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
Indianapolis, Indiana