Dr. Carli's Book on "liposuction"

Introduction

Many men and women are caught up in the battle of diet and exercise in an effort to remove fatty areas that just won't go away. We have done all we can, but these pockets of fat, often around the abdomen, flanks and thighs seem impossible to carve down and create the contour we can only imagine our bodies to have. Now, with liposuction, that body image can become a reality.

Though not a substitute for exercise and diet, liposuction is an excellent procedure. The result is usually quite satisfying, with almost no pain and a short recovery. Indeed, people realize liposuction has a lot of benefits with very minimal risk or inconveniences. These things can be discussed with me during your consultation. Read this book well, and prepare your list of questions regarding, the risks, benefits and limitations of liposuction.

Who is a candidate for Liposuction?

We could say 90% of the adult population to some extent could benefit from liposuction. The best candidates are people who are in good health that dieted and exercised but remain unable to get rid of the fat deposits. Liposuction is good for all people who have reached an ideal weight but have not reached the body image that can please them. It is a procedure for men and women. The result is usually very significant and pleasing to the vast majority of patients. The improvement is durable. If the patient doesn't gain weight again, the areas that were defatted will not get fat again since the fat cells do not regenerate. The fat cells that have been removed do not come back. If the patient does gain weight in the future, weight is more equally distributed over the whole body and does not have the tendency to build up in just those areas.


fig. 1. Android  fig. 2. Gynecoid
The fat distribution differs between men and women, but the treatment is the same.

Technique of Liposuction


fig. 3. The opening of the cannula is directed toward the muscle to prevent extracting subderminal fat.


fig. 4. The fat is sucked out.


fig. 5. Large tunnels in subcutaneous fat.

Liposuction started in the mid 70's in France and came over to this country in 1981. It consists of inserting small suction tubes (fig. 3) through small puncture wounds and suctioning the fat out with a vacuum, (fig. 4) After the fat has been removed, the skin falls and lays flat on the muscle thus making a better contour and form. (fig. 5) Liposuction can be performed under general spinal or local anesthesia. The technique of local anesthesia is called the tumescent technique. The tumescent technique consists of injecting large volumes of fluid with local anesthetic and vasoconstrictive drugs to minimize the bleeding. This solution remains in the suctioned areas for at least 12 hours after the surgery and allows for an easier recovery.

Post-operatively, the patient will wear a compressive garment for at least two weeks. The garment helps the skin conform to the tissues, keeps the swelling down and decreases irregularities underneath the skin.

For liposuction of the face, the compressive garment is less important and can be worn at night for just one week. By the way, liposuction of the face and neck is very rewarding and should be considered more often.

Most people can return to work within a few days following the liposuction. Within a week to ten days, the patient can go back to the gym for light exercise and three weeks later can go back to regular activities.

The Tumescent Technique

If you are interested in liposuction, go to a surgeon well versed in the Tumescent Technique. The tumescent technique has been a breakthrough. I have had the privilege of knowing the surgeon who pioneered this technique and I became well acquainted with it.

If you are interested in liposuction, go to a surgeon well versed in the Tumescent Technique. The tumescent technique has been a breakthrough. I have had the privilege of knowing the surgeon who pioneered this technique and I became well acquainted with it.

Most surgeons use the tumescent technique just to replace general or spinal anesthesia. Though it is true that it can work as just an anesthetic, its main advantages are to prevent complications and make the liposuction easier on the patient. The patient is injected with large volumes of a dilute solution of lidocaine (a local anesthetic) and epinepherine (a vasoconstrictive drug) to lessen pain and bleeding. This solution diffuses through the fat allowing an easier and more even removal of the fat.

The Advantages of the Tumescent Technique:

  1. Lowers the blood loss very significantly
  2. Avoids the depletion of body fluids
  3. Minimizes skin irregularity - the most common complication of liposuction.
  4. Improves to some degree, the cellulite, something that liposuction alone, without the tumescent technique, cannot accomplish.
  5. Alleviates considerably, the post-op discomfort of the first 24 hours.

In short, the tumescent technique makes liposuction surgically less traumatic, medically safer, and cosmetically better.

How I use the Tumescent Technique

I use the tumescent technique for every liposuction case, even when the patient is already anesthetized with general or spinal anesthesia.

  1. If the patient is in good health and has one or two areas to defat, the tumescent technique can be used without any other anesthesia requiring an anesthesiologist.
  2. If the patient has a medical condition or is elderly or there are more than two areas to defat, I use the tumescent technique in association with another of anesthesia such as spinal or MAC anesthesia. An anesthesiologist or CRNA is needed. This approach is the safest. Often, patients that want more than two areas done try to avoid an anesthesiology fee by having them all done with the tumescent technique alone.

I explain to them that it takes longer to administer the tumescent technique for more than two areas without the help of an anesthesiologist. The money saved in the anesthesiology fee is then spent for a longer operating room time. Therefore, there is no gain. Besides, having the anesthesiologist backup is safer.

Ultrasonic Liposuction/ Liposelection

In 1994, Michele Zocchi of Turino, Italy, devised a technique that emulsifies the fat before suctioning it out. This system was introduced to the United States in 1995. It was interesting because the emulsification of the fat allowed superficial liposuction with less skin irregularities. The problem at the time was that the machine caused too much heat, and the cooling system available needed to be improved. Due to the lack of sufficient cooling, burn injuries occurred and ultrasonic liposuction fell into disrepute. I met Dr. Zocchi several times. He told me that his system was very technique-dependent, with a rather long learning curve. He felt that technology would eventually develop a cooling system making that type of liposuction very safe. This technology was developed in the United States in 2000-2001. Two American companies manufacture the Ultrasonic System; Mentor Company, and the Vaser Company.The ultrasonic liposuction is now used nationwide without problems. It is an adjunct that has three indications:

  1. Superficial liposuction in patients with thin or flabby skin
  2. Fibrous fat
  3. Re-do's

Conventional liposuction remains most commonly used. Indeed, the Ultrasonic System is not needed in most cases and does prolong the liposuction time. What we do more today, is conventional liposuction combined with the Ultrasonic System, when indicated. Thus, the Ultrasonic technique is called Ultrasonic Assisted Liposuction.

Power Assisted Lipoplasty

It was devised as an alternative to ultrasonic for superficial liposuction. The MicroAire Power Assisted Lipoplasty Device uses a 2-mm reciprocating movement at 4000 cycles per minute to facilitate the movement of the cannula in tissue. So less force is required, especially in areas with more fibrous tissue. That makes the lipoplasty procedure easier on both patients and surgeons. PALS is not ultrasonic. No heat is generated. I use it in cases of small pockets of fibrous fat and thin skin.

Anesthesia

The advent of the tumescent technique created a controversy about anesthesia between proponents of no anesthesia and opponents of liposuction with anesthesia.

Most cosmetic surgeons, contrary to plastic surgeons, claim that liposuction is feasible by tumescing without anesthesia. They argue that anesthesia adds a risk. Theoretically it is correct. However, with the new monitoring and drugs that are available today, general anesthesia is very safe. The cosmetic surgeons blow the anesthesia risk out of proportion. Actually, the real problem is not medical but economical. Indeed, general anesthesia implies the need for a state certified facility with an anesthesiologist or anesthetist, as well as a fully adequate and fully staffed operating room. The tumescent technique can allow liposuction without all that surgical backup.

To the contrary, the surgeons having a state certified and licensed surgical facility underscore the advantage of combining tumescing and general anesthesia. Liposuction performed this way is pain free intraoperatively. The tumescent technique alone, even under the best conditions, is spotty and somewhat painful. That is why the surgeons have to do a less aggressive liposuction to minimize pain. For the same reason they use very small cannulas, again for less pain. In short, without anesthesia, on the account of pain, fat is left behind.

It would seem that the patient's only choice is between possible anesthesia risk and marginal liposuction. Fortunately, this is not the case. My anesthesia background kept me interested in its advancement. Over fifteen years ago, thanks to the surfacing of more sophisticated monitoring, a new technique of anesthesia, MAC, surfaced. MAC stands for "Monitored Anesthesia Care". It consists of a deep sedation, eliminating the potential risk of general anesthesia.

This technique became popular for use in many minor surgeries. In the case of liposuction, its use with the tumescent technique is ideal. The pain from the tumescent technique and the potential risk of general anesthesia, are both eliminated. In other words, a very thorough liposuction can be performed without pain or anesthesia risk.

I performed liposuction under general anesthesia before the tumescent technique. Then, I tried the tumescent technique alone and saw its shortcomings. To confirm my impression, in 1992, I underwent a liposuction myself with tumescing only. The most famous advocate of this approach in the U.S. was Dr. Jeffrey Klein, a dermatologist cosmetic surgeon in San Juan Capistrano. I went there, paid like a regular patient and had my liposuction done. As I had feared, it was not without pain and enough fat was left behind to require a second liposuction. That second procedure was done by a plastic surgeon, in a state certified facility under MAC. I then understood the MAC is perfectly indicated for liposuction and used it routinely ever since.

The Pain

Very exceptionally, I hear a patient mention the word "pain". It is more a soreness and tenderness that will not keep you off work. Within 72 hours, most patients can go back to work. Three weeks post-op some tenderness may still be present.

After Surgery

After surgery, you will likely experience fluid drainage from the very small incisions left open to prevent fluid collections A drainage tube may be inserted beneath the skin, in some rare cases, to prevent fluid build-up. To help control swelling, you will be fitted with a snug elastic compressive garment to wear over the treated area. The garment is typically worn for up to six weeks, to help your skin fit the new contour.

The side effects of liposuction surgery are soreness, swelling, and temporary numbness. You will still feel stiff and sore for a few days up to a few weeks - pain relievers are provided in case. Antibiotics will be taken for five days. It is normal to feel a bit depressed in the days or weeks following surgery. This feeling will subside as you begin to look and feel better.

Postoperatively

Antibiotics, pain relievers, aspirin, and antiembolic stockings prevent medical complications. Compressive garments, ultrasound treatments and time help the recovery and results.

Compressive Garments:

Everybody agrees that compressive garments help. There are different brands available to keep the patient comfortable postoperatively and reduce swelling as well as skin irregularities. Our patients leave the operating room with a compressive garment on. The question is, for how long? My recommendations vary with the area.

  1. Abdomen, Flanks, Chest, and Arms: Three weeks minimum. Day and night for the first week, and thereafter, daytime only. When there is no longer any seeping from the puncture wounds, you can discontinue the surgical garment that you were fitted with and change to a girdle (Macy's are the best, but J.C. Penney and Sears are fine). When switching to a girdle, buy the cheapest one because as swelling diminishes the girdle will become loose and need to be replaced in order to remain tight.
  2. Lower extremities: 2. The compressive garments need to be worn longer because the swelling lasts longer. Our policy is to wear them day and night for the first three weeks, and then daytime only for another three weeks.

Thereafter, it's up to the patient to continue wearing them for comfort purposes.

The Ultrasound Massaging:

This treatment is performed by our Medical Assistants, twice weekly for three weeks starting when the tenderness subsides, usually after ten days. This helps minimize swelling, skin irregularities, and also raises the level of comfort.

The Time:

At three weeks most of the swelling is gone, but to obtain the end result, count three months. The down time varies with each patient, but after the first week, normal activity can be resumed. You should wait two to three weeks before resuming sports activities.

Skin Shrinkage

Liposuction is a tool used to remove fat. It is now well-known and well-controlled. The main question remains, what about the skin? It is the skin that we cannot control well. The skin is the key factor between an excellent and an okay result with the same liposuction. The better the quality of the skin, the better the result. A good elastic skin almost guarantees a good result. A skin without elasticity due to age, pregnancies, or other causes cannot allow a good result. Elastic skin permits skin shrinkage with a nice smooth contouring result, whereas an inelastic skin can cause flabbiness and/or redundant skin. With an inelastic skin, a good recontouring can be obtained since the fat is gone. It's a good recontouring "with clothes on". "With clothes off", the skin problem becomes apparent. That distinction is very important to understand for people with inelastic skin. The excess and elasticity of the skin are the two main factors determining the results.

Factors influencing skin shrinkage:

  1. Type and quality of skin. They vary with the body area. Neck, arm, and chest tend to shrink well. The lower abdomen skin shrinks better than the upper abdomen skin. The inner and posterior thighs' skin shrinks less well than the outer thighs and inner knees. Genetics pregnancies and age affect the skin elasticity.
  2. Size of the pocket of fat; the larger the pocket of fat, the more the skin has been stretched, and shrinkage will be less.
  3. The type of liposuction; the more fat present just below the skin, the more it will prevent skin shrinkage. The deep liposuction will not achieve good skin shrinkage but it has lower risk of skin irregularities as opposed to superficial liposuction. This is why superficial liposuction, tosome extent, can help the skin that has lost its elasticity. Pre-op we can determine what kind of liposuction to use: deep, superficial, or both. In most cases we use both.
  4. The type of fat; the more fibrous the fat, the more difficult it is to extract the layer of fat just underlying the skin, interfering with superficial liposuction, and in turn with skin shrinkage.

In short, we control the fat well but not the skin. The abdomen illustrates the skin factor well.

Abdominal Liposuction vs. Tummy Tuck

Confusion between the two is common. The abdomen may have an excess of skin, fat and muscle distension, singly or in combination.

The surgery of choice depends upon the type of case. If fat is the only problem, the treatment is liposuction. If it is an excess of skin, the treatment is a tummy tuck, mini or full. (fig. 6) The difference between mini and full has to do with excess of skin above the umbilicus. If there is no excess of skin above the umbilicus a tummy tuck up to the umbilicus is enough. It's a mini tummy tuck. If the excess of skin extends above the umbilicus, the surgery needs to go up to the rib cage. It is a full tummy tuck.

In case of muscle distention only, which is rare, since it is usually associated with an excess of skin and fat, the muscle needs to be tightened up. The skin incision is like that for a tummy tuck. The full tummy tuck is the most extensive procedure in plastic surgery. It has the most complications. It should be reserved only for people that need it, that is to say to correct an excess of skin with or without muscle distention. To the contrary, liposuction is not as major as the tummy tuck. It is less painful with a shorter recovery and fewer complications.


fig. 6. Patient had liposuction and breast augmentation in a first stage.
Followed by breast lift and tummy tuck in a second stage six months later.

Most people that would like to have a tummy tuck actually need a liposuction since for most of them their problem is a fat deposit without an excess of skin. Liposuction done for the abdomen consists more of debulking than sculpting though both are combined for a better contour. After the liposuction you need to wait a good three months for the swelling to come down completely and for the skin to retract. The skin after the liposuction will always retract. The question is how much? In a large measure the amount of skin shrinkage has to do with the type of skin. If the skin has not lost its elasticity, a lot of retraction will take place and there will not be any excess of skin left, i.e., no need for a tummy tuck. The muscle, as opposed to the skin, if distended prior to liposuction, will remain distended. It is up to the patient to decide about a tightening of the muscle three to six months status-post liposuction.

Likewise if, three to six months status-post liposuction, there is redundant skin, a procedure can be done. (fig. 7)


fig. 7. Three views ofa patient that had liposuction anda tummy tuck in two stages.
First stage was liposuction. We can see the excess of skin resulted from liposuction.
A tummy tuck was performed six months later in a second stage.

A second surgery for an excess of skin or a distended muscle is decided on a case to case basis. It must be emphasized that often, after liposuction of the abdomen, due to skin shrinkage, there is no need for a skin procedure. It is difficult for patients to imagine that liposuction might take care of the skin without tummy tuck but we see it. However, it is not possible to say with certainty pre-operatively. That is the reason why we need to wait three to six months after the liposuction to know if anything else is required. Again, the result of the liposuction has less to do with the amount and the type of fat than the type of skin and the condition of the muscle. If the patient has good elastic skin and a non-distended muscle, a tummy tuck may not be needed. The liposuction will suffice.

In cases of full tummy tuck, after liposuction, the scars are more extensive than for a regular tummy tuck due to the amount of skin to be removed. It is the same problem we encounter in post-gastric bypass patients.

The more the skin the more the scars. Sometimes the tummy tuck needs to be repeated to get rid of all the redundant skin. Likewise, a scar revision may be required to correct a bad scar due to bad skin.

A flat and smooth abdomen can be obtained only if skin and muscle have not lost their tone.

How much fat can we remove in one session?

Presently, the standard in California is no more than five liters removed in one session. That figure is kind of arbitrary since there are several parameters that come into play but it is a good guideline.

The abdominal liposuction with a full tummy tuck done in one session would amount to malpractice. Indeed, the risk of combining these two major procedures is too high, the recovery too long, and the cosmetic result rather poor. The tummy tuck without defatting the abdomen in a first stage is contraindicated by plastic surgeons. Before you consult a surgeon, check to see if they are certified by the American Board of Plastic Surgery. Call them at 1-215-587-9322, or the ASPS at 1-800-635-0635, or the California Society of Plastic Surgeons at 1-800-722-2777. A good number of "Cosmetic" Surgeons, meaning not certified by the American Board of Plastic Surgery, are not trained to do a tummy tuck.

Doing a tummy tuck without defatting first is a mistake. Indeed, the tummy tuck with a fat deposit under the skin increases the surgical risk and compromises the cosmetic result. Besides, after the tummy tuck you would still have the fat and need a liposuction later on, in second stage.

Therefore, two surgeries are still necessary. It is important to understand that liposuction after a tummy tuck, cannot give as good results as liposuction before. Indeed the tummy tuck creates scarred tissue that makes the liposuction more difficult and less effective. Furthermore, doing the liposuction after a tummy tuck might create more redundant skin. This excess of skin resulting from the liposuction would require another tightening of the skin, i.e., a third surgery.

The proper way is to defat first and three to six months later take care of the skin and the muscle, if need be. Often times the patients will save themselves a full tummy tuck, i.e., a major surgery by doing liposuction first.

For the above reasons, the standard is:

Liposuction first and wait three to six months to decide if you want or need a skin or muscle procedure. By adhering to this standard, it can save time, money, risk, and obtain a better cosmetic result. Doing the reverse is a surgical mistake.

In conclusion, the advantages of doing the liposuctions first are obvious in terms of:

  1. Minimized surgical risks
  2. Optimized cosmetic results

Of note, again, is the fact that liposuction does not treat cellulite, muscle distension, (fig 8) nor flabby skin, (fig 9)


fig. 8. Liposuction removed the fat, but the abdomen is
still not flat due to the muscle distension.


fig. 9. Liposuction removed the fat. Some skin irregularities are present
due to flabby skin. Skin irregulrities are the most common source
of dissappointment. No excess of skin i.e. no need for a tummy tuck.

Symmetry

When doing two sides, we aim at symmetry. It is a challenge, for nobody has two sides that are exactly the same preoperatively. Furthermore, on the operating table, during the surgery, with the swelling, it can be difficult to make an accurate evaluation of symmetry. Shortly after the procedure, the difference is usually due to swelling and takes three to four months to subside. However, in some cases, once the swelling has disappeared, we can still notice some difference. It is usually subtle and can be readily touched up.

Redos

Liposuction removes fat cells and fat cells do not regenerate. However, as years go by, the fat cells left behind can swell and repeated liposuction can be required in some areas. Repeating liposuction in the same area can be a little harder than the first time on account of scar tissue created by the first liposuction.

Complications and Prevention

Our office gives each patient a long list of complications to read. It is not to scare you, but to let you know what is being reported in the world's literature. The medical complications are extremely rare. I started performing liposuction in 1984, and have yet to see a single medical complication. I am no exception. Most of my colleagues would tell you the same. We occasionally see a cosmetic problem such as asymmetry or skin irregularities. Both can usually be corrected. It becomes challenging only when too much is removed, or if the patient's skin is too thin or flabby.

The causes of medical complications, and the horror stories heard on television, are usually due to "too much" liposuction in one stage, or "too much" surgery when combining different procedures in one stage. Other causes can be missed preoperative medical conditions, or an operating room not meeting safety standards. Poor technique gives bad results but rarely cause medical complications.

The most common cause of death is a blood clot or pulmonary embolization. If the proper precautions are taken, this problem can be almost completely avoided. In my practice, these precautions are taken preoperatively, intraoperatively, and postoperatively.

Preoperatively:

  1. Good workup to diagnose a possible propensity to blood clots.
  2. Starting use of baby aspirin the morning of the surgery.

Intraoperatively:

  1. The use of Pneumatic Antiembolic Stockings and MAC anesthesia.

Postoperatively:

  1. Early mobilization starting the day of surgery.
  2. Wearing Antiembolic Stockings and taking baby aspirin for ten days.

The risk of hemorrhage is not seen with the tumescent technique. The complications that were felt possible with the use of lidocaine and epinephrine of the tumescent technique have been eliminated by a better knowledge of the dosages currently used.

An exceptional case of infection is reported from time to time. The precautions consist of taking antibiotics the morning prior to surgery along with the aspirin. Antibiotics are continued for five days after the surgery. Occasionally, when extensive liposuction has been performed in a patient that has fibrous fat, drains help in preventing the collection of serum fluid that could cause infection.

Conclusion

The front cover of this book shows a voluptuous woman in an 1808 painting. Today, the same woman would not be beautiful and she would probably look for liposuction. "Fat" is fought medically, and surgically all throughout our western world. That's why liposuction is the #1 cosmetic surgical procedure performed in the United States, for both men and women. If you are one of the millions of people seeking information about liposuction, this book should help you understand and prepare for the procedure.

Before and After Photos: Lower Extremities

Before and After Photos: Trunk


Muscle remains distended causing the abdomen not to be flat.


Liposuction of the chest in a male patient.

Before and After Photos: Neck


Neck liposuction combined with chin augmentation.

Dr. Carli, a leading plastic surgeon in the greater Los Angeles area, would be happy to help you achieve your aesthetic goals! Feel free to call us at (951) 688-8660 with any questions or concerns that you may have regarding Dr. Carli, the Magnolia Surgery Center, or cosmetic surgery. We also offer the option of filling out our online contact form. We look forward to speaking with you!