Introduction

“Welcome to Plain Talk About Plastic Surgery, your source for down-to-earth information and explanations about plastic surgery procedures and operations based on my three decades of experience.

I’m Dr. Elizabeth Kerner and in today’s podcast, we’re going to discuss liposuction.

The History of Liposuction from its Origin to Breakthrough in Greatly Minimizing Blood Loss

Interestingly, liposuction did not make it to the shores of the United States until about 1982. There is a plastic surgeon in France, Dr. Illouz, who really is the developer of the current technique of liposuction. Prior to this plastic surgeons in the 60s and 70s, had tried to remove fat, but they usually would do it with a device that looked like a scalpel that would go in and just cut hunks of fat out from various levels of the skin.

As you can imagine, this didn’t work very well. The blood loss was pretty significant and the inability to control the contour of the skin after you had done that was not controllable by the surgeon. In addition, this would create a large cavity underneath of the skin, which could fill with blood and serum, leading to further deformity, as well as injuring nerves and blood vessels.

So plastic surgeons in the 70s were quite frustrated because they wanted to be able to alter the contour of a woman or a man’s body – but mostly a woman in those days – by removing fat, but they were not successful with this closed technique.

Dr. Illouz in his research and studies, and also being a very smart individual, realized that the technique of tunneling, or doing what’s called interrupted dissection, would be the best way to go about this. And so he did his research and worked on his own patients and came up with the technique.

In 1982 he gave the first American presentation in Hawaii, and that was to the American Society of Plastic and Reconstructive Surgeons. And it completely revolutionized plastic surgery from that date on. It was such a revolutionary technique that many of the plastic surgeons who were at that sort of small meeting back then banded together to create a new society called the Lipoplasty Society.

And when I first came out into practice, I was a very proud member of the Lipoplasty Society, because many plastic surgeons did not do liposuction. They considered it unsafe.

Another very interesting development that Dr. Illouz thought of and taught on was the use of tumescent technique. And this is what we do these days. So he would inject a fluid into the fatty tissue, and it’s a little different than what we use now. And it would wet the fat making it easier to remove, but it would also deliver epinephrine to the fatty tissues and the blood vessels to cause them to constrict, so there wouldn’t be as much blood loss.

Somehow, between his presentation in 1982 and when things in the United States really started going in 1986, American surgeons just dropped the tumescent part.

When I first came into practice, my first liposuction on my own was a very small liposuction, and the blood loss was significant for this very tiny liposuction. And I thought, “Well, perhaps this is a technique that just really isn’t going to catch on.”

But American surgeons had just not adopted the practice of doing tumescence, and now that we do, it’s made it a very safe operation with, in most cases, very little blood loss.

Liposuction – from Soup to Nuts

I thought what I would do, would be to compare and contrast the different types of liposuction, and then explain my technique, and then we’ll go over risks and complications.

Traditional Liposuction

So, traditional liposuction involves using a hollow metal tube that’s connected to a suction machine that creates about two atmospheres of negative pressure to suck fat out of the tissue. So as I just mentioned, the surgeon will put a water solution, what we call tumescent or tumescent fluid, into the fatty tissue.

This is IV fluid that, in my case, has a little bit of numbing medicine just to help with post operative pain, but mostly a small amount of epinephrine. Then this is allowed to remain in contact with the fatty tissue for about 15 minutes to constrict the blood vessels.

In traditional liposuction, the cannula is introduced and fat is sucked out in little tunnels,. We try and not make a contiguous cavity, meaning you just suck out a large valley of fat, because then that area can fill with fluid and will also cause the skin to collapse there, creating an indention or a divot.

So liposuction in all forms is done by creating a honeycomb of little tunnels where the fat is removed. And traditional works just fine and we still use it in many areas of the body.

Ultrasonic Liposuction and its Skin-Tightening Effects

Ultrasonic liposuction became popular in the late 1990s. The ultrasound machine that we all know for looking at veins and looking at babies, had been adapted to create a cannula where ultrasound energy came out of the tip.

And this was used by general surgeons to help remove liver tumors, or tumors from the spleen – areas where there was a lot of bleeding. And the vibratory effects of the ultrasound would essentially emulsify or dissolve the tissue. This was then applied to liposuction.

So in an ultrasonic technique, you would put the tumescent fluid in, then wait your time, and then put in a small ultrasound probe. And ultrasound energy is emitted from the tip and hits the wet fat causing it to emulsify or explode.

In areas of very fibrous fatty tissue, which could be the flank area, the low back area, the outer thighs; for males, the breast area, really revolutionized our ability to remove this fibrous fat that just couldn’t be suctioned out in the traditional way.

The other wonderful side effect, that wasn’t really known at the time but became quite obvious, was that the energy that was delivered into the tissue from the ultrasound waves would create some heat at the bottom of the skin in the lower dermal level, and cause the skin to contract and tighten up.

So not only are you removing fat, but you’re creating tighter skin. This is done through a scarring process, but if you’re careful, it doesn’t create any visible or palpable scar exteriorly.

There were studies done back in those days to compare traditional and ultrasonic. It was quite easy to do that because a person’s body could act as the control.

You could do one thigh on the right side with traditional, and the left thigh with ultrasonic, and then just see which one got a better result: Which one was the skin tighter, which one had more fat tissue left behind. Those studies prompted me to incorporate ultrasonic liposuction into my practice.

The company that makes the ultrasonic machine is named Vaser. So we just call it Vaser liposuction. A lot like you just say Kleenex because of the Kleenex company.

Power-Assisted Liposuction (PAL) – Less Effort, but Inferior Skin-Tightening

There are some newer techniques now, one that’s very popular is PAL liposuction, and that’s just power-assisted liposuction. In that, the cannula tube goes in and, through a machine, it vibrates back and forth to simulate the movement of the surgeon’s hand when we’re pushing the cannula in and out of the fat to suck the fat out.

This doesn’t really remove more fat, it certainly does not create better tightening. It’s just easier for the surgeon because there’s less fatigue of your arm. I can certainly account to the fatigue of your arm when you’re doing a big liposuction. It’s quite a significant physical workout.

The PAL company says there’s no friction or heat created. So, to my mind, if you’re not creating any friction or heat, there’s no reason that you’re going to have better skin tightening with the power-assisted technique.

And I have seen no studies that go head to head with ultrasonic on one side, and the power-assisted on the other to show that power-assisted gives you a better or tighter result than just ultrasonic.

Water-Assisted Liposuction (WAL)

There’s a new machine now which uses a water-assisted removal of the fat. I haven’t seen it, I really haven’t researched it, and I haven’t talked to anybody that uses it on a regular basis.

It would seem to me that putting a lot more water into the fatty tissue to take out – in essence using a jet to emulsify the fatty tissue, would make it very hard to know what your end point would be.

I’m not saying it’s a bad technique, it’s just one that I have no experience with, and have seen very little in the literature to say whether this is just a passing fad or not.

Dr. Kerner’s Technique for Liposuction

Anesthesia

So how do I do liposuction? I do put my patients to sleep for several reasons. Most of the time, we have you in awkward positions: so you’re turned on your side, on your back, and your legs are frog-legged. It would be difficult to maintain that position and be comfortable.

In addition, it would make you rather vulnerable to be in those positions. And I’m taking out enough fat and, by doing that, I’m putting in a lot of fluid. It would be quite uncomfortable for me to tumesce your fatty tissue without you really being heavily sedated.

So for my patients if we’re going to the operating room, you’re pretty much just going to go on to sleep for this operation. It isn’t a big, deep, terrible anesthetic. It’s more in the colonoscopy range, but you are asleep for it.

There are certainly surgeons that do this in their office. Dermatologists in particular, do a lot of liposuction in their office because they don’t have operating room privileges. They do tend to do much smaller volumes. I have talked to patients that have had that done by a dermatologist and said they were fine, they took a Valium ahead of time. But they’re certainly not doing the larger volumes that we tend to do as plastic surgeons.

Preparation, the Procedure, Contouring and Feathering

I have marked on my patients prior to going back to the operating room because we do a little topographical map on the areas we’re going to liposuction. So that that helps me see where you have accumulation, where there might be looseness, or indentions, or stretch marks that we need to deal with.

You’ll go back to the operating room when you go off to sleep. If we’re doing the back and the thighs I’m going to turn you on your side, and liposuction one side, then go to the other side, liposuction the other side, and then roll you back on your back, and do the abdomen and then the inner thighs.

For liposuction I start first by making a little cut, this is about three millimeters, introduce the cannula to put the water solution into the fatty tissue. That takes several minutes to actually inject it into the fatty tissue.

Then we’ll wait until it’s a total of 15 minutes, and we do that by just setting the clock so that I can’t get impatient and go too quickly. Then for the next stage, I’ll introduce what’s called a basket extractor, which is a little cannula that has an expanded tip on it. And that helps to disrupt some of the fibrous tissue.

Many plastic surgeons have abandoned ultrasonic just to do the basket extractor. But I do think the ultrasonic does help with the skin tightening. But I’ll use the basket extractor more to get rid of the fibrous, firm areas. Then I’ll put in the ultrasonic, we don’t suck anything out after we’ve used the basket extractor because you really need a moist environment to make the ultrasonic work.

And then the ultrasound energy is delivered to all the areas and I’m able to use less energy to accomplish the same result. And I think scarring and firmness of the skin is significantly less.

Then the actual liposuction is done last. In that we put varying sizes of cannulas in to suck out the fat and do the contouring and feathering of the edges.

It’s interesting, I was looking back over Dr. Illouz’s first textbook, and he talked about, in the neck, using a very small cannula which is five millimeters – which is a huge cannula! Nowadays for big areas of liposuction in the thighs, or the hips or the abdomen, I may use a four and a half millimeter cannula.

But most of my work is done with three and three and a half millimeter cannulas. And in the face, to do under the neck, I would certainly use a two millimeter cannula. So the idea of using a five millimeter just sort of horrifies me today.

The Compression Garment / Postoperative Liposuction Girdle

The incisions are closed with little stitches and then you are put into your postoperative girdle. This we measure you for in the office before you go to surgery.

You’re going to wear your girdle most all of the time. So this is like 23 out of 24 hours for the first two to three weeks, and then go to 12 hours a day.

You’re certainly not going to be exercising very much at first because you have the girdle on and it’s quite hot, and we don’t want you to pass out. The girdle can be taken on and off to wash and dry it.

When it starts to become too loose, which is usually at seven to 10 days, there are commercial garments that you can purchase as your transitional garment. Most people are not able to stay with the very first surgical garment for the entire time.

The girdles have the crotch cut out so that you can go to the bathroom while you’re wearing it. If you need to have a bowel movement, you’ll probably have to pull it down. There are zippers on the side. If it starts to get loose a little too quickly, we just have you put a folded hand towel or a small bath towel in to provide compression.

Postoperative Pain