Liposuction is a surgical procedure to remove unwanted fat deposits from beneath the skin. It was originally introduced in the 1980s and involves using suction to aspirate fat through small incisions. There are several techniques including traditional suction-assisted liposuction, ultrasound-assisted, power-assisted, vaser-assisted, and laser-assisted liposuction. Patient selection, pre-operative evaluation and planning, anesthesia technique, and post-operative care are important considerations to achieve optimal results and avoid complications from liposuction.

1. Liposuction

2. Liposuction:
• surgical aspiration of fat from subcutaneous
plane leaving a more desirable body contour
and a smooth transition between suctioned
and nonsuctioned areas
• Originally introduced by Illouz in 1982
• Pierre Fournier, and Francis Otteni

3. • American Society of Plastic Surgery and
American Society for Aesthetic Plastic Surgery,
ranks top procedures performed in plastic
surgery for the last 10 years

4. • standard suction-assisted liposuction (SAL)
• Ultrasound assisted liposuction (UAL)
• power-assisted liposuction (PAL)
• vaser-assisted liposuction
• laser-assisted liposuction (LAL)

5. Anatomy

7. Zone of adherence

8. Classification
• Type I: Localized lipodystrophy.
– younger patients
– good skin tone
– minimal skin irregularities.
• Type II: Generalized lipodystrophy.
– diminished skin tone
– some skin irregularities
– circumferential lipodystrophy
• Type III: Skin redundancy and lipodystrophy.
– significant skin redundancy

9. Patient selection
four key elements to achieve and maintain
optimal results:
1. Lifestyle change
2. Regular exercise
3. Well-balanced diet
4. Body contouring.

12. Poor candidates:
• perfectionists with imperceptible deformities,
• those with underlying mental illness that
prohibits realistic expectations (body
dysmorphic disorder, or active eating
disorders)
• significantly overweight patients who are
incapable of weight reduction and/or weight
maintenance after liposuction

13. Initial evaluation
• goals of surgery
• patient has realistic expectations
• prioritize the body regions
• medications, allergies, and tobacco use
• diabetes, massive weight loss, previous
surgery, previous liposuction
• nutrition, hemoglobin, iron, B12

14. • Avoiding aspirin, NSAIDs, and hormonal
therapy 3 weeks prior to surgery
• oral contraceptives and estrogen 1 month
prior

15. Physical exam
• prior scars
• Hernias
• venous insufficiency
• pre-existing asymmetry or contour irregularity
• BMI

16. Key elements to be documented:
1. Evaluation of areas of lipodystrophy and
contour deformities
2. Skin tone and quality
3. Asymmetries
4. Dimpling and cellulite
5. Myofascial support
6. Zones of adherence

18. Patient education and informed consent:
• procedure
• postoperative course
• long-term results
• alternative treatments
• financial obligations
• complications
• risks.

19. Preoperative marking
• In front of a mirror
• Circle- Areas to be suctioned
• Hash marks- zones of adherence and areas to
avoid
• prevent access incision in or adjacent to zones
of adherence
• no longer than 3–4 mm

24. Anesthesia technique/location of
operation
• small-volume liposuction- LA
• avoid epidural and spinal anesthesia in office-
based settings
• Complex, large-volume liposuction and
combined cases- GA

25. Patient positioning
• Prone/supine
• Turnaround time should be <10 min
• prep the patient circumferentially while
standing
• arm is abducted at 90°, hips and knees flexed
at 30° with a pillow
• Lateral decubitus- rarely

26. Wetting solutions

27. • Infiltrate should be allowed to set for 7 min
and no longer than 30 min prior to suctioning

32. Fluid resuscitation
1. Replace losses from preoperative oral intake
loss as needed
2. Maintain fluid throughout the procedure and
manage it based on vital signs and urine
output
3. Employ the superwet infiltration technique
4. Administer crystalloid replacements, 0.25 mL
for each mL of lipoaspirate over 5 L

33. Treatment options
Suction-assisted lipoplasty:
• two-stage technique
• incisions 3–4 mm
• ease of use, malleable cannulas, a wide
variety of cannulas, and decades of experience
and results
• difficult to use in fibrous areas

34. Power-assisted liposuction:
• externally powered cannula, which is variable
in size and flex, and oscillates in 2–3-mm
reciprocating motion at rates of 4000–6000
cycles/min.
• for large volumes, fibrous areas, and revision
liposuction

35. Ultrasound-assisted liposuction:
• Ultrasonic energy
• three stages: (1) infiltration, (2) emulsification,
and (3) evacuation and contouring
• Skin protection from thermal injury.
– Limiting application of energy and bathing the
access site with saline

36. • Begun at a depth of approximately 1–2 cm,
depending on body area.
• Standard cannulas for final contouring
• Advantages:
– Less surgeon fatigue
– improved results in fibrous areas and in secondary
procedures.

37. • Disadvantage:
– increased equipment cost,
– slightly larger incisions,
– longer operative times,
– thermal injury.
– requires a superwet environment
– continuous movement to prevent excessive
exposure of the tissues to heat

39. Vaser-assisted
liposuction:
• a newer generation
ultrasound-assisted
liposuction device
that incorporates less
energy with more
efficient, solid probes

40. Laser-assisted liposuction:
• laser fiber via a small skin incision
• 924/975 nm, 1064 nm, 1319/1320, and 1450
nm
• four-stage technique:
– Infiltration
– application of energy to subcutaneous tissues
– Evacuation
– subdermal skin stimulation

41. • disrupt fat cell membranes and emulsify fat
• smaller regions (such as the neck)
• skin-tightening effects

42. Cannulas and probes

43. Surgical endpoints
Longstanding endpoints:
1. skin pinch,
2. final contour
3. volume of Aspirate
4. treatment time
5. blood in aspirate

45. Postoperative care
• compression garment customized- 24 hrs a
day for 2 weeks
• compression foam- the first week
• ambulate the day of the surgery
• Sequential compression devices till discharge
• postoperative visits- 5–7 days
• return to activity/work: 3–4 days or at 2 weeks

46. • Edema tends to peak from 3 to 5 days
• Postoperative lymphatic massage
• Bruising dissipate by 7–10 days
• final aesthetic result: 3–6 months

47. Complications
1. perioperative period (0–48 h)
2. early postoperative period (days 1–7)
3. late postoperative period (1 week to 3
months)

48. Perioperative
• anesthesia and cardiac complications
• cannula trauma to skin and/or internal organs
• Cannula injury to blood vessels, bowel and
other solid intra-abdominal organs
• volume loss/overload from bleeding or excess
fluid administration.

49. • Hypothermia (<36.4°C)
– Warming of wetting solutions
– increase of the ambient room temperature,
– use of preoperative and intraoperative warming
devices (Bair Hugger®, Arizant, Eden Prairie, MN).
– Prewarming the patient with forced air for 1 h

50. early postoperative:
• venous thromboembolism (1%)
– Homan’s signs, shortness of breath, chest pain,
and/or tachycardia
• Infection (necrotizing fasciitis)
– 1st gen cephalosporins
• Skin necrosis

51. Late complications:
• delayed seroma
– loose closure of cannula sites, postoperative
compression garments, and expressing residual fluid
over liposuction areas at the end of procedure
• Edema
• Paresthesias
– up to 10 weeks to recover
• Ecchymosis & Hyperpigmentation
• contour irregularities

52. Emerging technology
1. Mesotherapy or lipolysis:
– injection of phosphatidylcholine, deoxycholate,
and/or other agents which are purported to
dissolve fat in mesoderm
2. Lipodissolve
3. Low level laser therapy
4. LipoSonix: high-intensity focused ultrasound
5. Cryolipolysis