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Liposuction

The options for removing fat have exploded in recent years. KYBELLA® (an injectable that dissolves fat under the chin), CoolSculpting® (a noninvasive treatment that freezes the fat to remove it), Ultrasonic Assisted (UAL) or VASERlipo®, and laser liposuction with Smartlipo™ or SlimLipo™ are newly developed techniques. What is the difference? Which do you pick? And now with the boon of fat transfer, should you just remove the fat or should you use it to transfer it to another area like the face, hands, breasts, or buttocks?

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Liposuction is a common procedure for men and women. We recommend it for people stable at a normal weight who want to improve their body contour. The ideal patient is one with pockets of fat, such as “love handles” or “inner thighs,” resistant to diet and exercise.

There are many terms with liposuction: Tumescent, SAL, Ultrasonic, UAL, VASERlipo®, liposculpting, LipoSelection®, laser liposuction, Smartlipo™.

Almost all plastic surgeons use the tumescent technique to help with anesthesia and to reduce blood loss.

Liposuction Consultation

Before you consider liposuction, I recommend you get an evaluation by a Board Certified plastic surgeon who in addition to liposuction does procedures like fat transfer and abdominoplasty. Big questions you need answers for include:

  1. How much fat do you have? In what areas?
  2. What is your skin quality?
  3. Do you have areas where you would benefit from fat transfer?

Liposuction can be effective in many areas:

  • Face: chin, neck
  • Torso: upper arms, breast/chest (including the male breast or “gynecomastia”), abdomen, waist, hips, buttocks
  • Legs: thighs, knees, calves, and ankles

During your consultation, I will review all of these issues with you. If you receive liposuction, you will change your fat pattern. It is important to anticipate what those changes will be, as well as to address any areas which could be become a problem later on. I have seen many patients who had liposuction of the flank and thigh who present with fat arms and backs. This was predictable—those patients should have had liposuction to their back and arms at the time of their original liposuction. CoolSculpting® and KYBELLA® are good for individuals with small amounts of fat and good skin tone. If you have more fat or laxity of the skin, you will need another option.

Liposuction permanently removes fat cells through small incisions. As long as you maintain a stable weight with exercise and nutrition, the fat should not return.

What should I expect during liposuction?

Areas to be suctioned are filled with a fluid called “tumescent.” Tumescent fluid is made of anesthetic (to numb the local area and reduce the amount of general anesthetic), epinephrine (to reduce blood loss and bruising), and saline. For procedures of the trunk and thighs, I use two positions (from the front and back) to have a smooth natural transition in the sculpting from front to back. My bias is to use general anesthesia for patient safety, fluid regulation, and more fat removal. I perform the tumescent liposuction procedure in an outpatient surgery center in Palo Alto. Board certified anesthesia doctors give the anesthesia.

I treat my patients globally, usually addressing multiple areas, to help ensure a smooth, natural contour. This is important to make sure future weight fluctuations don’t create a “funny” body shape. I do all ranges of fat removal, from small touch ups to large volume removal (around 5 liters).

Liposuction may not work well as a stand-alone procedure. If your skin has many stretch marks, fine wrinkling, or drooping, you will likely need skin removal. This may involve abdominoplasty, mini-abdominoplasty, medial thigh lift, arm lift, necklift and /or facelift, or body lift.

"Dr. Greenberg completely resculpted my waistline and gave me curves that were better than when I was 25!" - K.S., Waltham
*Individual results may vary
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What are the different liposuction methods?

Ultrasonic liposuction, or UAL, uses ultrasonic energy waves to help break up the fat. I find my patients are very athletic–as most Bay Area people are–and they tend to have firm, fibrous fat. UAL is critical in fibrous areas such as the upper abdomen, back, and thighs, and in secondary liposuction cases. Men in general tend to be fibrous, and should use ultrasonic liposuction. I like to use UAL with most patients, as I feel it helps give a smoother result, larger fat volume removal, and better skin retraction.

SAL is traditional liposuction. This uses cannulas (thin tubes) hooked up to suction. I always follow use of the ultrasonic liposuction with traditional liposuction. As fat removal progresses, I use smaller and finer cannulas to help sculpt and contour.

Laser liposuction uses a laser as its energy source to break up fat as the ultrasonic does. Many use a small gauge cannula, so it needs to be combined with other fat removal techniques. Due to the small size of the cannula, the surgery takes more time. I prefer ultrasonic, as it preserves the stem cells in the fat.  Stem cells have huge effects on the quality of the skin (see my blogs on the subject).

All of these different kinds of liposuction are combined with the tumescent technique. All of them remove fat. Downtime following surgery is related to the amount of fat removed and areas treated.

It is difficult to redo a liposuction case. I urge you to choose your surgeon wisely, as your first shot is truly your best shot. Liposuction is one of the most common procedures I perform. I have co-authored a chapter on the subject published in a plastic surgical textbook. I redo many cases from other doctors due to irregularities, fat remaining, and poor shape. A disturbing trend is non-plastic surgeons doing liposuction. Many take a weekend course, and some of the laser liposuction companies are targeting non-plastic surgeons purposefully. There is a skill to doing good liposuction. It is not simply getting out as much fat as you can. I see patients who have loose skin, very irregular fat removal, and poor body shape. These patients were told “if the skin doesn’t look good, go to a plastic surgeon and get a tummy tuck.” When I meet these patients, I know their first surgeon was not a plastic surgeon. They did not have the right procedure for their body type. Please be evaluated by a plastic surgeon and get multiple consultations prior to doing the procedure. See my page on picking a plastic surgeon.

What is fat transfer?

Finally, fat transfer is the new frontier of plastic surgery. Instead of using synthetic fillers for the face or implants for the buttocks, changes can be done by using your own fat as an injection. Fat is liquid gold. Do not throw away your fat.

There are many techniques used. I have trained with fat transfer pioneer Dr. Roger Khouri, attended courses focused on fat transfer with other pioneers like Dr. Coleman, and performed fat transfer for a decade. I love it.  I harvest the fat using traditional liposuction techniques, centrifuge the fat to help concentrate it and make it more uniform, and then inject it by carefully placing the fat where needed.

  • MICROFAT. injecting under the skin using a fine cannula to add volume to an area.
  • NANOFAT. injecting with a small needle into the skin itself, to help correct lines (around the mouth, between the brow, on the forehead).

People who do not understand fat worry the fat could be lumpy or uneven.  Please know this is not seen in my practice, and is not supported by good technique and what we have seen during scientific study.  Also, the stem cells in the fat improve the quality of the overlying skin, making your “comforter” look prettier. Before you remove the fat, think! Is there an area which would benefit—the face, buttocks, hands, or breasts—from adding fat?

 

Skin Quality Matters

Skin quality is paramount to your result. Imagine the skin and fat on your abdomen is like a comforter. As you age, your bed under the comforter may become a little lumpy. A thick comforter of skin and fat smooths out the look of the underlying bed.

CoolSculpting® freezes the fat from the top down, in essence thinning your comforter to a summer blanket. If you have issues with skin quality, the CoolSculpting® treatment can make it worse. Sometimes liposuction is not an option because the removal of fat will cause the skin to wrinkle. Sometimes you can remove some of the deep fat and still do okay.

Please get an evaluation by a doctor who does abdominoplasty and skin tightening procedures. If your doctor only performs liposuction or CoolSculpting® therapy, they may recommend a procedure even though it is not the ideal procedure for you. Many of the skin issues caused by this are not fixable. With any noninvasive system, fat is absorbed in the bloodstream and a collection of fluid or liquefied fat under the skin could be an issue.

Liposuction Blogs

HOW MUCH WEIGHT WILL I LOSE WITH LIPO?

HAS YOUR SKIN CHANGED AFTER LIPOSUCTION? 5 THINGS TO KNOW.

LIPOSUCTION AND TUMMY TUCK. WHICH TO DO FIRST?

HOW MUCH FAT CAN YOU SAFELY REMOVE WITH LIPOSUCTION? DOES IT VARY WITH BMI?

LIPOSUCTION- DOES IT LAST? AND HOW MANY FAT CELLS DO WE HAVE?

Liposuction Blog

what are the noninvasive options

Many noninvasive liposuction techniques have been developed by a number of manufacturers. I was on the advisory board of one company. There is an injection Kybella. There are newer lasers which are noninvasive (no cuts in the skin).

CoolSculpting® is the most commonly used one. It works, and if you have a small amount of fat and good skin quality, it may be a good choice for you. I get why it is so enticing. No bruising, no recovery. Sign me up!

But there are a few things you must consider:

  • It is best for small amounts of fat. The typical liposuction case I do removes liters of fat. To achieve these results using a noninvasive technique would be difficult, and it would require many sessions.
  • It removes the superficial fat. BE WARY OF THIS if you have any issues with skin quality. Your skin is like a bathing suit, and as you age, the quality of the skin declines, particularly after pregnancies, weight changes, and menopause.  If you have stretch marks, cellulite, or irregularities, you do not want to thin your skin further.  Think of your skin like a comforter covering your body.  The thicker the comforter, the smoother and prettier the bed looks.  When you do surgical liposuction you remove the deep fat.  This allows the comforter to stay thick.
    • I do a lot of fat transfer to the face, and when I do, we see the quality of the skin improve. Please see all my blogs on stem cells in the fat and the skin improvements which they give. This is well studied.
    • When I do invasive liposuction, I am removing the deep fat, purposefully leaving the superficial fat under the skin to nourish the skin and help keep the skin filled out to look pretty. As you age, your skin loses elasticity. The quality worsens. You want to keep that superficial fat.
  • You cannot harvest this fat to transfer to someplace else. CoolSculpting® therapy kills the fat. One of the things I always ask when I am doing liposuction is “Where should we put this fat?” Most of us need to replenish fat lost in the face, the hands, the buttocks. Fat is liquid gold. Please read my blog, “Hold Onto That Fat!” for more information.

Liposuction of the face & neck

The face and neck are a special area and require evaluation by a surgeon.

Fat in the face is precious. I am not a fan of Ulthera or Coolsculpting to the face itself. You lose facial fat as you age, and this facial fat volume loss is a big contributor to facial aging and drooping. Be wary with buccal fat removal as well for this reason. (What looks good at age 20 may age you more at age 40)

The neck is another issue. When we talk about doing liposuction to the neck, we are really referring to the area under the chin primarily.  Liposuction can be a great tool to reduce fullness in this area. I generally use energy like ultrasound to help break up the fat and tighten the skin. There are risks though.

  • If your skin tone is poor, the skin may hang. If you are over the age of 30, the risk of this increases. There are also genetic issues where people have poorer skin tone to begin with.
  • Some people misinterpret the looseness under the chin as fat when it is really your skin loosening. This is particularly true as you age, particularly after menopause.
  • If you have a lot of fat, your skin may not be able to tighten enough.
  • The fullness may not be due to fat that is superficial and able to be liposuctioned. If you have fullness in the area under the chin from fat that is deep to your platysma muscle or if the fullness is due to a droopy submandibular gland, liposuction cannot fix it. You need a necklift.
  • If you have a small chin, fat grafting to build up the chin may help define your jawline.

Please see my blogs on fat grafting to the face (oddly adding volume in the upper face and mouth areas can make your face actually look thinner), facelifts, and necklifts. Realistic expectations are important here. We cannot tell exactly how much fat you have and how your skin will retract. Given how much smaller of a surgery and incision it is, liposuction may be worth the risk.