Introduction
Liposuction, formally known as suction-assisted lipectomy, represents one of the most commonly performed aesthetic surgical procedures worldwide. Primarily a body-contouring procedure, liposuction utilizes vacuum suction to remove subcutaneous adipose tissue in certain anatomical areas. However, liposuction should not be portrayed as a weight loss procedure. Since the inception of liposuction in the late 1970s, the procedure has continued to evolve, undergoing a series of technological and procedural advancements (eg, lasers and ultrasound).[1][2][3]
Anatomy and Physiology
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Anatomy and Physiology
A thorough understanding of the orientation and architecture of subcutaneous fat remains essential for clinicians aiming to achieve proficiency in liposuction. Clinically, fat can be appreciated as divided into 2 layers: the superficial fat layer and the deep fat layer, typically separated by a superficial fascia system, eg, the Scarpa fascia in the trunk or the superficial musculoaponeurotic system (SMAS) in the face.[4] The deep fat layer, which contains a larger volume of loosely organized adipose tissue, is treated first. The superficial fat layer, being thinner and denser, is addressed second to aid in skin tightening. Treating the superficial layer requires caution, as overtreatment may lead to complications, eg, contour irregularities or vascular compromise of the overlying tissue. Avoiding these complications involves minimizing aggressive superficial liposuction and ensuring cannula ports do not directly engage with the overlying skin.
The consistency of the fatty tissue can be divided into the following 2 groups:
- Fibrous fatty tissue: This tissue is less amenable to liposuction techniques and typically resides in the superficial layers.
- Areolar fat: This tissue is found deeper in the adipose layer and is more loosely organized with fewer fibrous stromal elements between the fat cells, and remains highly responsive to liposuction.
The zones of adherence (ZOA), where the subcutaneous tissue adheres to the fascia of the underlying muscle, should be avoided during liposuction to decrease the risk of contour irregularities. ZOA includes:
- The lateral gluteal depression
- Gluteal crease
- Distal posterior thigh
- Mid-medial thigh
- Inferolateral iliotibial tract [5]
Indications
In discussing the indications for liposuction, clinicians must take into account that liposuction is most often considered an aesthetic procedure and, as such, is entirely elective. Therefore, the burden of proof for demonstrating that the patient is a suitable candidate for the procedure lies with the surgeon. Indications of an ideal candidate for liposuction include:
- The patient must demonstrate deviations from normal body contour caused by excess adiposity in the region.
- The patient should be within 30% of their normal body mass index (BMI).[6]
- An ideal candidate is nonobese, with minimal skin laxity and minimal to moderately excessive adipose tissue.
- A patient's weight should be stable for 6 to 12 months before surgery.[7]
Contraindications
A thorough medical history should be taken in all patients, as well as a social history screening for alcohol, tobacco, and recreational drug use. The following factors can adversely affect liposuction outcomes:
- Smoking: Smoking cessation should be instituted for all patients at least 4 weeks before the procedure to maximize healing and reduce the risk of complications.[8]
- Clotting risks: The most disastrous complication of liposuction is a deep vein thrombosis (DVT) that could potentially lead to a pulmonary embolism (PE). Therefore, attempts to deduce the patient's risk for a DVT/PE should be performed using the Caprini score.[9]
- Body dysmorphic disorder: Furthermore, studies have demonstrated that up to 15% of patients seeking aesthetic surgery have body dysmorphic disorder (BDD), which occurs when patients have a distorted view of their appearance despite there not being any overt abnormality.[10] Patients with suspected BDD (based on screening questionnaires or during the initial interview) or those with unrealistic expectations and a tenuous understanding of the planned procedure should not proceed with surgery until proper evaluation with a mental health professional (eg, psychiatrist) is obtained.
Equipment
Since the introduction of liposuction, the design of cannulas has undergone significant evolution. Originally sharp and single-holed, modern cannulas are typically blunt-tipped with multiple openings near the tip. This advancement reduces the risk of accidental puncture into the pleura, peritoneum, or deep neck spaces, while also helping to minimize intraoperative blood loss.
The cannula serves to avulse adipose cells from the fibrous stroma separating the fat, allowing the fat to be suctioned. Cannulas with larger diameters and greater surface area cause more extensive stromal disruption and adipose avulsion, but also lead to increased indirect trauma and blood loss compared to smaller cannulas.[7][11] Cannula type and size are selected based on the surgeon's preference and the anatomical site of liposuction. A detailed discussion on cannula selection in various liposuction procedures, including body, submental, facial liposuction, and fat grafting, is beyond the scope of this course.[12][13][14][15]
Selection of the suction device—manual syringe versus suction machine—depends on both the fat volume and intended use. When fat is harvested for autologous fat grafting, high-pressure suction should be avoided to preserve cell viability. A manual syringe may be preferred for small-volume harvests, eg, facial fat grafting. Within the aspirate system, the cannula presents the highest resistance to flow.[16]
To improve safety and efficiency, a wetting solution—composed of lidocaine and epinephrine diluted in crystalloid (lactated Ringer's or normal saline)—is infiltrated into the target fat before liposuction is performed. The 4 wetting techniques recognized include dry, wet, superwet, and tumescent. Depending on the type of anesthesia, surgeons may use a 1:1 aspirate-to-infiltrate ratio or a 3:1 wet technique.[17][5]
Personnel
Liposuction may be performed under general anesthesia, intravenous sedation, or mild sedation that does not require an anesthesiologist. Some surgeons choose to forgo sedation entirely when using superwet or tumescent infiltration techniques.[18][19][20]
High-volume liposuction requires anesthesia to facilitate intravenous fluid administration and reduce the risk of hypotension. When the lipoaspirate volume remains below 4 liters, intravenous fluids may be unnecessary if the procedure is performed under oral or mild sedation. Once the aspirated volume exceeds 4 liters, maintenance fluids should be administered, along with an additional replacement of 0.25 mL of crystalloid for every 1 mL of lipoaspirate beyond the 4-liter mark.
While the biomechanics of regions below the head and neck permit large-volume liposuction and the corresponding use of large volumes of wetting solution, vigilant monitoring by both the surgeon and anesthesiologist remains critical. Particular attention should be paid to signs of hemodynamic instability and local anesthetic toxicity throughout the procedure.[18][20][21]
Preparation
As with all aesthetic procedures, preoperative photographs play an essential role in surgical planning and serve as documentation of the patient’s preoperative contour, particularly for those expressing dissatisfaction with their appearance. Marking the patient in the preoperative area helps identify specific regions of excess adipose tissue to be addressed during the procedure.
All necessary equipment must be present in the operating room and confirmed to be functioning properly before surgery begins. A standard surgical time-out should be conducted to address all concerns before incision, regardless of whether the procedure involves general or local anesthesia. Afterward, a wetting solution is administered, with a 15- to 30-minute interval allowed to achieve optimal vasoconstriction and anesthesia.
The patient is then prepared and draped using standard sterile technique. In large-volume liposuction cases, surgical team members must clearly communicate the planned patient positioning for each stage of the procedure (eg, supine, prone, or lateral decubitus). To reduce the risk of traumatic perforation during trunk liposuction, many surgeons position the patient in a slight jackknife configuration.
Technique or Treatment
Multiple techniques are commonly used during liposuction, though all follow several core principles, including:
- Cannula entry sites must be large enough to accommodate the cannula and are created in the skin using a scalpel. The dominant hand guides the cannula or syringe (in manual suction), while the nondominant hand remains spread on the skin to palpate the distal cannula’s position. This hand serves 2 essential roles: gently identifying areas of residual adiposity and continuously monitoring the cannula’s depth.
- Suction should occur just beneath the superficial fat layer. Skin dimpling indicates a cannula position that is too superficial, increasing the risk of contour irregularities.
- Traditional suction-assisted liposuction (SAL) remains the most widely used method of liposuction. However, recent innovations have introduced the following alternative techniques:
- Power-assisted liposuction (PAL): Uses a motorized cannula that oscillates back and forth, potentially increasing procedural efficiency.[22]
-
Ultrasound-assisted liposuction (UAL): Employs an ultrasound cannula to break down adipose cells, easing suction and reducing surgeon fatigue.[23]
-
Laser-assisted liposuction (LAL): Utilizes a laser-equipped cannula to disrupt fat tissue, potentially enhancing fat reduction.
Regardless of technique, liposuction concludes once the surgeon determines that no palpable fat remains in the targeted area. Current literature does not strongly support replacing SAL with UAL or LAL across all cases. However, select scenarios demonstrate the following advantages:
-
UAL outperforms SAL in treating gynecomastia.
-
LAL and UAL reduce blood loss in high-volume lipoaspirates.
-
LAL improves skin tightening in the submental region.
Complications
Patients must receive preoperative counseling to understand that minor bruising and swelling commonly follow liposuction. Several complications require awareness from both the patient and the clinical team.
Contour deformities represent the most frequent complication. Postoperative bruising typically resolves within 1 to 2 weeks, while edema may persist for several weeks. The final contour becomes apparent only after the swelling fully subsides. Other common complications include:
-
Seroma
-
Temporary weight gain
-
Paresthesias [24]
Although rare, the most severe complications include fat embolism (marked by shortness of breath and dyspnea), deep vein thrombosis (with calf pain and leg swelling), and pulmonary embolism (characterized by dyspnea and tachycardia). Prompt medical intervention remains crucial, as these complications can be fatal.[25]
Preventive measures, eg, thorough preoperative medical clearance, medication review, anticoagulant prophylaxis, the use of sequential compression devices on both legs, and early postoperative ambulation significantly reduce DVT risk. Lidocaine, used in wetting solutions, has a demonstrated safe upper limit of 55 mg/kg, although most surgeons recommend limiting usage to 35 mg/kg. Despite these guidelines, toxicity may still occur, especially under general anesthesia, where early signs such as perioral numbness and tinnitus remain undetectable. Toxicity often becomes apparent only after cardiovascular symptoms develop. Management of local anesthetic toxicity includes immediate discontinuation of lidocaine, supplemental oxygen, seizure control with medications such as benzodiazepines, and administration of a 20% lipid emulsion: a 100 mL bolus over 2 to 3 minutes followed by 200 to 250 mL over 15 to 20 minutes.[26]
Clinical Significance
Liposuction is one of the most popular cosmetic surgical procedures. Understanding the basic core principles of the procedure is valuable for the entire healthcare team involved. A comprehensive understanding of liposuction’s technical aspects, anatomical considerations, equipment, anesthesia, and potential complications holds critical clinical significance for improving patient safety, outcomes, and overall procedural success.
Mastery of subcutaneous fat architecture, including the differentiation between superficial and deep layers, is fundamental in achieving optimal contouring while minimizing complications. Effective treatment strategies rely on accurate preoperative markings, knowledge of fascial planes, and disciplined control of cannula depth to prevent contour irregularities and vascular compromise. The more the processes at work are understood, the better equipped a clinician is to manage these surgical patients, improve aesthetic outcomes, and, more importantly, address complications that may arise during the course of their treatment and recovery. Early intervention, patient education, and interprofessional planning are central to minimizing risks, optimizing aesthetic results, and ensuring the highest standard of care in liposuction procedures.
Enhancing Healthcare Team Outcomes
Effective liposuction care requires a coordinated, interprofessional approach that leverages the skills and responsibilities of physicians, advanced practitioners, nurses, pharmacists, and ancillary staff to ensure patient-centered care and optimize outcomes. Surgeons and advanced practitioners must possess advanced procedural skills and anatomical knowledge, including the ability to assess fat compartments, manage fluid shifts, and identify early signs of complications such as lidocaine toxicity or fat embolism. Strategic planning begins in the preoperative phase with comprehensive assessments, clear communication of risks and expectations, and informed consent. Surgeons and nurse practitioners collaborate to develop individualized treatment plans that align with patient goals, while ensuring clinical safety. Pharmacists play a crucial role in reviewing medications, preventing drug interactions, and advising on the safe use of local anesthetics, particularly regarding lidocaine dosing thresholds for wetting solutions.
Throughout the perioperative period, nurses coordinate care by preparing the operative field, managing sterile technique, and assisting with fluid administration and positioning during various stages of liposuction, particularly in large-volume cases. Intraoperatively, they monitor the patient's vitals and communicate concerns immediately, thereby enhancing team responsiveness and minimizing risk. Postoperative care includes vigilant observation for complications, timely ambulation to reduce thromboembolic risks, and patient education on expected recovery trajectories. Seamless communication between all members of the care team—surgeons, anesthesia clinicians, nurses, and pharmacists—ensures swift decision-making and promotes a culture of safety. Effective documentation, team debriefings, and shared protocols support continuous improvement and team performance, ultimately enhancing both patient satisfaction and procedural outcomes.
Nursing, Allied Health, and Interprofessional Team Interventions
Perhaps the most important role for the interprofessional team during the window of intervention is the application of sequential compression devices in the postoperative care area and encouraging early ambulation as soon as the patient is ready. Furthermore, as with all surgical procedures, the healthcare team must instruct the patient on care once they are discharged.
For liposuction, many surgeons opt for tight compressive dressings in the postoperative recovery phase to minimize edema and ecchymosis. The nursing team in the postoperative area must reiterate these instructions to the patient, ensuring that they fully understand them and have the capacity to follow them.
The nursing staff is usually the last healthcare team facet to see the patient before discharge, and a sense of interprofessional communication must be maintained throughout the team. Reviewing home medications, including those that should be avoided during the recovery phase and those that should be initiated immediately, is essential. Incision and drain care must also be reviewed with the patient.
Nursing, Allied Health, and Interprofessional Team Monitoring
High-risk surgical patients must be monitored closely overnight by a nursing member of the interprofessional team. High BMI, large volume liposuction of over 5000 mL, a procedure in length greater than 6 hours, combined procedures, high-risk comorbidities such as coronary artery disease, or any intraoperative aberrant vital signs are all criteria for admission to an observation unit for overnight monitoring by a skilled nursing member with continuous care.[22]
As is standard procedure before discharge, the healthcare team must certify that the patient is stable for discharge and has a well-entrusted environment and a reliable caretaker at home. Furthermore, for the management of complications and outcomes, it has been well-documented in the literature that the details of the surgical procedure and any unforeseen intraoperative events should be thoroughly documented.[23] Thorough counseling by the interprofessional team during the postoperative period can significantly enhance patient satisfaction and safety.
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