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Liposuction (LS) is the removal of fat through a hollow microcannula aided by suction. This procedure was initially introduced in Europe over two decades ago. Since then LS has become the most popular cosmetic procedure performed in the U.S. With the American pension for looking trim, some areas of fat around the upper arms and neck are noted to be resistant to diet and exercise. Other areas such as thighs and buttocks are shaped by heredity which resists all efforts at change. With refinements in technique LS has become an office-based procedure performed under local anesthesia with mild sedation in the majority of cases.

Nevertheless, this is not a minor procedure and has all the risks of major surgery including death. Therefore this procedure requires a well trained team with long term experience to monitor you throughout the procedure as I shall explain. It has been documented that about 50% of these procedures are performed by office-based non-surgeons with as little as a weekend training course in the mechanics of the procedure.

So you must ask if your doctor is experienced and trained in this endeavor before you submit to this operation. A simple “Yes!” will not do. Strict criteria for patient selection and perioperative management have been defined by the American Society of Plastic Surgeons and the American Society for Dermatologic Surgery. But poor patient selection and perfunctory patient monitoring have produced 95 verified fatalities with a mortality rate of 19 per 100,000 lipoplasties, which is 6 times the death rate for elective hernia surgery. So who is the best candidate and what can go wrong.

Informal guidelines for plastic surgeons propose that only healthy individuals who have failed weight control with diet and exercise be selected for ambulatory LS surgery. Body weight is not to exceed 30% above your ideal weight. This is not a treatment for morbid obesity and the majority of patients must have less than 50 lbs. to lose. Patients beyond these criteria have been done successfully under general anesthesia with increased morbidity. You must not have any liver dysfunction or any bleeding tendency. But with the best selection, problems including pulmonary embolism (PE) from fat or blood clots may still occur because the procedure is one of carefully moving the cannula back and forth shearing the fat and small blood vessels into the cannula exposing the larger remaining vessels to floating debris.

This complication is the most common of the known complications noted below in Table 1 comprising about 8% of all complications and 23% of the fatalities. A personal friend and colleague who has been doing this for 20 years reports that since the introduction of intravenous 5% ethyl alcohol a few years ago he has not seen any PE’s. This means that you cannot drive home or you will be DUI when stopped.

Click to see table

The advent of tumescent (wet) anesthesia with very dilute mega-doses of local lidocaine and very dilute epinephrine has been responsible for the movement to the office. Prior to the start of the procedure about 2 to 3 liters of a buffered Saline solution with the diluted lidocaine and epinephrine is introduced with fine needles into the area marked to be suctioned. This should not exceed 5 liters in an ambulatory setting. Although it appears that much fluid is removed with the fat, actually 60% remains behind in swollen cells and is reabsorbed slowly over the next 12 to 16 hours. Therefore intraoperative fluid balance becomes a demanding balancing act where overhydration can cause pulmonary edema (swelling) and underhydration can cause shock.

As these drugs are slowly resorbed it is possible to exceed toxic levels of lidocaine in cases with poor liver function, which can rarely cause cardiac toxicity and heart stoppage resulting in fatality. Body temperature and blood oxygenation must be continually monitored during and after the procedure.

Liposuction today comes in four modes, the standard suction assisted lipoplasty (SAL), the power assisted suction lipoplasty (PAL), the external ultrasound assisted lipoplasty (EUAL) and the internal ultrasound assisted lipoplasty (IUAL). UAL is used in combination with surgery to melt fat deposits and make them easier to remove when they are bound in fibrous tissue as in breast reduction. UAL introduces heat and sometimes unwanted burns when used aggressively. PAL is becoming more common since a reciprocating cannula can remove fat faster in larger amounts with less effort and produce cosmetic results superior to SAL.

The main PAL problems at this moment are increased noise and vibration of the moving tip which may result in an untoward skin or bowel perforation. Blood loss is no longer an issue with an average loss of about 1% of total blood volume. At the completion of the procedure compressive garments are applied to the area without restricting breathing or circulation. These must be worn for 2-3 days to limit bruising and to decrease the hollow space which would otherwise fill with serum causing a known complication, seroma, which would be reduced with needle aspiration postoperatively.

As a rule the larger the volume of fat removed the greater the possibility of redundant skin causing rippling and dimpling. This occurs in about 10% of large volume lipoplasties. In people above age 40, skin contraction may not be sufficient to avoid the need for some redundant skin excision in the future. Many older people who have lived with skin redundancy are nevertheless happy with their new contours without excision. It is smarter to have areas done in small stages than one big operation requiring more time, drugs and anesthesia. The success of your liposuction is only as good as the surgeon holding the cannula so be sure to see his case pictures, the befores and the afters, the good and the ugly.

Best of Luck in Your New Future,

Cerise Richards, M.D.