Theresa gained 75 pounds during her pregnancy. Three years later, she has lost 60 of them. With a body mass index of 27, she is slightly overweight. But her frustration is immense: When shopping for clothes, she has a four-size discrepancy between shirts and pants. Unable to spot reduce her hips and thighs, Theresa consulted a plastic surgeon and now asks you, the only nurse she knows personally, what you can advise about the liposuction procedure suggested for her problem areas. She saw a television report about some recent deaths after liposuction, and she is concerned. What do you tell her?

Albert, a healthy 19-year-old athlete troubled with enlarged breasts (gynecomastia) since age 16, is scheduled to undergo ultrasound-assisted liposuction (UAL) to remove excess breast tissue. Albert’s sister, Mary, wonders if she could also have the procedure to reduce her large breasts, which are a constant source of back and shoulder pain. Both Albert and Mary question you about this procedure. Would you be able to answer their questions or direct them to a valid source of information?

Liposuction, also known as lipoplasty or liposculpture, is the second most frequently performed cosmetic surgical procedure for both genders in the U.S. Only female breast augmentation and male nasal reconstruction were performed more frequently.¹ More often performed on young women, the demand is increasing among men and older people,¹ dispelling the notion that plastic surgery is only for the rich and famous. This growing popularity has fueled a need for nurses to fill extensive roles in pre-, intra-, and postoperative care of people having liposuction procedures in both inpatient and office settings. Their responsibilities include preoperative education, calculation of removed fat volumes, lengthy postoperative monitoring, and postoperative education to reduce complications and enhance favorable outcomes.

Women typically have more body fat than men and a greater proportion of subcutaneous fat.² This biological fact, combined with media images glorifying thinness, contributes to the predominance of women seeking liposuction. Reasons reported for seeking liposuction include dissatisfaction or embarrassment with appearance, loss of self-confidence, and physical discomfort caused by excess weight in specific areas. One study of 52,677 heterosexual men and women aged 18 to 65 years revealed that individuals specifically interested in having liposuction procedures tended to have poorer body image, and interest in liposuction was greater among heavier individuals. They were also more likely to report higher body mass index (BMI).³

People with a higher BMI and those who feel they are too heavy are more likely to express an interest in liposuction than those who are satisfied with their weight. This may indicate a belief that liposuction is for weight loss rather than body contouring.⁴

Body image modification can have positive psychological benefits and improve a patient’s self-esteem and perception of overall appearance.⁵ Patients report greater confidence and a sense of greater comfort in clothes.⁵ Although self-confidence, satisfaction with appearance, and psychological well-being may improve, cosmetic surgery cannot be expected to significantly change the way others view or treat a person.

Unrealistic expectations should be explored before surgery is performed. Some individuals seeking liposuction, especially repeated procedures, may have a psychiatric condition — body dysmorphic disorder — an obsessive or exaggerated preoccupation with body image when a defect is absent or is barely noticeable.⁶

Evolution of liposuction techniques

In 1964, the first fat-removal procedure was done by blunt curette dissection. Liposuction was first introduced in the U.S. in 1982. The initial technique, known as suction-assisted lipectomy (SAL), involved little or no fluid injected to facilitate fat cell removal. Blood loss was significant, and only limited fat volumes were removed. In the early 1990s, new fat-removal approaches emerged. These superwet and tumescent techniques, involving infusion of large volumes of fluid to facilitate fat removal, produced less ecchymosis, fewer complications, and shorter recovery times than dry SAL.⁷ Complications resulting from hypovolemic blood loss associated with blunt dissection and dry SAL became less common, although these newer techniques with injected fluid increase the risk of fluid overload.⁷

Liposuction procedures today remove an aspirate containing fat cells, injected fluid, and blood, rather than pure fat. The volume of fat removed classifies the procedure for example, small or low (less than 1,500 mL to 3,500 mL), moderate or intermediate (3,500 mL to 7,000 mL), large (7,000 mL to 12,000 mL), or mega volume (more than 12,000 mL).7 The injected fluid, known as the tumescent irrigation, is typically mixed as individual bags of 1,000 mL of Normal Saline or Ringer’s Lactate with small amounts of lidocaine (25 mL to 50 mL of a 1% solution) to anesthetize,⁸ and epinephrine (1 mL of a 1:1,000 solution) to promote blood vessel constriction and reduce blood loss.⁹ Total blood loss represents 1% to 10% of suctioned volume. However, true blood loss is difficult to estimate because most of it occurs in the tissues postoperatively.⁸ Mild anemia, rarely requiring transfusion, is common after liposuction. Warming the tumescent irrigation fluid before infiltration is an alternative technique practiced by some surgeons that has been found to promote greater patient comfort and result in more stable intraoperative vital signs.¹⁰

During the infusion phase, with the superwet technique, 1 mL of solution is injected for every mL of fat to be removed. With the tumescent technique, 3 mL of solution is injected with the use of a pressurized infusion bag for every 1 mL of fat to be removed. The infusion of large volumes underscores why meticulous attention to intake and output observation is crucial. After infusion, an evacuation or suction phase follows. The tumescent technique has been shown to result in less lymphatic vessel injury, also important in postoperative tissue fluid balance restoration.¹¹

By infusing fluid and suctioning fat cells, the physician creates a hollow space, or cavitation. Prolonged external pressure compresses the cavitated tissues. Adequate, even cavitation combined with postprocedural compression produces more evenly contoured areas with less rippling and dimpling, stimulating the skin to “shrink down” and conform to a new shape. However, the patient’s age, hydration, nutritional status, and the area from which fat was removed also influence the final appearance.

UAL

In 1996, tips that transmit ultrasound waves were added to liposuction cannulas in the U.S. Many tips used for internal UAL vibrate as well. Ultrasound energy is applied from one to seven minutes, depending on the size of the treated area, to liquefy (emulsification) and explode the solid fat cells. Liquefaction during UAL makes it easier to suction large volumes of fat. The surgeon can work closer to the underside of the skin and concentrate on specific areas for more precise contouring. Thick, round cannulas are typically used in the deepest layer of fat tissues to create smoother surfaces over the suctioned areas. Thinner, flatter cannulas are used with smaller pockets of fat closer to the skin surface in places like the neck or knee area.

The procedure is quicker with less blood loss than wet SAL. Assuming the surgeon is skilled in UAL, the injected fluid infiltrates and better disburses the ultrasound energy, resulting in more efficient cavitation, better results, and less skin damage.¹²

While the use of large fluid volumes for SAL are optional, UAL must use large volumes of wetting solution to produce fat emulsification by ultrasound energy. The cavitation process in UAL is up to 1,000 times more efficient in a wet environment. Larger incisions are required for internal UAL to allow the insertion of a shield to protect skin from burns during cannula insertion and removal. UAL is better for secondary liposuction of sites that have had liposuction before or those with fibrous tissues, such as over the epigastrium, the back, the flanks, and the male breasts. However, during UAL, fat cannot be harvested and recycled for reinjection like fat removed during SAL.¹²

When fat harvesting is the goal, newer T-shaped cannula tips are available which cause less trauma to fat cells and facilitate a greater percentage of harvested usable cells. Cannulas with rotating blade tips are also used when fat cell salvage is not a priority.⁷

Patients who have UAL of the abdomen can expect to have surgical drains in place, an uncommon practice with SAL.⁷

Different intensities of suction are required to remove fat during each technique. The force of suction required for SAL is high because the cells being removed are nearly all intact, while the force of suction required for UAL is much lower because the cells have already been liquefied, exploded, and reduced to smaller particles with ultrasound energy.¹²

Laser liposuction

Lasers can be used for liposuction both with and without wetting solutions. Studies indicate that when the laser technique is used, a larger percentage of fat can be liquefied with surrounding interstitial tissues and capillaries remaining intact.¹³,¹⁴ One area that shows especially favorable outcomes is the neck. The laser technique causes the rupture of fat cells, collagen coagulation, and coagulation of small blood vessels resulting in less blood loss and bruising. The skin covering areas treated by laser liposuction appears to retract better than with other techniques.¹⁵

Power prevails

A new technique, power liposuction, has emerged as a significant advance in the evolution of the liposuction procedure. The procedure, which uses a powerized canula that moves back and forth within the tissue, requires less force to remove unwanted fat. This is especially helpful when liposuction must be performed in fibrous areas.¹⁶

The technique not only increases the precision of the procedure, but also allows for a faster, less painful recovery for the patient. One study revealed that after four days, 87% of the patients who underwent power liposuction were completely pain-free, compared with only 3.6% of those treated with traditional liposuction.¹⁷

The power technique is also less of a strain on the surgeon. Because the surgeon uses less physical force to manipulate the canula, and no heat is generated during the procedure, power liposuction is less traumatic to tissues and results in less eccymosis than traditional techniques. The complications with power liposuction are less than those seen with traditional liposuction performed under local tumescent anesthesia. Because it is performed under local anesthesia, power liposuction allows for fine-tuning of the body contours with the patient in the standing position, reducing the number of postoperative touch-ups.¹⁶

Targeting problem areas

Typically treated areas are the abdomen, waist, back, posterior hips, buttocks, and thighs. The chin, underarms, knees, and ankles are less often treated. The body area most often chosen for liposuction is the abdomen (61%). Patient education and expectations prior to surgery are important to patient satisfaction with the results of the procedure, regardless of the areas targeted.¹⁸

Aside from cosmetic reasons for liposuction, fat can be removed from one area and injected into another as a means to correct deformities, fill scars, or maintain symmetry. The best graft survival rate occurs with fat harvested from the deepest layers of the donor site.¹⁹ Injected fat has also been used for other elective cosmetic procedures, such as enhancing the diameter of the penis.

Because fat cells appear to have properties similar to stem cells, other investigational uses for harvested fat cells include injecting them into the urethra and the bladder neck as a treatment for urinary stress incontinence20 and injection to promote bone healing after trauma, fracture, osteomyelitis, and tumor resection.²¹

UAL has emerged in the U.S. as a valuable tool for treating gynecomastia, a common finding in up to 50% of healthy men.²² UAL is preferred over SAL because when properly performed, it “teases out” fat, leaving men’s fibrous connective breast tissue intact.²³ Although performed often in other countries, this technique is less frequently performed in the U.S. for breast reduction in women because of uncertain implications for increasing an already existing one in eight lifetime risk for breast cancer.²⁴ However, research has yet to determine a link between liposuction techniques and subsequent tissue scarring and the incidence of breast cancer. One possibility is that tissue cavitation may produce cancer-causing free radicals, but to date there is conflicting research evidence.²⁵ The use of a combination of surgical excision and liposuction through a periareolar incision is often the surgical approach of choice, however, it does leave considerably more visible scarring than with techniques using canulas only.²² One study of 117 women having liposuction breast reduction did reveal positive benefits including an average loss of 1.9 bra cup sizes and an average return to work time of just four to eight days. Only two complications were reported by the women — one experienced a hematoma and another developed cellulitis.²⁶

Two long-term studies have evaluated the safety of fat injection to enlarge women’s breasts.²⁷,²⁸ One 10-year study of 37 women receiving fat injections to improve breast contour deformities after breast reconstruction following cancer revealed a low risk of complications, just 8.5%, consisting of cellulitis and superficial nonmalignant lumps. Overall, the women were very satisfied with their procedures and recoveries.²⁷ A two-year study also revealed a reduction in expenses, complications, and scars as well as fast recovery.²⁸

Liposuction is usually performed for contouring, not weight loss. A two-pound weight loss is expected for each liter of fat removed, much less than anticipated by most patients. With large-volume liposuction (LVL), patients can expect a reduction of one to two sizes in clothing; however, skin quality usually does not improve. Areas with cellulite, preoperative stretch marks, or sagging skin typically do not improve. Patients need to understand that secondary surgical procedures, such as lifts or skin excisions, may be required to achieve desired cosmetic effects. Interestingly, when liposuction is performed, especially when large fat volumes are removed, some women actually report changes in the postoperative pattern in which they gain weight, sometimes with an enlargement of the breasts.²⁹

Evidenced-based guidelines for patient selection, liposuction techniques, and care recommendations³⁰ can be reviewed at www.guideline.gov/summary/summary.aspxdoc_id=6563&nbr=004125&string=liposuction.

Benefits beyond aesthetics

Liposuction has recently emerged as a corrective procedure for inappropriate fat distribution among individuals with HIV/AIDS. HIV-1/highly active antiretroviral therapy-associated lipodystrophy syndrome is a stigmatizing and often psychologically devastating treatment consequence that may ultimately impact medication adherance. UAL has proven very effective for correcting cervical fat pad hypertrophy and facilitating fat transfer to areas that have sunken.³¹

Large-volume and small-volume liposuction procedures have been clinically shown to improve insulin sensitivity in obese patients and in turn reduce their risk of developing type-2 diabetes. Liposuction appears to disrupt the pathway that brings about insulin insensitivity in the obese patient. Ongoing research studies are exploring the effectiveness of using liposuction in the overall treatment of obesity and to improve insulin sensitivity.³²

Where to go

Because any physician can legally perform liposuction, patients should be careful to inquire about experience and proficiency when selecting a practitioner. Many plastic surgeons provide complimentary evaluation visits during which questions should be asked, outcome data evaluated, and when possible, photographs reviewed. Liposuction and contouring depend not only on selection of the appropriate technique and correct equipment, but also on the surgeon’s skills.

Small-volume liposuction is usually performed in offices under local anesthetic or IV sedation.⁷ Tumescent, superwet, and UAL procedures can be performed in office settings because of the reduced blood loss and intraoperative complications. However, large-volume or mega volume liposuction requires general anesthesia and airway management by an anesthesiologist or nurse anesthetist, sometimes in office settings, but more commonly in an outpatient surgical or hospital setting.⁷

Liposuction is often performed in conjunction with other cosmetic procedures, such as breast augmentation, face lift, or abdominoplasty (tummy tuck), depending on the length of time required for each and the risk of contamination.³³ Overnight stays are rarely required for liposuction, unless LVL is performed or inpatient monitoring is required because of secondary procedures. The risk of intra- or postoperative complications is no greater with procedures performed by experienced professionals in outpatient or office settings than in traditional inpatient surgical facilities when adequate preoperative screening is done. Surgical centers have actually been shown to be safer and have more favorable outcomes for liposuction procedures than hospital operating rooms.³⁴ The overall complication rate for liposuction procedures is 3%.³⁵

What can go wrong?

The Institute for Quality Improvement conducted a study among 23 organizations that compile information related to liposuction outcomes. The results of the study showed a low complication rate of 6%. The low complication rate was attributed to the surgeon’s adherence to published guidelines for liposuction regarding fat extraction, fluid infusion, lidocaine dosing, and epinephrine dosing.¹⁸

Beyond commonly expected pain, bleeding, and bruising, several complications — some potentially life-threatening — are associated with liposuction, even under the most careful circumstances.³⁶ Many can be minimized with careful patient selection and screening.³⁴

Physiological changes in fluid balance after liposuction are not unlike those seen in burn patients.⁸ Fluid injected into tissues during liposuction can disturb ionic balance, increase circulating volume, reduce levels of antidiuretic hormone (ADH), and produce diuresis as the body tries to maintain fluid balance. Prolonged, uncompensated increases of osmotic fluid pressure in the tissues cause edema and dilution of plasma proteins, ultimately increasing plasma volume and central venous pressure and causing pulmonary edema. Other factors, such as hypothyroidism or an inappropriate secretion of antidiuretic hormone (SIADH), may hinder the body’s ability to excrete large volumes of fluid delivered during surgery, further increasing the risk for postoperative complications. SIADH is a syndrome where the extracellular fluid volume increases (i.e., third spacing) as a result of ADH-impeded diuresis.⁸

LVL involves an even greater risk of complication than when smaller volumes are removed.³⁰ In fact, the American Society of Plastic Surgeons has recommended that patients having LVL be monitored for at least the first 24 hours after the procedure. These patients require intense preoperative education and postoperative monitoring to minimize complications and risks. However, even removal of small volumes in smaller individuals can produce severe hemodynamic changes.⁸

Removal of more than 4 L of fat at one time is potentially hazardous, placing patients at greater risk for hypotension, cardiac dysrhythmia, and fluid overload. Diuretics are sometimes used to prevent fluid overload with LVL. Epinephrine-containing wetting solutions themselves can create circulatory problems. Although the epinephrine blood level peaks in three hours, effects are still present about 12 hours after infusion. Large volumes of epinephrine-containing solution can increase cardiovascular workload and diminish circulation, delaying postoperative healing.⁹

Although only small amounts of lidocaine are used in most procedures, large amounts of wetting solution can allow toxic amounts of lidocaine to enter the bloodstream and cause adverse reactions.³⁶ The injected lidocaine content may be as high as 55 mg/kg of the patient’s body weight. High blood levels increase the risk of seizure and suppressed cardiac function for as long as 24 hours after injection.³⁷ Many commonly prescribed medications can increase the risk of lidocaine toxicity.

Immobilization and postoperative sedentary behavior can contribute to the development of deep vein thrombosis (DVT) and pulmonary emboli. In fact, patients with a history of DVT need careful monitoring and sometimes anticoagulation therapy,³⁸ and intraoperative pneumatic leg compression. Less often, emboli may be directly related to reinjected fat entering the venous circulation.³⁶ Fat can also be inadvertently injected into nerves or arteries of the face during facial procedures, causing sensory or motor loss, paresis, paresthesias, vision loss, cerebral artery embolism, and aphasia.³⁶ Symptoms of fat emboli include fever, shortness of breath, and confusion; they usually occur within 24 to 72 hours postoperatively.³⁶

Nerve damage can come from the forceful insertion of a cannula, particularly in the arms and legs, or when UAL is performed. Ultrasound energy at high amplitudes can damage peripheral nerve tissue. This damage, expressed as increased sensitivity to sensory stimuli, usually lasts only a short time, and sensation returns to near-complete or normal function.

Seroma, a collection of serous fluid that resembles a tumor, occurs most often with LVL in the abdominal area.³⁹ Seromas are associated more with UAL than SAL because free fatty acids released by emulsification cause irritation and inflammation of tissue.³⁹ These are typically treated by needle aspiration. Full thickness skin necrosis has also occurred, raising concerns about the thermal and dermal ischemic effects of UAL.³⁹

Although it is difficult to maintain sterility in the operative areas during prolonged procedures, the infection rate is low. Puncture sites are used for multiple insertions, patients are repositioned several times, and the skin is never completely sterilized.

Cannula insertion points are often camouflaged at skin folds such as below the buttocks, in the umbilicus, and under the axilla — areas considered to be particularly contaminated. Prophylactic antibiotic therapy is typically administered for this reason. The most common invading organism is Staphylococcus aureus, and case reports of necrotizing fasciitis and toxic shock syndrome have also been reported.³⁶

Liposuction complications can be minimized if —

• Liposuction is performed on localized fat deposits.
• A patient’s weight is not greater than 20% of his or her ideal weight.
• Normal daily activities are encouraged immediately postop.
• A compression garment (girdle) is worn from two to six weeks postop.³⁶
• Aerobic or strenuous exercise is avoided for the first two to three weeks after surgery.

Nurses’ involvement

When caring for patients having liposuction, nonjudgmental care is primary. Some nurses may have difficulty caring for those choosing elective procedures to change their appearance. And because they are usually healthy young people, these patients may be viewed inappropriately as being at low risk for complications.

When counseling people considering liposuction, obtain clear and detailed information to identify risks and insist on a complete history and physical. Nurses often spend a great deal of time with patients and form therapeutic relationships in which patients feel comfortable disclosing information, including use of medicines for psychological problems, use of alternative or complementary remedies, psychological concerns or fears, and postoperative expectations. Nurses can be helpful in identifying patients with bulimia, alcohol or drug abuse, or dependence on laxatives or diuretics — factors that can make patients poor candidates.³⁰

Nutritional and diet counseling are also important. Iron, folate, and vitamin B12 supplement use is encouraged preoperatively to stimulate bone marrow reserves to replace blood that will be lost. Crash dieting immediately before surgery is not recommended because sudden, massive weight loss causes a negative nitrogen balance and diminished albumin, which can trigger fluid retention, pulmonary edema, and delayed healing. However, gradual weight loss combined with exercise should be encouraged to bring patients within 50 pounds of their ideal weight when procedures are scheduled in advance. While not performed to achieve metabolic benefits, postoperatively, patients may experience lower blood glucose levels as well as lowered cholesterol levels.⁴⁰ While these metabolic findings may be viewed as positive changes, no clear cardiovascular risk factor benefit has been associated with liposuction.⁴¹

Surgical preparation often entails extensive marking periods with the patient, usually nude, standing and lying down to “map out” areas where activity with the cannula will be concentrated. Photos are taken beforehand and used as an intraoperative guide. Patients who are already concerned with their body image may be uncomfortable with this procedure and require additional reassurance that photos are a confidential part of their medical record and are needed by the surgeon. Usually two weeks before and after surgery, patients should avoid agents that could interfere with clotting, such as aspirin, gingko biloba, vitamin E, Midol, Pepto Bismol, and nonsteroidal drugs like ibuprofen (Motrin), naproxen (Aleve), indomethacin (Indocin), and ketorolac (Toradol). If patients smoke it is also important to encourage them to stop at least two weeks before and after surgery³⁶ to prevent delays in healing caused by smoking’s effect on tissue perfusion and the immune response.

Women of childbearing age must also be cautioned that their menstrual cycles may become irregular after liposuction, especially when the abdominal area is involved.⁴² Birth control measures should be explored and options discussed.

Contour irregularities occur in any area treated with liposuction and may require resuctioning or reinjection.³⁶ The use of a compression garment minimizes this poor outcome. Following liposuction, a compression garment is applied, often in the OR immediately after the procedure. Instruct the patient to wear the garment exactly as directed. For the first few days, the garment constricts blood vessels that have been surgically disrupted by the cannulas and diminishes bleeding and bruising. It also compresses tumescent irrigation fluid to exit through entrance incisions or back into the vasculature for excretion, thus enhancing fluid absorption. The garment also compresses cavitation, helping to contour the remaining fat. Caution must be taken that the garment does not restrict breathing or distal circulation. The skin underneath needs periodic inspection because sensation may be diminished. Allergic reaction to the compression garment, while rare, may occur.⁷

Patients should know that if they do not wear the prescribed garment, they risk bleeding and irregularly contoured results. Garments are fitted according to size; those that are too tight (particularly when only extending to the knees) can cause venous compression and pedal edema and raise the risk for venous thrombosis. Patients should be cautioned to minimize their sodium intake, elevate their feet above the level of the heart, and immediately tell their provider about unexpected swelling or calf tenderness or warmth.

Patients may experience a vasomotor response if the garment is changed in the standing position, even if they have a normal blood volume and an adequate hematocrit. Removal and replacement of the garment should be done with the patient supine.

Early ambulation should be encouraged for all patients after tumescent liposuction to help mobilize the excretion of third-spaced fluid to expedite recovery and to prevent deep vein thrombosis. This is especially crucial when tumescent megaliposuction is performed among obese individuals in a single procedure.⁴³

Body-contouring surgery is more affordable for the general population than ever before. It is highly likely that you will have contact with people contemplating liposuction and those who have had the procedure. An unbiased approach to care is necessary, considering the psychological ramifications, as well as the changes in physical appearance. You can help patients to evaluate their expectations, both physically and emotionally. Patient education is important to enhance results and minimize complication. Liposuction should not be discounted as a routine procedure without risk. Even when performed under ideal circumstances by a trained professional, it can cause dire consequences in otherwise healthy patients.³⁶

For additional information on liposuction, contact the American Society of Plastic Surgeons at 444 East Algonquin Road, Arlington Heights, IL 60005-4664; phone (847) 228-9900; www.plasticsurgery.org; or search the Mayo Clinic’s website, www.mayoclinic.com/health/liposuction/SN00009 for information about liposuction.