Chapter 253. Liposuction

Liposuction should be regarded not as a method of weight reduction or an alternative to diet and exercise, but as a body-contouring procedure. The ideal candidate is a healthy patient near his or her ideal body weight who has disproportionate, localized adipose deposits resistant to diet and exercise. Liposuction should be avoided in patients with unrealistic treatment goals and those with emotional or psychological instability (i.e., presence of an eating disorder or body dysmorphic disorder). A comprehensive preoperative consultation including a screening questionnaire is used to identify patients who are appropriate candidates. During the consultation, the risks, goals, anticipated results, and expected postoperative course are discussed.

Taking a thorough medical history will screen for patients who may be poor surgical candidates for liposuction (see Section “Risks and Precautions”). Patients at risk for complications should receive medical clearance before surgery.2,3 A careful review of all medications is essential. All anticoagulant medications, including vitamins and herbal supplements, should be discontinued 2 weeks before surgery. Use of medically necessary anticoagulant therapy is a contraindication for tumescent liposuction. Medications that are metabolized by the hepatic cytochrome P450 3A4 enzyme system should be identified. These medications may interfere with the hepatic metabolism of lidocaine, which leads to the potential for toxicity. They should be discontinued or tapered off 2 weeks before surgery if permitted by the prescribing physician. For patients who are unable to interrupt therapy, a lower maximum dose of lidocaine may be used (i.e., less than 35 mg/kg).

Preoperative laboratory testing includes complete blood count with differential and platelet count, prothrombin time, partial thromboplastin time, and chemistry panel (including liver function tests); serologic testing for human immunodeficiency virus and hepatitis B and C viruses; and serum pregnancy test (for females).2 An electrocardiogram may be considered when the patient is over the age of 60 or when indicated based on the patient's history or a review of systems.

Risks and precautions concerning liposuction are presented in Box 253-1.

Proper patient positioning is essential for safe and effective removal of adipose tissue. Specific positioning maneuvers differ by anatomic target site and are used to avoid important anatomic structures and optimize cannula access to fatty deposits.

Equipment

Liposuction requires the following equipment (Figs. 253-1 and 253-2):

• Tumescent local anesthetic solution
• Infiltration needles and/or cannulas
• Intravenous or peristaltic pump tubing
• Infiltration pump
• Liposuction cannulas (manual and/or powered)
• Aspiration tubing
• Aspiration pump with aspirate receptacles
• Monitoring device and emergency equipment

Anesthesia

Lidocaine is the preferred anesthetic for tumescent liposuction.2 The maximum dose reported to be safe is 55 mg/kg.4 Normal saline (0.9% sodium chloride) is typically used as a vehicle. Sodium bicarbonate is used to buffer the solution, and epinephrine is added to augment hemostasis and slow the absorption of lidocaine. The compositions of tumescent lidocaine solutions ranging from 0.05%–0.1% are shown in Table 253-1. Higher concentrations of lidocaine provide better analgesia and are useful in treating small or sensitive areas. Lower concentrations provide adequate anesthesia and are used when treating large or multiple areas. Accurate recordkeeping of tumescent anesthetic solution preparation and administration is critical to avoid lidocaine toxicity.

Technique

With the patient standing, the target areas for treatment as well as entry sites for cannula insertion are outlined with a permanent marker. The patient is brought to the procedure table and undergoes sterile preparation. Entry sites are anesthetized locally using 1% lidocaine with 1:100,000 epinephrine. These sites are then incised with a No. 11 blade. A blunt-tipped infiltration cannula or 21-gauge needle is inserted, and tumescent anesthesia fluid is delivered to the subcutaneous space. Rates of infiltration and amounts of fluid delivered vary depending on target area and patient tolerance.

Liposuction aspiration cannulas vary in diameter, tip style, and tip configuration. One innovation is powered liposuction using a motorized cannula. In general, larger cannulas with tapered tips and multiple distal apertures allow easier fat removal but also increase tissue injury. The choice of cannula depends on anatomic site as well as surgeon preference and experience. The cannula is inserted into entry sites with the tip apertures facing downward, away from the dermis. Tunneling with the cannula is performed in linear, even strokes with the surgeon's dominant hand, with the nondominant hand, or “smart hand,” controlling cannula tip position at all times. The majority of suctioning should be aimed parallel to the axis of lymphatic drainage to minimize tissue trauma. Uneven or overly aggressive suctioning can lead to contour irregularities and should be avoided. Endpoints can be measured as the time spent in a given area, the amount of fat suctioned, patient discomfort, and assessment of the target area by palpation. The transition from yellow adipocyte-rich aspirate into fat-sparse serosanguineous tumescent fluid is an additional endpoint. Comparative suctioned aspirate volumes and vital signs are also recorded throughout the procedure.

Several studies support the excellent safety profile and high rates of patient satisfaction observed with tumescent liposuction. A 1995 survey of dermatologic surgeons who performed tumescent liposuction on 15,336 patients found no fatalities or serious complications. There were no adverse events that necessitated hospitalization.5 In 2002, Housman et al reported a serious adverse event rate of 0.68 per 1,000 cases in a survey of 267 dermatologic surgeons who performed 66,570 liposuction procedures. No deaths were reported.6 In a prospective study involving 688 liposuction patients, Hanke et al found a major complication rate of only 0.14% and a minor complication rate of 0.57 percent. Eighty-four percent of patients reported high levels of satisfaction with the procedure7 (Figs. 253-3 and 253-4).

The majority of medical and surgical complications from tumescent liposuction, such as bleeding, hematoma, infection, and lidocaine toxicity, can be avoided by comprehensive perioperative patient evaluation and adherence to published guidelines of care. Aesthetic complications such as surface irregularities, persistent edema, and suboptimal target area fat reduction can be minimized by proper patient selection, patient education, and good technique. Dermatologic surgeons performing liposuction should be knowledgeable about the prevention and management of all potential intraoperative and postoperative complications.

Anticipated sequelae of tumescent liposuction include copious drainage from cannula entry sites, ecchymoses, edema, soreness, postural dizziness, and temporary dysesthesia. Proper education and instructions regarding diet, activity, and use of compression garments prepare patients for the postoperative period. The patient must be discharged to the care of a family member or friend. Patients are encouraged to ambulate and avoid immobilization. Heavy exercise and hot baths and showers should be avoided.

A series of follow-up visits is scheduled to assist the patient through the immediate postoperative period and to assess the long-term surgical outcome. Postoperative healing from liposuction is characterized by a protracted period of edema resolution followed by subsequent skin contracture, which leads to a delayed final treatment result. Taking preoperative and postoperative photographs and weight measurements is essential to address patients’ concerns and assess treatment response. Patients are encouraged to wait at least 6 months before judging the final cosmetic result. The performance of touch-up procedures in a treated area should be deferred for at least 1 year.