Information on Liposuction and Vaser® Ultrasonic LipoSelection™ from Our Practice Serving San Jose, Palo Alto, and the Entire San Francisco Bay Area

Various systems and techniques can be utilized to perform liposuction, a surgical procedure that removes stubborn excess fat from specific areas of the body. At An Enhanced You Cosmetic Surgery, Dr. Lowen uses the advanced Vaser® Ultrasonic LipoSelection™ system, as well as conventional liposuction techniques, to help his patients from San Jose , Palo Alto, and throughout the San Francisco Bay Area enjoy an improved body contour and renewed self-confidence.

 

 

Traditional Liposuction Overview

Liposuction is the permanent removal of unwanted body fat through small suction tubes placed into fat deposits via tiny incisions. Candidates for liposuction have excess subcutaneous fat, which they may have unsuccessfully tried to lose through diet and exercise. Liposuction is also called "suction-assisted lipoplasty" or SAL, and can be performed utilizing a number of techniques.

Areas commonly treated with liposuction include the area under the chin, the upper arms, the area under the armpit, the chest in men, the sides of the back, the waist, the abdomen, the hips, medial thighs and knees, front and back of the thigh, the buttocks, calves, and ankles. Best results are achieved in patients with definite body contour abnormalities who are near their normal weight. The goal is a smoother, flatter contour and better appearance in and out of clothing.

The liposuction procedure is typically done on an outpatient basis under general anesthesia, although small areas are occasionally done under local anesthesia. A tumescent or super-wet technique minimizes blood loss, so unless very large volumes are being removed, no transfusion of the patient's own blood is needed. Additionally, the newer technique of ultrasonic liposuction can be used for fibrous areas such as the male chest, or for larger-volume fat removal.

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Vaser® Ultrasonic LipoSelection™ Overview

Vaser® LipoSelection ™ is a refined ultrasonic liposuction system available at our Mountain View practice, located near Palo Alto and San Jose. Vaser® LipoSelection™ promises less bruising, more accurate liposculpting, and faster recovery than traditional liposuction techniques. The patented probes gently distribute the ultrasonic energy to allow fat to be broken up and emulsified into a liquid. This emulsion is then removed by gentle aspiration with hollow liposuction cannulas. With the Vaser® LipoSelection™ method, the risks of skin burns that are a concern with conventional ultrasonic lipoplasty have become exceedingly small because the incisions are protected by special port protectors made of plastic that prevent friction or heat injury to the skin and allow for improved healing.

All areas of the body can be treated with LipoSelection™, and outstanding results are possible in difficult to treat, fibrous areas, such as the flanks and male breasts (gynecomastia). Since the Vaser® is a gentle way of breaking up the fat, a smoother result is likely in delicate areas such as the inner thighs. Additionally, just like conventional liposuction, incisions can be carefully placed for minimal visibility and are only a fraction of an inch long.

The advantages of Vaser® LipoSelection™ ultrasonic assisted liposuction over conventional liposuction techniques are that it is less fatiguing for the surgeon, particularly when larger volumes of fat are removed. Also, gentle emulsification of fat is less traumatic to non-fatty tissues, sparing nerves, blood vessels, and fibrous tissue so patients experience less post-operative pain or discomfort.

For further information on Vaser® LipoSelection™, contact our practice serving San Jose , Palo Alto, and the entire San Francisco Bay Area, or visit http://www.soundsurgical.com/

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Liposuction Recovery

After surgery, the patient wears a compression garment for five to seven days. Most patients are active within two days and return to work and social activities in three to seven days. Patients having liposuction procedures at the waist and above feel comfortable being active sooner than those having procedures on the buttocks, hips and thighs. The post-operative garment is changed to a permanent spandex-type garment at one week, and usually worn for a month. The compression helps to resolve swelling and mold the desired contour. Bruising and swelling decline during the first one to two weeks. The results are apparent within the first two weeks, but to appreciate the final result requires resolution of the swelling which gradually decreases over a period of three months.

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Key Liposuction Terms

Liposculpture: This term was coined to denote the philosophy that removal of fat should be approached in a thoughtful way and done artistically and carefully. We are trying to create a pleasing form, so what is left behind is just as important as what is removed. Lipoplasty is not a treatment for obesity, and gross removal of fat is not the object. The techniques to achieve liposculpture take time and experience to refine.

Cannula: (can´-nu-la) A small, metal tube that removes the fat during the liposuction procedure, cannulas have been in a constant state of development and change during the past fifteen years. They generally have blunt tips and one or more openings at or near the tip. Different tip shapes and arrangements of the openings suit different purposes and surgeon preferences. Cannulas are hollow and are attached at the handle end to a suction source.

Suction: Pulling the fat through the cannula requires a source of suction, which is accomplished using either a vacuum pump connected to the cannula by tubing or a large syringe specially fitted so that when the plunger is withdrawn and locked in place, a suction is created. Both are equally effective and their use during the liposuction procedure is a matter of surgeon preference.

Superficial Liposculpture: The need for refinement in lipoplasty was clear when the techniques of deep fat removal alone often resulted in waviness and depressions, particularly in the hip and thigh area. A thick skin and fat flap unsupported by the deep fat will droop. Folds and waviness of the contour can occur. The goal of superficial liposculpture is to refine the contour, not just remove deep fat. Suctioning with fine cannulas below the skin surface, and sculpting the contour from the outside in allows the skin to contract over the reduced surface. If done sensibly by avoiding trauma to the skin, and leaving a smooth layer of fat on the under surface of the skin, superior contouring results can be obtained, compared to suctioning deep fat only.

Skin contraction is best when the skin has retained some youthful elasticity, but the ability to achieve good results in patients whose skin has lost some elasticity makes it possible to recommend liposuction to some patients in their fifties and older.

When SAL was first developed, cannulas as wide as 6 mm were used. The risks of excess fat removal along the path of the cannula resulting in depressions or grooves was correspondingly large. With years of experience, Dr. Lowen has found it possible to use cannulas in the range of 2.5 to 3.7 mm for the majority of liposuction patients. Using highly efficient cannulas and lower than usual suction, a degree of control of the process can be obtained that justifies use of the term liposculpture.

Super-wet or Wet Liposuction: The instillation of a ration of salt solution and dilute adrenaline into the fat compared to the total amount of fat and fluid to be removed, prior to beginning suction. It is not necessary to add the anesthetic, lidocaine, but reasonable amounts based on body weight are usually added for post-operative comfort. The total blood loss is about 1 percent of aspirate. Most plastic surgeons perform liposuction under general anesthesia and do not depend on fluid instillation for anesthesia. Using lower fluid volumes results in the same minimal degree of blood loss as using larger fluid volumes. Using smaller volumes of fluid decreases the risk of fluid overload, and allows safe removal of fat in the range of 2500-5000 cc, which many patients require to obtain their desired result. Using smaller amounts of fluid does not distort the tissues, so final shaping of the contour is more predictable.

Tumescent Liposuction: It is possible to do liposuction in an office setting under local anesthesia by instilling large volumes of salt solution, combined with an anesthetic, lidocaine, and dilute adrenaline into the tissues in a ration of approximately 3:1. Three times as much fluid is instilled as the anticipated fat and fluid removal. Blood loss is about one percent of total aspirate. The amount of fluid instilled results in a swollen or "tumesced" contour of the area with a tense skin surface. Tumescent liposuction is a drug-delivery system for anesthesia, as opposed to the wet or super-wet techniques which were developed by plastic surgeons to minimize blood loss. The tumescent technique was developed by Dr. Klein, a dermatologist, and allows liposuction to be performed without general anesthesia. This is reasonable if it is done within sensible guidelines for volume removal, in a well-equipped surgical facility, and with care to ensure sterility.

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In-Depth Liposuction Discussion

Lipoplasty, SAL, or liposculpture by any of its names is the most often performed cosmetic surgery procedure. Estimates are that more than 100,000 cases are done yearly. Along with these reports are disturbing reports of fatalities associated with liposuction. We now have a situation where an elective, cosmetic procedure had a mortality rate of 60/100,000, in 1998, compared with childbirth which has a mortality rate of 6/100,000.

The problems of severe complications or death seem to be associated with large-volume fat removal, over 5,000 cc of total fat and aspirated fluid, or when large-volume removal is combined with other cosmetic procedures, prolonging the operative time, or perforation of the abdominal cavity by the cannula. There was no mechanism for reporting deaths due to cosmetic surgery by the coroner's office, so the incidence of problems was probably under-reported.

Things have greatly improved since 1998. In the last period for which statistics were available (1999-2001), there were zero deaths reported by plastic surgeons. And California has passed legislation that requires reporting of any death that occurs in an outpatient setting or any hospital transfer that results in more than 24 hours of hospitalization. However, even though the safety of the liposuction procedure has improved, as with all surgery, there are still risks involved.

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Liposuction Risks

The potential risks of liposuction surgery are described below. Visit our center near Palo Alto and San Jose to learn how Dr. Lowen’s experience and careful treatment planning help minimize these risks.

 

Fluid Overload

Giving too much fluid, too fast, in relation to a person's body weight and circulatory system capacity will lead to excess fluid in the lungs and stress on the heart. This can result in pulmonary edema (fluid in the lungs) and heart failure. Fluid overload is avoided by doing one area of liposuction at a time and limiting fluid instillation to a safe amount, as determined by surgical judgment, training, and experience. This experience is best obtained in a surgical training residency such as general and plastic surgery where problems of shock, trauma, fluid balance, burn care, resuscitation, and the body's response to injury are part of the core curriculum of training.

If one wants to perform a typical liposuction of 3000 cc on a patient who is 5'6", 140 lb., with removal of excess fat of the abdomen, flanks and hips, one proceeds from area to area. One does not instill 4-5000 cc of fluid all at once. About 60 to 80 percent of the fluid instilled will remain in the body, and this is taken into account by the anesthesiologist so excess fluid is not given intravenously. Retention of fluid in the body is a good thing, since after surgery, the area liposuctioned will draw fluid out of the circulatory system. The 60 to 80 percent retained fluid acts as a reservoir to prevent a drain on the circulatory system which could otherwise cause dizziness, low blood pressure, or even shock.

The post-operative compression garment also acts as a G-suit (aviator's gravity suit) to keep excess fluid from re-accumulating in the suctioned areas. By keeping the garment on for three to five days, fluid equilibrium is gradually re-established and the patient is protected from sudden fluid shifts out of the circulatory system during this period.

After one or more areas are suctioned and fluid is partially removed, a margin of safety is provided for additional fluid added to the next area to be suctioned. In this way it is possible to remove 5000 cc's of fat safely, although the typical liposuction case is less than that. Large men and women with fat in a circumferential distribution around the thighs can easily approach the 5,000 level. If, however, one attempted to take 5,000 cc of fat out with a "tumescent" technique, and instilled a total of 15,000 cc of fluid or 15 liters, it is easy to see how problems of fluid overload could occur. If the fluid were not instilled very carefully and extracted sequentially, it would be easy to put the patient into a state of fluid overload and pulmonary edema. If the liposuction procedure were done in an office setting, and not in an accredited surgical facility fully equipped for cardiopulmonary resuscitation and staffed with trained and experienced nursing and anesthesia personnel, the chances of adequately treating respiratory failure, cardiac failure, or cardiac arrest would be decreased.

 

Scars

Papers published to show the results of lipoplasty, particularly ultrasonic liposuction, often show scars in places where scars are not desired and are a poor trade-off for the results obtained. Since the quality of scar healing is a combination of gentle tissue handling and a patient's own healing potential, it is best to place the scars where they will be least visible. In Dr. Lowen’s opinion, the 3/4" scars in the lower back above the sacrum, the lateral abdomen, or the mid-back in the bra-line, are not reasonable trade-offs for the purported advantages of ultrasonic liposuction. They are not in natural folds or wrinkles and are tip-offs of surgery. Please refer to the discussion on UAL above and see the references at the end of this section for a discussion of the pros and cons of UAL.

To minimize scarring for his liposuction patients, Dr. Lowen tailors the procedure to their specific needs. If he is treating the under arm or lateral back, he works from a hidden, underarm incision and a small flank incision with the skin edges protected from friction injury by a small plastic skin protector. The abdomen is treated by non-visible incisions in the pubic hair and umbilicus. The lateral hips by a single incision in the buttock crease, if possible, and an additional incision at the upper part of the hip bulge if necessary for larger fat deposits. The anterior thighs are treated through a groin incision and the knees and lower thighs by an incision behind the knee in a skin crease. Dr. Lowen tries to avoid an incision on the anterior knee when the front of the thigh is treated, but sometimes this is necessary. Asian and Hispanic patients tend to form thicker or darker scars, and this should be discussed when incisions located in more visible areas such as the front of the knee are planned.

Dark or raised liposuction scars are treated at our practice by ruby laser (removes brown pigment), vascular laser (flattens raised or persistently red scars), or surgical revision, depending on which technique is most likely to improve the scar in a given patient.

 

Infection

The risk of infection after liposuction is very low, and it is even lower in our practice than the usually quoted rate of one percent for clean surgery. Should it occur, it is usually a local reaction with redness and discomfort around one of the access incisions. These superficial skin infections are easily treated with oral antibiotics. However, serious, life-threatening, and fatal infections have been reported after liposuction. These infections can strike fast, spread quickly under tissue planes, and result in death of skin and the need to surgically remove the infected skin to prevent further spread, septic shock, and a potentially fatal outcome. The medical term for this severe infection is necrotizing fasciitis (fash-e-itis). The bacteria involved are usually a combination of streptococcus and gas-forming organisms that grow best under conditions of low oxygen.

The post-operative course of liposuction is usually mildly painful during the first several days after the lidocaine effect has worn off. Oral pain medications should be sufficient. If, however, there is an unusual and increasing pain, usually localized and not widespread, that is an indication of infection and must be investigated promptly. If a serious infection is suspected, the patient must be hospitalized, wound cultures taken, and antibiotics started immediately. Further treatment may include surgical debridement (removal) of infected skin, and after all infection is controlled, reconstructive surgery. The result will be some degree of undesired scarring as a result of skin grafting or flap reconstruction, but the need for surgical treatment in the interest of the patient's survival obviously takes precedence.

In an accredited surgical facility, where the background of the operating surgeon is a surgical residency, the techniques of sterile surgery are likely to be well known and observed carefully. The performance of liposuction in an office minor surgery suite or in an office exam room may pose an increased risk of infection. Small liposuction procedures, such as removal of a small amount of residual fat after a major procedure or minor removal of fat around the abdomen or hips, are reasonable to do in a well-equipped office surgical suite. Although the risks of infection are small, they are minimized by formal surgical prepping and draping, and formal surgical garb including gown, gloves, and mask. Performing liposuction wearing only gloves is sub-optimal in terms of sterility.

 

Venous or Fat Emboli

Emboli are uncommon risks which can occur in the post-operative period. Blood clots which may form in the legs can travel to the heart and impair circulation. Small fat particles or metabolic products of fat called free-fatty acids are thought to damage cell membranes in the lungs, causing fluid to accumulate. While there is no specific prevention for these conditions, precautions such as calf-compression devices are usually worn during surgery. Secondary symptoms would be shortness of breath, rapid heart rate, and chest discomfort. Treatment is medical, supportive, and directed at the underlying cause.

 

Perforation of a Body Cavity

A liposuction cannula should be used delicately and with care, since it is possible for it to go under the abdominal muscle into the abdominal cavity and injure the liver or bowel. Deaths have been reported from this error. Liposuction is not just grossly removing fat. The person performing liposuction potentially has your life in his or her hands. Particularly around the abdomen, waist, flanks, chest, and rib cage, care must be exercised to maintain the direction of cannula movement parallel to the body surface with the tip directed in an outward direction. This is quite possible to do accurately and well, with direct observation of the cannula position, intentional directing of the cannula tip, and use of the opposing hand to feel the cannula through the skin.

If after a liposuction procedure on the abdomen or flanks, abdominal pain, nausea, dizziness, or weakness is noted, the matter must be brought to the attention of the attending surgeon and the possibility of abdominal perforation must be ruled out. The situation would be similar to a perforated appendix. Delay makes matters worse, and if in doubt, or if you were unable to reach your surgeon promptly, a trip to the emergency room for evaluation by a general surgeon is critical and urgent.

While it might be reassuring to think that such an event could not happen if your surgery was performed by a board-certified plastic surgeon, you should know that such abdominal perforations have occurred when the procedure was done by well-trained plastic surgeons. Therefore, you should be well-informed and aware of the potential problem.

 

Delay

The main factors involved in severe patient morbidity and death after liposuction are failure to recognize and treat or refer for treatment the symptoms of infection and abdominal perforation. Fluid overload is usually recognized in the immediate post-operative period. Lidocaine toxicity may not be manifested until after the patient returns home, and infection usually becomes symptomatic one or two days after the procedure.

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Lidocaine Toxicity

The amount of lidocaine, the local anesthetic used in tumescent liposuction, that can be safely given to a particular patient depends on that patient's body weight. When given in a salt solution combined with dilute adrenaline, a vasoconstrictor, the total amount of lidocaine that can be given safely is much greater than the amount one could administer without adrenaline. This is the principal behind the tumescent technique and why it can be an effective drug-delivery system to achieve local anesthesia. The lidocaine must be distributed throughout the fat deposit for it to be an effective anesthetic. This is why so much fluid is used, as a vehicle, in the tumescent technique. Plastic surgeons usually put some lidocaine into their infiltration solutions, more for post-operative pain control than for anesthesia for the liposuction procedure. Lidocaine toxicity would not occur with these small amounts, but if the procedure is done solely under local in a doctor’s office, then the risk of lidocaine toxicity becomes a concern.

With a comprehensive approach to fat removal and sculpting, working around the abdomen and rib cage and doing multiple areas during the procedure, Dr. Lowen has found, as most plastic surgeons have, that general anesthesia is much more comfortable for the patient. Anesthesia is excellent and there is no concern about the patient moving or having discomfort or awareness. This allows Dr. Lowen to concentrate on the procedure. The possibility that a patient will move or feel discomfort while the plastic surgeon is working around the ribs or abdomen is avoided. Obviously great care must be taken in this area to avoid penetration of the abdominal or thoracic cavity by a liposuction cannula. A well-anesthetized patient thereby enhances the safety of the procedure. The anesthesiologist, a board-certified physician, has responsibility for the patient's anesthesia.

If the safe lidocaine level is approached after three to five liters of fluid are instilled, depending on the patient's body weight, further infiltration is done without lidocaine. The solution still has adrenaline, the vasoconstrictor, to prevent blood loss, and the risk of lidocaine toxicity is avoided.

If a 3:1 ratio of fluid to aspirate is used, and all this fluid contains lidocaine, either the amount of fluid and fat to be administered and removed during liposuction must be limited in a disciplined way, or excess lidocaine and fluid will be administered. The safe level of lidocaine is not an absolute, and reports of levels thought previously to be very high are being reported in the dermatologic literature as safe. The problem is that as higher levels of lidocaine are being used in an attempt to remove more and more fat in an outpatient office or surgical suite setting, risks of lidocaine toxicity are increased.

Lidocaine toxicity is manifested by ringing in the ears, a feeling of numbness around the mouth, dizziness, then seizures, low blood pressure, followed by circulatory collapse and cardiac arrest. Since individuals vary in their susceptibility to lidocaine toxicity, it is better to use as little as possible.

The combination of lidocaine toxicity and fluid overload are major factors in morbidity and mortality from liposuction.

 

Waviness, Unevenness, Surface Depressions, Abnormal Appearance

These liposuction complications are minimized by careful technique with even, incremental removal of fat using small diameter cannulas. Excess removal of fat in a woman's abdomen or hips can lead to an undesirable wrinkled appearance or masculinization of the abdomen. One should not "take out all the fat" as patients sometimes request.

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Summary

Since lipoplasty is the most commonly-performed cosmetic procedure today, many patients will be looking for its benefits and subjected to its risks. Having outlined the risks in a realistic fashion, it is important to remember that the level of overall satisfaction for liposuction is very high. It is one of the most satisfying procedures in Dr. Lowen’s practice for that very reason.

Removal of unwanted bulges, allowing you to wear smaller sizes of clothes, easier fitting of sizes that finally fit both hips and waist, an end to the frustration of dealing with fat that will not go away with diet and exercise, and sometimes dramatic transformations of body image, particularly in men, are the benefits to be anticipated.

Dr. Lowen’s preference is for LipoSelection™ by Vaser®. Refinement is accomplished after ultrasonic emulsification by small-cannula, usually power assisted, using a deep and superficial technique. Effort spent sculpting body contour at the time of surgery is well worth it. Excellent surgeons obtain excellent results using both suction lipoplasty and ultrasonic-assisted liposuction. UAL should be combined with SAL for best results and highest margin of safety if it is used.

Simple fat removal is not the goal with liposuction, recreating a lovely form is. The procedure is not a treatment for obesity, and best results are obtained in patients who are close to their ideal body weight. To learn more about Vaser® Ultrasonic LipoSelection™ or other liposuction techniques at our practice serving Palo Alto , San Jose, and the entire San Francisco Bay Area, please contact our plastic surgery center today.

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To learn more about Vaser® Ultrasonic LipoSelection™ or traditional liposuction options, contact our Palo Alto area office serving San Jose and the entire San Francisco Bay Area.