Proper Liposuction Evaluation and Technique

What’s New, What’s Old and What Works. An Expert Opinion

As a physician and surgeon, one of my main responsibilities is to honestly guide, educate, advise and protect my patients. I have been asked to discuss my own particular technique for liposculpture surgery and to give my opinions regarding many of the newer alternative liposuction or fat reducing procedures.

Let me begin with a brief introduction of myself. My name is Dr. David Amron and I am a board-certified dermatologic surgeon with a practice in Beverly Hills, California focusing on liposculpture surgery. As liposuction surgery is the only major cosmetic surgery I perform and I have done this procedure for over 18 years for thousands of patients, I have a lot of opinions and insight into the nuances of consistently achieving a great result and making my patient happy. I have spent years fine tuning my approach and have a particular philosophy on what constitutes a good candidate for liposuction. It is so much more than sucking out or melting as much fat as possible. Despite what a patient may want or the mistaken goal of a surgeon, this approach will commonly lead to a poor result.

One of the most important points I want to emphasize is the importance of choosing the honesty, integrity, artistry, eyes, hands, skills and good judgment of the surgeon over the machine. The machine is only a paint brush in the artist’s hands. Despite interesting technology and aggressive marketing hype, it will not guarantee a great result in a trusting patient. A concerning trend I have seen in the last few years with the introduction of some of this interesting technology is the mistaken tendency of the patient to choose or ask for the machine instead of spending time to find the right surgeon. Unfortunately companies, the media and sometimes even doctors themselves contribute to this when there is competition for dollars. Like I say on my radio show (and you are doing so by reading this article), please do your homework and spend time educating yourself. Do not be impulsive, continue to learn and hopefully the truth will come to guide you to a great result.

Presently in the United States, liposuction is still the most common cosmetic surgery. It also has one of the highest revision rates approaching 25% in some studies. It is much more difficult than most patients and even many naïve surgeons realize to consistently get a beautiful result. There are many reasons for this as we will start to see. I feel it is extremely important to “get it right” the first time. Every aspect of this procedure from clear honest communication with the patient, to complete evaluation, to meticulous technique should be directed toward this end. If a patient is not a candidate, e.g. they are simply overweight, maybe out of shape but not disproportionate, then I may have no role in their improvement and honestly tell them they are not a candidate for liposuction.

Unfortunately, approximately 30% of my surgeries are revision liposuction where I am using techniques to improve a bad or less than optimum result by another physician or possibly nonphysician. In my evaluation of this patient, I can always tell why a bad result has occurred. A bad result occurs for two reasons: either poor evaluation (including poor communication) or poor technique. The surgeon may have been too conservative, been too aggressive (too common), been uneven in his contouring, poorly blended areas, placed his incision points in strategically poor locations or thrown a patient out of balance and proper proportion. And once again, unfortunately no new technologically advanced machine can or ever will prevent any of these problems. Like a perfect haircut or a beautiful sculpture, it goes back to the skills and artistry of the person doing it.

With liposculpture surgery, as with any procedure, a great result begins with a complete honest evaluation as to who is a good candidate. Simply stated, liposuction is all about targeting areas of genetic disproportion and balancing a body. It has virtually nothing to do with being overweight, underweight or normal weight. It is about focusing on stubborn areas that can’t be taken care of with diet or exercise. This is one reason why it is so important to be fully evaluated from your neck to your ankles by someone with a good eye and ability to determine where you are out of balance if at all. It is a mistake to liposuct someone who is simply overweight or out of shape but not disproportionate. Once again, unfortunately this does not uncommonly occur and the result will be a person thrown out of proportion. This is why we hear of someone who has had lipo and the fat “went” to other area. The surgeon created disproportion. In addition, make sure that who is evaluating you for surgery is actually the surgeon and not somebody else. I have heard of patients who met their surgeon for liposuction in the operating room for the first time. Be wary of places that seem like factories and do not truly care about comprehensive individualized care.

With regard to my own approach to liposculpture, I strongly feel that local anesthesia is the gold standard and offers many advantages over general anesthesia for liposuction specifically. This is called “tumescent” liposuction which was developed by a dermatologic surgeon. I like to call this pure tumescent liposuction to differentiate it from other types where they maybe combining it with general anesthesia. Tumescent liposuction has essentially three major benefits. To begin with, studies show it is far safer, especially if compared to liposuction done with other procedures under general anesthesia. The second benefit is easier recovery. The tumescent fluid which is infiltrated into the fat helps hydrodissect (separate with water) and allow much more pure fat removal with decreased bleeding. This results in far less bruising and generally much faster recovery with less post operative discomfort. I only trust myself to do all the local anesthesia as there certainly is an art to infiltration so that the patient feels as little as possible. However, the greatest advantage of local anesthesia is that I have a patient that can always be positioned optimally, so that I can meticulously sculpt without ever jabbing the muscle or poking the skin. This allows me to stay only in the fat layer where I only belong. Jabbing the muscle (which could never be tolerated with a conscious patient) significantly increases bleeding, bruising and postoperative pain. On the other hand, jabbing, poking or tenting the skin with the canula at the wrong angle is one of the main causes of indentations and irregularities (as we will soon discuss).

With regard to my technique of sculpting, it begins with a good eye for the contour, balance and proper proportions for the male and especially the female body. Each body has its own differences, nuances and limitations. Good surgical technique also encompasses excellent judgment for not only where to target but also how aggressive to be. There must always be respect for skin tone as well as knowing how to deal with looser flabby tissue (flab is the term I use which is loose skin and muscle. Many people confuse flab with fat.)

Where I have learned to place my incisions in each part of the body I approach is extremely important. The goal is not only to place few incisions in places that hide well, but to strategically place them to be able to completely and evenly approach each area without jabbing the muscle or skin. My incisions are small nicks in the skin between two-three millimeters in length. I feel that not suturing the sites allows faster recovery by drainage of fluid postoperatively.

With regard to how I sculpt, this is a little more difficult to convey in words. The fat is embedded in a fairly dense connective tissue framework so it certainly is not just sucking fat out. One must tunnel very precisely in the fat and this is why liposculpture is truly a more accurate name then liposuction. I always start deep in the fat with small round canulas to debulk the deeper layers of fat. I almost always approach an area from two or more directions and crisscross my tunnels. As I move up in the fat layer, I progressively go to even smaller canulas and finish in the superficial fat layer with a flat tipped small canula I had designed for myself many years ago to make sure my surface is smooth. It is how I approach this superficial fat and how aggressive I choose to be with regard to rasping the dermis from underneath that controls how much skin tightening I choose to achieve. Liposculpting is a very tactile procedure and this is one of the main reasons why I do not prefer laser assisted liposuction or ultrasonic liposuction as I lose the “feelings” or vibrations which convey to me exactly where I am and how much I am bringing an area down. Remember, the goal is not to always be aggressive and just suck all the fat out. This is a very amateur approach and bad results will commonly occur. For a more detailed description of how I approach each particular area of the body, please consult my website in the section entitled “area by area.”

Now, with regard to alternative liposuction procedures, I will group them into internal and external modalities. With regard to the internal modalities, I will begin with mesotherapy (also known as lipozap or lipodissolve) as it will be the quickest to dismiss. One of the deceitful marketing tools is that mesotherapy many times is advertised as being better than liposuction. I find this not only inaccurate but insulting. Mesotherapy is the multiple injections of a nonstandardized solution of phosphatidylcholine into the fat. Now, I am not saying that it won’t ever dissolve fat because it might. But remember when I said that the fat is embedded in a dense connective tissue framework? Well, how do you control the dispersal of the fluid and trust you are going to dissolve everything evenly? Remember how particular I was in how I sculpted each area of the body? There is so much more involved to great liposculpting then just dissolving fat. And, not that this is the most important thing, but mesotherapy is not FDA approved, is not supported by any of the major cosmetic surgery societies and furthermore, no one that I know who specializes in body sculpting has chosen to incorporate it in their practice.

Laser assisted liposuction (eg. Smart lipo, cool lipo) and ultrasonic liposuction (eg. Vaser) are newer quite popular alternatives to more traditional forms of liposuction. The argument here goes that they melt fat and tighten skin, whereas traditional liposuction either does not tighten skin or makes your skin looser. Very alluring, but it’s not that simple or truly accurate. I sometimes call this liposeduction vs. liposuction. There are many surgeons that have embraced these newer machines. Personally, I do not trust simply melting fat and feel I can get as much tightening as I choose by how I deal with the area just under the skin. I prefer this because it gives me more of a feel. With regard to the laser sealing blood vessels, remember that with properly done tumescent anesthesia one gets very little bleeding due to the hydrostatic pressure and epinephrine vasoconstruction. One well done study in a major peer reviewed journal (Plastic and Reconstructive Surgery Sept. 2006) failed to demonstrate any clinical advantages of laser assisted lipoplasty.

However, I feel the bigger danger with many of the newer aggressively marketed machines is that they encourage the potential patient to search for the machine and forget that what is more important is the mind, hands, heart and eyes of the man (or woman) behind it. Since I do a lot of revision work to improve poorly done liposuction, I would have to say that in the past two years I have seen some of the worst disasters result from both laser assisted and ultrasonic liposuction. Once again, I don’t blame the machine but the judgment and skills of the person behind it. I am also aware that the media plays a large role in hyping up whatever is new.

Finally, with regard to many of the newer machines that are targeting either cellulite or tightening of the skin, I feel this is an interesting area as long as it is not too closely compared to well done liposculpture. There are some promising results with regard to this area. Velashape was the first FDA approved machine for cellulite and the temporary reduction of circumference (yes, temporary). There are other machines also used for cellulite. While this is a very intriguing area, I have not yet chosen to incorporate it in my practice as I am not yet sure it really works long term and is worth the cost of the procedure. In closing, I hope the insights and opinions I have shared help to guide you in the right direction.