America is facing an obesity crisis. More than 50% of the adult population is overweight, and a significant percentage of them are obese.

Recent studies linking truncal obesity to increased insulin resistance are part of the reason for the recent growing demand for liposuction surgery.

While a healthy diet and exercise remain crucial components for overall health, the benefits of decreasing truncal mass—which decreases insulin requirements and makes exercising easier—has led to the increasing demand for large-volume liposuction in particular.

Small-volume liposuction usually involves removing up to 5 liters of fat from the patient's body. Large-volume liposuction refers to cases in which 5 or more liters of fat are removed.

Large-volume liposuction does have a considerable amount of risk attached to it, but as long as the patient meets all of the criteria listed below, the risks associated with the surgery should be minimal.

One of the main factors that differentiate large-volume liposuction from the more traditional methods is that the patient loses more liquid than in other procedures.

Therefore, he or she requires solid cardiovascular and pulmonary health to keep the body safe during surgery.

CRITICAL FACTORS

Physicians and potential patients need to be aware of some critical factors prior to seeking treatment.

Patients are advised to seek surgeons with experience and training in this specific procedure, as opposed to aesthetic surgery in general.

The physician must choose an anesthesiologist carefully, as the surgeon and the anesthesiologist will communicate constantly and make adjustments during the procedure.

Large-volume liposuction should take place only in an accredited facility. In addition, make sure any staff members working on the surgery know the ins and outs of the procedure and are prepared to handle any issues that may arise.

Large-volume liposuction is not appropriate for everyone who wants to lose weight.

Physicians need to use a specific set of criteria to determine whether a candidate can safely benefit from this surgery.

Any candidate for large-volume liposuction should meet certain criteria prior to surgery.

Preoperative evaluations can be highly beneficial in determining which patients are or are not potential candidates for the surgery.

Candidates should be physically and mentally healthy with no untreated medical problems.

Undetected issues—such as cardiovascular problems, thyroid disease, and sleep apnea—can be potentially fatal in the operative and postoperative stages of surgery.

Figure 1. A healthy 26-year-old woman prior to traditional liposuction (left); and again 6 months after surgery (right), during which 7 liters of fat were removed and 360 cc of fat were added to each buttock.

Figure 1 shows the results of a healthy 26-year-old female who received a traditional liposuction procedure in order to contour the waist, abdomen, and buttocks.

Fat grafting (the transplanting of fat cells) was used to remove dimpling and to round out the buttocks.

AVOID PATIENT HEARTBREAK

Physicians should also evaluate a patient's mental state and expectations.

Anyone aspiring to perfection will be disappointed with the results. It is a surgeon's job to make sure a candidate's expectations are realistic.

In addition to a healthy body and mind, candidates should also have a stable weight or be in the process of losing weight through diet and exercise.

For those who are compliant, any diet medications should be discontinued no less than 2 weeks before surgery.

During the preoperative evaluation, patients should be given a thorough physical exam as well as be asked to complete a detailed family history.

The preoperative evaluation will determine if a candidate has a normal blood volume and if the lungs are healthy.

It is also imperative that candidates be nonsmokers with no previous abdominal surgery and be within 30 and 35 pounds of their target weight. For those who are close to their target weight, the risk of complications is lower than those who are not.

Surgery candidates must also maintain a stable preoperative weight. Crash dieting depletes volume and is hazardous to the patient's health. In addition, prospective patients should respond well to a "snap back" skin test for elasticity.

INTRAOPERATIVE DECISIONS

The tumescent technique has become a standard in recent years because the larger amounts of anesthetics used have several benefits.

The tumescent technique can result in fewer skin irregularities, and can reduce pain, bleeding, and swelling after surgery. Blood loss is minimized, and the need for a blood transfusion after surgery is reduced.

An anesthesia solution consisting of a mixture of saline (intravenous salt solution), lidocaine (a local anesthetic), and epinephrine (adrenaline that constricts blood vessels) is injected into the planned regions for fat sculpting.

A large amount of fluid is used to inflate the fat compartments and make them firm and swollen so that the cannulae can pass under the skin smoothly while fat is removed.

Figure 2. A healthy 28-year-old female with very good skin elasticity and the qualities of a good candidate (left). The right photo shows the patient 6 months after having 6.5 liters of fat removed via ultrasonic liposuction. There is significant contouring of the abdomen flanks without skin damage.

The tumescent liposuction procedure can take significantly longer (sometimes several hours longer) than traditional liposuction.

On the other hand, the superwet technique requires the injection of a volume of dilute local anesthesia that is less than half the volume used for the tumescent technique.

Using this technique, smaller volumes of fluid are injected—in many cases, the amount of fluid injected is equal to the amount of fat removed.

The superwet technique, like the tumescent technique, requires intravenous sedation or general anesthesia. Approximately 8% of the fluid removed by superwet liposuction is blood.

In performing large-volume liposuction, general endotracheal anesthesia is the preferred method of anesthesia. It is a balanced anesthetic containing narcotic, propofol, midazolam, and an inhalational agent.

Intraoperative monitoring during the procedure can include ECG and blood pressure monitoring; pulse, temperature, and carbon dioxide measurement; and urine output.

Communication between the surgeon and anesthesiologist is essential for a successful surgery. Constant monitoring of the patient's fluid balance is also necessary.

The anesthesiologist must be constantly aware of how much wetting infusion is given in relation to fat and saline aspirated, including urine and blood loss.

This is necessary in order to determine the patient's fluid balance and to avoid any fluid overload, as well as to avoid the possibility that the patient will not have enough fluid to sustain himself or herself.

Pneumatic compression cuffs are used for all patients undergoing large-volume liposuction. They are placed on the patient prior to surgery, in order to prevent pulmonary emboli.

In addition, the surgery should take no longer than 3.5 hours—this is to help reduce the amount of trauma and stress to the patient's body.

If the surgery will take longer than 3.5 hours, the surgeon can schedule it in different stages.

If large amounts of fat are to be removed from the lower back and flanks, the patient should be placed in the prone position in order to allow maximum access to those areas, as well as to help prevent oversuctioning (which can lead to skin damage).

Attention to body temperature also plays a crucial role in a successful procedure.

Patients are at a higher risk of developing hypothermia due to the exposure of large areas of the body to an infusion of wetting solutions.

Another factor is the lengthy time involved in doing the procedure. It is very important to prevent hypothermia, as it is difficult to correct once it sets in. Careful monitoring of the patient, as well as the room temperature, can help prevent this complication.

ULTRASOUND IS IN

The ultrasonic technique has become very popular in recent years for a number of reasons.

By using ultrasonic technology to blast apart fat deposits prior to removal, surgeons will find that patients experience less blood and fluid loss, reduced bruising, and improved postoperative contraction or tightening of the skin.

In order to qualify for the ultrasound technique, patients must have normal heart health; good skin elasticity (not loose or with stretch marks); and normal blood volume. The last point may be a matter of concern for menstruating women.

Figure 3. The photos track the progress of a 32-year-old male who had 7.6 liters of fat removed via ultrasound. Top top left and top right photos represent a lateral view 7 days after surgery; the top right photo demonstrates minimal bruising and mild postoperative edema. The bottom left and bottom right photos show before surgery and 4 months postsurgery.

As a point of reference, please see Figure 3, which depicts a 32-year-old male patient who had 7.6 liters of fat removed via an ultrasound-based procedure.

The top two photos represent a lateral view 7 days after surgery; the top right photo demonstrates minimal bruising and mild postoperative edema. The bottom two photos represent before and 4 months postsurgery.

Notice that the patient exhibits significant skin contouring, no damage or rippling of the skin, and a gradual decrease in the amounts of edema and bruising.

This patient is now able to exercise more readily because of his diminished abdominal girth.

POSTOPERATIVE CARE

After surgery, patients should be admitted to postoperative care for approximately 2 hours for close monitoring of their vital signs.

It is necessary to have a well-trained staff of registered nurses in the recovery room area in order to provide the maximum amount of care to a patient who has just undergone large-volume liposuction.

Usually 24 hours after the surgery, the physician sees the patient and instructs him or her about support garments, which are generally recommended 3 to 5 days after surgery, depending on how much edema is present.

Patients are usually asked to wear surgical garments for 4 to 6 months after the procedure.

If a significant amount of edema is present, the patient is given 25 mg of maxide, which helps eliminate excess water.

Patients should also be encouraged to walk 24 hours after surgery to increase circulation. After the first 7 to 10 days, patients should be encouraged to start lymphatic massage twice per week for 4 weeks.

Heating pads and ice packs are not recommended during the postoperative care procedure, as the use of these devices can lead to further injury.

After 2 weeks, the patient is usually advised to return to the gym and resume workouts two to three times per week.

In addition, they are given specific dietary instructions that often include a menu designed for glycemic control—to minimize insulin resistance.

The diet should be high in omega-3 fatty acids and vitamin C, and should be free of trans fat.

Multiple small daily meals should be recommended, with snacks in between. The patient is then weighed every 2 weeks to ensure that there is no weight gain.

Perhaps one of the most important aspects of postoperative care after large-volume liposuction is the support team involved with the aftercare.

After the procedure, the patient is released to a trusted, competent aftercare facility for 24 to 48 hours, or to a specialty nurse who will manage their immediate aftercare.

In both cases, the primary objective of all aftercare workers is to watch over the patient and determine if any additional medical action needs to be taken after the procedure—due to complications in breathing and swelling.

Susan Evans, MD, is the director of dermatology at Cosmetic Physicians of Beverly Hills, Calif. She has conducted research on the effects and advantages that diet and liposuction have on both insulin control and skin health. She can be reached at .