Liposuction and Redistribution of Fat

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

Here’s the tweet I posted Sunday evening:

I've told pts this for years now>>> Liposuction Study Finds That Lost Fat Returns - http://nyti.ms/kheltN

The New York Times article reports on a liposuction study published in the April issue of the journal Obesity (full reference below).   The NY Times article uses this photo as graphic illustration

and a quote from a plastic surgeon who says he is surprised.

Dr. Felmont Eaves III, a plastic surgeon in Charlotte, N.C., and president of the American Society for Aesthetic Plastic Surgery, said the study was “very well done,” and the results were surprising. He said he would mention it to his patients in the context of other information on liposuction.

I have told my patients for years to consider the fat cells in their body as drawers or storage bins.  If I take away some of the drawers and they continue to take in “fat” that needs to be stored, the body will put it somewhere.  If there are now fewer drawer options in the saddlebag or abdominal region, then where will it go?  Most likely the upper body, etc.

This article does more definitively define the answer to where it will be placed.

The study enrolled 32 healthy women (mean age 36) with disproportionate fat depots (lower abdomen, hips, or thighs) were enrolled and then randomly placed into either a small-volume liposuction group (n = 14, mean BMI: 24 ± 2 kg/m²) or control (n=18, mean BMI: 25 ± 2).  Participants agreed not to make lifestyle changes while enrolled.

Baseline body composition measurements included dual-energy X-ray absorptiometry (DXA) (a priori primary outcome), abdominal/limb circumferences, subcutaneous skinfold thickness, and magnetic resonance imaging (MRI) (torso/thighs).

The surgery group had their liposuction within 2-4 weeks of the baseline measurement.  Identical measurements were repeated at 6 weeks, 6 months, and 1 year later.

After 6 weeks, percent body fat (%BF) by DXA was decreased by 2.1% in the lipectomy group and by 0.28% in the control group (adjusted difference (AD): −1.82%; 95% confidence interval (CI): −2.79% to −0.85%; P = 0.0002).

This difference was smaller at 6 months, and by 1 year was no longer significant (0.59% (control) vs. −0.41% (lipectomy); AD: −1.00%; CI: −2.65 to 0.64; P = 0.23).

The fat (adipose tissue) reaccumulated differently across various sites. 

After 1 year the thigh region remained reduced, but fat (adipose tissue) reaccumulated in the abdominal region.   Following suction lipectomy, BF was restored and redistributed from the thigh to the abdomen.

…..

I do not find this surprising.  Once the drawer is removed, it can not store items any longer.

If you only liposuction the lower abdomen (area below the umbilicus), those patients are likely to return with increased fat in the upper abdomen.  It needs to be keep in proportion.

REFERENCE

Fat Redistribution Following Suction Lipectomy: Defense of Body Fat and Patterns of Restoration; Hernandez TL, Kittelson JM, Law CK, Ketch LL, Stob NR, Lindstrom RC, Scherzinger A, Stamm ER,  Eckel RH; Obesity, (7 April 2011); doi:10.1038/oby.2011.64

Florida Liposuction Death?

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.


I was going to wait until the autopsy came back to comment on this news article, but there are points to be made even now.
First, it isn’t known if the death was due to liposuction. 
This December 30th Palm Beach Post article gives the basics and that is all:   South Florida woman, 35, dies getting plastic surgery (bold highlights are mine).

Lidvian Zelaya's New Year's resolution for 2011 was to "look good," so she went to Strax Rejuvenation Center in Lauderhill on Monday to have fat liposuctioned from her waist and added to her buttocks, her husband, Osvaldo Vargas, said.

Three hours later, Vargas said, his wife was rushed to emergency facilities at a nearby medical center. When he arrived there, he was told she had died. She was 35. 

Vargas and his attorney, Spencer Aronfeld of Coral Gables, said they were not sure what doctor performed the procedure nor whether the procedure had started when the medical problems began.

It troubles me that the husband isn’t sure who performed the procedure.  It wasn’t a training hospital, but a private clinic (Strax Rejuvenation Center).  Perhaps it is reports like this one  and this one which has caused a loss of trust in physician integrity.

It troubles me that the husband wasn’t sure the procedure had even started when the medical problems began.  As difficult as it would have been, didn’t Lidvian’s surgeon (reported elsewhere to have seen Dr. Roger L. Gordon in consultation)  sit down and talk with the family?

He may not have done anything wrong.  It may turn out she had an allergic reaction to a medication or malignant hyperthermia or ….

Or perhaps Dr. Gordon did talk to the family, but the grief stricken husband didn’t hear or process it.

This also troubles me, as I know it will Dino Doc who has written on clearing patients for surgery.

From the ABC News article on January 3, 2011:  Did Florida Woman's New Year's Resolution Costs Her Life?  Cosmetic Surgery Gone Wrong Has Family Wondering What Happened 

According to the family, Zelaya was in perfect medical condition, and the clinic cleared her through a pre-operative screening. Now, the family is urging anyone considering cosmetic surgery to undergo a second, pre-surgical health evaluation by an independent primary care physician.

"I think it's an inherent conflict of interest if you are getting screened by the surgeon who wants to do the procedure," said Aronfeld.

Dino Doc that says a lot about why you are increasing asked to do pre-surgery clearances.


Related posts:
Know Your Surgeon (November 3, 2010)
Liposuction – Shaping not Weight-loss  (February 8, 2010)
Liposuction Overview  (October 6, 2010)
Major and Lethal Complications of Liposuction -- An Article Review  (July 16, 2008)

Liposuction Overview

 Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

I use the form of liposuction commonly called traditional though it is more accurately called superwet suction-assisted liposuction (SAL).   Why don’t I use ultrasound or laser assisted?  Cost mainly.  I find it difficult to purchase all the latest and greatest equipment.  I find it difficult to ask the hospitals/surgery centers I work at to do the same when I’m not sure I can guarantee them patients numbers needed to recoup the costs.

Superwet SAL has worked well for me and my patients.  I have found that the greatest improvements to liposuction since it’s introduction by Illouz in the 1980s have been the addition of the wetting technique and the improvement in cannula size (specifically much smaller ones available than the early years).

I have been trained to use ultrasonic liposuction and have used it, but without renting equipment it is not available routinely at all the facilities I work.  SAL is.

I wanted to state all the above before delving into the article “Updates and Advances in Liposuction” (full reference below) as a way of full disclosure.  The article is a very nice review of liposuction.

The authors point out the key elements to not just achieving a good result but to maintaining it.  Points which should be made to each patient: 

A successful body contouring patient must satisfy four key elements to achieve and maintain optimal results.
1. Lifestyle change
2. Regular exercise
3. Well-balanced diet
4. Body contouring

Notice the surgeon is only important in the last one.  The individual is the key in long-term satisfaction with liposuction.

In discussing the addition of wetting solutions (often lumped together incorrectly and simple called tumescent), the authors point out that initially when liposuction was done without any wetting solutions the blood loss was often up to 45% of the aspirate.  The addition of a wetting solution greatly reduces the amount of blood lost.

All of the formulations of wetting solution include some variant of fluid (NS/LR), epinephrine, and lidocaine.   Wetting solutions are used in three techniques:  wet, superwet, and tumescent.

The wet technique involves instillation of 200 to 300 mL of solution per area to be treated, regardless of the amount aspirated.

The superwet technique employs an infiltration of 1 mL per estimated mL of expected aspirate, and this is the technique practiced at our institution. 

Tumescent infiltration, popularized by Klein, involves infiltration of wetting solution that creates significant tissue turgor and results in infiltration of 3 to 4 mL of wetting solution per mL aspirated. 

Recent data suggest that, for patients undergoing general anesthesia with the superwet technique, the lidocaine component may be reduced and/or eliminated without postoperative sequela of increased pain.

I tend to use only epinephrine and not any lidocaine in my wetting solution.  I have a (healthy?) fear of lidocaine toxicity and since my liposuction patients have general anesthesia decided years ago there was no need for the added lidocaine.

Traditional liposuction is referred to as suction- assisted liposuction (SAL).  Other liposuction modalities include ultrasound-assisted liposuction (UAL), vaser-assisted liposuction (VAL), power-assisted liposuction (PAL), and laser-assisted liposuction (LAL).

SAL remains the most common modality for liposuction. As mentioned above, it is the one I use.  SAL uses variable-size cannulas and an external source of suction for removal of the aspirated fat.

PAL involves an external power source driving the cannula.  Advocates of PAL contend that it is best used for large volumes, fibrous areas, and revision liposuction.

UAL utilizes ultrasound energy to break down fat and allow removal.  With this technique, fat is emulsified, which allows removal through traditional liposuction cannulas.  This modality requires a superwet environment.

Advantages include less surgeon fatigue, as well as improved results in fibrous areas and in secondary procedures. 

Disadvantages have been reported to include larger incisions, longer operative times, and the possibility of thermal injury.  

VAL uses a newer generation ultrasound-assisted liposuction device.  The system uses less energy, decreasing its thermal component to the tissues.  VAL  may be better than the other modalities in large-volume liposuction as it has less blood loss. 

This is what the article has to say regarding LAL (bold emphasis is mine):

LAL has been at the forefront of marketing hype for the past several years. The treatment involves insertion of a laser fiber via a small skin incision. Depending on the manufacturer, the fiber may either be housed within a cannula or stand alone. ….  Most companies and physicians utilizing this technique employ a four-stage technique: infiltration, application of energy to the subcutaneous tissues, evacuation, and subdermal skin stimulation.  …… Currently, these devices are being heavily marketed for purported skin-tightening effects. The belief is that the heating of the subdermal tissue may in fact be the contributing factor for LAL’s possible skin tightening effect.  No large, prospective trials have been undertaken to examine the benefits of LAL over existing technologies, so unfortunately, most of the reports remain anecdotal. 

Liposuction is a shaping technique, not a weight-loss solution.  Liposuction will also not treat cellulite and can in fact make it appear worse.

Risks should be discussed with patients as with they are with all surgical procedure.  The risks common to all modalities of liposuction include contour deformity, ecchymosis, edema, seroma, infection, paresthesia/dysesthesia, anesthesia and cardiac complications, cannula trauma to skin and/or internal organs, volume loss/overload from bleeding or excess fluid administration, hypothermia, deep venous thrombosis (DVT)/ pulmonary embolism (PE), and death.  

In a questionnaire to board-certified members of ASAPS, Hughes reported a significant increase in complications when liposuction was combined with other procedures. This increase in the complication rate was most notable in liposuction combined with abdominoplasty. …….

Incidence of DVT in liposuction has been reported at <1%, but a marked increase in this percentage is demonstrated when liposuction is combined with other surgery (abdominoplasty/belt lipectomy).

Prolonged edema can occur up to three months from surgery and is best treated with supportive care and lymphatic massage.

Postoperative paresthesia/dysesthesia can occur in all forms of liposuction, is usually reversible, but may take up to 10 weeks to recover.  Improvement of paresthesia/dyesthesia issues are generally felt to be quicker with SAL than with UAL.  The newer technologies have not been investigated in this manner.

The most common postoperative complication from liposuction is contour deformity, which can occur in up to 20% of patients.

REFERENCES

Stephan, Phillip J., Kenkel, Jeffrey M.; Updates and Advances in Liposuction;  Aesthetic Surgery Journal January 2010 , 30: 1: 83-97, doi:10.1177/1090820X10362728

Liposuction – Shaping not Weight-loss

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.


H/T to Jeff Frentzen, PSP Blog, for the link to this article “Large Volume Liposuction - Nip/Tuck Gets It Very Wrong” by Natalie Kita (December 22, 2009)

I am not so silly as to miss seeing FX Network's plastic surgery-based drama Nip / Tuck for what it truly is: entertainment. I don't expect pinpoint scientific accuracy. However, when doing any sort of medical-based drama, doing it well requires that you must at least attempt to be somewhere in the realm of reality where the medical facts are concerned.

Last week's episode broke that rule ten times over when it portrayed a large volume liposuction case in which 150 lbs of the patient's body weight were removed during a lipo/tummy tuck combo surgery. We won't even get into the ethical considerations of sucking the fat out of a prisoner so he can be legally slim enough to receive his scheduled lethal injection. That's a blog for another day.

I have not been a fan of Nip/Tuck for several years now.  This just adds to my disdain for the show.  Be that as it may, lets look at liposuction.

Liposuction is a surgical procedure done for shaping, not weight loss.  It is considered to be one of the most frequently performed plastic surgery procedures in the United States.  Large-volume liposuction is defined as the removal of 5000 cc or greater of total aspirate during a single procedure.

A recent Aesthetic Surgery Journal article (full reference below) looked at 25 years of liposuction experience.  Their experience mirrors the history of liposuction during their study period:  July 1983 to January 2008. The liposuction techniques studied included dry liposuction, tumescent liposuction, tumescent UAL, and tumescent LAL.  Note how the technique and safety issues evolved over time.

1983-1985  Dry liposuction with 10-, 12-, and 15–mm diameter cannulas.

1985-1987  Dry liposuction with cannula diameters reduced to 5, 6, and 8 mm.  The submental area was at all times treated with a 3–mm cannula.

Liposuction was always performed in the deep plane; aspiration ceased once mostly blood was being obtained. For the first six months in which liposuction was performed, there were no parameters defining when to stop the aspiration and volumes as high as 8000 mL were obtained.
After those six months, in collaboration with the anesthesiologists, a calculation of volume reposition was made according to the aspiration obtained. For every 1000 mL extracted, there was a reposition of 1000 mL of isotonic saline solution and 1000 mL of polygeline solution (Haemaccel 3.5% colloidal intravenous infusion; Aventis, Strasbourg, France).
All patients had blood tests before surgery and 24 hours after surgery to measure hemoglobin and hematocrit values. Aspiration volumes were reduced after six months, ranging from 2000 to 4000 mL. Patients with hemoglobin values less than 8 and who experienced the symptoms of anemia (ie, increased heartbeat, low blood pressure, constant headache, dizziness, and weakness) were transfused.

1987 – present   Tumescent liposuction was performed in all patients, technique evolved over time.

At first, only isotonic saline solution was administered before aspirations.
Beginning in 1989, the infiltration solution was prepared using two adrenaline ampoules (1 mg of adrenaline per each 1 mL ampoule) per 1 L isotonic saline solution. No lidocaine was added. The solution was administered in a 1:1 ratio (the amount of solution being infiltrated was approximately the same as the aspiration obtained).
Cannula diameters were reduced to 3, 4, and 5 mm. The amount of fat extraction was limited to 5000 mL.

1998 – 1999   Ultrasound-assisted liposuction (UAL) (16000 Hz) was performed.
2007 – 2008  Laser-assisted liposuction (LAL) was performed with an internal diode laser (wavelength, 660 nm; power, 130 mW).
There were no changes in infiltration solution, volume extraction, or operating time when using either tumescent solution alone versus suction-assisted-liposuction (SAL) or LAL. Both of the latter techniques were performed using an internal cannula after the tumescent solution was applied, followed by performance of SAL.
The authors state that time frame was the main criteria for which technique was used. 

Most significantly, the use of tumescent liposuction reduced the incidence of anemia, but increased the incidence of seroma. The incidence of postoperative pain and fibrosis in our patients was similar regardless of the technique used. Aesthetic results using assisted liposuction devices in UAL and LAL procedures were similar to those achieved in tumescent liposuction.

 

 

The second reference article is from the ASPS Patient Safety Committee.  It is a great review of liposuction and it’s risks/safety.  Here is their assessment of liposuction for obesity:

Large-volume liposuction has become a technique for addressing contour irregularities, but preliminary studies also suggest improvement in cardiovascular risks, blood pressure reduction, and reduced levels of fasting insulin after liposuction.   Although liposuction may provide some physiologic benefit to the obese patient, there are inherent risks in these patients that must be considered, such as poor wound healing, increased risk of infection, deep vein thrombosis, and sleep apnea.  ……..  Liposuction is not considered a standard treatment for obesity.

Also from the same Safety Committee Advisory:

When referring to liposuction volume, total aspirate should be the volume recorded. Some states have imposed restrictions pertaining to the aspirate volume and surgical facility; these limits range from 1000 to 5000 cc (e.g., California, Florida, Kentucky, New York, Ohio, and Tennessee). Surgeons should consult their individual state regulations; however, it is the position of American Society of Plastic Surgeons that, regardless of the anesthetic method, large-volume liposuction (>5000 cc of total aspirate) should be performed in an acute-care hospital or in a facility that is either accredited or licensed. Postoperative vital signs and urinary output should be monitored overnight in an appropriate facility by qualified and competent staff members who are familiar with the perioperative care of the liposuction.

 

It must be remembered that liposuction is surgery.  As with all surgeries, complications can occur.  Minor complications that resolve on their own or with little additional treatment include small hematomas, seromas, and minor contour irregularities.  More severe complications are rare, but  include skin perforation, major contour defects, skin necrosis, thermal injury, vital organ injury, adverse anesthesia reaction, major hemorrhage, ischemic optic neuropathy, deep vein thrombosis, pulmonary embolism, and fat embolism. 

 

 

REFERENCES

Liposuction: 25 Years of Experience in 26,259 Patients Using Different Devices; Aesthetic Surgery Journal, Vol 29 (6), pp 509-512; Lina Triana, Carlos Triana, Carlos Barbato, Marco Zambrano
Evidence-Based Patient Safety Advisory: Liposuction; Plastic and Reconstructive Surgery. 124(4S):28S-44S, October 2009; Haeck, Phillip C.; Swanson, Jennifer A.; Gutowski, Karol A.; Basu, C Bob; Wandel, Amy G.; Damitz, Lynn A.; Reisman, Neal R.; Baker, Stephen B.; the ASPS Patient Safety Committee