Liposuction—— what you need to know
An experienced plastic surgeon’s viewpoint by
Dwight V. Galloway M.D.
Suction assisted lipectomy, or liposuction, means removing fat using negative pressure and came to us in 1983 from a Frenchman named Dr Yves Illouz. He had been using the technique of blunt tipped hollow tubes he called “cannulas” for several years before that and used large one centimeter in diameter tubes. He introduced the technique to the American plastic surgeons at our yearly meeting in Honolulu. Our, at first, cool reception turned to overwhelming acceptance by the plastic surgeons and we have since made many changes to his system but it is still the fundamental procedure. The most notable additions have been the use of much smaller tubes and various ways of liquefying the fat, such as laser and ultrasonic sound, mainly to decrease the amount of physical work required on the part of the surgeon. It is hard work! There have many claims of techniques to make the skin contract over the area of fat removal but in reality any method that removes the fat will give about the same result and Dr. Illouz will still tell you that. The operation does indeed damage the tissue supporting the fat cells and there is some numbness for up to 4 months after surgery, with all of the various methods, but permanent loss of feeling has not happened in my 28 years of doing the procedure. It is so common now as to be just another surgical instrument and is usually added to other procedures to help sculpt the body shape. For many years the breast was considered an area to be avoided because of the occasional calcification of damaged fat tissue that looked like the same identifying signs of breast cancer. However recently it is accepted and the X-ray doctors say they can tell the difference. The usual areas we treat are the body fat “depots” where we put on fat first and give it up last i.e. the abdomen, waist line, hips, inner and outer thighs and occasionally the area of the neck under the chin. Men have a different general body fat distribution than women with men getting more in the body and women more in the hips and thighs. Suctioning in areas that are not depots can give real dents as there is not enough supporting tissue to keep the skin from sticking to the muscle and the scar prevents us from filling out these areas with fat. Recently fat grafting to various areas has come into practice but much, if not all, of the injected fat is absorbed over the first 6 months after surgery.
The general technique of liposuction is to make a tiny puncture incision in an area usually covered with clothes or in a body crease and the metal “cannula” inserted into the fat and many passes thru the fatty tissue with the suction on and the fat sucked up into a jar. Nearly everyone now injects some form of local anesthetic with epinephrine into the area a few minutes before the suction is started to cut down on the bleeding and blood vessel damage in the procedure. The areas of desired fat removal are usually marked with a heavy marking pen with the patient standing shortly before operation and often photographs are taken with the marks in place for future evaluation. Repeat treatment in the same area gives a very limited improvement because most of the fat is removed at the first operation, and the resulting scar tissue makes it much more difficult to pass the cannula through the second time. The operation requires general anesthesia as it is quite painful under local anesthesia, ever with sedation. The nerves in the area are pulled on by the cannula suction and they are connected to the spinal cord like strings. If you pull on one end the pull is transferred directly to the spinal cord. In the face and neck there is a “ganglion” in between so the area under the chin can be done without pain under local anesthesia alone. Generally compression garments are used for about 6 weeks after operation, mainly for comfort after 3 weeks, because walking or other exercise pulls on the nerves in the resultant scar and makes you feel like your skin is falling off. The use of laser or ultrasound devices on the cannula tip can result in skin damage so great care must be used to prevent hitting the skin with those devices. The standard cannula is not so dangerous. Generally this is a very safe operation and many non plastic surgeons have used this procedure safely. The main complications are the “lumpy bumpy” results from irregular fat residuals and the “holes” left after taking out too much fat. Getting the skin to retract enough may require a surgical excision at the time of operation or even later. We cannot remove fat inside the abdominal cavity and doing the upper abdomen at the time of a full abdominoplasty is dangerous to the skin at the midline above the pubis. Not all the volume of tissue between the skin and muscle is fat and that will not come out through the cannula. In general, liposuction is a very good, safe and simple technique in the hands of a trained and experienced surgeon and an excellent addition to our armamentarium.
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