherwise, skin would remain on top of bone or muscle, creating an emaciated look. If the skin springs back after the pinch, it has appropriate elasticity. Cellulite is a dimpling of the skin surface. While liposuction of the area may be effective in removing fat bulges and helping clothes fit better, it will not remove cellulite.

During the consultation, discuss with your health care professional:

• Why liposuction can or cannot benefit you
• How the procedure would be done on you
• Where the surgery will be performed
• What kind of anesthesia would be used and your own preferences
• Risks and potential complications
• Confirm that the surgeon has a plan for medical emergencies, if the need arises
• Expected recovery time
• What kind of results you can expect
• What the procedure will cost, since it is elective and not covered by most insurance

Additionally, to make sure you select a surgeon who is right for you, ask questions about what kind of liposuction training he or she has had; whether he or she is certified by the American Board of Plastic Surgery, the American Board of Cosmetic Surgery or the American Board of Dermatology; and how much experience he or she has had performing liposuction. Ask to see some before and after photographs of his or her patients. You may also want to ask if you can speak with former patients about their liposuction experiences. Additionally, you may want to get a second opinion from another health care professional.

If you decide to have the procedure, you likely will have a preoperative visit with your surgeon in which before photographs of the area to be treated will be taken, consent forms signed and blood drawn for lab testing. If you have a medical condition, your primary health care professional may order additional tests to ensure you are healthy enough to undergo surgery before giving medical clearance for the procedure.

Treatment

Many liposuction procedures can be done in the physician's office-based operating room or an outpatient hospital operating room. Patients having large amounts of fat removed through liposuction or cosmetic procedures in addition to liposuction may spend the night in the hospital after surgery.

The technique used for your liposuction surgery depends on you and your particular problem area, your surgeon's preference, the location and number of areas to be treated and the amount of fat to be removed. The most commonly used techniques today include:

• Tumescent and super-wet. Basic liposuction involves infusing the area to be treated with a solution of saline; lidocaine, an anesthetic; and epinephrine, a drug that constricts blood vessels to curb bleeding. The difference between techniques is the total amount of fluid used. In the tumescent technique, the solution used is two to three times the amount of fat to be removed. In the super-wet technique, the amount of fluid infused is the same as the amount of fat slated for removal. Which version of these two techniques is used depends on your surgeon's preference and judgment regarding which is best for you.
  
  What kind of anesthesia is used for these techniques also depends on the amount of fat to be removed and your surgeon's preferences and medical judgment pertaining to what is best for you. Because the large volume of fluid used in the tumescent technique includes an anesthetic, your surgeon may not administer additional anesthesia before the procedure, especially when a small amount of fat is to be removed, such as 1.5 liters or less from one or two areas on the body. In such cases, a sedative in pill form may be given to relax you before surgery begins. Because the super-wet technique uses less anesthesia-containing fluid, additional anesthesia, such as an intravenous sedation, an epidural block or general anesthesia is used. General anesthesia is more common when large amounts of fat, such as more than 1.5 liters, are to be removed, or multiple areas on the body, such as thighs and hips, are to be treated.
  
  In these fluid infiltration techniques, a thin metal tube is inserted into the fat layer beneath the skin in the area to be treated. This tube is attached to an infusion pump, which pumps the solution into the area. This tube is removed and, after waiting for the anesthesia in the solution to take effect, an incision is made into the skin to accommodate a small hollow tube. This tube, called a cannula, is attached to a vacuum. The cannula is inserted through the incision into the fat layer beneath the skin. It is moved through the fat layer in a push-and-pull motion to break up the fat and suck it out of the body.
  
  The surgeon may make two to more incisions in each area for insertion of the cannula in various locations in the treatment area to suction out fat from different directions. Using a crisscross technique helps avoid creating tunnels in the fat that would result in wavy-looking skin irregularities after surgery.

• Ultrasound-assisted. This technique uses the same basic preparation as tumescent and super-wet liposuction, but employs a different type of cannula that emits ultrasound waves at its tip to liquefy the fat and then suctions it out of the body.
  
  When the ultrasonic energy hits the fat, the high-frequency vibrations explode the fat cells. The fat mixes with body fluids and the infused solution and is sucked out of the body. The real potential advantage of ultrasonic-assisted liposuction is the possibility for increased skin tightening. Also, in areas of the body that have a lot of fibrous tissue, such as the male chest, the addition of ultrasonic energy may provide a significant advantage.
  
  Disadvantages to the ultrasound-assisted liposuction procedure may include a more obvious scar due to a larger opening required for insertion, increased discomfort and a higher incidence of complications, such as skin burns and seromas (a collection of body fluid causing swelling). The latest generation of ultrasonic liposuction systems are much safer, and these complications occur much less frequently.
  
  Like other liposuction techniques, anesthesia for ultrasound-assisted liposuction varies from local to general, depending on the individual patient, how much fat is to be removed and the surgeon's preference.
• Laser-assisted. Similarly to ultrasound-assisted liposuction, laser-assisted liposuction, introduced in 2007, uses thermal (heat) energy to liquefy the fat. As with other liposuction techniques, laser-assisted liposuction involves the use of tumescent solution and standard liposuction to remove the liquefied fat. During the procedure, the surgeon inserts a thin laser fiber through small incisions in the skin. In addition to breaking up fat cells, the laser heats surrounding tissues. Side effects may include bruising, swelling, numbness, burns and minimal bleeding. Some studies have found no differences between the laser-assisted liposuction and standard liposuction techniques in terms of results, but many surgeons and some recent studies suggest enhanced skin tightening with laser-assisted liposuction

• Power. Using the same basic techniques as tumescent and super-wet liposuction, power liposuction, also called power-assisted liposuction, involves use of a motorized cannula. In addition to the surgeon physically moving the cannula back and forth through the fat to help break it up while suctioning, the cannula moves or vibrates itself under electrical or nitrogen power, moving short stroke distances. Meanwhile, the surgeon manipulates the direction of the cannula. Surgeons favoring power liposuction say it permits them to perform the procedure faster and with more precision, resulting in less trauma to surrounding tissues, and therefore, less bruising and discomfort and quicker recovery times. Power liposuction can be performed under local anesthesia or with IV sedation or general anesthesia.

Because liposuction vacuums out body fluids along with fat, patients should have intravenous fluid replacement while undergoing liposuction to prevent dehydration and shock.

After the procedure is complete, the incisions may be closed with stitches; in some cases, incisions are so small they do not require stitches. A compression garment is then placed over the body area treated. For a hip and thigh treatment, for example, a girdle-type garment is used. The garment smooths the treated area to help healing so the skin appears flat, and it helps control swelling. Most patients wear compression garments for one to six weeks, but they appear to be most effective in the first seven days after surgery. Your health care professional also may give you a prescription for postoperative pain, such as acetaminophen with codeine. An antibiotic also may be prescribed.

Patients usually are told to rest for at least two days after surgery. Many patients have their surgery on a Friday morning, return home that afternoon, rest over the weekend and resume work on Monday. Normal exercise and activities can be resumed in about a week or two. A follow-up visit to check on progress and remove any stitches is usually required five days to a week after surgery.

Common temporary postoperative side effects of liposuction are bruising, swelling and numbness of the skin in the area treated. They usually are temporary and subside in six weeks or less. Swelling, however, may take several months to disappear.

Although it is usually done on an outpatient basis and may be performed in your health care professional's office surgical suite, you must recognize that liposuction is still surgery, and all surgeries carry risks, including death.

Among the extremely rare, potentially life-threatening complications are:

• Anesthesia-related problems, such as breathing difficulties and fluid in the lungs
• Blood clots or fat clots that can migrate to the lungs
• Perforation of organs with the cannula
• Burning of tissues in ultrasound-assisted or laser-assisted liposuction

Uncommon complications include:

• Bleeding
• Excessive bruising
• Infection
• Seromas, or pockets of fluid collection under the skin, also can occur when large amounts fat are removed, but usually can be treated in an office setting by draining with a needle and syringe (seromas tend occur more often with ultrasound-assisted liposuction).

More common complications include:

• Irregularities in contour, such as lumps or divots where too little or too much fat was removed
• Asymmetry, where the contour differs on each side of the body
• Skin irregularities, such as loose, baggy or wavy skin

Many of the complications can be the result of poor surgical technique, lack of experience in the procedure or poor patient selection. Contour and symmetry problems can require additional, touch-up liposuction surgery, known as revision surgery. Various studies in the medical literature have reported revision rates ranging from five percent to 20 percent, depending on the type of patient, the number of areas treated at one time and how much fat was removed. A small amount of fat is considered less than 1.5 liters, while a large amount is four to five liters. Special considerations are needed when large amounts of fat (usually more than five liters) are removed.

Facts to Know

1. Liposuction is the most popular form of cosmetic surgery among both men and women in the United States, with 283,735 procedures performed in 2009, according to the American Society for Aesthetic Plastic Surgery.
2. Thirty-eight percent more women had liposuction in 2009 than in 1997, according to the American Society for Aesthetic Plastic Surgery.
3. Liposuction is an elective surgical procedure that contours the body.
4. Liposuction is not a weight-loss technique.
5. Body contour improvements produced by liposuction are permanent.
6. Each person has a set number of fat cells and, when weight is gained, the size of the fat cells increases, but not the number. Liposuction works by removing some fat cells.
7. The best candidates for liposuction are healthy, fit people within 30 percent of their ideal body weight with elastic skin who have isolated areas of fat that do not respond to diet and exercise.
8. Irregularities in body contours and symmetry are possible common complications of liposuction that can require additional, touch-up surgery.
9. Like any surgery, liposuction carries risks, including death. When performed by experienced, skilled surgeons, life-threatening complications are extremely rare. Other complications, such as bleeding, excessive bruising, infection and pockets of fluid collection under the skin, are also uncommon.
10. A small amount of fat removal during liposuction is considered less than 1.5 liters, while a large amount is four to five liters. Removing more than five liters of fat in a single liposuction treatment is considered too risky by most surgeons unless performed in a hospital with an overnight stay.

Questions to Ask

Review the following Questions to Ask about liposuction so you're prepared to discuss this important health issue with your health care professional.

1. Am I a good candidate for liposuction? Why or why not?
2. How will my liposuction surgery be performed?
3. Where will my liposuction be performed? Will it be in an accredited operating room or in some other type of facility?
4. What kind of anesthesia is best for me?
5. What can I expect immediately after the procedure and how long will my recovery take?
6. What risks and possible complications are involved in my procedure? What plans do you have in case of a medical emergency?
7. What are your credentials? Are you board certified and by what organization?
8. How many procedures like mine have you performed?
9. What is your complication rate? What is your rate of revision surgery?
10. Do you have before and after photographs of some of your patients that I may see?

Key Q&A

Organizations and Support

For information and support on Liposuction, please see the recommended organizations and Spanish-language resources listed below.

American Academy of Facial Plastic and Reconstructive Surgery
Website: https://www.aafprs.org
Address: 310 S. Henry St.
Alexandria, VA 22314
Phone: 703-299-9291
Email: info@aafprs.org

American Society for Aesthetic Plastic Surgery
Website: https://www.surgery.org
Address: Central Office
11081 Winners Circle
Los Alamitos, CA 90720-2813
Hotline: 1-888-ASAPS-11 (1-888-272-7711)
Email: asaps@surgery.org

American Society of Plastic Surgeons
Website: https://www.plasticsurgery.org
Address: 444 East Algonquin Road
Arlington Heights, IL 60005
Phone: 847-228-9900

Spanish-language resources

American Society of Plastic Surgeons
Website: https://www.plasticsurgery.org/cosmetic-procedures/liposucci%C3%B3n
Address: American Society of Plastic Surgeons Plastic Surgery Educational Foundation
444 E. Algonguin Rd.
Arlington Heights, IL 60005
Phone: 847-228-9900
Email: Public Relations: media@plasticsurgery.org

Medline Plus: Liposuction
Website: https://www.nlm.nih.gov/medlineplus/spanish/ency/article/002985.htm
Address: Customer Service
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov