Liposuction essentials

Since its introduction more than 30 year ago, liposuction continues to be one of the most popular cosmetic procedures.

Liposuction is a surgical procedure to remove deposits of subcutaneous fat from specific areas of the body such as the thighs, hips, abdomen, buttocks, knees, upper arms, neck and chin.

Liposuction was first performed in 1974 and was a great improvement over previous surgical body contouring techniques. There have been many advances in liposuction procedures over the past few decades, making it one of the most predictable and popular body contouring surgeries in the world.

The benefits of fat removal can be enormous, and liposuction is among the cosmetic surgery procedures with the highest rate of patient satisfaction. Many patients experience an immediate improvement in their self-esteem and overall confidence.

The basic liposuction procedure involves the insertion of a small tube-like instrument, called a cannula, into the layer of subcutaneous fat via tiny incisions made by the surgeon. The cannula is connected to a clear plastic hose which leads to a suction source. It breaks up and vacuums away the targeted fat deposits beneath the skin.

There are two main layers of subcutaneous fat: superficial and deep. Liposuction is primarily focused on the deeper layer of fat, since suctioning is thought to be safer and easier there. Suctioning in the superficial layer allows the surgeon to achieve subtle benefits in the procedure but, because of its proximity to blood vessels and nerve endings, it can increase the risk of contour irregularities and injury to the skin. Some surgeons believe superficial liposuction enhances skin retraction.

Although the cannula is designed to slide through fat tissue and cause minimum damage to blood vessels and nerves, some may be injured during the procedure. In some cases, liposuction is performed alone, in other cases it is used with plastic surgery procedures such as a facelift, breast reduction or a tummy tuck.

Liposuction and weight loss

Liposuction is not a way of losing weight. However, it may be a viable option for men and women who want to reduce bulges of fat that have resisted dieting and exercise. The ideal liposuction candidate is at or near their ideal weight, with good skin elasticity, and is seeking reduction of diet-resistant localised pockets of fat. Common sites include the hips, outer thighs, abdomen, lower back, knees and neck.

Overweight individuals can benefit if they are in the process of exercising and losing weight. However, liposuction is not a cure for obesity. Candidates must have realistic expectations of what liposuction can and cannot do.

If a person has loose skin, liposuction can actually make it worse. If this is the case, a body lift procedure may be required to remove excess skin and help the skin conform to the body’s new contours.

It should also be noted that liposuction does not improve cellulite (the dimpled appearance of the skin of commonly seen on the buttocks and thighs) or stretch marks (caused by pregnancy or rapid weight gain) as these appearance concerns are not related to fat accumulation beneath the skin.

Both men and women can achieve an improved and more contoured body shape through liposuction. The most commonly treated areas in women are the outer thighs and stomach, where as the most commonly treated areas in men are the abdomen and the flanks, or ‘love handles’. Some men have excess fatty tissue in and around the breast, or gynaecomastia, which can also be removed. A specific area treated by liposuction is less likely to increase to its former size because it has fewer fat cells.

Liposuction vs Liposculpture

These two terms are often used interchangeably, however, there are a few differences between liposuction and liposculpture. Liposuction refers to the removal of excess fat from localised areas on the body, while liposculpture implies more subtle shaping and contouring.

Liposuction is the removal of medium to large amounts of fat in areas such as below the chin, upper arms, outer breasts, lower abdomen, flanks, hips and thighs.

Liposculpture is the removal of small to medium amounts of fat to sharpen features, create a more shapely silhouette, accentuate the muscles beneath and create a more ‘cut’ appearance in the abdomen, buttocks, knees, calves, ankles, neck and lower cheeks.

Liposculpture causes minimal swelling and bruising and recovery is faster than with traditional liposuction but it is not suitable for patients seeking a larger amount of fat removal.

The liposuction procedure

Various types of anaesthesia can be used for liposuction, depending on the surgeon and the extent of the procedure. If only a small amount of fat and a limited number of body sites are involved, liposuction can be performed under local anaesthesia, which numbs only the affected areas. Local anaesthetic is usually used in conjunction with intravenous sedation to help relax the patient during the procedure. Some patients prefer general anaesthesia, particularly if a large volume of fat is being removed.

Generally, the surgeon makes tiny incisions in the areas to be suctioned and a cannula is inserted. Using the cannula, the surgeon moves in a specific pattern through the fat layer to break up fat cells, which are then vacuumed or suctioned out. The overlying skin remains attached to the connective tissue and underlying muscles of the skin during the operation. A thin blanket of fat is left under the skin to help prevent rippling or bumpy skin occurring after the liposuction is over.

The aim of liposuction is to decrease the bulk of fat in a specific area, but not to remove all the fat. Fat is an important tissue which helps to maintain skin shape and firmness and removing too much fat can cause loose skin and surface irregularities.

Depending on the size and number of the areas being treated, as well as the technique employed by the surgeon, the procedure can last from around one to five hours.

In addition to fat, body fluid is also removed during the procedure. Because of this, patients are given fluids intravenously during the operation. Drain tubes may remain in place for a few days to drain excess fluid.

After surgery, the patient can expect to be swollen and bruised. Most patients report feeling sore for a few days. It is also common to experience some numbness in the treated areas, although this should go away in the first few weeks. Patients are required to wear a compression garment for up to six weeks, but should be back to their normal routine after two to four weeks and vigorous exercise in a month. Although results can be seen as swelling subsides, it can take from six months to a year to achieve the final effect.

Although different surgeons may favour certain modalities and variations, it is important to remember that all liposuction is surgery, requiring incisions, anaesthesia and diligent post-operative care.

An ideal candidate for liposuction

• Is close to their ideal body weight (within 30 percent)

• Wants to remove specific areas of fat that are resistant to diet and exercise (fat pockets in the abdomen, arms, knees, inner and outer thighs, ‘love handles’ and neck)

• Weight has been stable for six months or more

• Has good skin tone and elasticity

• Does not have loose or saggy skin

• Does not have stretch marks

• Has realistic expectations

• Is emotionally stable

Liposuction techniques – which work best?

There are numerous liposuction techniques available today, however each doctor has their preferred method, all of which can offer effective, predictable results. As well as the technique employed, in every liposuction procedure the doctor takes into account the level of sedation administered, the type of cannula used and the patient’s wishes.

No single technique, piece of equipment or instrument necessarily offers better results. Most doctors will adapt techniques and tools to each individual patient to achieve optimal results. Generally, the technique that the doctor is most skilled in will cause the least complications.

There are generally three techniques used in liposuction surgery today: ‘wet’, ‘superwet’ and ‘tumescent’. These are all dependent on the amount of fluid preinjected – predominantly local anaesthetic, blood vessel constrictors and saline – into the fat cells before the actual liposuction surgery.

Liposuction was originally performed with what is now referred to as the ‘dry technique’. It derived its name from the fact that it did not preinject any fluids into the fat before surgery.

While fat removal using the dry method was effective, it was for the most part abandoned because of its association with increased discomfort for the patient, excessive blood loss, increased tissue and nerve damage, as well as extensive bruising and a greater propensity for uneven or asymmetrical results.

The introduction of tumescent liposuction was a significant advancement in liposuction surgery and made it a much safer and more predictable procedure. Tumescent refers to a saline-based solution that usually contains epinephrine (which causes smaller blood vessels to constrict and reduces bleeding and bruising) and lidocaine (an anaesthetic that provides localised pain relief) which is injected into the area to be treated. Ironically, the dry technique is wet (lots of blood loss), while the wet technique is dry.

Performing liposuction surgery with tumescent helps to separate tissues, allowing easier movement of the cannula through the swollen fat cells. Suction then removes the fat tissue and most of the injected fluid. The rest of the fluid is largely excreted by the body in the days following surgery. As the tumescent technique reduces bruising and swelling, larger quantities of fat can be removed.

The amount of tumescent fluid used varies from patient to patient and is usually driven by what level of anesthetic the patient prefers. Technically, the tumescent method also includes the ‘wet’ and ‘superwet’ techniques as these also inject fluid to expand, or tumesce, the target area. The main differences of the true tumescent technique and the ‘wet’ and ‘superwet’ modifications are the volume of fluid injected in relation to the amount of fat removed and the type of sedation used.

Generally, there is a balance between the volume of fluid injected and the anesthetic used – the more fluid, the less additional anaesthetic needed. For example, liposuction performed using the true tumescent technique will typically negate the need for additional sedation because the local anesthetic in the injected fluid is sufficient. Conversely, the wet technique preinjects a minimal amount of fluid so more sedation is required, usually in the form of general anaesthetic. The superwet technique, which normally involves an amount of fluid equal to the amount of fat to be removed, would typically require intravenous sedation. The volume of fluid and corresponding level of anaesthetic used is also dependent on the projected length of surgery and the amount of fat to be removed.

The terms ‘tumescent’, ‘wet’ and ‘superwet’ are used loosely. Generally, each doctor has their own preferred amount and composition of fluid to be injected and it has never been completely standardised. Doctors will usually adjust the amount of fluid used depending on the desires of the individual patient and their preference for local anesthesia only, intravenous sedation or general anesthesia.

Once the areas of fat to be treated have absorbed the injected solution, there are generally three ways to actually remove the fat: the traditional cannula method, the syringe technique and the energy-assisted method, which can further be broken into numerous sub-categories. The method of fat extraction used is mainly dependent on the doctor’s preference and their level of expertise.

Suction-assisted Liposuction (SAL)

This is the traditional method, by which the doctor removes fat by inserting a small, hollow tube (cannula) connected to a vacuum pressure unit, directing the cannula into areas to be suctioned through tiny incisions. One benefit is that traditional cannulae can be curved, bent and adapted as needed to reach multiple areas from each incision, whereas ultrasonic or laser probes are more fragile. In addition, ultrasonic cannulae are thicker than traditional cannulae so larger incisions into the skin are required. These days, traditional cannulae can be as small as 2mm in diameter; ultrasonic cannulae are usually 6mm.

Syringe technique

Dr Pierre Fournier introduced the syringe method, which uses a syringe instead of a machine to aspirate the fat. Many doctors believe using the syringe technique is more precise than machine-assisted suction and helps prevent extracting too much fat.

Energy-assisted liposuction

Recent advancements in liposuction surgery have seen the advent of different energy sources being used on the tip of the cannula to assist in dissolving and removing fat. These techniques include ultrasound-assisted liposuction, power-assisted liposuction, laser-assisted liposuction and water-assisted liposuction.
Generally, energy-assisted liposuction is less aggressive than traditional techniques and can be particularly beneficial for large-volume liposuction surgeries as the length of the procedure is usually reduced and the patient spends less time under anaesthetic. However, energy-assisted liposuction requires more technical skill as there is a greater risk of removing too much fat, resulting in unevenness. The heat generated during ultrasound- or laser-assisted liposuction can also burn the skin or damage the tissue under the skin.

Ultrasound-assisted liposuction (UAL)

With ultrasound-assisted liposuction, the doctor uses a cannula that produces ultrasonic (high-frequency sound) energy. The cannula is inserted into the fat through a tiny incision and then selectively destroys fat cells. The ultrasonic vibrations disrupt the fat cell membranes and liquefy the fat tissue, making its subsequent removal easier and quicker.

An ultrasonic cannula can usually move through firm fat tissue more easily than conventional cannulae. This technique allows the doctor to treat areas that have more dense fat deposits and to remove larger volumes of fat at one time. The tissue-selective ultrasound energy means only unwanted fat is targeted, preserving surrounding blood vessels, nerves and connecting tissue and promoting smoother contours with faster healing time. Ultrasonic liposuction can have the added advantage of tightening the skin during the process.

Power-assisted liposuction (PAL)

A cannula with a tip that mechanically vibrates in a back and forth motion breaks up fat cells with reduced effort for the doctor. According to professionals, each pass of the cannula achieves the equivalent of 40 or more passes with a traditional liposuction cannula, allowing the doctor to perform the procedure in a smaller amount of time.

Laser-assisted liposuction

Targeted laser energy acts to melt fat, coagulate blood vessels (to reduce bleeding and bruising) and simultaneously tighten overlying skin. The cannula used in laser-assisted liposuction is usually only 1 to 2mm in diameter, which further reduces bruising and healing time. Sometimes the energy is limited, so the procedure can take longer to perform. For this reason, some doctors believe it is better suited to smaller areas of the body, such as the neck, inside thighs and for ‘touch up’ body contouring.

Water-assisted liposuction (WAL)

During water-assisted liposuction, a thin fan-shaped water beam is used to loosen the structure of the fat tissue for easier suctioning and removal. The jet has an impact power comparable to a powerful showerhead and is associated with less risk of shearing and trauma to the adjacent tissues.

During the procedure the water is continually added and almost immediately aspirated through the same cannula. WAL requires less infiltration solution and therefore produces less swelling. The movement of the cannula, aided by the water beam, is gentler and causes less trauma to the surrounding tissues, reducing the amount of bruising post-operatively. This method is particularly useful for larger volume liposuction procedures.

There is not a consensus among doctors as to which technique is superior. There may be slightly less blood loss and a greater ability to remove fat in difficult areas with, for example, ultrasound-assisted liposuction but it can be associated with greater complications than the traditional suction-assisted liposuction. Because there are only small differences between the procedures, the technique that the doctor is most skilled in will cause the least complications.

See also non-surgical body contouring.