Liposuction is a common cosmetic procedure that been practiced for long time. According to the American society for aesthetic plastic surgery, liposuction was one of the most plastic surgeries in the United States with total number of procedures were around 456,828 cases in 2007 alone.

Liposuction is a procedure to remove excess subcutaneous fats by specific suction machine in a localized areas on the body as the abdomen, back, thigh, upper arms, hips, chest, etc. liposuction surgery helps in contouring the body shape, and targeting fatty tissues in specific locations more than a weight loss tool.

For many years, there were a lot of tries to improve the body shape and appearance. From the early tries what professor Dujarrier, a French plastic surgeon, who used a uterine curette to remove excess fat from the leg of a dancer. The procedure failed, and the dancer lost her leg after severe gangrene.

The Illouz technique, which was introduced in late seventies, introduced the wet liposuction, and it is one of the commonly used techniques in liposuction surgeries. Another technique known since 1980 is traditional suction-assisted lipoplasty, and it is considered one of the basic techniques in liposuction surgeries.

Anatomy and pathophysiology

All the areas of the body contain subcutaneous fat, without equal distribution some parts may contain a thicker layer of subcutaneous fat than others. Although fatty cells in the body acts as power reservoir, increase in fatty cell numbers or volume causes obesity.

In obesity, the increase in fat cells volume is known as hypertrophic obesity, while the increase in fat cell numbers is known as hyperplastic obesity. The latter was found to be more resistant to the usual diet regimen.

A lot of studies found a strong connection between obesity and certain hormones in the body as leptin, ghrelin, and adiponectin. These hormones can induce hunger and increase appetite like ghrelin hormone, while the leptin hormone decrease food intake. Some researchers suggests that liposuction can increase the leptin hormone production, while decrease the ghrelin hormone.

In a study by Schreiber et al. to study to evaluate the role of liposuction effect on ghrelin, leptin, and adiponectin hormones in obese Zucker rats. The results showed that; the levels of ghrelin in rats decreased significantly after the liposuction, while the levels of leptin increase. And adiponectin levels did not show any changes after the liposuction.

The researchers concluded that liposuction could affect the hormonal elements in obesity in a positive way and can help beside a proper diet in treatment of obesity.

The subcutaneous fat layer in the body consists of:

• • The superficial layer: it consists of groups of adipocyte cells condensed, and separated by connective tissue
  • The deep layer: the deep fatty layer is less compact than the superficial layer, with less connective tissue than the superficial layer

In liposuction, the targeted fat is the deep layer of subcutaneous fat because it is easy for suction with less side effects. The suction of the superficial fat layer can cause skin irregularities and increase the risk of skin injury during the procedure.

Fat distribution in the body differs from person to person, and according to varied factors such as:

• • Gender: as fat distribution in males and females are not the same; female body tend to accumulate fat more around hips and thighs, while male body accumulate body fat around center of the body and trunk
  • Age: in elderly, the body tends to decrease the subcutaneous, and increases the intra-abdominal fat
  • Other factors: there are multiple factors that can affect fat distribution as smoking, alcohol consumption, and genetics

Obesity is associated with multiple complications and co-morbidities. The accumulation of fats around the center of the body (central obesity) is associated with increase the risk of metabolic syndrome and diseases as hypertension, diabetes mellitus, and cardiovascular diseases.

In a study by Lihua Hu et al. to evaluate the prevalence of obesity, especially abdominal obesity, and its complications among the population of southern China. They founded that; there are significant correlation between waist circumference, and cardiovascular diseases risk.

There is growing evidence that liposuction surgery, and removal of large volume of subcutaneous fat is associated with improvements in lipid profile, decrease fat mass, and decrease in blood pressure. In a study by Giese et al. to evaluate the effect the large volume liposuction on the cardiometabolic parameters.

The authors founded that; after four months of large volume liposuctions, the patient’s weight, and body fat mass decreases with improvement in blood pressure levels, and fasting serum insulin levels.

Indication of liposuction

The liposuction surgery is cosmetic, and elective surgery, so the patient viability to the procedure should be investigated before the surgery. the indication of liposuction surgery include:

1. Removing of excess fat from localized area of the body
2. Treatment of gynecomastia cases in males
3. As a part of other cosmetic surgical procedures such as:
   • • Abdominoplasty (tummy tuck) surgery
     • Breast enlargement surgery
     • Breast reduction surgery
     • Face cosmetic surgeries

A new technique of liposuction is introduced for suction a larger fat during the liposuction procedure. It is known as large volume liposuction.

Another technique called ultrasound assisted liposuction is used in treatment of resistant cases that did not respond well to previous techniques.

Contraindication of liposuction

There is no absolute contraindication to liposuction, But the patient that may undergo liposuction surgery should be healthy and fit for surgery. The patient and the surgeon should discuss in detail all the medical history of the patient, and any medical condition or previous surgery that may compromise the surgical results. Contraindication of liposuction include:

• • Anticoagulation therapy including aspirin is contraindicated for at least two weeks before the surgery to avoid postoperative bleeding, or hematoma formation
  • Patients with cardiac valve replacement on coagulation therapy
  • Patients with atrial fibrillation who unable to stop anticoagulation therapy
  • Recent history of deep venous thrombosis
  • Patients with history with pulmonary embolism
  • Patients with peripheral vascular diseases
  • Uncontrolled systemic diseases like diabetes and hypertension
  • Smoking is a contraindicated for liposuction and should be stopped for at least 4 weeks before the surgery
  • Previous surgery at the possible site of the liposuction poses a higher risk of complication during the procedure
  • Patients suspected with body dysmorphic disorders should not undergo cosmetic surgery before mental health expert evaluation of the patient

A study by Lindstrom et al. to evaluate the effect of cessation of smoking preoperatively on the recovery of the patient. They founded that; cessation of smoking from four to eight weeks before the surgical operation has a significant impact on decreasing post-operative healing complications.

What can’t the liposuction do?

Before the surgery, the surgeon should be sure that his patient has realistic expectation. And to explain the potential problems that liposuction cannot fix it. Here are a few problems that cannot be treated with liposuction.

• • The saggy skin problem may look worse after the liposuction procedure
  • Liposuction cannot remove stretch marks
  • Liposuction do not remove cellulite and it may look even worse after the procedure
  • Liposuction is not a weight control surgery
  • The suctioned fat can recure because of post operative poor diet

Preoperative preparation

Good evaluation of the patient before the surgery is a key role in post operative speedy recovery. Before the operation, the clinician should be sure the patient is fit physically and psychologically to the procedure. a full detailed history and complete physical examination is mandatory to ensure satisfactory results after liposuction surgery

Patient history and physical examination

The precise patient selection plays a key role to ensure satisfying results of the liposuction surgery. The optimum patient for liposuction is:

• • The patient should have obvious accumulation of subcutaneous fat in specific area of the body
  • The patient body mass index should be below 30 and any increase in BMI should not be more than 30% of the normal BMI
  • The patient should not be obese with good skin laxity
  • The patient weight should be stable for at least six months before the surgery

A full detailed history should be obtained from the patient including:

• • Ask the patient if he complain of systemic diseases like hypertension and diabetes mellitus
  • The patient cardiovascular and respiratory status should be assessed before the surgery
  • The history of possible previous surgical procedures
  • If the patient had any problem with anesthesia before
  • Full detailed history about any allergies

During physical examination, the clinician should evaluate the skin elasticity, and the thickness of the fatty layer in the area that will be suctioned by using the pinch test. All the areas with cellulite should be examined carefully, and the patient should be aware that these areas of cellulite may not be affected with liposuction.

During the physical examination, the surgeon must examine the patient and search for a hernia, scars, previous surgery sutures.

Before the surgery, the surgeon should discuss with the patient about his expectation to his body shape after the surgery, also all patient concerns and questions about the procedure should be answered clearly.

Laboratory investigation

Before the surgery, the surgeon may ask for specific lab investigation to assess the general health condition of the patient. If the patient has any chronic systemic diseases, a specific lab tests may be ordered to make sure that he is fit for surgery. examples of lab investigation include:

• • Complete blood picture
  • Coagulation profile
  • Kidney function tests
  • Liver function tests
  • Urine analysis
  • Electrolyte levels must be assessed

The surgical procedure

The liposuction surgery usually undergoes under general anesthesia to control the patient position during the procedure, and to decrease the level of lidocaine to prevent subsequent lidocaine toxicity.

During fluid infiltrate, the patient’s body should be kept warm by thermal blanket, to protect against hypothermia.

The patient skin is prepared by scrubbing it with iodine solution to ensure sterile surface, and do not cause later infection. For prophylaxis, antibiotic therapy should be started twenty-four hours before the surgery.

There are four types of liposuction techniques. The techniques are tumescent liposuction, dry liposuction, wet liposuction, and superwet liposuction. The main difference between these techniques is the amount of tissue infiltrate, and the expected blood loss.

1. Dry liposuction

In this technique, there is no fluid injected into the adipose tissue, and it is mostly used in small volume liposuction. Around 30% of the aspiration during the procedure is blood.

2. Wet liposuction

In this technique, first, around 100-300 cm of fluid is infiltrated into the subcutaneous fat in the specific sites that would be later suctioned. The amount of aspirated blood is less than the dry technique. Adding epinephrin to the infiltrating tissue can decrease the amount of aspirated blood to less than 15% of the aspirated volume.

3. Superwet liposuction

This technique was developed in the late eighties. First a solution consists of equal parts of epinephrin, and local anesthesia is infiltrated to the subcutaneous fat before suctioning it later. This technique causes dramatic decrease in the aspirated blood to reach 2% of the total volume aspirated.

4. Tumescent liposuction

In this technique, lidocaine and epinephrin are directly injected into the subcutaneous fat just before the procedure. The blood loss is approximately 1% of the aspirated volume. Recently, most plastic surgeon use mix of both superwet, and tumescent techniques.

In the operation room

The liposuction surgery can be done with the traditional method, which consists of infiltration and suction, or the surgeon can use an ultrasound in this procedure, which is known as ultrasound assisted liposuction.

1. The traditional liposuction

In this technique, a small incision is made in the skin, then the infiltration fluid is introduced to the deep subcutaneous fat layer, then the suction cannula is inserted in the targeted area. After suction of the desired volume, the incision is sutured, and the wound would be covered with clean sterile dressings. A compressing bandage would then be applied to the site and should be kept for two weeks.

2. Ultrasound assisted liposuction

In this technique, the infiltration fluid is introduced to the specific site, then the ultrasound energy could be used to cause emulsifying of the fat cells that would be suctioned later. Sometimes, the surgeon can use the ultrasound and the suction at the same time. In this case the energy could induce the healing of the wound but may causes injuries to the adjacent tissue.

Ultrasound assisted liposuction can help in treatment of resistant areas such as back, face, and chest. It also led to enormous success in treatment of male gynecomastia without extensive scarring as in previous techniques.

3. Deep liposuction vs superficial liposuction

In the traditional liposuction surgery, the targeted fat layer is the deep subcutaneous fat, while in some procedures a more superficial fatty layer is targeted to enhance specific area skin contour, or to enhance the shape of skin cellulite.

4. Other liposuction techniques

The traditional suction assisted liposuction is the most widely used technique. Recently, other technologies are introduced to be more effective and decrease the surgeon effort during the procedure. From these techniques:

• • Power assisted liposuction
  • Laser assisted liposuction
  • water jet liposuction

Recovery and follow up

Liposuction is considered an outpatient surgery, that if there were no complications, or risk factors, the patient would be discharged on the same day. The patient would be advised to keep the drain in place until all the excess infiltrate fluid drain out of the body, which usually occurs within one week.

The patient would be advised to keep wearing the compressing bandage for a period range from two weeks to six weeks. This compressing bandage is believed to decrease bruising and postoperative edema, and help in skin contouring, and wound healing.

The patient should be encouraged to keep him self moving around to decrease the risk of developing deep venous thrombosis, or pulmonary embolism. The patient can take shower after two to three days after surgery and can return to his daily activity after one week. Avoidance of heavy lifting, or a strenuous activity is mandatory for at least two to three weeks.

Lymphatic massage is important to relieve lymphatic edema, and the surgeon should encourage the patient to continue in these sessions for four to six weeks. After liposuction, most of post operative edema is resolved within six weeks, while the overall swelling may take up to six months to disappear completely.

Complication of liposuction

Liposuction is a cosmetic procedure, so most patients may feel frustrated when they encounter a side effect after the procedure. It is appropriate to explain all the possible complications that may occur after the procedure to the patient. Complications of liposuction include:

• • Skin irregularities at the suctioned area is the most common complications
  • post-operative bruising: it is one of the most common side effects, which may take weeks before complete resolution
  • Post-operative seroma: it is a clear fluid accumulation under the skin following surgical procedure, post-operative seroma took some time before complete resolution and healing
  • Post-operative transient weight gain
  • Deep venous thrombosis is one of the serious side effects of the surgery and may progress to even more serious condition as pulmonary embolism
  • Fat embolism
  • Local anesthesia toxicity: one of the serious side effects, and due to the procedure technique, it may pass unnoticed until more serious side effects develop
  • Hematoma, hyperpigmentation, and local skin necrosis
  • Skin color changes is common with superficial liposuction techniques

A study by Sieffert et al. founded that; obese patients who undergo plastic surgeries as liposuction are susceptible to develop more adverse effects and complications in comparison to non-obese patients, with increase the risk of patient readmission within thirty days after the surgical procedure.

A study by Kaoutzanis et al showed that; liposuction is a safe procedure with low incidence of major complications, but when combined with other cosmetic surgery as abdominoplasty, the incidence of complications increases. The most common complications after liposuction include:

• • Hematoma 0.15%
  • Pulmonary complications 0.1%
  • Infection 0.1%
  • Deep venous thrombosis 0.006%
  • When liposuction is combined with other surgery, the relative risk is 4.81

Prognosis

Liposuction is an elective surgery, aims to remove excess localized fat accumulations in the body. although patients can gain weight after the surgery, but the body shape remain balanced. small proportion of patients may need additional enhancements to their procedure, while most liposuction patients have accepted results.

Recent studies founded that; following a liposuction surgery, most patients were satisfied about their results, with generalized improvement in quality of life.

In a study by Papadopulos et al. after six months of liposuction surgery, majority of patients were satisfied with their results, with overall improvements in quality of life, physical image, improvement of their health, and even reduction in their anxiety levels.

In a study by Broughton et al. to assess postoperative quality of life, procedure outcome, patient attitudes after the surgery. they founded that; after liposuction, most patients were satisfied about their results. They founded also most patients experienced mild to moderate post-operative pain. In the same study, the authors noticed that half of patients have regained weight after the procedure. And the abdomen was the most common recurrent site.

Although associated with increase rate of complications, some researchers are studying extensively the combination of liposuction surgery with other cosmetic surgery as abdominoplasty.

In a study by Vieira et al. they recommended that combining liposuction with abdominoplasty can decrease the overall complications that may occur after abdominoplasty alone as seroma.

In a study by Eric Swanson, the study showed the combination of liposuction and abdominoplasty surgeries have higher satisfaction levels than liposuction alone. While the patients experienced moderate pain similar to pain due to abdominoplasty surgery alone.

In Weiler et al study, they founded that, unlike the current opinion, the combination of liposuction and abdominoplasty surgery is a safe procedure with great aesthetic results, and overall reduction in postoperative complications.

In a study by F Smith et al. they founded that combination of liposuction and abdominoplasty is safe if a perforator vessel is spare.

Finally, liposuction surgery is a safe procedure to enhance people physical shape, increase their confidence, and improve the overall health.