Liposuction is defined as the removal of fat from deposits beneath the skin using a hollow stainless steel tube (called a cannula) with the assistance of a powerful vacuum. Previously general anesthesia or IV sedation has been used, but today most professionals use local anesthesia (see below) allowing patients to be awake and comfortable during the procedure.
Tumescent liposuction refers to a technique that uses large volumes of very dilute local anesthesia that is injected into the fat causing the targeted areas to become tumescent, or swollen and firm. Local anesthesia is widely regarded as the safest form of anesthesia. Because local anesthesia persists for many hours there is not a need for narcotic pain medications after surgery.
The “Art of Liposuction”
Liposuction is a medium of artistic expression that displays itself in (1) a practical application of scientific knowledge, (2) the production of what is beautiful, (3) a perfection of workmanship, (4) a perpetual quest for improvement in technique, and (5) a skill attained through clinical experience, and above all (6) making people feel happy about what they see in the mirror.
Risks of Liposuction
Risks of Liposuction must be well understood by all prospective liposuction patients. In order to minimize the risk of liposuction, the patient must be aware of the following facts:
- Too much liposuction is an excessive volume of aspirated fat, or an excessive number of areas treated. Excessive surgical trauma (excessive liposuction) is dangerous and is an important cause for serious liposuction complications.
- Disfiguring skin irregularities and depressions are frequently the result of the surgeon’s inattention to detail. A liposuction cannula is a stainless steel tube inserted through an incision in the skin that is employed to suction the fat. The size of the liposuction cannula can influence the smoothness of the skin after liposuction. The use of large cannulas tend to create irregularities more commonly than microcannulas.
Tumescent Technique is Safest
The tumescent technique for liposuction is unquestionably the safest form of liposuction. There have been no reported deaths associated with tumescent liposuction totally by local anesthesia. Even when general anesthesia is combined with the tumescent technique, liposuction is quite safe provided the volume of fat removed and the number of areas treated during a single surgery is not excessive. The dilute epinephrine contained in the tumescent anesthetic solution profoundly shrinks capillaries and thus virtually eliminates surgical blood loss.
Smoother Cosmetic Results
The tumescent technique permits the use of microcannulas which in turn yields smoother cosmetic results. Traditional liposuction cannulas (stainless steel tubes) have a relatively large diameter and remove fat rather quickly. However, with the use of large cannulas there is an increased risk of irregularities and depressions in the skin. Microcannulas allow fat to be removed in a smoother and more uniform fashion. Some surgeons prefer larger cannulas because it allows liposuction to be done more quickly.
After tumescent liposuction, there is a certain amount of blood-tinged local anesthetic solution that remains under the skin. This excess fluid is either slowly absorbed over several weeks into the blood stream, or it can be rapidly removed by drainage through skin incisions and absorbed by special absorptive pads. Rapid drainage of blood-tinged anesthetic solution out of incision sites, accelerates the rate of healing, and reduces post-operative pain swelling, and bruising. Post-liposuction drainage of blood-tinged anesthetic solution can be maximized by leaving incision sites open and not closed with sutures, using pads on the skin to absorb the drainage, and wearing compression garments to encourage drainage.
Liposuction of the Abdomen
The abdomen is the most common area of the body to be treated by liposuction among both men and women. Important factors that affect the success of abdominal liposuction include: the amount and location of abdominal fat, history of weight gain and weight loss, history of pregnancy, and the age and the sex of the patient.
A previous pregnancy tends to stretch the abdominal muscles, and cause the lower abdomen to bulge to a certain degree. This curvature of the abdominal wall muscles determines the flatness or the shape of the abdominal silhouette after liposuction. Nevertheless, the vast majority of women who have been pregnant are ultimately very happy with results obtained by liposuction alone, and do not require an abdominoplasty (tummy tuck).
Location of Abdominal Fat
Location of abdominal fat is an important factor in predicting the success of abdominal liposuction. Abdominal fat occurs in two different levels: superficial and deep. Superficial abdominal fat is located just below the skin and above the abdominal muscles. The deep abdominal fat is located inside the abdominal cavity on the intestines. Some people have more deep (intestinal) fat than subcutaneous fat. Subcutaneous fat can be removed by liposuction. Intestinal fat cannot be removed by liposuction because it would be too dangerous. Fat on the intestines can only be diminished by weight loss through diet and exercise. Thus liposuction cannot remove all of the abdominal fat. Most patients have more subcutaneous fat than intestinal fat. Thus, most patients will see a good cosmetic improvement with abdominal liposuction.
This is defined and determined by the degree of a patient’s happiness with the results. Ultimately the patient’s opinion of the cosmetic results depends on multiple factors, including 1) the patient’s expectations, 2) the patient’s preoperative cosmetic deficiencies, and 3) the surgeon’s technical skills and technique. The results are never completely predictable.
Age of the patient is not an important factor in the success of liposuction. Some of the happiest patients are women who are more than 60 of age. In a healthy older woman, liposuction can improve an obese abdomen with little risk or discomfort.
Female patients have softer and less fibrous fat than men, and therefore liposuction on a woman is easier to perform.
Upper abdomen skin may appear slightly wrinkled after liposuction. In older patients with decreased skin elasticity of the upper abdomen, there is a tendency for the skin to appear somewhat crêpé or slightly wrinkled. Interestingly, the lower abdominal skin does not seem to be susceptible to this type of post-liposuction crêpiness. The elasticity of Scarpa’s fascia might prevent crêpiness after liposuction of the lower abdomen.
The Old-Fashioned Tummy-Tuck
Tumescent liposuction of the abdomen is so effective that few patients require a tummy-tuck, also known as an abdominoplasty. Patients who are obese and have a pendulous lower abdomen, often find that tumescent liposuction will give a better cosmetic result than a tummy-tuck.
The traditional tummy-tuck involves several surgical steps. First, the subcutaneous fat is removed by liposuction or excision with a scalpel; next, the surgeon excises a large piece of skin from the lower abdomen just above the pubic area; then, the abdominal muscles are tightened using sutures; and finally, the large wound where the skin was excised is closed with staples or sutures.
If a patient decides that a tummy-tuck is needed, it is usually much safer to separate the traditional tummy-tuck into two separate surgical procedures. Abdominal liposuction should be the done initially. Then, one should wait a couple months and evaluate the cosmetic results of liposuction before deciding to proceed to the skin-excision part of the tummy-tuck. The surprising aspect of using this two-stage approach to abdominoplasty is the high degree of satisfaction that patients find from liposuction alone. In fact, the vast majority of patients are so pleased with the results of liposuction alone that they decide not to pursue the second stage skin resection.
Pain after tumescent liposuction of the abdomen typically does not require any pain medications stronger than acetaminophen (Tylenol). The quality of the pain is similar to the muscle soreness and burning experienced after having worked-out too much. The intensity of the pain is similar to that of a sunburn; it is most intense when the skin of the area is flexed or touched, such as getting in and out of a car, or rolling-over in bed, or when sitting still in a chair. There is minimal discomfort when walking or sitting.
With liposuction totally by local anesthesia, patients do not typically need any pain medication immediately after abdominal liposuction because the tumescent local anesthesia last for up to 18 hours. From 36 to 72 hours after surgery, patients experience the greatest degree of soreness and discomfort, but rarely need anything more than acetaminophen (Tylenol).
The use of smaller liposuction cannulas (microcannulas) requires a little more time to complete the surgery, but they are associated with less postoperative soreness, and allow smoother results. Because the incisions are smaller, they do not need to be closed by sutures; the open incisions allow more drainage of the blood-tinged tumescent fluid. When incisions are closed with sutures this fluid is trapped under the skin and causes prolonged swelling, and increased pain and soreness.
Swelling and Soreness
The day after surgery, as a result of open-drainage (incisions are not closed with sutures) of the blood-tinged anesthetic fluid and wearing a compression garment, the degree of cosmetic improvement is easily visible and quite dramatic. Over the next several days, after the drainage has ceased, and as the inflammatory healing process progresses, there is a gradual onset of swelling which decreases over the following four to 12 weeks. This subcutaneous abdominal swelling can reduce the ease with which the patient bends forward. For example, tying ones shoes becomes a minor challenge. The edema that occurs after liposuction of the abdomen typically takes longer to resolve than edema in other treated areas. A certain degree of swelling, firmness and lumpiness is normal for the first four to 12 weeks. This firmness of the abdominal skin and subcutaneous tissue gradually decrease over 3 to 4 months after surgery.
Activity and Bathing
There is no restriction on postoperative physical activity. Patients are advised not to remain in bed, but rather to walk about inside their home or leave their home for a short walk on the evening of the surgery. The patient is expected to shower at least once or twice daily beginning the morning after the day of surgery. Hot baths or jacuzzis are postponed for a week.
Pitfalls of Abdominal Liposuction
Risk Factors – Prior to deciding to do liposuction, the patient is evaluated by the surgeon to determine if there are any health problems that might increase the risk of surgical complications.
Abdominal Hernia – An abdominal hernia (muscle separation) near the bellybutton increases the risk of accidental penetration into the abdominal cavity by the liposuction cannula. To eliminate this increased risk, an abdominal hernia can be repaired by a general surgeon several weeks before abdominal liposuction. Typically an abdominal hernia repair is a simple procedure which can often be accomplished under local anesthesia.
Prior Abdominal Liposuction – Prior abdominal liposuction often causes a certain degree of scaring or fibrosis within the remaining subcutaneous fat. Doing liposuction a second time will be more difficult because of this excessive fibrosis.
Abdominal Cavity – The risk of a liposuction cannula accidentally penetrating the abdominal cavity and causing an intestinal injury is very small. If a liposuction cannula causes a bowel perforation, the patient will feel abdominal pain. If this unlikely event were to occur, a general surgeon will evaluate the patient and decide the best course of treatment.
Excessive Compression – Excessive compression after an abdominal liposuction can impair breathing by limiting the expansion of the lungs. Adjustable compression garments are recommended.
Excessive Fat Removal – Excessive fat removal from the abdomen is not advised. The goal is not to remove as much fat as possible, but rather to produce a result that is a cosmetic improvement and appears natural.
Other risk factors that may affect the relative safety and ultimate cosmetic results of abdominal liposuction include: prior abdominal surgery, laparoscopic procedures, and radiation therapy in the abdominal area.
Additional information can be found at www.liposuction.com