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What
is Cellulite?
Removal
of Cellulite
Liponic
Sculpturing
Liposuction
(Lipoplasty, Suction Lipectomy)
Good
Candidates for Liposuction
Liposuction
Techniques
Spot
Fat Reduction
Body
Weight and Liposuction
Tumescent
Liposuction
Ultrasonic-assisted
Liposuction - The Ne Plus Ultra
Liposuction
of the Arms, Calves and Ankles
Preparing
for Surgery
The
Surgical Procedure
After
Liposuction Surgery
Repeating
Liposuction
Liposuction
vs. "Tummy Tuck"
Abdominal
Etching
Safety
of Liposuction
Costs
of Liposuction
Fat
Transplantation
Body
Areas Benefited Most by Fat Transplantation
Performing
Fat Transplantation
Recovery
After Fat Transplantation
Finding
Dermatological Surgeons
Cellulite is the appearance of an unattractive dimpled skin or “dimpled fat” on or around the outer thighs, buttocks and other body areas where large areas of fat are found in close proximity to the skin. Women are more affected by cellulite formation than men, especially on the thighs, exemplified by the women in the John Paul Rubens painting above. Cellulite formations start in puberty in women as hormones change. Most women over age 18 have some degree of cellulite. In men, loose fat on the chest (pectoral) area and the thighs can resemble cellulite.
A person does not have to be overweight to develop this dimpled skin called cellulite and cellulite is not always reduced by weight loss.
The scientific theory of cellulite is that the skin's underlying supports called fibrous septae do not hold the skin together evenly and this uneven support causes the irregular bulging and dimples. The skin is tethered down by string-like tissues that pull it inward, toward the interior of the body. The tension of these strings pulls sections of fat in along with them. Cellulite has been compared to the dimples in a mattress that are caused by the strings that hold the “tucks” down.
Regular vigorous exercise is the best defense against the formation of cellulite.
Massage can be effective if performed very vigorously. But this technique may leave bruising until the person's body adapts to the massage. 10 to 20 sessions are needed to see results. Very soft fat - usually found in older persons - responds best to massage. But it is difficult to locate a masseuse who can rub vigorously enough to separate the fat from the "strings."
Ultrasonic cellulite treatments are often combined with massage and brushing of the skin. The treatments require 20 to 40 sessions, but is effective.
Liposuction can remove cellulite fat and the strings of tissue that pull the fat down by scraping under the surface of the skin to disconnect them from the fat. This works best in younger persons. However, in older persons liposuction may cause more dimpling of the skin.
Liponic Sculpturing is becoming very popular and uses machines with various types of rollers and vibrators. One new cellulite treatments that was developed in France is referred to as liponic sculpturing. This is a non-surgical technique which does not break the skin like liposuction. The procedure involves the use of a computer-controlled machine that moves over the skin to produce a rolling and sucking motion. This gradually improves the skin texture, improves the skin's appearance and removes the dimples.
Endermologie and Silhouette are two widely used liponic sculpturing cellulite-reducing
machines that are used alone or in conjunction with liposuction fat-removal.
Research has found that one to two sessions weekly gives the best results.
The sessions have been compared to having a message. For the treatment,
a person wears a special pantyhose to allow the apparatus to smoothly glide
over the skin. Costs for this type of cellulite treatment are about $65-75
per half hour session when signing up for 15 sessions but will vary greatly
from office to office. About five sessions are needed to see the
first results and about 15 treatments may be needed to eliminate the dimples.
The results last about one year but regular exercise reduces cellulite
reappearance.
Diagram of Endermologie
machine. Two rollers work on the skin while a vacuum (yellow hose) pulls
up the skin.
The second diagram
shows the two rollers with the vacuum pulling the skin up between the rollers.
Liposuction (Lipoplasty, Suction Lipectomy)
Liposuction is the removal of body fat by suction (liposuction). The liposuction procedure is the most common cosmetic surgery and has greatly improved since its introduction in 1979. The technique removes unwanted bulges created by excess localized fat deposits. The best results are obtained when fat is removed from the abdomen (sagging stomach), flanks, wide hips, upper outer thighs, buttocks, or facial deposits (jowls) and double chins. In men, liposuction is often used to correct gynecomastia (enlarged breasts). Some men use it to gain "washboard abs," the sculptured abdominal muscles preferred by body builders.
As we age, hormonal changes alter the patterns of fat deposition throughout the body. Even vigorous exercise cannot alter these patterns of fat deposition. In men, fat tissue accumulates in the abdomen (stomach) area while in women fat accumulates around the buttocks and thighs. In both sexes, there is a general downward movement of fat in the face which leads to fat accumulating under the eyes, on the sides of the face (jowls), and under the chin.
Liposuction helps improve the contours of the body by removing localized accumulations of fat. It is not an effective treatment for obesity. Localized fat accumulations are often inherited.
Good Candidates for Liposuction
The best candidates for liposuction are individuals who consistently exercise and are of relatively normal weight. The person should be psychologically stable, physically healthy, and have realistic expectations of results. A person with firm, elastic skin will have better final body contours than someone with loose hanging skin. The best candidates have excess fat in certain areas of their body that cannot be removed through either dieting or exercise or in medical terms "body contour in areas refractory to good exercise and nutritional regimens which is caused by dysmorphic deposition of subcutaneous fat". For example, this can be excess fat in the abdomen or the hips that exercise does not remove and where all alternative methods have been attempted to lose the unwanted, localized fat accumulation.
Patients can be slightly to moderately overweight and gain from the surgery, but obese persons are not considered good candidates. The technique is not a good method for weight loss. Age by itself is not a significant factor. The candidate should be in good general health without significant heart or lung problems.
A California survey of 8,000 liposuction patients found that satisfaction rate was about 90 percent. In 10 percent of cases, a second liposuction procedure was performed within six months.
Early methods of liposuction often required a lengthy hospital stay but today it is usually an outpatient procedure. Modern liposuction is a 2-to-5 hour procedure in an outpatient surgery center. Local anesthetic is used and there is little or no blood loss. Up to 10 liters of fat may be removed and skin incisions are now as small as one eighth of an inch in length. The is little or no scarring in most cases but there may be a mild and temporary bruising of the skin.
Liposuction surgery is essentially a true spot fat reducer that permanently removes fat from specific areas of the body such as the abdomen or the hips. Once puberty is reached, no new fat cells develop. The fat cells either swell or shrink in size depending upon weight gain or loss. When fat cells are removed from a treated area, they do not return. After the procedure, if a person gains a large amount of weight, then areas that were not treated, such as the such as arms, breasts, buttocks, face, or neck will become proportionately larger.
Total body weight is not influenced by liposuction. You can regain your original weight after any kind of liposuction. You have a set number of fat cells and if liposuction removes a portion of them, the remaining fat cells simply grow larger if you gain weight. The positive effect of liposuction is that there are fewer fat cells remaining in the areas that were liposuctioned. So the new weight will distribute itself more in balance with your new body contours.
Fat deposits are removed from underneath the skin by inserting long slim tubes called cannulas through tiny incisions in the skin. The thin suction cannulas have varying shapes and sizes of orifices for different body areas. The cannulas are carefully manipulated through the fat deposits and a suction machine removes the fat, somewhat like a vacuum cleaner. Liposuction results are permanent. There are tiny scars left after the surgery which fade with healing.
Liposuction is performed painlessly under local anesthesia with the patient is awake. Most patients receive a tranquilizer prior to the surgery, and some patients choose to use pain reducing or tranquilizing drugs. If a large amount of fat is to be removed, the procedure may be performed under general anesthesia and the person may remain in the hospital for reasons of safety. After the procedure, the incisions are bandaged.
The removal of fat tissue from under the skin results in a separation of the skin and it's underlying tissue. As part of the healing process, the skin must re-form the attachments to these tissues. To help hold the skin in place during the healing and reattachment process, special elastic garments are worn. They also help to minimize the swelling and discoloration in the treated areas. The discoloration will subside in a few days, but the swelling may persist for several weeks.
The most common problem after liposuction is a waviness of skin which results from irregular fat removal. Exercise or/or cellulite treatments are then used to smooth the skin surface.
The earliest stage of liposuction was first developed in Europe in the mid-1970s. In 1987, the procedure was revolutionized by a dermatologic surgeon, Jeffrey Klein, of San Juan Capistrano, California. His technique of tumescent liposuction allowed liposuction to be performed using only local anesthetics and vasoconstrictors. This procedure markedly reduced blood loss and bruising when compared to previous methods. Since Dr. Klein’s surgical breakthrough many further refinements in tumescent liposuction have made the procedure safer and cosmetically more successful.
The word “tumescent” means that the tissue is greatly swollen and expanded. The technique infuses a special solution into the fat tissue prior to removal. The solution expands the fat tissue and makes its removal easier. The solution contains lidocaine, a local anesthetic, to eliminate pain in combination with the drug epinephrine, which temporarily shrinks capillaries to reduce bleeding. Recently, many surgeons have been adding a small amount of triamcinolone (10 mg), a hydrocortisone-like anti-inflammatory medication, to each liter of solution and this has resulted in a marked decrease in postoperative soreness.
This procedure is so effective that liposuction patients no longer need intravenous sedatives, narcotic analgesics, or general anesthesia. Postoperative discomfort is minimized since the local anesthesia remains in the surgically treated areas for approximately 18 hours after surgery. Patients usually require nothing more than plain Tylenol for discomfort after surgery.
Dr. Klein has emphasized the safety of his approach which minimizes risk and optimizes patient comfort. He says there have been no deaths associated with his version of tumescent liposuction. He is of the opinion that the greatest risk in liposuction techniques is the use of anesthetics, which his technique minimizes.
Another advantages of tumescent liposuction is the reduced cost by having
the procedure done in the office setting rather a hospital or outpatient
surgery center. There is usually less bruising, swelling, pain and post
anesthetic complications such as nausea than occurs with traditional liposuction.
Ultrasound-assisted liposuction (UAL) when combined with tumescent techniques is the most advanced form of liposuction. This approach has been practiced in Europe and South America for a number of years. The suction cannula emits high-frequency sound waves that liquefies fat cells but leaves the surrounding structures, such as blood vessels and connective tissues, apparently undamaged. Ultrasonic liposuction reduces tissue and blood loss while allowing large amounts of fat to be removed smoothly. Some surgeons state that, unlike traditional liposuction, ultrasonic liposuction actually stimulates skin tightening.
Dr. Rod J. Rohrich, chairman of the University of Texas Southwestern Department of Plastic Surgery, expects the new method to become the preferred method for performing liposuction in parts of the body that are difficult when using traditional liposuction. These difficult areas are the back, flanks and large breasts in males affected with gynecomastia. He also says that ultrasound liposuction can be used to resculpt body areas where previous liposuction wasn't completely satisfactory such as the abdomen, the back and the "love handle" areas of the hips.
During ultrasound liposuction, a tumescent fluid is first inserted in the fatty deposits, then the ultrasound cannula is carefully guided through the fatty deposits. Ultrasonic energy causes fat cells to vibrate, break from their cellular attachments, burst and liquefy. The liquefied fat and the tumescent fluid are then drawn out by low-pressure suction. Ultrasound liposuction reduces the effort needed to remove fat and results in a gentler surgical procedure with less loss of blood, less bruising and less pain.
UAL allows relatively large volumes of fat removal with little blood loss and minimal postoperative bruising. Rohrich said about 26 pounds of fat can be removed safely in one ultrasonic session. He cautions that the new technique be performed by “a properly trained plastic surgeon" .
Liposuction of the Arms, Calves and Ankles
Liposuction experts once advised against fat removal from the extremities such as the arms, calves, and ankles. The improvements in the procedures have revived the use of liposuction in appropriately selected patients.
Patrick J. Lillis, M.D., a dermatologic surgeon in Loveland, Colorado, and the author of numerous textbooks on liposuction surgery, wrote in the journal Dermatologic Surgery (December 1997) that the goal of tumescent liposuction of the upper arms should be the removal of fat as thoroughly as possible but to take great care to avoid trauma to the underside of the dermis. This approach results in a dramatic contraction of the skin and often eliminates the need for skin excision (brachioplasty) to remove excess skin.
Fat around the calves and ankles is usually obvious by early adolescence. Liposuction of the calves and ankles is more difficult than the arms because of the irregular contours of this region. Yet, when performed carefully on selected patients, the removal of fat from the calves and ankles produces significant cosmetic improvements. After such procedures, the patient elevates their legs for at least three days after treatment and wears elastic compression garments for several days.
Physicians performing liposuction will emphasize performing exercise and dietary control before the procedure. If you are using aspirin or other blood thinners (anti-coagulants) or large doses of Vitamin E, you will be asked to discontinue their use for a week before your surgery.
The result gained from liposuction depends on your previous body size and contour. Women usually lose one to three dress sizes if the abdomen, buttocks, and hips are treated.
When you arrive for surgery, you may be given a tranquilizer such as Valium®, and may be injected with anti-pain medications such as Demerol®. You will lie on the table and have the unwanted fat deposits filled with the "tumescent solution" of sterile salt water, adrenaline and anesthetic. If you are having large volumes of fat removed, you may given intravenous fluids.
In about 20 minutes, after the local anesthetic has taken effect, very small openings are made in the skin where the fat is to be removed. A thin tube, the cannula with the diameter of a cocktail straw, is inserted through these openings into the fat which is sucked out. The procedure is virtually painless and can take from 30 minutes to five hours, depending on the amount of fat removed. The average liposuction procedure removes two to six quarts of fat.
During the procedure, some patients are awake and others sleep. In some offices you can bring in a VCR movie to watch on television. After finishing, the incisions are dressed with healing foam pads. You will wear an elastic compression undergarment to hold the skin in place for proper healing. After three or four days, you can resume most normal activities, although strenuous exercise and heavy lifting should be avoided for five weeks. For bathing in a shower, the elastic garment is removed and you shower with the foam pads in place. Afterward dry the pads with a hair dryer on a cool setting. The elastic body garment should be put back on.
During the first one to three days after liposuction, there is some drainage from the incision sites. This is some excess tumescent solution leaking out, plus a small amount of blood (average total blood loss is two to three tablespoons or about one-tenth of what you would give in a blood donation). Drainage usually stops by the third to the seventh day, depending on volume of fat was removed. Most people find sensations arising after surgery as more of a discomfort rather than actual pain. Some say the area feels like a deep bruise.
After five days, the foam pads and the elastic garment are removed after about two weeks. Your body will be swollen, but this vanishes over about two months as your skin adjusts to is new contour. The suctioned area will shrink over the next few months as healing continues. Where skin covered a large deposit of fat, it may appear somewhat wrinkled but it shrinks into place. Skin usually has enough elasticity to shrink and readjust to new body contour. Regular exercise helps tighten the skin.
At times, liposuction treatments leave a somewhat uneven skin. In these cases, the cellulite removal machines are often used after liposuction to improve healing and smooth the skin.
There is a maximum amount of fat that can be extracted during any one operation. At times further liposuction is used to finish a procedure but this is usually at least three months later.
The “tummy tuck” procedure is one way to improve sagging "pot bellies." This surgical procedure is now often replaced by liposuction alone. If properly done, liposuction combined with exercise shrinks the skin and improves lower abdomen shape. While the changes may not be as dramatic as a “tummy tuck”, this can be more than adequate.
Some surgeons use liposuction techniques on male patients to produce “abdominal etching”, a new liposuction technique that creates a muscular, rippled appearance in the abdominal area. In recent years, plastic surgeons have developed ways of improving muscle contour with cosmetic implants and "sculpting" techniques.
Calf implants that were originally developed to restore leg contour in accident or polio victims, are now sometimes used with liposuction and fat transplants to create cosmetic fullness in the lower leg. Similarly, pectoral implants and liposuction, which were developed to build the chests of men with Poland's syndrome, are used to "bulk out" the pectoral muscles of healthy men.
Liposuction surgery has been shown to be a very safe procedure with very few complications. The tumescent procedures are one of the safest surgical procedures. Serious complications, such as blood clots and infections, and allergic reactions are extremely rare. Most of the dangers associated with surgery are related to the type of anesthesia that is used.
Costs for liposuction surgery vary with doctors and locations. Having a procedure performed under local anesthesia markedly decreases the costs of liposuction. Charges run between $1,500 to $3,000 per area treated. An example of such an area would be the lower abdomen or the outer thighs. Both thighs could run $3,000 while removal of fat from under the chin would cost about $1,500.
Fat transplantation is the removal of fat from one part of the body, such as during liposuction, and injected into other areas of the body such as the breasts, buttocks, cheeks, face, calves, lips, pectorals and even the penis. Historically, fat transplants have been used for thirty years, but the number of transplants has soared in the last five. The procedure is very safe and there are almost no side effects.
Fat transplantation is improving as techniques are being refined. Until recently, the problem with fat transplants was the results were frequently unpredictable because there was no way to predict how much of the newly placed fat would be retained. In some studies, fat was chemically labeled, then injected and checked years later. It was found that retention varied widely from one patient to the next. Different surgeons had varying results because their techniques of fat harvesting and fat injection were different. Some patients would retain 100 percent of the fat while others retain none of the fat.
Sydney Coleman, a physician from New York City, pioneered successful and permanent fat transplanting techniques in the 1980’s. He developed special instruments and used low-vacuum suctions to treat the harvested fat very gently. Additionally, he spread the fat carefully into the transplanted area somewhat like butter. His careful methods are very time consuming, but produce excellent results.
Body Areas Benefited Most by Fat Transplantation
Lips and cheeks are the most popular sites for fat transplantation. As we age, the face loses its fullness. The fat under the skin, the "foundation" (subcutaneous fatty layer) of the face shrinks, resulting in an more hollow looking face and wrinkles around the mouth. Careful "reverse sculpting" can add up to 8 ounces of fat to create the higher cheekbones, heavier lips and fuller foreheads we had in our youth. This also smoothes facial contours.
An older approach used for facial changes was to put plastic "implants" in cheekbones and chins, but as the patients aged and the subcutaneous fat was reduced, implants became more prominent, and unbalanced the contour of the face.
Good candidates for transplantation of fat into the breasts are post-nursing women who's lost some the lactation-associated enlargement of the breast and whose skin is slightly sagging, but are not wishing for breast implants or breast reduction. A fat transplant can refill the breast and may restore or improve its original shape. But fat transplants will not produce the same size breast obtained with artificial implants.
Fat injection into the breast softens and slightly changes the interior structure of the breast. “Calcification" may occur and show up on a mammogram. This happens to any soft tissue that is surgically manipulated, and even after some bruises. However, calcification can also occur with breast cancer, and may confuse a physician analyzing a mammogram. However, radiologists specialize in reading X-rays and can differentiate fat transplant effects from cancer. There is no known risk of fat injection into breasts.
Pectoral muscles in men, often competitive body builders, are implanted with fat to increase the size of the pectoral muscles or calf muscles. This procedure is one of the more successful since fat stays inside muscle tissue very well.
Buttocks retain transplanted fat very well but the buttocks require a very large amount of injected fat to change the body contour.
Penis enlargements often use fat transplants during penis enlargement and lengthening procedures. Lengthening is accomplished by cutting a connecting ligament from the penis to the pubic bone when erect. This increases length about one-half to one inch. Fat then is injected under the skin of the penis to add thickness. The procedure takes about 30 minutes but the transplanted fat may be somewhat irregular.
Performing Fat Transplantation
The patient is prepared for tumescent liposuction as described above. However, instead of using a standard liposuction cannula, a special new cannula handles the flow of fat more gently. The cannula is attached to a syringe which is used to create a more mild vacuum than used with normal liposuction. The fat is removed from an area of excessive fat and handled with great care to keep the cells intact and to not disturb the cell structure. Uninjured cells are better retained by the body at their sites in implantation. The fat cells are extracted along with quantities of the tumescent solution. The liquid is removed after centrifugation separates the fat cells from the solution. This harvested fat is then injected into the recipient area with Dr. Coleman's very small, specially designed blunt cannula. Very small amounts of fat are injected into different levels under the skin at a rate of few drops at a time. This is a slow process that takes several hours.
The weight of fat injected into each facial area, when treating the face, is precisely measured to preserve the natural symmetry of the face. Often the fat transplant is immediately followed by a laser resurfacing procedure to tighten the surface skin.
Recovery After Fat Transplantation
Fat implantation is usually done in conjunction with other procedures such as liposuction and laser peeling and the recovery is similar to that for liposuction. Foam pads and elastic compression dressings are fitted over the injected areas. On those that have been both laser treated and fat-enhanced, recovery will be similar to a skin peel but there will be more swelling of the fat injections.
For breasts that received a fat transplantation, a special bra is worn for two to three weeks to allow the fat to stay in place. Another rigid cover is used for penis transplants. The swelling lasts about three weeks.
Sometimes a hyperbaric chamber, in which the air pressure is greatly increased to drive more oxygen into the skin, is used to speed healing and improve the retention of transplanted fat.
Finding Dermatological Surgeons
The American Society for Dermatologic Surgery (ASDS) was formed in 1970 to promote excellence in dermatologic surgery and to foster high standards of patient care. To obtain a referral list of dermatological surgeons in your specific geographic area, call the ASDS consumer hot line, (800) 441-2737, or visit its website at www.asds-net.org.
American Society of Plastic and Reconstructive Surgeons, 444 East Algonquin Road, Arlington Heights, Illinois 60005-4664, 847-228-9900 is another source of surgeons in your area.