According to the recent statistics of the American Society of aesthetic plastic surgery, almost 500,000 patients had liposuction in the past year. It is the most common cosmetic operation performed on both men and women. Over the past 30 years, Dr. Sherman has been on the forefront of development of technology and teaching liposuction. He has performed several thousand procedures with liposuction, and with this experience will be able to address the areas of your concern and predict the results of the operation. Liposuction, also referred to as lipo, is not the answer for dieting, but rather addresses the areas that are out of proportion with the rest of your figure.
The modern era of liposuction plastic surgery started in 1980 when Swiss and French physicians first presented their techniques of “lipolysis.” Viewed from the current perspective, the description of their procedures was revolutionary, but primitive by today’s standards.
The techniques of liposuction, ultrasound or ultrasonic liposuction (UAL) and power assisted liposuction (PAL) are safe and consistently produce results that were not obtainable in the past. All aspects of the newer techniques have been analyzed to maximize patient safety during the lipo surgery: the metabolism of fats, the anesthesia, and the reproduction of standard techniques that afford the patient good results and maximize the patient safety and comfort.
It should be noted that there is no ideal method for liposuction. Almost on a monthly basis, a new “revolutionary” technique is introduced through popular magazines and television. Often the time needed to objectively analyze new instrumentation and publish these results in professional journals is years after the introduction of a “brilliant lipo” or other technique that professes to render all other methods obsolete. However, newer innovations have made the results more predictable and consistent. The most important factor in determining the result for a liposuction is the experience and knowledge of the surgeon involved. Good results are obtainable with almost any technique, and similarly poor results are equally obtainable with newer as yet, unproven techniques.
Ideally, the patient should have a stable weight for months before surgery. Patients with high BMIs (body mass index) should seek dietary consultation and weight management before lipo is entertained. If you desire, our office may help you to arrange this consultation.
In women, the most frequent areas of liposuction are the abdomen, outer thighs, inner thighs, and circumferential legs. Other areas include the hips, waist, and upper back rolls. In men, typically the “love handles” at the waist are treated as well as the breasts, and chest area to treat gynecomastia (enlarged breasts in men).
The amount of fat that may be removed varies from patient to patient. This is based on the height and weight of the patient, and the relative health of each patient. Massive amounts of fat should not be removed at one time; the “insult” to the patient is too much. Patient should be comfortable at all times, and the convalescence should be manageable and comfortable. The amount of fat that is removed during liposuction may range up to 5 or 6 liters. Occasionally, it is advantageous to stage liposuction, limiting the amount of fat to be removed at each operation rendering the procedure safer, and the convalescence easier.
This is a volume and contour procedure. This is not the surgical answer to diet management. As noted above, we often recommend that patients seek dietary counseling and support to ensure that the procedure results are not short-lived.
Tumescent fluid consisting of lidocaine, epinephrine mixed with saline is injected prior to the procedure starting. This minimizes pain and reduces the bruising.
Liposuction overview by John E. Sherman, MD, FACS New York Plastic Surgeon
Unless a medical condition prevents office based surgery, almost all liposuctions are performed in our fully accredited operating room facility. Depending upon the amount of fat removed, and the amount of sites that need to be performed, the operation takes between one and one and ½ hours. After the operation, the patient is returned to the recovery room and leaves the facility roughly 1 to 2 hours after surgery. A compressive garment is worn by the patient for approximately 4 or 5 days. Most of our patients discard the garment at this time, since it does not affect the end result.
The pain level from surgery has been described as a profound Charlie horse, or a number 2 on the pain scale. This is caused by the cannula touching the muscles below which results in pain equivalent to a very prolonged workout in the gym. This subsides after 24 to 48 hours. Most of our patients report returning to work within 3 to 5 days, depending on the amount of fat removed, and of course, their work description.
Depending upon the needs of the patient and the operation, the vast majority of our procedures are performed under intravenous sedation anesthesia. When multiple positions are necessary sometimes general anesthesia is necessary. Anesthesia is always performed by a highly experienced board-certified anesthesiologist.
The use of tumescent fluid was first described in 1980, and now is used throughout all of our procedures. It has become the most widely used method of anesthesia and infiltration for liposuction throughout plastic surgery.
This method describes the introduction of a dilute solution of lidocaine and epinephrine into the tissues prior to surgery to aid in the anesthesia, to minimize the amount of blood that is lost, and to aid in the production of a smoother result. It may also be combined with other forms of anesthesia: intravenous sedation, or general anesthesia. We routinely combine tumescence with intravenous anesthesia for our procedures.
The most common complication of this procedure is contour irregularities. Since Dr. Sherman has performed thousands of liposuctions, in his hands, this is very rare. However, the occasional touchup might be required at 4 or 5 months after the procedure. There is no charge for this revision, outside the cost of the anesthesiologist (if necessary) and operating room facility. The patient must maintain his or her preoperative weight before revision is performed. Of course, as in any surgical procedure there are the potential complications such as bleeding, medical complications, infection, and fat emboli. Dr. Sherman will discuss these complications with you, and the frequency in which they have occurred in his practice.
Liposuction for Men
The most commonly performed cosmetic procedure for men is lipo. The 2nd most popular procedure is the treatment of gynecomastia. If both of these procedures are added together, it represents about 40% of all cosmetic procedures performed for men. These numbers do not reflect the noninvasive fat removal that is used for smaller amounts of fat.
Approximately 30% of our patients are men. The introduction of ultrasound liposuction, (UAL) augmented with power liposuction (PAL) in this patient group has increased the effectiveness of the procedure. This is because the areas that are usually treated in men have dense fibrous fat compared to women. In the past, this has been difficult to treat. This is especially true for gynecomastia. The traditional liposuction for gynecomastia is not as effective. (See gynecomastia section below).
The most common site for liposuction in the male patient is the waist (love handles). This is followed by the abdomen and treatment to the breast for gynecomastia. Fat distribution may exist even if the patient is slender. This distribution of fat is inherited, and is not dependent on diet or exercise.
Ultrasound Assisted Liposuction:
Ultrasound liposuction (UAL) was first introduced in 1993 in Europe, and in 1995 in the United States. Dr. Sherman was one of the first practitioners using ultrasound liposuction, having used the procedure both in Europe and in the United States shortly after its introduction. He has taught the procedure in courses offered to other plastic surgeons, and has been featured on many television shows and print media.
The principle of ultrasound liposuction is similar to the mechanism of the ultrasound apparatus that the dental hygienist uses to remove plaque from your teeth. A sound wave is delivered through a probe that helps emulsify the fat in the surrounding tissue. In the hands of the experienced surgeon, the operation is easier to perform allowing better results to be achieved, and is predictable. In the male patient, the ultrasound helps break up dense breast tissue/fat with minimal effort. Ultrasound assisted liposuction is also especially useful in revision cases where patients have uneven contour. While some studies have shown that ultrasound assists skin contraction this has not been definitively proven.
Over the past decade, with the advent of power assisted liposuction and other modalities, it has allowed us to decrease the actual time of ultrasound use. This greatly diminishes swelling, and other potential complications.
At consultation Dr. Sherman will discuss the possible use of ultrasound, the predictable results, and of course, all potential complications.
Power Assisted Liposuction (PAL)
Power assisted liposuction augments other liposuction procedures. Dr. Sherman routinely uses PAL on almost all cases.
The moving cannula is similar to the motion of an electric toothbrush. The cannula moves rapidly with a short excursion. As with all modalities, the cannula is attached to the aspirator (vacuum pump). There is a small similarity to the ultrasound liposuction technique, in that the vibrating cannula enables the surgeon to remove the fat with less mechanical work and force. This enables us to perform the procedure more efficiently and enables us to obtain the best and smoothest result.
For most patients, Dr. Sherman combines power assisted liposuction with modest amounts of ultrasound assisted liposuction, followed by traditional feathering with manual cannula liposuction to achieve the best result.
The development of breasts in a male is known as gynecomastia. The correction of gynecomastia is the 2nd most commonly performed operation on men. This condition commonly occurs during pubescence in approximately 60 to 70% of healthy males between the ages of 12 and 15. In most patients, the gynecomastia disappears and is not treated. It is also common in the later years of life as the hormonal balance of the male changes. Any new development of gynecomastia should be investigated by an internist to rule out any underlying hormonal problems.
In some conditions, the gynecomastia may be treated medically without the need for surgery. If surgery is necessary, the most common approach is liposuction. Since gynecomastia represents production of excess breast tissue without redundant skin, removal of the excess breast tissue should result in skin retraction. In general, the younger the patient, the more skin retraction can ensue.
The second approach, which used to be standard before the advent of liposuction, is an open excision of breast tissue. If necessary, this is performed through a small incision around the areola (nipple area), separating the breast tissue from the skin and the underlying muscle. Breast tissue is then removed without difficulty. Occasionally, a small drain may be placed in this area which is then removed two or three days after surgery. Liposuction for gynecomastia usually takes less than one hour of surgery time. If an open approach is used, additional time is needed. Liposuction for gynecomastia is often combined with liposuction of the abdomen and the waist area. At consultation, Dr. Sherman will discuss the options for treatment, and explain each thoroughly. (Click here for more info).
Liposuction is individualized according to the needs of the patient. It is usually performed in our fully accredited office-based facility. If a hospital facility is desired by the patient, or if preexisting medical conditions warrant, Dr. Sherman operates at the New York Presbyterian Hospital-Weill Cornell Medical Center; Lenox Hill Hospital, and the Greenwich Hospital. Depending on the facility that you choose, the costs of each facility varies.
The operation usually takes one to two hours depending upon the amount of sites to be performed, and the amount of fat to be removed. The patient is then monitored in our recovery room and leaves our facility approximately one to two hours after surgery. If you live out of the New York area, it is best to spend the first night after surgery at one of our local hotels that we use for convalescence.
Liposuction may be performed under local anesthesia if there is an isolated area that needs to be addressed, such as the area of the neck below the chin. However, most of our patients undergo surgery with intravenous sedation anesthesia, a type of “twilight” sleep. We also use LMA anesthesia, where a soft tube is placed in the airway for protection. The patient is breathing without the assistance of the anesthesiologist, unaware of the procedure that is being performed. All our anesthesiologists are board-certified and highly experienced. Each has worked with Dr. Sherman over the years. We believe that the choice of anesthesiologist is as critical as the choice of plastic surgeon. Nurse anesthetists are never used.
The length of time that is needed for convalescence after liposuction depends on the amount of fat that is removed, and the reaction of each patient. Other factors include the general health of the patient and the elasticity of the skin. Most of our patients return to work in 3 to 5 days after the liposuction procedure. It may take up to two weeks to resume exercise and normal activity.
Patients are instructed to wear a compression garment for several days after the liposuction procedure. After this time, support garments such as exercise shorts may make you more comfortable, but it is not necessary, and has no bearing on the final result. Postoperative massage and ultrasound may also be useful. All of these are available through our office.
As in any operation, there are complications related to surgery, and in particular to liposuction. Generally, the risk of infection, bleeding and unsightly scars is minimal. The revision rate for these procedures is significantly under 5% of patients. In general, the larger the liposuction the more the possibility of revision exists. At the time of consultation, Dr. Sherman will address all potential complications and will tell you the incidence of each complication in his practice.
There is no insurance reimbursement for liposuction.