Major Liposuction


Major Liposuction

Justin B. Cohen & Terence M. Myckatyn
A 41-year-old woman presents to the clinic to discuss possible surgical options to improve the appearance of her “saddlebags.”


  • Significant, diffuse lipodystrophy noted bilaterally in “saddlebag” regions of upper lateral thighs.

  • Skin redundancy and residual adiposity noted on the central trunk.



  • Weight stability.

  • Medical comorbidities.

  • Patient concerns, expectations, and goals of treatment.

Physical examination

  • Evaluate regions of suboptimal contour, asymmetry, lipodystrophy.

  • Evaluate skin quality and tone (thickness and elasticity): Pinch test.

  • Examine for hernias, diastasis.


  • Liposuction is a contouring procedure.

    • Best in areas of thick, elastic skin with underlying contour irregularity of fat.

    • Does NOT address cellulite or obesity.

    • Does NOT resect skin.

  • Perform preoperative markings with patient upright to determine treatment areas and asymmetries, and outline zones of adherence.

  • Target deep fat layer and cross-tunnel to prevent contour irregularities.

  • Wetting solution technique (Table 33.1)

    • Lidocaine, epinephrine, and bicarbonate solution added to saline or lactated Ringer solution.

    • Provides anesthesia and hemostasis.

    • Maximum lidocaine with epinephrine: 35 mg/kg.

    Wetting solutions for liposuction



    Estimated blood loss (% volume)





    200–300 mL per area



    1 mL of infiltrate per 1 mL of aspirate



    2–3 mL of infiltrate per 1 mL of aspirate (or to skin turgor)


  • Liposuction modality

    • Suction-assisted liposuction (SAL): Traditional liposuction technique.

    • Power-assisted liposuction (PAL): Motorized oscillating hand piece.

    • Ultrasound-assisted liposuction (UAL): Ultrasonic energy is applied after wetting solution to emulsify fat before aspiration.

      • Ideal for fibrous regions: Buttocks, lumbar region, gynecomastia.

      • Precautions to avoid cutaneous thermal injury.

    • Laser-assisted liposuction (LAL).

  • Fluid management for large-volume liposuction (critical safety issue)

    • Replace preoperative deficits.

    • Employ superwet or tumescent technique.

    • Administer maintenance intravenous fluid (IVF) + IVF replacement of 0.25 mL/1 mL of aspirate over 5 L.

    • Titrate IVF to patient′s clinical picture (e.g., urine output, vital signs).

    • Maintain intraoperative fluid ratio: (IVF + infiltrate)/aspirate = 1.2.

    • Older technique (Pitman): IVF + infiltrate = 2 × aspirate.

    • 25 to 30% of infiltrate is removed with aspirate.

  • If large-volume liposuction (≥ 4 to 5 L) is performed, it must be done in an acute-care hospital or accredited facility.

    • Monitor vital signs and fluid balance with Foley catheter. Overnight inpatient observation.

    • Warm patient, fluids, and operating room to avoid hypothermia.

    • Dilute lidocaine further if greater volume of infiltration is necessary.

  • Deep venous thrombosis (DVT) prophylaxis

    • Mechanical: sequential compression devices.

    • Ambulate day of surgery.

    • Chemoprophylaxis not standardly required.

  • Postoperative care

    • Early ambulation.

    • Compression garments for 4 to 6 weeks.

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Jun 18, 2020 | Posted by in General Surgery | Comments Off on Major Liposuction
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