Liposuction

Gynecologic Surgery 

Liposuction 

A Gynecologist’s Perspective 

Eric Swisher, MD; Patrice M. Weiss, MD 

Interest in liposuction and body contouring is growing and a skilled 

surgeon of any specialty with knowledge of the pertinent anatomy can 

safely perform these procedures. However, one approach does not fit 

all surgeons, so established guidelines for training and practice across 

the multiple specialties performing liposuction have been inconsistent. 

Liposuction procedures have 

grown by tremendous numbers, 

and it is liposuction, perhaps, 

that poses the greatest 

challenge for acceptance by 

ObGyn physicians and the plastic surgery 

community. Admittedly, the use 

of liposuction by a gynecologist is controversial; 

however, a skilled surgeon 

of any specialty with knowledge of the 

pertinent anatomy has the potential to 

safely perform liposuction and provide 

satisfactory cosmetic outcomes. Here, 

a history, summation of training, procedural 

description, and sample of typical 

results is provided for those interested 

in learning more about liposuction. The 

underlying intent is to allow providers to 

offer a means to meet a woman’s request 

for contour enhancement in an ethical 

fashion, a comfortable setting, and with 

an emphasis on quality and safety. 

Use by ObGyns 

Despite the marked increase in liposuction 

procedures and various other cosmetic 

therapies, including laser hair 

removal, onabotulinumtoxinA (Botox) 

injections, microderm abrasion, vaginal 

rejuvenation, and tattoo removal, such 

therapies are not generally considered 

part of gynecologic practice. For this 

reason, the American College of Obstetricians 

and Gynecologists (ACOG) has 

not established training guidelines or 

competency measurements for these 

Eric Swisher, MD, is Assistant Professor, Virginia 

Tech Carilion School of Medicine, Vice Chief of 

Service, and Assistant Director of Minimally Invasive 

Gynecologic Surgery, Department of Obstetrics and 

Gynecology, Carilion Roanoke Memorial Hospital, 

Roanoke, VA. Patrice M. Weiss, MD, Chair and 

Professor, Department of Obstetrics and Gynecology, 

Carilion Clinic/Virginia Tech Carilion School of 

Medicine, Roanoke, VA. 

Follow The Female Patient on and The Female Patient | VOL 37 MARCH 2012 39

Liposuction: A Gynecologist’s Perspective 

elective procedures. 1 Nevertheless, more 

women, as evidenced by the growing 

number of cosmetic procedures being 

performed in this country, are seeking 

information and access to these cosmetic 

interventions. Often, it is the woman’s 

gynecologist whom she first approaches 

to inquire about cosmetic therapy. Even 

with this rapidly growing consumer demand, 

there are a relatively small number 

of practitioners certified to provide 

these procedures. 2 

Obstetricians and gynecologists are 

the women’s health physicians from 

whom many women still seek both specialty 

and primary care. Is there a justified 

role for cosmetic therapies in the 

scope of the practicing ObGyn? Market 

FOCUSPOINT‣ 

An ACOG task force on the role 

of the ObGyn in cosmetic procedures 

did not clearly define the responsibilities 

of the individual practitioner. 

demand certainly argues the increasing 

importance of this question. Should 

education and training be offered in 

residency programs? If so, will this expanded 

scope of clinical practice include 

additional skills to train providers 

in counseling patients about such 

relevant issues as self-esteem, body image, 

peer-pressure, and a greater understanding 

of sexuality? These questions 

lack easy answers. 

As pointed out in an editorial by 

Laube, 2 an ACOG task force on the role 

of the ObGyn in cosmetic procedures did 

not clearly define the responsibilities of 

the individual practitioner. Instead, a review 

of cosmetic practice among gynecologists 

only poses additional challenges, 

such as ethical issues and financial 

conflicts. Ethical dilemmas arise from 

both the marketing of these practices 

and the financial incentives of elective 

procedures, despite the patient-driven 

demand for such services. As posed by 

Laube, should these financial incentives 

warrant condemnation if performed 

within the appropriate ethical framework 

with informed decision-making? 

Ours is a market-driven economy with 

cosmetic procedures increasing by over 

800% during the last 15 years. Over 

two-thirds of the general American public 

approves of cosmetic interventions, 

and one-third of women report considering 

or having had cosmetic surgery 

that included Botox injections, microderm 

abrasion, laser hair removal, and 

liposuction. 2 In recent years, liposuction 

has become one of the most common 

cosmetic surgery procedures in the 

United States. The American Society for 

Aesthetic Plastic Surgery reported liposuction 

was performed on 176,863 patients 

in 1997. This number increased to 

283,735 in 2010. 3 

Techniques 

Much of the popularity of liposuction 

lies in the evolution of techniques that 

have made lipectomy or lipoplasty more 

accessible and affordable. Fischer, an 

Italian gynecologist, introduced modern 

liposuction in 1974. The tumescent 

technique was brought to the procedure 

by dermatologists, Klein and Lillis, in 

1985. 4 Innumerable alterations in the 

technology have followed, but many of 

the basic principles of tumescent anesthesia 

and negative pressure lipectomy 

introduced by Klein and Lillis remain. 

Liposuction generally involves the use 

of fenestrated blunt metal cannulas and 

suction to disrupt and remove subcutaneous 

adipose tissue. As the technique 

has evolved, cannulas have become 

smaller (1-4 mm) and various methods of 

disruption have become available. Earlier 

approaches to liposuction included 

manual disruption of the adipose tissue 

septations with a rasped cannula followed 

by aspiration of the disrupted fat. 

More recently, energy-assisted methods 

40 The Female Patient | VOL 37 MARCH 2012 All articles are available online at www.femalepatient.com

Swisher and Weiss 

(eg, power-assisted liposuction) using 

rotation, reciprocation, ultrasound, pulsatile 

water infiltration, and laser have 

combined disruption and aspiration 

into a single step for improved results 

and efficiency. The use and advantages 

of the specific modalities is beyond the 

scope of this article. No particular method 

has demonstrated clinical superiority, 

so surgeon preference dictates the 

technique implemented. 

Patient Selection 

Patient selection is critical to a successful 

liposuction procedure or any cosmetic 

procedure for that matter. Though 

larger patients are seeking to meet contouring 

goals with liposuction and succeeding, 

results are generally less than 

ideal. Liposuction is not a means to 

weight loss but rather intended for contour 

improvement. Patients at or near an 

ideal body weight with localized areas 

of concerning adipose tissue are much 

better candidates than the obese. That 

said, a patient’s goals and expectations 

are paramount in preoperative planning. 

Even an ideal liposuction patient 

is a poor candidate for the procedure if 

his or her expectations are unrealistic. 

Likewise, an obese patient who simply 

wants a reduced pannus or better-fitting 

clothing may very well find suboptimal 

liposuction results satisfying. The 

surgeon must thoroughly explore and 

evaluate the cosmetic patient’s goals to 

ensure they correlate with a realistic 

outcome for the procedure. 

Common treatment sites include the 

abdomen, flanks, thigh, and the submental 

fat pad. To minimize complications, 

medical conditions that affect 

healing and surgical risk, such as diabetes, 

hypertension, lupus, coagulopathies, 

and tobacco use among others, are 

contraindications to liposuction procedures 

in most cases. Liver dysfunction, 

which could affect lidocaine metabolism, 

is also a concern when screening 

patients. Age, skin elasticity, and striae 

do not affect safety but will certainly influence 

potential results and should be 

reviewed with the patient preoperatively. 

Preoperative and postoperative photographs 

are critical to documentation, 

patient education, and a more objective 

FIGURE 1. Left: Preoperative abdominal view for abdomen and fl ank liposuction. 

Right: Postoperative result following power-assisted liposuction. 

Photos courtesy of Dr Eric Swisher. 

FIGURE 2. Left: Preoperative abdominal view with pannus which did not 

require abdominoplasty. Right: Postoperative following power-assisted liposuction 

productive of 3,500 cc of adipose supernatant. Photos courtesy of Dr Eric Swisher. 

FIGURE 3. Left: Preoperative oblique view prior to liposuction. 

Right: Postoperative following power-assisted liposuction of the upper abdomen, 

lower abdomen, and fl ank. Photos courtesy of Dr Eric Swisher. 

The Female Patient | VOL 37 MARCH 2012 41


evaluation of very subjective surgical results 

(Figures 1-3, page 00). 

Anesthesia 

Tumescent anesthesia revolutionized 

liposuction as compared to the earlier 

techniques performed under general 

anesthesia. The local approach to anesthesia 

has brought liposuction out of 

the operating room and into the office 

in carefully selected cases. To achieve 

FOCUSPOINT‣ 

Safety with tumescent anesthesia 

is well established but requires 

careful attention to dose. 

tumescent anesthesia, a dilute solution 

of lidocaine, epinephrine, and sodium 

bicarbonate is introduced by needle or 

cannula into the tissue to be treated. 

This infiltration anesthetizes the tissue, 

constricts blood vessels for improved 

hemostasis, expands the adipose treatment 

area for improved safety, and provides 

postoperative analgesia. 

In vitro evidence demonstrates that 

lidocaine is actually bactericidal for 

organisms isolated from skin lesions. 5-7 

Lidocaine appears to have antibacterial 

effects for both gram-negative and grampositive 

bacteria, and in gram-negative 

bacteria, such as Escherichia coli and 

Pseudomonas aeruginosa, lidocaine appears 

to act synergistically with antibiotics 

by depolarizing the bacterial cell 

membrane and increasing cell membrane 

permeability. 6 Though in vivo 

studies have been mixed, supportive 

findings in vitro may explain the very 

low rate of infection associated with 

procedures utilizing this technique. 

Safety with tumescent anesthesia is 

well established but requires careful 

attention to dose. The lipophilic properties 

of lidocaine and the vasoconstriction 

of epinephrine facilitate the 

recovery of much of the administered 

dose with the aspirated adipose tissue. 

An infiltration of up to 45 to 50 mg/kg of 

lidocaine is generally considered a safe 

threshold for dosing tumescent anesthesia. 

The mixture used is typically 1000 

mg of lidocaine (2 x 50-cc bottles), 1 mg 

of epinephrine (1 ampule of 1:1000), and 

10 mEq sodium bicarbonate per liter. 8,9 

Lidocaine toxicity is rare, but includes 

cardiac arrhythmias and central nervous 

system effects including seizures. 

Surgical complications associated with 

liposuction include hematoma, seroma, 

infection, embolic events, tissue necrosis, 

and contour irregularities. Any office 

or facility providing liposuction 

must be fully prepared for such complications. 

Despite the potential risk, a 

2002 review of 66,000 cases using tumescent 

anesthesia identified a complication 

rate of 0.68 per thousand and 

no deaths. 10 Another review including 

15,336 patients undergoing tumescent 

liposuction did not identify any serious 

complications. 11 

The Procedure 

Preparation for a liposuction procedure 

begins with the patient selection process 

and thorough counseling about 

risks and expectations. Laboratory testing 

varies but often includes a complete 

blood count, prothrombin time, partial 

thromboplastin time, hepatitis panel, 

and HIV screening. Vitamin K is sometimes 

administered preoperatively to 

limit ecchymosis. 

Perioperative antibiotic prophylaxis 

is typical and may be continued for several 

days postoperatively. In addition 

to tumescent anesthesia, the surgeon’s 

choice of narcotic and anxiolytic may 

be administered. We use oral dosing and 

do not establish intravenous access. 

Patients are marked prior to infiltration 

of tumescent fluid to highlight focal 

areas of adipose tissue to guide aspiration 

efforts. Skin preparation and 

draping are performed as per standard 

surgical aseptic technique. Small 1- to 

42 The Female Patient | VOL 37 MARCH 2012


FIGURE 4. Typical incision placement for abdominal 

and fl ank liposuction. Photo courtesy of Dr Eric Swisher. 

3-mm incisions using a scalpel or skin 

punch are used for infiltration access 

and cannula insertion. These incisions 

are strategically placed to allow optimal 

cosmesis and access to the targeted adipose 

tissue (Figure 4). 

Once tumescent anesthesia is established 

and the target area is again surgically 

prepped, 2- to 4-mm cannulas 

are introduced into the adipose layer 

through the small skin incisions to aspirate 

the unwanted fat. Cannulas are 

inserted and withdrawn using a gentle 

to-and-fro motion in a fan-like pattern to 

create tunnels in the adipose layer and 

collapse the protuberant tissue. 

FOCUSPOINT‣ 

Shallow subcutaneous aspiration 

is also ill-advised to avoid 

the creation of visible 

superficial tracts or focal 

devascularization. 

Various techniques assist in the safe 

aspiration of fat with a smooth contour 

in the final result. The angle and depth 

of entry is important to avoid perforation 

of the underlying fascia or peritoneum. 

Cannula insertion is generally parallel 

to the underlying fascial plane. With the 

tumescent technique and a conscious 

patient, the intact sensitivity of the deeper 

tissue planes adds to the safety of the 

procedure. Shallow subcutaneous aspiration 

is also ill-advised to avoid the creation 

of visible superficial tracts or focal 

devascularization. The art that defines a 

successful liposuction procedure is the 

balance between maximal removal of 

unwanted adipose tissue and avoidance 

of overly aggressive or misdirected aspiration 

evidenced by contour irregularities 

or subcutaneous grooves. 

Postoperative Care 

Postoperative care includes oral analgesics 

(hydrocodone or oxycodone) and 

a compression garment. Compression 

promotes drainage, limits bruising and 

swelling, and facilitates tissue retraction. 

For 24 hours following tumescent anesthesia 

and liposuction, patients should 

expect a significant volume of serosanguinous 

drainage. This drainage may in 

fact contribute to the low post-procedural 

infection rates in tandem with the use 

of prophylactic antibiotics and the bacteriostatic 

properties of lidocaine. Over the 

next 1 to 2 weeks, tissue edema creates 

induration, which obscures the surgical 

results but does contribute to the beneficial 

retraction attributed to the healing 

process. The final result is best-appreciated 

2 to 3 months postoperatively. Subtle 

improvements may continue for several 

months thereafter. 

Financial Considerations 

Incorporating liposuction into our gynecologic 

practice has had no impact 

on malpractice insurance premiums, 

and this appears typical of the industry. 

From a risk-analysis standpoint, 

liposuction imparts less malpractice 

exposure than most gynecologic and 


Swisher and Weiss 

obstetric procedures. Patient satisfaction 

and management of expectations 

is more critical to mitigating the risk of 

claims arising from cosmetic work. Preoperative 

and postoperative photos are 

imperative because patient recollection 

and her evolving body image may quickly 

erode the impression of even the most 

satisfactory result. 

Capital outlay for liposuction varies 

with the technology employed. A simple 

aspirator, traditional cannula set, and 

infusion pump for tumescent anesthesia 

would generally be in the $10,000 range 

inclusive of other necessary equipment, 

such as tubing and drapes. If a practice 

were not already equipped to provide inoffice 

surgical procedures, then a crash 

cart, procedure table, and other purchase 

costs would apply. A more advanced approach 

with power-assisted, laser, or 

ultrasonic modalities would add to the 

start-up cost and may also require additional 

per procedure costs. Staffing requirements 

would be limited as a single 

nurse circulator is adequate for a typical 

case, and most nurses in a gynecologic 

office would possess the skills to provide 

surgical support. Average charges for liposuction 

are listed in the Table. 

TABLE. Average Charges for Liposuction 

Procedure Materials Time Typical Fee 

Abdominal liposuction $300 to $500 3 hours $2500 to $3500 

Submental liposuction $300 1 hour $800 to $1000 

Thigh liposuction $300 2 hours $2000 

Training 

Liposuction training would be an additional 

cost up front and would vary 

depending on the requirements of the 

particular surgeon. Training courses 

differ in price, but currently the reputable 

options are in the $3500 to $5000 

range for an introductory course. Surgical 

competence, artistic vision for cosmesis, 

previous cosmetic experience, 

and support staff comfort will impact 

the training needs of any beginning liposuction 

practitioner. 

While a weekend course is hardly 

expected to make even the best of surgeons 

a liposuction expert, the theories 

behind the process and the general surgical 

principles are easily mastered by 

a competent gynecologic surgeon in a 

short course. Proctoring may be helpful 

for the initial few cases and would assure 

proper procedures are established 

from the very beginning. Comfort with 

preoperative planning, applying variations 

in surgical approach, avoidance of 

irregularities, and complication management 

evolve with experience as in 

any surgical practice. 

The learning curve is rather steep, 

and comfort with the procedure for uncomplicated 

liposuction cases can be 

expected at the 10- to 20-case threshold. 

Management of more extensive or more 

challenging cases would obviously require 

cumulative experience, and this 

would be case- and surgeon-dependent. 

Conclusion 

It is clear that the interest in liposuction 

and body contouring is growing. Nevertheless, 

universal standards for liposuction 

training remain elusive. Any surgeon 

seeking to perform liposuction brings a 

different background of experience and 

talent to his or her cosmetic aspirations. 

For many, a postgraduate course reviewing 

the principles and practice of liposuc- 

FOCUSPOINT 

Surgical competence, artistic vision 

for cosmesis, previous cosmetic 

experience, and support staff comfort 

will impact the training needs of any 

beginning liposuction practitioner. 

The Female Patient | VOL 37 MARCH 2012 45


tion with hands-on surgical experience 

may be sufficient. Other practitioners 

may require mentoring and more focused 

training and assistance. 

One approach does not fit all surgeons, 

so established guidelines for training 

and practice across the multiple specialties 

performing liposuction have been 

inconsistent. It is certain that liposuction 

requires a mixture of surgical talent 

and art, the latter of which cannot be 

easily taught. Including liposuction and 

other cosmetic practices into residency 

training may standardize the process to 

some extent. While it may be time for a 

more universal standard of training and 

certification, the optimal approach to 

this end continues to evolve. 

The authors report no actual or potential 

conflicts of interest in relation to this 

article. 

References 

1. American College of Obstetricians and Gynecologists 

Committee on Gynecologic Practice (reaffi rmed 2008). 

ACOG Committee Opinion: Nongynecologic Procedures. 

No 253, March 2011. http://www.acog.org/Resources_ 

And_Publications/Committee_Opinions/Committee_on_ 

Gynecologic_Practice/Nongynecologic_Procedures.aspx. 

Accessed December 22, 2011. 

2. Laube DW. Cosmetic therapies in obstetrics and gynecology 

practice: putting a toe in the water? Obstet Gynecol. 

2008;111(5):1034-1036. 

3. Statistics. American Society for Aesthetic Plastic Surgery. 

http://www.surgery.org/media/statistics. Accessed 

December 22, 2011. 

4. Klein JA. The tumescent technique for liposuction surgery. 

J Am Acad Cosmetic Surg. 1987;4:263-267. 

5. Miller MA, Shelley WB. Antibacterial properties of 

lidocaine on bacteria isolated from dermal lesions. Arch 

Dermatol. 1985;121(19):1157-1159. 

6. Kirk GA, Koontz FP, Chavez AJ. Lidocaine inhibits growth 

of Staphylococcus aureus in propofol. Anesthesiology. 

1992;77:A407. Abstract. 

7. Thompson KD, Welykyj S, Massa MC. Antibacterial activity 

of lidocaine in combination with a bicarbonate buffer. 

J Dermatol Surg Oncol. 1993;19(3):216-220. 

8. Klein JA. Anesthetic formulation of tumescent solutions. 

Dermatol Clin. 1999;17(4):751-759. 

9. Ostad A, Kageyama N, Moy RL. Tumescent anesthesia 

with a lidocaine dose of 55 mg/kg is safe for liposuction. 

Dermatol Surg. 1996;22(11):921-927. 

10. Housman TS, Lawrence N, Mellen BG, et al. The safety of 

liposuction: results of a national survey. Dermatol Surg. 

2002;28(11):971-978. 

11. Hanke CW, Bernstein G, Bullock S. Safety of tumescent 

liposuction in 15,336 patients. National survey results. 

Dermatol Surg. 1995;21(5):459-462. 

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