Aesth. Plast. Surg.

30:574 588, 2006

DOI: 10.1007/s00266-006-0050-7

Safe Total Corporal Contouring with Large-Volume Liposuction for the Obese
Patient

Lakshyajit D. Dhami, M.S., M.Ch., and Meenakshi Agarwal, M.S., M.Ch., D.N.B.
Nanavati Hospital and Vasudhan Arjin Cosmetic Surgery and Laser Center, C-212, Lancelot, S.V. Road, Borivali West,
Mumbai, 400 092, India

Abstract. The advent of the tumescent technique in 1987 sions were administered. The hospital stay ranged from 8 to
allowed for safe total corporal contouring as an ambulatory, 24 h for both liposuction and liposuction with a lipectomy.
single-session megaliposuction with the patient under re- Serous discharge from access sites and serosanguinous fluid
gional anesthesia supplemented by local anesthetic only in accumulation requiring drainage were necessitated in 32 of
selected areas. Safety and aesthetic issues define large-vol- 296 cases (10.8%). Minor recontouring touch-ups were re-
ume liposuction as having a 5,000-ml aspirate, mega-volume quested in 17 of 296 cases (5.7%). Early ambulation was
liposuction as having an 8,000-ml aspirate, and giganto- encouraged for mobilization of third-space fluid shifts to
volume liposuction as having an aspirate of 12,000 ml or expedite recovery and to prevent deep vein thrombosis.
more. Clinically, a total volume comprising 5,000 ml of fat Follow-up evaluation ranged from 6 to 52 months, with 38
and wetting solution aspirated during the procedure quali- (12.8%) of 296 patients requesting further sessions for
fies for megaliposuction/large-volume liposuction. Between other new areas. Average weight reduction observed was 7
September 2000 and August 2005, 470 cases of liposuction to 11.6 kg (approx. 4 to 10% of pre-operative body weight).
were managed. In 296 (63%) of the 470 cases, the total Meticulous perioperative monitoring of systemic functions
volume of aspirate exceeded 5 l (range, 5,000 22,000 ml). ensures safety in tumescent megaliposuction for the obese,
Concurrent limited or total-block lipectomy was performed and rewarding results are achieved in a single sitting.
in 70 of 296 cases (23.6%). Regional anesthesia with con-
scious sedation was preferred, except where liposuction Key words: Large-volume liposuction—Megaliposuc-
targeted areas above the subcostal region (the upper trunk, tion—Obese—Tumescent technique
lateral chest, gynecomastia, breast, arms, and face), or when
the patient so desired. Tumescent infiltration was achieved
with hypotonic lactated RingerÕs solution, adrenalin,
triamcinalone, and hyalase in all cases during the last one
year of the series. This approach has clinically shown less History
tissue edema in the postoperative period than with con-
ventional physiologic saline used in place of the RingerÕs In a quest for everlasting beauty, man has made at-
lactate solution. The amount injected varied from 1,000 to tempts to defy the aging process by making use of all
8,000 ml depending on the size, site, and area. Local anes- the available materials at hand. He has used various
thetic was included only for the terminal portion of the oils, chemicals, minerals, and camouflage techniques.
tumescent mixture, wherever the subcostal regions were The earliest of the surgical techniques to enhance
infiltrated. The aspirate was restricted to the unstained physical appearances involved amputation of the
white/yellow fat, and the amount of fat aspirated did not unsightly deformity.
have any bearing on the amount of solution infiltrated. The concept of removing excess fat from localized
There were no major complications, and no blood transfu- body sites to achieve similar gains is credited to
Charles Dujarrier, who in France attempted to re-
move subcutaneous fat using a uterine curette on the
Correspondence to Lakshyajit D. Dhami M.S., M.Ch.; calves and knees of a ballerina in 1921 [5,21,34]. An
email: dhami@vsnl.com or drdhami@vasudhan.com inadvertent injury to the femoral artery led to
L.D. Dhami et al. 575

amputation of the dancerÕs leg. This unfortunate suction Surgery. The first articles on liposuction ap-
complication arrested further progress in this field, peared in the literature in July 1984.
but it sure was a valiant attempt at the time [15]. At the same time, a quantum jump in this field was
Schrudde in 1964 [34] revived interest in this pro- orchestrated by Gregory Hetter [16,34] who traveled
cedure and extracted fat from the leg, gaining access to Europe to learn liposuction using blunt cannulas
through a small incision with a sharp curettage, but from Illouz in France. Hetter was instrumental in
was faced with the daunting task of managing the getting Illouz to make the landmark presentation at
difficult hematomas and seromas that resulted from the American Society of Plastic and Reconstructive
this technique. Subsequently, Pitanguy [33] favored Surgeons (ASPRS) in Hawaii in 1983. A self-ap-
an en bloc removal of both fat and skin to eliminate pointed blue ribbon panel of the Aesthetic Society of
excess thigh adiposities, but the extensively noticeable America then traveled to Paris to see the procedure
incisions did not allow the technique to become performed. Greg Hetter, Frank Harnahan, Dick
popular. Mladick, and Carson Lewis went on to create the
Lipoplasty Society of North America, which taught
safe liposuction to board-certified plastic surgeons.
Modern Liposuction Jeffery Klein, of California, initially described the
tumescent technique for lipoaspiration in June 1986,
Modern liposuction began with the technique and and the first article describing this technique was
instruments of Giorgio Fischer and his father, Arpad published in January 1987 [25]. Ever since, lipoaspi-
Fischer, both gynecologists from Rome, Italy, in 1974 ration and fluid management have added a greater
[34]. They developed their instruments themselves, safety dimension. Ultrasonic liposuction was devel-
and their early cannulas contained a cutting blade oped by the Italian surgeon, Michael Zocchi [37] in
within them. They eventually developed a blunt hol- 1996.
low cannula connected to a suction apparatus and Liposuction has evolved over the past 15 years with
published their results in 1976. They developed the the introduction of the tumescent and superwet
technique of crisscross tunnel formation from multi- techniques, ultrasound-assisted liposuction, power-
ple access sites with their improved cannulas and assisted liposuction, and laser lipolysis. These
demonstrated good results with fewer complications. advances have made it possible to remove larger
In 1978, Kesselring and Meyer [22] published their volumes of fat with negligible blood loss and rela-
results using a sharp curettage aided by suction. The tively trifle complications.
technique could not gain much acceptance in view of
the significant complications.
Pierre Fournier [10] of Paris, France improvised on Introduction
the FischerÕs liposculpture technique and was the
initial advocate of the ‘‘dry technique,’’ in which no Liposuction is more of an art than a surgical proce-
fluids are infiltrated before liposuction. He went on to dure. It entails a practical application of scientific
become an authority on liposuction and fat trans- knowledge with precision and craftsmanship, a skill
plantation, promoting the benefits of tumescent attained with clinical experience. It brings as much
anesthesia. He was instrumental in technology contentment and joy to the person undergoing it as to
transfer to the next generation of surgeons the surgeon practicing the intimidating task of
representing varied specialties all over the world. delivering that eventual result.
Rapid growth and popularity of this procedure Ultrasonic liposuction for fat removal is similar to
across continents happened when Illouz [17,18,19], of phaco-emulsification of the ocular lens for cataracts.
Paris, France, began favoring the ‘‘wet technique,’’ in It permits elimination of localized fat deposits
which a solution of hypotonic vasoconstrictor saline through miniature incisions that leave an incon-
and hyaluronidase is infiltrated into the adipose tissue spicuous scar. The principal indications are fat
before aspiration. He termed this a ‘‘dissecting hy- deposits in the gluteocrural areas, hips, and abdo-
drotomy,’’ which facilitated removal of fat and men. The ideal body shape is trim and athletic.
reduction of trauma with less bleeding. Therefore, a well-contoured shoulder and chest, a
In 1977, Lawrence Field [8], a California derma- flat abdomen, and a narrow hip and thigh area are
tologist, was the first American to visit France and sought, and liposculpturing is anticipated to bestow
learn the new field of liposuction. Norman Martin these expectations.
[34], an otolaryngologist, visited Illouz in 1980 and An increase in fat content can be either hypertro-
began performing liposuction in Los Angeles in 1981. phic or hyperplastic. An increase in total fat cell
In 1982, physicians from different specialties were numbers is hyperplastic obesity. It predominates as
trained by Illouz and Fournier [34]. body fat levels exceed 40% and proves to be more
In 1983 and 1984, several interspecialty courses resistant to dieting and exercise regimens. In those
were held, and Julius Newman [34], an otolaryngol- cases in which the actual number of fat cells remains
ogist, was the first to use the term ‘‘liposuction.’’ He stable, the cells increase or decrease in their volume
went on to establish the American Society of Lipo- with weight gain or loss [36].
576 Contouring With Large-Volume Liposuction

procedure to be performed with the patient under

regional anesthesia and conscious sedation. Local
anesthesia may be supplemented for areas proximal
to the level of the regional anesthesia.
Limits of lidocaine dosage have been explored
since the development of this technique. Lillis [29]
unofficially reported no complications with tumescent
lidocaine dosages exceeding 70 mg/kg [34]. Ostad
et al. [32] proposed the maximum tumescent safe
lidocaine dosage to be 55 mg per kilogram of body
weight. The maximum safe dose of tumescent
lidocaine was a major contention issue.
Fig. 1. Megaliposuction: a 17,000 ml aspirate (in jars of
The demonstration that the peak lidocaine con-
2,500 ml each) and a dermolipectomy weighing 4.5 kg.
centration in the blood occurs approximately 12 h
Localized fat accumulation patterns also vary by after the tumescent infiltration is initiated, compared
race and age. A decrease in the subcutaneous fatty with 2 h as originally conceived, was an unprecedented
layer and an elevation in intraabdominal fat contents finding. A safe dosage of tumescent lidocaine was
are seen with increasing age. Women have a pro- shown to be 35 to 50 mg/kg by Klien in 1990 [26,27].
portionately higher percentage of body fat than men The rate for infusion of the tumescent anesthesia was
as well as a gynecoid pattern of fat deposition char- shown to be independent of plasma lidocaine levels.
acterized by increased deposits over the lateral thigh, For many years before the advent of the tumescent
buttock, hips, and truncal region, whereas men show procedure, the dry technique with the patient under
an android pattern that centers on the truncal and general anesthesia was practiced. Refinement and
abdominal regions. improvement of this technique over the years cur-
Liposuction is effective in changing the contour rently allows liposuction to be performed with
because it permanently removes fat cells that are exceptional finesse and gentleness and totally by re-
unevenly distributed. The remaining adipocytes still gional and supplemental local anesthesia. The sting-
can store fat. For that reason, liposuction cannot ing pain originally associated with infiltration of local
prevent further weight gain, but rather effects weight anesthesia from the acidic pH of commercially
distribution. available lidocaine has been eliminated by the addi-
Fat in the trunk and extremities has superficial and tion of sodium bicarbonate to the anesthetic solution.
deep layers. The superficial layer comprises small The common definition of large-volume liposuc-
dense pockets of fat separated by vertical, well-or- tion refers either to the total fat removed during the
ganized fibrous septa. The deeper fat layer is orga- procedure or the total volume removed during the
nized more loosely, with looser areolar fatty tissue procedure (fat plus wetting solution). Because many
interspersed with less regular fascial septae interven- of the complications associated with large-volume
ing between the pockets. Vertical septa originate from liposuction are related to fluid shifts and fluid bal-
the fascia and extend upward toward the dermis. ance, classification of the procedure as large volume
These layers are important in avoidance of potential on the basis of the total volume removed from the
complications during liposuction. patient, including fat, wetting solution, and blood, is
Suction lipectomy was advocated initially for more acceptable.
treating localized collections of fat and for removing Large-volume liposuction clinically refers to the
less than 1,500 ml of material. However, many pa- removal of more than 5,000 ml of total volume from
tients wished to have multiple areas treated or had the patient. Gilliland et al. [12,13] have appropriately
diffuse collections of fat. In such instances, it is nec- segregated and better defined large-volume liposuc-
essary to remove more than 1,500 ml of material and tion as aspiration of 5,000 ml, megavolume liposuc-
to perform circumferential lipectomy for optimal tion as aspiration of 8,000 ml, and gigantovolume
aesthetic results. However, when more than 1,500 ml liposuction as aspiration of 12,000 ml or more be-
of material is removed, anesthetic requirements, fluid cause the safety and aesthetics issues differ at each
replacement, and treatment of blood loss become level (Fig. 1).
important if the procedure is to be performed safely.

Evolution of Instrumentation
Tumescent Anesthesia
Initially, large cannulas were used for liposuction,
Tumescence is the state of being ‘‘swollen and firm.’’ some even as large as 1 cm in diameter. These
Tumescent liposuction uses large volumes of very instruments caused damage to neurovascular bun-
dilute, hypotonic solutions of a vasoconstrictor agent dles, occasionally leading to uneven contours and
gently injected into the subcutaneous fat and virtually seromas or hematomas in patients. The subsequent
eliminates surgical blood loss. It also permits the use of local anesthesia necessitated a gentle touch, so
L.D. Dhami et al. 577

a variety of smaller cannulas were developed. The Italy. His interest in ultrasound was originally fo-
standard cannulas of the 1980s were huge, with cused on harvesting collagen from aspirated fat. The
diameters of 6 to 10 mm and cross-sectional areas chance observations that adipose tissues were effec-
9 to 25 times larger than those of the current 2-mm tively emulsified while connective tissue structures
microcannulas. Illouz and Fournier [18,19,34] popu- were preserved in vitro led to the concept of using
larized liposuction using their newer generation of ultrasound adjunctively in vivo.
blunt-tipped cannulas and the ‘‘wet technique.’’ The American Society of Plastic and Reconstruc-
The cannulas used today are extremely small, some tive Surgeons has promoted ultrasonic liposuction,
with an inside diameter less than 0.6 mm. Blunt-tip- but surgeons of other specialties have abandoned this
ped cannulas are standard because they decrease in- technique because they consider the internal ultra-
jury to blood vessels and reduce bleeding. The use of sound to increase the risk of cutaneous burns and
multiple side ports allows for efficient evacuation of seroma formation while providing little additional
fat. Manual systems consisting of syringes and can- benefit over standard liposuction.
nula tips also have been developed because some Large-volume tumescent liposuctions have gained
surgeons prefer the use of quiet, disposable instru- acceptance with the West in the specialty that regu-
ments (Tulip, Tulip Products, San Diego, California). larly practices the procedure in large numbers. The
These also became popular as a backup system. first author has initiated this trend in India and
Aspiration units, developed by manufacturers in advocate it. None of these major safety concerns have
consultation with surgeons, have gradually become been noted in our series.
more powerful and quiet, allowing for an efficient,
pleasant surgical environment.
Other Indications
A shaving instrument with suction to remove fat
has been reported for use in submental resection.
Noncosmetic applications of liposuction were pio-
A full-body version of this technology and new
neered or developed by surgeons of other specialties.
powered liposuction cannulas have been developed.
Liposuction could be used to remove lipomas and
The shaving devices, designed to facilitate tunneling
angiolipomas, and to improve hyperhydrosis. Lipo-
through fibrous adipose tissue, use a rotary internal
suction techniques can assist in hematoma evacua-
blade built into the cannula. The literature reports
tion. Klein [28] demonstrated liposuction techniques
powered liposuction devices that use a reciprocating
for breast reduction. Field [9] pioneered liposuction
cannula to facilitate fat removal [20]. These devices
to facilitate flap movement in cutaneous reconstruc-
are believed to decrease the physical effort of the
tion, gynecomastia, and benign symmetrical lipoma-
surgeon, but the experience of most surgeons is that
tosis (MadelungÕs disease).
they do nothing more than vibrate in their hands.
The initial European ultrasonic liposuction emul-
sified fat with an ultrasonic cannula, which then was Patients and Methods
aspirated in the second step. This two-stage proce-
dure was time consuming. It was modified in the Megaliposuction in our series over 5 years (Septem-
United States, and a suction cannula currently ber 2000 to August 2005) is clinically defined as more
emulsifies and aspirates the fat simultaneously. than 5,000 ml of aspirate that includes the fat and
Although the proponents of the superwet and wetting solution.
tumescent techniques have their pros and cons open Suction-assisted lipectomy (SAL) or ultrasound-
for discussion, most modern liposuction is a combi- assisted liposuction (UAL) has been performed for a
nation of these two techniques. The task force of the total of 470 patients, 296 (60%) of whom underwent
American Society of Plastic and Reconstructive Sur- megaliposuction. Whereas conventional SAL was
geons [1], Plastic Surgery Educational Foundation performed for 60 patients in the 2 years between
(PSEF), the American Society for Aesthetic Plastic September 2000 and August 2002, 236 patients were
Surgery, Aesthetic Surgery Education and Research treated with UAL in the next 3 years, between Sep-
Foundation (ASERF), and the Lipoplasty Society of tember 2002 and August 2005 (Table 1). The youn-
North America, with Franklin Di Spaltro as the gest patient was 14 years old and the oldest was 67
chairperson, investigated ultrasound-assisted lipopl- years old (mean, 39 years). Individual patient weight
asty in 1995, evaluated the safety issues, and provided ranged from 45 to 178 kg. Female patients dominated
inputs to the Food and Drug Administration (FDA) the series (260/296, 86%) in a ratio of 7.2:1. A com-
for its approval. bination of tumescent and the superwet liposuction
was performed simultaneously by two surgeons in
multiple corporal areas.
Variations of Liposuction Before September 2002, the conventional tumes-
cent liposuction technique was used. After September
Ultrasound is used as an ablative tool in urology and 2002, ultrasound-assisted liposuction was performed
neurosurgery. Ultrasonic liposuction was developed for all patients by the same surgeons using the
and introduced in the early 1990s by Zocchi [37] in Ultrasonic Sonoca machine (Soring GmbH Medi-
578 Contouring With Large-Volume Liposuction

Surgical Technique

Preoperative Markings

Precise and accurate preoperative marking is essential

for a good result. With the patient standing, areas to
be treated are outlined with a fibertip marking pen.
Areas to be avoided or areas for fat grafting also are
separately identified. Port sites per area are defined to
allow cross-tunneling aspiration to minimize surface
abnormalities.

Preparation and Positioning

The patient is prepared circumferentially in the torso

and lower extremity because these areas can be
Fig. 2. Team work emphasizing safety, meticulous moni- treated without repeated prepping and repositioning.
toring, and appropriate patient selection. There is a The patientÕs skin is painted with 10% povi-
reduction in the duration of surgery, and the surgeonsÕ done iodine solution while he or she stands next to a
faculties are better directed toward contouring.
sterile draped operating table. At completion of the
skin preparation, the patient lies on the table and is
sedated or given regional anesthesia as required.
zintechnik, Quickborn, Germany) (Fig. 2). No
autologous blood transfusion was administered.
Volumes of 5,000 ml to 22,000 ml (mean, 13,500 ml) Tumescent Infiltration
were aspirated. Weight reduction at the patientÕs
follow-up visit 6 months after surgery varied from 1 All areas to be treated are injected with large volumes
to 25 kg (average, 9.5 kg) (Table 2). For 70 (23.6%) of of a diluted epinephrine solution until turgor of the
296 patients, SAL combined with block abdomin- tissues is appreciable equally on both sides. Effective
oplasty/mini-abdominoplasty was performed. The vasoconstriction is achieved in about 10 min, but the
duration of the surgical procedure ranged from 2 to 3 effect is more pronounced after about 20 min.
hours with a two-surgeon team. Of the 296 patients, The following tumescent fluid hypotonic RingerÕs
38 (12.8%) sought further liposuctions for newer lactate (a maximum of 8,000 ml) was used in this
areas 7 days to 6 months after the primary procedure series:
(Fig. 4).

Postoperative Care 1 Ringer lactate (ml) 1,000

2 Distilled water (ml) 300
Early ambulation, within 24 h, was encouraged for 3 Injectable adrenaline (amp) 1
mobilization of third-space fluid shifts to expedite 4 Injectable hyalase (amp) 1
5 Injectable triamcinalone (mg) 10
recovery and to prevent deep vein thrombosis. Pa-
tients were advised to avoid prolonged sitting for 3 to
4 weeks after abdominal liposuction. Pressure gar-
ments were to be worn for up to 3 months in most Physiologic saline was used in place of RingerÕs
instances considering the extensive mobilization of lactate solution during the initial 4 years. Authors
the skin panniculus in different areas. In these areas, have noted an appreciable subjective reduction in
the skin required more time to shrink to conform to the tissue swelling postoperatively after substitution
the new base. of RingerÕs lactate solution for the conventional
It is important to support the heavy skin and sub- normal saline. The hypotonic solution results in
cutaneous fat of the obese patient longer than advo- turgidity of the local adipocytes that rupture more
cated to prevent it from gravitating down and forming easily with SAL or UAL, and thus causes less tissue
folds. In certain cases, this period may be extended by trauma.
another 3 months because skin retraction in these The intense local vasoconstriction reduces blood
dissections takes longer time than with the conven- loss to insignificant amounts for most procedures. A
tional postoperative regimen. Pressure (fingertip) profound and long-standing anesthesia is created at
massage or an ultrasound massage and a further ex- the local site. Local anesthesia lasts 6 to 10 h into the
tended period of wearing the pressure garment are postoperative period, and patients rarely require
advised for persistent edema, pain, or firm and lumpy additional analgesia in the first few hours after
areas. surgery (Figs. 5 and 6).
L.D. Dhami et al. 579

Table 1. Liposuction: total number of patients who underwent suction-assisted lipectomy (SAL) and ultrasound-assisted
liposuction (UAL) in 5 years

Liposuction volume (in ml)

Conventional liposuction Megaliposuction

<5,000 5,000 7,999 8,000 11,999 >12,000 Total patients

No. of patients 174 121 110 65 470

Amount of fluid infiltrated (l) 1.0 2.5 2.0 3.5 2.5 6.0 6.0 8.0
Average hemoglobin fall (g %) — 0.6 1.1 2.4
Total patients 174 296 (60 SAL, 236 UAL)

Fig. 3. A 28-year-old unmarried

girl with large-volume liposuc-
tion of the abdomen, thighs,
back, and buttocks. The total
aspirate in the two sessions was
21,000 ml. In sequence is shown
the preoperative view, the post-
operative view 6 months after the
first ultrasound-assisted liposuc-
tion (UAL) (12,000 ml), and the
postoperative view a further 6
months after the second UAL
(9,000 ml).

Table 2. Average weight loss of patients 6 months after operation

Liposuction volume (in ml)

Conventional liposuction Megaliposuction (SAL + UAL)

(SAL + UAL)
<5,000 5,000 7,999 8,000 11,999 >12,000

No. of patients 174 121 110 65

Average weight 4% (2 6) 4% (1 14) 7% (2 25) 10% (2 22)
loss at 6 mo (kg) mean: 3.2 mean: 7.0 mean: 9.5 mean: 11.6

SAL, suction-assisted lipectomy; UAL, ultrasound-assisted lipectomy

Aspiration formed once the basic earmarked areas have been

symmetrically contoured bilaterally. Closure of these
Access incisions are placed at the periphery of the access incision sites is accomplished with interrupted
operative field in concealed areas. They are used loose sutures to permit easy drainage of fluid and to
separately for all areas because removing all fat from reduce edema and seroma.
a single incision may lead to a depression around the The end point of aspiration is determined by the
access site. contents and volume of aspirate, and also by
Aspiration begins 20 min after injection. Deeper the appearance and feel of the treated area as well
areas and areas with more voluminous fat deposits as the bilateral symmetry. Aspirate volumes from
are aspirated using cannulas 5 or 6 mm in diameter. bilaterally symmetric areas should be approximately
Smaller fat deposits and the more superficial areas are the same, although the volume of the preoperative
aspirated with cannulas 2 to 4 mm in diameter. The injection will influence the volume of the aspirate.
cannulas move parallel to the fat plane, with the Caution is to be exercised in the learning curve
openings directed away from the skin surface in a to- with shifts to UAL, or by the beginning aesthetic
and-fro motion along the same path. The site is plastic surgeon to minimize concurrent damage to
changed when the aspirate tends to become blood the vital structures and damage to the overlying
stained. Feathering of the peripheral areas is per- skin (Fig. 7).
580 Contouring With Large-Volume Liposuction

Fig. 4. (A) Before and (B) after

ultrasound-assisted liposuction
(UAL) of the abdomen with ab-
dominoplasty. A 24-year-old girl
with large-volume liposuction of
the abdomen and total aspirate
of 17,000 ml, and dermolipecto-
my of 4.5 kg (as shown in Fig. 1).

Fig. 5. (A) Before and (B) 4

months after ultrasound-assisted
liposuction (UAL) of the ante-
rior trunk (abdomen and thighs).
A 30-year-old unmarried girl
with large-volume liposuction of
abdomen and thighs and a total
aspirate of 10,000 ml.

Fig. 6. (A) Before and (B) 6

months after the second ultra-
sound-assisted liposuction
(UAL) of the posterior trunk
(back, buttocks, and arms).
Second session: The same
30-year-old unmarried girl as in
Fig. 5a and b with a total large-
volume liposuction aspirate of
16,500 ml in the two sessions.
L.D. Dhami et al. 581

Fig. 7. Pre-, immediate, post-

UAL (ultrasound-assisted
liposuction), and 3 months
post-UAL of the buttocks. A
40-year-old lady with large-vol-
ume liposuction of the buttocks
and a total aspirate of 5,500 ml.

Technique and Instrumentation thesia was used previously when anesthesiolo-

gists were unaware that the FDA limits on lidocaine
Although it is not essential to suction the subdermal (7 mg/kg) were designed exclusively for epidural
layer of fat in large-volume lipoaspirations, the au- anesthesia, and that the limits for tumescent local
thors concur with the massive all-layer liposuction anesthesia are much higher (45 mg/kg).
(MALL) concept [11] because this approach helps to
reduce the thickness and consistency of the superficial
fat and to enhance skin retraction. This, however, is Spinal Anesthesia
better indicated in cases requiring only a limited
correction for body contouring rather than volume Spinal anesthesia is used for the operation because
reduction. the duration of surgery is about 3 h, with the patient
Large adiposity of the abdomen, arms, or inner traveling home the same day. This reduces the drugs
thighs tends to have an excess volume of fat, the administered to the patient because a general anes-
weight of which overstretches the panniculus and thesia is avoided. A 27-gauge needle avoids the often
results in a ptosis of the skin overlying the area. In troublesome postspinal anesthesia headaches. Fen-
these cases, the need is to reduce the large fat volume tanyl is additionally added to the high spinal because
to permit effective skin retraction. Liposuction of all it has a bupivacaine-sparing effect on spinal anes-
fat layers addresses the issue better, and the clinical thesia [3,4,24,35]. This covers the subcostal areas as
results are appreciable. well and further reduces the need for lidocaine in the
infiltrating solution.

Discussion

The self-esteem of significantly obese individuals is Intravenous Fluids in Large-Volume Liposuctions

greatly enhanced by a safe and limited surgical
intervention that achieves even a minimally accept- The fluids administered are by clinical judgment, with
able aesthetic contour of the profile in proportion to clinicians keeping an eye on the clinical monitors of
the body structure. Elevation of the self-esteem of the pulse rate and blood pressure, as well as urine
these obese patients is an important indication, and it color and amount. The administered fluid amount
forms the essence of the much touted large-volume normally is calculated as a sum of the normal
liposuction. In most instances, the technique may be requirement for the patient who has had anesthesia of
combined with a block dermolipectomy [7]. 8 ml/kg per hour, 1,000 ml of crystalloids for an 8-h
Many surgeons still are apprehensive about the starvation, and blood loss, if any, that is more than
physiology of large-volume liposuction as well as anticipated or expected.
patient exposure to prolonged procedures, anesthe- In megaliposuctions with about 10 l of fat and
sia, fluid shifts, and high doses of infused epinephrine wetting solution aspirated in a normally fit patient
[2] and lidocaine. The superwet and tumescent tech- and surgery lasting about 3 h, the following factors
niques performed with the patient under regional need to be considered:
anesthesia permits regional local anesthesia of the  Total intravenous (IV) fluid usually given to a
skin and subcutaneous tissues by direct infiltration. patient under general anesthesia: 2,000 ml of
Large volumes of a hypotonic physiological saline or crystalloid plus 1,000 ml of artificial colloids/
lactated Ringer’s solution with epinephrine and lim-
plasma expander. Depending on the clinical
ited use of dilute anesthetic solutions produce
tumescence, firmness, and anesthesia of targeted parameters, the rate of the fluid is adjusted
areas. Dilution of lidocaine and epinephrine dimin- accordingly.
ishes and delays their peak plasma concentrations,  Total IV fluid usually given to a patient under
thereby reducing potential toxicity. General anes- spinal anesthesia: 1,000 to 1,500 ml of crystal-
582 Contouring With Large-Volume Liposuction

loids administered preoperatively as a priming the tumescent solution with dilute epinephrine that
solution and another 2,000 ml of crystalloids produces intense widespread capillary constriction in
given at the time of spinal anesthesia. Here again, the targeted fat, which in turn greatly delays the rate
depending on the clinical parameters, the rate of of the drugÕs absorption. This undiluted epinephrine
the fluid is adjusted accordingly. Overall, the is absorbed into the bloodstream over 24 to 36 h. This
patient under spinal anesthesia will need about reduces the peak concentration of the drug in the
blood, which in turn reduces its potential receptor
1,500 ml of crystalloids and 500 ml of colloid
stimulant actions.
more than required for general anesthesia. The profound vasoconstriction is so absolute that
liposuction can be performed with virtually no blood
loss. In contrast, the older forms of liposuction used
Local Anesthetic in the Tumescent Solution before the invention of the tumescent technique were
associated with so much surgical blood loss that
The aim is not to exceed the toxic dose of the drug in autologous blood transfusions often were routine
mg/ml per kilogram of body weight. A single drug (Figs. 8 13).
alone would exceed the toxic level because it would be Clinically, the skin should have sufficient inherent
needed in a large amount. This is addressed by using elasticity to recoil and contract after removal of fat.
a larger quantity of drug in a lower concentration Stretch marks are a strong indication of poor elas-
(i.e., instead of using 10 ml of a 2% solution, it is ticity, as is delayed rebound after manual stretching.
advisable to use 40 ml of a 0.5% solution), or by Significant skin overhang indicates a need for
adding two drugs with different toxicity (i.e., lido- adjunctive surgical procedures.
caine that causes central nervous system depression Access incision sites are small, and it is advisable
or stimulation and bupivacaine that is cardiotoxic). not to close them with sutures to permit drainage of
The tumescent infiltration solution is additionally the excess wetting solution and seroma. Larger
added to the local anesthetic only in the terminal cannulas require larger incisions, but these must be
portion to be used for infiltration between the sup- sutured loosely. Delayed drainage of the blood-tinged
raumbilical and subcostal areas when the patient is tumescent solution produces prolonged swelling,
bruising, and pain after liposuction. Larger cannulas
remove fat rapidly, and there is a risk of removing
too much fat and producing skin depressions and
1 RingerÕs lactate (ml) 1,000
2 Distilled water (ml) 300
irregularities. An attempt to make a small change in
3 Injectable adrenaline (amp) 1 the direction with a large cannula results in a ten-
4 Injectable hyalase (amp) 1 dency to reenter a preexisting tunnel within the fat.
5 Injectable triamcinalone (mg) 10 This lack of precise control results in the skin irreg-
6 Injectable xylocaine 2% (ml) 40 ularities associated with the use of large cannulas.
7 Injectable bupivicaine 0.5% (ml) 30 Large cannulas are advocated only in cases of large-
8 Injectable soda bicarbonate (ml) 40 volume liposuction with access from sites of origin
for sacrifice of the panniculus. Microcannulas with an
under spinal anesthesia/Epidural Anesthesia (EA). external diameter of 4 mm can remove fat very effi-
This solution contains the following: ciently. They are effective in achieving a smoother
A 40 ml solution of 2% lidocaine is 800 mg of the liposuction because they allow for a more gradual
drug. Because the toxic dose of lidocaine is 7 to 8 mg/ and controlled removal of fat.
kg when used with adrenaline, it is safe when used for a Pretunneling (Mladick [30]) increases instrument
patient with a body weight of 80 to 100 kg. control because it creates desired planes of fat re-
moval without suction and is passed into the super-
ficial layer of the desired area of removal. It prevents
Adrenaline an inadvertent removal in the subdermal fat layer
that can result in contour irregularities. Similarly,
Each 1,300 ml of the tumescent fluid has 1 ampule of cross-tunneling with at least two port sites at right
adrenaline (1:1,000). Thus, even when 6 ampules of angles is used to treat an area of adiposity. The use of
the drug were used during the maximum infiltration multiple port sites provides for better contouring and
in the current series, no side effects or complications feathering of edges.
attributable to the large dose of adrenaline were Fat layers are treated from deep to superficial in
noticed in the entire series over the 5-year period sequence and in parallel tracks. As the procedure is
because adrenaline causes vasoconstriction, which moved more superficially, cannula size can be de-
prevents sudden absorption of more adrenaline until creased along with suction intensity to help decrease
its effect has waned. Hence, systemic toxic effects of the risk of irregularity to the surface layers. Most tra-
this drug are not seen. ditional liposuction treatment involves removal of the
Tumescent liposuction has proved to be extremely deeper fat layers. Superficial liposuction is performed
safe even with the use of unprecedented large doses of for individuals with flaccid skin or LFDs (Localized
L.D. Dhami et al. 583

Fig. 8. (A) Before and (B) 1

year after ultrasound-assisted
liposuction (UAL) of the abdo-
men and trochanteric areas.
A 55-year-old lady with large-
volume liposuction of the
abdomen and trochanteric area
and a total aspirate of 8,000 ml.

Fig. 9. Views before and after

the first ultrasound-assisted
liposuction (UAL), then 5
months after the second UAL.
A 27-year-old unmarried girl
with large-volume liposuction of
the abdomen, thighs, back, and
buttocks, and a total aspirate of
32,000 ml: first session (anterior
trunk, 14,000 ml) and second
session (posterior trunk,
18,000 ml).

Fig. 10. Before and after ultra-

sound-assisted liposuction
(UAL) with abdominoplasty.
A 50-year-old lady who had
large-volume liposuction of the
abdomen with abdominoplasty
and a total lipoaspirate of
8,500 ml.

Fat Deposits) as an aid to better skin retraction. It is is accomplished with a loose deep dermal absorb-
accomplished with narrow cannulas that make multi- able suture. Absorbable materials are applied to
ple closely spaced passes in the subdermal fat to effect prevent spoilage of the compressive binders and
an undermining of the affected tissue. dressings.
Symmetry (if bilateral), skin pinch of less than
1 in., and shape and overall smooth contour
determine the clinical end points of the procedure. Ultrasound-Assisted Liposuction
Further removal of the remaining fat gives the
advancing cannula a grittier feel as it passes in the Ultrasonic techniques used were internal with can-
tunnels against the remaining fibrous septae. Port nula. The high ultrasonic energy produced by passing
sites are reexcised to improve cosmesis, and closure electrical energy to a piezoelectric crystal creates mi-
584 Contouring With Large-Volume Liposuction

Fig. 11. Before and after ultra-

sound-assisted liposuction
(UAL) of the abdomen. A 47-
year-old man with large-volume
liposuction of abdomen and a
total aspirate of 20,000 ml.

Fig. 12. Before and after ultra-

sound-assisted liposuction
(UAL) of the chest. A 32-year-old
man with large-volume liposuc-
tion of chest, abdomen, and
thighs and a total aspirate of
8,500 ml.

Fig. 13. Before and after ultra-

sound-assisted liposuction
(UAL) of the trochanteric re-
gion. A 43-year-old lady with
large-volume liposuction of the
arms, abdomen, and trochan-
teric regions and a total aspirate
of 9,000 ml.

crocavities in a liquid or semiliquid medium during Zocchi [37] states that the susceptibility of a liquid
expansion cycle of the sound wave. This property of or biologic tissue to microcavity formation depends
microcavitation is used in UAL. on the molecular cohesion of the material, and that
L.D. Dhami et al. 585

the negative pressure required is related to the density tibility to superficial contour deformities due to
of the tissue for its aspiration. Low-density tissues minimal amounts of deep fat and adherence of the
such as fat cells have low molecular cohesion, which more superficial layer to the underlying fascia of the
favors microcavity formation and aspiration. muscle.
Connective tissue and muscle are essentially unaf- Team work and judicious, appropriate selection of
fected by this process because they are more dense, a surgically and medically fit patient are the essential
but damage may result by an accumulation of sec- factors resulting in an overall reduced duration of the
ondary thermal energy and micromechanical trauma surgery to within 3 h. These factors also reduce
on sustained application of ultrasound after complete the patientsÕ exposure to the rigorous physiological
emulsification by microcavitation. This direct micro- demands of this procedure.
mechanical trauma and the secondary thermal effects Perioperatively, low suction, slow and regular
of persistent ultrasound energy are the mechanism of cannula motion, and adequate pretunneling with fine-
action for external UAL. to-small cannulas achieve desired results with mini-
There is enhanced fat removal with minimal blood mal morbidity to the patient. This approach also is
loss, improved skin retraction, and safer large-vol- less taxing to the surgical team.
ume procedures with the UAL [14]. Reports of Although SAL achieves almost similar results, the
cutaneous burns, hypo- and hyperesthesia, and ser- authorsÕ experience with UAL has shown that better
oma formation have resulted in considerable debate skin shrinkage and retraction is achieved with UAL
concerning the long-term effects and clinical use of by virtue of its physical collagen stimulation action.
UAL. Subsequent evidence with long-term follow-up This energy not only helps to break the turgid
periods have shown the technique to be well estab- adipocytes more easily, but it also helps in areas of
lished and accepted [6,14,23,31]. It is especially indi- fibrotic fat and in male patients. Because UAL is less
cated for male patients and for areas of dense fibrotic physically exerting for the surgeon, more attention
fat. can be given to the sculpturing than to the mechanical
The inner knee and medial thigh with less dense fat process itself.
are better managed with a standard wet technique Patients are encouraged to ambulate on the same
rather than UAL. Improved results with less fatigue in day of surgery to prevent deep vein thrombosis. This
treating fibrous areas such as gynecomastia, posterior obviates the need to administer the heparin prophy-
trunk, upper abdomen, and posterior hip rolls support laxis, and also achieves an improved intraspace fluid
the use of UAL as an adjunct to lipoplasty rather than shift, which facilitates an early recovery of the patient
as an alternative. The UAL procedure is presumed to and discharge from the day care facility.
enhance skin retraction by a controlled thermal stim- In the postoperative period after abdominal lipo-
ulation of the dermal collagen. The results of UAL suction, patients are advised to avoid prolonged sit-
used in large-volume liposuction for patients with lax ting for 3 to 4 weeks to prevent the development of
skin have been good, and in this series have shown a skin folds and creases. Pressure garments are to be
decrease in concurrent lipectomies [31]. worn religiously for 3 months to facilitate better skin
retraction after the extensive lipodissection and to
prevent drag from the weight of the dissected pan-
Complications and Cautions niculus. Whereas a regular fingertip massage is good
for small areas of induration, an ultrasound massage
A dissatisfied patient is by far the most common works well for lumpy areas and sites with persistent
problem resulting from a patientÕs unrealistic expec- pain or edema.
tations before surgery. Careful and accurate com-
munication between patient and surgeon helps the
patient to make a well-informed decision and obvi- Minor Complications
ates many a ‘‘fact-justifying’’ consultation in the
postoperative period. Minor complications noted after all liposuction
The access incision, when placed in the center of procedures include superficial irregularities of the
the operative field, leaves a residual bulge or a crater skin, seroma, hematoma, focal skin necrosis, allergic
at that location. A side-to-side cannula movement reactions to drugs, visible or disfiguring scars, dis-
may result in scarring, surface irregularities, or skin coloration of the skin, syncopal attacks postopera-
necrosis, whereas an overzealous correction results in tively, temporary bruising, numbness or nerve
a scooped effect and probably the need for an addi- injury, and temporary adverse drug reactions (Ta-
tional correction at a later date if the patient so de- ble 3) (Fig. 14 15). These complications do cause
sires. the patient to function at a suboptimal level, but
Care must be exercised in relation to the gluteal have not been noted to disturb the normal routine
crease, lateral gluteal depression, distal posterior in the postoperative phase. Postliposuction micturi-
thigh, middle medial thigh, and the inferolateral, ili- tion syncope is not rare, and patients need to be
otibial band. These areas have an increased suscep- advised in this regard.
586 Contouring With Large-Volume Liposuction

Fig. 14. A complication, ecchy-

mosis, superficial skin necrosis
and its resolution in a 32-year-
old man in a sequence after
megaliposuction. It resolved
spontaneously over 4 to 6 weeks
with conservative management.

Fig. 15. (A) A complication:

seroma. A large seroma is seen
bulging under the panniculus.
(B) Drainage is accomplished
after opening of a suture, which is
left open to allow further drain-
age. It resolves conservatively.

Fig. 16. (A) A complication: A

full-thickness necrosis of the
anterior abdominal wall was
eventually closed by secondary
suturing. (B) Note the deviation
of the umbilicus after the sec-
ondary closure.

Conclusion It is to be appreciated and emphasised that the

dreaded complications giving rise to apprehensions in
Large-volume liposuction can be performed safely in the minds of many surgeons are absent in every large
properly selected patients who have a realistic series of large-volume liposuction. Credit goes to a
understanding of the procedureÕs expectations and strict adherence to the five pillars of safety: safe sur-
limitations. Such patients tend to be very satisfied geon, safe anesthesiologist, safe facility, safe
with the results. The motivation, goals, and expec- coworkers, and a properly selected patient.
tations of the patient must agree with what is clini- The superwet technique of fluid infiltration is used
cally possible. Patients should be psychologically to maintain an almost bloodless aspirate. Compres-
stable with good diet and exercise habits or evidence sive postoperative garments are always worn to
of motivation toward them. The procedure is ideally minimize postoperative bleeding, swelling, and a
performed at accredited centers with appropriate third-spacing of fluid. The long-term results after
equipment and a well-trained staff. large-volume liposuction depend on the preoperative
The surgeons who perform large-volume liposuc- condition of the patientÕs skin, the patientÕs overall
tion must understand the physiology and the differ- health and expectations, and the ability of the patient
ences between large- and smaller-volume liposuction. to maintain a healthy weight and lifestyle postoper-
The anesthesiologist is an integral member of the atively. In difficult cases, it is prudent to be wise, and
team and must have a complete understanding of the a staged or combined procedure is safer for both the
procedure. He or she must be be well trained to patient and the surgeon.
handle preoperative, perioperative, or postoperative Large-volume liposuction is advocated as thera-
problems of fluid shifts and drug toxicity. The pa- peutic body contouring for excessively obese, well-
tientÕs core body temperature must be maintained by motivated, and physically fit patients. When meticu-
using heating blanket systems on the table, minimiz- lously executed as a standard operative procedure, it
ing body exposure, and using a warmed wetting carries negligible risks and maximizes the eventual
solution. realistic aesthetic and functional gains.
L.D. Dhami et al. 587

Table 3. Sequelae and complications

Sequelae/complication Management

Immediate (noted up to 48 h)
Pain Conservative/symptomatic
Oozing
Early (noted up to the first week)
Bruising, ecchymosis, swelling Conservative/symptomatic
Altered pain sensation with paresthesia
Late (noted up to 6 months)
Sequelae/complication Management No. of patients. %
Seroma Drained (1 to 3 drainages)
Liposuction alone (all areas) 24/226 10.6
Liposuction with abdominoplasty 8/70 11.4
Necrosis Debridement and secondary closure 7/296 2.4
Persistent induration with local rigidity Local ultrasonic massage 5/296 1.7
Contour irregularities Local ultrasonic therapy+ revisional surgery 17/296 5.7
Micturition syncope/orthostatic hypotension Conservative/reassurance 15/296 5.1
Patients seeking further liposuction Further sessions requested for other (new) areas 38/296 12.8

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