Liposuction is primarily a method of shaping, contouring of the body, not a method of weight loss or removing the excessive kilograms as many patients incorrectly believe. It is one of the most common surgical procedures in the aesthetic surgery. Liposuction is performed using a device that produces the negative pressure. The subcutaneous adipose tissue is evacuated with the special tubes or cannulas through the small skin incisions of 4-5 mm in length. The cannulas are connected to the device that produces the negative pressure (aspirator) through the silicone tube. The ideal liposuction patient has a normal or slightly increased body weight, localized deposits of the subcutaneous adipose tissue which can not be eliminated by physical exercising or reduced meals, is between 20 and 45 years old, has the normal skin tension or skin tonus, and has a good general and cardiac health. The tension or skin tonus is extremely important in the postoperative period because such a skin, because of its elasticity, can shrink or contract or adjust to the new-formed contours of the subcutaneous adipose tissue. A patient with the skin that has stretch marks is definitely not a candidate for liposuction because such skin has irrevocably lost its skin elasticity, and the liposuction consequence is the redundant hanging skin and greater visibility of the deepened stretch marks. Liposuction can be done in most of the body areas where the subcutaneous adipose tissue is thicker than 2-3 cm. However, liposuction is most often performed on the front abdominal wall, hips, inner and outer sides of the thighs, inner sides of the knee, lateral sides of the buttocks and the male mammary areas in gynecomasty. Liposuction can be done under general (if it is planned to treat larger regions of the body) or reinforced local anesthesia (if it is planned to perform liposuction of the small, localized areas). After long experience based on the numerous liposuction procedures, we feel that the hydroliposuction is the most appropriate method which achieves the best aesthetic results. Hydroliposuction achieves the optimal result when a combination of deep and superfitial liposuction is used. We use only thin cannulas, of 3 and 4 mm in diameter, which tunnel excellently, or make the subcutaneous adipose tissue more loose to be removed more easily. Such cannulas allow a surgeon an excellent control over the surface skin above the treated areas, which reduces the possibility for the emergence of the postoperative irregularities of the skin surface (hollows and bulges). In addition, thin cannulas minimally traumatize the surrounding tissues, primarily the blood vessels, so the postoperative hematomas and swelling are significantly less expressed, and the postoperative recovery is much faster, accompanied by almost painless early postoperative period. After the hydroliposuction, the majority of patients lose about 5-10 kg in a few postoperative months. Although there is no clear explanation for that phenomenon, it is very welcome for our patients. Hydroliposuction is a method of permanent removal of the obstinate fatty layers that can not be removed any other way, but only if a patient changes her/his usual diet and physical activity, or if she/he does not get more than ten kilograms. Hydroliposuction can successfully remove the deposits of the cellulite if they are in the initial stages that are not characterized by the permanent fibrous changes in the subcutaneous adipose tissue. If it is the final stage of the cellulite, known as the “orange peel”, then liposuction can not ideally smooth the skin, but it can significantly improve the contours of the treated areas.
Methods for removing the adipose tissue
The first liposuction method was “dry” or traditional liposuction that is now used very rarely. After that, the following types of liposuction are developed:
- hydroliposuction, or tumescent version of hydroliposuction, “wet liposuction, superwet liposuction”
- “ultrasound-assisted liposuction”- UAL
- “power assisted liposuction”- PAL
- “laser assisted liposuction”, limited for the treatment of the smaller deposits of the adipose subcutaneous tissue; about 250 ml of the adipose tissue can be removed in one session
- “twin cannula assisted liposuction”- TCAL
Hydroliposuction
We use only hydroliposuction which, we feel, achieves the best cosmetic results and provides the brief postoperative period and a quick return to the patient’s normal life activities. In hydroliposuction, the preoperative areas are infiltrirated with the saline solution containing the local anesthetic and vasoconstrictor (usually we use lidocaine and epinephrine). Lidocaine allows almost painless early postoperative period. Epinephrine achieves the constriction of the small blood vessels in the subcutaneous adipose tissue, thus enabling a surgeon to evacuate more adipose tissue, and considerably less bloody content. The specified solution separates the subcutaneous adipose tissue from the underlying muscles and allows easy removal of the adipose tissue and minimizes the possibility of the intraoperative muscle damage. The hydroliposuction version is a tumescent technique during which about 3 times more liquid is applied than the total amount of the adipose tissue which is to be removed. We achieve great results by combining the deep and superfitial hydroliposuction using the cannulas of 3 and 4 mm in diameter. We believe that for the optimal aesthetic result, except the above mentioned methods, a long experience and manual skills of a surgeon and his tendency for the aesthetic sculpturing of the body is essential. The hydroliposuction procedure usually lasts 1-3 hours, depending on the extent of the area treated. After the completion of the procedures we close the incisions with the intracutaneous sutures which are located below the surface of the skin and which consequently allow almost invisible scars. Immediately after the procedure, the patient is given a special garment which must be worn for the following 4-8 weeks because it provides a better contraction of the skin, and significantly better adjustment of the skin to the subcutaneous adipose tissue, as well as better contouring, shaping of the body.
Parts of the body from which the adipose tissue can be removed by liposuction
- face (cheeks), chin
- breasts (gynecomasty), abdomen, hips
- buttocks
- thighs
- lower legs
- upper arms
- knees
Procedure
The first step is preoperative examination of the patient. The approach to each patient is strictly individual. A thorough family and personal history (smoking, alcohol preference, chronic taking of aspirin, chronic diseases and other data) has to be taken. Wishes and expectations of a patient from the procedure are carefully observed. After the consultation follows the examination, and a significant part of the examination is a psychological evaluation of each patient. It is important to detect any possible asymmetry of the areas which will be corrected in the operation. The noted asymmetries have to be shown to the patient and preoperatively photo documented. A very important part of the examination is the skin and subcutaneous tissue palpation, or the assessment of the tension or tonus of the skin and muscles underlying the adipose tissue. After that follows the circumference measurement of the treated areas in order to compare the same circumference in the postoperative period, so that the result of the operation could be exactly evaluated.
Surgical procedure
The preoperative “marking” of the areas that will be treated by liposuction in standing position. The marked areas include the front, side abdominal walls (hips) and lateral or side wall of the right thigh area where most often the deposits of the subcutaneous adipose tissue persist. The outer line of the marker indicates the entire target area of hydroliposuction, and the inner lines indicate where the subcutaneous adipose tissue is expressed to the fullest extent. The arrows indicate directions where the cannulas penetrate through the subcutaneous adipose tissue.
Hydroliposuction includes the preoperative application of the saline solution with epinephrine and lidocaine into the areas which are planned to be operated. The aim of the application of the mentioned solution is vasoconstriction or narrowing of the blood vessels that the adipose tissue is abundant with, so that in the procedure more fatty, and less bloody content is removed, as well as analgesia or soothing the pain in the early postoperative period.
Stab incision with a scalpel, about 4 mm long. The specified incision is made outside the borders of the liposuction area, and it must be wide enough for the liposuction cannulas to pass freely through the incision. The specified incision is being sewn with the precise intracutaneous suture which achieves almost complete scar invisibility.
The liposuction cannulas are introduced through the stab incisions. Then the cannula is drawn through the subcutaneous adipose tissue to the depth of 2-3 cm. Mostly we use the liposuction cannulas of 4 and 3 mm in diameter, because they least traumatize the tissue, including the blood vessels that are spread in the adipose tissue, and at the same time they provide the adequate and quick extraction of the adipose tissue, excellent body contouring, and they reduce the chance for the appearance of the skin surface irregularities. The specified cannulas allow hydroliposuction performance in the deeper and superfitial layers of the subcutaneous adipose tissue.
In the picture the liposuction cannulas of 3, 4, 6 and 7 mm in diameter are shown. In the “Polyclinic Ostojić” most hydroliposuctions are done using the thinnest cannulas of 3 and 4 mm in diameter which can be used to achieve better control of the extraction of the adipose tissue, and at the same time the trauma of the surrounding tissue is significantly less than when using the cannulas larger in diameter.
The most modern device, or aspirator with which liposuction is performed, is shown. The device works on the principle of negative or suction pressure which extracts the subcutaneous adipose tissue through the cannulas, then through the tube to the scaled bottle of aspirator.
On the above pictures the condition before and after the performed hydroliposuction of the left hip is shown. It is noticeable that there is a significant difference in the amount of the subcutaneous adipose tissue that can be taken between the thumb and forefinger after a thorough removal of the excessive subcutaneous adipose tissue. The specified procedure significantly shortens the waist circumference, which is the basic aim of liposuction: contouring or shaping of the body.
The completed liposuction procedure on the right side of the front abdominal wall is clearly shown with the thumb and forefinger test in the left picture. The same test shows the abundant subcutaneous adipose tissue on the left side of the front abdominal wall before liposuction. The difference between the right operated and left unoperated side of the front abdominal wall is evident in the thickness of the tissue that can be taken between the fingers.
The same case is shown in various projections. On the left picture it is visible that the right side of the abdominal wall is significantly lower in comparison to the left unoperated side. On the right picture the simultaneous fingers test is shown.
The image on the left shows the abundant subcutaneous adipose tissue of the left hip. After a thorough hydroliposuction it is clear that the amount of the subcutaneous adipose tissue is drastically reduced, as well as the waist circumference, which contributes significantly to a nicer contour of the front and side walls of the abdomen, as well as the entire body.
The comparison between the completed hydroliposuction of the right hip area and the opposite, left side which is not treated surgically. The significantly better shape of the right leg in relation to the opposite side is evident. The comparison can be made using the visible lines drawn during the preoperative marking.
The incision through which the cannula is introduced is 5-6 mm long. We always sew hydroliposuction incisions with the intracutaneous suture as shown in the pictures above. This is the exact sewing by the principles of the aesthetic surgery with the final aim for the scar to be almost invisible and to avoid traces of the outer single sutures.
After sewing all the liposuction incisions and putting the bend, a special liposuction garment is set. The samples of garments for the complete liposuction of the abdomen and legs (the picture left), or the liposuction garment for the abdomen and hips (the picture right) are shown. Wearing a garment is very important in the postoperative period because it allows much better contraction of the skin in the treated areas, which contributes to better contouring of the body. In addition, the garments represent a mechanical protection of the treated areas from trauma, including the movements of friction which are potentially the most dangerous. In our practice we apply only the best garments.
On the above pictures a scaled bottle of aspirator with the removed fatty tissue 2 hours after the hydroliposuction is shown. On the scale of the bottle it is evident that the total of the removed adipose and bloody contents is 2000 ml, where the blood is only about 200 ml of the total content, and everything else is pure subcutaneous fat. This is the result of applying hydroliposuction during which the areas are preoperatively infiltrated with the saline solution of epinephrine and lidocaine. The specified solution causes vasoconstriction of the blood vessels in the adipose tissue, so in this way much more pure adipose tissue can be removed, and considerably less blood, which is visible on the lower images. Lidocaine as analgetic contributes to the state of analgesia or absence of pain in the early postoperative period.
The small pieces of pure, bloodless subcutaneous fat passing through the tube of aspirator are shown.
Postoperative period
It is recommended to take some rest for several days, as well as sleeping on the back with slightly raised feet. Short walks are advisable. In the first two postoperative days a slightly higher temperature (up to 38°C) can appear, which does not need to be cured, or the antipiretic can be taken. The patients may feel weakness, mild fatigue at strain, somnolence in the first few postoperative days. Medications containing acetylsalicyl acid (Aspirin and Andol) are not allowed because they increase the chance of bleeding. We recommend broad-spectrum antibiotic after discharging the patient for home care (we prefer Sumamed or azythromycin, 500 mg, at the proposed plan of the therapy). Hematomas or swelling of the operated areas can be most visible 2-4 days after the procedure, and they usually last for 3-4 weeks. Recovery can be accelerated by the lymph drainage treatments, and usually ten treatments are sufficient during the 3 postoperative weeks. A garment has to be worn for a minimum of 6, and optimally 8 weeks. It is not taken off the first postoperative week, and then it can be taken off for half an hour a day. The patients do not suffer from any postoperative pain because they receive the intramuscular injections the first postoperative day, and then the tablets of analgetics the next few days. Most of the patients describe mild pain in the operated areas which they compare with the pain in the muscles after excessive physical activity. The result of liposuction is final after 3-4 months.
Complications
The complications of the procedure are very rare. Early and late complications are possible.
Early complications are:
- bleeding
- infection
- fat embolism
- seroma formation in the areas from where the adipose tissue has been removed
- alergy reactions to the medications and sutures used in the surgical procedure
Late complications are:
- irregularities of the skin surface (hollows or bulges in the treated areas of the body)
- hypertrophic scars and keloids (very rarely, and they can occur with people who are prone to creating hypertrophic scars and keloids)
- subcutaneous ” lumps and bumps ” of the fat tissue and/or cellulite, “numbness”
Can I lose weight with liposuction?
Many patients misinterpret this procedure and consider it a method of removing excess weight or weight loss. Liposuction is primarily a method of shaping or contouring the body. Although frequent cases have been reported where patients after, for example, performed hydrolysis, mostly lose five to ten kilograms in several postoperative months, no clear explanation for the occurrence of the phenomenon has been found (however, it is more than welcome to our patients).
Hydrolysis is a method of permanently removing rigid fat deposits which cannot be removed by any other means, but only if the patient changes the previous diet and exercise regime, or if he or she does not attain more than ten kilograms. Hydroliposuction can successfully remove cellulite accumulations in the case of initial stages of cellulite that are not characterized by permanent fibrotic changes in the subcutaneous fat tissue. If this happens in the final stage of cellulite, known as “orange peel skin”, then liposuction can not ideally smooth the skin, but it can significantly improve the contours of the affected areas.
What kind of patients are ideal for liposuction?
Can I get liposuction if I have stretch marks?
The ideal patients for liposuction are people between 20 and 45 years of age, normal to mildly elevated body weight. They have localized accumulations of subcutaneous fat tissue that cannot be removed by special exercise and diet regimens. They should have a good general and cardiac health condition and their skin should have normal tonus. Tonus or skin tension is an extremely important factor in the postoperative period, since such skin can be well adjusted to the new contours of the subcutaneous fat tissue. Patients with skin stretch marks do not belong to ideal candidates for liposuction. Stress is an indicator that the skin irretrievably lost elasticity, and the consequence of liposuction is the potentiation of excessive hanging skin and greater visibility of deepened stretch marks.
Which parts of the body are suitable for liposuction?
On most body parts where there is subcutaneous fat tissue of two to three centimeters thick. The parts of the body most suitable for liposuction are the buttocks (lateral surfaces), the inner surface of the knee, the thighs (inner and outer surfaces), the hips and the front abdominal wall. Often the fat tissue is removed from the face (cheeks, chin) and on male lactic regions in gynecomastia.
What type of anesthesia is used in liposuction?
When liposuction involves larger areas of the body, general anesthesia is used, and the local application is used for smaller procedures, or treatment of smaller areas.
What are the most common / most popular methods for removing fat tissue?
Classical or “dry” liposuction (the first method, today very rarely used), hydrolysis (tumescent variant of hydrolysis), ultrasound liposuction, vibrating liposuction and laser lipolysis.
Which liposuction method achieves the best results?
Based on numerous procedures of liposuction and many years of experience, we believe that hydrolysis can achieve the best aesthetic results. The most optimal results are achieved using a combination of deep and superficial liposuction. In “Ostojić Practice” we use only thin cannules (in diameter from three to four millimeters). They perfectly tunnel – break subcutaneous fat tissue and pull it out. The advantage of thin cannules is that the surgeon allows excellent control of the skin above the treated areas, which directly affects the reduction of the risk of postoperative irregularities in the surface of the skin such as the recesses and protrusion. Thin cannules minimally traumatize surrounding tissue, which is why postoperative hematomas are significantly reduced, and consequently postoperative recovery is much faster.
What does the procedure look like?
The first phase is a preoperative examination of a patient in whom access to each patient is strictly individual. We talk with the patients, listen to them carefully about their wishes and expectations of the procedure. A thorough family and personal history search is taken into account, followed by a psychological evaluation. Thereafter, the eventual asymmetries of the regions to be treated are detected. Possible asymmetries must be presented to the patient and photographed before surgery. One of the very important phases of the examination is the palpation of the skin and subcutaneous tissue, or the estimation of the tension of the skin and muscles that are located below the fat tissue. Finally, the range of areas to be treated in order to measure the extent of the postoperative course or that the exact result can be evaluated by the exact numbers.
What are the complications of liposuction and how common are they?
Complications of the procedure are extremely rare, and possible early and late complications are possible. Possible early complications are bleeding, infection, fat embolism, serum formation or fluid in the areas from which the fat tissue is removed. The possible later complications include the irregularity of the skin surface, hypertrophic scars and subcutaneous “lumps” of the fat tissue.
What does it look like and what to look after in the postoperative period?
Patients are recommended to rest in the next few days, and they should sleep should on their backs with slightly raised legs. Easy and short walks are recommended. In the first two days after surgery, the hematomas and swelling of the regions operated on are the most pronounced, with a possible temperature up to 38 ° C. The temperature should not be specifically treated, possibly an antipyretic may be taken, and the hematomas go away after three to four weeks (the process can be accelerated by lymphatic drainage treatments). In a few postoperative days, patients may also feel nausea, drowsiness, and slight fatigue. Acetylsalicylic acid preparations such as Aspirin and Andol should not be consumed as they increase the risk of bleeding.
The brace on the treated parts must be worn at least six, and it is optimal for eight weeks. The brace cannot be removed the first postoperative week at all, and then it can take up to half an hour a day. Patients do not suffer from postoperative pain because they receive intramuscular injections on the first day after surgery, and then the analgesic tablets are taken over the next few days. Mild pain can be felt through the postoperative period, and most patients describe it as a muscle inflammation after intense physical activity. The result of liposuction is definite after three to four months.
