Liposuction, or suction-assisted lipectomy, is the one of the most commonly performed surgical cosmetic procedure in the United States. According to the American Society for Aesthetic Plastic Surgery, in 2017, there were over 304,000 liposuction procedures performed in the United States.1,2 By gender breakdown, liposuction was also the second-most performed surgical cosmetic procedure for women, and the most commonly performed surgical cosmetic procedure for men.2 Broadly, the procedure itself is the surgical removal of subcutaneous fat with the assistance of mechanical suction with a cannula inserted through small incisions through the skin, though specific techniques vary, to be discussed below. Common sites for liposuction include the abdomen, thighs, buttocks, male breasts, and arms. Cosmetic indications for liposuction include fat that is resistant to diet or exercise and breast reduction. 1 Medical indications include hyperhidrosis of the axillae, lymphedema, and lipomas. 1,3 Notably, obesity is not listed as a medical indication. Contraindications of liposuction include patients with severe systemic disease, cardiovascular disease, clotting disorders, and pregnancy. 4 Liposuction of donor sites such as the abdomen and inner thighs can also be used for fat harvesting for subsequent fat grafting to other areas of the body. In 2017, there were over 76,000 fat grafting procedures to the face, breasts, and buttocks. Fat transfer to the face is increasing in popularity and saw a 22.3% increase in 2017 as compared to 2016.2 The long-term effects of liposuction on quality of life, patient satisfaction, and modifiable risk factors for diabetes and cardiovascular disease have also been explored and other applications for liposuction are currently being investigated as well.5
Tumescent liposuction is considered the standard of care in liposuction. As indicated in its name, tumescent liposuction requires the surgeon to first engorge or swell the area with crystalloid fluid, Klein’s solution, subcutaneously using a cannula. Klein’s solution consists of normal saline, epinephrine, and lidocaine, which serves as the local anesthetic. Saline expands the adipose tissue while epinephrine promotes vasoconstriction to decrease bleeding. 1 The recommended maximum dose of lidocaine is 55 mg/kg, and the recommended concentration of epinephrine is 0.25-1.mg/L without its total dosage exceeding 50 micrograms/kg. 4 The cannula is introduced via small incisions (adits) in the skin that range between one and three millimeters, after local anesthesia with 1 ml of 2% lidocaine1, 4 The surgeon moves the cannula in a back-and-forth motion to create “tunnels” and passes the cannula through five to ten times. About 2-3 L of fluid is distributed gradually.
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After a period of approximately half an hour to allow for the uniform distribution of the Klein’s solution, aspiration by microcannula liposuction can begin. This microcannula is between 1.5 and 3 mm in diameter.1 The surgeon moves the cannula in a similar fashion as previously discussed, creating “tunnels” and passing the cannula through five to ten times, with care to not make “sweeping” arcs with the cannula but instead pulling back and reinserting into a newly created tunnel. At the surgeon’s discretion (visual and tactile monitoring), once there has been a satisfactory amount of Klein’s fluid and fat removed (ideally close to a one-to-one ratio to the Klein’s solution introduced), the tissue is left to drain, and the incisions sites do not require suture closure. It is not recommended to remove more than 5000 mL in a single operation.4 Residual lidocaine as a component of Klein’s solution provides additional analgesia post-operatively, increasing the comfort of the patient during recovery. Tumescent liposuction employs only local anesthesia from the Klein’s but can also be used in conjunction with general anesthesia. Notable advantages of tumescent liposuction include proven safety, outpatient setting, reduced costs, and rapid post-op recovery time. However, the drawback is that the procedure is long and is not appropriate for extractions of over 5 liters. 1
In contrast to tumescent liposuction, conventional liposuction is only performed under general anesthesia, thereby requiring hospital admission, which increases the cost and the risk of hospital-acquired infections. General anesthesia also carries more risk than local anesthesia. The points of entry through the skin for the cannulas are larger, measuring 1-1.5 cm, and the cannulas are 6 mm – 1 cm in diameter. Larger cannulas are more traumatic to tissue and increases the risk of bleeding, possibly to the point of required blood transfusions. The skin incisions will require sutures. Conventional liposuction takes less time, around 1-2 hours, but the recovery time is longer than with tumescent liposuction. 1
There have been developments in liposuction tools and techniques that come with their own sets of advantages and drawbacks. Power-assisted liposuction with a special reciprocating cannula assists the surgeon in repetitive motions and lessens physician fatigue. Power-assisted liposuction allows for quick removal of fat but requires the use of large cannulas. This procedure also requires IM or IV sedatives and/or nitrous oxide. Ultrasound-assisted liposuction (UAL), as the name implies, uses ultrasound waves to dislodge or damage fat cells, leading to easier removal. 1,6 However, an adverse consequence of UAL is the potential burning of skin, increased risk of seroma formation, and significant bruising and swelling post-operatively. 1 Radiofrequency-assisted liposuction applies energy to the dermis while heating deep adipose and subcutaneous tissue without compromising the skin. Laser-assisted liposuction is being explored and uses a 1064-nm-wavelength neodymium: yttrium-aluminum-garnet laser to aid in the coagulation of small vasculature, rupture of fat cells, and coagulation of collagen in the fat tissue. Water-assisted liposuction emits jets of tumescent solution with concurrent suctioning of the adipose tissue and delivered fluids. 6
Post-operative care should include compression garments for 2-4 weeks. In the first two days, two layers of tight pressure dressing, known as bimodal compression, is recommended. Post-operative analgesics and antibiotics should also be prescribed. Draining of surgery site and incisions should be monitored, as improper draining can lead to irregularity and secondary infection. Regular follow-ups should be scheduled, and the patient can usually return to low-impact work in 3-5 days. Exercising can resume after ten days. 1
Complications are rare given proper preoperative and intra-operative precautions. Risk of seroma formation is minimized by avoiding aggressive aspiration and to be conscientious that UAL carries a higher risk for seromas. 1,6 Postoperative edema is usually self-limiting, but utilizing small cannulas and proper pressure dressing can help the course.1 To be noted, prolonged compression can cause creasing, hyperpigmentation, pain, and swelling.4,6 Management of existing comorbidities is important, as postoperative bruising is commonly seen in hypertensive patients and panniculitis and fat necrosis, though rare, has a higher risk of occurrence in diabetics. Sterile technique, small incisions, the antibacterial effects of lidocaine, and antibiotic regiments minimize the risk of infection, with less than one percent occurrence reported.6 Postoperative syncope may occur when removing pressure dressings, so one should be conscientious of patient positioning changing dressings. 1 The most common postoperative complication is contour irregularities. Contour irregularities can be minimized with the selection of smaller cannulas, turning off suction when exiting tunnels, cross-hatching pattern, periodic re-evaluation of the area visually and tactilely, and patient positioning. Autologous fat transfer or fat grafting can be used to correct deformities during surgery or in a separate procedure. The most concerning and potentially fatal operative complications of liposuction are pulmonary emboli, fat emboli, sepsis, necrotizing fasciitis, and organ perforation. Risk factors for the development of serious systemic complications are poor sterility, excessive use of wetting solution in the procedure, lenient postoperative discharge standards, and inappropriate patient selection. 6
Liposuction as Treatment
Typically, lipectomy is viewed as a cosmetic or aesthetic procedure. With advancements in surgical techniques and overall popularity, the opportunity to explore the role of subcutaneous fat as a modifiable risk factor in some diseases and the possibility of liposuction as a treatment for obesity emerged. Obesity is defined as a chronic condition that is defined, for adults, as a BMI of greater than 30 kg/m2.7 Specifically, abdominal obesity (increased waist circumference, increased subcutaneous fat, increased visceral fat) is a known risk factor in insulin resistance and coronary artery disease. In a study published in the New England Journal of Medicine, researchers measured body composition (BMI, weight, fat mass, body fat percentage, subcutaneous adipose-tissue volume, visceral adipose-tissue volume, and thigh adipose-tissue volume), specific risk factors for coronary heart disease (waist circumference, blood pressure, plasma glucose, plasma insulin, total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides), and inflammatory mediators (leptin, adiponectin, tumor necrosis factor alpha, interleukin-6, and C-reactive protein) of 15 obese women (8 with normal glucose tolerance and 7 with Type 2 Diabetes Mellitus) before and 10-12 weeks after large volume (over 4 liters of lipoaspirate) tumescent liposuction. Liposuction showed significant decreases in BMI, weight, overall fat mass, body fat percentage and subcutaneous adipose-tissue volume but no significant decrease in visceral or thigh adipose tissue, as to be expected. Of the coronary heart disease risk factors measured, this liposuction only significantly decreased waist circumference. The only inflammatory mediator that was decreased significantly was leptin, notably without significant changes in interleukin-6, adiponectin tumor necrosis-alpha or CRP. Effect of insulin on glucose production, lipolysis, and glucose breakdown did not show a significant difference post-liposuction. This study demonstrates that the amount of subcutaneous adipose tissue removed with liposuction does not have the same metabolic benefits that analogous weight loss via pharmacotherapy, diet, or bariatric surgery does, hence highlighting the role of negative energy balance in obesity treatment and providing insight into the role of visceral adipose tissue, that which is not affected by liposuction, in managing insulin action and risk of coronary heart disease. Thus, liposuction cannot be considered a treatment for obesity. 5
As noted, a medical indication for liposuction is for the treatment of arm lymphedema. A study published in 2017 by Hoffner, et.al, examined the effects of liposuction not only on the treatment of lymphedema and its physical implications but also the long-term effects on quality of life for the patients receiving the treatment. Upper extremity lymphedema is common sequelae of mastectomy, and cancer treatments involving the lymphatic system, with 20% of women developing the condition following mastectomy. Chronic lymphedema then precipitates deposition of subcutaneous fat. From a physical standpoint, the lymphedema causes swelling of the limb, resulting in restrict range of motion, discomfort, fibrosis, and potential for recurring infection. Using the 36-item short-form health survey (SF-36), researchers assed health-related quality of life for 60 patients. The questionnaire was administered 1, 3, 6, and 12 months post-treatment and showed significant increases in patient’s health-related quality of life.8
Future Applications of Liposuction and Clinical Trials
Currently, according to the National Institute of Health and the U.S. National Library of Medicine, there are numerous clinical trials in progress and recently completed that explore future applications of liposuction and the resulting harvested lipoaspirates, or its components, as treatment or part of a treatment plan for a variety of conditions, such as hair loss, wound healing, glaucomatous neurodegeneration, osteoarthritis, and erectile dysfunction. There appears to be an emphasis on adipose-derived regenerative cells (ADRC) or adipose-derived stem cells (ADSC). 9-13 Advantages of ADCSs include low immunogenicity and immunosuppressive properties as well as growth factors to promote regeneration and healing. 14
1. Venkataram J. Tumescent liposuction: a review. Journal of cutaneous and aesthetic surgery. 2008;1(2):49-57.
2. Cosmetic Surgery National Data Bank Statistics. Aesthetic surgery journal. 2018;38(suppl_3):1-24.
3. Stewart CJ, Munnoch DA. Liposuction as an effective treatment for lower extremity lymphoedema: A single surgeon’s experience over nine years. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2018;71(2):239-245.
4. Mysore V. Tumescent liposuction: standard guidelines of care. Indian journal of dermatology, venereology and leprology. 2008;74 Suppl:S54-60.
5. Klein S, Fontana L, Young VL, et al. Absence of an Effect of Liposuction on Insulin Action and Risk Factors for Coronary Heart Disease. New England Journal of Medicine. 2004;350(25):2549-2557.
6. Chia CT, Neinstein RM, Theodorou SJ. Evidence-Based Medicine: Liposuction. Plastic and reconstructive surgery. 2017;139(1):267e-274e.
7. Smith KB, Smith MS. Obesity Statistics. Primary care. 2016;43(1):121-135, ix.
8. Hoffner M, Bagheri S, Hansson E, Manjer J, Troëng T, Brorson H. SF-36 Shows Increased Quality of Life Following Complete Reduction of Postmastectomy Lymphedema with Liposuction. Lymphatic Research and Biology. 2017;15(1):87-98.
9. Effect of Autologous Fat Grafting on Acute Burn Wound Healing. https://ClinicalTrials.gov/show/NCT03791710.
10. Autologous Adipose-Derived Stromal Vascular Fraction Cells for Osteoarthritis Treatment. https://ClinicalTrials.gov/show/NCT02967874.
11. Autologous Stromal Vascular Fraction of Cells for Treatment of Knee Articular Cartilage Dystrophy. https://ClinicalTrials.gov/show/NCT02827851.
12. Effectiveness and Safety of Adipose-Derived Regenerative Cells for Treatment of Glaucomatous Neurodegeneration. https://ClinicalTrials.gov/show/NCT02144103.
13. Evaluate the Use of Liposuction and Cell Separation Devices for Autologous Fat (Adipose) Derived Cells to Treat the Symptoms of Erectile Dysfunction. https://ClinicalTrials.gov/show/NCT01601353.
14. Frese L, Dijkman PE, Hoerstrup SP. Adipose Tissue-Derived Stem Cells in Regenerative Medicine. 2016;43(4):268-274.
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