The Limitations Of Liposuction

At least once a week, I find myself explaining to a patient that the liposuction procedure she expected to have will not be a good option for her.  In explaining why a particular patient is not a good candidate for liposuction, the main challenge is always one of clarifying what liposuction does NOT do.  I have been shocked over the years by how few physicians of other medical specialties also do not understand what liposuction can, and CANNOT, do.  Therefore, I will attempt to provide some clarity.

Liposuction does not tighten skin- ever. Neither does any special diet or exercise.  Liposuction only removes fat.  If the skin is already loose, it will get even looser with liposuction.

So, who is a good candidate for liposuction?  

Liposuction is appropriate for decreasing the subcutaneous (under the skin) fat in people whose skin is appropriately tight.  Therefore, if someone’s skin is not already loose and they still have good elasticity, then they could be a good candidate for liposuction to remove a localized area of fat excess.  While that may appear obvious when you read it, the vast majority of patients who have already had children, who have lost significant weight, or who are older can get confused by common liposuction marketing. 

These patients see ads for liposuction showing great results, and even CoolSculpting or Kybella giving great results, and therefore want to be able to do those treatments.  Unfortunately, though, the patients who enjoy good results from these three fat reduction procedures all share one important key quality- they all have tight skin.

Everyone wants to think that liposuction will reduce the fat under the skin, and the skin will snap back into place on top of the new, thinner body.  That image assumes that the skin has enough elasticity to snap back like that.  It assumes that skin is like Spandex.  In reality, as we get older our skin gets less like Spandex and more like they want.  In the real world, though, it loses its elasticity as we age.  Even worse, this aging of the skin and loss of elasticity happens even more quickly when it gets stretched severely, as with pregnancy or significant weight gain. 

Therefore, whereas people usually think of liposuction as analogous to taking some air out of a rubber balloon, which then shrinks back down to a smaller size but the same shape, it is often more analogous to removing air from a Mylar balloon that just collapses, folds, and wrinkles as it deflates.  Without elasticity and skin that is tight enough to begin with, liposuction alone is not the answer.

Most commonly, I see young women in their 20’s, 30’s, or 40’s who have had children and are unhappy with their tummies.  These patients usually schedule liposuction consultations, expecting that this treatment will flatten their tummies and make it like it used to be.  Even before I open the exam room door to meet the patient, I have already asked my nurse if the patient has had children already.  If they have been pregnant, I am pretty sure that they will not be able to achieve their goals with just liposuction. 

The reason is simple: Their abdomen skin was probably stretched so much by their pregnancy that the skin is now too loose to perform liposuction alone.  Admittedly, many of these patients with loose skin also have excess fat on their tummies as well as excess skin.  Still, simple liposuction of this excess fat will only make the skin laxity worse.  In fact, if the skin is loose enough that it actually folds over above the pubic area (this extremely common fold of skin is called a pannus), then plain liposuction alone could actually make the skin droop even lower.  

There is no choice for such patients other than removing this extra skin through some version of a tummy-tuck (abdominoplasty).  The tummy-tuck will create a tight, flat abdomen.  A tummy tuck is usually combined with some amount of liposuction to reduce the fat thickness at the same time as removing the extra skin.  While there are various types of tummy-tucks depending on the severity and location of excess skin, the principle is always the same.   If there is excess or loose skin, some of this skin must be removed to make things tight again.  Liposuction alone will not tighten it- it will make it worse.  

This exact same concept applies to every other part of the body as well.  For example, many patients ask for liposuction of their arms.  If the arm skin is not already loose and drooping, and if there is good elasticity, liposuction can give excellent results.  If the skin is already loose or sagging, then an arm lift (skin excision) is needed. 

The same is true of thighs.  In contrast, patients often can benefit from liposuction alone to the love handles or the back for a curious reason:  the dermis of the skin is much thicker there and there is better elasticity in those areas. Therefore, the skin in the back is less likely to fold when it deflates and so will not droop after liposuction.

In older patients, this challenge of skin laxity and loss of elasticity is even worse.  This is a challenge in all regions of the body, including the face.  Whereas a patient in his 20’s might get a better jawline from liposuction under the chin, a patient in his 60’s will almost certainly have too much skin laxity in that area to get any meaningful result from liposuction alone, even if there is some fat excess under the chin.  That is because any fat excess below the chin will be inevitably combined with skin drooping. 

This situation requires a neck lift to remove some of the skin excess. If a neck lift is performed, liposuction might be added to debulk this area, but it is only possible because the loose, extra skin is being removed at the same time.

In addition to pregnancy and advancing age, massive weight loss can also create skin that is too loose for just liposuction.  If someone has been significantly overweight for a long time, their skin will have stretched to accommodate the extra bulk.  Then, when such people are successful in losing much of this weight, they are often greeted with an unwelcome surprise- their drooping skin looks worse than their excess fat did! 

This problem is less severe for younger patients who might still have good elasticity when they lose weight, but their skin will still be looser than if they had never become obese.  In older patients who have poor elasticity to begin with, massive weight loss can lead to massive amounts of drooping skin, which requires surgical removal.  In fact, there is often no role at all for liposuction in such patients: While their old problem was always too much fat, their new problem is all loose skin!

Without a doubt, there can be exceptions to these general rules.  I have seen young moms with 4 children who have no loose skin on their tummies at all.  I have seen 70-year-old women with no skin laxity on their necks and perfect jawlines.  And I have (unfortunately) seen young women in their 20’s who never had children and never were overweight but had somehow developed so much loose abdominal skin that they needed mini-abdominoplasties (tummy-tucks).  Unfortunately, this all comes down to genetics.

Hopefully, this explanation and examples are helpful in clarifying what liposuction does- and doesn’t- do.  There are always grey areas, though, and sometimes it can be hard to tell without a careful examination whether or not someone is a good liposuction candidate.  For this reason, it’s crucial that you talk to a Board-Certified Plastic Surgeon who has all the options available and who can help you pick what the best plan is for you.