S05E102 Debunking Common Liposuction Myths

Join hosts Dr. Lawrence Tong @yorkvilleplasticsurgery, Dr. Sam Jejurikar @samjejurikar,and Dr. Sam Rhee @bergencosmetic as they dive into common misconceptions about liposuction. This episode covers everything from post-pregnancy liposuction results, the myth of liposuction as a weight loss procedure, and the misconception that fat can't return to the same area after liposuction. The surgeons explain the safety guidelines for fat removal, discuss the efficacy of technologies like VASER and BodyTite, and the realities of liposuction under local anesthesia. Learn about the limitations and truths of this popular procedure and the importance of proper patient education.

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S05E102 Debunking Common Liposuction Myths

TRANSCRIPT

[00:00:00]

Dr. Sam Rhee: Welcome to another episode of Three Plastic Surgeons and a Fourth. I have, uh, I have with us, as always, Dr. Lawrence Tong from Toronto, Canada. He is at Yorkville Plastic Surgery. Dr. Sam Jejurikar from Dallas, Texas. His handle is Instagram handle is at samjejurikar, uh, and The third plastic surgeon who will not be joining us, but will be joining us again soon is Dr.

Salvatore Pacella from La Jolla, California. And his Instagram handle is at San Diego plastic surgeon. And I'm Sam Rhee. I'm in Paramus, New Jersey. And my Instagram handle is at Bergen cosmetic. We have a topic today, which. Uh, came out of the fact that we realized patients have so many common misconceptions about a lot of plastic surgery procedures, where they think they know what these procedures [00:01:00] are all about, but there's actually a lot out there that is actually myth, rumor, or just completely not true.

And so today we're going to go ahead and cover liposuction, which is probably one of the most popular and most common procedures, but what we're Before we start on the misconceptions of liposuction, we'll have Dr. Sam Jejurikar talk about our disclaimer.

Dr. Sam Jejurikar: Yes, this show is not a substitute for professional medical advice, diagnosis, or treatment. This show is for informational purposes only. Treatment and results may vary based upon the circumstances, situation, and medical judgment. After appropriate discussion, always seek the advice of your surgeon or other qualified health provider with any questions you may have regarding medical care and never disregard professional medical advice or delay seeking advice because of something in this show,

Dr. Sam Rhee: Excellent. So I would say I get asked at cocktail parties or casual dinners about liposuction more than any other procedure. And I hear more [00:02:00] misconceptions about liposuction than maybe any other procedure as well. I was just at a holiday party last night someone was asking about liposuction and I probably should have said, hey, just listen to this podcast episode and, and, uh, I'll answer all your questions.

So, let me ask both of you, what is the most common misconception you hear about liposuction from patients or just randomly out there, um, that you would like to avoid? Both

Dr. Sam Jejurikar: um, I think there's so many, well, maybe we'll just take turns. Um, I'd say the one that's coming to mind right away for me right now is after pregnancy. that liposuction can yield a result that's equivalent to a larger body contouring operation. At least once a week, I'll see a patient who comes in for a lipo consult.

Who's had multiple children who has changes to the abdominal wall and the fact that they have muscle that's stretched out and loose and separated. They've got stretch [00:03:00] marks and they just want a little bit of lipo. When I explained to them that the results will not be good, they're like, yeah, yeah. I just don't want the scar associated with the tummy tuck.

And they'll still sort of press for liposuction. And, um, even after the consult is done and they're meeting with my surgical coordinator and they get their tummy tuck consult, you know, uh, pricing and all that, they'll call back later or they'll ask for a liposuction quote. And I've had to instruct my staff that they're not allowed to give them those quotes because it's not a difference being one result being slightly better than the other.

In the wrong candidate, liposuction yields results that are bad.

Dr. Lawrence Tong: Um, the biggest one for me is, you know, a patient will come in and we'll talk about liposuction and they'll say, well, do you think I'm going to lose 15 pounds from this? So, A big misconception is that liposuction is for weight loss and it is definitely 100 [00:04:00] percent not a weight loss procedure. I have, you know, it's important for patients to know that this is for sculpting certain areas where you might have excess curves or excess bulges to reduce the amount of fat that sits under the skin and that the amount of fat that we remove is not so significant that you're going to be losing weight.

a lot of weight associated with this. And, uh, so, you know, that's, that's a very common misconception that I get. And, um, and you know, patients need to be educated about that.

Dr. Sam Rhee: of those are ones I hear a lot. Let me ask, let me pose this one. Uh, and this one was the one I heard last night. They said, I heard that once I do liposuction, I can get fat again and that area won't get fat. Isn't that true?

Dr. Sam Jejurikar: That's, that is a great question. So the first, just sort of general, quick answer is obviously you can get [00:05:00] fat again after liposuction. Liposuction is not a panacea against poor lifestyle choices. Can you gain weight in the exact same place? Yes, you definitely can gain weight. Fat cells, although you remove fat cells from a given area, um, fat cells, you don't get rid of a hundred percent of the fat cells and under extreme situations, fat cells can hypertrophy or grow well beyond their normal size with more triglycerides.

Now, it's not true for all patients that a small weight gain would potentially lead to weight gain in the same place, but for some patients it is. So there's no consistent answer to this. And then finally, what I would say is in the abdomen in particular, if you get liposuction of your abdomen, you definitely can continue to get a fat abdomen after liposuction.

Except you can't get repeat liposuction the next go around because it's deep fat within the abdominal cavity, which is known as visceral fat. And that is only responsive to weight loss or lifestyle modification.[00:06:00]

Dr. Sam Rhee: Uh, how about the misconception about, uh, I like the one that you mentioned, Sam, about the skin versus just liposuction. But, um, and I also like the one you said, Larry, about, about weight loss. Uh, how about the one saying, um, you know what? I, I have, um, you know, all this fat everywhere. You can, why can't you just lipo more?

Like, is there some sort of limit to lipo? I, I heard there was no limit. You could just take out all the fat that I need in all of these areas. You just have to just keep going.

Dr. Lawrence Tong: So that's, that's not true. You can't, you can't just keep going. Uh, there is a limit. Uh, the American Society of Plastic Surgeons has a guideline for five liters in one session. Um, and five liters means The stuff that gets removed, that's called the aspirate. So when we do liposuction, when we remove the, uh, when we're doing the [00:07:00] liposuction, it's, it's not just fat that's coming out, it's, it's a combination of fat, blood, uh, the, the, the tumescent fluid, which is a fluid that we inject, um, under the skin in and around the fat, uh, as a, as a method of, of, um, doing the liposuction.

And, uh, there's a, there's a, recommendation of five liters because, um, above that, the, um, the patient should be hospitalized or spend a night, um, you know, in, um, in hospital to be observed. Um, and so there is a limit. Beyond that, you can't liposuction every part of the body. Not every part of the body is amenable, uh, to liposuction.

So When, you know, when we see patients, sometimes they'll, they'll inquire about areas that, um, that aren't really amenable. They'll, they'll, you know, they'll, [00:08:00] a recent one that I got was, you know, right here at the, at the top of the spine. They had this thick, thicker area of tissue there. And, uh, when I looked at it, it was actually the patient's spine.

That's it. No, you can't liposuction that. You have bad posture. You sit in front of the computer all the time and it's, it's not, it's, it's not fat. Or some people will want, I don't know, like their forearms liposuction. You know, that's not an area that's done. So the answer is no, it's not unlimited. Um, you can't lipo, Uh, as much as you want.

You can, you know, break up your, your, your areas of need into multiple procedures. If necessary, I always stop, um, at five liters. I don't like to admit patients, uh, for cosmetic, uh, for, for liposuction because they're, you know, um,

Dr. Sam Rhee: today,

Dr. Lawrence Tong: that taking out more than five liters is probably too much. And then there are [00:09:00] areas that, you know, you, you just don't do liposuction.

Dr. Sam Rhee: I'm sorry,

Dr. Sam Jejurikar: Yeah. Just to expound on what Larry said. People think because there's small incisions utilized for liposuction that it is minimally invasive surgery or that it's not real surgery. But when you start getting over five liters of liposuction aspirate, there's profound blood loss that can occur with it.

There's electrolyte abnormalities that can occur with it. It can be very dangerous. So, um, I guess that leads into another myth. Liposuction is a very real operation with real potential risks that go along with it. And it's important that patients are aware of that. You can't just keep going because it can be dangerous to do so.

Dr. Sam Rhee: How about the misconception about massages and compression garments? You need 50 massage sessions or you need to wear the tightest compression garments possible. Otherwise, these areas are going to blow up and your results will be terrible.[00:10:00]

Dr. Sam Jejurikar: You know, I think we have different opinions on this. Um, I think we, we had a previous episode where we talked about, I think about this. And I think we do. Slightly different practices. I do think that there are different kinds of patients getting liposuction. Okay, so let's say we have a 20 year old female that's never had kids, has perfect skin elasticity, coming in for just a small area.

Yeah, compression is not that important. Lymphatic massage is not that important. Ultimately, with great skin elasticity, you'll get great results with liposuction. You just need to wear compression for a few weeks. It'll tighten up pretty nicely. Wear compression garments might be helpful in that patient.

A lymphatic massage would be helpful in that patient is during that period of time where you're dealing with swelling. They'll look better during that period of time. Then you have different patients, and I do firmly believe this, the patients that you see who have somewhat compromised skin elasticity, maybe not quite so bad that they're getting a tummy tuck and they have all these stretch marks, but their skin, you know, they might be in their late 30s or 40s, and [00:11:00] I'm using technology like VASER.

Body tight to try to get the skin to tighten. In those patients, I do think that in the first six weeks, that lymphatic massage a couple times a week yields better results because their skin doesn't stretch as much. And I like for the first six weeks, snug compression so the skin doesn't get to expand. I make my patients, or I encourage my patients even beyond those six weeks to wear compression for another six months, which I know you guys don't, don't do.

But again, it's just mainly so that they look their best when they're not wearing compression during that phase. But I'm not ready to call that a misconception or a myth. I think there's just different ways that people practice where that's concerned.

Dr. Sam Rhee: Uh, I'm starting to lean towards a longer compression periods and, uh, more massage treatments myself. After that episode, I started playing around with that with my patients and I feel like you're right. There's, there's something to it for sure, especially like you said, some of the patients who have some compromised skin elasticity, there's definitely something to be said for that.

So, so you, you're [00:12:00] converting me slowly there, Sam. I'm, I'm starting to believe in that. What else, uh, uh,

Dr. Lawrence Tong: I

Dr. Sam Jejurikar: think LT wants to chime in on this.

Dr. Lawrence Tong: going to say, since I podcast, I have not changed anything. Um, but, but I, but I do believe that massage, uh, lymphatic massage is helpful for a speedier recovery. I definitely think that's true. It's just whether or not you believe that that actually affects the result in the longterm. And I'm not quite convinced about that.

And plus, you know, Sometimes when my patients go get it, they complain that it, that it hurts. So it's just an added, you know, something that they have to do. And I'm not convinced that, uh, it adds to the long term result. Maybe it's because all my patients are 20 and 30 year olds with a BMI of 25. Just kidding.

Dr. Sam Rhee: I was like, all right, Larry [00:13:00] has a very good practice demographic there. Wow. All right. Uh, what other misconceptions do you hear that you know of that? Uh, how about, um, a lot of, I've started to see a lot of people who wanted calf liposuction. Uh, they, they believe that calf liposuction is safe and can be done.

Dr. Lawrence Tong: I do

Dr. Sam Jejurikar: um, you do? So what do you tell patients about the recovery with that?

Dr. Lawrence Tong: That they're going to have prolonged swelling with the area just because of its location. But I used to be a skeptic. And then I started doing some cases and they actually get pretty nice results. It's those patients who have, it's not just the calf, it's that junction from the calf to the ankle where it just sort of looks one diameter instead of

Dr. Sam Jejurikar: You mean a, you mean a cankle? Exactly.

Dr. Lawrence Tong: So, [00:14:00] um,

Dr. Sam Jejurikar: knows what a cankle is.

Dr. Lawrence Tong: that, that, you know, in the right patient, you know, somebody who had, who you verify that it's fat and not, you know, edema, they're gonna, they're usually get a very nice result. And it's not so much liposuction of the calf, but at that lower part of the calf and ankle area, where if you just liposuction that and, and shape it, um, I think the results are actually quite good. When I went through training, um, you know, the prevailing thought was that, you know, calves. aren't good to do. But, um, you know, there was a couple of cases that I, that I did because, and I told the patient, you know, might not do much, but I was pleasantly surprised at how, how well it turned out. So when patients come and ask me, it's not something that I will, you know, automatically be dismissive of.

It is an operation that works.[00:15:00]

Dr. Sam Jejurikar: I completely agree with Larry. Um, I think calve liposuction is It's very beneficial, um, but I do modify some things postoperatively because I, I think patients can stay swollen for a year after you do a liposuction of the calves. So I have them wear compression garments that go below the knee 24 7 for three months.

I warn them that they're going to have swollen ankles and swollen feet. for six months, nine months postoperatively. Um, and you, and you have to just make sure they really understand that cause they think something's going wrong postoperatively. But I think if, if a patient's willing to accept that, I think, I think, um, it can be a really nice result. These small

Dr. Lawrence Tong: you do it?

Dr. Sam Jejurikar: Do I?

Dr. Lawrence Tong: No, uh, Dr.

Dr. Sam Jejurikar: Rae.

Dr. Sam Rhee: I don't. I've never done calf liposuction, and it's not something that Um, I thought was a significant part of my practice, maybe, or, [00:16:00] and I was also of the old school where the, I just sort of follow the principles we trained. I'd also seen one or two cases. of complications of compartment syndrome after calf liposuction.

And that really freaked me out. So I've never tried it. Um, I, I, but hearing you guys talk about it, that's really interesting. Um, I'm glad that it's safe and I'm glad that, uh, you know, people get good results with it. That's awesome. Uh, I don't, I'm probably not going to start doing calf liposuction now, but I might end up referring to you guys, uh, you know, when I get those patients.

Dr. Sam Jejurikar: What about ankle liposuction? Will you do that? I know you won't say them. Larry, will you do that? I

Dr. Lawrence Tong: Yeah, I mean, there's, there's fat around. I mean, when, usually when a patient is, is asking for calf liposuction, it ends up being a combination of calf and ankle liposuction. So, so yes.

Dr. Sam Jejurikar: find my results to be not as good around the ankles [00:17:00] as more approximately in the calves. I think the swelling there lasts for such a long time. And I, during my fellowship, saw a very bad complication in that area from, from one of the guys I trained with. So I'm a little, I'm a little more nervous around the ankles.

Dr. Sam Rhee: I love knee liposuction. I'll do a lot of around the knee lipo, but nothing sort of much below that.

Dr. Sam Jejurikar: What about, what are your guys philosophies on using additional technology like heat technology and doing fat grafting. Do you feel comfortable using technologies like VASER, radio frequency, uh, Renuvion, even power assisted? Like what technologies will you use and then fat graft?

Dr. Lawrence Tong: now you're talking about fat grafting at the same time as liposuction, uh, for like, uh, if somebody's had liposuction before and they have some contour deformities.

Dr. Sam Jejurikar: Or whatever reason you might want to [00:18:00] use those technologies. Yeah. Or do you not standardly use those technologies when you do liposuction?

Dr. Lawrence Tong: So I use power assisted liposuction as my standard for all liposuctions. So for viewers, that is a type of liposuction where the, the instrument that we use, which is called a cannula, is mechanized so it oscillates very quickly back and forth. And that helps to, you know, break down the fat. And, um, the benefit of that is that it's more efficient at removing fat, um, per time, and then the surgeon has less effort because we're not putting so much force in trying to advance the cannula which allows us to you know, have a surgery which is more akin to sculpting than just sort of brute force.

So I think you know most people do power assisted liposuction these days and I think it's a it's a great tool. It saves, you know, saves your arm definitely. But [00:19:00] as for adjunctive, Um, procedures, I, I think it's important to realize that they do something, um, and it's usually to try to tighten the skin, but the, uh, the effect is, I would say, more on the subtle or, or mild side.

So, generally, something like, uh, Renuvion, I might use, uh, from time to time. Again, I'm not 100 percent convinced that it, it makes sense. A huge difference, but in some cases, I think it does. Um, I know that Dr. Jejurikar, you're an, uh, you're an advocate, I think, for these technologies. Um, why don't you let us know sort of your sort of experience with them?

Dr. Sam Jejurikar: Um, I mean, I, I think, um, I use VASER basically as an alternative to, to power assisted. I, I think the combination of VASER and body tighter VASER and Renuvion, I won't say [00:20:00] leads to dramatic skin tightening. Probably more moderate skin tightening. It's never going to be effective cutting it out. But, but, um, you know, my question was largely sort of in relations to fat grafting, because there's this whole school of thought that, um.

If you use heat technology or something that you're going to damage fat cells and that

Dr. Lawrence Tong: Oh, you're talking for Harvest.

Dr. Sam Jejurikar: for harvesting purposes. Yeah. Like, do you feel comfortable doing that? And I used to not, we all trained in a, in a place in a time where if you do anything to the fat cells that could potentially traumatize it, those fat cells wouldn't, wouldn't be okay to do fat grafting with.

But, um, there's been a lot of research that actually shows it's fine to use. Things like Vaser and Body Tide and FatCraft and I'm done and done. Many, many, many cases and haven't noticed any change in my fat grafting retention rate. So that's where I was going. I feel like that was not a good question on my part though, because neither of you have any idea what I [00:21:00] was asking.

So

Dr. Lawrence Tong: no, I, I will use the, I will definitely use Power Assisted to, to harvest fat grafting if I'm fat grafting the body. Um, and I, I haven't noticed any negative effects in terms of, uh, survival with, with using that. Yeah,

Dr. Sam Rhee: What is the maximum, if a patient asks, what is the maximum you can inject for fat grafting into somebody? Like, 10 liters, 8 liters, 2 liters, 1 liter? Like, what is it that, um, You feel like, and does all of it survive? They're always asking, like, if you inject, you know, X amount, will all of it survive or not?

Dr. Sam Jejurikar: Um, so first of all, we already ascertained that the maximum amount of fat we could harvest through liposuction is five liters. So that's going to be our first cutoff. And like Larry mentioned, when you, when you do five liters of liposuction, there [00:22:00] is. plasma, there's oil, and then there's fat. And for patients that are really thin, there's going to be a lower concentration of fat within that.

So let's assume we have a finite amount of fat to work with. Then beyond that, there is, um, when you inject fat, what's really important for determining fat cell survivability is the pressure within the tissue. So, um, You know, whether it's the butt, whether it's the breast, um, you know, we're looking for more superficial planes of injection within the fatty layers.

And there's a point where when you exceed the pressure by which capillaries can grow in to support those fat cells, once you start to exceed that amount, even if you inject more fat, the percentage of fat cells that survive the transfer is going to actually go down dramatically. So there is a maximum amount, depending on just tissue quality.

What percentage, so let's say the surgeon does everything right. They're paying attention to, you know, to [00:23:00] tissue turgor or the, or the overall tightness. If everything is done perfectly, I'll typically tell patients that I expect 50 to 60 percent of the fat to survive the transfer. But then, the way I define that is, you know, how much of those fat cells do we think are around at 6 or 8 weeks post op?

Fat is then dynamic. I mean, fat cells, when you are in times of extreme starvation, yields triglycerides and the fat shrinks and people think they're losing their fat. Conversely, people put on weight, fat cells will swell. So, you know, the results of fat grafting are dynamic and are changing. So that is my very long winded way to not really give an answer to that question.

Dr. Sam Rhee: I was like, I was like, all right, let me, let me try to pull that answer out of that somehow.

Dr. Sam Jejurikar: I mean, that's an impossible question to

Dr. Lawrence Tong: 60 percent is, is basically what I tell them. And it depends on the area of the body. Right, like if you're fat grafting the face, [00:24:00] uh, there are areas that are definitely better and areas that aren't so good. Like for example, the lips, if you fat graft the lips, they usually don't, they don't survive as well.

Dr. Sam Rhee: Yeah, no, I was just wondering, because there are a lot of patients that are like, doctor, just inject as much fat into my butt as I can, you can. And when you tell them afterwards how much it is, they're like, but why didn't you inject more? Like you should have injected all of it. And you're like, That doesn't make sense.

Like that's actually, as Sam says, counterproductive to what would actually be helpful for results. So I think that's one of the misconceptions is, is that, um, you can just keep injecting all the fat that you take out. Um, you know, you take out, like you said, five liters, you should be able to inject five liters, and that's, that's not the case.

Dr. Lawrence Tong: yeah, at some point you can't, you know, if you're, if you're doing a Brazilian butt lift and you keep injecting, the fat starts coming back out the same hole at some point.

Dr. Sam Rhee: That's right. The pressure [00:25:00] is just very, very,

Dr. Lawrence Tong: Yeah. And so if you've got, if you've got into there that's. You know, you know you're done.

Dr. Sam Rhee: All right. Are there any other misconceptions you want to hit on before we close up on this topic?

Dr. Sam Jejurikar: I thought of one more thing, actually, just to get your opinion. Can, do you think patients can get the same degree of results from awake liposuction as they can from Liposuction under anesthesia.

Dr. Sam Rhee: Go ahead, Larry.

Dr. Lawrence Tong: Definitely not because, um, if you did the same liposuction that you typically do in a person who's under general anesthesia, when they're just awake, they would be in a lot of discomfort. And so I feel that you can't be as aggressive as you, as you would if the patient is still awake. Now. You know, are there methods to, [00:26:00] um, you know, get the pain under control such that you can get it to the equivalent?

I guess it's possible, but I think that's a very select group of patients that you can achieve that in. So I definitely do not think, I mean, it depends on what you're doing, but, um, in general, no, I think you can be much more, you know, Uh, free, uh, to, to remove fat in, in the, you know, areas that you want if a patient is under general anesthesia.

And I think you're just limited. You're limiting yourself if, if you try to do it, um, in an awake state. So when patients ask me about that, that's what I tell them. I said, it can be done, but you know, why would you, um, undergo a procedure where you, you might be limited in. Achieving the result that you want to achieve, just go under general anesthesia.

Dr. Sam Rhee: That's interesting. I, I'll be devil's advocate [00:27:00] and say, you know, cause I do a fair amount under light sedation. Uh, they're not like awake, awake, like without anything, like pure local, but they'll usually have a little bit of something on board. But, uh, You know, nothing that would even qualify for real sedation.

And I would say the biggest, and I feel like I can get results that are comparable. Um, the biggest drawback to it is that I have to go slow. I can't go fast. My rate of liposuction is slower. My rate of infusion is slower. Everything is slower. Because you're right, if you try to go really aggressive and really fast, patients are not going to like it.

So, um, It's, you know, I think

Dr. Sam Jejurikar: When, when, when you say light sedation, like what do you, what are you using?

Dr. Sam Rhee: maybe a little bit of Xanax or something, you know, um, maybe, uh, half a Percocet on board or something like that on top of the local. So just a little bit of oral sedation, something very light. And, uh, I feel like, [00:28:00] um, in most patients I can achieve a comfortable state as long as I, uh, infusing slowly, liposuctioning slowly, um, That is pretty comparable to what I would do, uh, under full general anesthesia.

Um, it's, to me, it's, it's something that I've done a lot of. Let me put it that way. I've done, I would say, 90 percent of my lipo in that, um, sort of setup. And so, maybe it's just because of that. Maybe I'm wrong. Maybe if I had done it all under general, I would probably say, Oh, no, I could be way more aggressive, but it's what I know.

And so it's just sort of been my experience with it.

Dr. Sam Jejurikar: Yeah. I mean, I I've definitely done a fair amount of awake lipo in the past, and there's still some areas that I'll do like underneath the neck, I think is really easy to

Dr. Lawrence Tong: neck is fine.

Dr. Sam Jejurikar: patients. Yeah. While they're, while they're awake, [00:29:00] limited areas, you know, if it's a fit patient with a relatively small volume of liposuction, I feel pretty comfortable. Um, doing it in the manner Sam described, except it does take so long that I don't love it for that reason. Um, but like large volume liposuction, four or five liters in a patient. I

Dr. Sam Rhee: Oh, yeah, I agree with

Dr. Sam Jejurikar: don't, I don't, I don't feel like I can get great results on that.

Dr. Sam Rhee: Yes. Okay. You're right. Large volume lipo. Yes, absolutely. But I don't do a ton of large volume lipo in, in a lot of my cases, but you're right that that would probably necessitate. A deeper level of anesthesia. Good.

Dr. Lawrence Tong: agree with both of you. Smaller areas, definitely you can do it. Larger areas, no.

Dr. Sam Rhee: Wow. Well, this was informative. I think it was super helpful for a lot of people, hopefully. And if anyone out there has any other misconceptions about anything else, send them to us. [00:30:00] We're happy to answer them. And until next time, thank you very much guys. Take care.