Procedure

Most often in SAL procedures, general anesthesia is used. This is especially suitable and safer for larger procedures because the anesthesia dose is more precise. With general anesthesia, the airway (breathing passage) is well controlled giving a much greater margin of safety. Also, it is impossible to completely numb deeper areas with local anesthesia. In addition, using excessive amount of xylocaine with epinephrine can be dangerous to both young and old patients.

The liposuction procedure involves making one or more small (1/4″) poke wounds in areas like the abdomen, hips or thighs. Occasionally, the neck, arms, chest, calves, back, knees and even the hump on the back of the neck can be treated. In reconstructive surgery, it can be used to thin out the tissue flaps or to thin the breast edges during breast reduction. Through these small incisions, a long metal tube (a cannula), with small holes at one end and connected to one atmosphere of negative pressure at the other end, is inserted. The cannula is repeatedly moved in and out of the surgical site. A network of holes, like a sponge or Swiss cheese, is made in the bulging area and the fat is liquefied and removed. I will aggressively remove all of the fat until the skin no longer springs back. Afterwards, the overlying skin is compressed with a binder or girdle to tighten the tissues. This compression garment decreases blood loss and bruising and helps the skin to smooth out over the newly sculpted area. It is generally used for three weeks.

After surgery, patients should be warmed with a medical heating blanket since they get cold from the fluids and the anesthesia. Patients must get up and briefly walk around beginning the day of surgery. Patients are encouraged to shower on the second day after the operation (a lukewarm shower at first). For the first 2-3 days, a light headache and low-grade temperature are often seen. If a patient is light headed when standing, this indicates that they do not have enough fluid in their system. Gatorade or Campbell’s soup can help this situation. Often the legs can have some edema (swelling) for several days. Sutures are removed in the first week after surgery.

The volume of fat removed depends on the size of the patient, the number of areas treated, and the age and the health of the patient. Large volume liposuctions (over 5000ccs) should be performed in an accredited or licensed facility. Since liposuction removes fluid, it causes a shift in the delicate balance of the body, similar to a major burn. For this reason, it is extremely important that the physician be well trained surgically to recognize, understand, and treat these changes. The amount of fluid given back to a patient depends on the amount of fat removed and should be carefully monitored.

Techniques

The technique used today is referred to as the “wet” approach. The area to be suctioned is filled with a solution salt-water, local anesthetic, and vasoconstrictor. The salt-water (saline) serves to emulsify and soften the fat and makes it easier to remove. The vasoconstrictor called epinephrine, decreases the blood loss. The local anesthetic allows less anesthesia to be used and makes it more comfortable after surgery. The “wet” approach is vastly superior to the older dry technique, which resulted in more swelling, bruising and blood loss.

The cannulas (tubes) that were originally used for liposuction have changed dramatically. When I began practice in 1983, the average cannula was 10mm thick. Today, cannulas in the 3-5mm range are commonly used with an occasional 1.5mm for very fine tissue sculpting. These smaller cannulas have enabled me to get a smoother end result. (i.e. if we use smaller “chisels” the final sculpting is more even).

Often, I begin with a larger tube for the deepest fat and use a finer tube for the superficial fat. These cannulas now have multiple openings at the tip, causing less injury to the tissues. Also, with all the tip holes facing away from the skin, fat removal close to the skin surface is possible minimizing the possibility of ridges, wrinkles and irregularities.

Two new techniques have been developed for liposuction. First, a power-assisted system is available in which the cannula itself moves with a very small forward and backward motion. This “chipping away” at small amounts of fat with the cannula instead of using larger arm movement gives a refined result. This allows smaller more delicate cannulas to be used. I use this technique to perform SAL surgery. Another technique is called ultrasonic-assisted liposuction. It is supposed to be easier on the surgeon (less effort). The cannula vibrates at a very rapid rate creating heat, which emulsifies the fat. The problem with this system is that it requires a slightly larger insertion wound and that burns can occur from injury just under the skin. Also, there is more tissue damage and bleeding with this technique. This approach does not appear to aid in the smoothness of the final result.

Complications

Minor problems such as small hematomas (blood clots), small seromas and small contour irregularities usually go away after a short time period.

Major problems such as skin necrosis, major contour irregularities, fat embolism or infections can occur but are extremely rare. Steroid use and massive weight loss can effect the healing and end result.

Conclusion

Good sculptors sculpt well. The best SAL results are obtained by surgeons with extensive experience. The training and qualifications are very important for a good result. Liposuction is not just an interesting technology. It is a life changing surgery for people who continue to exercise and eat healthy. Unfortunately 20% of patients gain a substantial amount of weight which compromises the results. Not only do the treated areas expand, but the fat is deposited in untreated areas. The end result depends on a surgeon with excellent training, a skilled staff, careful patient selection, and a full pre-op evaluation. Also, diligent intra- operative and post-operative monitoring will help give the safest and most successful outcome to the procedure.

History

In June of 1977, Yves-Gerard Illouz, M.D. began experimenting with removing fat. As he related to me in Paris “I was approached by a beautiful opera singer with a large lipoma (fatty tumor) on the back of her neck. Other surgeons had told her she needed a large scar on the neck to remove it. She did not want to affect her opera career. I started experimenting with a side of beef by softening the fat with saline and taking a large tube and sucking out the fat. I had 40 friends have liposuction of the abdomen and hips and wrote my first paper. Several months later, I had another forty friends have liposuction of the arms, neck, etc. This was my second paper.” The rest is history. ~ David Benvenuti, M.D.

Questions and Answers About Liposuction

  1. Am I a candidate for liposuction?
    Anybody can have liposuction, but the final result depends entirely on the overlaying skin. If it is tight and taut, the results are excellent. If it is loose and wrinkly, the results will be less satisfactory.
  2. What areas can be liposuctioned?
    Almost anywhere on the body.
  3. Where are the incisions?
    A poke hole closed with 1 or 2 stitches is usually placed 2″ to 4″ away from the area being liposuctioned.
  4. How long do the stitches stay in?
    5-6 days.
  5. What type of anesthesia is used?
    General anesthesia.
  6. Is liposuction painful?
    Liposuction feels like a very strenuous physical workout. The treated areas are tender and swollen.
  7. How long is the recovery?
    3-5 days to return to work for a moderate suction.
  8. Will I lose weight?
    Fat is very light so there is little weight loss. What you will notice is a reduction in inches.
  9. Will I have bruising and swelling?
    With the tumescent technique, the bruising is minimal and the swelling is moderate.
  10. How long before I can return to exercise?
    Light exercise in 2 weeks. Strenuous exercise at 3-4 weeks.
  11. When will I see the final results?
    Early results at 3 months but final results 6-9 months.
  12. Can I gain weight after liposuction?
    Yes, but the fat goes to other areas. With weight gain, your entire body will get heavier, but the change in shape will remain.
  13. Do I have to wear anything after the surgery?
    Yes, an abdominal binder around the mid-body or a full girdle when legs and knees are involved is worn for 3 three weeks.

References

1. Guyuron, Bahman, MD; Genioplasty: Little, Brown & Co., 1993.

2. Guyuron, Bahman, et al; Aesthetic Plastic Surgery, 19: 257-264, 1995.

3. McCarthy, Joseph (ed); Plastic Surgery, 1 :30, 1990.

4. Rubin, J. Peter, et al; Complications and Toxicities of Implantable Biomaterials used in Facial Reconstruction and Aesthetic Surgery- Plastic and Reconstructive Surgery, 100(5): 1336,-1353, 1997.

5. Zide, Barry, DMD, MD; The Mentalis Muscle, an Essential Component of Chin and Lower Lip Position- Plastic and Reconstructive Surgery, 105(3): 1213-1215, 2000.

6. Gonzales-Ulloa, Mario; The Role of Chin Correction in Profileplasty- Plastic and Reconstructive Surgery, 4l (5): 477-486, 1968.

7. Ricketts, Robert M, DDS; Esthetics, Environment and the Law of Lip Relation- Am. J. Orthodontics: 272-298, 1968.

8. Benvenuti, David, MD; Problems with Art) facial Material in Lip Augmentation- Int. Bulletin of Plastic Surgery, January, 1999.

9. Benvenuti, David, MD; Chin Procedures Make Improvements to Facial Features, Daily Pilot Newspaper, 1992.

10. Kawamoto, II. K.; Osseus Genioplasty, Aesthetic Surgery Journal, 20(6), 2001; 516.