Achieving Ideal Body^® Proportions by Liposuction

Adults have a fixed number of fat cells, and the only way to remove these fat cells is by liposuction. This provides permanent correction of body disproportions. Contrary to rumor, any weight gain after surgery is evenly distributed all over the body - it does not return specifically to the treated areas or accumulate instead in untreated areas.

Liposuction and Body Weight

Patients often remark, "I heard that if you have liposuction on the hips and thighs, when you gain weight you'll gain it in other areas, like your face and your arms." This is not true. Think of it this way: the rest of the body does not know that their fat cell neighbors in the love handles have "left the building." Their size is simply determined by how many calories get delivered to them. They will swell if the body consumes more calories than it burns, or shrink if the body burns more calories than it takes in.

So, how does a rumor like this get started? One possible explanation is that people rely on their clothes as a guide to when to cut back on calories. After liposuction, their clothes fit more loosely because fat cells in these areas have dearly departed. So it is possible that they may gain weight until they fit clothes like they did before. Only now they are fuller in other parts of the body that were not reduced with liposuction, like the face and arms.

These patients see me in follow-up and say: "Doctor, I'm disappointed. I really didn't notice that big of a difference after liposuction." Before any further discussion, these patients are asked to step on the scales. Invariably, they weigh more, sometimes ten pounds more, than they did at the time of liposuction. Of course, they should weigh less, not more, because the fat that was removed at surgery weighed several pounds, and sometimes as much as ten pounds. Patients are often surprised when they learn of this weight gain.V

So the patient has actually gained weight since the surgery and this has compromised their reduction from liposuction. In fact, if they had not had liposuction, they would likely not be able to fit into their pants. Patients ask, how did I gain that weight? Likely they gained weight because they were less active, but continued eating the same way. More calories, less exercise equals weight gain. Plus, their usual "alarm" - fitting clothes - did not alert them to cut back.

Fortunately, the outcome can still be a favorable one. Because the number of fat cells is fixed, there is no permanent harm done by temporary swelling of the fat cells. But, the patient needs to return to full activity and proper diet. When the weight returns to normal (the same as at the time of surgery or less), the patient will better appreciate the results of liposuction. With good behavior, the result just gets better and better.

I usually take photographs at least three months after liposuction. This allows enough time for the swelling to go down fully. Ideally, the patient will weigh the same as what they did on the day of surgery, or even a little less, accounting for the volume of fat removed by liposuction. This is about two pounds per liter. So if a patient had three liters (3000 cc) of fat removed by liposuction, she should weigh six pounds less when the swelling has gone down. Therefore, to appreciate the results of liposuction without any compromise due to postoperative weight gain or loss, this patient should weigh 6 pounds less than on the day of surgery, when the postoperative photographs are taken.

Liposuction and Fat Cell Removal

Another popular misconception surrounding liposuction: "If I gain weight it will just come back and I will have wasted my time and money having liposuction."

Certainly, if any benefit realized by liposuction was lost the next time we put on five pounds, there would be no point in having liposuction in the first place. But, the results are still there at the higher weight. The patient will always fit into her clothes better, regardless of how much she weighs, for the rest of her life because there are fewer fat cells in the treated areas. And when she loses the five pounds, her shape returns to what it was right after liposuction. In fact, it is impossible to lose the benefit of liposuction, even if she wanted to do so, barring extreme weight gain.

Patients sometimes look at me with a degree of skepticism when I explain this, but they need only look at long-term results to see that this is true. They understand the concept once they understand that fat cell numbers are genetically determined and do not change during weight gain or loss. The only way to change fat cell distribution is by physically removing them using liposuction (or adding by fat injection). Liposuction permanently improves body proportions. This capability is the reason liposuction has been the most popular cosmetic operation of the last couple of decades.

Most patients are attentive to diet and exercise after surgery and lose rather than gain weight. By correcting body disproportions, patients experience a psychological benefit, and find that they are better motivated to maintain their improved body form.

Fluid management technique

Using the tumescent technique, fluids are injected into the tissues before liposuction is performed. The original tumescent technique involved giving so much fluid, as much as 10 liters, that the tissues became tightly distended. The "super wet" technique is a modified form of tumescent liposuction, in which fluids are infused in approximately a 1:1 ratio with what is suctioned off by liposuction (the "aspirate"). This represents an ideal relationship between what is infused and what is removed, providing the right liquid medium to facilitate ultrasonic liposuction, but avoiding over- or under-hydration of the patient.

Obese Patients

Although liposuction has been used to treat obesity, it is now recognized that this is not the best application of liposuction. In very obese patients, the volume of fat and fluid removed may be much larger (well over five liters), making fluid management more difficult, and increasing the risk. Furthermore, the difference in body contours is proportionately less, making the procedure less worthwhile. Also, these patients have not developed good eating habits and exercise regimens (obesity speaks for itself) so that they may be more likely to gain weight after surgery, particularly if they are even less active.

Patients with a "beer belly" are the worst candidates for liposuction. These patients have very protuberant abdomens, but there is minimal subcutaneous fat. There is not much surface fat to grab. Almost all the fat is on the inside the abdomen ("intraperitoneal"), wrapped around the organs and therefore inaccessible to liposuction. These patients are understandably disappointed, but are sorted out early in the consultation. They are glad to be told candidly that they are not good candidates so they do not waste their time and money having a procedure that is unlikely to help much. I recommend professional weight loss counseling. Dieting and weight loss is the only way to reduce a "beer belly

History of Liposuction

Advances in liposuction include the evolution of instruments, energy source, wetting solutions used to pre-treat the areas, and anesthesia.

Liposuction (1982)

Instrument: cannula, large bore
Energy: physical
Solution: either none ("dry liposuction) or small volumes
Results: Small volumes of fat removed, spot treatments, irregularities and blood loss.

Liposuction was refined and reintroduced by a French plastic surgeon, Dr. Illouz, in the1970's. Liposuction started off as basically making an incision and suctioning fat. Sounds simple enough, but this was a big advance in body contouring!

Tumescent technique (1990)

Instrument: blunt cannulae, smaller caliber
Energy: Physical
Solutions: Tumescent: saline, lidocaine, epinephrine
Results: Larger volumes of fat removal, multiple areas, smoother borders and less blood loss.

In 1990, an American dermatologist, Dr. Klein, described the tumescent technique. This was a big step forward. The tissues were injected with a large volume of saline solution prior to perfroming liposuction. This saline solution contained epinephrine, to reduce blood loss, and lidocaine, a local anesthetic. The local anesthetic allowed the procedure to be performed using local anesthetic alone, in the doctor's office, making it a tool for non-surgeons.

The fluid injected into the tissues served to hydrate the patient during surgery, so that little or no extra I.V. fluid administration was needed. The infusion of fluid into the tissues filled up the tissues, making them "tumescent." This facilitated liposuction by magnifying the fat layer, helping to make the contours smoother because it was easier for the operator to avoid going too close to the skin or oversuctioning areas, which would cause irregularities.

The epinephrine contained in this fluid greatly reduced blood loss. This enabled the surgeon to treat multiple areas at one time and remove greater quantities of fat. The surgeon was no longer limited to spot treatments. All of the affected areas could be treated simultaneously. Patients could be treated at one setting instead of returning for multiple procedures. The technique had matured and could now deliver worthwhile results for the thousands of people with body contour problems. Its popularity grew and it quickly became the most popular cosmetic operation performed, a distinction it has held for two decades, except for being edged to second place for one year by breast augmentation recently.

Ultrasonic Liposuction (1995)

Instrument: Ultrasonic generator
Energy: Ultrasound, physical
Solutions: Saline, lidocaine, epinephrine
Results: Selective fat cell removal, less tissue trauma, possibly better skin contraction

Ultrasonic liposuction, also called ultrasonic-assisted liposuction, was developed by an Italian plastic surgeon, Dr. Michele Zocchi, in 1988. It was used extensively in Europe and South America for several years, before being introduced in the United States in 1995.

Ultrasonic energy has been used in many areas of medicine since the 1970's. One of its first applications was in eye surgery, to selectively dissolve cataracts. It was subsequently used to remove tumors in neurosurgery. The same principle is applied to fat removal. An ultrasonic probe produces a high frequency sound wave which causes fat cells to dissolve. The technique is used in combination with tumescent ("superwet" really) liposuction. The tissues are first injected with fluid, the ultrasonic probe is introduced to dissolve fat cells and the liquefied fat is then suctioned out.

Ultrasonic liposuction does not replace tumescent liposuction. It adds to the effectiveness of tumescent liposuction, allowing the plastic surgeon to remove large volumes of fat from multiple areas at one setting. It has improved results in fibrous areas that may be difficult to treat with traditional liposuction - the upper abdomen, flanks, back, and male breasts. The fat is liquefied before its removal, so that the resulting contours are smooth. Because ultrasonic energy is used to break up the fat cells, less physical force may be required from the plastic surgeon. It makes sense that the less physical force is used, the better the connective tissue under the skin is preserved, along with nerves and blood vessels. This may mean less bruising of the tissues, less discomfort, and a shorter recovery time. An added advantage of ultrasonic liposuction may be improved skin tone and appearance, due to preservation of the underlying connective tissue and possible collagen stimulation. It is important to recognize that these are theoretical advantages that have not been clinically proven.

Understanding the Different Types of Liposuction Procedures

Patients (and even surgeons!) may be forgiven if they confuse "tumescent", "ultrasonic", "laser", "Vaser^®" and "power-assisted"- all words to describe types of liposuction!

Stated simply, most patients want: the modern, up-to-date kind of liposuction that works better and is kinder than the old-fashioned technique, particularly that technique they saw on television, which showed a surgeon apparently pummeling a patient with a long metal instrument.

With ultrasonic liposuction, the traditional benefits of liposuction remain the same. Usually multiple sites are treated, using small incisions. This allows correction of body contour disproportions.

As discussed above, these disproportions, for example, saddle bags in women and love handles in men, are inherited and are not corrected by diet and exercise alone. In women, the lower body is usually the concern - the abdomen, hips, flanks, buttocks, thighs, and knees. In men, the abdomen, flanks, and breasts tend to be affected. Each of these areas is treated simultaneously, removing more fat where necessary to produce optimal body contours. Other commonly treated areas are the arms, calves, and under the chin ("submental fat").

In the past, surgeons relied on physical energy alone to dislodge fat cells, which were then suctioned away. The surgeon literally pummelled the fat with a blunt instrument ("cannula"). The flimsy fat cells were dislodged from their attachments and suctioned away. This technique was effective, but it was nonselective. Other tissues were traumatized too.

Surgeons prefer selective techniques because there is less "collateral damage" to other tissues. We've seen this principle applied to medical laser treatments which target skin pigments, such as laser treatment of birthmarks or laser hair removal.

In liposuction, a cell type is targeted - the lowly fat cell, which is like a flimsy balloon full of Jell-O. If you expose it to high frequency sound waves, micro-bubbles are generated from pressure changes. This is called "cavitation." The flimsy cell membrane cannot contain these bubbles, and gives way, releasing its liquid fat contents ("emulsification"), which are then suctioned off. But the important tissues are left intact; the nerves, blood vessels, and connective tissue stay behind, like the branches of a tree that has lost its leaves. No question, they have still been traumatized, but not as much as they would have been without the benefit of ultrasound.

Skin Tightening: Another Possible Ultrasonic Energy Advantage

The main component of connective tissue is collagen, the body's most abundant protein. It turns out that if you heat up collagen just the right amount, it contracts. Surgeons see this effect when we use the carbon dioxide laser on facial skin; the skin visibly contracts. It is possible that the same effect is going on under the skin. Surgeons have noticed improved skin contraction after ultrasonic treatment. It is important to note that this effect has not been scientifically validated.

In some patients, I perform ultrasonic liposuction primarily for the skin tightening effect, not so much fat removal. This is the complete opposite of what we used to tell patients - that liposuction helps get rid of fat, but possibly at the expense of loose skin. I've had patients that I have treated and retreated in certain areas to get the maximum benefit from ultrasonic exposure and achieved improved skin tone. There is variability in this effect, depending on the patient. There are limits and in some patients the skin does not seem to respond as well.

Ultrasonic versus non-ultrasonic liposuction

In the past, before I started using ultrasonic assistance, I would be exhausted after a day doing liposuction. Surgeons sometimes called this their "liposuction workout." Not anymore. After pre-treating an area with ultrasound, the "mop up" liposuction is physically much less demanding. Of course, I do not object to a workout if that's going to give my patient the best result, but if it is possible to achieve a better result with less physical trauma to the patient, so much the better! Surgeons do well to remember that the patient on the receiving end. Less trauma to the tissues should mean an easier and less painful recovery. So, fortunately, it is a win-win situation - less trauma, better result. One plastic surgeon is fond of remarking at meetings, "Remember, we enjoy surgery much more than our patients." So anything we can do to lessen the trauma and discomfort is welcome news for our patients. And since I began using ultrasonic liposuction, I have an elliptical machine I use at home for working out instead.

How does ultrasonic technology work?

Ultrasonic waves are produced by transforming electric energy that comes out of the plug in the wall into high-frequency energy, 20,000 cycles per second, which is too high to be perceived by the human ear.

This energy is transmitted to the hand piece, which transforms it into mechanical vibrations. The titanium rod connected to the hand piece actually moves back and forth invisibly at an almost unimaginable 20,000 times a second! This vibration causes little bubbles to form in the fat cells, destabilizing them. The flimsy membranes disintegrate, releasing the liquefied fat. Fortunately, this implosion does not happen in denser tissues types such as connective tissue, nerves, or blood vessels. Some of the energy converts to heat, heating up the tissues in contact with the probe. For this reason, surgeons keep the probe moving when ultrasound is applied; otherwise this heat could build up and cause a burn. Ultrasound is always used in a liquid medium (remember sound travels better in water). This maximizes the effect of ultrasound in dissolving fat cells, and minimizes the risk of overheating the tissues. The incision is protected with a plastic sleeve, so it is not burned. This is why the incision, and resulting scar is made a little longer, to accommodate this plastic protector.

In summary, a two-step process (injection, then suction) becomes a three step process (injection, ultrasound, suction). All of the advantages of the tumescent technique are preserved. Added to these are the advantages of ultrasonic assistance.

Advantages of Ultrasound

Disadvantages of Ultrasound

How do the advantages compare with the disadvantages? Well, expense should not even be on the list. Any surgeon who does any appreciable volume of liposuction can invest in ultrasonic equipment. The added time is insignificant; in fact, the ultrasound treatment makes up the "mop up" liposuction part of the procedure easier, less tiring, and shorter. I find that ultrasonic assistance adds very little time to these procedures. And burns? In over 2,000 cases, I have experienced two small burns (patient C.M. in "Complications" is one), which were easily revised and of no concern to the patients. And, it does not really matter if the incision is eight millimeters long rather than six millimeters long, particularly if they are strategically placed in hidden spots.

However, I caution patients that the tools always take a back seat to the technical prowess of the surgeon. There are skilled surgeons practicing without ultrasound who can achieve excellent results and there are less skilled plastic surgeons using ultrasonic liposuction with mediocre outcomes, due to inexpert technique.

Similar to laser skin resurfacing, the ultrasonic technique was very popular at first. This burst of popularity has been called the "zealot stage." Then there were reports of complications such as burns and fluid collections under the skin (called "seromas"). In most cases, these problems resulted from overtreatment. Burns may be avoided with proper skin protection and by always moving the cannula when in use, similar to ironing clothing. Seromas are very rare after liposuction if areas are not subjected to excessive trauma, and can be avoided almost entirely by using appropriate ultrasound times. It is better to come back another day and retreat an area than overtreat it the first time.

Concerned about complications, some plastic surgeons reverted back to traditional liposuction, without ultrasonic assistance. However, with the prudent use of this tool, limiting ultrasound times to a few minutes per area, and avoidance of overtreatment, the advantages may be realized without additional risks. Moderation is the key. Using the optimal ultrasound times is like using the correct dose of medication.

The Anesthetic

Liposuction is performed in an ambulatory surgery center under an unconscious intravenous anesthetic. The surgery takes one to two hours, depending on the number of areas treated. Patients are asleep for surgery and awaken quickly afterward. Because local anesthetic is also used, patients require less medication and usually recover quickly after surgery, with minimal discomfort. Patients go home the same day. Touchup treatments are done either under a brief intravenous sedation or local anesthetic, if the area to be treated is small. We do have a preference for intravenous sedation because our surgical facility is on-site and this is most comfortable for the patient.