Liposuction or Suction Assisted Lipectomy or Lipoplasty (SAL) has rapidly risen from a European novelty in the late 1970s to becoming the most commonly performed procedure by Plastic Surgeons in most parts of the world, such that over 100,000 procedures employing SAL are performed annually in the USA alone. SAL is defined as the removal of adipose tissue (fat) by the use of small cannulas [tubes] connected to a vacuum source. The fat from a given area is permanently removed. It is the gold standard of body contouring operations.
The cuts for inserting the lipo cannulae are only 3 to 4mm in size and are usually kept in concealed areas. But enough number of mini-cuts are needed to ensure that the cannulas can be passed through the tissues in criss-cross fashion to get a uniform result. Although relatively simple in theory, the practice of SAL is quite sophisticated requiring careful patient selection, meticulous technique, precise fluid and electrolyte balance and an understanding of the risks and limits of the technique. Modern SAL achieves a lot but with surprisingly quick recovery and minimal pain.
Who is a candidate? It is clear to me after numerous consultations with patients requesting liposuction that, perhaps not surprisingly, a large number of them are unaware of the indications for this operation. All too often requests for this procedure come from patients who suffer from generalized obesity and are looking for a quick way to solve their weight problem. The question, "Doctor, how many kilos I will lose with this operation?" is met with great disappointment once I have explained that this is not an operation designed for weight loss. Liposuction is not a substitute for a healthy diet. While the foregoing may seem obvious, I mention it because some patients may expect localized fat removal to affect a dramatic weight loss. This is not possible. SAL selectively removes fat only from those areas in which the patient desires reduction, which are generally "problem" areas in the lateral thighs and buttocks in women and the flanks in men.
Fat distribution is determined by two factors, heredity and diet. Heredity determines the number and location of the fat cells, which are fixed and unchanging after puberty. Diet can increase or decrease the amount of fat in each individual cell but will not affect their total number or distribution [except rarely]. So, if you have a familial tendency for big thighs your, strenuous attempts at weight loss will leave you with a thin upper body and larger thighs simply because you have inherited a greater number of stubborn fat cells in your thighs. Since actual fat cells are removed by liposuction, the result is permanent reduction of fat from the treated area. So in the example given above, liposuction would permanently remove the stubborn fat from the thighs. Following SAL, the body will always have less fat in the treated areas. This will allow for a much more even weight loss or gain.
Fat cells in certain areas are called ‘privileged fat’. These cells store fat when food intake is in excess but do not give it away on exercise or dieting. So these areas only enlarge and seldom decrease. Liposuction permanently removes them, dieting does not. Your appearance after SAL is influenced by a number of factors which are different for each patient. The general state of health, overall condition of skin, age, weight, and hormonal influences all make a difference. However it is possible to remove fat deposits under the skin in a wide variety of areas from the chin to the ankles limited only by the surgeon’s knowledge and imagination. Good skin elasticity seen in the younger age groups is a desirable attribute since it makes for a smooth surface contour. Once SAL is carried out, the skin envelope has to shrink to adjust to the new reduced volume of fat and this occurs more quickly and effectively the younger one is. Some patients have lax muscles and loose skin with or without excess fat and they will require additional procedures like abdominoplasty ("tummy tuck") or thigh lifts. Liposuction is of no benefit if there is gross skin excess.
During the first appointment, the patient’s suitability for the procedure is assessed and measurements of height, weight and circumference of areas of concern are taken. A general history is also taken and I usually like to explain in detail about the nature of the surgery and what can reasonably be expected in terms of outcome. It is of vital importance that the patient’s expectations are in line with what the surgeon can deliver. I usually also like to take preoperative photographs so that there is some degree of objectivity when looking at the postoperative results.
Surgery: The operation lasts from 30 minutes to two hours depending on how many areas are treated. Surgery may take longer if the person has particularly tough or fibrous interior which makes extraction of fat more laborious. If only a couple areas are treated on the face and neck, local anesthetic can be given usually with some sedation. Larger areas can be treated under general or regional (spinal/epidural) anesthesia. Fat is suctioned out from the areas in a sequential manner by passing the cannula back and forth. Further refinements are done using still smaller tubes just under the skin in order to encourage skin retraction. For most procedures, a 24-hour stay in hospital is enough and the patients are encouraged to ambulate very early. There are usually no bandages or dressings but a compression garment is worn. A urinary catheter may be placed prior to surgery if larger degrees of aspiration are performed. This is removed at the end.
Post-Surgery: Blood stained fluid may drain out of the puncture holes for 12 to 48 hours. This is the balance from the fluid injected prior to liposuction. Oral tablets given are usually sufficient for pain. All patients are encouraged to take an iron supplement for one month after surgery. A short course of antibiotics is also given. Stitches if any are self-dissolving and the scars are rarely troublesome.
Results: It is important to realize that soon after the surgery, the tissues are swollen and indeed the area may appear larger than before. Even the weight may paradoxically be more! Usually the results become apparent to the tune of 50% by the end of three weeks and 100% by three months. During the first three weeks, the patient will have to wear a support garment which will help to reduce edema (swelling) and restrict bruising of the skin. Minor waving and nodularity improves with time.
Complications: In this area more than any other operation in cosmetic surgery, myths and media mis-information abound. The fact is that liposuction is one of the safest operations. Equally it is also true that it can be a major operation as far as the body is concerned. Some of the liposuction candidates may not be in the best of health on account of some degree of obesity, sedentary habit or other medical factors. In higher risk candidates there may be a higher rate of complications. Unfortunately as this surgery is relatively easier to perform and appears to be a no-brainer, many quacks and less qualified [for aesthetic surgery that is] doctors decide to do the surgery after attending a weekend course or watching a DVD or video on You-tube! Studies have shown that horrendous complications may result if liposuction is performed by incompetent persons. On the whole, a number of studies have shown that serious complications are uncommon with this kind of surgery when performed by qualified individuals. Thus while no surgery can be totally safe, liposuction compares favorably with any cosmetic procedure in terms of outcome.
Although I make every effort to give as smooth and symmetric a result as possible, small differences can occur from side to side. After having spoken to a number of my colleagues, it seems that no one of us is exempt from encountering this occasionally. A minority of patients will need secondary surgery after six months, most frequently to remove additional fat or improve skin retraction.
Refinements: In the 21st century, liposuction has been considerably refined with respect to better understanding, better instruments, finer bore cannulae and the concept of superficial suction to encourage skin retraction. Innovations like Vibro-liposuction and Power assisted liposuction [PAL] as well s Syringe liposuction are all helping us to achieve far superior results in a gentler way. Fat grafting is now more routinely combined with liposuction to take body contouring to the next higher plane of sophistication. We are not only simply removing fat but also adding it to strategic locations to achieve a reshaping and re-balancing. Liposculpture is the new buzz word. A typical example is removing fat from abdomen and hip rolls while adding the same fat to the buttocks in a female. Laser lipolysis and Laser assisted liposuction are in developmental stage and may eventually have a place in the hierarchy of Lipoplasty