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Fig. 4.10 Access points marked in red are placed in hidden areas from
which different areas can be accessed for liposuction as marked by yellow arrows
easier and less traumatic aspiration, and the subsequent aspiration requiring less physical effort on the part of the surgeon. Its downside is the additional time required prior to
actual aspiration. In our practice, we use a 5 mm single,
double, or triple basket cannulas with PAL to rapidly separate fat in proposed treatment areas. In areas that are highly
brotic, that may have scarring in the area, or in very thin
patients, we prefer to use UAL as the pretreatment tool of
choice.
4.3.2.4 Aspiration
Aspiration efciency is determined by various equipment
factors, but none is more important than the cannula selection. Selecting the right cannula is a balance between
choosing one that is delicate and will minimize the risk of
contour deformities, and at the same time is efcient in
aspirating the fat. There are not many publications dealing
with the physics of liposuction cannulas. Fodor etal. [55]
established the basic principles for optimizing aspiration
(Table4.11):
We also know a larger cannula will be able to aspirate
more efciently and is less traumatic to the fat should fat
transfer be considered.
M. Jugenburg and W. Jalil
Table 4.11 Basic principles for optimizing aspiration
• Port opening size less should be no less than 0.5 times the
cross-section of the cannula
• Enlarging port size beyond 1:1 ratio of port to cannula crosssection does not improve aspiration
• In multiport cannulas, total port cross-section greater than 1.5
times the cannula cross-section adds no additional efciency
• Multiple smaller ports are more efcient than fewer larger ports
In our practice, most body cases are performed with the
following three cannulas: 5mm straight basket cannula for
routine liposuction when focusing on a specic area; 5mm
bent basket cannula to allow access around bony prominences (such as around ribs or pelvic bones) or around body
contours; and 4 mm 12-hole long cannula for generalized
liposuction or larger areas. When performing liposuction in a
thinner patient, or for more nesse, we decrease the cannula
diameter to 4 and 3mm. In heavier patients, and when trying
to aspirate larger volumes while being atraumatic (such as in
more aggressive upper abdominal liposuction during lipoabdominoplasty), we use blunt tip Mercedes 6 mm cannula
(Fig.4.11).
Skin protectors may be used when there is a concern
about tissue injury at the port from the cannula.
When performing the aspiration, the surgeon’s hand
should move in broad strokes initially, to aspirate fat from
the target area as uniformly as possible, fanning out and
always moving. Staying in one place or one area for too long
may result in overcorrection or contour deformities. A target
area should be approached from at least two different
directions, so that the liposuction strokes criss-cross in order
to obtain smooth results.
The simplest method to aspirate fat is use syringe suction.
This technique was popularized by Toledo [56] and is appropriate for low-volume liposuction or in situations where
suction-assisted lipoplasty is unavailable. It is ideal when
treating limited areas and a more complex pump setup is not
required. On the downside, it is more labor intensive, slower,
and suction can be lost at access incisions.
The most common aspiration modality, however, is
suction- assisted lipoplasty (SAL) where a remote liposuction pump creates the suction force. These pumps allow for
variable suction pressure, are less straining on the surgeon,
and allow for less effort and thus larger-volume liposuction.
Suction setting on these pumps is adjustable. High suction
means more rapid aspiration, but also increased risk of contour deformities and vascular injury. In our practice, we keep
our suction set at 40mmHg (max setting is 70).
When handling fat, it is recommended that the surgeon
places his or her hand at on the surface, to feel the liposuction cannula under his or her hand. This will guide the liposuction process. Various degrees of pressure can be applied
to modulate the amount of fat being aspirated. The pressure
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Fig. 4.11 Liposuction cannulas: there are a wide variety of liposuction
cannulas in terms of diameter, length, number and distribution of ports,
and shapes. (1) Curved VentX for ab etching, (2) curved luer lock cannula for aspiration or fat grafting on curved surfaces, (3) short cannula
for areas where liposuction port cannot be placed sufciently far from
the treatment area, (4) cannula with a Toomey syringe adapter for manual liposuction or fat injection, (5) bent basket PAL cannula, (6) straight
basket PAL cannula, (7) straight single port PAL cannula, (8) Del
Vecchio multiport large-diameter cannula for rapid large-volume lipo-
can be applied in a gradient, not as uniform pressure, to
shape the liposuction area when trying to control the resultant
fat contour, as in high-denition liposuction. The nondominant hand can also be used as a guard to limit the extent
of the liposuction, to prevent the cannula from entering
unwanted region.
4.3.2.5 Fat Equalization
In the past, once the aspiration was completed, the surgery
was over. However, more recently, more and more surgeons
have realized the value of fat equalization after liposuction.
Toledo and Mauad [57] recommend the treatment areas
should be thoroughly assessed by the pinch test and by wetting the surface and sweeping the hand or a roller over the
surface to detect any contour irregularities. First described
by Saylan [58], and later popularized by Wall [54], fat equalization or fat shifting is a great tool to ensure contour irregularities are avoided and the patient attains smooth results.
The concept is that the residual fat after liposuction is further
separated and massaged to spread out. Any residual lump is
mechanically broken up with a cannula and then massaged to
shift fat cells into surrounding areas, which then act as autografts and help smooth the contour.
suction, (9) large-diameter Mercedes-style cannula for large-volume
atraumatic liposuction, (10) bent Del Vecchio-style multiport cannula
for liposuction access to areas around curved surfaces, (11) multihole
“cheese grader” cannula for gynecomastia, (12) multiport long cannula
custom cannula with an adapter for PAL handles, (13) extra-long ne
PAL-compatible cannula (allows access to lateral chest and axilla via
groin incision), (14) large-diameter triple-basket cannula for aggressive
separation, and (15) single port re-injection cannula for large-volume
fat grafting
4.3.3 Variations ofLipo Techniques
In addition to the above stated techniques there are certain
complementary techniques or technologies that can be added
on to various techniques. These add-ons come in various
forms and have been presented at numerous aesthetic conferences internationally with each stating improved results.
4.3.3.1 SST—Simultaneous Separation
andTumescence
SST was described by Wall and Del Vecchio [59] and
involves simultaneous inltration and separation of fat for
quick vasoconstriction, and immediate separation, in order to
reduce operative time.
SAFE Liposuction Introduced and popularized as
SAFELipo by Simeon Wall [54, 60],
SAFE liposuction is a three-step process of fat separation,
aspiration, and fat equalization that aims to facilitate fat
removal and minimize contour irregularities at the donor
site. Wall Jr. described the SAFELipo technique using powerassisted liposuction tools and an exploded basket cannula
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that is used to pretreat the donor site in order to facilitate a
less traumatic aspiration of the donor fat. This is achieved by
mechanical vibration and no suction. The result is separated
and emulsied fat that can be removed under lower suction,
with less bleeding and less trauma to the surrounding connective tissue. Subsequently, once the aspiration is completed, the exploded basket cannula again under no suction,
and manual fat shifting, is used to equalize the residual fat
and facilitate a smoother outcome.
HiDef Lipo Introduced by Mentz and Ersek [61, 62] and
later modied and popularized by Alfredo Hoyos [63], this
liposuction technique focuses more on body sculpting than
on fat removal. Surgeons can utilize different forms of
liposuction but what remains important in this technique is
the need for careful preoperative markings that accomplish
the goal of enhancing the underlying muscular anatomy
thus simulating the appearance of an athletic physique for
the patient. The surgeon must constantly keep in mind the
need to retain fat in some areas, while aspirating from
others.
4.3.4 Additional Treatments
4.3.4.1 Tissue Tightening
Helium plasma-Renuvion®/J-Plasma® system (Apyx Med
CORP, Clearwater Florida) is a device that is often used after
the completion of liposuction. Its system combines the
unique properties of cold helium plasma with the efciency
of RF energy [64, 65].
In our experience, this tool has demonstrated impressive
short-term results when used in the abdominal area of
patients with minimal skin laxity. The result is not skin contraction but instead skin adhesion to the deeper layer, making
it difcult to pinch, and thus creating an illusion of skin
tightening (Table4.12). In our limited experience, it appears
that the tightness is maximal at 2 weeks after surgery and
signicant tightness persists for about 3 months. At 1-year
follow-up, some but not all patients still have demonstrable
skin adhesion present. The results seem to be related to the
treatment time. Apyx recommends four to six passes per area
and this appears to result in signicantly better and longerlasting results compared to fewer than four passes.
Other modalities include radiofrequency and laser-based
devices that deliver energy in a controlled manner to induce
tissue contraction as well. However, none of these devices
are a replacement for actual skin excision procedure and
their use should be limited to minimal skin laxity.
4.3.4.2 Hemoglobin Management
When signicant liposuction is planned, the possibility of
signicant blood loss should be considered. Baseline Hgb
level should be obtained to ensure the patient is in a safe zone
prior to the start of the procedure. Patients with low Hgb
should be postponed until their Hgb levels normalize.
Best hemoglobin management is prevention of blood loss
and a good Hgb baseline. Efforts should be made to minimize blood loss during the surgery:
• Sufcient inltration of wetting solution.
• Allowing for the epinephrine to act before commencing
aspiration.
• Cessation of liposuction when excessive bleeding noted.
• Administration of drugs to minimize intraoperative blood
loss (anti-hypertensives, tranexamic acid, etc.)
• Atraumatic cannula selection.
• Warming of intravenous (IV) uids (hypothermia leads to
coagulopathy).
After surgery, the patient should be kept warm, well
hydrated, and proper compression garment applied to minimize bleeding and third-spacing.
Blood loss is of course inevitable outcome from any surgical procedure, especially liposuction where larger-volume
aspirations can have a signicant impact on a patient’s hemoglobin levels. In such situations, use of intraoperative cell
salvage that helps to recycle patient’s blood avoids the need
for transfusions. From anecdotal evidence, patients appear to
recover better and quicker when their hemoglobin levels are
replenished; however, at this time there are no studies to support that assertion.
4.4 Post-liposuction Massage
Table 4.12 Use of helium plasma and its advantages
Advantages Disadvantages
Ideal for patients who are not
ready for excisional surgery
Applicable to multiple areas
on body
Cost of device
Additional time to operation
Learning curve and potential for
increasing complications (burns)
Lack of published studies
demonstrating clinical efcacy
Post-liposuction massage is a great adjunct to postoperative
care. In the initial recovery phase, massage helps to evacuate
residual uid, blood, and oily debris to minimize postoperative edema and uid retention (Fig.4.12). In later stages of
healing, it helps to ensure smooth results and minimal brosis. Massage is best used to create fresh blood ow and move
any unwanted residual uid or inammation that might get
stuck in one area. Patients are warned that initially it will be
uncomfortable as their skin will be hypersensitive, however
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Fig. 4.12 Direction of lymphatic massage in the leg. The illustration also shows the group of lymph nodes toward which massage has to be done
with massage this hypersensitivity will resolve faster. We
recommend to our patients to start massage soon after surgery. Although massage is done ideally directly in contact
with skin, if a patient is wearing a garment they are encouraged to massage through the garment as well. When possible, patients should remove garments during massages, and
massage several times a day. More is better when it comes to
post-liposuction massage. A professional massage will be
more effective as pain will prevent patients from massaging
aggressively enough. For that reason, we recommend a professional massage at least once a week during the rst 3
months. After 3 months, patients can decrease the frequency
of daily massages and may stop professional massages.
tional areas (arms, breast coverage) as needed. The purpose
is to provide smooth, even compression to aid patients in
their recovery while reducing risk of seromas, swelling, and
contouring the healing body.
A proper tting Faja is one that provides even compression without over-compressing. Patients should be free to
remove their Fajas when they feel the need to do so. Taking
a break from a Faja is encouraged. It is important, especially
with postoperative patients, to always wear a barrier between
their skin and garment/Faja in the initial weeks that is smooth
and free from ribbing and wrinkling, and is seamless and a
proper t to allow for a smooth undergarment and layer of
protection that can lay at and provide a smooth barrier (no
wrinkles or extra excessive material that cannot lay at
against skin), which is a protection between patients and gar-
4.5 Post-liposuction Garments
ment. This will avoid and prevent uid build-up that cannot
travel to lymph system, indentations on skin, irritations, and
There is a wide variety of postoperative garments that are
used after liposuction, in order to minimize edema, provide
compression support, and help shape the body. Fajas have
been popular in South America and are now gaining popularity among liposuction patients in North America as well. The
word Faja comes from the Spanish word for wrap. A Faja
comes in a variety of styles, specic to supporting and aiding
in the recovery of recent plastic surgery procedures. A Faja
base coverage tends to always include coverage of the
abdominal and surrounding area and can target specic addi-
other damage.
Stage 1 Fajas are worn immediately following a surgical
procedure and are made of a light, breathable cotton material
with a light to medium level of compression that can be worn
immediately post-surgery. After surgery, the uid needs to be
expelled and the surgeon will not be able to get all of it during the surgical process. This period is known as the “rst
stage” of postoperative recovery, and compression garments
help with that process. After a cosmetic procedure, there is
some amount of swelling and bruising and postsurgical gar-
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ments (Fajas) can help with these issues as well. Stage 1 is
worn immediately post-surgery and can be worn for up to
15days at which time the transition takes place to a Stage 2
garment. For maximum recovery, patients should start wearing a second-stage garment as soon as they are nished with
the rst-stage garment. This allows the body to return to
using its normal lymphatic functioning. When the lymphatic
system is functioning properly, it will naturally ush the
body of excess uid and reduce swelling at which point the
next stage is required.
Stage 2 Faja assists in continued recovery and contouring
results. Stage 2 Faja is of high compression levels worn after
10–15days for a minimum of 3months after surgery. This
includes taking limited breaks from the Faja in the initial
stages (only to clean the Faja, take a shower, or self or professional massage plus break periods to allow for renewed
oxygen levels).
In both Stages 1 and 2, Fajas should be worn 21–22h a
day initially, gradually reducing the time to 10–12h a day or
night at the 12-week mark. Stage 2 Faja often becomes a
comfort level in recovery and is worn for a longer term. If a
liposuction patient completes or is close to completing the
suggested recovery period or wants to move to a lighter compression garment, a Stage 3 Faja can be worn as everyday
wear while providing a level of support and maintaining an
overall look and feel that is desired by the patient. Everyday
wear is commonly used by patients who wish to obtain their
most desired look. Shapewear is another term used for thirdstage garments. Compression is minimal and comfort is an
added benet.
If slight lines from Faja are noticed, allow for breaks (no
Faja) and light moisturizing of the area to allow the area to
recover.
To aid in recovery, posture, and reduce swelling, the following are optional accessories such as 360 foam, lipo
sheets, and ab boards that can be used under a Faja to increase
comfort, reduce pain, increase compression levels, reduce
swelling, ensure uniform compression, and contour the body.
4.6 Safety inLiposuction
Although liposuction can be performed very safely, and the
overwhelming majority of liposuction literature conrms its
safety, risk of complications and mortality still persists [66].
Overall complication rate in liposuction can be 5%, although
most of these complications are minor [67]. Complications
leading to fatal outcomes include embolism (fat and thromboembolic), sepsis, necrotizing fasciitis, and organ perforation. Grazer and de Jong surveyed North American
board-certied ASAPS members. They found 95 fatalities in
496,245 liposuction procedures, corresponding to 1in 5224
or 19.1 per 100,000 mortality rate [68]. Pulmonary embo-
Table 4.13 Liposuction complications
Local complications Systemic complications
• Medical • Hypothermia
– Edema • Fluid imbalance
– Seroma – Fluid overload
– Ecchymoses – Hypovolemia
– Hematoma • Syncope
– Infection • Blood loss
– Skin necrosis (“Lipo burn”) • Embolism
Liposuction injury – Thromboembolism
Compression garment
injury
– Neurological pathology Micro
• Cosmetic Macro
– Over/under correction • Perforations
– Surface irregularities • Fulminant infection
– Skin laxity • Lidocaine toxicity
– Asymmetry • Death
– Skin hyperpigmentation • Lipoembolism syndrome
– Scarring
– Fat embolism
(LES)
lism represented 23.4% of fatalities. Lidocaine toxicity could
not be properly assessed due to lack of toxicology data; however, it remains a major suspect in unexplained deaths after
liposuction. Most deaths reported in this study occurred during the rst night suggesting that patients remain monitored
in the early postoperative period.
Proper patient selection, diagnosis, planning, meticulous
surgical technique, as well postsurgical care are all factors in
maximizing surgical outcome and minimizing the risk of
medical and cosmetic complications (Table4.13).
4.6.1 Edema
Postoperative swelling is normal and expected with liposuction. Edema typically becomes apparent at 24–48h after the
procedure, and then continues to slowly resolve over the next
2–4weeks. Swanson [69, 70] performed magnetic resonance
imaging (MRI) studies that demonstrated 66% of the swelling resolved at 1month, 87% at 3.3months, and total resolution of swelling by 9.3months after surgery.
While all patients are expected to have edema after surgery, signicant persistent edema can affect small proportion
of patients [71]. Diuretics can help speed up resolution of
edema. Edema that does not resolve with time may benet
from repeat liposuction and appropriate compression garments [72] (Table4.14).
4.6.1.1 Seroma
Postoperative seroma can occur after liposuction, with risk
increasing proportionally with the amount of injury to the
lymphatic circulation, and the amount of dead space created
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Table 4.14 Methods to minimize postoperative edema
• Compression garments
• Leaving skin ports open to allow uid to ow out
• Use of drains
• Postoperative massage
• Diuretics
Table 4.15 Management of persistent seromas
• Acute seromas
– Needle aspirations and subsequent compression
– Drain placement
• Chronic seromas
– Fluid aspiration and injection of an irritant (tetracycline 500mg
in 2cc NS or triamcinolone)
– Curettage of the seroma cavity
– Excision of the seroma cavity
and localized trauma. Use of energy devices also increases
the risk of seroma formations [73]. Localized seromas can
occur in 3% of cases [71]. In our experience, when signicant liposuction is performed leaving only a thin layer of
subcutaneous fat behind, the use of drains to avoid seroma
formation is essential. Some surgeons do not use drain and
instead just leave incisions open to allow for free drainage
over the next 24–48h before those wounds close. Should a
seroma develop, there are various measures one can take to
manage it (Table4.15).
Long-term seroma tends to form a cyst-like lining and
often needs to be surgically managed. The “cystic lining”
can be a few layers thick or many layers thick. “Chemical
cauterization” of the cystic cavity for better adhesions of the
layers may be an option after drainage and curettage.
4.6.1.2 Ecchymoses
Ecchymosis is normal and starts to form during the procedure and early after the procedure, typically peaking at 7–10
days. It can be severe if vasoconstriction was poor during the
surgery, or if the patient was taking any anti-coagulant substances (pharmacologic or dietary). Severe ecchymoses can
potentially indicate underlying skin necrosis or may be a
cause of it. Patients should be seen the day after surgery to
ensure there are no indications of skin necrosis, which would
require urgent referral to a hyperbaric oxygen therapy, and
topical creams to open the perfusion in the area. Duskylooking skin may need a nitroglycerine ointment or cream to
improve the micro circulation.
When signicant ecchymosis is noted during the proce-
dure, or there is abnormal bleeding without an obvious etiology, adding tranexamic acid to the procedure may be helpful.
In our practice we prophylactically administer IV tranexamic
acid in patients with a history of easy bruising or administer
it during the procedure if concerns about increased blood in
the aspirate arise.
4.6.1.3 Hematoma
Hematoma should be a rare complication in a well-executed
liposuction procedure. Proper patient selection and preparation, along with proper use of the wetting solution and liposuction technique should result in minimal bleeding during
and after the surgery.
When a hematoma appears intraoperatively, the blood
should be aspirated with a cannula and compression applied
for no less than 5min. Additional wetting solution can be
inltrated into the area and liposuction should be performed
in a different area while the epinephrine is allowed to act.
Tranexamic acid can be added as an additional tool to help
minimize blood loss. When a hematoma is identied postoperatively, it can be left alone when small, or drained if it is
large enough to affect the contour [74].
4.6.1.4 Infection
Infection is extremely uncommon (<1% incidence) [75, 76].
In our experience infection after liposuction has been associated with secondary infection of a seroma, or a drain site.
The most common systemic cause of infection is immunocompromised state such as in poorly controlled diabetics.
Any sign of infection (localized edema, erythema, warmth,
and tenderness that is signicantly different from surrounding areas) should be treated aggressively. Intravenous antibiotics are the rst line of treatment. If there is an obvious
collection, or one is suspected, it should be aspirated. When
the infection is associated with necrotic skin and secondary
infection, the necrotic area should be debrided.
4.6.1.5 Skin Necrosis
Skin necrosis can develop either because of signicant damage to the subdermal plexus (“lipo burn”) or as a result of
excessive compression postoperatively resulting in a pressure sore lesion (“Faja burn”). Initial presentation resembles
ecchymoses; however, lesions are darker and look more ominous. Once suspected, treatment requires immediate attempts
at re-perfusion. Topical vasodilators and referral to hyperbaric oxygen chamber are helpful to prevent or minimize the
skin necrosis. Compression garments should be discontinued
immediately. The incidence of this complication varies, and
in our experience is most often seen in cases of overly aggressive liposuction (Table4.16).
4.6.1.6 Neurological Adverse Events
Postoperative hypoesthesia is common and normal after
liposuction and tends to resolve shortly after surgery. Some
degree of hypoesthesia can persist up to a year. In the early
stages of recovery, areas of hypoesthesia should be assessed
for capillary rell, to ensure there is no risk of skin
necrosis.
Pain and hypersensitivity of the skin are normal and
expected. Surgical pain should be improving daily as should
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Table 4.16 Risk factors for skin necrosis
Excessive supercial liposuction
Turning the cannula opening toward the dermis
Sharp cannula use
Use of energy devices causing thermal injury (UAL, LAL, RFAL)
Inappropriate use of compressive garments
Microvascular disease (smokers, diabetics)
Excessive internal pressure (seroma/hematoma)
skin hypersensitivity. Pain is maximal during the rst
24–48h. Although immediately after surgery the patient may
or may not experience signicant pain (if there is still residual lidocaine-containing wetting solution left behind), typically postoperative pain becomes evident over the rst night
after surgery. Patients report pain as well as hypersensitivity
of the skin over the liposuctioned areas. Some of this pain
may be related to the inammatory response, and minimizing intraoperative bleeding may help minimize the
postoperative pain. Oral analgesics are sufcient to control
the pain. For abdominal liposuction, if a patient reports
abdominal pain that is not improving or is getting worse, we
always check for abdominal injury. Even though it is
extremely rare, it is the one potential complication we want
to exclude rst. We ensure patients can pass gas or have
bowel movements, their pain is improving and not worsening, and they do not have peritoneal signs. Ileus can sometimes develop secondary to narcotic use, and patients need to
be monitored for this possible complication. NSAIDs are
much safer to control pain over a period of time versus a
narcotic.
Chronic pain after liposuction is rare, and may be due to a
neuroma formation, injury to the underlying tissues, or damage to nerve bers. UAL may cause damage to phospholipids
in the myelin sheath of cutaneous sensory nerves [72, 77].
4.6.1.7 Overcorrection
Overcorrection is excessive fat removal and its incidence
depends on the surgeon’s experience. Improper positioning
of the patient can obscure natural contour and lead to overcorrection. A supine or prone position exaggerates bulges,
changes the body contours, and can result in overcorrection.
Use of larger cannulas can lead to excessive aspiration. If a
small area of overcorrection is identied, “liposhifting” as
described by Saylan [58], or fat equalization, can be used to
correct the defect. Autologous fat grafting can be performed
when overcorrection is identied intraoperatively [29, 30,
57]. When the correction is identied postoperatively, any
revision (liposhifting, equalization, or fat grafting) should be
postponed for at least 6 months to allow edema to completely
settle [78].
4.6.1.8 Under-Correction
Under-correction is leaving behind excess fat. This may be a
result because wetting solution or positioning obscures the
result of liposuction. Some areas are prone to undercorrection as a result of anatomic challenges. These include
periumbilical fat, infra-mammary region, arms just proximal
to the elbow, and areas immediately adjacent to the liposuction port. In order to minimize this problem, all liposuction
areas should be carefully assessed at the completion of the
procedure. When an area of under-correction is identied
intraoperatively, additional liposuction, changing cannula to
better reach the problem area, or creating an additional
access port is recommended. When under-correction is identied postoperatively, any revision should be delayed by 6
months to allow for the area to heal and nalize before performing additional liposuction.
4.6.1.9 Skin Irregularities andContour Issues
This is probably the most common cosmetic problem after
liposuction. It is the result of uneven fat removal, brosis formation, or suctioning out fat too close to the skin
that will inherently lead to a cobblestone appearance.
Additionally, an ill-tting postoperative garment can also
result in skin contour irregularities resulting in depressions, dimples, grooves, wrinkles, or folds in the skin.
Pre-existing cellulite, indentations, and scars may worsen
the appearance of the liposuction results. There is a correlation between liposuction volume and this complication
(Table4.17).
To minimize this problem, the surgeon should focus on
smooth even fat removal, and creating an even supercial
layer of fat. Illouz recommended leaving 5mm layer of fat
under the skin [79]. After completion of the liposuction,
the surgical eld should be thoroughly assessed by pinching and rolling over the skin in attempt to identify any contour irregularities. When one is identied, fat equalization
[54, 58] is an ideal tool to correct this problem
intraoperatively.
It is not the fat that is removed, but the fat that remains after
liposuction that determines success. (Pierre Fournier).
Table 4.17 Risk factors for contour irregularities
• Overly aggressive liposuction
• Supercial liposuction
• Large-diameter cannula
• Poor surgical technique
• Improper positioning
• Improperly worn pressure garments
• Poor skin elasticity
• Failure to massage after surgery
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Patients should also be instructed to wear their garments
correctly to avoid surface irregularities, and to check and
adjust their garments regularly to limit fold and crease formation in the garment.
4.6.1.10 Ongoing Skin Laxity
Liposuction may cause mild skin retraction but does not
cause any signicant skin contraction and as such will always
leave behind some skin laxity. Patients with poor skin elasticity, large-volume fat removal, or with pre-existing skin
excess (who are candidates for excisional surgeries) will
have residual skin laxity after liposuction. These patients
should be advised that they will have ongoing skin laxity,
will need to wear compression garments for a longer time to
encourage maximal skin retraction, and may eventually
require a skin excision procedure. Recently, we have started
to use helium plasma tool to correct minimal skin laxity. As
this is a new tool, there is currently no concrete evidence to
demonstrate long-term benets; however, in our anecdotal
experience this tool has shown promising results.
4.6.1.11 Asymmetry
Asymmetry is normal and should be discussed with the
patient preoperatively. Signicant asymmetry after liposuction can be treated with additional liposuction, liposhifting,
and fat grafting.
4.6.1.12 Hyperpigmentation
Post-inammatory hyperpigmentation may occur and when
this discoloration persists beyond 6 weeks, it may be the
result of dermal injury, inammation, or infection [72]
(Table 4.18). These lesions will take long time to resolve,
and may be associated with scarring supercially, and brosis and contour irregularities internally. Fitzpatrick skin
types IV–VI will be more prone to post-inammatory hyperpigmentation (PIH).
4.6.1.13 Scars
Mechanical trauma at the incision site from the movement of
the cannula can injure the surrounding tissue affecting the
quality of the healing scar, with the subsequent scar being
depressed, hypertrophic, or a keloid. The surrounding skin
may become hyperpigmented, worsening the appearance of
the scar. Poor placement of the incision sites can also make
the scar more visible.
Table 4.18 Etiology of skin hyperpigmentation
Hemosiderin deposition from ecchymoses or hematoma
Excessive garment compression
Friction or shear trauma at the port site
Sun exposure
4.6.1.14 Hypothermia
Hypothermia is dened as core temperature below 35°C.It
may predispose the patient to consumptive coagulopathy,
increased surgical bleeding, cardiac events, and infection.
Measures to prevent hypothermia include warming IV uids,
warming of wetting solution, warming blankets, minimizing
body exposure during the surgery, and raising the room
temperature.
4.6.1.15 Signicant Blood Loss
Signicant blood loss requiring blood transfusion should be
a rare complication when patient selection is properly done,
and the surgical technique follows basic principles of
liposuction.
Blood loss from liposuction occurs via three
mechanisms:
1. Blood loss in the lipoaspirate
2. Bleeding into dead spaces
3. Blood loss via postoperative draining
When estimating blood loss, Courtiss etal. [80] estimated
that internal blood loss was equal to external blood loss.
Blood loss into dead space is likely to continue after the procedure has been completed, and thus postoperative compression garments are essential to minimize this process. In our
experience, third-spacing in thigh liposuction has been associated with the greatest hemoglobin drops postoperatively.
4.6.1.16 Fluid Abnormalities
Fluid management is an important part of the procedure, as
large amounts of uid may be injected subcutaneously, with
estimates of 70–75% of this uid being absorbed intravascularly within 160min of administration [81, 82]. It is important for the anesthesiologist to not overload the patient with
uids. Excessive uid can lead to excessive postoperative
edema, and hemodilution can result in hypercoagulability
and disseminated intravascular coagulopathy (DIC).Acute
pulmonary edema has also been reported in literature, especially in large-volume liposuction, which is likely a combination of a large volume of inltration along with excess
intravenous uids. On the other hand, third- spacing of uid
after liposuction can result in hypovolemia, which often
presents with syncope, nausea, and vomiting.
Rohrich etal. [83] found superwet liposuction was safe, and
they established a safe ratio of liquids administered per volume
of liposuction: 1.8mL/cc of lipoaspirate when total aspiration
volume is under 5000cc, or 1.2mL/cc of lipoaspirate when total
aspiration was over 5000cc. Postoperatively, the recommended
maintenance uids were: 1.6cc/kg/h in cases of <5000cc aspiration, and 1.3cc/kg/h when aspiration was over 5000cc.
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4.6.1.17 Syncope
Vasovagal syncope, hypovolemia, and residual anesthetic
drugs predispose patient to syncope after surgery. Patients
should be warned of this so that they do not panic should it
occur, and they should also be instructed to have a caregiver
with them at all times when upright for the rst 24h after
surgery, or longer for larger cases. Per os (PO) uids are
encouraged, and patients are instructed to get up from a
supine position slowly and in stages. First sit up and wait,
then stand up and wait before walking.
4.6.1.18 Pulmonary Embolism
DVT andThromboembolism
Pulmonary thromboembolism (PE) accounts for the majority
of fatalities in liposuction procedures, representing 25% of
fatalities in a survey by Grazer and de Jong [68, 81]. Also,
50% of Deep Venous Thromboembolism (DVTs) occur during the surgery, usually in distal calf veins, and 50% of these
cases resolve spontaneously in 72h, while 25% will extend
above the popliteal vein with pulmonary embolism even if
the patient remains asymptomatic [84]. Once pulmonary
thromboembolism becomes symptomatic, 10% will die
within the rst hour [84]. Any patient suspected of pulmonary thromboembolism (shortness of breath or chest pain)
should be worked-up thoroughly and if found positive,
treated immediately with anti-coagulation. Because of the
preventability of this potentially fatal complication, most
surgeons use the Caprini risk classication and some form of
DVT prophylaxis for their patients. Intraoperative sequential
compression devices and early mobilization are applied to all
patients. When the risk of thromboembolism is increased,
patients are given chemoprophylaxis.
4.6.1.19 Fat Embolism
Fat embolism is a potentially fatal complication; however, a
distinction has to be made between fat embolism syndrome
and macro fat embolism. Fat embolism syndrome is of variable severity with overall mortality of 10–15% [85]. Its onset
is gradual, showing respiratory, neurological, and skin
changes, which usually take 48–72h to present themselves. It
is believed to be the manifestation of endothelial irritation by
the presence of free fatty acid in the bloodstream [86]. Proper
hydration is theorized as a preventative measure against Fat
Embolism Syndrome (FES), as it is thought that the mechanism of action is such that the surface of the micro fat emboli
allows activated platelets to adhere to, causing then macroscopic embolism [87]. Adequate hydration will then limit circulatory stasis and thus lower the risk of complications.
In macro fat embolism, macroscopic fragments (>3cm)
of fatty tissue can lead to pulmonary embolism with a very
high mortality rate [85], as a result of trauma to medium to
large caliber blood vessels allowing for uptake of fatty fragments [88].
4.6.1.20 Perforations
Perforation injuries, specically abdominal wall perforation
during liposuction, can be fatal if unrecognized and not
treated appropriately (Table 4.19) [89]. Survey by Grazer
and de Jong demonstrated that this complication accounted
for 15% of fatalities [68]. Penetration of the peritoneal cavity
or the pleural cavity by a cannula can be easily missed under
systemic anesthesia, while under local anesthesia such an
event would be immediately reported by the patient [90, 91].
It is essential that during the liposuction procedure, the
surgeon is aware of the cannula tip at all times. Positioning
the patient correctly is also essential in lowering the risk of
inadvertent perforation. Hyper-extending the surgical table,
and ensuring the cannula is always tangential or pointing
away from abdominal wall will lower the risk of
perforations.
Early diagnosis is essential and if the surgeon has any
concerns, the patient should be monitored postoperatively
for symptoms of abdominal injury (Table4.20). If an abdominal perforation is suspected, abdominal computed tomography (CT) should be obtained. Treatment of a conrmed
perforation requires immediate exploration and repair.
Perforation of the pleural cavity is also a potential risk.
Inadvertent pleural injury can result in a tension
pneumothorax.
4.6.1.21 Severe/Systemic Infection
Severe infection and necrotizing fasciitis are an exceedingly
rare complication and should not occur without gross contamination, bowel perforation, or in patients in immunocom-
Table 4.19 Risk factors for visceral perforation
• Obesity
• Previous abdominal surgeries
– Postoperative hernia
– Weakened abdominal wall
– Increased brosis necessitating more vigorous liposuction
• Diastasis
• Hernias
• Improper positioning of the patient
Table 4.20 Indications of abdominal wall perforation
Worsening abdominal pain
Persistent nausea and vomiting
Absence of bowel sounds
Lack of hunger
Rebound tenderness and other signs of peritonitis
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promised state. Treatment involves aggressive washout or
debridement, intravenous antibiotics, and supportive
therapy.
4.6.1.22 Lidocaine Toxicity
Lidocaine toxicity is a potentially lethal complication that
should be avoided with carefully planned and calculated
lidocaine dosing in the wetting solution. Surgeons should
lower their toxic dose calculations when other drugs that act
on cytochrome CYP3A4 such as SSRIs [92] are taken by the
patient before surgery.
When larger volume of wetting solution is being used, the
surgeon should monitor for signs of toxicity, which progresses from initial mild central nervous system (CNS)
symptoms to severe cardiovascular symptoms if the plasma
levels of lidocaine are allowed to rise above safe levels [93,
94]. Patients will report nausea and vomiting with increasing
lidocaine dose. Some patients with plasma lidocaine concentration of 1–6μg/mL experience mild unpleasant symptoms
such as light headedness, perioral numbness, nausea, confusion, and tingling sensation of the tongue. Plasma dose of
5–6μg/mL starts to develop obvious signs of lidocaine toxicity: CNS symptoms may include mild drowsiness, nervousness, euphoria, confusion, and blurred or double vision. As
the plasma lidocaine levels increase, respiratory depression
and respiratory arrest occur, which then lead to respiratory
acids increasing lidocaine toxicity. CVS symptoms occur
well after CNS symptoms. Symptoms include bradycardia,
hypotension, and depressed myocardial contractility, which
can lead to cardiovascular arrest (Table4.21).
In a patient under general anesthesia, these signs and
symptoms are obscured. For this reason, some believe tumescent liposuction on an awake patient is safer.
4.6.1.23 Management [95]
• Prevention—properly calculate maximum dose of local
anesthetic
• Stop infusion agent
• Establish IV access
• Continuous cardiac monitoring
• Airway support
Table 4.21 Indications of lidocaine toxicity
CNS effects Cardiovascular effects
• Circumoral numbness,
facial tingling
• Vertigo • Late: peripheral vasodilation
• Light headedness • Sinus bradycardia
• Dizziness • Ventricular dysrhythmias
• Convulsions • Impaired cardiac muscle
• Early: hypertension and
tachycardia
and hypotension
contraction
• Cardiac arrest
• Hyperventilate
• Consider epinephrine to augment cardiac output and vascular tone
• Consider bicarbonate for acidosis
• Initiate cardiopulmonary resuscitation (CPR) in arrest
• Manage seizures with benzodiazepines
• Lipid emulsion therapy (20% intralipid) for severe cases
[96, 97]
– Bupivacaine has a longer half-life and more likely to
require intralipid
– Bolus 1–1.5mL/kg over 1min, can repeat every 3min
up to a total of 3mL/kg
– Infusion 0.25mL/kg/min until hemodynamically sta-
ble for minimum of 10min
– If CPR required, continue to circulate the drug
4.6.1.24 Authors’ Preferred Liposuction
Technique
• Preoperative work-up
– Labs—CBC routinely
– Past surgical history
– Medical history
– Medications
– Allergies
• Markings
– Identify target areas for liposuction
– Mark areas of proposed maximal liposuction
– Mark borders of liposuction area
– Dene any anatomic landmarks or desired shapes (as
in HiDef)
• Surgical preparation
– Chlorhexidine or betadine
• Selection of liposuction skin port sites
– Location is a balance between hiding the scar and hav-
ing good access to the target zone
– Use of liposuction ports
Minimize tissue trauma for better scar
#15 blade for 4–5 mm cannulas; #11 blade for
smaller incision
• Intra- and postoperative monitoring
– Blood pressure, cardiac monitoring, and pulse
oximetry
• Wetting solution
– Standard tumescent needle—Klein
– SST (simultaneous separation tumescence)—Del
Vecchio
– Rate of infusion—inltration pump at maximal
setting
– Superwet technique—1:1 inltration to expected fat
aspiration
– Solution content
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