Tuesday, October 7, 2008

Liposuction: Suction Assisted Lipectomy (SAL) Procedure and FAQ

Synonym: liposuction, suction assisted lipolysis, "fat suctioning", and "fat sucking"

Currently, and for a number of years, liposuction – the most commonly performed aesthetic (cosmetic) surgery (ASPS 1998 National Clearinghouse of Plastic Surgery Statistics) – has produced almost instant gratification and fulfillment of dreamlike wishes. Although intended as a method of sculpting and shaping areas of the body, its use as a weight loss alternative has opened it to potential abuse. These abuses may take the form of massive liposuctions in unsuitable candidates; poor patient selection in general; advertising-generated and misleading expectations; and non-plastic surgeons performing cosmetic surgery. Some of these abuses have resulted in spectacular complications and have generated lurid exposés in the media. This adverse publicity, unfortunately, places blame on the operation as opposed to the operators.This is regrettable, since liposuction is such a valuable cosmetic procedure. Anyone considering liposuction surgery needs to seriously examine both motives and expectations. What do you really hope to gain through liposuction surgery? Can it actually be accomplished by a combination of moderate weight loss and toning through exercise? Should you invest in a meeting with a nutritionist and a trainer instead of a plastic surgeon? Are your expectations for what surgery can do realistic? If your answers to these questions still lead you to want liposuction, you should prepare for your consultation carefully, armed with further questions.


Ideally this surgical technique would be reserved for people who:

  • Are at or near ideal weight
  • Have localized areas of abnormal or disproportionate fat deposits
  • Have regional fat deposits that are unresponsive to a program of reduced dietary intake and exercise
  • Have reasonably good elastic skin tone that will "shrink to fit" when excess fat is removed
  • Have reasonable expectations
  • Are looking for improvement, not perfection
  • Are in good health both physically and emotionally

However, it is not surprising that the criteria have been expanded to include a broad segment of people with problems of body shape and proportion. Among women, the most common areas requested for reshaping are thighs, hips, buttocks, abdomen, and face and neck. For men, the more common needs are for the abdomen, love handles, and neck. But virtually any area where "fat comes to rest" may be the object of liposuction.

The basic science of fat metabolism that allows liposuction to work is interesting. Suffice it to say, removed fat doesn't "grow back". But this doesn't prevent post-liposuction patients from gaining weight. Patients wishing to get and maintain the best results from liposuction continue to sustain a healthy lifestyle including dietary discretion and regular exercise.

Objectives & Facts

  • Shaping and sculpting areas of localized fat
  • Not meant for weight reduction
  • Will not tighten skin
  • Will not eliminate "cellulite"

Before Surgery

Whether at the time of consultation or later, once you have made up your mind to go ahead, you will need to take measures to ready yourself for surgery. While many of these measures will be at your plastic surgeon's request, others will be a matter of laying the mental groundwork for surgery, both for yourself and your family.

From a medical perspective, in preparing for any cosmetic surgery, there are certain steps that need to be taken. While each plastic surgeon may differ somewhat in the preparations they recommend, the basic objectives will be the same:

  • That you are in good physical and mental health
  • That you are not taking medications or over-the-counter supplements that could interfere with surgery or anesthesia
  • That transportation to and from surgery and homecare arrangements have been made

When surgery is scheduled, you usually will receive instructions from the staff covering all of the necessary pre-surgical planning. These instructions will include:

  • A list of drugs, medications, and food supplements that you will need to avoid because of their negative effect on surgery
  • Information about smoking cessation and the additional risks of surgery and smoking
  • Do's and don'ts in the weeks before surgery
  • Reporting any colds or infections that arise which may force surgery to be delayed
  • Making arrangements for transportation and assistance for post-operative care
  • Forms for your doctor for medical history and physical examination

The Surgical Procedure

Location – When the volume of liposuction is very small and/or the number of areas few, the procedure is usually performed as a day-patient. Under some circumstances, however – even with these criteria – we will recommend an overnight stay. For larger volume liposuctions, where many areas are involved, or when other surgical procedures are performed simultaneously, we advise staying overnight or even several nights.

Anesthesia – There are various anesthetic techniques that are used in liposuction surgery. However, for most liposuctions (except for very small areas), surgeons uses general anesthesia (complete sleep) exclusively. It is administered by a physician anesthesiologist in order to provide the safest, most controlled form of anesthesia.

Surgery Techniques – Once you are asleep, the first step in the process of liposuction – is the injection of the large amounts of fluid into the fat. In this "tumescent" or superwet technique, the fluid reduces the amount of bleeding and provides some anesthesia to the areas. It also separates the compartments of fat and makes the extraction easier. Then, surgeons uses both standard "tumescent" liposuction [SAL] and "ultrasonic-assisted liposuction" [UAL]. In the standard technique, a number of tiny incisions (so small that when they heal, they are barely perceptible) are made, through which hollow metal tubes or cannulas attached to suction are inserted. These cannulas vary in size with the largest being about the diameter of a pencil and the smaller ones the diameter of spaghetti. As the cannula is moved in-and-out of the fat, it removes cores of fat until the desired shape has been attained.

Where the fatty area is very tough and fibrous – such as in the back, flanks, breasts, and hips (especially in men) – or where there are very large volumes to be removed, ultrasonic-assisted liposuction (UAL) may be used. In this technique, there are special cannulas attached to a device that emits ultrasonic waves that rupture the fat cells before they are suctioned away. It is believed that this method may result in less bleeding and bruising and may create some degree of skin shrinkage. It, however, has its own set of risks and is used as an adjunct to standard tumescent liposuction, not a replacement.

Risks & Complications – All surgeries are associated with some risks. These relate to the potential for complications and untoward events during or after a surgical procedure. We can think of these in two groups:

1. General Risks – Risks that are common to all operations and
2. Specific Risks – Those that are unique to a particular surgery.

General Risks include:

  • Bleeding
  • Infection
  • Scarring
  • Swelling
  • Bruising
  • Anesthetic risks

Specific Risks include:

  • Unfavorable scarring
  • Skin loss/slough
  • Asymmetry
  • Alterations in skin sensitivity
  • Lumpiness
  • Waviness
  • Irregularities
  • Loose skin
  • Areas of hard scar tissue
  • Discoloration (permanent or temporary)
  • Injury to deeper structures (very rare)

After Surgery

Following discharge from the recovery area, you will either be sent directly home or spend the night and be discharged the next day. As mentioned earlier, there are numerous reasons for staying overnight, including: personal preference, number of areas and amount of fat removed, other surgeries performed simultaneously, and so on.

Everyone has some degree of pain after any surgery. The amount and the way you deal with it are very individual. You will receive medication to control the pain.

Surgeons encourage his patients to be physically active as soon after surgery as is practical. This is particularly true of liposuction. You will be wearing various elastic garments and girdles for 3-6 weeks. These both control the amount of post-operative swelling and help to shape the new contours. You will be able to change these daily (or more often, if necessary). The timing of normal showering and bathing will depend on a number of factors.

Most people recover sufficiently to return to work in about 1 week. You will be encouraged to quickly resume full, normal physical activities and exercise. Your new shape should be a motivator to resume or begin a regimen of exercise, shaping, and toning.

Suture removal is generally not required. The small scars will take months to soften and decolorize from red-to-pink-to-white. The results will be evident within several weeks. Still, where the fat has been removed, the tissues will be firm and even somewhat swollen for weeks to months. Staff will instruct you in the appropriate method of massaging these areas to speed the softening.

Conclusions and Patient Acceptance

Because the resulting new shape is often so dramatic, liposuction is among the most satisfying cosmetic procedures. Please refer to FAQ (frequently asked questions) below to review the details and concerns of many patients.

Liposuction FAQ

Will the fat come back?
You are born with essentially a fixed number of fat cells that increase or decrease in size based upon weight gain or loss. When cells are removed, they do not grow back. However, that does not mean that you can't gain weight! You can and will, if you overindulge. But the excess fat will be deposited predominantly in areas other than those that have been liposuctioned. That means other areas will get fat. And you may not be pleased with which areas they are!

How long does it take to heal?
We encourage patients to be physically active as soon after surgery as is practical. This is particularly true of liposuction. You will be wearing various elastic garments and girdles for 3-6 weeks. These both control the amount of post-operative swelling and help to shape the new contours. You will be able to change these daily (or more often, if necessary). The timing of normal showering and bathing will depend on a number of factors.

Most people recover sufficiently to return to work in about 1 week. You will be encouraged to quickly resume full, normal physical activities and exercise. Your new shape should be a motivator to resume or begin a regimen of exercise, shaping, and toning.

Suture removal is generally not required. The small scars will take months to soften and decolorize from re-to-pink-to-white. The results will be evident within several weeks. Still, where the fat has been removed, the tissues will be firm and even somewhat swollen for weeks to months. Massaging these areas will help to soften them more rapidly. You can combine professional massage (as long as it is gentle) and lymphatic drainage techniques in these areas with your own self-massage. Staff will instruct you in the appropriate method of massaging these areas to speed the softening.

Should I apply heat or ice to the areas?
Absolutely not! Both cold and heat can severely injure the skin in the liposuctioned areas. The skin will not tolerate these.

How long will the results last?
The results are permanent. But this doesn't mean that you can't gain weight! It just means that the fat cells that were removed will not grow back. If you gain weight, very little of it will be deposited in the remaining cells in the liposuctioned areas. It will tend to find its way to other areas which will then enlarge in size and become unattractive. See "Will the fat come back?"

Is this surgery covered by my insurance?
Generally, no. This is a cosmetic operation and is not covered by health insurance. Very infrequently, when there is a functional problem such as a large fatty tumor – a lipoma for example – or when a breast reduction is being performed using liposuction, some insurances may cover this procedure.

When can I start jogging and lifting weights?
As soon as you are comfortable. Everyone's pain tolerance is different. But you will probably find that within a few days, you are able to resume brisk walking and within a week or so, jogging. Weight lifting probably almost immediately.

Will I have bandages?
There will be little adhesive clear plastic dressings over each incision. The general areas of liposuction will be covered with a girdle or compressive garment. Other than these, there will probably not be any dressings.

When can I bathe and shower?
It depends on whether liposuction has been combined with other surgeries, as well as, other factors. However, assuming just liposuction has been performed, you will be able to shower — but not take a bath — beginning at about 48 hours after surgery. When you do shower, you will need to keep in mind:

  • No hot water on the liposuctioned areas; they will burn very easily!
  • No rubbing the liposuctioned areas
  • Blot or pat the areas dry
  • Reapply your girdle or garment as soon as you are dry after completing your shower

Does someone have to be with me at home after surgery?
Unless you have had only a small area liposuctioned under a local anesthetic, you should plan to have someone with you for the remainder of the day and night of surgery.

Could I really get the same results if I just dieted and exercised?
If it's a matter of becoming thinner and more toned that you're after, yes, diet and exercise is the answer, not liposuction. On the other hand, if there are shapes, bulges, and contours that don't seem to change much regardless of your weight or level of fitness, liposuction is the solution. We cannot "spot weight reduce"; we can't change the unattractive shapes that we have inherited, like full "saddlebags" or love handles and so forth. But liposuction can sculpt away these unpleasant shapes that dieting won't remove.

Can I drive myself home after surgery?
No. Even if you have had a very limited liposuction under local anesthesia, the surgical experience may make you weak, shaky, or distracted enough that it is dangerous to drive. You should have someone bring you to surgery and take you back home. If you have had a general anesthetic, driving is out of the question.

Will Endermologie help?
Don't waste your time or money. Endermologie has not been demonstrated to produce any long-term change or improvement, in spite of what the advertisements say.

Can I have my surgery with a local anesthetic like I saw on TV?
No. We really don't believe that this particular method as shown on TV is safe, useful, or effective for our patients. As presented, it really was a gimmick that doesn't provide a safe and controlled surgical environment for the performance of good liposuction.

Will liposuction lift my butt?
No. In fact, liposuctioning the buttocks under most circumstances has the opposite effect and makes the buttocks flat and sagging.

Will my skin be looser after surgery?
It depends on a number of factors including: your skin tone, elasticity, and the amount of fat removed. If the elasticity is fair- to- poor, you may have some degree of looser skin after liposuction. It's not always possible to be sure about the amount of laxity that will be present after surgery. To an extent, the surgery will cause the skin to shrink a bit, even where skin tone is only fair. In making your decision to have liposuction surgery, this may be one of the considerations. We will try to inform you to the best of our ability how much skin laxity, if any, to expect.

Should I lose weight before the surgery?
I don't recommend losing weight specifically for the liposuction surgery. If you were to go on a major short-term diet and lose weight, it might give an unrealistic picture of the locations and amounts of surgical sculpting that are needed. Then, after surgery, you might gain back the weight and create new problems. It is preferable to save the weight loss and toning exercise for after the surgery.

See "How Long Does It Take To Heal"

How many scars will I have?
We won't know for sure in advance. The number of scars will be determined at surgery by the number of access incisions necessary to get to the fat that needs to be sculpted. In any case, they will likely heal well with minimal visibility.

When will the results be complete?
It will probably take up to 6 months or more for all of the normal scar tissue to soften and for all swelling to be completely gone. Nevertheless, your new shape will be clearly present and enjoyable in about one to three months.

Can I continue my vitamins and supplements up until surgery?
It depends on just what those are. Please give the staff a complete list of these well in advance of the surgery date (at least 2 weeks) so that ones that interfere with surgery or anesthesia can be discontinued in time. Vitamin E and supplements that are intended to assist in weight loss or contain stimulants must be discontinued by at least 2 weeks prior to surgery.

When can I resume my vitamins and supplements?
Probably by 2 weeks after surgery. But speak with the staff to be sure.

When can I begin having sex again?
As with exercise, in the case of liposuction, we encourage resuming sex when you are comfortable and as long as no pressure or trauma is applied to the areas that have been liposuctioned. You will find, however, that especially if the abdomen has been liposuctioned, the genital area may be very swollen and bruised for a while. Don't be concerned. It will eventually disappear and look normal again.

Do I have to sleep in a special position?

Do I have to stop smoking or should I use the nicotine patches or gum instead?
The nicotine in cigarettes as well as the nicotine replacement medications have a very bad effect on the skin following surgery and can result in poor healing with areas of skin loss. Therefore, no smoking, nicotine replacements, or supplements following surgery for at least 1 week. Drugs that suppress the desire to smoke, such as Zybanâ can be used. Our staff will prescribe this for you if you wish. See also "Effects of Smoking".

Should I be on a special diet before surgery?
No. We suggest that you be on a well-balanced diet. Avoid radical or weight-reducing diets prior to surgery. You may take vitamin and mineral supplements, but avoid health-food supplements the ingredients of which are uncommon and may have drug effects.

Are there special medicines that I should take before surgery?
Our staff will provide you with preoperative instructions that include any medicines or supplements that we wish you to take. You should, of course, inform us of any medications that you are taking regularly or which your own doctor has prescribed. If those will not interfere with surgery or anesthesia, we will allow you to continue to take them. Otherwise, supplements such as iron, vitamin K, Vitamin C, Beta Carotene are all right. But Vitamin E needs to be eliminated beginning 2 weeks prior to surgery, as it causes prolonged bleeding.

Will I need any special tests before surgery?
Yes. You will be asked to have a complete pre-operative medical history, physical examination, and laboratory tests before surgery. Especially as this is elective surgery, we need to be sure that you are in good health. These can be performed either by your own physician or our staff will recommend a physician or a Physician Assistant to complete these for you.

How soon can I lie in the sun or use a tanning bed?
You need to protect the areas that have been liposuctioned from the sun until all bruising has completely disappeared. Otherwise, you will find that the skin will take-on a pigmentation that looks as if the skin is "dirty". This is from iron pigment being deposited and fixed in the skin by the sun-tanning effect. In addition, early on in the healing course, when the skin doesn't have normal "feeling" (is a little numb), you could get a severe burn from sun exposure without being aware of it. Otherwise, (disregarding the skin cancer risks) as long as you protect the liposuctioned skin zones, you can be in the sun or tan other areas to your heart's content.

Will both sides of my body be completely even?
No. The body is not symmetrical to begin with. You are probably aware that your shoes don't fit exactly the same on both feet, and gloves don't fit exactly the same, as well. A woman will find that her breasts are not exactly the same either. This is normal human asymmetry. Liposuction will not be able to create perfect symmetry; you shouldn't expect it.

What about touch-ups?
It's not uncommon to need to perform a little adjustment to the final result. This probably wouldn't be for many months or even a year after the original surgery. It should be a minor bit of "tailoring" but would not include any additional fat that you gained (obviously, this should be avoided) in the interim.

Can you put the fat that you take out somewhere else?
Some small amounts of fat can be transplanted to areas such as the face or certain other small spots or divots and indentations. Such fat transplants, if done in a way that layers small quantities in various places, will have a good chance of "taking" and remaining for a prolonged period of time, though not permanently. However, large volumes can't be transplanted with any success. Transplanting fat to the breasts is contraindicated, as it becomes calcified and on a mammogram looks like a cancer.

Is there anything to be done if my skin is loose after the liposuction?
Depending on the area of loose skin, sometimes it's possible later on to remove excess skin and tighten the location. This is true of the abdomen, upper-inner thighs, and back of thighs in particular.

How much weight will I lose?
Remember, this is not a weight loss surgery. We have no idea as to how much weight will be lost. And, this is not as important as contour changes. A small weight loss can produce a major contour change.

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