Plastic Surgery and Modern Techniques (ISSN: 2577-1701)

Article / case report

"Current Evidence Based Practice Guidelines for Liposuction and Future Trends"

Salil Bharadwaj*


Department of Plastic Surgery, Bahrain Specialist Hospital, Bahrain


*Corresponding author:Salil Bharadwaj, Consultant Plastic Surgeon, Department of Plastic Surgery, Bahrain Specialist Hospital, P.O Box 10588, Juffair, Manama, Bahrain. Tel: +97336055143;+97317812211; Email:



Received Date:17July, 2017; Accepted Date: 19 September, 2017; Published Date: 25 September, 2017

Case Report

 Modern Liposuction has evolved from humble beginnings as a rather experimental procedure 40 or so years ago, to being one of the most popular procedures in aesthetic surgerytoday. It was the second most popular aesthetic procedure globally (1,453,340 cases)[1] in 2016(up 4%) as well as most popular procedure in the United States (414,335cases), up 4.6% from 2015[2].

 Subsequent toIllouz’s presentation of a technique for removing subcutaneous fat with a blunt cannula attached to a suction generating device at the 1982 Annual Meeting of the American Society of Plastic and Reconstructive Surgeons, the procedure has undergone many refinements and evolved with improvement in techniques and technology[3].

 My endeavour in this article is to briefly discuss current evidence based best practice principles and highlight future trends.

 Potential liposuction patients who strive to improve their appearance through diet, exercise, and a healthy lifestyle are more likely to be satisfied with their long-term postoperative results[4].It is paramountfor both the patient and the surgeon to remember that liposuction is not a weight-loss technique; it is a body reshaping (contouring) technique.

 A consensus statement onlarge-volume liposuction (defined as >5 litters oftotal aspirate), regardless of anaesthetic method, has underscored the recommendation for operatingin either an acute-care hospital or in an accredited or licensed facility when removing large volumes[5].

 Depending on patient characteristics liposuction can be done either in a hospital or office based setting, but the American Society ofPlastic Surgeons Practice Advisory recommends avoidingneuraxial anaesthesia (i.e., spinal, epidural)in office-based settings because of potential hypotension and volume overload issues[6].

 The super wet (infiltration of 1 mL per estimatedmL of expected aspirate) and the tumescent (3 to 4 mL of wetting solution per mL aspirated) are the most widely used wetting techniques in operation. The maximum recommended safe dose of lidocaine is 55mg/kg and that of epinephrine 50mcg/kg in the solution[7,8].Recent data suggest that, for patientsundergoing generalanaesthesia with the super wet technique, the lidocainecomponent may be reduced and/or eliminated withoutpostoperative sequel of increased pain[9,10].This is important in view of the well-known toxicity issues associated. Wetting fluids should be warmed to room temperature and the patient should be maintained at normothermic temperatures to decrease postoperative complications.

 Fluid management guidelines for liposuction state that for small volume aspirations (less than 5 litters) maintenance fluid along with correction of preoperative losses as well as the subcutaneous infiltrate is adequate, whereas large volume liposuction (above 5 litters) in addition to the above, requires 0.25 ml of crystalloid per millilitre of aspirate above 5 litters[11,12].

 New devices continue to emerge for use in this procedure, most of them with little evidence to support their claims of superiority. It isa formidable task for surgeons to stay abreast ofall the latest techniques, technologies and, more importantly, evidence surrounding their uses. The common technologies in use are Suction Assisted Liposuction (SAL), Power Assisted Liposuction (PAL), Ultrasound Assisted Liposuction (UAL), Laser Assisted Liposuction (LAL) and the more recent Radio Frequency Assisted Liposuction (RFAL).

 Though UAL and its current avatar VASER has been found to have some benefit in treating fibrotic areas and in limiting blood loss, larger incisions required, concerns with burns, cost, long learning curve and slow procedure times have seen its popularity on the decline,with erstwhile advocates now employing it in only 7-10% cases[13,14].

 LAL has shown in a randomized, blinded study to result in up to 17% skin contraction and 25% improvement in skin elasticity[15].On the contrary Prado et al. conducted a randomized,double-blind, controlled study examiningLAL and SALthat showed no clinical differencein aesthetic outcomes between these techniques. Cost, slow operative time, multiple stages, potential for skin injury and the learning curve limits its usage[16].PALfared well in a three-way comparison (SAL vs. UAL vs. PAL) foroverall efficiency, reduced vascular injury and most favourablecost-benefit ratio[17].More recently, PAL was quantified as being 17% more efficient than SAL and less influenced bythe region of fat distribution, the reciprocating motion aidingcannula penetration into ‘difficult’ and fibrous areas[18]. This technique has been found tocause less trauma, swelling andecchymosis in addition to shorter recovery and diminishedoperator fatigue, particularly in large volume liposuction[19]. The early drawbacks of machine noise and excessive vibrations to operator have been overcome with the newer devices. Currently PAL is the author’s preferred technique.

 RFAL is an emerging technology that produces controlled thermal injury at the sub dermal surface to enhancecoetaneous contraction as it heals. There appears to be a biphasic skin contraction,with 14% and 24% noted at 6 and 12 weeks respectively;explained by a stimulation of neocollagenesis[20].This technique has to be used in conjunction with SAL and though increasing operative time, it has shown promise.

 At the end of the day it’s not the type of device used but the surgeon’s skill and patient characteristics that determine the final result(Figure 1-3).

All plastic surgeons that perform liposuction should be familiar with the risks, unto wards equelae, and complications associated with the procedure. Fortunately, most complications of liposuction are minor in nature and tend to resolve spontaneously. Venous thromboembolism following surgicalprocedures, particularly liposuction continues to generate a great deal ofattention in the professional and lay media.

 A recent article cited the incidence of deep vein thrombosis to be less than 1 percent in liposuction[21]. Newall et al.reported a 0 percent deep vein thrombosis rate in a retrospective series of patients who underwent large-volume liposuction and received chemoprophylaxis with low-molecular-weight heparin[22]. In 2011 the ASPS Venous ThromboembolismTask Force recommended risk stratification based on the 2005 Caprini scale for patients undergoing liposuction and the need for low molecular weight prophylaxis[23].These guidelines should be incorporated by all plastic surgeons in their practice.

 Although indirectly related to liposuction,the topic of fat transfer is among the most currentand still debated topics in plastic surgery,despite initial investigations going back morethan 25 years. Fat transfer may be performed as a primaryprocedure (e.g., breast or buttock augmentation),as an adjunct (e.g., face-lift surgery or breast reconstruction), or for the potential of “stem cell” therapy[24].Adiposestem cell pluripotentiality and unlimited capacity forself-renewal, represents a great promise fortissue engineering. Cell-assisted lipotransferis a novel approach to autologousfat transplantation in which adipose-derived stem cells are attached to the aspirated fat[25] (Figure 4).

The “holy grail” for body-sculpting technology is non-invasive technologies that minimize tissue morbidity, decrease downtime, and increase skin contraction/tightening, which lessens the need for skin excision by way of surgical intervention. This has led to a new industry: non-invasive body contouring[26].In this regard are non-invasive technologies as cryolipolysis (e.gZeronaTM,Coolsculpt), high-intensity focused ultrasound -HIFU (e.gLiposonix) and radiofrequency devices (e.gBodyFXTM) for fat cell disruption and lysis.

 The proven benefit of liposuction as an adjunct in procedures such as abdominoplasty,breast reduction, face-neck lifting andbody lifts cannot be stressed enough. It is an essential tool for the three-dimensional composite sculpting/remodelling of body structures(Figure 5,6).When liposuction was first introduced andpopularized in the early 1980s, it indelibly alteredthe field of body contouring surgery and redefined plastic surgery for future generations ofsurgeons.Unless a “cure” for obesity is discovered, or a tectonic shift in human nature, lifestyle, or fashion trends occurs, it is likely than our concerns withlipodystrophy will persist unabated. Moreover, asmore practitioners and manufacturers becomeinvolved in this area and research continues intothe understanding of adipocyte physiology, the fields ofliposuction, lipolysis, obesity, and fat cell metabolismwill continue to gain more interest and realizemore advancement[24].

Figure 1:Liposuction trunk and arms.

Figure 2:Liposuction trunk and arms.

Figure 3:Liposuction of submandibular area and neck.

Figure 4:Liposuction abdomen and flanks with fat transfer to buttocks.

Figure 5:Lipo - abdominoplasty with fat transfer to buttocks.

Figure 6:Lipo - abdominoplasty with fat transfer to buttocks.

1.       International Society of Aesthetic Plastic Surgery (ISAPS)(2016) Global statistics.

2.       American Society of Plastic Surgery (ASPS) (2016) Plastic Surgery Procedural Statistics.

3.       Lewis CM (1990) Early history of lipoplasty in the United States. AesthetPlastSurg14:123-126.

4.       Rohrich RJ, Broughton G, Horton B, Lipschitz A, Kenkel JM, et al. (2004) The key to longterm success in liposuction: A guide for plastic surgeons and patients. PlastReconstrSurg114:1945-1952.

5.       Haeck PC, Swanson JA, Gutowski KA, Basu CB, Wandel AG, et al. (2009) Evidence-based patient safety advisory: Liposuction. PlastReconstrSurg124:28-44.

6.       Iverson RE, Lynch DJ, American Society of Plastic Surgeons Committee on Patient Safety (2004) Practice advisory on liposuction. PlastReconstrSurg113:1478-1490.

7.       Ostad A, Kageyama N, Moy RL (1996) Tumescent anesthesia with a lidocaine dose of 55 mg/kg is safe for liposuction. DermatolSurg22:921-927.

8.       Sood J, Jayaraman L, Sethi N (2011) Liposuction: Anaesthesia challenges. Indian J Anaesth55:220-227.

9.       Hatef DA, Brown SA, Lipschitz AH, Kenkel JM (2009) Efficacy of lidocaine for pain control in subcutaneous infiltration during liposuction. Aesthetic Surg J 29:122-127.

10.    Perry AW, Petti C, Rankin M (1999) Lidocaine is not necessary in liposuction. PlastReconstrSurg104:1900-1902.

11.    Trott SA1, Beran SJ, Rohrich RJ, Kenkel JM, Adams WP Jr, et al. (1998) Safety considerations and fluid resuscitation in liposuction: An analysis of 53 consecutive patients.  PlastReconstrSurg102: 2220-2229.

12.    Rohrich RJ, Leedy JE, Swamy R, Brown SA, Coleman J (2006) Fluid resuscitation in liposuction: a retrospective review of 89 consecutive cases. PlastReconstrSurg117:431-435.

13.    Hunstad JP, Aitken ME (2006) Liposuction: techniques and guidelines. ClinPlastSurg33:13-25.

14.    Ahmad J, Eaves FF, Rohrich RJ, Kenkel JM (2011) The American Society for Aesthetic Plastic Surgery (ASAPS) survey: current trends in liposuction. AesthetSurg J 31:214-224.

15.    DiBernardo BE (2011) Treatment of cellulite using a 1440-nm pulsed laser with one-year follow-up. AesthetSurg J31:328-341.

16.    Prado A, Andrades P, DanillaS, Leniz P, Castillo P, et al. (2006) A prospective, randomized, double-blind, controlled clinical trial comparing laser-assisted lipoplasty with suction-assisted lipoplasty. PlastReconstrSurg118:1032-1045.

17.    Scuderi N, Paolini G, Grippaudo FR, Tenna S (2000) Comparative evaluation of traditional, ultrasonic and pneumatic-assisted lipoplasty: analysis of local and systemic effects, efficacy and costs of these methods. Aesthetic PlastSurg24:395-400.

18.    Scuderi N, Tenna S, Spalvieri C, De Gado F (2005) Power-assisted lipoplasty versus traditional suction-assisted lipoplasty: comparative evaluation and analysis of output. Aesthetic PlastSurg29:49-52.

19.    Rebelo A (2006) Power-assisted liposuction. ClinPlastSurg 33: 91-105.

20.    Paul M, Mulholland RS (2009) A new approach for adipose tissue treatment and body contouring using radiofrequency-assisted liposuction. Aesthetic PlastSurg33:687-694.

21.    Stephan PJ, Kenkel JM (2010) Updates and advances in liposuction. AesthetSurg J30:83-97.

22.    Newall G, Ruiz-Razura A, Mentz HA, Patronella CK, Ibarra FR, et al.(2006) A retrospective study on the use of a low-molecular-weight heparin for thromboembolism prophylaxis in large-volume liposuction and body contouring procedures. Aesthetic PlastSurg30:86-95.

23.    Murphy RX Jr1, Alderman A, Gutowski K, Kerrigan C, Rosolowski K, et al. (2012)Evidence-based practices for thromboembolism prevention: summary of the ASPS Venous Thromboembolism Task Force Report.PlastReconstrSurg 130: 168-175.

24.    Matarasso A, Levine SM (2013) Evidence-based medicine: liposuction. PlastReconstrSurg132:1697-1705.

25.    Steridomas A, De Faria J, Nicaretta B, Papadopoulos O, Papalambros E, et al. (2010) Cell-assisted lipotransfer. AesthetSurg J 30: 78-81.

26.    Shridharani SM, Broyles JM, Matarasso A (2014) Liposuction devices: technology update. Med Devices (Auckl) 7: 241-251.

Citation: Bharadwaj S (2017) Current Evidence Based Practice Guidelines for Liposuction and Future Trends. Plast Surg Mod Tech 2: 126. DOI: 10.29011/2577-1701.100026
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