The body mass index, calculated from the patient’s height and weight in metric units of kilograms per meter squared, is a good method with which to assess the patient’s relative risk-to-benefit ratio for the procedure. Although liposuction may reduce cardiovascular risk, blood pressure, and fasting insulin levels, it should not be considered a treatment for obesity. Patients with inherent risks including those with poor wound healing, infection, deep venous thrombosis, sleep apnea, or a body mass index greater than 30 would benefit from additional counseling, and lifestyle modification should be considered before a body-contouring procedure.
Dr Koo performs a thorough physical examination which includes documentation of the patient’s height, weight, and circumferences of all pertinent body areas. Dr Koo will look at all previous surgical scars including, of course, a possible previous C Section scar and will attempt to remove all possible scars and stretch marks that are within the area that can be removed with an abdominoplasty.
Typically, Dr Koo recommends waiting a minimum of 6 months after childbirth prior to considering any plastic surgery to reshape the breasts and body. This allows time to lose the water weight gain, establish good eating and exercise habits, and allows the skin to retract. With weight and skin tone stabilization, the breasts and abdomen will revert to as mich of the pre-pregancy condition that is possible. For some women, depending on activity level, eating habits, and genetics, this could take up to one or more years.
Dr Koo also recommends waiting until the patient is not considering any more children before major skin resection such as a tummy tuck (abdominoplasty) to prevent relapse of stretch and split of the abdominal muscles again with recurrent pregnancies.
The saggy, flat breasts and lax, loose abdomen and hanging skin can all be removed and abdominal muscles tightened completely to a pre-pregnancy state. The maintenance of the shape and appearance is then up to the patient to continue to eat healthy with regular activity levels which Dr Koo encourages and helps with suggested excercise classes and trainers. If the patient is looking for firm, lifted breasts that are full and round, then a breast implant along with the breast lift may be necessary. She will discuss all the possibilities and let the patient know what surgery is in her best interest for long term results.
Lipodystrophy can be located in the following areas: abdomen, flanks, thighs, arms, neck, knees, back, buttocks, and breasts. Careful physical examination entails site-specific evaluation. Dr Michele Koo examines patients for the presence of occult hernias. Men who present for abdominal liposuction should be examined with particular care, as abdominal prominence may often be attributed to intraabdominal fat, which is not addressed by liposuction. In men interested in body contouring of the anterior chest, the examination of those with gynecomastia may direct the method of surgical treatment. Ultrasound-assisted liposuction or direct excision of skin and breast tissue may be necessary in those with additional fibrous tissue.
Other anatomical areas that require special attention if liposuction is to be performed are the legs and ankles. Patient satisfaction is not as high with liposuction in these areas. Pain can be a prolonged problem and complications are more frequent than with liposuction of most other areas. It is important to understand the patterns of fat distribution and how they relate to the anatomy of the area. The preoperative markings, careful attention to the suction area, and close postoperative follow-up are extremely important for liposuction of the legs and ankles.
Skin evaluation is pertinent in the evaluation of any patient seeking body-contouring procedures. For those seeking liposuction, adequate skin elasticity should be present to allow for skin retraction after surgery. Particular attention should be given to associated wrinkles, laxity, and surface irregularities, including dimpling. Scars should be noted.
Cellulite is a term that is used to describe the lipomatous deposits under the skin that outwardly give the skin a lumpy or orange peel-like appearance. Cellulite is often noted in areas such as the hips, buttocks, or thighs. Cellulite is predetermined by genetics, so even thin women can develop the appearance. Factors such as hormones, pregnancy, and aging may all attribute to the appearance of cellulite. Patients should be aware that liposuction procedures do not address cellulite and may in fact worsen its appearance. In contrast, dimpling is usually considered to be a more isolated area of concavity that may be secondary to underlying scar or fascial attachments and may be improved by the liposuction process.
Any asymmetry or contour irregularities is noted and brought to the patient’s attention. Dr Koo makes additional effort to correct any dimpling or asymmetry intraoperatively; however, this is frequently difficult to achieve. The patient should be aware of possible persistent asymmetry, depressions, and dimpling after the liposuction procedure.
Society of Anesthesiologists status of a patient before scheduling liposuction because it is an important factor in determining the most appropriate location for the procedure to be performed safely.
Various types of anesthesia or anesthesia combinations are appropriate for liposuction, depending on the overall health of the patient, the estimated volume of the aspirate to be removed, and the postoperative discharge plan. Dr Michele Koo is extremely careful about her anesthesia provider and hand picks those that give anesthesia to her patients. Dr Koo is the patients’ best advocate and ensures that all precautions are taken for the safety and well being of her patients.
In smaller volume liposuction cases, anesthetic infiltrate solutions alone may provide adequate pain relief. Termed wetting solution, this anesthetic infiltration solution not only facilitates the procedure but also provides preemptive and prolonged postoperative local analgesia.
5 Doses of lidocaine up to 50 mg/kg have been used; however, it is important to note that plasma lidocaine levels can peak 10 to 12 hours after infiltration when epinephrine is present in the wetting solution. Lidocaine toxicity has been implicated in a series of liposuction-related deaths. Signs and symptoms of lidocaine toxicity can be seen at plasma levels between 3 and 6 μg/ml. Initially, patients may experience lightheadedness, drowsiness, tinnitus, a metallic taste in the mouth, slurred speech, and numbness of the lips and tongue. At higher plasma concentrations, shivering, muscle twitching, tremors, convulsions, central nervous system depression, and coma may result. Respiratory depression and cardiac arrest can also occur with higher doses. Marcaine is rapidly absorbed, poorly reversed, and has a long half-life, making it a less suitable agent for subcutaneous infiltration in liposuction procedures.
Epinephrine is a critical additive in the infiltrate solution. It is recommended that doses of epinephrine not exceed 0.07 mg/kg, although doses as high as 10 mg/kg have been used safely.
Moderate sedation or analgesia, termed conscious sedation, is defined as purposeful responsiveness, with response to verbal or tactile stimulation evident. No airway intervention is required; however, supplemental oxygen may be administered as indicated. Patients demonstrate adequate spontaneous ventilation, with maintenance of cardiovascular function. Although numerous agents can be administered to achieve this level of sedation, it is imperative that the physician be adequately trained in anesthetic medications and airway management if intravenous sedation is planned without the presence of an anesthesia professional. In limited, smaller volume liposuction cases, intravenous sedation may be administered to maintain patient comfort.
In general anesthesia, the patient is unarousable, even with repeated painful stimulation, and independent ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive-pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. As with any surgical procedure, medication is titrated to effect, and a certified anesthetic provider is present for any procedure under general anesthesia.
The physician is primarily responsible for providing and supervising anesthesia and analgesia. A certified registered nurse anesthetist or other qualified health care provider may administer anesthesia, but only under direct physician supervision, unless state law specifically provides otherwise. Dr Koo has a core staff that she works with that is completely trained and familiar with her methods, techniques, and preferences and only that staff is allowed in her operating room. Dr Koo and all operating room and key facility personnel are fully trained to recognize emergencies and complications.
The dry technique was the first method developed. It was performed under general anesthesia without the infiltration of subcutaneous solutions before insertion of the liposuction cannula. Substantial swelling and discoloration is a common consequence of the dry technique. This technique is also associated with a large amount of blood loss, with suction aspirate consisting of 20 to 45 percent blood. These sequelae sharply limited the amount of fat that could be removed without transfusion or hospitalization, which resulted in the abandonment of this approach, except in limited applications. The dry technique is not recommended for suction volumes greater than 1000 ml because of the amount of blood loss incurred. The dry technique should never be used in conjunction with ultrasound-assisted liposuction.
The wet technique entails injecting 200 to 300 ml of infiltrate or wetting solution, with or without additives, into the operative field before insertion of the liposuction cannula. Small doses of the vasoconstrictor epinephrine were added to the infiltrate, which significantly decreased the blood loss to 4 to 30 percent of the aspirate. The wet technique was the method of choice in the early 1980s.
The superwet technique, developed in the mid-1980s, uses 1 ml of solution for each 1 ml of fat to be removed. The surgeon’s preoperative estimate of the suction aspirate is considered in this technique. The infiltrate solution consists of saline or lactated Ringer’s solution with epinephrine and, in some cases, lidocaine. Using larger volumes of subcutaneous infiltrate, blood loss generally decreases to less than 1 percent of the aspirate volume.
The tumescent technique was introduced in 1985. It uses the largest volume of infiltrate and involves infusing 3 to 4 ml of the infiltrate solution for each planned milliliter of aspirate. Drug concentrations in the tumescent infiltrate solution vary, but typically they consist of a range of 0.025% to 0.1% lidocaine and epinephrine 1:1,000,000 in a lactated Ringer’s or normal saline solution. Estimated blood loss with the tumescent technique is approximately 1 percent of the aspirate, comparable to the superwet technique.
Since the advent of epinephrine-containing wetting solutions and sophisticated fluid management techniques, increasingly larger volumes of liposuction aspiration have been reported. Large-volume liposuction, defined as a total aspirate of 5000 ml or greater, can be a safe and effective procedure when patients are carefully selected and when anesthetic and surgical techniques are properly performed. Meticulous fluid balance calculations are necessary to avoid volume abnormalities, as metabolic alterations and fluid shifts result from medication effect, hypodermoclysis, and surgical technique. General practice guidelines recommend overnight observation postoperatively for patients undergoing large-volume liposuction.
Dr Koo is very precise and accurate with the preoperative marking and discusses the areas of liposuction during the preoperative consultation several times prior to the surgery and again on the day of surgery to ensure that the patient understands completely the areas to be contoured and they coincide with the areas of concern for the patient. This is essential to satisfactory results. Patients are marked with a fiber-tip marking pen in the upright position or standing. Areas to be avoided, such as the zones of adherence, is noted carefully.
Dr Michele Koo uses multiple-access incisions for almost all areas because removing all fat from a single access incision may lead to depressions around the access site and contour deformity. Incisions are placed in natural skin folds and asymmetrically to limit visibility of the resultant scars.
Dr Koo places the patient in the appropriate position for access to the treatment site. If multiple areas are to be treated during a single operation, it is convenient to prepare the patient circumferentially so that all areas of the trunk and extremities may be treated without repeated preparation and repositioning. Dr Koo feels that she is able to achieve the most optimal results with circumferential liposuction along with the tummy tuck (abdominoplasty) repositions the patient intraoperatively to better treat and evaluate surgical progress and symmetry.
A thorough operative record includes documentation of each stage of the liposuction procedure. The infiltration solution mixture should be documented and the volume of subcutaneous infiltrate used should be noted as well. Oftentimes, surgeons will note the amount of infiltrate and volume of aspirate by body area and record the total volumes for the entire procedure. This information, along with intravenous fluid administration and monitoring of vital signs and urine output, are important factors for maintaining adequate fluid management intraoperatively and postoperatively. A diligent fluid management strategy between the surgeon and anesthesia provider is important for avoiding volume overload sequelae.
Sequential compression devices should be in place before a general anesthetic is used in most liposuction procedures. Patients who undergo other types of anesthesia or minor procedures may do so without sequential compression devices.
The use of postoperative compression for 6 weeks is usually indicated after liposuction procedures to minimize edema and support the soft tissues. The various compression modalities and garments available for each area can be extremely useful but must be tailored to the area of treatment. The use of a foam material underneath the compression garment to increase compression and protect areas of irritation is frequently beneficial.
No single liposuction technique is best suited for all patients in all circumstances. Factors such as the patient’s overall health, body mass index, the estimated volume of aspirate to be removed, the number of sites to be addressed, and any other concomitant procedures to be performed should be considered by the surgeon to determine the best technique for the individual patient.
Ultrasound-assisted lipoplasty. Introduced in the late 1980s, ultrasound-assisted liposuction uses a cannula or probe to deliver fat-liquefying ultrasound subcutaneously. This technique permits the removal of fat from fibrous areas such as the upper abdomen, back, and flanks with greater ease, especially during secondary procedures. To prevent thermal injuries while performing ultrasound-assisted liposuction, two technique rules are of critical importance. First, the ultrasound probe or cannula must be kept in motion. Second, the infiltrate solution is a required component of ultrasound-assisted liposuction because it plays a crucial role in the process of fat emulsification and cooling the heat generated in the process. The dry technique should never be used in ultrasound-assisted liposuction, regardless of the planned volume of aspirate.
Suction-assisted lipoplasty. Suction-assisted lipoplasty is the most commonly performed aesthetic procedure in the United States. Suction-assisted lipoplasty procedures use an external source of suction to facilitate the removal of fatty tissue.
Power-assisted lipoplasty. Power-assisted lipoplasty is an approach in which the system that drives the cannula is a power source other than the surgeon’s arm. Systems are either electrically driven or gas-driven by nitrogen or compressed air tanks. A small motor moves the 2- to 4-mm cannula tip in a forward and backward motion, replicating the motion of the surgeon and decreasing physician fatigue. The cannulas are small and flexible and are comparable in length and diameter to standard suction-assisted liposuction cannulas. Power-assisted liposuction is effective for large-volume removals, fibrous areas, and revisions. It is typically used in conjunction with the tumescent or superwet technique. The excessive vibration of the cannula and the noise of the power system are the two main disadvantages of this technique.
Combination ultrasound-assisted lipoplasty and suction-assisted lipoplasty. A combination of techniques may be used for treatment of various areas of lipodystrophy.
Other. Syringe aspiration of fat has been used for addressing superficial irregularities independently or in conjunction with another liposuction modality. This method for aspiration may result in less blood loss and has been reported to be a more precise and accurate mode of fat removal. The main disadvantage of syringe aspiration is prolonged operating time. This technique is effective for sensitive and smaller volume areas, such as the neck. It also is commonly used for harvesting fat for transfer, as less mechanical damage to the fat cells allows for a greater percentage of viable cells for transfer.
Embolism may occur from fat or venous thrombosis. The signs of pulmonary embolism may be shortness of breath or difficulty breathing. Deep venous thrombosis may be present with calf or leg pain, Homan’s sign, swelling or erythema of the lower extremity, persistent tachycardia, and/ or mild pyrexia. The thrombus is not usually palpable. Treatment of deep venous thrombosis may entail anticoagulation or placement of a venous filter. Patients who develop a pulmonary embolus may undergo thrombectomy or thrombolysis as well. Although the exact pathophysiology of fat embolism syndrome remains somewhat controversial, signs or symptoms of fat emboli after liposuction require emergency medical care, as permanent disability or fatality may result.
Advances in the understanding of fluid management in the care of the patient undergoing liposuction has increased the margin of safety of this procedure. Firm guidelines for the appropriate amount of fluid resuscitation have yet to be established; however, there are multiple formulas and fluid balance calculations for determining the appropriate balance of intravenous fluid administration and subcutaneous infiltration. The key to appropriate perioperative fluid homeostasis is proper patient selection and consistent communication between the surgeon and the anesthesiologist with regard to perioperative fluid replacement and urine output. The surgeon should be cognizant of all fluid administered and removed with aspirate and excreted as urine output to avoid problems with hypovolemia or fluid overload.
Fatal complications secondary to liposuction may be attributed to anesthetic cardiopulmonary complications, necrotizing fasciitis with overwhelming infection, hypovolemic shock, fat embolism, pulmonary embolism, disseminated intravascular coagulopathy, or intraperitoneal and bowel perforation. Less common reports of death resulting from liposuction procedures have also included toxic shock syndrome, acute respiratory distress, and hypersensitivity to medications or instruments used during the procedure.
Intestinal or organ perforation from the liposuction cannula, though rare, usually occurs with a preexisting abdominal scar. The abdomen, thorax, retroperitoneum, and major vessels in the subcutaneous space are all potential areas into which a cannula can be misdirected and potentially result in major injury. Kidney perforation has been reported. Symptoms of organ perforation may not become apparent for several days. When internal organs are violated, patients may present for follow-up with symptoms of an acute abdomen, and an emergent laparotomy may be indicated to assess the extent of damage and to repair injury, as visceral perforations and their associated infections may be fatal. Gentle technique and awareness of the possibility of misdirection of the cannula in the presence of a scar will prevent this complication.
The total blood loss involved in suction-assisted lipectomy is principally dependent on (1) the amount of blood present in each milliliter of aspirate and (2) the absolute amount of aspirate. Total blood loss can be estimated as the percentage of blood in the aspirate multiplied by the total amount suctioned. Clinically, the blood loss is rarely a limiting or significant factor in cases in which total aspirate is less than 1000 ml, regardless of the infiltration method used. The dry technique results in a suction aspirate containing 20 to 45 percent blood.
Any of the complications described in the previous section can also occur in the later postoperative period. Surgeons should recognize additional complications that may present as convalescence continues.
Patients with a higher body mass index have been found to have a significantly increased risk for developing postoperative seromas. Ultrasound-assisted liposuction has also been associated with a slightly increased risk of seroma formation. Suggestions for decreasing the incidence of seroma include expressing any remaining fluid before closure; using a single suture to close incisions, allowing for fluid egress; applying a well-fitting compression garment; and encouraging the patient to ambulate soon after surgery. Simple aspiration is the most common treatment for a seroma. An implantable catheter or drain can be used to avoid repeated aspiration.
Although large areas of skin loss is rare, ulceration or friction injury is more commonly noted at the entrance site from incorrect use of the cannula, tension on skin margins, or an incision that is too small for the instruments used. Burns have also been associated with ultrasound-assisted liposuction, as the ultrasound cannula can become very hot, and prolonged contact with the skin may result in skin damage.
Infections can occur and have been known to progress to serious and life-threatening conditions if not appropriately attended to. Many surgeons will prescribe perioperative antibiotics to minimize the risk of infection. Physicians who perform liposuction should be familiar with the signs and symptoms of conditions such as toxic shock syndrome and necrotizing fasciitis.
The most common postoperative sequelae of liposuction are contour irregularities; these may be considered complications if they persist for over 6 months. Because contour irregularities may be secondary to postoperative swelling and skin elasticity, they may be treated conservatively for at least 6 months after the initial operation. However, for areas of excessive fat removal or insufficient fat removal, secondary liposuction, fat grafting, and dermolipectomy can be considered to address the persistent area(s) of concern. Nonsurgical treatments for early contour irregularities include manual lymphatic massage and Endermologie (LPG Systems, Valence, France). Long-term swelling may be noted in a small number of liposuction patients.
Skin hyperpigmentation may be attributed to several factors. Hemosiderin deposition by ecchymosis, external pressure from bandages applied, and possible friction from the inlet holes of the cannula have been suspected of increasing the likelihood of hyperpigmentation postoperatively. Several areas are known to be prone to hyperpigmentation (e.g., the medial thigh). This effect is more often attributed to ultrasound-assisted liposuction and extended treatment time to a single area (>10 minutes). Patients should also be cautioned that oral iron therapy, exogenous drug administration (particularly estrogen), and sun exposure may contribute to the development of hyperpigmentation after liposuction.
Patients may experience paresthesias after surgery. Patients have reported hypersensitivity and numbness after surgery that may persist for weeks or months. In a small number of patients, these paresthesias may be permanent.
The analysis of the sequelae of liposuction and tummy tucks does not provide specific percentages of complications associated with liposuction. Seromas, infection, and tissue irregularities are the most common minor problems. Deep venous thrombosis, associated with pulmonary embolism and death, is the most frequent serious complication of liposuction. Thus, the prevention and, if necessary, the expeditious diagnosis and treatment of deep venous thrombosis are integral to the care of the liposuction patient.
Dr Koo examines patients who may desire secondary surgery to correct contour irregularities carefully and counsels them to ascertain their realistic goals for surgery. Previous surgical procedures are considered and careful notation is made to document the site of secondary surgery and the anticipated amount of secondary lipoaspirate or augmentation with dermal fat grafts of lipotransfer. Skin resection may be necessary for areas of inadequate skin retraction.
Physical outcome and ease of recovery are not the only factors that define patient and physician satisfaction, as successful body contouring surgery requires a patient to embrace positive lifestyle habits. Dr Koo recognizes the importance of patient education on postoperative alternatives in diet and exercise and will help the patient establish a connection with nutritionists as well as exercise trainers. This will ultimately help the patient maintain successes achieved with the liposuction and tummy tuck procedures.
Dr Michele Koo always maintains a relationship with her patients seeing them post operatively indefinitely thereby making sure that they “check in” for annual breast examinations as well as keeping track of their weight and exercise maintenance. Dr Koo wants to change and enhance the patients life and lifestyle and continues to take care of her patients years after any procedures at no further follow-up charges.
