Liposuction and Breast Enlargement

James J. Romano, MD

Liposuction is by far the single-most-performed and -requested cosmetic surgical operation in the United States today. Its popularity is fueled by the fact that in most trained hands it is relatively safe, results provide immediate gratification for the client, and there is often only mild discomfort with a rapid recovery. Many physicians—not just plastic surgeons—are learning, marketing, and offering this procedure.

Our societal near-obsession with body image and shape, combined with the limitations of diet and exercise, has helped to create a tremendous public demand for this procedure. In conjunction with this growing trend is the importance of the esthetician’s role in answering questions about the surgery, advising on the process of physician selection, and helping in patient preparation, healing, and maintenance of results through hands-on treatment.

Liposuction is a technique for the selective and minimally invasive removal of fat, developed in France around 1977. This technique was presented to the American Society of Plastic and Reconstructive Surgeons in Hawaii in 1982, and liposuction was introduced to American plastic surgeons as a totally new concept and procedure. It caught on rapidly, and today is performed in essentially the same form, but with some theoretical and technical improvements.

Physician Selection
No discussion of liposuction is complete without mention of physician selection. Of equal if not of greater significance than the rapidly escalating numbers of patients seeking liposuction is the explosion in the ranks of physicians not trained as plastic surgeons performing liposuction. Lawmakers in several states are taking aim at this. The growth is fueled in large part by physicians from many different specialties trying to escape some of the insurance reimbursement limits imposed by managed care on their practices; they seek higher fee-generating procedures such as liposuction, which is not regulated by insurance companies. Despite this, don’t rule out that there are still many qualified physicians in different specialties performing very good liposuction procedures.

This only reiterates the need for clients and estheticians to form a professional relationship with a physician who offers liposuction treatments and to seek qualified physicians well trained in this procedure. Inquire not only about the specifics of the physician’s training, number of procedures, and length of time performing liposuction, but also about specific board certification, number of complications, hospital admission and operating room privileges, and outpatient procedure facility certifications. Call the local and state medical societies, and don’t merely rely on word-of-mouth.

Physiology and Biology of Fat
Fat, or adipose tissue, is composed of fat cells (adipocytes), which store fat (mainly triglycerides), and a loose supportive connective tissue structure containing vessels and nerves. Fat cells play numerous metabolic roles in the body including that of an energy source, a storage place, and interaction with insulin and hormone synthesis, to name a few. Studies suggest that adult fat cells are incapable of multiplication; therefore, there are a fixed number distributed in a genetically predetermined fashion throughout the body.

Regardless of the function, as a person gains weight these cells expand, and as weight is lost they contract, but the number and distribution remain essentially unchanged. This accounts for why so many normal-weight patients complain of localized fatty deposits unresponsive to diet and exercise, and why liposuction is perfect for such clients. This also explains why dieting does not interfere or conflict with liposuction. Dieting reduces a client’s weight and overall size, and may show some improvement in specific areas, but liposuction affects shape and contour. In other words, liposuction removes fat cells so that this reduced overall number imparts a “protective effect” on the treated area and weight gain or loss won’t be noticed as much as in the non-treated areas.

This is what fat typically looks like right after it has been liposuctioned out of the body.

Techniques and Effects
Liposuction is performed by, first, determining the areas of fat excess to be treated and injecting these areas with anesthetic solution. Next, the fat is removed through several small incisions with thin tubes connected to suction. The small-diameter tubular instrument used to remove the fat is called a “cannula.” These instruments come in various shapes and sizes depending on the amount and location of the fat. They have highly polished surfaces to slip through the fatty tissues with minimum friction or damage to the tissues. They are blunt-tipped to prevent cutting and bleeding, and essentially “push aside” and protect the vessels and nerves. The cannula suctions out the fat through one or several strategically placed holes at the tip.

Therefore, conventional liposuction relies on this mechanical disruption of fat cells by the movement of the cannula and the vacuum of the suction pump.

Tumescent liposuction. Tumescent (swollen) liposuction is a relatively recent advance and is so popular that it is now used by most physicians. It employs a dilute local anesthetic solution that is generously injected into specific areas. This reduces bleeding, bruising, discomfort, and pain, and contributes to more rapid recovery and often a more predictable result. It can be the sole anesthetic alone, or combined with intravenous sedation or general anesthesia.

Ultrasonic Liposuction
Ultrasonic liposuction, or ultrasonic-assisted liposuction, is a new technology that has generated substantial interest. Ultrasonic sound waves, much like shock waves, are transmitted into the fatty tissues from the tip of the cannula probe. The fat cells are disrupted and the fat is removed by low-pressure vacuum. This technique has not been embraced enthusiastically. Most plastic surgeons recognize that there are a few more risks and no overwhelming advantages to justify its widespread use. It is touted as a “gimmick” by many plastic surgeons. Considered to still be somewhat in the investigative category, time and additional experience will provide more answers on this technique in the relatively near future.

Regardless of the method, liposuction relies on the natural contractile properties of the elastic fibers and collagen-shortening tendencies of the skin. Therefore, the more springy the skin in the areas to undergo liposuction, the better and more predictable the results. Liposuction allows the skin to contract down and mold around a reduced fatty framework. This process is theoretically enhanced in certain areas by scratching the undersurface of the skin—by laser or “superficial liposuction”—and by wearing compressive elastic garments post-operatively.

Estheticians play an important role in this process through pre-operative treatments designed to help reduce edema and body treatments such as wraps or massage that help eliminate toxins and edema before, during, and after surgery.

Candidates for Liposuction
Just about any area of the body with fat accumulations can undergo liposuction. The most popular and best responding areas are the neck, abdomen, inner thighs, outer thighs, hips, flanks, and knees. Other areas often liposuctioned are the face, arms, calves, ankles, legs, and back. Other “problem” areas also respond nicely to liposuction, such as the folds of the upper chest just above the breast and next to the armpit, the inner and outer arms, the breast, the folds beneath the shoulder blades on the back, and the pubic region.

The best candidates are those at or near their ideal or stable weight with localized fatty areas unresponsive to dieting and exercise. Other patients who are somewhat larger obtain an equally remarkable result and typically describe fitting into clothes often two sizes smaller within two weeks after surgery.

A number of patients who are obese seek liposuction as an alternative, or “jump-start,” to dieting. Although many doctors do not perform this, tumescent liposuction has made it much safer. A few physicians now specialize in so-called “large volume liposuction,” which is more risky.

Liposuction is not a substitute for more extensive surgery when there are loose, hanging folds of skin that need to be removed, or when the patient has laxity of ligaments and muscles that need to be tightened. In these situations procedures that remove skin and tighten supporting structures—such as a facelift or tummy-tuck—may be in order. At times when the degree of skin elasticity is not easy to assess, I present to my patients a potential “staged” procedure. The liposuction is done first, and if not enough skin contracts, then the skin excision and internal tightening is done at a later date. Interestingly, this is not only safer but often provides a better result than if both are combined into a single surgery.

Healing and Recovery
The results of liposuction are immediately obvious. In fact, when operating under local anesthesia, I sometimes have my clients look in the mirror upon completing the procedure to render an opinion and determine if a different contour is desired in any of the treated areas.

In general, during the two days following the procedure the client will experience significant swelling, but this rapidly subsides within days and resolves quickly over the next six weeks. Any small residual resolves more slowly over the next four to six months. I always tell patients they generally will look great right away and continue to improve over the next six months. Bruising is usually minimal, and showering is permitted after two days. Many clients return to work or some activity within two to four days. Many can return to some form of a graduated exercise program in ten to fourteen days. I am impressed by how minimal pain and discomfort are, especially with an expertly administered tumescent anesthetic.

Complications in Liposuction
Liposuction carries all the usual risks of a surgical procedure, although complications are quite rare. Sequellae, or byproducts of the procedure, are seen in 5 to 15 percent of patients and usually consist of contour deformities (“bumps” or “dents”), small areas of numbness, discoloration, or wrinkling of the skin. Tell your clients to discuss the common and less common of these in detail with the physician before surgery. Also, it is not unusual for clients to benefit later from a small “touch-up” procedure. Again, make sure your client knows ahead of time how the physician handles such situations.

The Esthetician’s role
The esthetician can play a great role in the pre- and post-operative care for any liposuction treatment. Fundamentally, skin contraction and elasticity are the determinants of success or failure. The numerous interventions you can offer to reduce edema and enhance elasticity should not be underestimated.

Liposuction Myths
Myth: Patients won’t gain weight after liposuction. Yes they can! If they do, however, it is seen mostly in the areas not treated since the normal number of fat cells are still present there and can continue to expand.
Myth: Liposuction causes more fat to go to non-treated areas of the body after a weight gain. This is not true for the same reason as noted above.
Myth: Liposuction is a substitute for weight loss and dieting. In fact, they both work together well and a physician can help customize a plan for the client. I suggest to my clients that dieting reduces overall size, exercise firms and tones, and liposuction shapes and contours.
Myth: Liposuction by itself will cause loose hanging folds of skin to shrink and disappear. Skin excision procedures are occasionally necessary to remove excess skin. This can usually be determined prior to liposuction.

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