As defined on the website www.liposuction.com, “The concept of liposuction is

surprisingly simple. Liposuction is a surgical technique that improves the body’s contour

by removing excess fat deposits located between the skin and muscle.” It does not remove

fat from areas deeper than just under the skin. Also known as suction-assisted lipectomy,

the procedure removes small to moderate or even large amounts of localized deposits of

fat. This is done by inserting a stainless-steel or titanium tube known as a cannula through

incisions made into the skin, moving it back and forth to loosen excess fat, and suctioning

the fat out using a vacuum or a cannula-attached syringe. When used in this book, the term

“lipo” means lipoSUCTION. Fat is actually removed and not the fake fat removal

procedures where fat is frozen or heated and they play games with tape measures, mirrors

and photoshopped pictures.

For several decades, patients have been awake usually.  Oral and/or iv sedation is

typically used but general anesthesia is not necessary and is largely a convenience for

the surgeon. General anesthesia increases risks and for this elective procedure and is

not recommended. However, in the past decade as more and more plastic surgeons

have started performing liposuction they have made use of general anesthesia or

deeper sedation more commonplace, because they are used to working on unconscious

patients. Performing a procedure on anesthetized unconscious patient is

easier and faster, resulting in less stress for the surgeon with little long-term benefit for

the patient. When patients request, we are able to arrange for a deeper level of

anesthesia but this is less than 5% of patients. The trend in the industry is changing as

plastic surgeons perform an increasing percentage of these procedures. However, it is

reasonable to say that use of general anesthesia benefits the surgeon more than the

patient.

The most frequently treated areas for women are the abdomen, breasts, hips, outer

thighs, anterior thighs, inner thighs, knees, arms, buttocks, cheeks and neck. In men, who

comprise about 15% of liposuction patients, the most commonly treated areas include the

chin and neck area, abdomen, flanks (“love-handles”), and breasts. Many techniques of

liposuction have accomplished amazing improvements on the abdomen, hips, thighs,

calves, arms, buttocks, back, chin and neck. Less common areas treated include the mons

pubis and breasts. A liposuction procedure may include more than one area, e.g., the

abdomen, back, and thighs all in one session on the same day. Liposuction is also used to

reduce breast size in men with large breasts (gynecomastia AKA “Man boobs”) or to

remove fat tumors (lipomas) but it is most commonly used for cosmetic body contouring.

The simple answer is not really for most patients. There are times when pre-existing

medical problems or the need for extensive reconstructive procedures may create

advantages for a procedure to be performed in a hospital. However, for the vast

majority of healthy patients it is not necessary to be hospitalized. Liposuction is an

art. the term body contouring is preferred. (It sounds a little more tasteful than

liposuction.) But removing fat, contouring the body is an art form more so than a

surgery. It does involve some surgical and scientific techniques and some

technological skills- but to get a good result and to make people happy you have to

approach it as something more than an operation. Part of the art is being able to

perform this medical procedure on an awake patient in a less risky environment than a

hospital. Hospital acquired infections are generally more serious than the less

frequent infections in an office setting. The plastic surgery societies have done a

wonderful job of misleading the public and especially the media. The vast majority of

plastic surgeons who perform liposuction as it is practiced today, did not learn it in

their residency training or in a hospital. They learned it the same way as doctors in

other specialties. Having had the experience and privilege of both training and being

trained by plastic surgeons, one can say that their training provides a perspective

based on reconstruction and tissue removal and other more advanced surgical

interventions. However, liposuction per se, is not a reconstructive technique, and does

not require five years of training to master the skills necessary to be good at it.

Indeed, one should be leery of someone who claims that it took them five years to

learn how to do liposuction. Granted, they did learn quite a lot in their five or six

years of training but not very much of it had to do with liposuction.

Routinely, patients return to work in 2 to 3 days. When liposuction is done totally

by local anesthesia, patients can usually depart from the surgical facility within 30

minutes to an hour of the completion of surgery. When general anesthesia is

employed, then patients usually require one to three hours of post-anesthesia

observation before being discharged home. Most patients can return to a desk-

type job within two days after tumescent liposuction. Because of the medications

used for sedation during the procedure, it is not recommended to drive for at least

a day.   After a procedure performed under oral or iv sedation, the patient is alert

and may feel that they are able to perform their normal duties within a day or so.

The riskiest situations with liposuction procedures result from doing too much

liposuction in a single session. Also, doing multiple related or unrelated surgical

procedures on the same day that liposuction surgery is performed is the basis for

complications. Two separate smaller sessions can be safer than one big procedure. Based

on my own experience with thousands of procedures in over 1500 sessions and based on

current worldwide experience, liposuction when performed as a stand-alone procedure is

amazingly safe. Rare problems that can potentially occur with any surgical procedure

include infections, seromas, bleeding, skin necrosis or ulcerations, burns from lasers, and

rarely nerve injury.   Any honest plastic surgeon will tell you that these complications do

indeed occur and are not exactly rare. However, it is interesting that these complications

only make the nightly news when it happens to a patient of a non-plastic surgeon in a

non-hospital setting.

To paraphrase a statement formerly posted on the FDA website, (I share a position

that they have issued.) “…Any doctor with knowledge of a few basic surgical skills can

be trained to perform liposuction.”    Although plastic surgeons would have the public

think otherwise. Most plastic surgeons who have been out of their training for more than

three or four years did not learn liposuction as it is performed today in their residency

anyway. It is pertinent to point out that the majority of plastic surgeons who do

liposuction learned it just like the doctors of other specialties, in post-graduate training

sessions, seminars, working with other doctors who do these things, etc. I have trained

two or three plastic surgeons (on the “down low”) and 17 other doctors.  Basically, the

concept is that liposuction is a skill that can be mastered without a 6-year residency.

Liposuction - much like robotics, lasers, new imaging studies, use of new drugs or

immunotherapies - is a skill that most doctors learn long after they have completed their

residency. It is disingenuous to say the least to imply that only plastic surgeons can learn

new skills after they complete their residency. People skills and an artistic eye are more

important than surgical training to achieve good results safely with liposuction.

The answer to this question will be perceived to be controversial. Conventional

wisdom teaches us that liposuction should not be a treatment for obesity. However, we

have found that liposuction can be a great motivational tool. With obese patients,

generally a staged approach is necessary. What is not feasible in a single session can

often be accomplished in multiple sessions. While certainly not curing obesity, even

obese patients benefit from looking better, feeling better about their appearance and

having clothing fit better. Reducing a woman’s dress size by two or three sizes or

permitting her to fit into clothing she already has can motivate her to do the lifestyle

changes and modify her eating habits - still essential and correcting obesity. We have

many examples of patients who went from a size 22 or 24 dress down to an 8 or 10. Thus,

when combined with a medically supervised weight loss program liposuction can be

viewed as a significant adjunct in the treatment for obesity. There are no age or weight

limits per se. Areas of localized fat i.e. fat just under the skin that can be pinched during

consultation - are the best for liposuction surgery. The patients who see the best results

are those who have a stable weight near or within the healthy range. Patients who are

happy with their weight but have localized problem areas that they would like sculpted

are ideal candidates.

Elastic compression garments (specially designed post-operative girdles) are

intended: 1) to reduce bleeding immediately after surgery. 2) to reduce swelling. 3) to

reduce the time that it takes to heal.

Tumescent liposuction technique has greatly eliminated surgical bleeding as a problem.

Most surgeons require that patients wear an elastic compression garment for up to several

weeks after liposuction.

The compression garment reduces the risk of fluid accumulation (seromas) and reduces

bleeding after the procedure. Most importantly, it also facilitates molding of the new

contours and improves results of body shaping procedures.

Yes, it is important though that the diabetes be under good control. Wound healing

difficulties, postoperative infections etc. are more common in diabetics. However, as

therapeutic modalities go, liposuction is underrated in terms of its potential benefits for

treatment of medical conditions-like diabetes. Most salient among these medical

conditions would be “pre-diabetes.” We have observed in our practice a high percentage

of liposuction patients will have evidence of insulin resistance and/or glucose intolerance

or in other words in “pre-diabetes.” Many were not previously aware of this concern.

We spend considerably more energy with both the medical pre-operative work up and the

postoperative follow-up of medical conditions identified preoperatively. When re-

assessed at 12-week intervals the most dramatic changes are in the measurement of

hemoglobin A-1 C in patients who didn’t know that they were prediabetic. The A1C test

is a measure essentially of the average blood sugar over 3 months’ time. The

improvement is often comparable to the magnitude of improvement with prescription

drugs like metformin or even more potent oral hypoglycemic drugs.

We treat patients with high blood pressure all the time. Obviously, the blood

pressure must be well-controlled before the procedure is performed. Additional

monitoring during the procedure is necessary. Sometimes additional medications

perioperatively are utilized.

Microcannulas: A liposuction cannula is a stainless-steel tube which is gently and

skillfully inserted into subcutaneous fat through a tiny incision in the skin. A microcannula

has an outside diameter of less than 3-4 millimeters (mm). Many plastic surgeons prefer the

traditionally larger sized cannulas, for example those having an outside diameter ranging

from 4 mm to 6 mm or more even -require larger incisions which usually leave more visible

scars, causing more drainage, requiring drain tubes after the procedure, etc. This results in

prolonged swelling, bruising and pain after liposuction. Smoother liposuction results can be

achieved by using microcannulas which allow a more gradual and controlled removal of fat.

This improves the ability of the surgeon to achieve smoother results. Procedures done with

microcannulas also take longer. Larger cannulas are associated with an increased risk of

irregularities and unevenness producing skin depressions etc. Larger cannulas used in

hospital-based surgery may remove fat so quickly that there is a risk of removing too much

fat with avoidable injury to blood vessels and connective tissues. It is also more difficult to

precisely control the direction of a large cannula, without excessive injury to blood vessels

and connective tissues. Smaller cannulas cause less injury to these tissues which are crucial

to healing and good results with less unevenness skin necrosis and bleeding. With any

attempt to make a small incremental change in the direction of a large cannula there is

tendency to re-enter a pre-existing tunnel within the fat. This lack of precise control

contributes to the risk of skin irregularities associated with liposuction when using large

cannulas.

No, not our patients- Gentle handling of the fat during harvesting enhances viability after

transfer. We minimize technology during this step. Second, we only transfer viable fat that is

expected to survive, discarding the rest. Third, since we’ve started using PRP routinely with

fat transfers especially to the breast and face as well as buttocks. We have observed

outstanding viability and even progression of growth of the fat at one year or later.

Yes, I am convinced there is a relationship. Men who smoke marijuana frequently

have a recurrence of breast tissue after treatment with liposculpture, requiring repeat

or multiple treatments.

During the two days immediately after liposuction, the amount of pain experienced

depends on the concentration of anesthesia used for liposuction. The local anesthetic

effect actually lasts for more than a day. Soreness is usually the most significant 2 to 4

days after liposuction and then decreases steadily. We routinely prescribe pain

medication for use during those few days, but many patients do not even feel it necessary

to fill the prescription. The tenderness and soreness typically are a nuisance for up to 4

weeks-usually less. But it is not disabling enough even to miss work. The compression

garment used after liposuction procedures helps to reduce pain tremendously.

Very likely the answer is yes.  A tummy tuck is basically a skin removal procedure.

 Body contouring is more than just having tight skin. As traditionally performed, a

tummy tuck is two dimensional.   The plastic surgeon operates within a sterile field

involving only the front side of the patient. A large crescent of skin is removed as a

flap, as the belly button is relocated. The remaining edges are reattached resulting in a

scar from stem to stern. A shapely woman is a three-dimensional structure having height,

width and depth.  Repositioning in order to contour the flanks, the sides, the lower back,

bra line areas as well as the areas addressed with a tummy tuck is necessary to contour a

shapely figure. This sculpting process is much easier with an awake patient and almost

impossible with an unconscious patient under general anesthesia used for tummy tucks.

(See examples of tummy tucks improved)

First of all, it takes a different type of thinking and evaluating to think artistically

rather than just medically or surgically. All three thought processes are essential to a

successful consultation. We do the consultation standing in front of a mirror. The patient,

basically, is almost naked. I am looking at her; She is looking at herself, so we are

looking at the same image. While asking questions, before I grab an area of fat; I want

her to grab whatever it is she is concerned about. We are touching and feeling and

looking at and moving as she changes her position in front of the mirror. With more than

just words, we are communicating and conveying that artistic message. We view the

project much as a sculptor would as they get to know a piece of clay or stone. – The

Artist will touch it; they feel it; they look at it from all angles, and then they begin to

work. The big difference is a sculptor has something that is not alive.  Unlike the stone,

my medium talks back to me; it is cooperative, and he or she heals-further enhancing the

fruit of my labor. This experience is no doubt different than how traditionally trained

plastic surgeons approach things. Most of us who are not plastic surgeons work with our

patients while awake. That situation makes it easier to consider the three-dimensional

concerns of the patient. A successful consultation views the patients concerns in 360°. If

one thinks of some of the reconstructive procedures that plastic surgeons do, obviously,

designed by men, he thinks in two dimensions. Women have taught me to recognize that

a woman is a three-dimensional structure. We cannot just worry about those two

dimensions that poke out of the sterile surgical field. Like, for example, with an

abdominoplasty, the plastic surgeon takes a big flap of skin, removes it, repositions the

umbilicus, and still thinking in two dimensions. Too often, the flanks, bra line and the

rest of the waistline are ignored. Body contouring must be approached in three

dimensions and that process starts during the consultation.  Like it or not, non-plastic

surgeons who are more artistic in their approach have made the plastic surgeons revise

their thinking.

There are several important nutritional considerations. Most often, when we do a

liposuction procedure, part of what we are managing is skin tightening. The patient does

not want to leave loose skin in the areas where we aggressively remove the fat. So, any

time skin needs to tighten, (and tightened skin is important throughout all of aesthetics),

new collagen has to form. One forms new collagen with protein. Having enough protein

in your diet for collagen synthesis is important. Our recommendation is to supplement

zinc and Vitamin C as well. Other recommendations may apply based on individual

considerations. There are a lot of nutritional considerations that might require taking

away some supplements rather than adding some supplements. These considerations

would be unique to specific individuals.  That's beyond the scope of this book.

Liposuction is more than an aesthetic or cosmetic procedure- not to mention it's an

emotional kind of experience. Improvement in one’s body self-image is a life-changing

experience. Liposuction in time will be viewed as a legitimate treatment for early

diabetes, as a tool for harvesting stem cells for treatment of maladies affecting all organ

systems. In time, the multiple medical treatments with stem cells will rely heavily upon

harvesting the stem cells from abdominal fat. These multiple medical treatments will

require the expertise of many doctors in specialties other than plastic surgery.

Yes and no. Liposuction does permanently remove fat cells. However, it is possible

to regain weight- both in the areas treated as well as in other areas. After liposuction, the

body’s new shape can be more or less permanent If a person changes their lifestyle,

making permanent improvement in their eating habits, exercise…etc. Liposuction can

facilitate a new beginning. If a patient does gain a modest amount of weight after

liposuction, then the figure will simply be a larger version of the new body shape.

Sometimes this can even be quite flattering when the weight goes where desired. Fat

cells that are removed by liposuction do not grow back.

Yes, almost everyone has some degree of anxiety before having any surgical

procedure, including liposuction. Some people have more anxiety than others.

Understanding what’s involved and having all your questions answered before hand

reduces anxiety considerably. One mission of this book is to separate the anxiety

associated with liposuction per se from other riskier procedures frequently done

concurrently by plastic surgeons. Over the decade and a half that I have been studying or

performing this procedure it has been interesting to observe how liposuction has been

portrayed more and more as “going under the knife.” This “going under the knife”

perception is a consequence of self-serving propaganda espoused by Plastic Surgical

professional organizations to increase their market share. Liposuction per se, is a safe

procedure with low risk and often amazing results. Historically it was not always done

concurrent with other reconstructive procedures that carry greater risk. Much of the

explainable anxiety that exists today is on the basis of other procedures e.g. tummy tucks

done concurrently.