The Skinny on Plastic Surgery

EDITOR’S NOTE: This month we are pleased to introduce a column by Dr. Robert Clement, which will demystify plastic surgery procedures. From athletes to “fitness tourists,” appearance is important, but is a procedure the right decision? This column will present the science behind the rumors. We begin with liposuction and note that even Dr. Timothy Noakes has said in his book, The Lore of Running, that a surgical procedure may be the only way to get rid of some pockets of fat no matter how much you run.

The ideal candidate for liposuction is a patient who is at approximately normal, ideal body weight but who has localized pockets of fat over the hips, thighs, abdomen, or neck. Cellulite (the dimpled appearance of skin caused by fat deposits located just below the surface of the skin) is one of the most common complaints of people who have gained weight, especially over the hips and thighs. In the past, cellulite was not dramatically affected by liposuction, but there are now some new tools and techniques that can improve results.

Liposuction is one of the safest procedures performed in the United States today. Like any surgery, there are common problems (bleeding, infection, skin problems, scarring and/or failure of the skin to re-drape, and pulmonary emboli). However, with the advent of smaller and better equipment and improved techniques over the past 50 years, liposuction has evolved into one of the best procedures for the plastic surgeon to perform.

The main improvements that have developed involve a surgical instrument (the cannula) and its diameter. A cannula is a thin tube inserted into the subcutaneous fat. Today, most cannulas are much smaller (2.0-3.7 mm in diameter) than the original 6.0-9.0 cm and have been significantly refined, improving our ability to remove fat more evenly. This greatly reduces the chance of disfigurement.

Multiple instruments have been developed to remove fat during liposuction. The blunt-tipped cannula originated in France in the early 1980s and was pioneered by Dr. Yves-Gerard Illouz. Dr. Illouz used two types of technique: dry, in which no solution was placed in the subcutaneous tissue, and wet, where different wetting solutions were used in the subcutaneous fat. Today, the wet technique is implemented no matter what type of instrument is used to remove the fat. The solution, which consists of saline, Xylocaine, and epinephrine, provides pain reduction for about three to four hours as well as significant blood vessel restriction, limiting the amount of blood loss.

As solutions improved and reduced the amount of blood loss, the Plastic Surgery Society revised its criteria for safe levels of fat removal to approximately 5,000 to 6,000 cc at one time (2,000 cc is equal to a 2 liter bottle of soda). While there are people who do high-volume liposuction (8,000 to 10,000 cc at a time), it is more risky and requires absolute attention to detail for patient safety.

Although multiple instruments have been developed to remove the fat, they are all powered by an atmospheric pressure vacuum pump. Vaser liposuction uses a radio frequency device to help melt fat, using the heat produced to also tighten the skin. This is also true in laser liposuction, which employs a laser beam to melt the fat and tighten the skin with heating. Skin tightening is not significantly improved with this technique. Power-assisted liposuction is a power-driven device which reduces the workload for surgeon. Tickle liposuction uses a standard cannula that vibrates inside the tissue, loosening the fat and removing it with suction. The Body-Jet is the newest modality, using water sprays attached to the liposuction cannula to loosen fat, which is then removed by the liposuction machine. This device provides excellent fat for use in grafting to fill areas such as face, breasts, or buttocks. Fat grafting is currently (and will continue to be) one of the hottest subjects in plastic surgery over the next few years.

While these new instruments are interesting and exciting, I am not convinced that these modalities have any significant advantage over standard liposuction; they also have potential problems that the standard liposuction does not. The original blunt-tipped cannula, refined to a smaller diameter, remains my standard method for removing fat. While I have had the opportunity to use all the different types of cannulas and techniques, the original process has given me the best results.