Liposuction is certainly one of the most commonly performed aesthetic plastic surgery procedures. And by definition it treats the largest body surface areas of any cosmetic operation. Since its introduction in the U.S. over 40 years ago, it has risen to prominence because it not only treats refractory fat issues, which are ubiquitous, but it is very effective in doing so. But despite its success, it is a cosmetic procedure that has also garnered a ‘dangerous’ reputation. It is unique amongst cosmetic operations because not only can aesthetic issues arise but deadly complications have also occurred.
Deaths and major medical illnesses that result from a cosmetic procedure will understandably always attract a lot of media and public attention. Over the years the rare major complications that have occurred from liposuction have made more than a few patients inquire during a consultation about the safety of liposuction. Patients will ask such questions as…what are my chances of dying from liposuction?…is it a safe thing for me to do as I wouldn’t want to die from the vanity of having cosmetic surgery? These are very valid questions given liposuction’s history and the best answer comes from discussing in detail why such a lethal complication can occur from a cosmetic procedure and how to optimize safety.
What makes liposuction very unique from other cosmetic procedures is that the trauma to the tissues is hidden under the skin. There may only be a few small nicks in the skin to perform the procedure but what goes on underneath and is not seen from the outside is the severe trauma to the fatty tissues. Liposuction is, in essence, deceiving as to the insult that it creates on the body. Depending on the amount of liposuction done, it places more stress on the body than that of a tummy tuck or a breast reduction for example. Those zones of injury are more obvious but less in surface area. Breaking up fat and suctioning it also creates the risk of fat emboli, small pieces of fat getting into the bloodstream and traveling to the lungs. No other cosmetic procedure can cause that same potential problem.
One of the keys to making liposuction safer is to limit the amount of fat that is removed in a single operation. While every patient before liposuction surgery usually utters…’take as much as you can’…’don’t leave any behind’…that make not be the safest strategy. What was learned in the 1990s, an era when high volume liposuction became popular, was that the risks of complications increased exponentially. When high volumes of fat are removed, the trauma to the tissues and the body’s response to that stress, cause major physiologic changes that make liposuction not just a simple cosmetic procedure. Such volumes of fat removal also make for longer operative and anesthesia times, particularly when combined with other simultaneously performed procedures such as a tummy tuck and/or breast reshaping.
What constitutes high volume liposuction? Any amount over 5 liters of liposuction aspirate qualifies. This has become a well cited volume level and in some states it is now even illegal to remove more fat than that in a single setting. Most liposuction cases are more in the range of 1.5 to 3 liters, a very safe amount. Thus, all liposuction is not created equal…the amount of fat removed changes the risk potential.You don’t want the maximum amount of fat removed, you want the safest amount that can be removed.
Another key safety issue is the qualifications and training of the doctor performing the procedure. One of the many features that makes liposuction unique amongst cosmetic procedures is the equipment needed to do it are relatively inexpensive and not subject to any scrutiny to acquire. A medical license and a credit card is all one needs in most cases. In addition it looks simple to do with seemingly simple in and out movements of the cannula. This makes it the easiest entry level cosmetic surgery procedure to ‘try’. No one without proper training tries to do a facelift or a tummy tuck, but this is not true when it comes to liposuction. What is lacking without proper training, besides the aesthetic outcome of the procedure, is the judgment of when and how it is performed. Knowing the basics steps of an operation is one thing, mastering the technique and becoming proficient with it is quite another. There are contentious debates about what qualifies a doctor to perform cosmetic surgery including liposuction. I will leave the many nuances of that heated debate to others. While board-certified plastic surgeons offer the most assurity of a broad education and experience in body reshaping surgery, the converse argument is what is the minimum education that one needs. And from that perspective do you as a patient want the most minimally trained doctor to perform your liposuction? Thus all doctors that perform liposuction are not created equal…the amount of training and experience can change the risk potential. One really doesn’t want the lowest cost or the easiest way to do liposuction…one wants the safest and most comfortable method.
Another unique aspect of liposuction is that its hollow-bored instruments have to be reused. One of the most risk-laden aspects of liposuction, and one that is almost never discussed or patients are even aware of, is the sterility of the cannulas used for the procedure. These must be metal cannulas so they do not break with the repetitive motion under the skin. Plastic cannulas that would have one-time use would likely break or at least have the potential to do so. This may leave plastic fragments under the skin. Metal cannulas are reusable and must be cleaned and sterilized for each patient. What is the cleaning and sterilization process used? Is it the same for a liposuction procedure done in an operating room setting or an office facility? In theory it is but is it? My biggest concern about non-surgically trained doctors performing liposuction is the attention paid to such instrument cleaning in a traditional non-operative room office setting. The few cases of severe infection after liposuction that I have seen or heard of locally, including devastating necrotizing fasciitis, have been office-based procedures. Thus, liposuction instrument processing may not be equal…potentially increasing the risk potential of infection.
There are great debates, usually between plastic surgeons and dermatologists, of whether it is safer to do liposuction under general or local anesthesia. If you are never put to sleep, by definition you are probably have smaller amounts of liposuction done and thus will have lower risks of major complications. Most certainly liposuction under local anesthesia is not being performed with other cosmetic procedures. So it is unquestionably true that liposuction done under local anesthesia is safer… but this does not mean it is more comfortable, efficient or even more effective. If liposuction is being done by itself, then a patient can entertain the debate of local vs. general anesthesia. But this is an irrelevant issue if one is having other cosmetic procedures that require a more profound anesthetic. Conversely, liposuction done under local anesthesia can become equally if not more dangerous than that done under general anesthesia. If large amounts of the numbing agent lidocaine are given when attempting to do a lot of liposuction over a long period time, toxic drug levels can ensue. Such lidocaine toxicity is a well known cause of morbidity. Thus, anesthesia used for liposuction is not created equal…its associated risks are more complex than just whether one is awake or asleep.
Like all technologies, liposuction has seen similar increases in the tools available to perform it. Today there are multiple methods of performing liposuction all with advocates claiming that each one is better. But whether it is Smartlipo, Vaser Lipo, Hydro Lipo and numerous others, the trauma that is induced to the tissues does not change. No liposuction technique is truly gentler or less invasive to the tissues than any other. It is still invasive surgery and the risks, regardless of the liposuction technique used, does not change. Thus, the bodily trauma from liposuction is created equal…technology does not in and of itself decrease the risk potential.
Liposuction when done in low to medium volume removal is a very safe procedure with largely aesthetic risks such as skin irregularities and unevenness. What increases the risk or danger levels in liposuction are the volume of fat removed, the doctor and facility location where it is performed, and the length of surgery and anesthetic times. Most major complications of liposuction, including death, can be traced to one or more of these contributing factors.
Dr. Barry Eppley
Indianapolis, Indiana