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Liposuction: Keeping It Safe

Liposuction: Keeping It Safe

Liposuction is a very hot topic these days.  It has been the most common plastic surgery procedure performed for the past ten years.  It was introduced over 30 years ago in France as a less invasive alternative to surgical removal procedures.  The technique was investigated by a panel from the American Board of Plastic Surgery and found to be safe and effective.  From that point forward, American plastic surgery residencies became the training ground for this specialized procedure.  By the time I had completed my residency training, I had performed hundreds of liposuction cases.

Over the past ten years, however, new liposuction technologies have been marketed directly to patients touting exaggerated benefits. The promise of better results and less downtime mixed with a catchy modern name overshadow the fact that these new machines have not been investigated by the FDA and have no scientific data demonstrating their safety or effectiveness.  The FDA has certain bylaws that allow new liposuction technology into the market without any actual scientific data.  This is the reason there is supposedly new and better liposuction or laser machine advertised every few months.  Even scarier is the fact that liposuction may be performed with one of these machines as long as the company provides the practitioner with a weekend course that involves a lecture and a video, but no actual patient contact.  Armed with this, the federal government allows any doctor the legal right to perform liposuction on a patient in his or her own office.  This means your liposuction could end up being performed by an internist, allergist, obstetrician or radiologist, for example, who has no practical experience in liposuction.

Before choosing a liposuction procedure, every patient should have a precise understanding of both the risks and what can be comfortably achieved.  Liposuction is intended to permanently remove focal areas of fat to create a harmonious body contour. It is not a weight-loss tool and is ideal for healthy patients with stable weight and good skin elasticity.

Tumescent Liposuction
The tumescent liposuction technique is employed by the vast majority of board-certified plastic surgeons in the United States and in the world.   Here, a local anesthetic is injected into the area of fat.  Lidocaine is used to numb the area and epinephrine is used to reduce bruising. The fluid itself acts as a lubricant for the use of thin medical tubes that remove the fat precisely and slowly. Occasionally, vibrational tubes are used to loosen the fat in a process called Power-Assisted Liposuction; this makes fat removal even gentler.

The technique has many attributes.  This is the only technique that allows liposculpture.  Fat is removed selectively until the desired contour is sculpted on the table. The feel of the tissue must be smooth and transition nicely into adjacent body parts.  Often some fat is not removed but molded internally to fill adjacent hollow areas, a technique called SAFE lipo.  Furthermore, the fat that has been removed can be re-injected nearby or in different parts of the body to improve body proportions. This process is called autologous fat grafting or fat transfer.  All this is possible because tumescent liposuction is the least traumatizing technique to the fat and skin as well as the muscle/nerve structures below the skin.

The procedure can be performed in an office setting under local anesthetic for small areas. In the interest of safety, procedures that involve moderate or large body areas should be done in the operating room under light sedation.  If combined with other procedure such as a tummy tuck or breast augmentation, general anesthesia is warranted.

Laser Liposuction (Smartlipo)
Smartlipo or laser lipolysis is a recent liposuction technology owned by Cynosure.  The company has a large marketing division aimed to introduce this office-based liposuction to non-plastic surgeons.  The premise of this technology is that fat is melted before it is suctioned out.  The first local anesthetic is injected into the area.  The fat is heated with the laser probe until a certain temperature of the skin is reached. Next, a liposuction tube is used to suction out the melted fat.  Cynosure claims the procedure can be done entirely under local anesthesia with no regard to the surface area to be treated.  It claims this technique is less invasive, has less bruising, swelling and pain than tumescent liposuction.  Also, it claims to have found a way to tighten loose skin at the same time due to the heat generated just under the skin.  All this, however, has never been scientifically demonstrated in the eight years that this machine has been in the market.  In fact, the only unbiased scientific study done demonstrated no difference in results or downtime.  In fact, laser liposuction takes longer to perform and is more invasive, because it adds a heating element to the existing tumescent technique that is used.

Why do over 95 % of board-certified plastic surgeons avoid this device, especially when plastic surgeons are the most highly trained and prolific practitioners of liposuction?   First, laser liposuction melts and destroys the fat. This limits the surgeon’s ability to sculpt the fat and utilize living fat cells to shape the body. The more important reason that plastic surgeons avoid laser liposuction is the higher complication rates.  Over 40% of plastic surgeons in the U.S. have been referred people who have had Smartlipo that developed burns and widespread skin irregularities. The problem with using heat to treat a large area is that certain spots get hotter than others, and can result in damage to the overlying skin or surrounding muscle and nerves.  Cynosure has gone through over five different versions of the Smartlipo device since its inception. Each version has been aimed at decreasing this issue that continues to occur with the minimally trained doctors that are sold the product.  The prevalence of this problem has turned many plastic surgeons into revision specialists for laser liposuction deformities.  In most cases, plastic surgeons utilized tumescent liposuction and fat grafting to fix the problem.

Smartlipo’s claim that all procedures can be comfortably and safely done in the office without anesthesia is misleading.  A person’s comfort with Smartlipo is based on the ability of the physician to deliver a safe amount of local anesthetic to the area to be treated.  Like all medications, there is a safe maximum dose that cannot be exceeded.  If the area to be treated is large, the operating room is the only appropriate place to be regardless of what liposuction device is being used.

Ultrasonic Liposuction
Ultrasonic liposuction is another technology that utilizes ultrasound waves to rupture the fat cells so that it can be more easily removed.  I have used this technique and find that it helps in fibrous areas such as the flanks and outer thighs.  When used by a well-trained plastic surgeon, it makes fat removal more effective, but it does not allow the fat to be sculpted.  In addition, skin burns are a known complication as well as the formation of fluid collection under the skin called seromas.  Newer versions such as Tickle lipo and Vaserlipo continue to extend the reach of this technology.  I have found that Power-Assisted Liposuction utilizing the tumescent technique achieves the same ease of fat removal without the risk associated with sonic energy.

Even newer liposuction machines such as AirSculpt, made by a European company, combine infrasonic waves with laser waves. Once again, the FDA has no studies to prove their safety, but this procedure is already being offered in offices.

Non-invasive Cryolipolysis (Coolsculpt)
It is ironic that while one end of the marketing frenzy is touting the benefits of heating fat from within the body, another end of the spectrum is shouting loud and hard about freezing fat from the outside.  Since 2010, externally freezing fat has become a rising trend.  This is the basis of Coolsculpt, manufactured by Zeltiq.  Once again, this is a technology that was approved by the FDA with no third-party scientific data supporting its safety.

The hypothesis is that freezing fat externally induces fat cell death. The immune system then eats up the dead fat cells in a process called apoptosis and a slimming effect is gradually noticed over ensuing months.  The company claims the treatment is a painless office procedure that has no downtime and accomplishes results of standard tumescent liposuction with several treatments.  No scientific controlled studies have been performed to evaluate how much fat reduction is expected with this treatment.  However, individual case reports suggest 20 % fat reduction is expected per treatment cycle and that at least two treatment cycles are needed to obtain any noticeable result.  With this in mind, I performed treatments on several people.  All of them reported no change in appearance either immediately or after one year. More importantly, all complained that the procedure was painful for the entire hour that the machine was applied.  The numbness was present for three months after this procedure.

Based on the lack of scientific data and my own experience, I feel that Coolsculpt is probably ineffective at attaining the noticeable improvement my patients expect.  The procedure is not pain-free and the results are minimal at best.  A spot liposuction treatment in my office under local anesthetic would be quicker, less painful, and surpass the 20 % improvement that has been seen with Coolsculpt. The technology is in its infancy and needs to improve to be worth the cost.

How to decide what’s best
The list of new devices literally goes on and on.  After all, is said and done, the best advice is to not fall prey to seductive marketing and the allure of low-cost. Office-based procedures.  Avoid doctors who advertise themselves as “cosmetic surgeons” because they perform liposuction in their office, but in reality, they are trained in a totally different field of expertise. A board-certified plastic surgeon is recognized by the American government as a specialist that has an ethical duty to support safe practices in this field.  Find a board-certified plastic surgeon who is experienced in a particular liposuction technique.  Look at photos of their patients and not those provided by the company that sold the liposuction machine.  Finally, ask your surgeon if he has local hospital privileges to perform liposuction. These are practical guidelines that cut through the marketing hype and will lead you to make a safe and effective choice.

Here at Advanced Cosmetic and Plastic Surgery, we utilize the tumescent technique because it’s safe and effective. We extensively use power-assisted technology and fat grafting to sculpt the body. We regularly treat patients that have had insubstantial treatments using non-invasive procedures.  Moreover, we support and reconstruct patients that have had complications from other liposuction treatments done by unqualified practitioners.  Whether these procedures were done in other countries or in the Danbury area,  we can help.

Advanced Cosmetic & Plastic Surgery offers the newest and most sophisticated cosmetic surgery procedures for men and women, including neck and face lifts, eyelid surgery, rhinoplasty (nose surgery), liposuction, abdominoplasty (tummy tuck), breast augmentation, reduction or reconstruction, as well as Botox, Juvederm and other injectable fillers.  All procedures are done by ASC surgeons Dr. David Goldenberg, Dr. Sohel Islam, Dr. Prashant Soni, and Dr. Julia Toto.  ASC offices are located in the Fairfield County, CT towns of Danbury, New Milford, Norwalk, Ridgefield and Southbury.

– Dr. Prashant Soni


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