Liposuction
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Liposuction, or simply lipo, is a type of fat-removal procedure used in
plastic surgery Plastic surgery is a surgical specialty involving the restoration, reconstruction or alteration of the human body. It can be divided into two main categories: reconstructive surgery and cosmetic surgery. Reconstructive surgery includes craniofa ...
. Evidence does not support an effect on weight beyond a couple of months and does not appear to affect
obesity Obesity is a medical condition, sometimes considered a disease, in which excess body fat has accumulated to such an extent that it may negatively affect health. People are classified as obese when their body mass index (BMI)—a person's we ...
-related problems. In the United States, liposuction is the most common
cosmetic surgery Plastic surgery is a surgical specialty involving the restoration, reconstruction or alteration of the human body. It can be divided into two main categories: reconstructive surgery and cosmetic surgery. Reconstructive surgery includes craniofa ...
. The procedure may be performed under general, regional, or local
anesthesia Anesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prevention of pain), paralysis (muscle relaxation), ...
. It involves using a
cannula A cannula (; Latin meaning 'little reed'; plural or ) is a tube that can be inserted into the body, often for the delivery or removal of fluid or for the gathering of samples. In simple terms, a cannula can surround the inner or outer surfaces ...
and negative pressure to suck out fat. As a cosmetic procedure it is believed to work best on people with a normal weight and good skin elasticity. While the suctioned fat cells are permanently gone, after a few months overall body fat generally returns to the same level as before treatment. This is despite maintaining the previous diet and exercise regimen. While the fat returns somewhat to the treated area, most of the increased fat occurs in the abdominal area.
Visceral fat Adipose tissue, body fat, or simply fat is a loose connective tissue composed mostly of adipocytes. In addition to adipocytes, adipose tissue contains the stromal vascular fraction (SVF) of cells including preadipocytes, fibroblasts, vascular e ...
—⁠the fat surrounding the internal organs—increases, and this condition has been linked to life-shortening diseases such as
diabetes Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ap ...
,
stroke A stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both cause parts of the brain to stop functionin ...
, and
heart attack A myocardial infarction (MI), commonly known as a heart attack, occurs when blood flow decreases or stops to the coronary artery of the heart, causing damage to the heart muscle. The most common symptom is chest pain or discomfort which may tr ...
.


Cosmetic liposuction

There are two different uses for liposuction: cosmetic liposuction to change the body's contour or shape and reconstructive, medically necessary liposuction. Reconstructive uses include treatment of
lipedema Lipedema is a condition that is almost exclusively found in women and results in enlargement of both legs due to deposits of fat under the skin. Women of any weight may develop lipedema and the fat associated with lipedema is resistant to traditi ...
, to remove excess fat in the chronic medical condition
lymphedema Lymphedema, also known as lymphoedema and lymphatic edema, is a condition of localized swelling caused by a compromised lymphatic system. The lymphatic system functions as a critical portion of the body's immune system and returns interstitial fl ...
, and to remove lipomas from areas of the body. Cosmetic liposuction should not be used as a weight-loss plan but to aesthetically improve the appearance of body parts and contour. Benefits from cosmetic liposuction appears to be of a short-term nature with little long-term effect. After a few months fat typically returns and redistributes. Liposuction does not help
obesity Obesity is a medical condition, sometimes considered a disease, in which excess body fat has accumulated to such an extent that it may negatively affect health. People are classified as obese when their body mass index (BMI)—a person's we ...
-related metabolic disorders like
insulin resistance Insulin resistance (IR) is a pathological condition in which cell (biology), cells fail to respond normally to the hormone insulin. Insulin is a hormone that facilitates the transport of glucose from blood into cells, thereby reducing blood gluco ...
.


Reconstructive, medically necessary liposuction

There are many articles and references to liposuction as "cosmetic" and not reimbursed by medical insurance companies. Most of this information is outdated. If the documentation supports the liposuction for a medical reason (
lipedema Lipedema is a condition that is almost exclusively found in women and results in enlargement of both legs due to deposits of fat under the skin. Women of any weight may develop lipedema and the fat associated with lipedema is resistant to traditi ...
,
lymphedema Lymphedema, also known as lymphoedema and lymphatic edema, is a condition of localized swelling caused by a compromised lymphatic system. The lymphatic system functions as a critical portion of the body's immune system and returns interstitial fl ...
,
lipoma A lipoma is a benign tumor made of fat tissue. They are generally soft to the touch, movable, and painless. They usually occur just under the skin, but occasionally may be deeper. Most are less than in size. Common locations include upper back, ...
s) as reconstructive, and not investigational, experimental, or unproven, the claim is medically necessary and should be reimbursed. While most insurance companies may initially deny the claim, many can be won upon appeal if the documentation and patient's need supports the criteria for
reconstructive surgery Reconstructive surgery is surgery performed to restore normal appearance and function to body parts malformed by a disease or medical condition. Description Reconstructive surgery is a term with training, clinical, and reimbursement implica ...
. The techniques and terms listed below: tumescent, lymph-sparing, Tumescent Local Anesthesia (TLA), Water-Assisted Liposuction (WAL), Power-Assisted Liposuction (PAL), Laser-Assisted Liposuction (LAL) all apply to reconstructive, medically necessary liposuction.


Techniques

In general, fat is removed via a
cannula A cannula (; Latin meaning 'little reed'; plural or ) is a tube that can be inserted into the body, often for the delivery or removal of fluid or for the gathering of samples. In simple terms, a cannula can surround the inner or outer surfaces ...
(a hollow tube) and aspirator (a suction device). Liposuction techniques can be categorized by the amount of fluid injected, and by the mechanism by which the cannula works. If the removed fat is used as filler for the face, lips, or breasts knowledge of the precise technique used to remove the fat is indicated. There are numerous types of liposuction. Some can be described as techniques or modalities. Often surgeons will use two or more of the different techniques below in the same session.


Suction-assisted liposuction (SAL)

This is the most generic term for liposuction. In the CPT manual it is referred to as "suction-assisted lipectomy" and includes codes: 15876–15879.


Micro-cannula

This does not address a particular technique but the diameter of the cannula, a stainless steel tube which is inserted into subcutaneous fat through a small opening or incision in the skin. The outside diameter of micro-cannulas range from 1 mm to 3 mm.Wollina, Uwe & Goldman, Alberto & Heinig, Birgit. (2010). Microcannular tumescent liposuction in advanced lipedema and Dercum's disease. Giornale italiano di dermatologia e venereologia : organo ufficiale, Società italiana di dermatologia e sifilografia. 145. 151-9.


Lymph-sparing liposuction

This technique does not require a particular wand and is most often performed with either tumescent liposuction or WAL (below). It refers to the specific surgical technique, the skill of the surgeon, and the extensive training that is unique to removing lipedema fat.van de Pas, C. B., Boonen, R. S., Stevens, S., Willemsen, S., Valkema, R., & Neumann, M. (2020). Does tumescent liposuction damage the lymph vessels in lipoedema patients? Phlebology, 35(4), 231–236. https://doi.org/10.1177/0268355519885217 Because the scope is different for removal of lipedema fat versus cosmetic contouring, if lymph-sparing is not addressed in the surgical operative notes, a medical necessity review committee could determine that the procedure poses “a risk to the lymph system.”


Tumescent local anesthesia (TLA)/tumescent liposuction

This may be referenced either way above, but the technique is the same. This is an anesthesia technique recommended for lymph-sparing liposuction surgery. Tumescent Liposuction refers to the use of anesthesia during liposuction. The word “tumescent” means swollen and firm. By injecting a large volume of very dilute lidocaine (local anesthetic) and epinephrine (capillary constrictor) into subcutaneous fat, the targeted tissue becomes swollen and firm, or tumescent. This technique does not require a special or specific type of wand.


Power-assisted liposuction (PAL)

Referred to as "a vibrating cannula" in research studies, PAL uses a specific type of wand that creates an up and down, vibrating-like motion of the cannula to acquire greater fat removal. When compared to simple suction-assisted liposuction, PAL requires less energy for the surgeon to operate while also resulting in greater fat removal. It is commonly used for difficult, secondary, scarred areas, and when harvesting large volumes of fat for transfers to other areas.Venkataram J. Tumescent liposuction: a review. J Cutan Aesthet Surg. 2008;1(2):49-57. doi:10.4103/0974-2077.44159 Note that techniques can be combined; for instance one could refer to the procedure as "lymph-sparing, tumescent liposuction using a vibrating (PAL) microcannula to treat lipedema."


Water-jet assisted liposuction (WAL)

A specific technique and wand commonly used for patients who require lymph-sparing liposuction for lipedema. The lipedema fat is removed using a fan-shaped jet of water, which includes the anesthetic. In contrast to tumescent liposuction above, where the anesthetic solution is injected separately and beforehand, the WAL wand both injects the solution and suctions the fat. BodyJet is a Water-Assisted Liposuction system.


Fibro-lympho-lipo-aspiration (FLLA)

This rare and unique term for liposuction for lipedema is used in a specific paper by Campisi, ''Fibro-Lipo-Lymph-Aspiration With a Lymph Vessel Sparing Procedure to Treat Advanced Lymphedema After Multiple Lymphatic-Venous Anastomoses: The Complete Treatment Protocol''. This term emphasizes the uniqueness of the reconstructive procedure versus the cosmetic procedure. Everything about the surgical suction application via cannula is different from standard suction lipectomy. The goal of FLLA is to relieve symptoms such as pain, ameliorate disability, improve function and quality of life, and halt disease progression. Only small blunt cannulas are used, great care is used to not injure lymphatic which are already abnormal and increased risk of injury. Only the longitudinal orientation of cannulas is used at critical junctures. Preoperatively critical lymphatic structures are scanned and marked. FLLA surgery is significantly more time-consuming than cosmetic surgery often requiring 4–5 hours per body part; much larger aspirate volume is removed versus cosmetic suction lipectomy. The benefit to lymphatics function comes not only from the removal of subcutaneous adipose tissue, but also the all components of the loose connective tissue including removing fibrosis in the interstitial space.


Ultrasound-assisted liposuction (UAL)

Ultrasound-assisted liposuction techniques used in the 1980s and 1990s were associated with cases of tissue damage, usually from excessive exposure to ultrasound energy. Third-generation UAL devices address this problem by using pulsed energy delivery and a specialized probe that allows physicians to safely remove excess fat. UAL is beneficial in people with a particular skin tone, in liposuction of areas that are more difficult to remove fat, that include treatment of gynecomastia, or areas where secondary liposuction is being performed.


Laser-assisted liposuction/lipolysis (LAL)

Referred to as Smart Lipo, this technique uses laser technology to coagulate and tighten the skin and boost collagen performance. Uses include "cankles", debulking surgery for elephantiasis nostras and lipedema.


Cryolipolyis or fat freezing

Sold under the brand name of CoolSculpting, cryolipolyis is not a type of liposuction but rather a non-surgical fat reduction procedure that freezes fat cells; it is an FDA-approved, non-invasive procedure that uses the power of cooling to disrupt fat cells underneath the dermis. This freezing energy crystallizes and eventually kills targeted fat cells without harming the surrounding healthy tissue. The body's metabolic processes work to remove the dead fat cells. Coolsculpting is not recommended for those with lipedema, lymphedema or other conditions that affect the lymphatic system. The model
Linda Evangelista Linda Evangelista (; born May 10, 1965) is a Canadian fashion model. She is regarded as one of the most accomplished and influential models of all time, and has been featured on over 700 magazine covers. Evangelista is primarily known for being ...
reportedly was left unrecognisable after a Cryolipolyis procedure.


Radiofrequency-Assisted Liposuction

Radiofrequency-assisted Liposuction, also known as RFAL, is a new procedure that is being done by thermal energy to promote skin tightening and remove unwanted fat. In this technique, radio waves of specific frequency are used to melt fat.


After care—sutures

Doctors disagree on the issues of scarring with not suturing versus resolution of the swelling allowed by leaving the wounds open to drain fluid. Suturing is more common with a large cannula. Since the incisions are small, and the amount of fluid that must drain out is large, some surgeons opt to leave the incisions open, while others suture them only partially, leaving space for the fluid to drain out.


Safety and risks

Liposuction is considered very safe, though not all liposuction surgery is equal. Small volume liposuction (<1,000 cc) done awake is different from large volume liposuction (>5,000 cc, in some cases 10,000 cc) done with anesthesia and a hospital stay. Suction-assisted lipectomy (aka liposuction) were identified from the Tracking Operations and Outcomes for Plastic Surgeons database maintained by The American Society of Plastic Surgeons (ASPS). The ASPS maintains a registry of plastic surgery cases called TOPS (Tracking Operations & Outcomes for Plastic Surgeons) which is the largest database of plastic surgery cases. The TOPS database is only voluntary, not available to the public, and does not follow cases long-term or get testimony and experience of patients, only from doctors who profit from doing liposuction. Based on this database, no deaths were found in about 4,500 cases done by plastic surgeons. However, non-plastic surgeons are not included in this. In the (Chow I., et al., 2015) study, sixty-nine of 4,534 patients (1.5 percent) meeting inclusion criteria experienced a postoperative complication. Their conclusion was that: Liposuction by board-certified plastic surgeons is safe, with a low risk of life-threatening complications. Traditional liposuction volume thresholds do not accurately convey individualized risk. The authors' risk assessment model demonstrates that volumes in excess of 100 ml per unit of body mass index confer an increased risk of complications. There exists a spectrum of complications that may occur due to any liposuction. Risk is increased when treated areas cover a greater percentage of the body, incisions are numerous, a large amount of tissue is removed, and concurrent surgeries are done at the same time. To address safety issues, in 2009 the American Society of Plastic Surgeons (ASPS) published ''Evidence-Based Patient Safety Advisory: Liposuction''. This 17-page document addresses key safety issues and offers recommendations. In addition, the increase in tumescent and lymph-sparing techniques have had a positive impact on diminishing complications. In a 2009 paper, the author found from a series of 3,240 procedures, no deaths occurred, and no complications requiring hospitalization were experienced. In nine cases, complications developed that needed further action. The conclusion was that liposuction using exclusively Tumescent Local Anesthesia (TLA) is a proven safe procedure provided that the existing guidelines are meticulously followed. Some side effects and complications include, but are not limited to, the following: * Pain, which may be temporary or chronic * Post-liposuction fat redistribution or post liposuction weight gain * Bruising *
Infections An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable di ...
*
Embolisms An embolism is the lodging of an embolus, a blockage-causing piece of material, inside a blood vessel. The embolus may be a blood clot (thrombus), a fat globule (fat embolism), a bubble of air or other gas ( gas embolism), amniotic fluid (amn ...
may occur when loosened fat enters the blood through blood vessels ruptured during liposuction. Pieces of fat can wind up in the lungs, or even the brain. Fat emboli may cause permanent disability or, in some cases, be fatal. * Puncture wounds in the organs (visceral perforations) may require surgery for repair. They can also prove fatal. *
Seroma A seroma is a pocket of clear serous fluid (filtered blood plasma). They may sometimes develop in the body after surgery, particularly after breast surgery, abdominal surgery, and reconstructive surgery. They can be diagnosed by physical signs, ...
is a pooling of serum, the straw-colored liquid from blood, in areas where tissue has been removed. *
Paresthesias Paresthesia is an abnormal sensation of the skin (tingling, pricking, chilling, burning, numbness) with no apparent physical cause. Paresthesia may be transient or chronic, and may have any of dozens of possible underlying causes. Paresthesias ar ...
(changes in sensation that may be caused by nerve compression) is an altered sensation at the site of the liposuction. This may either be in the form of an increased sensitivity (pain), or numbness in the area. In some cases, these changes in sensation may be permanent, although typical patients recover over the span of several weeks. * Swelling, in some cases, may persist for weeks or months after liposuction. * Skin
necrosis Necrosis () is a form of cell injury which results in the premature death of cells in living tissue by autolysis. Necrosis is caused by factors external to the cell or tissue, such as infection, or trauma which result in the unregulated dige ...
occurs when the skin above the liposuction site changes color and falls off. Large areas of skin necrosis may become infected with bacteria or microorganisms. *
Burn A burn is an injury to skin, or other tissues, caused by heat, cold, electricity, chemicals, friction, or ultraviolet radiation (like sunburn). Most burns are due to heat from hot liquids (called scalding), solids, or fire. Burns occur mainl ...
s can occur during ultrasound-assisted liposuction if the ultrasound probe becomes hot. * Fluid imbalance may impact you after you go home. The condition can result in serious ailments such as heart problems, excess fluid collecting in the lungs, or kidney problems. * Toxicity from anesthesia due to the use of
lidocaine Lidocaine, also known as lignocaine and sold under the brand name Xylocaine among others, is a local anesthetic of the amino amide type. It is also used to treat ventricular tachycardia. When used for local anaesthesia or in nerve blocks, lidoca ...
, a skin-numbing drug, can cause lightheadedness, restlessness, drowsiness, a ringing in the ears, slurred speech, a metallic taste in the mouth, numbness of the lips and tongue, shivering, muscle twitching and convulsions. Lidocaine usage has already been linked to deaths from liposuction. *
Scars A scar (or scar tissue) is an area of fibrous tissue that replaces normal skin after an injury. Scars result from the biological process of wound repair in the skin, as well as in other organs, and tissues of the body. Thus, scarring is a natu ...
at the site of the incision are usually small and fade with time, although some may be larger or more prominent. *
Deformities A deformity, dysmorphism, or dysmorphic feature is a major abnormality of an organism that makes a part of the body appear or function differently than how it is supposed to. Causes Deformity can be caused by a variety of factors: *Arthritis an ...
in the shape of the body may occur at the liposuction site after the procedure for about 20% of patients. *
Death Death is the irreversible cessation of all biological functions that sustain an organism. For organisms with a brain, death can also be defined as the irreversible cessation of functioning of the whole brain, including brainstem, and brain ...
Serious complications include
deep vein thrombosis Deep vein thrombosis (DVT) is a type of venous thrombosis involving the formation of a blood clot in a deep vein, most commonly in the legs or pelvis. A minority of DVTs occur in the arms. Symptoms can include pain, swelling, redness, and enla ...
,
organ perforation Organ perforation is a complete penetration of the wall of a hollow organ in the body, such as the gastrointestinal tract in the case of gastrointestinal perforation. It mainly refers to accidental or pathologic perforation, rather than intentiona ...
, bleeding, and
infection An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dise ...
. Death occurs in about one per ten thousand cases.


History

In 1977, Fischer and Fischer reviewed 245 cases with the planotome instrument for treating cellulite in the lateral trochanteric (hip-thigh) areas. There was a 4.9 per cent incidence of
seroma A seroma is a pocket of clear serous fluid (filtered blood plasma). They may sometimes develop in the body after surgery, particularly after breast surgery, abdominal surgery, and reconstructive surgery. They can be diagnosed by physical signs, ...
s, despite incision-wound suction
catheter In medicine, a catheter (/ˈkæθətər/) is a thin tube made from medical grade materials serving a broad range of functions. Catheters are medical devices that can be inserted in the body to treat diseases or perform a surgical procedure. Cath ...
s and compression dressings; 2.0 per cent of the cases presented pseudo-cyst formation that required removal of the capsule (
cyst A cyst is a closed sac, having a distinct envelope and cell division, division compared with the nearby Biological tissue, tissue. Hence, it is a cluster of Cell (biology), cells that have grouped together to form a sac (like the manner in which ...
) through a wider incision (>) and the use of the panotome. Relatively modern techniques for body contouring and removal of fat were first performed by a French surgeon, Charles Dujarier, but a 1926 case that resulted in the amputation of the leg of a French dancer due to excessive tissue removal and too-tight suturing set back interest in body contouring for decades. Liposuction evolved from work in the late 1960s from surgeons in Europe using techniques to cut away fat, which were limited to regions without many blood vessels due to the amount of bleeding the technique caused. In the mid-1970s in Rome, Arpad and Giorgio Fischer created the technique of using a blunt
cannula A cannula (; Latin meaning 'little reed'; plural or ) is a tube that can be inserted into the body, often for the delivery or removal of fluid or for the gathering of samples. In simple terms, a cannula can surround the inner or outer surfaces ...
linked to suction; they used it only to remove fat on the outer thighs.
Yves-Gérard Illouz Yves-Gérard Illouz (also known as Gérard Illiouz; September 12, 1929 – January 21, 2015) was a French surgeon who developed safer methods of liposuction. He was a co-founder of Médecins Sans Frontières (Doctors Without Borders). __NOTOC__ ...
and Fournier extended the Fischers' work to the whole body, which they were able to use by using different sized cannulae. Illouz later developed the "wet" technique in which the fat tissue was injected with saline and
hyaluronidase Hyaluronidases are a family of enzymes that catalyse the degradation of hyaluronic acid (HA). Karl Meyer classified these enzymes in 1971, into three distinct groups, a scheme based on the enzyme reaction products. The three main types of hyal ...
, which helped dissolve tissue holding the fat, prior to suctioning. Lidocaine was also added as a local anesthetic. Fournier also advocated using compression after the operation, and travelled and lectured to spread the technique. The Europeans had performed the procedures under general anesthesia; in the 1980s American dermatologists pioneered techniques allowing only local anesthetics to be used. Jeffrey Klein published a method that became known as "tumescent" in which a large volume of very dilute lidocaine, along with
epinephrine Adrenaline, also known as epinephrine, is a hormone and medication which is involved in regulating visceral functions (e.g., respiration). It appears as a white microcrystalline granule. Adrenaline is normally produced by the adrenal glands and ...
to help control bleeding via
vasoconstriction Vasoconstriction is the narrowing of the blood vessels resulting from contraction of the muscular wall of the vessels, in particular the large arteries and small arterioles. The process is the opposite of vasodilation, the widening of blood vessel ...
, and
sodium bicarbonate Sodium bicarbonate (IUPAC name: sodium hydrogencarbonate), commonly known as baking soda or bicarbonate of soda, is a chemical compound with the formula NaHCO3. It is a salt composed of a sodium cation ( Na+) and a bicarbonate anion ( HCO3−) ...
as a
buffering agent A buffer solution (more precisely, pH buffer or hydrogen ion buffer) is an aqueous solution consisting of a mixture of a weak acid and its conjugate base, or vice versa. Its pH changes very little when a small amount of strong acid or base is a ...
. In 2015 liposuction surpassed
breast augmentation surgery A breast implant is a prosthesis used to change the size, shape, and contour of a person's breast. In reconstructive plastic surgery, breast implants can be placed to restore a natural looking breast following a mastectomy, to correct congenita ...
as the most commonly performed cosmetic procedure in the US.


See also

*
Bariatrics Bariatrics is the branch of medicine that deals with the causes, prevention, and treatment of obesity. Terminology The term ''bariatrics'' was coined around 1965,Dictionary.com, based on Random House Unabridged Dictionary, Random House (2006)R ...
– branch of medicine that deals with the causes, prevention, and treatment of obesity *
Gastric bypass surgery Gastric bypass surgery refers to a technique in which the stomach is divided into a small upper pouch and a much larger lower "remnant" pouch and then the small intestine is rearranged to connect to both. Surgeons have developed several differ ...
*
Lipotomy Bariatric surgery (or weight loss surgery) includes a variety of procedures performed on people who are obese. Long term weight loss through the standard of care procedures ( Roux en-Y bypass, sleeve gastrectomy, and biliopancreatic diversion ...
*
Spot reduction Spot reduction refers to the claim that fat in a certain area of the body can be targeted for reduction through exercise of specific muscles in that desired area. For example, exercising the abdominal muscles in an effort to lose weight in or aro ...


References


External links

{{Authority control Abdominal surgical procedures Management of obesity Medical ultrasonography Plastic surgery Surgical removal procedures