Liposuction is one of the most common cosmetic surgeries performed and, by far and away, the largest procedure in body surface areas treated. Despite its wide usage and high-tech tools and devices available to perform the procedure, there is a significant occurrence of cosmetic complications (contour asymmetries and skin irregularities) and the need for secondary revisions.

Aesthetic complications in liposuction occur with some frequency for several reasons. Part of their occurrence is due to the inherent nature of the procedure. It is a blind operation that is done largely by feel and experience. You can’t really see on the inside what you are doing. One must rely on external indicators to get a gauge on how much fat has been removed and how even it is. Using a straight-shaped device probes and extraction cannulas on curved body surfaces also makes smooth and even fat removal unpredictable. Lastly, because it is easy to acquire equipment and seemingly simple to do, there are a large number of inexperience poorly trained physicians performing the procedure. Collectively, this makes it not infrequent that the cosmetic results from liposuction may fall short of a patient’s expectations.

While the initial or primary liposuction procedure is straightforward to perform, secondary or revisional liposuction is much more challenging. The asymmetric or contour irregularities that exist pose more significant challenges due to scar and a broad areas of subcutaneous fibrosis. Liposuction problems generally fall into three types; too much fat removed, too little fat removed, and combinations of both which are the most common.

The ‘simplest’ liposuction problem is that of inadequate fat removal. This appears as high spots on flat surfaces and asymmetries on curved ones. It is the most likely to be improved by further liposuction efforts as more fat can be selectively removed. Because there is residual fat they may also be less scar present. It is usually best to use small cannulas for extraction as the areas are often relatively small and direct access through an incision near it can prevent creating other problem areas in the path of the cannula.

Too much fat removed poses a more difficult liposuction revisional problem for two reasons. First, there is a need for more fat tissue to build the area back up. In small areas there is usually not a donor site problem. In larger areas that may be more relevant. Secondly, scar is now present in the subcutaneous tissues and the predictability of how the skin will redrape over a recontoured area is more uncertain. The combination of skin contracture release and interpositional fat injections placed underneath is the only way to improve indentations. While release alone may look adequate at the time of the procedure, the lack of underlying fat will reveal itself quite quickly later. After surgery massage and skin smoothing devices are also very beneficial. It is fair to say that liposuction-induced skin irregularities can never be made perfectly smooth but they can be improved.

There are well known body areas that are prone to skin irregularity problems after liposuction and include the abdomen, inner thighs, back of the arms and upper knee regions. These occur because these are also areas that have more skin elasticity problems and it is always best to leave more superficial fat under the skin to guard against these irregularities. While every patient wants the maximum amount of fat removed in every liposuction procedure, conservative extraction in many areas is a wise choice.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

LipoDissolve, or the injection introduction of a fat-emulsifying chemical solution to treat small areas of excessive fat for cosmetic improvement, is a controversial procedure that is not FDA approved. (or even off-label as it has no approved medical uses) Despite its regulatory status in the United States, I have found LipoDissolve in my practice to be a valuable adjunct for mild to moderate fat reductions if it is used carefully and on those patients with very small fat issues. I have not experienced to date in over 150 patients any of its potential complications as reported on the internet and other media venues. I believe that my methods of rigid patient selection and keeping the number of injections per treatment sessions limited is the basis for my very favorable patient experience. All patients do get a fair amount of swelling in the treated areas for the first week with some discomfort but they are well apprised that this will occur prior to treatment. The amount of fat reduction has met most patient’s expectations whichi have been kept to a modest level by thorough pre-treatment counseling. One application that I have found particularly useful is in the treatment irregularities or residual fat areas AFTER liposuction surgery.

 
Even in the best of hands, some small percentage of liposuction patients will have irregularities in the skin over the treated areas. These areas may be made up of either depressions (too much fat removed), high spots (not enough fat removed), or some admixture of both. The decision to treat any of these residual liposuction issues should be delayed for at least 6 weeks after surgery and ideally not until 3 months after the original procedure, giving the body time to completely heal and resolve temporary irregular areas due to swelling and retained fluids such as blood. Once an irregular area is confirmed and the target is stable (meaning it will not improve with any more time and everyone is certain of that), it must then be determined what the cause (too much or little fat left) of it is. Depressed areas can only be treated by fat injections through another surgery. Elevated or too high areas represent too much fat still which can be improved by further fat removal. This is where the role of LipoDissolve can be very valuable.

 
The thought and expense of returning to surgery is not appealing to patient and plastic surgeon alike. Plus, to get at the area a long straight cannula from afar must be introduced which will traumatize some treated areas which look fine and has the potential of causing another ‘problem’ while trying to solve the current one. A spot treatment, like LipoDissolve, is ideal. It can be injected directly into the problem area, in the office, with no recovery, and at a very low cost. Most ‘high spots’ after liposuction are generally small and each area may only require a few injections. While it may require a few injections sessions over several months to get the desired result, the ease of LipoDissolve administration and the ability to place it exactly where the problem is makes it a better solution to those postoperative liposuction issues where too much fat is the cause.

 
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis