Body Balance

Cosmetic Surgery Magazine article, posted 2005

We’ve all got a bit of stubborn fat that just won’t budge. It’s when this fat makes buying clothes difficult, or you hide away from public because of your pockets of fat, that liposuction may be useful.

Many people think of liposuction as a cure-all for weight loss. It isn’t. Liposuction is better used as a balancing technique to give the body the best shape possible, keeping in mind there are other structures that give a body it’s shape such as muscle and bone.

Beverly Hills plastic surgeon Nicholas Nikolov M.D. doesn’t believe liposuction is for weight loss. “It’s meant to contour the body and selectively reduce areas so we can make the body appear slimmer and more proportionate.”

Reducing certain areas changes the appearance of other areas. “Simply the way we remove fat in certain areas can give the optical illusion of someone being slimmer than they really are,” explained Dr Nikolov.

To do this the surgeon and patient have to look at the body as a whole rather than isolating troublesome areas. By examining the body in a full length mirror it is easier to see what removing fat from one area will do to the appearance of another. “You have to balance the body in the best way possible. You have to take the whole body into consideration and not just look at a particular part,” said Dr. Nikolov. “For instance, if you do the lateral thigh the patient may notice that their hips are bulging up more, so you have to keep in mind the total picture.”

To do the procedure Dr Nikolov injects the tissue with fluid prior to liposuction. Dr Nikolov uses a wetting technique like most surgeons. Variable amounts of fluid are injected depending on the amount of anticipated aspirate (fat removed). However, unlike the tumescent technique where the ratio of injected fluid is 3 to 1, Dr Nikolov uses low amounts of fluid generally, with a ratio of 1 to 1.

"The majority of people go back to work about a week later."

Depending on the ratio, these techniques are known as wetting technique, super wetting technique or tumescent technique. The ratio of fluid injected compared to aspirate is what makes each technique unique. The 1 to 1 ratio (wet technique) has minimal drawbacks and disadvantages compared to tumescent. The different procedures accomplish the same goal, however, the wetting technique minimizes distortion of the area and also avoids the possibility of overloading the body with local anesthetic. “Some of the advantages of using this technique is that it gives the body the fluid it needs to deal with local trauma because the tissues swell. Also, it allows for less blood loss as a result of the vaso-constrictor contained in the fluid. A local anesthetic is in the solution, which is beneficial during surgery. It also helps after surgery by controlling the pain during the immediate postoperative period,” explained Dr Nikolov.

Another technique which has been observed to have a positive effect on the result of liposuction is external ultrasound. Much like an ultrasound machine used for healing in physical therapy, the ultrasound waves are used over the area to be treated. “It’s applied over the area to be treated after the fluid has been injected,” said Dr Nikolov. “The fluid helps the ultrasound energy to be transmitted to the fat a lot better. We think it helps in dispersing the fluid more evely throughout the tissue which results in less blood loss and probably a smoother contour.”

Unlike internal ultrasound it doesn’t destroy any fat. Rather, the evidence shows external ultrasound helps loosen up the fat cells so they are easier to remove.

Liposuction is performed as a day procedure. While the patient is still in recovery after the procedure is finished, a compression garment with a layer of foam covering the treated areas is put on to ensure even pressure to the area. This is worn for three days and then a more comfortable compression garment is substituted. “This looks like a lycra workout garment and stays on 24 hours a day, except when the patient is showering, for three weeks,” said Dr Nikolov. “This helps everything heal smoothly and reduces swelling.”

There is one very small but important instruction in using the compression garments. They must be kept wrinkle free. “Patients have to be obsessive about wrinkles in the compression garment. Creases can cause indentations or depressions in the skin and are very hard to correct,” explained Dr Nikolov. The majority of people go back to work about a week later if they have a desk job, and are able to exercise three weeks post-operatively. Usually a result in the body contour can be seen one to three days after the surgery, however the final results won’t be seen for three months when all the swelling has subsided.


Liposuction doesn’t remove or help cellulite. This condition is believed to be caused by toxins captured within the fatty areas of the body and in fact has nothing to do with the fat cells themselves. It appears lumpy like orange peel because the connective fiber of the skin, which is constructed in a gridlike pattern like a fishing net, lies right between the bulging fat cells and the skin. The fat cells bulge through these connective fibers resulting in the appearance of cellulite. “In performing liposuction on somebody who has a lot of cellulite there may be a higher danger of irregularity because of the way the fat is organized,” said Dr Nikolov. “However, if there is a dimple in a particular area, in some cases we can release and improve it. But as a general rule, liposuction does not help cellulite.”