Plastic surgery

PART VII

BODY CONTOURING

CHAPTER 65  LIPOSUCTION

MARY K. GINGRASS

Liposuction is the surgical aspiration of fat from the subcutaneous plane leaving a more desirable body contour and a smooth transition between the suctioned and the nonsuctioned areas. Liposuction is one of the most popular cosmetic procedures performed by board-certified plastic surgeons in the United States. Although liposuction is not a technically difficult procedure to perform, it requires thoughtful planning and careful patient selection to achieve consistently pleasing results. Poor planning or poor execution can result in uncorrectable deformities.

HISTORY

The aspiration of fat using blunt cannulas and negative-pressure suction was first popularized in Europe in the late 1970s.1 Three French surgeons, Drs. Yves-Gerard Illouz, Pierre Fournier, and Francis Otteni, were the first to present their lipoaspiration experience at the 1982 American Society of Plastic and Reconstructive Surgeons annual meeting in Honolulu, Hawaii. The procedure was initially met with skepticism in the United States. In late 1982, a “blue ribbon committee” was commissioned by the American Society of Plastic and Reconstructive Surgeons to visit Dr. Illouz in Paris and the committee returned with a cautiously optimistic report. American surgeons’ interest in liposuction and public demand for minimally invasive body contouring have steadily risen since then.

PATIENT SELECTION

Patient selection is a critical determinant of a good surgical result, especially in body contouring. Not all patients who request liposuction are good candidates. The consultation begins with an assessment of the patient’s goals. What does the patient wish to change about his or her body? What does the patient expect to accomplish with liposuction? The surgeon then provides the patient with a realistic appraisal of what can and cannot be accomplished. Some patients may require alternative procedures (such as an abdominoplasty) or liposuction combined with an open surgical procedure. An astute surgeon is wary of patients who are particularly poor candidates for liposuction such as (a) perfectionists with imperceptible “deformities,” (b) those with underlying mental illness that prohibits realistic expectations (body dysmorphic disorder, or active eating disorders), and (c) significantly overweight patients who are incapable of weight reduction and/or weight maintenance after liposuction. If a patient is steadily gaining weight before liposuction, he or she are likely to continue this trend after liposuction.

A detailed weight history is an important part of any liposuction consultation. Ideal candidates are at a stable weight with a working diet and exercise regimen in place. Patients who have a history of frequent or significant weight fluctuations are at high risk for weight gain after liposuction. Maintaining a stable weight and practicing a diet and exercise regimen for at least 6 to 12 months indicates the necessary commitment to lifestyle change.

Liposuction should not be offered as a treatment for obesity. In a perfect world, it is used to remove genetically distributed or diet-resistant fat. In practical terms, however, it is frequently used to remove fat that could be lessened with diet and exercise. Ideal liposuction candidates are within 20% of their ideal body weight or less than 50 lb above chart weight. Abnormally distributed bulges of fat or fat that resides outside the confines of the ideal body shape are the “target” areas that are most commonly suctioned.

PATIENT EVALUATION

A thorough physical examination is always performed. Although the focus of the examination should be on “problem areas,” it is important to take the entire body shape into consideration. An overall harmonious body contour is the desirable outcome. The patient is examined for areas of disproportionate fat, asymmetry between the two sides, dimpling/cellulite, varicosities, and zones of adherence. Asymmetries are noted and, if they are significant, they are brought to the attention of the patient. If the abdomen is being considered as a potential surgical site, it should be carefully examined for hernias, significant abdominal wall laxity, abdominal scars, history of abdominal radiation, and anything that might affect abdominal wall integrity.

One of the most important physical findings, which will have significant bearing on the final outcome, is the patient’s skin tone, or dermal quality. It is important to pinch and palpate the skin, assessing for the degree of laxity and dermal thickness. A thicker dermis is more likely to retract after liposuction and give a desirable result. Thin, stretched skin with striae (indicating dermal breakage) is unlikely to retract and may look worse after liposuction. If it is determined that the skin quality is unsuitable for liposuction, alternative procedures are proposed, such as skin excision, if indicated.Liposuction does not treat cellulite; thus one should not make promises to this effect.

The quality of the fat should also be assessed because it may affect the outcome. The anatomy of the subcutaneous adipose tissue varies throughout the body. Some areas of the body have both a deep adipose compartment and a superficial adipose compartment, which are separated by a discrete subcutaneous fascia. The superficial fat in the trunk and thigh consists of smaller lobules, tightly organized within vertically oriented, thin, fibrous septa. The deep fat consists of larger lobules arranged more loosely within widely spaced and more irregularly arranged septa (Figure 65.1).2 In these areas, the deep layer of fat is the target for liposuction. The overlying superficial fat is (usually) relatively thin and will act as a protective layer to hide small contour deformities, especially for the inexperienced liposuction surgeon. In contrast, other areas of the body that are commonly suctioned (arms and lower legs) have only one layer of fat. Suctioning these areas with smaller cannulas will help avoid contour irregularities.

FIGURE 65.1. Superficial and deep fat layers. Markman and Barton studied the subcutaneous tissue of the trunk and lower extremity, finding that the fat lobules in the superficial layer (SL) are small and tightly packed within closely spaced septa, whereas those of the deep layer (DL) are larger, more irregular, and less organized. The arrangement becomes less obvious in the gluteal and thigh area, and disappears as one proceeds from trochanter to knee. There is only one fat layer in the lower leg. (Adapted from Markman B, Barton F Jr. Anatomy of the subcutaneous tissue of the trunk and lower extremity. Plast Reconstr Surg. 1987;80:252.)

Superficial liposuction, a technique popularized by Marco Gasparotti and others, uses small cannulas to aspirate fat from the superficial planes (1 to 2 mm). Proponents of this technique contend that aspiration in the superficial plane leads to predictable contraction of the overlying skin. Superficial liposuction leaves very little margin for error and should not be attempted until the liposuction surgeon has gained considerable experience in the deep and intermediate planes.

INFORMED CONSENT

Informed consent should be regarded by the surgeon not only as a legal responsibility but also as a mutually beneficial transaction. The patient is informed of the risks, benefits, and available alternatives to the procedure being considered. A well-informed patient knows what to expect in the postoperative period. In the event of a postoperative complication, there is less likelihood of compromise of the doctor–patient relationship if the patient was well informed initially.

ANESTHESIA

The appropriate type of anesthesia should be chosen based on surgeon preference, patient choice, estimated volume to be removed, and whether other surgical procedures are being combined with liposuction. Liposuction can be performed safely as an outpatient procedure in an office setting or in an outpatient surgery facility as long as strict adherence to patient safety is maintained. Local or regional anesthesia is generally appropriate for aspiration of smaller volumes, and general anesthesia is preferable when larger volumes are removed. When large-volume liposuction (>5,000 mL of total aspirate) is performed, or when liposuction is combined with a significant open surgical procedure(s), hospital admission or 24-hour observation in a hospital setting is recommended.

Attention to perioperative fluid management is imperative when significant volumes are suctioned. Approximately 70% of the injected subcutaneous fluid will be absorbed and must therefore be taken into account when calculating intraoperative intravenous (IV) fluid. Anesthesiologists unfamiliar with liposuction may not be aware of this fact and excessive fluids may be administered. When the superwet technique is used (see Wetting Solution below), the following guidelines for fluid resuscitation are recommended: (a) for volumes <5 L of total aspirate, administer maintenance fluid plus subcutaneous wetting solution; (b) for volumes ≥5 L total aspirate, administer maintenance fluid plus subcutaneous wetting solution plus 0.25 mL of IV crystalloid per milliliter of aspirate above 5 L.3

SURGICAL PLANNING AND INSTRUMENTATION

There are a number of tools available to the liposuction surgeon. Each tool has its advantages and disadvantages and some surgeons simply prefer one tool or technique over another. The following discussion is only an introductory comparison, not an in-depth analysis, of the available techniques.

Traditional suction-assisted lipoplasty (SAL) became popular in the United States in the 1980s. The technique uses varying diameter, blunt-tip cannulas attached via large-bore tubing to a source of high vacuum, which effectively suctions fat through a hole or holes in the tip of the cannula. Syringe SAL is a variation whereby fat is aspirated with a cannula attached to a syringe. Suction is created when the plunger is withdrawn, collecting the fat into the syringe. This technique is frequently used if fat is being harvested for fat grafting.

SAL has a long track record and is considered the “gold standard.” Traditional SAL cannulas are typically bendable and come in many sizes and tip configurations, and most hospital operating rooms and surgery centers own this type of equipment. SAL is an excellent technique for small- to medium-volume cases and removal of soft fat. The sheer simplicity of SAL makes it a valuable tool that is essential to have in any plastic surgeon’s armamentarium. It is a less efficient tool for the removal of fat from more fibrous areas and requires a fair amount of physical effort on the part of the surgeon, which becomes a disadvantage in larger volume cases. Bruising is expected as a result of disruption of blood vessels by the shearing and suction forces. Cross-tunneling is a necessary step with SAL to avoid contour irregularity, which one study reported to be as high as 20%.4 The most frequently reported unsatisfactory results in this study were insufficient fat removal and excessive waviness. Asymmetry, excessive fat removal, and unacceptable scarring occurred with less frequency.

Ultrasound-assisted liposuction (UAL) was introduced in the United States in the mid-1990s to address some of the shortcomings of SAL. Ultrasonic energy is produced in a piezoelectric crystal within the UAL hand piece. The ultrasonic energy is transmitted down the attached probe or cannula to its tip, where it causes micromechanical, thermal, and cavitational effects on subcutaneous fat. The intervening fibroconnective tissues remain relatively unharmed and available for postoperative skin retraction. The emulsified fat is suctioned away with low-power suction. UAL requires much less physical effort on the part of the surgeon than does SAL because much of the “work” is done by the ultrasonic energy. UAL is an extremely efficient tool for the removal of fat in fibrous areas such as the upper back, the hypogastrium, and the breast. UAL has been shown to cause less disruption of vasculature than SAL,5 which translates into less bruising in most cases. There is energy dissipation in all directions at the tip of the UAL probe or cannula, which gives it a certain “airbrush” effect. Some surgeons believe it is a superior tool for sculpting and find there is less need for cross-tunneling compared with SAL.

There are also disadvantages to UAL. There is potential for frictional injury at the skin entry site, so constant irrigation at the incision or a skin protector must be used. Seroma rates can be high with prolonged ultrasound treatment times. There is some elevation of tissue temperature with UAL and, if improper technique is used, thermal injury can occur. With proper training, these problems rarely occur. UAL is safe and effective when the surgeon is properly trained and the procedure is performed properly.6

Power-assisted liposuction (PAL) was developed in the late 1990s to address some of the concerns about UAL. PAL is basically traditional SAL powered by a reciprocating cannula. The main advantages of PAL over SAL are its efficiency in fibrous areas and its ease of operation for the surgeon. There is no particular salvage of fibroconnective tissue or neurovascular structures as there is with UAL. The main advantage of PAL over UAL is that there is no heat generation. PAL is an excellent tool for the surgeons who remain uncomfortable with the potential for heat and the power of UAL.

The use of laser assistance to improve liposuction results has recently been proposed. Proponents advocate that the application of laser energy, applied either externally or internally to the fatty layer, disrupts adipocyte cell membranes. However, studies by Prado et al. failed to demonstrate clinical advantages with internally applied laser-assisted liposuction over traditional SAL in a double-blind, randomized, controlled trial.7 Studies by Brown et al. failed to show any adipocyte disruption by histologic or scanning electron microscopy in porcine and human fat treated with laser-assisted lipoplasty versus traditional SAL. This study also failed to show any clinically significant differences in patients treated with internal or external laser-assisted lipoplasty.8

MARKING AND POSITIONING

Preoperative markings provide an important “topographic map,” enabling the surgeon to visualize the targeted convexities, avoid concavities, and address asymmetries when the patient is lying on the operating table. Markings should be made immediately prior to surgery with the patient in a standing position. A permanent marking pen is imperative so that the markings will not wash off when the patient is prepped. Asymmetries are carefully marked and brought to the attention of the patient. Depressions and indentations can be marked with a different color marker so that these areas can be avoided or treated to a lesser degree than surrounding areas (Figure 65.2).

Patient positioning is planned before the patient enters the operating room and depends on which areas are being suctioned. Although most body areas can be suctioned from either the prone or supine positions, some surgeons prefer the lateral decubitus position for the hip rolls and lateral thighs. When several body areas are to be suctioned, an intraoperative position change is necessary. Some surgeons prefer to prep the patient circumferentially while standing and then have the patient lie down on a sterile drape. A locally anesthetized patient can rotate on the operating table as necessary throughout the procedure. When the procedure is performed under general anesthesia a position change is usually required. The patient is first prepped in the prone position, which allows easy access to the back, flanks, buttocks, lateral thighs, and the posterior aspect of the entire lower extremity. The patient is then turned to the supine position and reprepped and draped. The abdomen, breasts, arms, and the anterior aspect of the lower extremity can be addressed from this position.

Patients are prepped with a 3-minute Betadine scrub, followed by Betadine paint. Warming blankets are recommended on unexposed body parts and a Foley catheter should be placed when aspirations >5 L are planned. When liposuction is combined with an open surgical procedure, or when large-volume liposuction is performed, compression hose and/or sequential compression device boots for deep vein thrombosis prophylaxis are recommended.

FIGURE 65.2. Preoperative markings before circumferential thigh liposuction. Markings are similar to a topographic map. Lines and circles represent surface features of the body showing the specific shape and size relationships between the component parts. In this case, progressively smaller circles indicate a “higher” point (or more fat) in relation to the surrounding areas. Markings are extremely important to assist the surgeon in getting smooth, even, and predictable results.

WETTING SOLUTION

Liposuction was first practiced as a “dry” technique, meaning that nothing was done to prepare the fat prior to suctioning it from the subcutaneous plane. As one might expect, hemorrhagic complications were common. Illouz is credited for developing the “wet” technique, which he described as a “dissecting hydrotomy,” wherein he instilled normal saline, water, and hyaluronidase in the hope of creating a weak hypotonic solution to lyse the adipocyte cell wall.9 Hetter10 is credited with adding lidocaine and dilute epinephrine to the wetting solution. Jeffrey Klein, a dermatologist, developed and coined the term tumescent technique, which is now used for the infiltration of large-volume, dilute lidocaine with epinephrine solution for the purpose of performing liposuction with low blood loss.11 The importance of infiltration of wetting solution cannot be overstated. The superwet technique is defined as a 1:1 ratio of the volume of wetting solution infused to the volume of aspirate. The term tumescent technique was classically described as a ratio of 2 or 3:1. Technically, the tumescent and the superwet techniques differ in the ratio of volume infused to volume of aspirate; however, both involve infusion of wetting solution to the point of tissue turgor or a “peau d’orange” of the overlying skin. Practically, the term tumescent liposuction is used as a generic term for liposuction using abundant wetting solution.

Injection of the wetting solution has a number of advantages. It provides a mechanism for delivery of anesthetic and vasoconstricting agent, thereby providing a component of intraoperative anesthesia, decreasing blood loss and postoperative bruising, and also providing postoperative analgesia. Administration of wetting solution eases the passage of the cannula through the tissue and minimizes fluid requirements during and after surgery. Some surgeons believe that magnification of the area to be suctioned is an advantage, whereas others believe that distortion of the area is a disadvantage. It is the author’s opinion that “final contour” is an end point that comes with experience, and infiltration of wetting solution is a necessary part of the equation for the student to master.

Table 65.1 describes the author’s standard wetting solution recipes.

It is the author’s preference to use lidocaine in the tumescent solution even when general anesthesia is used for the liposuction procedure. Although it is technically not necessary, it probably provides some intraoperative local anesthetic effect which would theoretically decrease the amount of general anesthetic and/or narcotic given by our anesthesia colleagues, both during the procedure and in the recover room.

The total amount of lidocaine infused per patient should not exceed the maximum recommended subcutaneous dose of 35 mg/kg (Chapter 12).12 The maximum dose for each patient should be calculated preoperatively and the case is planned accordingly. If more infiltrate is needed once the maximum dose has been reached, lidocaine can be omitted from the final bags as long as general anesthesia is used (see the discussion of lidocaine toxicity in the section Risks and Possible Complications).

The actual infiltration technique is especially important. An uneven infiltration of wetting solution increases the chances of an uneven final result. An electrical infiltration pump which provides even flow rates while infusing is invaluable. Infiltration is begun in the deepest plane of the area to be suctioned and proceeds in a systematic fashion from deep to superficial. Each level, or “plane,” should be evenly infiltrated before slowly moving a bit more superficial. Palpation over the area with the nondominant hand is used to guide this process. The infiltrated fat should be evenly firm, and there should be no disproportionate bulges in the skin at the end of the infiltration process. The wetting solution should be “feathered” at the edges of the target area, just like the suctioned fat is feathered.

ASPIRATION OF FAT

The wetting solution is allowed 7 to 10 minutes for maximal vasoconstrictive effect. Aspiration is performed through various small incisions, the location of which depends on the area being suctioned. Every attempt is made to hide incisions in anatomic creases or Langer cleavage lines, when appropriate, although most liposuction cannulas are small enough that the eventual scars are almost imperceptible. As a general rule, liposuction is performed using the dominant hand, making even strokes in a systematic fashion. The cannula is inserted into the deep plane first. Using even in-and-out strokes, the cannula is moved back and forth in a fanlike pattern, with the incision as the fulcrum. The cannula is moved more superficially as fat is removed. The nondominant hand is kept over the area being suctioned to provide tactile feedback as to the depth of the underlying cannula and the distribution of remaining fat. Cross-tunneling (suctioning an area from a second incision at right angles from the first incision) is recommended for most areas to avoid contour deformity (Figure 65.3).

The end point of aspiration is determined by a number of factors. Contour of the patient is the most important factor, but can be difficult to determine because of infused wetting solution and patient positioning. The aspirated volume should also be carefully recorded and is especially helpful in achieving symmetry when bilateral areas are suctioned. When UAL is used, the amount of time that ultrasonic energy is applied should be recorded and considered when determining the end point and can be helpful when attempting to obtain symmetry between sides. The pinch test, another helpful guide, is performed by gently pinching the patient’s skin and subcutaneous fat between the thumb and forefingers to assess the thickness and smoothness of the underlying subcutaneous tissue and for comparing preoperative with postoperative thickness. Simply pinching or rolling the tissue between one’s thumb and index finger helps in the assessment of irregularities. When all is said and done, it does not matter it is removed; it matters what is left behind!

Final contouring is routinely performed at the end of the liposuction procedure. The surgeon may use saline to wet the skin and glide his or her hand over the surface to assist in finding small irregularities. Usually, smaller diameter cannulas (2.5 or 3.0 mm) are chosen to do the final contouring and feathering. The old adage “the enemy of good is better” should be kept in mind. Over-resection is more difficult to fix than under-resection, so it is better to err on the side of under-resection.

BODY AREAS TREATABLE WITH LIPOSUCTION

Numerous body areas are amenable to liposuction given the plethora of equipment now available. Today’s patient can be treated from head to toe (Figures 65.4 to 65.7). The face and neck can be successfully treated with liposuction, although fat injection into the face instead of aspiration is increasingly popular. The trunk, including the abdomen, back, breast, and posterior hips (flanks), as well as the lower extremity, including the knees, calves, and ankles, have all been successfully treated with liposuction. In the author’s experience, treatment of gynecomastia is particularly amenable to UAL13(Chapter 57). The upper arm is also well suited for UAL or SAL when the skin is not too loose. The buttocks can be successfully treated but should be approached with some degree of caution. Creation of flat or ptotic buttocks is not only unsightly, but can require excisional measures to repair.

FIGURE 65.3. Cross-tunneling. Cross-tunneling is a technique used to enhance smoothness and to decrease the risk of contour irregularity. The patient is in the prone position with her head on the left side of the picture. A. The liposuction cannula is inserted into the gluteal crease incision (black arrow) to suction the left lateral thigh, and into the parasacral area to suction the left posterior hip. B. A second incision is made and the same areas are suctioned from a separate incision in the midaxillary line (at approximately a right angle from the first “line” of suction).

POSTOPERATIVE COURSE

Incisions for cannulas larger than 3.0 mm are generally closed with a 5-0 nylon suture. Some surgeons recommend leaving smaller incisions open to allow wetting solution to drain. The patient is dressed in a compression garment that covers the areas that have been suctioned. The author believe that compression foam (e.g., Topi-Foam, Byron Medical, Tucson, AZ) under a garment decreases early bruising and edema, which seems to speed recovery. An abdominal binder can be used when only the hips and/or abdomen are treated. If thigh suction is also done, a girdle is preferable. The patient may experience significant serosanguineous drainage from incision sites for approximately 24 to 36 hours, which can be alarming to family and friends if they are not informed in advance.Showering is permissible on postoperative day 1 or 2. A vasovagal response is not uncommon the first time the postoperative garment is removed, so patients should be warned ahead of time to have someone with them the first time they remove their garment. The patient is instructed to replace the compression foam over the suctioned areas until days 3 to 5 if tolerated.

Drains are recommended for gynecomastia and when >2,000 mL lipoaspirate is removed from the abdomen alone. They are left in place until drainage is less than 25 to 30 mL in a 24-hour period. Ideally, foam padding is left in place for 3 to 5 days. Compression garments are generally encouraged 24 hours per day for 4 weeks (6 weeks if circumferential thigh suctioning is performed). Postoperative follow-up visits are scheduled at 5 to 7 days to remove sutures; at 2 weeks to make sure that bruising is subsiding normally and to advance the patient’s activity; at 8 to 12 weeks to make sure that edema is subsiding normally and to assess the early result. The final postoperative contour will not be evident for approximately 6 months. Maximal swelling can be expected at postoperative days 3 to 5. In the author’s experience, 60% to 80% of the swelling subsides by 6 weeks postprocedure, and it takes a full 4 to 6 months for 100% of the swelling to resolve, depending on the extent of the procedure.

Patients begin ambulating on the day of surgery. Oral fluids are encouraged. Physical activity should be low for the first week to discourage excessive edema, followed by a gradual increase in activity during the second week, depending on the amount of suction that was done. At the end of the first week, most patients can return to work and should be encouraged to begin light exercise, such as brisk walking on a treadmill (with compression garments on!). At 3 to 4 weeks, if edema and bruising are resolving appropriately, the patient should be advancing to full activity and may “wean” him- or herself out of the compression garment over the course of a week. These are general guidelines for patients undergoing average volume liposuction (lipoaspirate 2,000 to 5,000 mL) and must be tailored to the individual patient. Large-volume liposuction and circumferential thigh patients will need a more restrictive postoperative regimen.

RISKS AND POSSIBLE COMPLICATIONS

Any surgical procedure has risks. Fortunately, serious complications are rarely associated with liposuction procedures. The most common undesirable sequelae after liposuction are contour irregularities, which are related to inexperience and lack of attention to detail. Contour irregularities generally fall into four categories: (a) overcorrection, (b) undercorrection, (c) failure of skin retraction or abnormal skin retraction, and (d) complex deformities consisting of combinations of a, b, and c.14 Revisionary procedures should be performed only after all the swelling has completely subsided. Generally, the treatment of undercorrection is removal of more fat; the treatment of overcorrection is fat injection (Chapter 44); the treatment of loose skin is skin excision; and the treatment of complex deformities is beyond the scope of this chapter. The best way to “treat” contour irregularities is to avoid them.

Other risks, including unusual bleeding, which could result in unusual ecchymosis or permanent skin discoloration, hematoma, seroma, infection, dysesthesia, fat embolism, thromboembolism, fluid imbalance, lidocaine toxicity, skin necrosis, perforation of viscera, and death, fortunately, are rare.

Lidocaine toxicity deserves special mention because according to the Physicians’ Desk Reference, the maximal recommended dose of subcutaneous lidocaine HCl when used in combination with epinephrine is 7 mg/kg in an adult, yet numerous studies have documented the safety and efficacy of larger doses (greater than 35 mg/kg) of lidocaine for the purposes of liposuction11 (Chapter 12). Table 65.2 lists the signs and symptoms of lidocaine toxicity. If lidocaine toxicity is suspected, the injection of lidocaine is stopped immediately. Benzodiazepines are the drug of choice for the treatment of seizures.

FIGURE 65.4. Ultrasound-assisted liposuction of a 27-year-old woman shown before (A, C) and 12 months after (B, D) UAL of the abdomen, posterior hips, and circumferential thighs. A total of 4,700 mL of wetting solution was infiltrated and a total of 4,775 mL of lipoaspirate (fluid and fat) was removed: 575 mL from the abdomen, 475 mL from each posterior hip, and 1,625 mL from each thigh which was treated circumferentially.

FIGURE 65.5. Ultrasound-assisted liposuction of a 50-year-old woman. She was treated with UAL to the abdomen, posterior hips, and lateral thighs. A total of 1,250 mL, 600 mL, and 700 mL of wetting solution was infiltrated into the abdomen, hips and lateral thighs, respectively. A total of 1,300 mL, 900 mL, and 925 mL of lipoaspirate, respectively, was removed from each area. The total infiltrated was 3,850 mL, and the total aspirated was 4,950 mL. Preoperative views A and C, Postoperative views B and D.

CONCLUSION

Liposuction is an extremely popular cosmetic procedure in today’s body-conscious society. Technically, it is a relatively easy procedure to perform adequately; however, it requires strict attention to detail and a keen aesthetic eye to perfect the art of liposuction. Sucking fat is easy, whereas sculpting the body by removal of the right amount of fat, and leaving behind a more optimal body contour, is an art.

FIGURE 65.6. Ultrasound-assisted liposuction of the breast in a 47-year-old man with gynecomastia. The patient is shown before (A, C) and 4 months after (B, D) UAL of the breast. A total of 650 mL of wetting solution was infiltrated into each breast and 575 mL of lipoaspirate (fluid and fat) was removed from each breast.

FIGURE 65.7. Suction-assisted lipoplasty of the neck in a 53-year-old woman shown before (A, B) and after (C) SAL of the neck. Superior results can generally be obtained with liposuction of the neck in the younger population; however, this woman had very good skin retraction for her age. Careful preoperative assessment of skin quality and thorough preoperative counseling with this type of patient is imperative. In this case, incisions were made in the submental area and behind each ear in order to allow contouring along the jawline.

References

1.  Fournier P. Popularization of the technique. In: Hetter GP, ed. Lipoplasty: The Theory and Practice of Blunt Suction Lipectomy. 2nd ed. Boston, MA: Little Brown; 1990:35-38.

2.  Markman B, Barton FE. Anatomy of the subcutaneous tissue of the trunk and lower extremity. Plast Reconstr Surg. 1987;80:248.

3.  Rohrich RJ, Kenkel JM, Janis JE, et al. An update on the role of subcutaneous infiltration in suction-assisted lipoplasty. Plast Reconstr Surg. 2003;111:926.

4.  Pitman GH, Teimourian B. Suction lipectomy: complications and result by survey. Plast Reconstr Surg. 1985;76:65.

5.  Kenkel JM, Robinson J, Beran SJ, et al. The tissue effects of ultrasound assisted lipoplasty. Plast Reconstr Surg. 1998;102:213.

6.  Ablaza VJ, Gingrass MK, Perry LC, et al. Tissue temperatures during ultrasound assisted lipoplasty. Plast Reconstr Surg. 1998;102:534.

7.  Prado A, Andrades P, Danilla S, Leniz P, Castillo P, Gaeto F. A prospective, randomized, double-blind, controlled clinical trial comparing laser-assisted lipoplasty with suction assisted lipoplasty. Plast Reconstr Surg. 2006;118:1032.

8.  Brown S, Rohrich R, Kenkel J, Young V, Hoopman J, Coimbra M. Effect of low-level laser therapy on abdominal adipocytes before lipoplasty procedures. Plast Reconstr Surg. 2004;113:1796.

9.  The wet technique. In: Illouz YG, DeVillers YT, eds. Body Sculpturing by Lipoplasty. New York, NY: Livingstone Churchill; 1989:124.

10.  Hetter GP. The effect of low dose epinephrine on the hematocrit drop following lipolysis. Aesthetic Plast Surg. 1984;8(1):19.

11.  Klein JA. The tumescent technique for liposuction surgery. Am J Cosmetic Surg. 1987;4:263.

12.  Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol. 1990;16:248.

13.  Gingrass MK, Shermak, MA. The treatment of gynecomastia with ultrasound-assisted lipoplasty. Perspect Plast Surg. 1999;12:101-112.

14.  Gingrass MK, Hensel JM. Secondary liposuction. In: Mathes SJ, Hentz VR, eds. Plastic Surgery. 2nd ed. Philadelphia, PA: Saunders/Elsevier. Volume VI. 381-388. Specifically 382.