Why is liposuction performed?

Before we discuss why liposuction is performed, it is important to understand how fat accumulates within the body.

An overview of fat and the body

The anatomical term for ‘loose connective tissue’ is adipose tissue. This is more commonly referred to as fat. This tissue stores fatty acids and triglycerides for energy purposes and also functions as a means to help insulate or cushion the body.

Fat is considered a natural component of the subcutaneous tissue layer and can be found almost all over the body. The distribution of fat cells is not typically even, resulting in some areas featuring more prominent portions of fatty deposits than others. Liposuction is a procedure that addresses exactly that – contouring of the more prominent areas where fat has accumulated by removing excess fat cells. The result is more even distribution and smoother body contouring, ultimately helping to achieve a more aesthetically desirable body shape.

When an accumulation of fat leads to excess in the body, often resulting in a person becoming overweight or obese, fat content becomes hypertrophic (abnormally thick) or hyperplastic (resulting in an abnormal build-up thereof). Hyperplastic fat content is regarded as being somewhat difficult to get rid of with just diet and exercise regimens alone – this is where liposuction may be beneficial.

The distribution of fat may be somewhat different between females and males. In general females have what is known as a gynoid pattern (fat which mostly accumulates around the trunk, hips, buttocks and outer thigh portions of the body). Males more typically have an android pattern (fat mostly accumulates around the trunk and abdominal portions of the body). ⁽¹⁾

Structurally, fat is stored in both superficial and deep fatty layers, particularly in the extremities and trunk (middle) portions of the body.

• The superficial layer typically consists of small, dense fatty pockets that are separated by fibrous septa/e (connective tissue/s).
• Deeper layers are more loosely structured, consisting of areolar fatty tissue (tissues which bind the outer layers of skin to the muscles located beneath) that is interspersed with more rigid fascial septa/e (tough connective tissue compartments which have separate nerves and blood supply). Vertical septa extend upwards from the fascia into the dermis (the layer of tissue below the epidermis / outer skin layer).

Cellulite, for example, is most likely a result of an enlargement having taken place in fat cells within the superficial layer. The action results in compartmental bulging between the more rigid connective tissues which are resistant to the increased volume. Surface irregularities (the dimpling effect) are thus the result as volume increases between the deeper fat pockets.

Liposuction procedures are generally focussed on the deeper fat layers as the removal of fatty deposits is considered easier and safer when targeting these layers. It also produces the most desired result. When targeting the superficial layer, more subtle results are achievable, however the risk of developing issues with contouring aesthetics is higher and there is more chance of injury to the skin.

Factors that make a person an ideal candidate for liposuction

Liposuction is aimed at targeting cosmetic concerns using techniques that facilitate enhanced body shaping (contouring). Target area examples include abnormalities in the chin line or neck and fat bulges anywhere else on the body, including ‘love handles’ (deposits of fat at the sides of the waistline). Many of these bulges or abnormalities are not able to be successfully removed with standard nutrition and exercise regimens alone. Some significant weight loss may already have been achieved, but a person may struggle to rid themselves of ‘that last persistent bulge’ – liposuction can be effective in this instance.

In general, candidates for liposuction must be in good health and not have any significant medical conditions like diabetes, cardiovascular disorders, problems with clotting or infectious diseases which can result in increased risks should a surgical procedure be performed.

The consulting surgeon will assess a potential candidate according to certain guidelines which will include some of the following:

• A potential patient must be at least 18 years of age or older.
• He/she must be in a generally good state of health (physically and mentally) and be at a normal weight or only slightly overweight (no more than 4 to 10 kilograms / around 10 to 20 pounds) or within 20% to 30% of their ideal body weight with localised fat deposits in certain areas of the body. A healthier physical state also helps the healing process following the procedure.
• If overweight, a patient must have already tried to lose weight with a healthier diet and exercise regimen.
• If some weight loss has been achieved, a patient must have stable weight which is being maintained with regular exercise and healthy eating habits.
• A patient must have realistic expectations regarding the procedure and the types of results that can be achieved.
• He/she must also have sufficiently elastic skin (older patients tend to have diminished skin elasticity and as such will need to be guided as to what kind of results are achievable).
• Female patients must not be pregnant at the time.
• A patient must show interest in maintaining a well-balanced and nutritious diet following the procedure – this will help to maintain the results achieved with the procedure.

Which portions of the body can be considered for liposuction?

Facial area, neck and jowl liposuction

Liposuction can be considered for the harvesting of fatty deposits (fat pads) in the facial and neck areas. Such a procedure is often referred to as cervicofacial liposuction. The process involves the administration of negative pressure while using a hollow cannula (a thin tube inserted into the body during liposuction). This helps with gently harvesting fat cells, contouring and sculpting the area in question according to a patient’s desired result.

Fat removal procedures can make use of rhytidectomy incisions (mostly used in face-lift procedures), often near the jowls or wattles (loose skin in the lower cheek area). This approach can be somewhat technically challenging when it comes to harvesting subcutaneous fat. The trick is being able to accomplish fat removal and contouring in an even manner, and open surgical techniques like this run the risk of producing irregularities. Uneven contouring can result in a patient having obvious differences in appearance of the upper and lower facial areas once healed. Scarring is another difficulty that is not entirely favourable in this portion of the body.

Cervicofacial liposuction (lipo-contouring) can be done in combination with other facial surgical procedures that may be desired. Some which can be done along with liposuction include:

• Rhytidectomy (face lift)
• Genioplasty (chin augmentation)
• Malar implants (cheek augmentation)
• Platysmaplasty (reconstruction of the neck muscles)

Most procedures require small incisions that result in reduced scarring which can easily be cosmetically hidden.

Liposculpture (the use of liposuction to contour and accentuate certain features) harvested fat cells can be re-injected into subcutaneous layers elsewhere to help achieve more desirable sculpting results is an effective procedure often used by cosmetic surgeons. This method of body contouring can be applied to any portion, not just the facial area.

When used in the facial area, this procedure allows the surgeon the ability to shape the neck and face using minimally invasive techniques (like submental lipo-suctioning which can achieve more acute angles that enhance the projection of the chin). Minimally invasive techniques also mean that the patient can recover more rapidly, which is an attractive advantage.

The structural characteristics of a person’s face have genetic influences as well as varying degrees of environmental impacts, which include factors like aging (natural and premature), nutritional state, exercise, exposure to medications or toxins (like tobacco or alcohol) or even trauma or injury. Such influencing combinations can impact the facial support structures and cause a variety of changes like:

• Malar or buccal (cheek) drooping and fat pads
• Loss of skin elasticity
• The formations of fine and deep lines and wrinkles
• Facial sagging (like a loss of the natural lower jawline contour or excess submental fat / jowl fat)
• The development of jowls or wattles and loose skin around the chin.

Fat deposits can also affect the neck area and contribute to what is known as ‘banding’ – developing a ‘turkey gobbler’. Altered distribution of facial and neck fat deposits can be corrected with liposuction techniques alone, or along with other facial cosmetic procedures.

It is possible for individuals to appear genetically susceptible to an undesirable distribution of facial fat, even at a young age or at a healthy overall bodyweight. ‘Baby fat’ can sometimes linger into adulthood and persist for an individual. Older patients may wish to address aging-related problem areas influenced by certain genetic and environmental factors.

During a consultation, a plastic surgeon will assess the quality of skin and muscle tone before recommending any facial adjustments, including liposuction.

A surgeon may consider an individual as a candidate for liposuction if it can be determined that he or she has diet-resistant fatty deposits in the facial and neck areas.

Upper arm liposuction

Liposuction is commonly requested for treating the upper arms in individuals who have experienced dramatic weight loss (resulting in soft tissue laxity / sagging). Structural changes influenced by the aging process can also result in sagging and heavy fatty deposits.

The highest amount of fat that is typically located around the centre of the upper arms. Fatty deposits are generally minimal, accompanied by a moderate excess of skin.

Liposuction may be recommended, followed by a brachioplasty (arm lift) procedure to help correct the appearance and improve contouring of the arm/s for a more desirable shape. If skin contraction is favourable following liposuction, an arm lift may not be necessary.

Liposuction around the trunk / abdomen

The number of fat cells (adipose tissues) a person has is generally stable throughout adulthood. When weight is gained due to fat, the increase is mostly attributed to the enlargement of the existing cells rather than the production new ones. In the case of weight loss, existing cells simply reduce in size.

Females typically have a proportionally higher percentage of fat in the body than males. The distribution of fat cells in females does tend to be more on the disproportionate side in the hips, buttocks and upper thighs. Males, in general, tend to display a more even distribution of fat cells in the trunk area (middle area including the stomach and waist) of the body.

Fat accumulation in the trunk does tend to progressively develop with age in both sexes. This is referred to as intra-abdominal fat (or visceral fat). A surgeon will take care during consultations to differentiate between visceral fat (which is not ideally treatable with liposuction) and subcutaneous layer fatty deposits.

In women, liposuction of the hips, buttocks and thighs can help to improve the appearance of a violin shape which is also referred to as ‘violin hips’. This shape is clearly discernible from both the front and back and occurs when fat is distributed over the upper portion of the hip bone (i.e. the iliac crest) and top of the leg bone (femur) in what is referred to as the subtrochanteric area, with an intervening gluteal depression.

Lower body liposuction – thighs, knees, calves and ankles

Fatty deposits can result in abnormal localised distributions affecting:

• The thighs: Outer thighs (‘saddle bags’), upper inner thighs, the entire inner thigh, front of the thighs, back of the thighs and at the junction of the thighs and groin area.
• The knees
• The calves
• The ankles

Localised fatty deposits can affect individuals within a normal weight range or those who are heavily overweight or obese. For those working to treat obesity-related concerns, liposuction may even form part of the recommended plan of action along with bariatric surgery or even post-bariatric plastic surgery procedures.

Most patients seek an aesthetically pleasing gradual tapering look (strong thighs and more delicate ankles). Bulges or volume in the knees may be natural, however some patients may choose to reduce this with liposuction.

A surgeon will carefully assess the tone, quality, elasticity and volume of skin during a consultation to evaluate any possibility of laxity in the targeted area. Laxity may be corrected with additional procedures. In the case of the thigh, a surgeon may recommend an excision thigh lift. Liposuction around the knee can achieve corrections of fatty deposits around the medial (inner knees) and lateral infrapatellar (under the knees) pockets.

Liposuction may be considered for patients wishing to reduce any ‘bulkiness’ around the calves in order to achieve a more desirable shape to the legs (i.e. a more tapered look). When evaluating the calves, a surgeon may classify a patient’s legs into one of two types:

1. Localised heavy legs (the lower calf areas and ankles show definite fatty deposits, giving the leg a tubular appearance)
2. Circumferential (fat distributions are not well-defined, making the entire leg look fat / large)

Liposuction for breast reduction and buttock contouring

The abnormal enlargement or excess breast tissue in females is referred to as macromastia or female breast hypertrophy. Excessive fatty tissues, gland hypertrophy (wherein glands are interspersed with fatty lobules) or a combination of both, are often reasons for this condition which varies in severity from mild (less than 300g of excess breast tissue) to moderate (between 300 and 800g) and severe (greater than 800g).

Excess breast tissue can occur during puberty, following pregnancy, during a period of weight gain or menopause. Genetic influences in some females also plays a role and can be worsened during any of the aforementioned possibilities or life stages.

As a result of excess breast tissue, female patients may also complain of accompanying symptoms, like pain in the back, breasts or even neck areas, as well as display poor posture. For many, being overweight may also be a factor. Feelings of embarrassment, difficulties experienced with the fit of clothing and participation in physical activity may also be mentioned during a consultation.

Liposuction may be useful for correcting minor to moderate instances of macromastia wherein no breast drooping or sagging correction is desired. Scarring and loss of sensation in the breasts may occur following a reduction via liposuction techniques.

Should a female display any mammographic concerns (such as signs of breast tissue disease), liposuction for reduction purposes may not be considered. A surgeon may also not consider this procedure if a woman has poor skin quality, elasticity issues and obvious drooping or sagging of the breasts.

Contouring of the buttocks is achievable with liposuction techniques, however a surgeon may recommend other shaping procedures depending on the nature of a patient’s condition and their overall desires. Implants, autologous fat transfer or autologous tissue flaps (wherein fat or tissue is transferred from one portion of the body to another) are some of the other options available.

A patient may seek liposuction in the buttock area if they have fullness at the base which is often referred to as a ‘banana roll’ deformity. This portion of the body provides some degree of support to the buttocks and thus a surgeon may exercise caution in recommending liposuction in order to achieve a more desirable fold or contour. Liposuction in this regard, could lead to drooping or sagging which can be tricky to correct thereafter.

What is ‘large volume liposuction’?

There does not appear to be a precise definition for what ‘large volume liposuction’ really entails, however, the generally accepted explanation refers to a very high volume of harvested fat and wetting solution (a liquid that contains epinephrine to reduce the amount of bleeding, and when injected, mixes with fat, making removal via suction easier) during a procedure. A high volume of fat removal may be considered to be 4 litres, however most surgeons will classify a patient as ‘large volume’ liposuction candidate if 5 litres (or more) of fat, wetting solution and blood are extracted. ⁽²⁾

With larger volume extraction, extra precaution is required from the surgeon and his or her team as a patient is at serious risk of developing life-threatening complications. Surgeons and their medical teams should be sufficiently trained and highly experienced in large volume liposuction techniques and have a comprehensive knowledge of common physiological changes that can be experienced during such large volume procedures. A surgical facility must also be well equipped to handle any eventuality or conceivable complication, both during surgery and in the recovery period after a procedure.

Patient selection criteria must be carefully evaluated. Overweight or obese individuals may not necessarily be ideal candidates and a surgeon will need to cautiously consider all physiological and psychological influences beforehand in this regard. Any patient with an uncontrolled medical condition will immediately be disqualified as a candidate for this procedure.

It must also be determined whether an individual can physically cope with the large volumes of wetting solution which will need to be used during the procedure. A surgeon will take certain conditions into very careful consideration, especially those related to cardiovascular (circulatory), renal (kidney), hepatic (liver), pulmonary (respiratory) and thyroid systems as life-threatening complications can occur, resulting in fatalities. A history of obstructive sleep apnoea may also disqualify a particular individual.

Large volume liposuction in individuals with reasonable expectations can achieve improvement regarding pre-existing contour irregularities, skin laxity and asymmetry. There is a possibility that secondary procedures may be required for further correction. This can include touch-up liposuction procedures or other relevant cosmetic surgery.

Instances in which liposuction will not be considered

A plastic surgeon will not consider liposuction:

• As a substitute for healthy weight loss methods: If overall weight loss is the primary goal, liposuction is not considered a substitute, especially for those struggling with obesity. A cosmetic surgeon may allow procedures to remove fat deposits in isolated areas of the body from time to time but will not encourage this as a primary weight loss method. If it becomes apparent that a patient has indulged in crash dieting before a consultation, a surgeon may not consider them a potential candidate. Crash dieting can increase a person’s risk for complications due to electrolyte imbalances and nutritional deficiencies. A person who is morbidly obese (has a BMI over 35 – 40) will also not qualify as a candidate, especially if other medical conditions have been diagnosed, such as diabetes. Such individuals are at high risk of serious complications that may be life-threatening, during and after a procedure.
• To treat cellulite: Skin which develops an uneven, lumpy and dimpled appearance is not considered ideal for liposuction correction. Cellulite is fairly common around the hips, thighs and buttock areas of the body, especially in women. The appearance of cellulite may improve somewhat following a procedure but will not disappear.
• To resolve unrealistic expectations: A surgeon will assess the nature of a patient’s physical discontent. Ethically, a doctor will exercise caution in recommending the procedure if clues arise that a person is seeking surgery due to displaced unhappiness – the intention of the procedure is not aimed at solving another (unrelated) problematic area of a person’s life, such as marital disputes, relationship troubles or a difficulty within the workplace. Such problems should be addressed in an entirely different way in order to resolve, like psychological counselling.

A surgeon may be cautious about performing liposuction on certain areas of the body, such as the sides of the breasts, which may be prone to malignant tumour formations. If a surgeon feels that an alternative procedure will be able to better accomplish the goals of a patient, like an abdominoplasty (tummy tuck) or reduction mammaplasty (breast reduction), this will be recommended and discussed in detail with the patient.

References:

^{1. US National Library of Medicine - National Institutes of Health. October 2008. Liposuction: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2825130/ [Accessed 17.04.2018]}

^{2. US National Library of Medicine - National Institutes of Health. February 2009. Safety and benefits of large-volume liposuction: a single center experience: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2654881/ [Accessed 17.04.2018]}