Procedures

What is liposuction?
Liposuction is the surgical aspiration, or sucking of subcutaneous fat with the aid of a cannula attached to a vacuum system. The terms lipoplasty, and liposculpture have also been used. The term liposuction however is the most common form used when describing the cosmetic procedure of removing fat from under the skin.

DIMITRI KOUMANIS,MD

LIPOSUCTION & COOLSCULPTING

CAPITAL AREA

GLENS FALLS NEW YORK

History
In the early 1900s, physicians had attempted to contour fat using a surgical tool designed for scraping. This frequently led to unevenness, blood clots and abscesses. Additionally, surgeons attempted to reshape the body with the surgical removal of both fat and skin, leaving the patient with excessive scarring.

Although the first known use of suction to remove fat was by French surgeon Charles Dujarier in the 1920s, it wasn’t until 1974 when father and son Italian gynecologists Arpad and Giorgio Fischer developed what is today, considered modern liposuction. The invention of a blunt, hollow, surgical instrument known as a cannula allowed them to tunnel and suction out fat while avoiding blood vessels.[1]

In 1978, French physician Yves-Gerard Illouz popularized liposuction with the addition of a new technique involving the injection of saline (salt water) into the fat prior to suction. This technique that was coined “wet technique” decreased bleeding and led to easier suctioning. [2]

Not long after, the wet technique was developed, Pierre Fournier added the use of a local anesthetic which laid the foundation for what it is called today, the tumescent technique. Fournier is also responsible for the development of a criss-cross entry technique that allowed for more even contouring. Additionally, the introduction of post operative compression resulted in faster healing times.[3, 4]

Liposuction had become popular in the United States by the 1980s but had been met with a fair amount of scrutiny. Reports of excessive bleeding, rippling skin and lumpiness paved a difficult road for for New York dermatologist Rhoda Narins, and plastic surgeons Julius Newman and Richard Dolsky who were among the first to offer liposuction in the US. It wasn`t until 1985 when California dermatologist Jeffery Klein perfected the tumescent technique, revolutionizing liposuction. The technique that involved the injection of both local anesthetic and saline into the fat allowed for liposuction to be preformed entirely under local anesthesia. The addition of a smaller cannula led to less blood loss, and smoother skin results.

In 1992, another significant development in liposuction was made by an Italian professor, Michele Zocchi. Ultrasonic Assisted Lipoplasty was developed as an alternative to conventional cannula suction. This technique used a cannula that transmitted ultrasonic vibrations, rupturing the walls of fat cells, emulsifying the fat and making it easier to suction.

Power-assisted liposuction, became available a few years later but was not approved for general use until 1998. This technology used a high-speed linear reciprocating suction cannula allowing for easier removal of fatty tissue not excluding dense, fibrous tissue.

A relatively recent development, laser assisted liposuction, was pioneered by Columbian surgeon, Rodrigo Neira in 1999 in an attempt to lessen pain and recovery time associated with liposuction. In addition, he found that the fat had been emulsified, similar to ultrasonic assisted liposuction. The chief benefit of the laser assisted liposuction over ultrasonic assisted liposuction was the temperature. The laser was cool, where the ultrasonic was extremely hot and could burn the skin.

Laser lipolysis, is a newer procedure that is currently not available in the US. The procedure depends on injections similar to the tumescent technique, followed by the insertion of a fiber optic device that contains a laser. The laser light is said to only effect yellow material in the body, that being fat. The fat is emulsified and later reabsorbed by the body, requiring no suction and allowing for smaller incisions. Because the body has to reabsorb the fat, this procedure is not intended for high volume applications.

Coinciding with technological advances, the evolution of incisions has also been noteworthy. Original incisions for liposuction were in excess of one inch. Today, the procedures that require incisions rarely even reach a full 1/8th of an inch, keeping in mind some techniques require no incision at all. Additionally, the placement of the incision has matured. Surgeons have progressed to inconspicuous placement of their incisions, leaving minimal evidence of the procedure once healing is complete.

Overall, the advantage of 40 years of unceasing improvements have led to easier removal of larger quantities, faster recovery times, less risk, blood loss and discomfort. Research and technology has also opened doors to “side branches” of the study of liposuction providing additional tools like autologous fat transfer, and the pairing of liposuction with other aesthetic procedures such as thigh lifts and tummy tucks.

 

How Popular is Liposuction?
Liposuction rapidly gained popularity in the early 1980’s and has continued to grow as the most commonly performed aesthetic procedure. Uneventful recovery, minimal scaring and predictable results have contributed to increased popularity. Additionally, advancements in technology as well as laboratory and clinical research has enriched the popularity of liposuction. Between 2006 and 2011 alone, an increase of over 860,000 liposuction procedures was seen according to The American Society for Aesthetic Plastic Surgery.[5]


Who are Candidates for Liposuction?
Psychological, physical and medical evaluation of a patient are key to a satisfactory result and a safe procedure. A detailed medical history, complete physical examination and discussion of both the patient’s as well as the surgeon’s expectations are necessary preoperatively.

A patient with high anxiety, low self-esteem, or unrealistic expectations can be a risk to a satisfactory outcome as well as an accurate preoperative diagnosis. First impressions and/or note of a patient’s prior attitude toward the results of previous procedures help to detect an underlying psychological problem. Frequent tools used to assess a patient’s mental preparedness and level of awareness of the reality of the procedure vary from physician to physician. Some will ask patients to bring in an image from a magazine or the internet of what they are expecting, others will use computer imaging to demonstrate expected results. With even the slightest doubt, it is recommended surgery be avoided.

A detailed medical history is crucial to achieve a safe procedure for the patient. Chronic lung disease, bleeding disorders and acute or chronic systemic diseases are of specific importance. Additionally, smoking, poor lifestyle or dietary habits, electrolyte imbalance, protein deficiency, alcohol or recreational drug dependence and large doses of certain vitamins are just some red flags that physicians look for. Prescriptions that the patient is taking are also noted because of the potential for additional risk to the patient if taken the days leading up to and directly following surgery.

Thorough physical examination should include evaluation of the patient’s preexisting conditions such as neurological or orthopedic, to prevent aggravation during the procedure. Physicians are able to provide positioning aids to facilitate the safest and most comfortable position for the patient during surgery.

Once the surgeon has deemed the patient “cleared” or a safe candidate for surgery, there are still steps to take to ensure the procedure is not only safe for the patient, but will also provide satisfactory results. Frequently, liposuction attracts a group of patients that desire a quick fix for obesity and while liposuction excels in treating figure imperfections, there is no proven data suggesting it is a permanent means for weight loss or maintenance. Significantly overweight patients are unlikely to obtain the results they desire and are at increased risk for complications during the procedure. Optimally, liposuction should be used to remove diet and exercise resistant and genetically distributed fat.

There are multiple aspects that a surgeon takes into consideration when evaluating a patient specifically as a candidate for liposuction. An ideal patient has been maintaining a stable weight as a result of a healthy diet and exercise regimen for at least 6 months. Patients who have a history of frequent or drastic weight fluctuations have an increased risk for weight gain postoperatively. It is important that the patient is no more than 30 lbs over their projected, ideal BMI. In addition, the quality of the fat is also examined. Thick, fibrous fat is preferable to soft, loose fat because the latter is easy to over-resect and frequently is associated with skin that doesn’t retract well. Skin tone, dermal quality, disproportionate fat, asymmetry, dimpling or cellulite, varicosities and scar tissue are also observed and analyzed. Frequently, a skin pinch thickness test is performed. Three cm or more indicates sufficient subcutaneous fat to benefit from liposuction. Fascial laxity should also be assessed preoperatively. For example, protruding fascia that is firm secondary to intraperitoneal fat is commonly best treated through exercise and will unlikely have long term satisfactory results with liposuction.

Successive successful procedures are performed on disproportionate abdomen, hip, thigh, buttock, breasts, back, upper arm, face and neck fat although other options are available and with the right combination of the above noted qualities, can have equally satisfactory results.

Instrumentation
Depending on the type of liposuction that the patient and the surgeon discuss and agree upon, instrumentation will vary. Cannulas (hollow tubes), have a blunt tip and generally range from 2 to 6 mm in diameter. Large cannulas allow for faster fat evacuation where small and medium cannulas provide a more precise and symmetrical contour. Frequently more than once size will be used to provide optimal results.

At the end of the cannula there is tubing that is composed of flexible polymers, commonly 1/2 in in diameter. This tubing is responsible for connecting the cannula to the evacuation device.

The aspiration device its self comes in many forms but is typically composed of filters, canisters and a vacuum pump. The negative pressure created by these pumps allows for the evacuation of fat as well as the vaporization of water. Vaporization is the component that is responsible for efficiency or the speed at which the aspiration occurs.

As an alternative to a vacuum pump, syringe suction can be used. The syringe connects directly to the cannula and negative pressure is created when the surgeon pulls back on the plunger. This method is typically seen when small amounts of fat are being removed from one area and re-injected into another.

For large quantities of fat aspiration, power assisted liposuction uses a mechanical cannula that helps to sculpt the fat once inserted into the subcutaneous fat. The tip reciprocates at approximately 4000 times per minute effortlessly loosening fatty tissue and removing it from the body.

More specialized options include but are not limited to systems with ultrasound, laser, twin cannulas, water beams, and cool sculpting.

Types of Liposuction
Although there are a variety of machines that are used to perform liposuction. Suction assisted liposuction and power-assisted liposuction remain the standard. Laser liposuction methods are now very popular with surgeons and patients alike. Talk to your plastic surgeon to see which method fits your case the best.

Suction assisted liposuction (SAL)
Suction assisted liposuction is the gold standard in liposuction and is what most people think of when they think of liposuction. A small cannula attached to tubing, connected to a negative pressure system (suction) is inserted through a small incision. The cannula is moved back and forth in a too and fro motion within the area with excess fatty tissue. The motion provided by the surgeon loosens fat and allows the suction to remove it from the body via the cannula and tubing. The blunt tip on the cannula allows for a more gentle removal and less bleeding. Because fat is less dense and structurally weaker than the surrounding nerves and blood vessels, the fat can be evacuated, leaving the blood vessels and nerves behind, intact. This method is versatile in that large quantities can be removed from areas like the abdomen, buttocks, and thighs or small quantities can be removed from the face or neck simply by exchanging the vacuum machine for a small, syringe.

Power assisted liposuction (PAL)
Power assisted liposuction is a technique similar to SAL, but more advanced in that the cannula contains a high-speed linear reciprocating suction device that spins back and forth at approximately 4000 times per minute, while easing through fatty tissue. This technique is particularly helpful if the patient has dense, fibrous tissue that may be difficult to navigate and remove through the physical too and fro motion alone. The addition of the mechanical cannula lessens the physical taxing on the surgeon while causing less trauma to the patient’s body, leading to less bleeding, bruising and pain.

Twin-cannula assisted liposuction (TCL)
Twin-cannula assisted liposuction resembles PAL in that it relies on a cannula with power to assist with the procedure. Additionally, TCL uses a tube-within-a-tube cannula that allows for more superficial or sub dermal dissection because of the spacing effect of the outer cannula as well as the fact that the cannulas do not get hot, thus eliminating the concern for friction burns to the patient.

Water assisted liposuction (WAL)
WAL depends on a thin, fan-like, beam of water to loosen the structure of the fatty tissue making it easier for the cannula to aspirate. Continuous water spray is matched by suction in the cannula that aspirates it as fast as it goes in, facilitating a constant cycle. This variation of liposuction requires less infiltration solution and leads to a decrease in edema that can be seen in other variations of the procedure.

Laser Assisted Liposuction (LAL)
LAL uses a laser to melt fat in the target area, facilitating easier removal or even reabsorption depending on the size of the target area and amount of liquified fat. As one of the most popular options in the field of liposuction, there are multiple varieties of LAL.[6]

Whether or not tumescent liposuction versus laser-assisted liposuction is the better procedure has been contested by some plastic surgeons.[7]

The following techniques using liposuction and their description are descriptions from the companies themselves. Talk to your surgeon and see if Laser Liposuction techniques are suitable for you as a patient.

SmartLipo
With over nine years of clinical studies and evidence-based science, Smartlipo is the market leader in LAL, in a market that is projected to grow 12.3% per year through 2017. Their specially designed system includes a wavelength of 1064 nm for efficacy and safety as well as technology like the ThermaGuide, ThermaView and SmartSense systems.

The ThermaGuide assists in monitoring the site of lasing for instant temperature feedback. This is made possible through the ThermaGuide cannula which contains a sensor that measures tissue temperature. Laser energy is only delivered until the target temperature is reached providing a safer, more uniform treatment. The system’s technology allows the surgeon to set a specific temperature setting to alert the surgeon when laser energy temperatures are approaching the target temperature.

ThermaView is a component of the Smartlipo system that displays temperature images as a built in safety feature. This eliminates the need for handheld thermal cameras all while providing another tool to prevent thermal wounds.

SmartSense is an intelligent hand piece delivery system that works with the SmartLipo system to further optimize treatment. The hand piece senses a cease in motion and stops firing the laser within 0.2 seconds for added safety all while remaining ready and resumes firing as soon as the hand piece is set back into motion.

The collaboration of tools provided by the SmartLipo system allows for better control, more precision, beneficial tissue retraction through soft tissue coagulation, safer procedures and consistent results.

CoolLipo
Similar to other laser lipo systems, CoolLipo is a technology that depends on laser wavelengths to dissolve fat and firm the skin. CoolLipo is specifically designed for smaller areas such as the face, chin, and neck. Because of the use of cool technology, it does not create heat and therefore does not provide a potential for a thermal wound.

LipoLite
LipoLite was developed with minimally invasive treatment of small areas in mind. Lipolite is recommended for areas like the face, which are too tight and small of an area to use conventional sized liposuction instrumentation. LipoLite uses a 1064 nm wavelength to target the photo-mechanical and photo-thermal destruction of fatty tissues. A tiny cannula containing a fiberoptic laser allow for easy emulsification and removal of fat through a small incision. Because of the small incision, recovery and post operative pain are minimal.

ProLipo PLUS
This variation of liposuction was designed with very specific precision on mind. Selective photothermia is used to heat fat cells while leaving surrounding tissues intact. Prolipo utilizes two different wavelengths of 1064nm and 1320nm that can be custom blended for a particular area of the body. The first wavelength (1064nm) is used to heat fat causing it to rupture, while the second wavelength (1319nm) affects the skin causing it to tighten. The tightening factor, frequently draws older patients with poor skin elasticity. Because it is used for smaller target areas, frequently the procedure can be performed under local anesthesia with small incisions.

LipoTherme
Another well regarded laser lipolysis technology, LipoTherme uses their LipoControl technology with their LipoTherme laser at 980nm to provide safer treatment. Like other laser treatments, a wavelength is used to emulsify the fat and a small cannula is used to remove it. Again, this is another minimally invasive option allowing for local anesthetic, and faster healing times.

Ultrasonic Assisted Liposuction (UAL)
UAL refers to a group of various techniques that use ultrasonic high frequency sound waves to heat and destroy the membrane of fat cells and remove them. The ultrasonic energy begins as electricity but is quickly converted to heat and a series of rapid vibrations before entering the body. UAL is narrowly directed and meant to only focus on the layer of fat. Within UAL there are two variations; external and internal.

External ultrasonic assisted liposuction uses paddles or pads on the outside of the body around the area of desired effect. After approximately 12 minutes of external sound waves, the physician is able to make an incision and remove the emulsified fat. Although E-UAL requires only small incisions to remove the liquified fat, it is frequently not chosen because of the frequency of burns to the skin as well as contour irregularities.

Conversely, internal ultrasonic assisted liposuction requires an incision from the beginning, and uses a cannula that emits ultrasonic waves. The cannula resonates at a high ultrasound frequency, shaking fat cells loose while leaving surrounding tissues intact. While the ultrasonic high frequency sound waves are being emitted, the cannula is removing the liquefied fat from the body and suctioning it into a canister. This variation too comes with risks such as burns, skin punctures and excessive undermining of tissue due to thermal wounds.

Autologous fat transfer
AFT is an option for liposuction patients that allows patients to have fat removed from one area and have it injected in another. Frequently small amounts of fat are aspirated through a cannula and into a syringe which is then reinjected into an area that the patient desires increased contour or filling such as the breasts or wrinkles in the neck and face. Commonly, it is extracted from body parts like the abdomen, buttocks and thighs. AFT can improve creased and sunken areas of the face, add fullness to lips and cheeks, be used in place of buttocks implants and/ or increase the size of a patients breasts. Because the injection being used is the patient’s own tissue, the risks commonly associated with implants as well as other immune responses are significantly lessened. One of the leading plastic surgeons and clinical researchers of fat grafting is Dr. Sydney Coleman. He has produced numerous articles on the subject matter.[3, 8, 9]

Various Techniques used in conjuncture with liposuction

Dry Technique
Intuitive, given its name, the dry technique does not use injections of lidocaine, epinephrine, or any solution. This technique is infrequent today.

Wet Technique
A step up from the dry technique, the wet technique injects approximately 100 milliliters of local anesthesia containing epinephrine helping with vasoconstriction and some pain maintenance but no fluid replacement.

Super wet technique
Similar to the wet technique, but in a large quantity, the super wet technique provides local anesthetic, and vasoconstriction but still falls over 50% short of the amount of fluid that is replaced in the most common technique; tumescent.

Tumescent technique
Tumescent technique is an additional tool used in conjuncture with various types of liposuction to aid in the dissection and level of safety of the procedure. The technique includes injections of a dilute solution of lidocaine and epinephrine approximately 20 minutes prior to making the incision and beginning liposuction. The volume of subcutaneous infiltrate differs based on the total volume of aspirate. Research shows that a 1:1 ratio of dilute solution to aspirate sufficiently replenishes fluids and provides adequate hemostasis and analgesia.

This solution provides benefits such as decreased blood loss, decreased need for systemic anesthetic agents, decreased need for intravenous fluids, easier facilitation of passage of the cannula through tissues as well as facilitation of the use of ultrasound-assisted liposuction (if it is being used). This is possible because of the solutions composition. The epinephrine shrinks localized blood vessels, minimizing bleeding. The lidocaine numbs the area both during the procedure and immediately following the procedure resulting in less pain and need for post operative narcotics. Additionally, the solution temporarily expands the volume of the target area, making fat cells easier to aspirate. Because the use of tumescent technique allows for removal of a larger volume of fat aspirate with minimal blood loss, aspirate in excess of 5000 mL can be removed without the need for a blood transfusion. [10]

With many options for body contouring, it is up to both the surgeon and the patient to decide what is best for the patient. If liposuction is the chosen route, the specific type and or conglomeration of types will be based on which procedure will safely abstract the right amount of fat, leave the patient’s fluid levels in balance, cause the least disruption to the patient’s neighboring tissue, cause the least discomfort to the patient and leave the patient the most aesthetically pleased.

Preoperative markings and preparation
The day of surgery, the surgeon will ask the patient to stand nude in the operating room to facilitate optimal marking of the patient. Standing, allows the surgeon to see how the patient’s tissue sits currently, and allows them to mark areas that are undergoing treatment in great detail. Frequently, different color permanent markers are used to distinguish between sights of maximum removal, dells, undesirable adhesions, locations of folds to be created, incision markings and borders. Frequently, circles inside of circles are used for marking, taking note that the inner most circle signifies the point of maximum fat deposition. Estimated guidelines for the amount of aspirate anticipated are also frequently written next to the coinciding area of treatment. Additionally, photographs either taken in the office recently, or that day prior to markings as well as photographs with the markings will be hung on the walls in the operating room providing continuous imagery for the surgeon of what the areas looked like while the patient was standing.

Figure 1 shows the areas that are typically addressed during a liposuction procedure. Not all areas are needed by everyone but these are the areas that are safe to undergo liposuction. Your plastic surgeon will go over your areas of concern.

Figure 1: Anatomical areas where liposuction frequently performed

(Need out own diagram here Terry to replace these as they have a copyright!!!)

Procedure
The surgeon and staff will have discussed and prepared for the upcoming positioning of the patient intraoperatively. Circumferential treatment will be noted and plans to reposition the patient will have been discussed and prepared for. Additionally, position on the table in relation to exposure of the planned incision sites is noted.  Great care in padding pressure points is taken along with an attempt to maintain normal postural position for the neck to avoid pinching cervical roots.

With the patient still standing the surgeon preps the patient with a germicidal agent maintaining a 3 inch perimeter surrounding the treatment areas. The patient is placed on a sterile draped operating table with a mayo stand cover placed centrally to be used as a sterile draw sheet if the patient needs to be flipped for circumferential treatments. A sterile drape is hung as a barrier between anesthesia the operating field and sterile towels or stockinets are used to cover the feet. This preparation and positioning method is used to supply the opportunity for surgical manipulation and repositioning without having to break sterility and re-position, re-prep, re-scrub, and re-drape. To insure sufficient body temperature for the patient, a fluid warmer and or warming blanket may be used.

Each area is treated through multiple incisions, taking care to suction each area at different angles to allow for more even suction and less contour irregularities. Suction is applied to deeper tissues first, followed by more superficial areas. Ideally, surgeons will use a narrow gauge cannula to avoid depressions. The surgeon can judge their progress through a visible diminution in contour as well as a clear reduction in the pinch thickness test. Additionally, aspirate volumes can be compared with preoperative anticipation volumes.

Anesthesia
The preference of the anesthesiologist, surgeon and the patient is taken into consideration when planning the anesthesia aspect of the procedure. Length of time of the procedure, patient health, positioning, and amount of anticipated aspirate also play a key role in the patient’s anesthesia care.

Because of the availability to techniques such a tumescent technique, the addiction of preoperative lidocaine injection significantly reduces the amount of pain associated with liposuction procedures and allows for select procedures to be done under localized anesthesia.

Postoperative care
During the first 48 hours immediately following surgery, blood-colored fluid will drain from the incision sites. The surgeon will have recommended the patient prepare their beds and furniture with protective sheets. Although compressive garments do not influence the aesthetic final result, many surgeons request their patients wear them to aid in the recovery process.

Patients undergoing small volume removal, which can be defined as less than 2500mL, can expect to return to sedentary activities within 4-6 days.

Treatment involving multiple incisions, circumferential treatment or large quantities of aspirate require a more prolonger recovery. Patients with more than 5000mL of aspirate (considered large volume liposuction) typically remain in the hospital overnight for observation and will not return to sedentary work for closer to 10 days. Vigorous activities such as sports are not resumed for 3 weeks.

Are There Any Added Health Benefits
Research conducted in 2000 at SUNY Downstate University links liposuction and the potential for health benefits, specifically to diabetes. Type II diabetes begins with insulin resistance. The pancreas is functioning properly, making plenty of insulin but the body does not recognize and use it properly causing blood sugar to rise dangerously. While this can typically be controlled with pills, the continual rise in the number of cases in the US demands alternative treatments.

Approximately 12 lbs of subcutaneous fat was removed from 14 healthy, overweight, premenopausal women. Half of these women had some degree of insulin resistance. Six weeks later, weight loss was recorded as well as a measurable degree of decreased insulin resistance.

SUNY Downstate went on to present further findings demonstrating that in 75% of women who underwent liposuction, an improvement in weight, blood pressure, and insulin resistance was found at 4 months postoperatively and still remained when it was checked again a year later.

Although the details are sparse, and the physiology has not yet become fully clear, evidence does link liposuction and decreased blood pressure as well as type II insulin resistance.[11, 12]

A study in the New England Journal of Medicine however argued against any health benefits that liposuction may have when considering obesity-associated metabolic abnormalities.[13]

That being said, liposuction is not a substitute for medical attention, including the need for medication, exercise and a good diet. Only your physician should treat your diabetes and heart issues. Additionally, people with severe heart or other medical conditions may not be candidates for liposuction.

Side effects and complications
Potential side effects include but are not limited to surface depressions, contour irregularities, seromas, bruising, swelling, pain, numbness and scaring. More serious complications though rare, are a potential with liposuction as with any surgical procedure. Infection, embolism, visceral perforations, skin necrosis, burns, fluid imbalance, toxicity from anesthesia have occurred. However, in the correct hands this surgery has a long track record of being safe. Please discuss with your Board Certified Surgeon the potential complications. There are studies that have been done that discuss the safety issues needed to be considered when performing the procedure. [14]

The importance of a board certified plastic surgeon
Because of the ever increasing popularity of liposuction, various specialties are marketing themselves in liposuction regardless of whether or not they were trained as such. It is crucial that patients do their homework when selecting a surgeon. Board certification in plastic surgery should be the first and foremost consideration for a patient. While other surgeons (general, OBGYN, etc.) may market themselves as liposuction experts, and may even be a cheaper alternative, they were not trained in plastic surgery and pose a risk to patients.

Board certified plastic surgeons are trained to perform surgery. Although this sounds obvious, people tend to overlook the fact that out of all of the medical specialties, only 24 of them are surgical, and have gone through surgical training. Plastic surgery is one of the 24. Board certified plastic surgeons complete a minimum of five years of surgical training following medical school that specializes them in both facial and body procedures.

Additionally, plastic surgeons are trained not only to prevent emergencies specific to liposuction but also to handle them if necessary. Their educational foundation in anatomy, physiology, and a complete understanding of the relative body systems including but not limited to circulation, ventilation, and fluid and electrolyte balance are critical to a safe outcome for a liposuction patient.

Technical skill possessed by a plastic surgeon is unique. Experience gained during their years of residency in complex reconstructive surgery provides plastic surgeons with outstanding technical skills that other surgical specialties lack in these specific areas. Moreover, continuous deliberation on both form and function throughout their years of training has fine-tuned these surgeon’s sense of aesthetics which is a unique qualification that cannot be replaced by the quick skimming of a text book.

Also important, a board certified plastic surgeon has more to offer patients. Because their recommendations are not limited by lack of training or hospital privileges, plastic surgeons are able to suggest and pair treatments to best suit a patients specific needs. Liposuction may not be a safe option for a patient, or conversely they may need liposuction in conjuncture with an abdominoplasty or thigh lift. These are evaluations and services that only a board certified plastic surgeon can safely make.

Patients are encouraged to check with their physician and request their credentials. If a patient is uncomfortable asking, there are various websites such as certificationmatters.org that allow a patient to check for free.

Other alternatives
An in office physical exam and medical history may reveal that a patients desired contour shaping cannot be achieved with liposuction alone. The physician and patient may decide on another alternative, or a combination of two.

An ever-increasing population of overweight individuals as well as medical advancements in bariatric surgery have left large numbers of patients who have undergone massive weight loss with excess skin and fat that cannot be treated with liposuction.

Still commonly, serial pregnancies, aging, heredity, and prior surgery also leave patients in a similar position. Because of the lax skin and or underlying abdominal diastasis, these patients require an abdominoplasty. Today there are multiple variations of abdominoplasty that can be performed to aid patients in achieving a more desirable abdominal profile through the removal of excess fat restoration of weakened or separated muscles.

Through a discussion between the patient and the surgeon, an anterior abdominoplasty or a circumferential abdominoplasty will be chosen. An anterior abdominoplasty best suit patients with desired body contouring that is limited to just the front surface of their abdomen. Conversely, circumferential abdominoplasties best fit patients with skin excess and laxity extending into the flanks and posterior aspect of the trunk.

Preoperatively the patient is marked in a standing position. Markings for an abdominoplasty are minimal, and typically contain boundaries and incision marks only. The patient is then prepped with a germicidal agent and sterilely positioned and draped. Anesthesia for this procedure is most frequently general anesthesia due to the amount of time the procedure takes as well as the surgical extent of the procedure. A foley catheter is placed to facilitate bladder emptying, as the patient may not be ambulatory in the hours immediately following surgery.

The patient is injected with tumescent solution to vasoconstrict, provide postoperative analgesia (limited necessity for narcotics) and provide fluid, easing the dissection. Once the tumescent solution has sit for approximately 20 minutes, an incision is made horizontally in the area between the pubic hairline and the navel. The shape and length of the incision is determined by the extent of the correction desired. If skin removal is necessary in the upper abdomen as well, an incision around the navel is frequently mandated. Through these incisions, the surgeon will remove excess fat and skin and repair weakened or separated abdominal muscles. Drains will be placed to evacuate blood and fluid.

Postoperatively, patients will remind in the hospital for 72 hours for observation. Typically patients are dressed with compression garments as well as additional compression devices on the patients legs to assist blood flow until the patient is ambulatory.

Coolsculpting
Coolsculpting is a FDA approved, noninvasive procedure that requires no needles, incisions or down time. Developed by Harvard scientists, coolsculpting uses a targeted cooling process that kills the fat cells underneath the skin, freezing them to the point of elimination. Once crystalized, the fat cells die and are naturally eliminated from your body.

Costs and Financing
Because liposuction is widely considered a cosmetic procedure it is almost always not covered by insurance, leaving the payment an out of pocket expense to the patient.

The cost of liposuction varies widely and depends on a conglomeration of factors. Surgeon’s fee, hospital or surgical facility costs, anesthesia fees, prescriptions, post-surgery garments and medical tests are only some of the costs that are associated with liposuction.

To give a ballpark figure, the average cost of liposuction surgery according to the American Society of Plastic Surgeons in 2012 was 2,852$. Looking at numerous websites and published costs from plastic surgeons around the country the range is between $2500 and $4000. This number is solely the price of the procedure and does not include anesthesia, hospital fees, etc.  As well it depends on how many areas you will need to be sculpted. Please consult with a plastic surgeon in your area for more details.

Financing is available through various organizations such as CareCredit or Prosper. These organizations offer a convenient way to pay for cosmetic or dermatologic treatments through monthly payments over time. Applications are available online at carecredit.com/cosmetic.