Liposuction: 25 Years of Experience in 26,259 Patients Using Different Devices

Methods 

Data were obtained from four different surgeons (LT, CT, CB, and MZ). Between 1983 and 1996, these data were obtained from personal databases; from 1996 until 2008, data were collected from the database of Corpus and Rostrum Plastic Surgery Clinic, Cali, Colombia. The entire study period was from July 1983 to January 2008. The liposuction techniques studied included dry liposuction, tumescent liposuction, tumescent UAL, and tumescent LAL.

All patients received a preoperative evaluation, including blood sampling to measure hemoglobin/hematocrit values and cardiologic evaluation with electrocardiography. Anesthesia was administered via epidural blockage and/or general anesthesia.3 Liposuction was performed exclusively in the ventral and dorsal decubitus positions.

Dry liposuction was performed the first two years using 10-, 12-, and 15–mm diameter cannulas; in later years, the cannula diameters were reduced to 5, 6, and 8 mm. The submental area was at all times treated with a 3–mm cannula. Liposuction was always performed in the deep plane; aspiration ceased once mostly blood was being obtained. For the first six months in which liposuction was performed, there were no parameters defining when to stop the aspiration and volumes as high as 8000 mL were obtained. After those six months, in collaboration with the anesthesiologists, a calculation of volume reposition was made according to the aspiration obtained. For every 1000 mL extracted, there was a reposition of 1000 mL of isotonic saline solution and 1000 mL of polygeline solution (Haemaccel 3.5% colloidal intravenous infusion; Aventis, Strasbourg, France). All patients had blood tests before surgery and 24 hours after surgery to measure hemoglobin and hematocrit values. Aspiration volumes were reduced after six months, ranging from 2000 to 4000 mL. Patients with hemoglobin values less than 8 and who experienced the symptoms of anemia (ie, increased heartbeat, low blood pressure, constant headache, dizziness, and weakness) were transfused.

Dry liposuction was performed between 1983 and 1987, at which point the clinic switched to tumescent liposuction. After 1987, tumescent liposuction was performed in all patients, although the exact technique evolved over time. At first, only isotonic saline solution was administered before aspirations. Beginning in 1989, the infiltration solution was prepared using two adrenaline ampoules (1 mg of adrenaline per each 1 mL ampoule) per 1 L isotonic saline solution. No lidocaine was added. The solution was administered in a 1:1 ratio (the amount of solution being infiltrated was approximately the same as the aspiration obtained). Cannula diameters were reduced to 3, 4, and 5 mm. The amount of fat extraction was limited to 5000 mL.

There were no changes in infiltration solution, volume extraction, or operating time when using either tumescent solution alone versus suction-assisted-liposuction (SAL) or LAL. Both of the latter techniques were performed using an internal cannula after the tumescent solution was applied, followed by performance of SAL. There were no special criteria for patient selection for these techniques, other than the timeframe in which the different techniques were used: UAL (16000 Hz) was performed between 1998 and 19994; LAL was performed between 2007 and 20085, 6, 7 with an internal diode laser (wavelength, 660 nm; power, 130 mW). Incisions were always sutured and patients were instructed to wear a compressive girdle for two months postoperatively in all cases.

In 30% of cases, liposuction was performed in conjunction with one or more additional procedures (Table 1). The surgical plan for each patient included an estimate of the surgical risk and duration of surgery. Combined surgery was contraindicated if the estimated operating time was longer than five hours and the patient was overweight or had other surgical risks.8, 9 In our clinical experience, if these guidelines were followed, complication rates for combined procedures tended to be the same as those for liposuction alone.

Table 1. Procedures performed in combination with liposuction*

	Associated procedure	No. of procedures	Percent of patients undergoing
	Combined surgery	7971	30.3%
	Abdominoplasty	6221	78%
	Breast augmentation	1497	19%
	Blepharoplasty	87	1%
	Gluteal lipoinjection	3110	11.8%
	Others	112	1%

* Overall, 7971 patients out of a total of 26,259 patients (30.3%) underwent combined surgery. Because some patients underwent multiple procedures, the total number of procedures is higher than 7971 and the percentages total more than 100%.

Results 

During the 25-year period covered in this study, 26,259 liposuction procedures were performed using the different assisted techniques listed above. Nearly two-thirds of patients (64.5%) had a body mass index (BMI) between 25 and 30; 25.7% had a BMI higher than 30 and 25.7% had a BMI lower than 25. Fifty-five percent of patients were 25 to 34 years old; 25% were less than 25 years old, 15% were 35 to 45 years old, and 5% were more than 45 years old. With respect to the different techniques performed, 7933 patients underwent dry liposuction, 16,874 underwent tumescent liposuction, 307 had tumescent UAL, and 1145 had LAL. Better improvement in skin retraction in the front part of the axillae, submental area, and inner thighs was observed with LAL when compared with tumescent liposuction alone, but no difference was observed in this respect between LAL and UAL. LAL was associated with a lower incidence of inflammation and ecchymosis in comparison with tumescent liposuction alone.

Patient satisfaction with the results averaged 82%; satisfaction levels were similar for all of the liposuction techniques covered in our review. Results were obtained by asking patients to fill out a questionnaire three months after surgery. Only 34% of the patients answered the questionnaire, which was instituted only after the year 2000. Other information from the study was obtained through a review of medical records. The number of revisions performed in patients who underwent dry liposuction was 12%; the revision rate dropped to 2% once tumescent liposuction was introduced.

Complications 

Complication rates are summarized in Table 2. Anemia was present in 18% of all patients and 60% of dry liposuction patients. The incidence of seroma was 5% for all patients, but 49% for those patients who underwent tumescent UAL. Because we sutured all of our incisions, if seroma was present, the fluid was extracted with a syringe until no more was produced.

Table 2. Number of patients with complications using different liposuction techniques

				Liposuction type
	Complication	Total (N = 26,259)	Dry (n = 7933)	Tumescent (n = 16,874)	Ultrasound (n = 307)	Laser (n = 1145)
	Seroma	1313	0	1012	150	183
	Fibrosis	604	188	337	6	21
	Pain	23,633	7140	15,187	276	1031
	Skin necrosis	13	3	8	1	4
	Deep vein thrombosis	8	2	5	1	4
	Infection	3	1	2	0	0
	Pulmonary embolus	8	3	5	0	0
	Anemia	4773	4760	13	0	0
	Mortality	3	0	3	0	0

The incidence of fibrosis was 2.3% and was similar for all techniques. Fibrosis was successfully treated with techniques such as massage, ultrasound, carboxytherapy, radio frequency, and vacuum external devices.

Ninety percent of patients reported experiencing postoperative pain, regardless of the technique that was used. Since 1999, we have advised all of our patients to use an analgesic pump for the first three days after surgery; use of the pump was voluntary. This measure has allowed patients a more comfortable recovery period. Infections secondary to the prolonged use of the epidural catheter have not been encountered in any of our patients.

The incidence of skin necrosis was significantly higher in patients who underwent UAL (0.33%) than for other techniques, which led us to abandon this practice. Infection rates for dry liposuction and tumescent liposuction were similar.

In our series, the incidence of both deep vein thrombosis and of pulmonary embolism was 0.03%; it was similar in dry and tumescent procedures. Mortality occurred in 0.01% of cases and was associated with performance of the tumescent liposuction procedure mainly because of pulmonary embolus. In the mortality group, all patients had a low surgery risk and did not undergo any associated procedures.

The number of revisions using dry liposuction was 12%; once tumescent liposuction was introduced, the revision rate was reduced to 2%. We believe that this reduction was related to the use of smaller cannulas in tumescent liposuction.

Discussion 

In 1983, two of the authors (CT and CB) traveled to Paris to learn how to perform liposuction from Yves-Gerard Illouz, who is generally regarded as the father of modern liposuction. We returned to Colombia with liposuction equipment and cannulas purchased from Dr. Illouz and began performing dry SAL procedures. Working together with anesthesiologists, we achieved safe results and a high degree of patient satisfaction. Nevertheless, the blood loss and need for transfusions was always a concern and eventually led us to abandon dry liposuction in favor of using infiltration solutions before the aspiration process. After the use of tumescent solution was reported, we started using epinephrine and isotonic saline solution as a way to reduce blood loss and still obtain good postoperative results.

As liposuction became more popular, new technologies were introduced to improve the technique. Although we did not encounter any problems with tumescent liposuction, we began using UAL, which offered an easier means of extracting fat. However, we stopped performing this technique after a short time because of the incidence of skin necrosis encountered in our own practice and in the reports of colleagues. Since 2007, we have been using LAL with good results. Although in our experience the degree of improvement associated with the use of this technique has not been dramatic, it has helped us to obtain better skin retraction in areas such as the front part of the axillae, the submental area, and the inner thighs. With respect to complications, anemia was encountered mainly in dry liposuction procedures, which is why we switched to alternative procedures that normally did not require transfusions. We believe that the incidence of seroma can be reduced by instructing the patient to wear a compressive girdle for seven days after surgery, tightening it further on the eighth postoperative day and continuing to do so until inflammation is no longer present.

We also believe that mortality was present in the tumescent group because this group included the largest number of patients in the series. To avoid these complications, since 2004 we have administered enoxaheparine to all of our patients one day before and for at least one day after surgery; in some patients, this was continued until postoperative day four. We also introduced the use of intraoperative intermittent compressive leg bandages in our patients in 2007.10, 11 In our practice, preoperative tests and any history of medical revisions are crucial elements in estimating patient risk. Patients with a moderate to high risk are contraindicated for surgery.

Conclusions 

Over the course of our experience with various liposuction procedures, we gathered a great deal of outcomes data. Most significantly, the use of tumescent liposuction reduced the incidence of anemia, but increased the incidence of seroma. The incidence of postoperative pain and fibrosis in our patients was similar regardless of the technique used. Aesthetic results using assisted liposuction devices in UAL and LAL procedures were similar to those achieved in tumescent liposuction.