Seeing an aesthetic procedure all over social media can breed a strange sort of FOMO. (Hey, we’re not immune.) Yet it may be difficult to distinguish for-the-’Gram fads from truly “Worth It” tweaks. Which is why we’re launching a new series on RealSelf: Everybody’s Doing It. Each month, we’ll explore all sides of an of-the-moment cosmetic procedure, to bring you the uncensored truth about its efficacy and safety so you can decide if it’s right for you. Here, in our second installment, we’re examining the role of technology in liposuction.
One of the earliest liposuction surgeries on record dates back to 1926, when French surgeon Charles Dujarier aimed to sculpt the calves of a young ballerina by carving out fat with a sharp curette. (À quel prix, la beauté?) The crude operation resulted in gangrene and eventual amputation, casting a progress-stunting pall over the procedure for decades to come.
Today, lipo is the most sought-after (not to mention grid-worthy) plastic surgery procedure in the world, with more than 1.5 million takers in 2017 alone, according to the International Society of Aesthetic Plastic Surgery. In the U.S., interest in the operation spiked nearly 32% between 2014 and 2018. Doctors attribute lipo’s ratcheting popularity, in part, to society’s next-level body goals—“our focus on ever-more-elite and high-achieving levels of fitness as opposed to just being ‘in shape,’” explains Dr. Jacob Unger, a plastic surgeon in Nashville.
Further propelling lipo up the charts is its reputation as a reliably safe and transformational fix for stubborn flab—a track record hard-earned over the past four decades. “Way back when, liposuction was done as a dry technique and blood loss was significant,” explains New York City plastic surgeon Dr. Umbareen Mahmood. By the early ’80s, surgeons were routinely using wetting solution—that is, filling the fatty area with a prescribed quantity of fluid, “either normal saline or [electrolyte-infused] lactated Ringer’s, plus a proportion of lidocaine for anesthetic effect and epinephrine to cause vasoconstriction and prevent bleeding,” she adds—before breaking apart and vacuuming out fat with vigorous thrusts of a stainless steel cannula.
Over the years, doctors have deepened their knowledge of fat anatomy and nuances; improved the patient-selection process for lipo; adopted smaller, more refined cannulas, for loosening and extracting fat; capped the allowable amount taken during outpatient procedures; and developed protocols to slash complications. To what effect? Lipo’s published mortality rate in the ’90s was roughly 1 in 5,000 (mainly due to blood clots). In 2019, it’s about 1 in 20,000, says Dallas plastic surgeon Dr. Rod Rohrich, with those rare “deaths typically occurring when lipo is performed in combination with a tummy tuck versus liposuction alone, which is very safe.” Liposuctioning multiple areas during a single surgery has also been shown to hike complication rates.
While lipo videos on social media make the operation seem mindlessly mechanical—jab, jab, jab, aaaand abs!—a thoughtful technique and unflinching attention to detail are critical to safety. To clear out fat as efficiently as possible, plastic surgeons rely on various forms of fat-dislodging tech—from power-driven cannulas to collagen-sparking thermal devices like laser fibers and ultrasound-emitting probes. While most of these tools have been around since the ’90s, a relative newcomer to the lipo arena is radiofrequency, which is now being tapped for its purported skin-tightening prowess.
As the role of technology arguably shifts from surgical assistant (making the task easier) to surgical enhancement (making results better), devices are becoming pivotal players in lipo’s evolution from fat-sucking procedure to body-sculpting phenomenon.
We’re seeing it unfold all over social media—the hyper-etched abdominals and precisely defined deltoids emerging from the high-definition liposculpture movement. Noticeably absent among the likes and comments on these posts are the reservations shared offline by plastic surgeons who personally dislike the Hulk-ish aesthetic or are troubled by the potential consequences that could arise from slapping superhero muscles on a bunch of mere mortals.
Equally concerning to many surgeons is the modern-day spin surrounding lipo—particularly, the myriad of trademarked liposuction treatments (hello, Fun Lipo) aiming to convince us that Insert-Gimmicky-Name-Here version is somehow superior to or less invasive than traditional, time-tested methods. “These companies get very creative with their marketing, to the point of being duplicitous and misleading,” says Philadelphia plastic surgeon Dr. Christian Subbio. “It becomes quite confusing for patients to navigate this new age of lipo.”
Ah, but that’s where we come in. With the help of top plastic surgeons, we’ve compiled a no-BS guide to liposuction—from prioritizing doctors over devices to ensuring a smooth surgery and recovery.
First things first: Are you a good candidate for lipo?
During lipo consults, expect potential surgeons to be sizing you up every bit as much as you are them—and ultimately picking you only if you meet certain criteria. “The more selective we are when choosing appropriate patients for surgery, the less risky lipo becomes,” notes Dr. Subbio.
The ideal candidate is, first and foremost, a healthy adult with realistic expectations who understands the limitations of liposuction. Unlike a tummy tuck, say, lipo cannot tighten abdominal muscles or remove excess skin. Dr. Subbio adds, “If someone comes in, wanting lipo, but what they really need after having a set of twins and another child is a tummy tuck, I’d rather lose their business than give them the wrong surgery.”
Another lipo limitation is the volume of fat that can be safely targeted. “There’s not necessarily a legal limit, but most board-certified plastic surgeons follow the five-liter rule—which, at 11 pounds, is still pretty significant,” explains Dr. Mahmood. (Patients looking to lose larger quantities require an overnight hospital stay to have their fluid and electrolyte levels monitored.)
Liposuction is not a weight-loss method, after all—nor is it “a quick fix for poor lifestyle choices,” says Dr. Subbio. People should generally be within 30% of their ideal weight, notes Dr. Mahmood, and aiming to treat pockets of pinchable fat that are resistant to diet and exercise. Hot spots for lipo include the abs, love handles, back, bra rolls, upper arms, inner and outer thighs, knees, ankles, and under the chin.
Recent lipo studies unanimously emphasize that optimal candidates are fit, active nonsmokers with a BMI less than 30. A 2019 paper in the Aesthetic Surgery Journal (ASJ) notes that “patients with a BMI greater than 30 have a sixfold higher risk for VTE [venous thromboembolism, or blood clot formation], while those with a BMI greater than 40 are more than an eightfold risk.” Still, most doctors don’t view that number as an absolute cutoff. “Years ago, I might have turned someone away for not fitting the [BMI] criteria,” admits Dr. Mahmood. “But for those who are slightly overweight, liposuction can serve as more of a debulking tool than a contouring tool, often providing enough of a change to kick-start a new workout routine.”
Surgeons are less apt to budge on the issue of skin quality. “Patients need to have good elasticity, so that when we remove fat, the skin will snap back into place rather than drop and hang,” says Dr. Subbio. Obvious signs of laxity are a panniculus—an apron of loose skin that folds down over the lower abdomen—and stretch marks, “which are subdermal scars signifying that the skin has lost a significant degree of elasticity and is not going to shrink-wrap back down the way it should, once we reduce the underlying fat,” he adds.
Related: RealSelf’s Guide to Traveling Out-of-State for Plastic Surgery
Lipo lingo—what does it all mean?
“Patients often come in, requesting certain types of lipo without fully grasping their meaning or the risks and benefits associated with each,” says Dr. Mahmood. The most prevalent terms can be neatly split between techniques and technologies—all involve the non-negotiable first step of swelling the treatment area with wetting solution.
Liposuction techniques
Buzzy liposuction techniques you may have heard of include…
SAFELipo
SAFELipo is a three-step process introduced in 2010 by plastic surgeon Dr. Simeon Wall Jr. to minimize contour irregularities, or divots and lumps—the most common complication associated with lipo. (The inner thighs, abdomen and arms are the most prone, notes Dr. Rohrich.) The technique has since become standard practice for surgeons worldwide. SAFE is an acronym for Separation, Aspiration and Fat Equalization. Surgeons first tunnel through deep fat with a vibrating (heat-free) cannula without suction, to free fat cells from one another and surrounding tissues. They can then gently suction fat away without traumatizing skin and vessels. As a final step, they use their cannula (again, off suction) “to dislodge any remaining fat that’s still on the dermis or in the tissue, spreading around those little pieces, which act almost like fat grafts, filling in uneven areas to smooth everything out,” says San Francisco plastic surgeon Dr. David Sieber.
360 Lipo
360 Lipo treats the entire circumference of the torso as opposed to discrete spots, “to give a more harmonious appearance to the abdomen,” says Dr. Sieber. Despite what the name may imply, 360 Lipo isn’t always high-volume fat reduction. “There are patients in whom the circumferential fat is voluminous, and they may be clinging to eight liters in their trunk alone,” says Dr. Subbio. “But others may have only 1.5 liters, evenly distributed around their circumference.” According to Dr. Mahmood, strategic 360 Lipo can “change the proportions of one’s waist-to-hip ratio, to make the butt look more prominent and projected,” offering a less dramatic alternative to the potentially risky Brazilian butt lift.
High-definition lipo
High-definition lipo imparts a 3-D vibe “by leaving a slightly thicker layer of fat over muscular areas, to give them definition, and taking more fat out of areas where there are naturally shadows, to enhance the contours,” says Dr. Sieber. The approach is usually reserved for superfit patients who’ve committed to a healthy lifestyle. High-def is generally more aggressive than basic lipo, partly because surgeons are working in multiple planes. “When we’re doing standard lipo for an overall volume reduction, we’re typically targeting loose, easy-to-grab fat from deep under the fascia [connective tissue covering our muscles],” explains Dr. Unger. “High-def lipo removes fat from that deep layer as well as the superficial layer below the dermis to create visible valleys offsetting the peaks left behind.” (Removing superficial fat is associated with a higher risk of contour deformities.) Since skin compression is key to the cut look, doctors often use ultrasound or radiofrequency energy—more on those ahead—during high-def lipo.
While high-definition lipo, in its truest form, can look extreme—Ninja Turtles are a common comparison—surgeons can soften the effect, “creating more subtle shadows to just hint at the musculature,” says Dr. Subbio, who finds this conservative take to be more tasteful and also predicts it will age better. The concern with more radical results is that “as we gain abdominal fat with age, the overly sculpted six-pack will look distorted,” adds Dr. Sieber, potentially requiring revision work.
As Dr. Unger explains, “humans don’t gain or lose fat cells after the age of 5—existing cells simply expand or contract with weight gain or loss. So if you gain weight after removing a large volume of fat cells, it can only go to areas where fat cells remain. In harsh high-def scenarios, weight gain is hyperaccentuated because there are parts of the abdomen with no ability to retain fat because everything’s been sucked out, contrasted by little islands of fat ready and waiting for the hormonal signaling to allow them to collect, grow and expand.”
Liposuction technologies
To implement their go-to techniques, surgeons rely on various technologies that break down fat more gently than the manual jabs of conventional suction-assisted liposuction. They find energy to be especially useful in dense, fibrous zones, like the back, and say certain tools can also tighten the skin a bit. “Regardless of the energy source involved, fat is always removed using either traditional suction-assisted liposuction or power-assisted lipo,” notes Dr. Sieber.
Power-assisted liposuction
Power-assisted lipo uses an oscillating cannula to break up fat cells quickly and without heat, sparing patients extra time under anesthesia and potential thermal damage.
Laser liposuction
Laser lipo (aka “Smartlipo”) liquefies fat cells, theoretically making them easier to extract. The heat also sparks collagen production, to modestly firm the skin. As noted in the aforementioned ASJ study, “Proponents of laser-assisted lipo describe its reduced post-operative pain and skin tightening effects…. However, no large, prospective studies have confirmed these effects in relation to other liposuction modalities.” What’s more, Dr. Mahmood insists that “laser lipo needs to be performed by a doctor who is very experienced with lasers, because the laser heats the fat to about 900ºF and, if not handled properly, can cause third-degree burns and permanent scars.” For her, she adds, the risks of laser lipo far outweigh the benefits.
Ultrasound-assisted liposuction
The brand VASER has become synonymous with ultrasonic lipo and is frequently used in high-definition cases. The ultrasound waves generate a vibratory mechanical energy, which essentially shakes fat cells free from surrounding structures “rather than ripping them off of connective tissue by means of traditional lipo,” Dr. Sieber says. While heat is “a by-product of this high ultrasonic energy,” notes Dr. Mahmood, it’s far less intense and focused than that of a laser, which poses a much higher risk of burns and scarring. She likes VASER for stubborn spots and areas that have been previously treated with CoolSculpting, which “causes fat to become very fibrotic,” she says.
Radiofrequency-assisted liposuction
Radiofrequency-assisted lipo has been popularized by the BodyTite device, which emulsifies fat for easier removal while ramping up collagen production in the skin. Dr. Unger, who is a paid investigator for BodyTite, says studies looking at skin tightening in the arms “show approximately a third reduction of skin surface area with BodyTite compared to lipo alone. There’s definitely a tightening factor above and beyond that of just removing fat from the area and allowing the skin to contract.” The device has built-in temperature controls to curb the risk of burns.
So how do you choose a technique or technology?
The short answer is, you don’t—your surgeon does.
As one recently published lipo study summarizes: “The choice of technique for removing fat … remains surgeon preference, and no single technique has proven superior in any large, controlled comparative study.”
Ultimately, you’re choosing a doctor, not a device. It’s your job to find “a board-certified plastic surgeon trained in all the various modalities who can look at you holistically and determine what is best for your unique body and goals,” says Dr. Unger.
Plastic surgeons, we should note, are split over the value that energy adds to lipo. Dr. Subbio, who uses both BodyTite and VASER in practice, believes “the addition of energy can help give that extra 20–30% [improvement] in the right patient.” However, he notes, “the artistry, skill and credentials of the operating surgeon far outweigh everything else.”
New York City plastic surgeon Dr. Steven Levine, on the other hand, cringes when he hears doctors use the word tightening to describe the action of anything other than a scalpel. “I have a VASER, but I don’t think I get a better result from it—it simply makes it easier for me to get to a certain end point. When you do good suction in the right areas, you get skin contraction. You may be able to get some additional on-the-table contraction from devices, but in a few months, the skin is going to stretch back out because you haven’t actually removed any.”
Dr. Sieber, who uses VASER on his high-def patients, says that the tool is “probably not totally essential, but it allows for a slightly better outcome.” In his experience, he explains, “you can end up traumatizing the skin with the traditional technique, causing bruising and skin discoloration, which may take six months to go away. VASER spares that trauma, because you’re not right under the skin, beating it up with a cannula.”
Related: How 3 Women Asked for Time Off Work to Have Plastic Surgery
Reality check: liposuction risks and recovery
As we alluded to at the start of our story (and thanks for sticking with us!) liposuction chains are popping up across the country. And many of these unregulated plastic surgery factories are promoting lipo as a lunchtime treatment. Let us be clear—liposuction is a serious medical procedure, with real risks and downtime. “These chains are opening up multiple offices in many cities, and they’re taking all comers—the doctors who work there are actually penalized for turning away patients,” says Dr. Subbio. “They’re advertising lipo as a ‘scalpel-free tummy tuck,’ with one day of recovery, and trying to make it seem completely noninvasive.” When really, if not done carefully by an appropriately trained surgeon, lipo can be lethal. “Every year, someone dies from it because organs have been punctured,” he adds.
At the risk of sounding like a broken record: make sure your surgeon is board-certified in plastic surgery or dermatology—not family medicine, radiology, obstetrics or the like—and have a frank conversation with them about your personal lipo eligibility, plus all the risks involved.
Lipo can be performed under local with IV sedation, but the majority of plastic surgeons prefer to use general anesthesia (for all but the smallest of spots) to keep patients safe and comfortable throughout the duration of surgery, which can last several hours, depending on the number and size of areas being treated. While avoiding general may seem like a win, administering local anesthetic repeatedly can, in rare cases, lead to lidocaine toxicity and heart damage. “Some people are fast metabolizers of lidocaine, and once we reach the max amount we can safely give based on weight, we have only two options—keep going, with you in pain, or stop and deliver a subpar result,” explains Dr. Sieber. General anesthesia skirts the issue entirely.
As previously discussed, contour irregularities and skin laxity are the main hiccups of lipo—but seroma formation is a potential risk too. Some surgeons use drains to prevent these pockets of fluid from accumulating near incision sites. Generally speaking, “the more aggressive the procedure and the more energy involved, the more likely it is you’ll need a drain,” says Dr. Subbio, noting that both scenarios can stir up excess fluid.
Expect to wear compression garments of some sort—foam, a Faja or a board, depending on your surgeon’s preference—for several weeks to months following liposuction. They’re essential for reducing swelling and bruising, thwarting fluid buildup and scoring the smoothest shape.
Downtime varies with the extent of surgery. “When you have good lipo done completely, you’re not going to have a pain-free recovery,” says Dr. Sieber. If you have only your arms done, plan on three to five days of discomfort; for 360 Lipo, you’ll likely want to take off 7–10 days or more.
While some streamlining of the silhouette is usually apparent soon after surgery, the full effect may take three to six months to emerge. Of course, the healing process after lipo is as individual as the procedure itself, so be sure to get a realistic timeline from your plastic surgeon and follow their aftercare instructions to the letter.
