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Where Is It Done?


Today, body contouring surgery, including liposuction, is done primarily in ambulatory surgery centers and in-office operating suites. My patients have surgery at the Surgery Center of Leawood, an adjoining state-licensed ambulatory surgery center. All members of the American Society of Plastic Surgeons must use accredited facilities. This is an important safety consideration.




Proper anesthesia is vital to patient safety. I prefer a total intravenous anesthetic. This is a form of anesthesia that provides, in my opinion, the ideal balance of patient comfort and safety. Patients are asleep for their surgery and wake up afterward with no recollection of the surgery. This type of general anesthesia differs from traditional general anesthesia in avoiding gas, intubation, paralysis, and mechanical ventilation. I call this type of anesthesia “SAFE” anesthesia. These letters stand for “Spontaneous breathing, Avoid gas, Face up, and Extremities mobile.” (Swanson E. The case against chemoprophylaxis for venous thromboembolism prevention and the rationale for SAFE anesthesia. Plast Reconstr Surg Glob Open 2014;2:e160.)


The surgery takes 1–2 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.


How Do You Know How Much Fat to Remove?


The volume of fat removed is determined not so much by the surgeon as by the patient’s body characteristics and how much extra fat is present to start with. At first, the fat comes out readily, a stream of fat globules coming out the suction tubing that is gratifying to watch and listen to, as the fat globules reverberate down the suction tubing and spill into the canister. Gradually, the fat stream slows to a trickle. Also, the tissue resistance decreases. I keep a hand on the treated area and reassess the change in contour as the fat comes off. An experienced surgeon knows how far to “push the envelope.” This is the art of liposuction. It is important to take off as much excess fat as possible, to produce the best result for the patient, but it is even more important not to overdo the treatment. If the surgeon persists to try to take off another 10% or so, after the fat stream has been reduced to a trickle, this could cause unnecessary tissue trauma, more bruising, and increase the risk of skin irregularities or poor skin contraction. It is far better to avoid such problems, and return for a touch-up if necessary later on.


Most patients, right before surgery, tell me to take as much fat off as possible (“Don’t hold back, doc!”). Nothing personal, but they’d rather not come back for more surgery. Yes, they want it to be safe and all that, but they want as dramatic a result as possible!


I assure my patients that I will take off as much fat as I can without overdoing it and increasing the risk of complications. Patients understand that my job is to push the envelope as much as I can without pushing too far. I tell my patients I will treat them as if they are never coming back. The possibility of doing a touch-up later does not mean I’m going to leave to another time something I could do today.


A garment is worn to help reduce swelling for a period of 1 month. Patients wake up wearing it. This garment is removed for short periods to bathe and shower and may be worn under regular clothing. Bruising usually disappears within 1 month. Most of the swelling (about two-thirds) is gone in a month and patients may then wear shorts or a bathing suit. It takes about 3 months for the swelling to completely disappear.


The volume removed from each area is measured, in ccs. Often there is more fatty tissue on one side than the other so that it is common for volumes to be different from one side to the other. During surgery, I assess how much to remove visually, by looking at the treated area, using my hand to judge the level and pinch-test to assess thickness, feeling the tissue resistance, and by taking into account the volume removed, which the nurse records in real time as the fat is removed.


Liposuction and Anesthesia


Patients are usually aware of the importance of the anesthetic. Liposuction is unlikely to be a life-threatening procedure in itself. However, anesthetic factors such as airway management, fluid administration, and medication effects can be life-threatening. When I discuss complications, it is not unusual for me to discuss many of the details of how the anesthesia works, modifications that make it safer, and how patients are monitored during surgery.


Types of Anesthesia:


Local Anesthesia:


The area is numbed with anesthetic.


Many practitioners, particularly dermatologists, use local anesthesia exclusively. “Local” anesthetic is anesthetic medication that is injected directly into the tissues to numb them. The patient is awake during liposuction under local anesthetic. Advantages to the patient include the avoidance of a deeper level of anesthesia, less cost, and virtually no recovery time. A disadvantage is patient discomfort during longer procedures in which multiple areas are treated.


There was one memorable television report showing a patient casually talking on the telephone while having liposuction, but this is not the typical experience! Patients who have had previous liposuction elsewhere under local anesthetic typically tell me it was not a day at the beach and they welcome a short I.V. anesthetic.


Many surgeons, including myself, use local anesthesia alone only for small liposuction cases, such as a touch-up liposuction to limited areas. Patients tolerate this well and have minimal discomfort, like a trip to the dentist.


Conscious Sedation:


Patients are given intravenous medications to relax them plus local anesthetic. They remain awake during surgery. They may require substantial amounts of medication and can take several hours to fully recover after surgery.


General Endotracheal Anesthesia


The classical general anesthetic calls for a muscle relaxant, intubation, a breathing machine (“ventilator”), and an inhalational anesthetic agent (“gas”). Patients are paralyzed to allow mechanical ventilation, which necessitates an endotracheal tube to secure the airway.


This type of anesthesia certainly provides deep sedation, controlled ventilation, and a motionless patient for the surgeon. This level of anesthesia is necessary for major surgical procedures that require mechanical ventilation such as intra-abdominal surgery or open-heart surgery. But, it is a deeper level of anesthesia than is necessary for plastic surgical procedures, even for an abdominoplasty (tummy tuck).


There are additional risks related to general endotracheal anesthesia. Insertion of the endotracheal tube can occasionally be traumatic to the teeth and vocal cords. Positive pressure ventilation can overventilate patients, affecting their pH balance (respiratory alkalemia), causing secondary hypokalemia, and sometimes causing a pneumothorax. Anesthetic gas can cause nausea, irritate the bronchial linings, and may have a depressant effect on the heart muscle. Muscle relaxants paralyze the calf muscle pump, possibly increasing the risk of blood clots and also reduce the sympathetic tone to the leg veins (possibly setting the stage for blood clots). Though rare, these agents can prolong the recovery time in patients with enzyme deficiency, trigger malignant hyperthermia (a potentially fatal complication), or allow unrecognized awakening in surgery.  This is just a partial list of possible problems.


Total Intravenous Sedation

Dr. Eric Swanson-SAFE anesthesia diagram

“SAFE” Anesthesia: Spontaneous breathing, Avoid gas, Face up, Extremities mobile.



This is the type of anesthesia that I use almost exclusively. The patient is asleep. The medications (propofol and fentanyl) are given intravenously. An LMA™ is used during surgery to maintain the airway. Patients breathe spontaneously. They are not ventilated. They are not paralyzed and gas is not used. Patients are never turned prone (face down) during surgery. I consider this a “goldilocks” anesthetic—not too much (general endotracheal anesthesia) and not too little (local anesthesia or conscious sedation).


The anesthetist administers the medication through the I.V. tubing, and uses an infusion pump to provide a continuous delivery of a short-acting anesthetic called Diprivan (propofol). This “wonder drug” has made traditional general anesthesia unnecessary for many types of surgery, particularly outpatient surgery such as liposuction. Many patients are already familiar with this type of anesthetic, which has been used for years for G.I. procedures, knee arthroscopies and dental procedures.


If Diprivan is a “wonder drug,” the LMA (short for “laryngeal mask airway”) is a “wonder airway”. Designed by a British anesthesiologist about 30 years ago, it provides a reliable airway without the need for intubation. This ingenious but weird-looking device lodges in the back of the throat and protects the airway, without going between the vocal cords. It is unnecessary for the anesthetist to intubate the patient. The LMA eliminates the need to pass a tube between the vocal cords, which can be difficult to do in some patients and occasionally traumatic to the vocal cords. Some patients still need to be intubated, such as those with esophageal regurgitation, but the majority may be safely treated with an LMA.


Once the patient is asleep, I inject dilute local anesthetic solution into all the areas that I plan to treat with liposuction. Why use local anesthetic if the patient is asleep already? There are two reasons:


  • This way the anesthetist can use smaller amounts of propofol. The less anesthetic she gives, the less medication is in the patient’s system, and the faster the patient will wake up after surgery.
  •  The effect of the local anesthetic lasts for 8–10 hours, so there is minimal pain for the first several hours after surgery, making the recovery phase more comfortable, and reducing the need for painkillers after surgery. Less painkillers means less side effects from painkillers, such as nausea, sedation, and constipation.


As a general principle, any opportunity to eliminate a risk factor is worthwhile to keep the odds in favor of patient safety and comfort. This is part of the well-known “KISS” principle (Keep It Simple, Stupid). The incorporation of a technique that has a risk without a necessary benefit should be questioned. Rituals need to be examined. This is not easy for any surgeon who has developed habits.


Fluid Management


Using the tumescent technique, fluids are injected into the tissues before liposuction is performed. The original tumescent technique involved giving  large amounts of fluid, as much as 10 liters, whereas the tissues became tightly distended. The “superwet” 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 a liquid medium to facilitate liposuction, but avoiding overhydration of the patient.


Positioning in Surgery


Prolonged motionlessness can cause problems. Nerves can be damaged by unrelieved pressure. Skin breakdown can occur at pressure points. It is advantageous to move patients during surgery. Our patients start supine on the operating table, but are then moved to one side and then the other when the anesthetic solution is injected. This turning routine is repeated when liposuction is performed. The patient is treated for about 30 minutes in a supine position, followed by 30 minutes on one side, and then 30 minutes on the other side. This ensures that there is no prolonged pressure while the patient is in one position. The intraoperative movement of the lower extremities may also be helpful to avoid blood pooling in the calves (“venous stasis”) which can cause dreaded deep vein blood clots.


Dr. Eric Swanson-Lipo areas-patient lying on side-illustration

Many plastic surgeons place the patient prone on the operating table. This is the anesthetist’s least favorite position for some very good reasons. The airway is more difficult to manage and endotracheal intubation is needed. If the tube comes out, it’s a big problem because the patient is face-down. Pressure on the face is not ideal and can potentially cause problems. Pressure at the hips caused by rolls used to bolster the hips may interfere with venous return from the legs. There is often a period of inactivity, about 20 minutes, in the operating room while the patient is turned from face-up to face-down on the operating table. Often the patient needs to be re-prepped and draped because of loss of sterility.


Prone positioning is unnecessary. Moving the patient from side to side allows full-body access, avoids problems related to prone positioning, avoids a need for intubation, and improves operating time and efficiency by eliminating unnecessary interruptions.


Dr. Eric Swanson-Lipo areas-patient lying on back-illustration



The Incisions


I use as few incisions as possible to access the areas I need to treat. When treating the abdomen and flanks, I use an incision on either side of the pubic area and on each flank (see illustration). These are placed so that they would typically be hidden by a bikini. The access incisions for the thighs are in the groin crease on either side and on the lower buttock. The knee incision is tucked in the crease just below and on the medial (inner) side of the knee. These small scars fade with time and are usually inconspicuous. I do not use incisions placed midway along the arms, thighs, or calves, where they might be visible, or outside the bikini area on the abdomen and hips. The cannulae (long hollow instruments) are long enough to permit such limited incisions and still access all the areas.


Blood Clots (Deep Venous Thromboses)


The development of blood clots in the legs is a major concern. These clots can develop even without surgery. This is why flight attendants have passengers get up and move around on long flights. Inactivity raises the risk of blood pooling in the legs, called “stasis.” If a piece of this blood clot breaks off, it travels to the heart and then to the lungs, where it becomes a pulmonary embolus. This can be a fatal complication. Accordingly, it is important to take steps to minimize the risk of this complication.


Preventive measures include reducing periods of immobilization, such as very long surgery times or bed rest after surgery. It makes sense to avoid muscle relaxation, including the use of paralytic agents that are part of a traditional general anesthetic. Movement of the patient’s legs and position changes during surgery also make sense. Early ambulation is important. Getting up to go to the bathroom after surgery get the legs moving. Outpatient surgery forces the patient to ambulate during the first 24 hours. I usually see patients the day after surgery, so that I am assured they are up and moving. The trip to the doctor’s office helps. The objective is to reduce the risk of blood clots to a level as close as possible to the baseline risk that we have without surgery.


Blood Thinners


Some surgeons have recommended the use of blood thinners such as Heparin or Lovenox. Some newer types are taken by mouth—rivaroxaban (Xarelto) and apixaban (Eliquis). All of these medications can increase the risk of bleeding. It is impossible to accurately predict who will develop a blood clot, even by adding up potential risk factors. It is not clear that the increased risk of bleeding justifies the routine use of these medications (Swanson E. The case against chemoprophylaxis for venous thromboembolism prevention and the rationale for SAFE anesthesia. Plast Reconstr Surg Glob Open 2014;2:e160).


Ultrasound Surveillance


The Swanson Center is presently engaged in a clinical trial to determine the feasibility and effectiveness of using Doppler ultrasound to screen patients before surgery, the day after surgery, and about 1 week after surgery. This highly accurate and noninvasive method can detect small clots before they grow and become dangerous. Early results are promising (Swanson E. Ultrasound screening for deep venous thrombosis detection: Prospective evaluation of 200 plastic surgery outpatients. Plast Reconstr Surg Glob Open 2015;3:e332).


Outpatient Surgery


Improvements in anesthesia have shortened patient recovery times, allowing surgery to be performed safely in an outpatient setting. Benefits include greater convenience, easier scheduling, greater consistency in medical personnel, better cost-containment, and avoidance of hospital-acquired (“nosocomial”) infections. As a safety measure, the American Society of

Plastic Surgeons mandates that its members use only accredited outpatient facilities or licensed ambulatory surgery centers.


Dr. Eric Swanson and patient photo

Waking up in the Recovery Room


Liposuction of the Arms


The arms are a favorable area for liposuction. It is very common for me to treat the arms and armpits (“axillae”) at the same time as liposuction of the lower body. Women often complain about extra “flab” in their arms and will shake this area to demonstrate. They may be embarrassed about it and will avoid wearing sleeveless tops, even during the summer. Most women are understandably concerned about what will happen to the skin after the fat is suctioned. They don’t want to end up with a lot of loose skin hanging down. Often, the skin responds better than expected, even in older patients. The skin tone may be no better, but it is unlikely to be made worse and the removal of the extra fat improves the contour. It is always possible to come back and remove the extra skin (“brachioplasties”) if necessary.


However, I have had plenty of women over 50 with compromised skin tone who have had liposuction, and surprisingly few return for brachioplasties. It is always a plus to avoid a brachioplasty scar because this scar, which goes down the back border of the arm, cannot be completely hidden.


In patients who have lost a great deal of weight and have loose skin hanging to start with, it is better to proceed directly to brachioplasties, which are usually done in combination with liposuction. There is a limit, after all, to skin contraction. The brachioplasty scar is always preferable to loose skin that is sometimes called a “bat wing.”


“Bra Fat” (Axilla) Liposuction


Women often reach around and grab a roll of fat just lateral to their breasts. This is commonly called the “bra fat.” It can bulge around the bra strap, which is not very attractive. Even though this area is actually below the axilla, we refer to it as the “axilla” or sometimes the “scapular” area.


The same armpit incision used to treat the arms may be used for access to the axillary area. There is often a crease between this fat roll and the “love handle.” By treating the extra fat in the roll above and below this crease, the crease may be softened or sometimes eliminated.


Liposuction of the Arms: How It Is Done


An incision is made in the armpit. The area is first injected with anesthetic solution, the same way that liposuction is performed in other areas, using the “superwet” technique. The second step is the introduction of the ultrasonic probe to dissolve fat cells. The third step is removal of the fat using liposuction.


Some surgeons have been reluctant to treat the arms or calves because of concerns about complications. However, if the superwet technique is used, ultrasonic times are kept to a few minutes at the most, incisions are limited, and overtreatment avoided, these become very favorable areas to treat with minimal risk.


It is unusual for me to treat just the arms and axillae. Most women also have areas of the lower body to treat, so these areas are treated at the same time as liposuction of the lower body. The exception is the patient who has liposuction of the lower body and then returns to have the arms done. Of course, ideally these areas are treated in one operation. Because of the difference in fat distribution in men, very few men require liposuction of the arms, although I frequently treat the axillary areas when I perform liposuction on male breasts.




Dr. Eric Swanson-SAFE anesthesia diagram

Dr. Eric Swanson-Lipo areas-patient lying on side-illustration

Dr. Eric Swanson-Lipo areas-patient lying on back-illustration

Dr. Eric Swanson and patient photo