What you Should Know Before Having Liposuction
Liposuction is the most common plastic or cosmetic surgery procedure performed in the United States. It’s the removal of fat from the face and/or body using suction with the goal of creating a more slender and shapelier body contour.
Every surgery has complications, however, what can you and your surgeon do to minimize their occurrence?
Preparing for Liposuction Surgery. What can You do?
There is a higher complication rate with a higher body weight compared to height (higher body mass index or BMI). Losing weight not only lowers your surgical complication rate, but also gives you a better cosmetic outcome. Optimizing any medical illness by checking your values and taking appropriate doses of medications, such as high blood pressure or diabetes, stopping smoking for 2-4 weeks prior lowers infection risk, nutritional diet and multivitamins prior to surgery speeds recovery, no aspirin use for two weeks before lowers bruising, and no eating foodstuffs 8 hours before surgery and no clear liquids four hours beforehand.
What can be done by your Surgeon to lower complications?
A comprehensive history and physical examination is the hallmark of limiting any surgical risks. Liposuction today is performed by administering fluid into the areas to undergo liposuction, which contains lidocaine (numbing during procedure and up to 24 hours after), epinephrine or adrenaline (limits bleeding) , and bicarbonate (diminishes burning during administration).
There are a group of medications that inhibit the liver enzyme that metabolizing lidocaine, increasing the blood concentration of lidocaine and the risk of having a toxic dose. So stopping or lowering the dose of these medications limits this risk. The medication list includes: anti-fungals, benzodiazepines like valium, erythromycin antibiotics, calcium channel blockers used to treat high blood pressure, such as Cardizem and Procardia, and the most common group of medications of concern- anti-depressants. A comprehensive Harvard study showed that only those with major depression or bipolar disorder benefited more than placebo. Thus, if patients concur, I taper off of the anti-depressant two weeks prior to surgery.
Performing Liposuction Anesthesia.
There are two main techniques of anesthesia: Tumescent Technique versus General Anesthesia. All procedures should use cardiac monitoring with blood pressure, pulse, and oxygenation continually monitored with ECG and temperature preferred. If one is removing more than 100 cc of fat, an intravenous line should be placed in case medication administration or fluid is needed. It’s better to state the techniques as awake and asleep, since there are many similarities. True Tumescent liposuction uses the wetting solution (referred to as tumescent solution) of salt water placed into the treated body sites containing lidocaine, epinephrine and bicarbonate. This is the safest technique, but is limited by the amount of fat that can be removed and the number of body sites that can be treated. If one wants to use the safest technique And have more body sites treated, than a second surgery or staged procedure can be performed a month or so later.
Lidocaine in the tumescent solution is the anesthesia to minimize discomfort. It is recommended to use a lidocaine dose of 50 mg/kg or less, with 55 mg/kg a strict maximum dose. A typical patient can have their abdomen, flanks, hips and lower back treated safely with minimal discomfort. Adding the inner and outer thighs (typical in women), usually requires more lidocaine, oral and IV sedation or a staged procedure. If one adds intravenous and/or oral sedation and analgesia (pain medications), more fat can be removed, more anatomical areas can be treated, high-definition liposculpting can be achieved, since patients tolerate the procedure better with less discomfort. General anesthesia is when the patient is unconscious, however, the tumescent solution is used, but limiting the amount of lidocaine by 25-50% of the awake dose. The patient has no perception during the procedure, more fat can be removed, more anatomical areas treated, and high-definition liposculpting is easier to perform. Another advantage, a Tummy Tuck or Avelar lipoabdominoplasty can be performed simultaneously. The drawbacks of this technique is more postoperative pain and bruising, higher risk of a blood clot forming in the lower extremities (deep venous thrombosis or DVT) embolizing to the lungs (pulmonary embolism or PE), and the risk of general anesthesia with increased risk of airway obstruction and pneumonia with a mortality rate of about 1:20,000.
This is one of the highest risk factors in liposuction and also one of controversy with no universally recognized criteria or limits. Different states of the union have different recommendations of quantities. California states that maximum is 4 liters of fat or 5 liters of total fluid containing fat and infranatant (water and blood admixture) is recommended as an outpatient. More fat can be removed safely as long as other concerns are met. Judicious intravenous fluid administration minimizes the risk of delivering too much fluid, since both the IV fluid and liposuction fluid are absorbed into the blood stream. Less body areas treated with the same amount of fat removal is safer than many areas.
Younger and healthier patients weighing less and not on medications affecting lidocaine metabolism make the procedure safer and may enable more fat to be removed. In most cases, the location of fat removal and the sculpting of the body yields better cosmetic outcomes than the mere amount of fat removal. A smooth skin contour and athletic body shape is the goal most patients and surgeons are trying to create.
Liposuction can be performed with suction alone or a variety of energy based systems can be added to improve outcomes. The body shape is related to bone structure, muscle mass, fat distribution and skin. Bone structure cannot be changed. Muscle mass can be improved with muscle strengthening exercises before and after surgery. More fat can be extracted when energy based systems, such as laser “Smart Lipo” or “VASER (Ultrasound) Liposuction” is added. However, in inexperienced hands the incidence of skin contour irregularities and skin burns increases. Skin tightening has been shown to be the best with ultrasound (53% better than suction alone) compared to laser (28%). Ultrasound also yields 26% less bruising and bleeding compared to suction alone. Nothing is a substitute for an experienced, well trained surgeon who can minimize skin contour irregularities and create an aesthetically pleasing finished product of the New You.
Adding fat grafting or fat transfer to a liposuction procedure, which I do in 35% of my body contouring cases, can add volume to the face, breasts, hands buttocks and calves to maximize the desired rejuvenation results. My fat grafting is always combined with growth factors (platelet rich plasma or PRP) and stem cells with stromal vascular fraction cells (SVF) to enrich the fat to provide up to 80% fat cell survival rate. As long as the fat is placed in the under skin space (subcutaneous) and not into the muscle, such as in the gluteal muscle in Brazilian Butt Lift surgery, the procedure of fat transfer is very safe. Intra-muscle fat placement in the gluteal muscle can cause pulmonary fat embolism in 1:3000 cases.
Postoperative care to minimize complications.
Keeping the small incisions open to drain the fluid lowers the amount of swelling and bruising after the procedure. Compression garment use for 4-6 weeks, and manual massage four times a day minimizes the incidence of fluid collection underneath the skin, known as a seroma. Non-invasive body contouring devices that use either ultrasound (Vasershape or Quantashape) or radiofrequency (Venus Legacy) to further skin tighten excess skin that may remain, absorb some residual stubborn fat, and smooth skin contour are often added as adjuvant procedures.
Performing over thousands of cases of liposuction safely and teaching over 26 live surgical workshops in the United States and abroad, the above information on both anesthesia and liposuction techniques results in safe procedures with optimal cosmetic outcomes.