Our annual Most Worth It list recognizes the most-loved aesthetic procedures—from noninvasive tweaks to the gold standard in surgery—as chosen by RealSelf community members like you. This story highlights one or more of the 44 Most Worth It honorees for 2022; you can see the full list and learn more about patients’ favorite procedures here.
Liposuction has long ranked among the most popular procedures in plastic surgery—yet it may also be the most misunderstood. While fat removal techniques have evolved tremendously over the years, making lipo increasingly safer and more sophisticated, the process is still often perceived as simplistic or even barbaric—“when, really, the converse is true,” says Dr. Adam Kolker, a board-certified plastic surgeon in New York City. “It’s actually one of the more challenging procedures in plastic surgery.” Not only is it “incredibly sculptural,” he adds, demanding both an artistic eye and an intimate knowledge of anatomy, but it’s uniquely thoughtful, requiring surgeons to predict which bodies will—and won’t—respond favorably to what Dr. Kolker calls “a change in the relationship” between skin and fat.
For context, the traditional liposuction procedure is a minimally-invasive cosmetic procedure that involves suctioning out body fat via a small incision on the target areas of the body. The cannula is inserted alongside a tumescent solution (a combo of saline, local anesthesia like lidocaine, and epinephrine) into your tissue, where it then suctions out the amount of fat as needed for the desired results. There are newer variations on this method, such as ultrasound-assisted liposuction (UAL), which uses ultrasonic energy to break up fat.
It’s not a weight loss method, and can’t help with obesity or cellulite; rather, it’s best for those who are already at a healthy body weight. The final results can take a few months to be noticeable until swelling subsides. And, as with any surgical procedure, there’s a risk of side effects, like hematoma, pockets of fluid, and rarely, blood clots.
Also worth keeping in mind: While liposuction results are technically permanent, any weight gain can cause the remaining number of fat cells to expand or lead to the formation of brand-new ones. So, a healthy lifestyle (think: a healthy diet and regular exercise routine) is important to maintain the results.
On your quest for the perfect lipo surgeon, be discerning, particularly when scrolling through before- and after-photo galleries. Because oftentimes, our experts say, it’s a few distinct details—those outlined below—that will coalesce into the most amazing outcomes.
Inconspicuous cannula scars
On the path to natural results, the best plastic surgeons strive to cover their tracks. While lipo doesn’t involve lengthy cuts with a scalpel, gaining access to fat deposits means inserting a stainless steel cannula under the skin, in multiple locations, and leaving small marks behind. “Often, the cannula sites are the only visible evidence of liposuction surgery, so as with all other cosmetic surgeries, the goal is to place incisions in natural lines of skin tension, shadows, or areas that are concealed under clothing,” explains Dr. Umbareen Mahmood, a board-certified plastic surgeon in New York City. Some parts of the body graciously provide hiding spots—the belly button, when treating the abdomen, or a bum crease, when slimming the outer thigh—but others, like the middle back, lack the creases and folds that can camouflage cannula access sites. In those areas, surgeons generally aim for a swathe of skin on areas of your body that will routinely be covered by undergarments, such as within the bra line or bikini line.
Smooth contours
Here, we’re talking about two things: avoiding contour irregularities, like lumps and bumps, and ensuring one treatment zone flows seamlessly into the next.
Contour irregularities are among the more common complications of lipo. These textural hiccups can happen if surgeons remove too much fat (especially from parts that are prone to divots, like the outer thighs) or if they target an inappropriate plane. As Dr. Kolker explains, “there’s a system of fascia, or connective tissue, that invests the entire body, and there’s fat above it and below it, but it’s going to be in different proportions in different areas.” These ratios can also vary from person to person. Syphoning superficial fat—the padding just below the skin—instead of deeper reserves in certain areas can leave visible lumps, so defatting the proper plane is critical for an untouched-looking outcome. That said, certain people are simply more susceptible to lumps, notes Dr. Mahmood, like those with “soft, easily malleable or ‘doughy’ tissue.”
To minimize dents during body contouring with lipo, surgeons use a technique called fat equalization. “It involves going over the liposuction sites with a specific cannula, called an exploded tip or basket cannula, without suction, to basically help disperse any loose fat particles so they can act like small fat grafts over the treated areas,” Dr. Mahmood explains, filling in gaps for a smoothed effect.
Preventing bulges also means approaching the body three-dimensionally. While 360 lipo has become a bit of a buzzword, it’s actually more standard practice than trending technique, since every body part has not just a front but two sides and a back to consider. Take the abdomen: “There are some individuals who have very uniquely focused localized fat and may be candidates for just anterior [frontal] abdominal contouring, but in more cases than not, you’re going to need to address these areas in 360 degrees,” says Dr. Kolker.
Reducing an area in isolation tends to magnify neighboring trouble spots, even if they weren’t all that bothersome to begin with. “To have liposuction of the abdomen but neglect the flanks will result in a flat, boxy abdominal appearance,” explains Dr. Mahmood. Similarly, suctioning only the lower back to smooth a posterior muffin top will make bra rolls look more prominent. For this reason, she adds, “I typically recommend doing liposuction of the abdomen and flanks together, then the upper and lower back together.”
Natural muscle definition
“Overetched high-definition lipo results almost uniformly make me cringe,” Dr. Kolker says. The best way to subtly define the musculature is to follow the inherent peaks and valleys of the area you’re contouring. On the female abdomen, says Dr. Mahmood, “the key elements to highlight are the linea alba—the vertical line extending from the top of the abdomen to the belly button—and the linea semilunaris, or the vertical lines on each side of the abdomen.”
When aiming for authenticity, it’s also important to respect regions that should never be totally flat, like the space between the belly button and the pubic region, notes Dr. Kolker, “where there should always be a little bit of convexity.”
While the sculpted look is highly sought-after, it’s not for everyone. “Many patients see the results of others and desire the same, not recognizing that their body characteristics are very different at baseline,” says Dr. Mahmood. “Ideal candidates have a BMI less than 28, are healthy, fit, nonsmokers, have good underlying muscle tone, and have no overlying skin laxity.”
Tight skin
When asked for the secret to a nonsurgical-looking lipo result, both experts replied: the right candidate. And one of the biggest shared traits among strong contenders is taut, springy skin. It’s why lipo results in twentysomethings almost always look better than in thirtysomethings, Dr. Kolker notes, and why thirtysomethings tend to look better than fortysomethings, and so forth.
During consultation, plastic surgeons will do a series of pinch tests, to gauge excess fat quantity and quality as well as skin snap—how quickly skin bounces back post-pinch. In most cases, “there will be some degree of skin retraction with liposuction, particularly if patients adhere to postoperative compression garment wearing,” says Dr. Mahmood. Surgeons may also be able to encourage a smidge more tightening by incorporating radiofrequency or plasma energy during surgery. But those devices can do only so much for loose skin. According to Dr. Mahmood, “existing hanging folds of lower abdominal tissue or significant stretch marks are clear indications that the skin will not retract sufficiently” following fat removal—and that a tummy tuck may be in order.
