Procedures - Liposuction

Liposuction/liposculpture terminology has become somewhat confusing over the past years since several advances have been made. Traditional liposuction consisted of a cannula that is connected to a vacumm pump that then aspirates fat cell out of the body. These fat cells are then collected in containers and disposed. Today although the principals of liposuction have not changed some tools available to the surgeon have. It is these tools that have added confusion to the public perception. A number of new techniques, including ultrasound-assisted lipoplasty (UAL), the tumescent technique, and the power assisted liposuctions, are a few of the terms being used. To explain in greater detail, liposuction techniques will depend on three variables: the type of anesthesia, the amount of 'tumescent fluid' used, and the type of cannula used. The type of anesthesia is local, Local with IV sedation, Regional (used during childbirth) and General. The amount of tumescent fluid is discussed in Fluid injection liposuction. However, the size, type and style of cannula used is the area that will also determine what method of liposuction you will have. Whether a surgeon uses standard liposuction (traditional cannulas), power-assisted liposuctions (oscilating cannulas), or ultrasound-assisted liposuctions (ultra-sonic cannula) makes no difference - these are merely the tools. Many will claim less swelling or bruising with the various cannulas but I have not noticed this to be true. The results are the same with any of the cannula choices.

Fluid Injection Liposuctions.

In the past when liposuction was first invented, the extraction of fat was done without any fluid placed in the body. This limited the amount of fat that could be removed since there was bleeding and it created a tremendous amount of bruising, swelling and pain. Later as the procedure evolved, a physician by the name of Klein developed a solution that contained a mixture of intravenous salt solution, an anesthetic (Lidocaine), and more importantly a vasoconstrictor (Epinephrine), which limited the amount of bleeding during the procedure. Now, greater amounts of fat could be removed very safely with very little bleeding, bruising and pain. The formula was known as Klein's formula but the fluid came to be known as 'tumescent fluid'. This medicated solution is injected into fatty areas before the fat is removed. Regardless of the type of anesthesia used (local, IV sedation, Regional, or General) this fluid is almost universally injected into the tissues since it helps in facilitating fat removal provides anesthesia during and after surgery and cuts down on the swelling, bleeding, bruising, improving the postoperative recovery period.

The amount of fluid injected will determine the type of technique used. The words tumescent, wet and super-wet techniques refer to the amount of fluid used during the liposuction. If the amount of fluid injected is less than the amount of fat to be removed then it is called the 'wet technique. If the amount of fluid injected equals the amount of fat to be removed it is called 'super-wet'. If the amount of fluid injected is twice or more than the amount of fat to be removed, then it is called tumescent liposuction. Don't let the word tumescent through you off, 'tumescent fluid' is the fluid that is injected in all techniques (wet, super-wet and tumescent). However 'tumescent technique' refers to the swollen and firm or "tumesced" state of the fatty tissuees when they are filled with solution. In this technique large volumes of fluid are placed obviating the need for general anesthesia and therefore can be performed under local only. The "super-wet" technique is similar to the tumescent technique, except that lesser amounts of fluid are used. This technique often requires IV sedation or general anesthesia and typically takes one to two hours of surgery time.

Whatever the amount of fluid used, some of it will be suctioned out during surgery, but the rest will ooze out from the incision sites over the next 24 hours. This is somewhat messy, but it is normal, so we recommend placing towels in the car of the person who is taking you home, place towels on the floor of the house and on the bed. Also wear something you don't mind getting dirty after surgery.

Ultrasonic-Assisted Liposuctions (UAL).

The ultrasound-assisted liposuction (UAL) was invented in Europe by an Italian surgeon with a doctoral degree in acoustical physics-- the study of sound energy. Dr. Michele Zocchi invented a technique whereby a sound wave generator is attached to a sterile hand piece with a titanium rod which vibrates at a very high but slightly audible pitch. This sound wave delivers energy to the fat tissue just beyond the end of the probe so that the fat is liquefied, making it easier to remove.

In fact, the fat is so liquefied that only low-pressure suction is required to remove it. Where the traditional lipoplasty machine removed the fat quite roughly and traumatized the fat and adjacent tissue rather severely, UAL is a gentler procedure, for the surgeon and the patient. Because the machine breaks up the fat, areas which had been poorly responsive to the older technique are more effectively treated. Some examples are the "love-handles" and abnormally large breasts on men and the back area around the shoulder blades on both sexes.

Another advantage of the UAL is that the less-traumatic technique allows removal of larger volumes of fat with a lower percentage of blood in the material removed. We have been commonly removing twice the total volumes we were previously able to do.

A few disadvantages need to be noted. The incisions are slightly larger than for a traditional lipoplasty, usually requiring two stitches, instead of one. More incisions may be necessary, since the ultrasonic cannulas are straight and cannot be made to go around curves. Some increase in expense is incurred, since the UAL machine costs much more than a pure suction pump, and the procedure takes slightly longer.

Power-Assisted Liposuctions (PAL).

Power-Assisted Liposuction (PAL) is a relatively new technique, approved for general use by the FDA in December 1998. PAL utilizes a motorized liposuction cannula that oscillates and reciprocates (moves back and forth) a few millimeters at 3 - 8,000 times per minute. The vibrations allow the cannula to penetrate the tissue and greatly reduce the physical exertion by the physician. Some patients liken the sensations of the vibrating cannula to that of a gentle massage.

The power-assisted method appears to enhance and improve the thoroughness of the removal of the fatty tissue. It is always used in conjunction with tumescent liposuction and facilitates removal of fat especially in fibrous (tough) areas, such as the upper abdomen, love handles, back and breasts. The power-assisted method has utility in most other body areas as well.

Power assisted liposuction has several advantages over ultrasonic assisted liposuction: the power assisted liposuction cannula is smaller (microcannula), resulting in smaller scars: there is no potential for burns with the power assisted liposuction; operation takes less time with power assisted liposuction, therefore is safer for patients; and the operation can cause less bruising, swelling and discomfort. Also with PAL there is less fatigue for the surgeon, allowing him to be more precise and focusing his attention to the sculpting aspect of the procedure.

If you're considering liposuction...

The concept of suction lipolysis, more commonly known as liposuction, liposculpture, lipoplasty or suction lipectomy, originated in Europe in the late 1970's. Liposuction is a procedure that can help sculpt the body by removing unwanted fat from specific areas. The most frequently treated areas in women include the waistline, abdomen, outer thighs, inner thighs, buttocks, knees, ankles, and neckline. In men, the most commonly treated areas are the love handles, breasts, abdomen, and neckline.

The procedure is based upon the removal of fat through a closed system suction cannula apparatus. (A cannula is a thin, metal tube). This procedure utilizes tiny, hidden incisions for introduction of the cannula, and is controlled by the operator via direct observation and palpation. Since no skin is removed, the skin must shrink by means of its intrinsic elastic properties. Because the body no longer produces new fat cells after adolescence, fat removal is permanent for most.

"Localized Fat Deposits (LFD's)," also called "blocked fat," are physiologically different from the fat immediately beneath the skin. Their location is determined by the genetic background, ethnicity, and gender of the patient. The most distressing characteristic of this deep fat is its resistance to loss via dieting. (Patients normally lose only one pound of blocked fat for every six pounds of superficial fat lost during normal dieting). While this is a minor consideration for patients who are clinically obese, many people who are close to their ideal weight can be plagued with unsightly areas, which do not respond to either diet or exercise. LFD's are very effectively treated with suction lipectomy (liposculpture).

Am I a candidate for liposuction?

In most cases of young healthy patients with excellent skin tone and much localized areas of fat deposits, skin re-draping is almost always excellent. The skin has an amazing property of being able to retract and shrink down to its new position without creating any overhang in your skin. The analogy is much like when you are 10-20 pounds overweight and you embark on a weight loss program. When you reach your final goal you are usually not left with loose skin that overhangs but rather a slimmer, trimmer you with perhaps more body definition.

However, if you are overweight by 60 or 70 pounds, you are older, or you already have loose skin, then, when you loose the weight, you may see some changes to the skin that indeed would leave some overhang and skin irregularities. This would also be true with liposuction.

These of course are generalities and like everything in life there are exceptions. Much of your particular case will depend on your skin type, if you have fluffy, loose skin to begin with and perhaps you have stretch marks then this is the type of skin that has lost its elastic properties and will not retract as well as we would like. These cases are usually patients that have had children or have been through extreme changes in body weight either by weight loss or weight gain. In these cases it is best to combine liposuction with some sort of skin reducing procedure. This is the why your consultation will be crucial. You may believe you want liposuction in the abdominal area, but you may learn that an abdominoplasty, or tummy tuck, may meet your goals more effectively.

Preparing for your surgery.

Every plastic surgeon has his/her own ritual and guidelines, in our practice we have found it helpful to perform the following things:

1. Prior to surgery there are certain medicines you want to avoid, such as, Vitamin E, aspirin or aspirin products. These may increase the chances of bleeding during surgery. After your consultation with Dr. Mendieta you will receive an extensive list of other medication to avoid.

2. Smoking causes spasms of the blood vessels and also creates poor oxygenation to the tissues. This increases the chances of complications, therefore, if you smoke, plan to quit at least one to two weeks before your surgery and don't resume for at least two weeks after your surgery.

3. You will need a body garment after the surgery, which is to be worn for 4 weeks. This helps in reducing swelling.

4. The first 24 hours are somewhat messy since most of the fluid that was used in the tumescent technique may ooze out. This is completely normal and to be expected. You will need to place towels in the car for your way home, towels on the bed and floor so that the fluid is collected. This only goes on for 24-48 hours. This fluid tends to be red in color so don't be alarmed.

5. Starting a mild exercise program before the surgery may be helpful especially if you are overweight. This does not have to be elaborate; it can be just walking around the block several times.

6. The most dreaded complication is a pulmonary embolism, which is a blood clot in the lower legs. We can try and prevent them with the use of antiembolic stockings during surgery. After surgery it is important that you move the lower legs as much as possible to avoid the formation of clots.

7. Whether your surgery is done as an outpatient or inpatient basis, you should arrange for someone to drive you home after your surgery and to help you for a day or two.

8. If you are very overweight and a great deal of liposuction is being performed, sometimes it is best to donate your own blood before surgery, in case a blood transfusion is needed after the surgery. This is more for cases in which 8-10 liters are to be removed.

9. After your surgery something that has been tremendously helpful and has increased the quality of our results has been Endermologie treatment. This is a specialized massage that is given with a machine and it helps in reducing the swelling, redistributing the fat and further contouring the body. It helps a great deal with the recuperation time and also further enhances the results. It is worth the extra cost.

Where your surgery will be performed.

Much has been written and talked about in the news regarding liposuction. However, liposuction can be performed very safely as long as certain parameters are adhered to. The majority of patients seeking liposuction are young and in good health requiring only the removal of localized fat deposits. The amount of fat to be removed is usually less than 4 liters of fat. In these patients, liposuction is extremely safe, and can be done in an outpatient basis. The procedure can be performed in an office facility, a freestanding surgery center, or a hospital outpatient facility. Occasionally, the surgery may be done as an inpatient in a hospital, in which case you can plan on staying for a day or two.

Our guidelines for safety are based on your medical condition, weight status and the amount of fat to be removed:

• If you are healthy and we expect to remove 4,000 cc's of fat or less, then, it is done in our surgical center.
• If we expect to remove between 4,000 and 7,000 cc's of fat it needs to be done in the hospital with an overnight stay. This will allow us to monitor you better and replace fluids adequately.
• If we expect to remove more than 7,000 cc's of fat (this can be done quite safely) but several things need to be done:
  • It will be done in a hospital setting.
  • You will need 2 or 3 nights in the hospital - this will allow us to monitor your fluid status and to check blood levels after surgery. Many times when such a large amount is removed the recuperation period, will be much quicker if we maintain blood levels high. This is why, when we expect to remove more than 8 liters.
  • We would encourage you to donate your own blood. This way it can be given back to you after surgery. If you are not able to donate your own blood, then it may require a blood transfusion from the blood bank. (This is especially true for cases that are over 10 liters of fat removal.) Nowadays blood transfusions are extremely safe given today's technology.

In terms of your weight:

Body Mass index is a number that is determined by your height and your current weight and it is compared to the weight that you should be at. This number allows us to assess how much over your ideal body weight you may be and consequently, assess your risk factor for many medical conditions that overweight patients can develop.

• If you are in good health and your Body Mass index is below 30, then the operation can be safely performed in our surgical center as an outpatient basis. However,
• If you are over 30% of your ideal body weight or your Body Mass Index is greater than 31, then it needs to be done in the hospital. The reason is because you will require at least one or two night stay - over in a hospital.

To see where you fall and see what your Body Mass index is please visit our Body Mass Index page.

Types of anesthesia.

This procedure can be done with local anesthesia, Local with IV sedation and regional anesthesia ( like what is used during childbirth) or general anesthesia.

Your surgery.

Liposuction has become somewhat confusing to the general public since so many different words are being used. Before we begin lets clarify a few things. Liposuction and liposculpture is the same thing. The variables that will exist during the procedure are three. The type of anesthesia, the amount of tumescent fluid, used, and the type of cannula used. The anesthesia can be with local only (using tumescent fluid only), Local with IV Sedation ( involves tumescent fluid plus medicines given intravenously so that you don't remember anything), regional ( like that given with childbirth) or general. Any of these types of anesthesia will almost always involve the placement of tumescent fluid. This fluid contains Lidocaine (an anesthetic) and epinephrine (a blood vessel constrictor). This specialized fluid will cause the fat to be removed more easily, reduces blood loss and provides anesthesia during and after surgery. It is for this reason that tumescent fluid has become standard no matter what anesthesia is being used.

The surgery involves placing several small strategically hidden incisions. Through these incisions the tumescent fluid is injected. The amount of fluid injected will determine which technique is used: Wet, Super-wet, or tumescent, see fluid injection liposuctions. After fluid placement, using specialized cannulas liposuction is begun. The size, the type and style of cannula used will depend on the surgeon's preference. This is the area that will also determine what method of liposuction you will have. Whether a surgeon uses standard liposuction (traditional cannulas), power-assisted liposuctions (oscilating cannulas), or ultrasound-assisted liposuctions (ultra-sonic cannula) makes no difference - these are merely the tools. Many will claim less swelling or bruising with the various cannulas but I have not noticed this to be true. The results are the same with any of the cannula choices. The fat is extracted and the principal is much like a vacuum cleaner of fat. The fat is collected in containers and disposed of. The time and cost required to perform liposuction will depend on the size of the area, the amount of fat being removed, the type of anesthesia and the technique used.

What to expect, getting back to normal.

When liposuction is performed a special fluid is used called Tumescent fluid. This fluid is crucial in providing anesthesia, cutting down on the bruising, and bleeding Although most of it will be suctioned out during surgery, some will ooze from the incision sites over the next 24 hours. This is somewhat messy, but it is normal, we recommend to place towels in the car for whoever is taking you home, place towels on the floor of the house and on the bed. Also wear something you don't mind getting dirty after surgery. The color of this fluid will be pink or red, do not worry you are not bleeding, this is normal oozing and it will stop after 24-48 hours.

You will need to wear a snug body garment for 4-6 weeks; this will help in decreasing the swelling and will also help with skin retraction. The bruising will last for 3-4 weeks, you can return to work in 5-7 days; however some patients have recuperated so well that they have been able to return after three days. We recommend taking a week off and don't expect to feel completely normal for about a month. At first, your old clothes will not fit since you are swollen, the swelling will begin to decrease after two weeks, and at this time you may begin to see some changes In your body. The greatest improvement is seen at one month, but you will continue to see refinements and improvements for the next 3-6 months. Returning to the gym will be anywhere from 3-4 weeks. We don't recommend for you to wear any tight clothes or underwear for at least 3-4 weeks. Your garment and loose clothes will be your best friend for the weeks to come.

Something that may greatly improve your post-operative recovery is "endermology". A series of specialized massages that are done with a machine that help in the lymphatic drainage and smoothing out the results of your liposuction. Not all plastic surgeons may agree with this but we have found it makes a big difference in our practice.

Your new look.

You will see a noticeable difference in the shape of your body quite soon after surgery. For the first two weeks don't be surprised if your clothes don't fit you. Even though we have removed the unwanted fat, and your body looks thinner, you are swollen. After two weeks this swelling begins to come down and you will feel more yourself. However, it will take a month before you are back to normal. Improvement will become even more apparent after about four to six weeks, when most of the swelling has subsided. After about three months, any persistent mild swelling usually disappears and the final contour will be visible.

If your expectations are realistic, you will probably be very pleased with the results of your surgery. You may find that you are more comfortable in a wide variety of clothes and more at ease with your body. And, by eating a healthy diet and getting regular exercise, you can help to maintain your new shape.

All liposuction surgeries carry some uncertainty and risk.

We pride our selves in our patient care, and safety is our primary concern. For further information on our safety guidelines please read our frequently asked liposuction questions page.

Liposuction is perhaps one of the most abused procedures by non-trained physicians. It is in this arena that you will find many doctors that have taken a weekend course and are not trained in the procedure attempting the technique. It is therefore crucial that you seek a surgeon who is well qualified and Board Certified by the American Board of Plastic surgery, or has extensive training in liposuction. However, it's important to keep in mind that even though a well-trained surgeon and a state-of-the art facility can improve your chance of having a good result, there are no guarantees. Liposuction is usually performed in very young and healthy patients therefore it is very safe, however, like anything in life even though precautions are taken and safety measures instituted, though they are rare, complications can and do occur. Special care has to be taken whenever more than 5 liters of fat are to be removed and multiple areas or procedures are being performed. The complications are the following:

1. Skin sensory changes: Numbness is normal. These sensation changes are because the nerves are regenerating and it may take up to six months to go away. Very rarely will it take longer than six months, but if it does it can take up to one year. The number of patients that have had permanent sensory changes is extremely rare. Certain exercises that may help with the hypersensitivity changes are what we call "desensitization technique". The theory is that we need to over stimulate the body so that the body gets accustomed to the normal touch. Therefore you need to use a variety of materials, i.e. cotton balls, t-shirts, towels, napkins, the hand and constantly touch the body with these materials. You will notice that after some time these things will not bother you and the sensation improves. Other medicines that may help are Vitamin B6, B12, Niacin, but consult with your physician.

2. Hyper or Hypo-Pigmentation: Immediately after your liposuction you will have bruising and this will last for 4-5 weeks. The bruising can be improved with the use of Arnica creams and pills. You need to take this immediately after your surgery and continued for 3-4 weeks. (Consult your physician before using). If you have very pale skin this can last for up to 6 weeks. However after two months if your skin has persistent discoloration then this could be what we call hyper-pigmentation. This is the darkening of the skin and this occurs most often in Hispanics, Afro-Americans and patients with olive colored skin. Although it may occur in very pale patients. This is essentially a result from the skin retracting and taking on a darker color. This discoloration may improve but it will take up to one year. There are a few things that can be done to help the recovery.

• The use of Retin-A cream applied once daily coupled with
• A hydroquinone, which is a lightening cream, used twice daily.
• Also the use of low level glycolic peels in a repeated fashion.
• Sometimes you can combine Kojic acid with the above regimen. All these are prescription medicines and would need to be followed by a MD. Not all physicians may agree with the above but these have been helpful in our practice.

3. Skin Irregularities or waviness: The skin has an amazing way of redistributing itself, and especially in the beginning because of all the swelling it will difficult to see your final result. Things that may help in speeding up your recovery are Massage therapy, Ultrasound therapy, and Endermology. Endermology which is a special machine that gives massages, we have found to be a tremendous help in reducing the swelling and speeding up recovery. Not all physicians believe in this, but it has helped in our practice. If skin dimpling or bagginess develops it can be permanent, this occurs more in poor quality skin like patients with stretch marks or cellulite. In these cases it may require fat transfer to the affected area or a tummy tuck to correct the problem.

4. Asymmetry of the body, (one side different than the other): This is a very common complaint; in actuality everyone has one side of the body that is very different than the other. We just don't notice it anymore because we have been looking at our bodies for so long that we no longer see the difference. If you ask to see you?re before pictures you will start to see the differences that you did not see before. Also in the beginning because both sides of the body heal at different rates, there is almost always more swelling on one side than the other and we just need to give it time to heal. Liposuction results take at least 6 months to be finalized.

5. Infections: This is very rare but if it does occur it is usually resolved with oral antibiotics. Very rarely will it be a severe infection that requires IV therapy and hospitalization.

6. Poor Scar Quality: This is rarely an issue since the incisions are very small and well hidden. In some patients they can develop keloid, hypertrophic scars or wide scars. Many times a simple scar revision can improve the scar. (Unless it is a keloid.)

7. Reaction to the lidocaine or epinephrine: This is extremely rare, it could create heart arrhythmias. Lidocaine and epinephrine are the key ingredients in our tumescent fluid. These medicines are crucial in helping with pain control and controlling bleeding during liposuction. It is used cautiously, this medicine can be given in certain doses, if higher doses than recommended are used it can create heart arrhythmias. Careful monitoring of the amount given has to be done. In our office we have chart that does not allow us to go beyond the recommended doses. This becomes an issue when large volume liposuction, greater then 8 liters, is being done.

8. Burning of the skin: This is an issue more with ultrasonic liposuction, since it works on heat principals. This heat can cause a burn to the skin. This is rare but possible

9. Bowel perforation: This also is rare but the cannula could enter the abdominal cavity and perforate the bowel. This is an extremely rare occurrence and is only mentioned for thoroughness.

10. Pneumothorax: this is a perforation of the lung, This is an extremely rare occurrence and is only mentioned for thoroughness.

The following complications are more for large volume liposuction (when removing more than 6-8 liters):

1. Your fluid status needs to be carefully monitored. The reason is because if too much fluid is given then you can develop water in the lungs (Pulmonary edema) or if too little fluid is given then you can have hypo-volemic shock. These complications are very rare but one needs to be attuned to this and monitor fluids carefully. This is why a hospital overnight stay may be required. A foley catheter is usually placed and maintained overnight this is perhaps one of the best ways to monitor your fluid status.

2. Your body temperature fluctuates and may require re-warming. This is best monitored with constant temperature sticker probes. This is especially true after very large volume liposuction - greater than 6 or 7 liters.

3. You may develop anemia requiring blood transfusion. Again this is very unlikely, but there is a higher chance after 7-8 liter removal. If this amount is predicted to be removed you can donate your own blood 10 -14 days before the procedure. If not it can be arranged to have your blood type available in the hospital.

4. Fat embolism is possible but it is extremely rare and not a well understood phenomenon. It is believed by some that this does not actually happen. The theory is that fat cells enter the blood stream and go to the lungs limiting the amount of oxygen in your system. The treatment is supportive care (oxygen) and maybe steroids. This can occur with any amount of liposuction but perhaps is more common with larger than 7 liter removals.

5. Pulmonary embolism is very rare but it is a very concerning issue. This is a blood clot in the lower legs that travels to the lungs and does not allow your blood to receive oxygen. In order to help prevent this, we place pneumatic stocking compressions to allow continuous circulation through your lower legs to help prevent blood from stagnating and forming a blood clot. This is why we encourage our patients to walk after surgery, since this stimulates blood to continuously flow.