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While far from the oldest aesthetic procedure in plastic surgery, liposuction has become one of the most frequently performed around the world in the past four decades since its initial clinical introduction. Its ubiquitous nature in aesthetic surgery is not only because of the commonality of an excessive fat problem but also due to its use by a broad spectrum of cosmetic practitioners in a variety of settings.

Liposuction has evolved over the years and has gone through a variety of advancements from tumescent solutions, cannula designs and fat particulation methods. But despite the improvements in liposuction techniques the one consistent theme that has always been present is the need in the end to extract the fat by the introduction of some form of a cannula attached to a negative pressure device. This means that all liposuction methods share an invasive nature that introduces a similar amount of subcutaneous trauma.

Despite the small innocuous looking skin entrance sites used in liposuction, what goes on under the skin belies its minimalist external appearance. The subcutaneous tissue trauma is extensive and its extent correlates to the body surface area treated. While often viewed as a benign aesthetic procedure, where marketing and advertising downplay the magnitude of the operation, this understating of the procedure has led to well known major complications. Back in the earlier days of liposuction, where ‘more was better’, the medical sequelae of high or large volume liposuction became realized with the problems of fat emboli and pulmonary dysfunction, prolonged recoveries and even death as a result have occurred.

These medical problems led to the necessity to create a definition of large volume liposuction as being an extracted volume over 5 liters where these risks become more pronounced. And in some states led to this being an actual regulation of the amount of fat allowed to be extracted in a single surgical procedure. While this liposuction category is well accepted and is a very good medical guideline, how is applied to a particular patient must be considered in the context of their body measurements such as body surface area (BSA) and body mass index. (BMI) In theory a larger patient (taller and heavier) may be able to have more fat safely extracted than a smaller patients so the 5 liter number is not an absolute one. But no studies have ever been done to determine a sliding scale of safe liposuction volume extraction based on BSA or BMI.

Such higher volumes of liposuction extraction has become back into play, so to speak, with the now widespread use of BBL surgery. (Brazilian butt lift) In an effort to maximize the amount of concentrated or semi-concentrated fat to inject into the buttocks, higher volumes of liposuction are again being more commonly  done. While most of the major complications that have arisen with BBL surgery have come from fat emboli from inadvertent entrance into the deep gluteal veins, the tissue trauma from the donor harvest can also become a source of them as well.

I think it is important for patients in particular to understand that liposuction is an elective procedure that is far from innocuous and ‘more is not always better’. While every patient wants to maximize their body reduction/reshaping,  whether it is from liposuction alone or as part of a BBL procedure,  safety precedes the opportunity for a slightly better reductive or fat obtaining outcome.  While keeping under the limit of 5 liters of fat extraction is not an absolute number, it remains a good medical guideline in liposuction surgery.

Dr. Barry Eppley

Indianapolis, Indiana

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