Liposuction

I think there are really several reasons for this. First of all, there have been some wonderful refinements in the techniques of body contouring surgery, and these have led to improved liposuction results. Over time, when results from surgery improve, patients tend to speak about their experience positively, and this probably affects the overall level of interest in the society for a given surgical operation. I also think that there are changes in our society overall which contribute to the increase in liposuction popularity. Certainly in the last decade or so, there is an increase in emphasis on physical form in our culture. We have certainly come a long way from the old pattern where people kept themselves in shape in their 20s, then they got married and began an inevitable downhill course. Once you had your kids, it was expected that you would just sag and turn into mush. The woman would hide everything under bulky dresses, and the men would wear loose fitting business suits.

Now, many of my patients deliver babies, and the first question out of their mouth is “when can I get back to the gym to work out?” Even the casual dress movement has probably contributed to this especially for men in the work environment, since they can’t hide all that extra fat as well. Obviously, I am being a little light-hearted in my description here, but we really have witnessed what I view as a wonderful trend in our society where people view exercise as an important part of their lives and keep up with it well into their 70s and 80s and beyond. The benefits of this are obvious. People are healthier, sleep better, and have more energy but we probably also get a little pickier about our appearance when we invest so much energy in it. As you push the exercise to a certain point, depending upon your genetic make-up, you may find that despite everything you do, there are certain zones that are quite simply resistant to diet and exercise. This is where liposuction can be helpful.

An ideal liposuction candidate would be someone who exercises regularly, is careful about diet, and has not experienced major weight fluctuations. They are close to their ideal body weight. Despite these measures, they have certain zones of fat that have been resistant to diet and exercise, and the skin tone in these areas is excellent. Their goal is to improve the visual harmony of the body, as well as to improve the fit of clothes across certain zones of the body. Of course, the person should be in excellent health.

Obviously, someone who falls into this ideal category is likely to get an ideal result. I don’t mean to imply that I don’t operate on anyone outside of this category, but it is just that as we move further away from this ideal, clear and accurate communication between the doctor and patients becomes very important to achieve the best possible liposuction results.

I do not have arbitrary age limits. When I am evaluating a liposuction candidate, I am looking at the patient’s goals, the quality of the patient’s skin tone, and the patients’ general health. There are patients in their 20s who I turn down for liposuction surgery, and there are some in their 60s who are acceptable candidates. It all comes down to a matter of individualized assessment.

In general, when you perform fat-reduction surgery outside of the classical zones where the fat is organized in a different way, it is much more likely that there will be undesirable surgical consequences, such as diminished skin tone or surface irregularities. I am not saying that I never perform surgery outside of the classic zones, but it is just that doctors who do so have to very carefully evaluate each patient. In the classic zones, we will often perform what I refer to as finesse liposuction. This is in an individual who is already in very good shape, for whom a relatively minor adjustment of contour may be done to further improve the artistic lines of the body. It would be a mistake to perform this type of surgery outside of the classic zones, because the risk/benefit ratio would not be in the patients’ favor.

What happens if you perform liposuction outside of these areas?

In general, when you perform fat-reduction surgery outside of the classical zones where the fat is organized in a different way, it is much more likely that there will be undesirable surgical consequences, such as diminished skin tone or surface irregularities. I am not saying that I never perform surgery outside of the classic zones, but it is just that doctors who do so have to very carefully evaluate each patient. In the classic zones, we will often perform what I refer to as finesse liposuction. This is in an individual who is already in very good shape, for whom a relatively minor adjustment of contour may be done to further improve the artistic lines of the body. It would be a mistake to perform this type of surgery outside of the classic zones, because the risk/benefit ratio would not be in the patients’ favor.

Are there any other things that you look for in a patient in order to predict the success of liposuction surgery?

Yes. When I look at my patient, I always have in the back of my mind what I refer to as the four keys. The first is a classic zone of fat distribution with the rest of the body in relatively good shape. This is the one we have already talked about. The other important criteria are that the skin tone should be acceptable, that the patient should be in good health without significant medical problems, and that the patient’s expectations should be realistic relative to what contemporary liposuction techniques can offer.

Are there any other things that you look for in evaluating a liposuction patient?

I believe that the holistic approach for the patient seeking liposuction or any body contouring surgery is absolutely essential. You can’t separate a surgical procedure from the context of a patient’s lifestyle and activities if you are truly interested in providing a good long-term outcome for your patient. A patient may appear to be a good physical candidate for the procedure, but if you find out that this is the type of patient who really doesn’t have a good exercise program and is constantly cycling up and down in their weight, there is a very high probability that the result will be mediocre. It makes me sad when I see patients who haven’t been dealt with honestly in this regard—where they have been promised some sort of a quick fix, and no one has taken the time to try to figure out whether their lifestyle is an appropriate balance for liposuction surgery. The patient’s interest should always be put first, even if that means telling the patient no.

You mentioned that liposuction has gone through a process of technical refinement. Could you describe this a little more for me?

I have very much enjoyed witnessing and participating in the evolution of body contouring surgery. When liposuction was introduced to this country in the mid ’80s, it was relatively crude. Nonetheless, it represented a significant advance over the only other option that was available at the time. Previous body contouring surgery techniques resulted in very long scars in common locations, and this was unacceptable for most people in the United States. The great advance in liposuction came when doctors realized that fat could be extracted through relatively small incisions, using long hollow tubes called cannulas. The first liposuctions resulted in significant bleeding and bruising, and the amount of fat that could be removed safely in a single session was quite limited. There were also problems with the finished details of the work, since the initial cannulas used for liposuction were very large and tended to produce irregularities. We then entered into a refinement phase, as people began to design the cannulas smaller and with different tip configurations, so that there was more finesse in the liposuction procedure.

The next big liposuction advance came in the early ’90s, when it became widely appreciated that there was an advantage to introducing fluid into the area of liposuction prior to the fat extraction. This fluid, which is the same solution used in an IV, was mixed with a local anesthetic and a vasoconstrictor know as epinephrine. To those of us who were working with this liposuction technique at the time, the advantages of this advancement were very apparent. I found that the fat came out more easily and more uniformly. There was also much less bruising and blood loss, so that it become possible to contour several zones at the same time.

By the mid 1990s, I became very intrigued with the technique known as ultrasonic liposuction, pioneered by an Italian surgeon. Here, the concept of fat removal was fundamentally different from what had come before. The earliest liposuction techniques were essentially a mechanical disruption of the fat, followed by suction to withdraw it. With ultrasonic liposuction, ultrasonic energy of a specific frequency is used to break apart the fat cells, and specialized cannulas are then used to remove the fatty material. I was intrigued when the early pioneers of this liposuction technique began to present results that, quite frankly, were better than what I was obtaining at the time. I become very interested any time this sort of thing happens, because I always want to advance the state of the art for my patients. As with any new idea, it is important to figure out whether this is just hype or whether there really are advantages. After carefully investigating it, I began to use the liposuction technique in selected patients. I was one of the earliest adapters of this liposuction technique in the Chicago area, and as I worked with it, I found that the results I was obtaining really were better than what I had obtained with the classical techniques—especially in certain zones.

I have continued to advance my technique of liposuction as new technologies become available. I now make frequent use of techniques that employ laser and radiofrequency energy.

Could you describe for me what the liposuction surgical experience is like?

One of the most important steps in liposuction surgery actually occurs before the operation itself. This is when I meet the patient in the pre-operative area and make detailed topographical markings on the body to guide me during the surgery.

When I perform surgery at the surgicenter, there is very little recollection that goes on from the patient’s perspective. The surgery is mostly carried out under a very light general anesthetic, so that there will be no memory of the actual events of the surgery. The liposuction patient will wake up in a private recovery room. He or she will be wearing the appropriate support garment, usually with some extra padding in place to put pressure on the zones where I have extracted the fat. Most liposuction patients tell me they feel a little chilly, but are not particularly in pain. This is because the solution that I put in prior to the liposuction has a local anesthetic. Most patients will be able to go home after an hour to an hour and a half.
When I perform surgery with the patient under local anesthesia with oral sedation in my Chicago or Winnetka office, the patient is pleasantly relaxed during the procedure. Often, he or she will take a short nap while I am performing the surgery. When the surgery is finished and the garment is in place, the patient walks from the operating room to the recovery area and is able to go home in a short while.

The next few days are essentially spent in couch-potato-type activities. It is okay to get up and go for a short walk—in fact, this is encouraged—but we don’t want excessive motion across the areas of surgery. Most liposuction patients will come back to see us in three to four days, at which time the preliminary support garment is removed, and they are fitted with a fresh support garment. From that point forward, the patient may shower as he or she desires and return to work as long as it does not involve extremely stressful activity. The patient is usually able to resume gentle exercise such as walking, treadmill and Stairmaster by the middle of the next week. I don’t want to see exercise that causes a shearing motion across the zones of liposuction or extreme exercise for several weeks.
I do believe that the support garment is very important. This is a girdle with zippers on either side, which applies compression to the zones of the liposuction surgery. I think that this helps to squeeze the swelling out and hold the skin in
place so that it will settle into a good pattern.

It seems to me that one of the hardest things in performing liposuction surgery would be to judge just how much fat you want to take. Is that the case?

I think this is one of the most important aspects of body-contouring surgery, and there is absolutely no substitute for the experience of the surgeon in this regard. To rephrase your question a little bit, not only is it important to consider how much fat you take during liposuction, but even more important is how much you leave. Some of the newer techniques are very powerful. Unfortunately, in inexperienced or injudicious hands, this can lead to some very sad outcomes.

What happens if you overdo it?

If you “overdo” liposuction, you lose the beautiful curves of the body, and you get loose skin. I guess it all comes down to a matter of artistic vision. For me, body contouring surgery is about adjusting the curves, not eliminating them.

What can patients do to make sure they not only have a good outcome, but a safe one?

That’s another very important question. In general, there are several factors, which, in my opinion, significantly increase the riskiness of the procedure that every patient should be aware of.

The first problem can occur when an injudicious surgeon chooses to extract very large volumes of fat, especially in the outpatient setting. Under these circumstances, between the amount of fluid that is added to the body prior to the liposuction and the amount of fluid and fat that is removed, there can be some very significant changes in the patient’s physiology—not unlike those that occur with trauma. Unfortunately, we now see people taking weekend courses and proclaiming themselves experts in this type of surgery, when they haven’t even studied the basics of surgical physiology or had no practical exposure to it in their training. This leads them to underestimate the risks of what they are putting their patients through and really push the envelope. I, for one, am not interested in using liposuction to extract massive volumes of fat from people. Most of these people have an eating disorder, and they are just going to put the fat back on, even if the procedure could be done with safety.

A second problem comes up when surgeons are not strict in their criteria for patient selection. If, for example, a patient has a heart problem, why should you do elective surgery like this? Of course, if you combine poorer patient selection with large-volume liposuction, they are really flirting with disaster.

Last but not least, there is the issue the surgeon’s quality and training. It is a matter of considerable personal sacrifice for an individual to obtain the full training necessary to be a board-certified plastic surgeon. There are always individuals who will want to cut corners and take the shortcut. The problem with people who take weekend courses is that they may be seduced into believing that they really are doing a simple piece of surgery—but not understand in any way the physiology of what they are doing. This is where truly frightening things can occur.

How do you select a doctor to perform liposuction?

I would certainly recommend that anyone considering liposuction surgery should check the doctor’s educational credentials very carefully. If that doctor doesn’t have a strong background in surgery and surgical physiology, then you might want to think seriously about looking elsewhere. The reason for this is simple: These doctors may not even be aware of the potential for danger and so blunder into situations that a more knowledgeable physician would avoid. Look for doctors who are certified by the American Board of Plastic Surgery and members of the American Society of Plastic Surgery, since they have gone through many years of advanced training. Ask about a doctor’s hospital admitting privileges. After you have lived in an area for a while, you have a general sense of which are the better hospitals—and even doctors who perform surgery in their offices must maintain hospital affiliations.

Why is skin tone important when you evaluate a patient for liposuction?

This is probably one of the easiest traps for the inexperienced surgeon to fall into. If you evaluate a patient without assessing skin tone, she may appear to be a very good candidate for the surgery; yet when you extract the fat, the skin does not contour in properly. It may even hang loose in folds or have other irregularities that will be very annoying to the patient.

What causes patients to lose their skin tone? Is it mostly a function of aging?

Aging may be a part of it, but actually that is not the most important thing. We often see this in people who have a history of very significant weight fluctuation, where they go up and down in their weight and engage in crash diets. This often breaks the elastic fibers of the skin and leaves them in a position where liposuction really won’t produce a very artistic result. Some patients also lose skin tone in the abdominal area when they go through one or several pregnancies. Of course, there are some patients who can carry six children and yet have beautiful skin tone, so this is a highly individual matter. There is also just a genetic component. Some people have very stretchy skin and this will affect the result on anything that I do, be it a facelift or body contouring surgery.

Will exercise help skin tone?

I am always the biggest fan of exercise, but if the skin tone has really been harmed, exercise alone won’t do it. Of course, I will still encourage patients to exercise because of all the other benefits, including tightening of the deeper support structures, which can be beneficial in body contour with or without surgery.

Can anything be done surgically to help patients who have diminished skin tone?

Absolutely. This is where the advanced techniques of body contouring surgery can be a very real benefit to the patient. These include techniques such as abdominoplasty, where not only is extra fat removed, but the skin is tightened, as well as the deeper supporting structures of the abdominal wall. These are more involved techniques, however, and require a longer recovery period than what is typically seen with liposuction. In the past few years, I have used radiofrequency assisted liposuction, which helps to tighten the skin and deeper tissues.

What about the patient who does have some loss of skin tone, but just wants clothes to fit better? Is there any role for liposuction in this patient?

This, of course, would be an important issue to discuss with the patient. If the skin tone isn’t great, the result won’t be great, either, but sometimes there are some zones that are more accommodating than others. One area that frequently bothers patients is the hip region, and this can sometimes respond well to liposuction, even with moderate skin tone loss. It all gets back to placing patients’ needs first and communicating accurately with them.