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SRPS
SELECTED READINGS
IN PLASTIC SURGERY
Would like to thank
SRPS
SELECTED READINGS
IN PLASTIC SURGERY
B O D Y
CONTOURING
ANDREW TRUSSLER MD
VOLUME 10: NUMBER 22
For their support of plastic surgery education
as a Platinum Education Partner
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OUR EDUCATIONAL PARTNERS
Selected Readings in Plastic Surgery appreciates the generous
support provided by our educational partners.
PLATINUM PARTNERS
facial aesthetics
SILVER PARTNER
SRPS 10 (20), 2008
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247. T?nseth KA, Hokland BM, Tindholdt TT, et al: Patientreported outcomes after breast reconstruction with deep
inferior epigastric perforator flaps. Scand J Plast Reconstr Surg
Hand Surg 41:173, 2007.
248. Drazan L, Vesely J, Hyza P, et al: Bilateral breast reconstruction with DIEP flaps: 4 years’ experience. J Plast Reconstr
Aesthet Surg, Aug 16, 2007 [Epub ahead of print]. DOI:
10.1016/j.bjps.2007.06.028.
249. Munhoz AM, Arruda E, Montag E, et al: Immediate skinsparing mastectomy reconstruction with deep inferior epigastric perforator (DIEP) flap. Technical aspects and outcome. Breast J 13:470, 2007.
250. Schaverien MV, Perks AG, McCulley SJ: Comparison of
outcomes and donor-site morbidity in unilateral free TRAM
versus DIEP flap breast reconstruction. J Plast Reconstr
Aesthet Surg 60:1219, 2007.
251. Nahabedian MY, Tsangaris T, Momen B: Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free
TRAM flap: Is there a difference? Plast Reconstr Surg 115:436,
2005.
252. Serletti JM: Breast reconstruction with the TRAM flap:
pedicled and free. J Surg Oncol 94:532, 2006.
253. Glasberg SB, D’Amico RA: Use of regenerative human
acellular tissue (AlloDerm) to reconstruct the abdominal
wall following pedicle TRAM flap breast reconstruction
surgery. Plast Reconstr Surg 118:8, 2006.
254. Bajaj AK, Chevray PM, Chang DW: Comparison of donor-site
complications and functional outcomes in free musclesparing TRAM flap and free DIEP flap breast reconstruction.
Plast Reconstr Surg 117:737, 2006.
255. Futter CM, Webster MHC, Hagan S, et al: A retrospective
comparison of abdominal muscle strength following breast
reconstruction with a free TRAM or DIEP flap. Br J Plast Surg
53:578, 2000.
256. Futter CM, Weiler-Mithoff E, Hagen S, et al: Do pre-operative
abdominal exercises prevent post-operative donor site complications for women undergoing DIEP flap breast reconstruction? A two-centre, prospective randomised controlled
trial. Br J Plast Surg 56:674, 2003.
257. Yan XQ, Yang HY, Zhao YM, et al: Deep inferior epigastric
perforator flap for breast reconstruction: experience with 43
flaps. Chin Med J (Engl)120:380, 2007.
258. Kroll SS, Schusterman MA, Reece GP, et al: Breast reconstruction with myocutaneous flaps in previously irradiated
patients. Plast Reconstr Surg 93:460, 1994.
259. Williams JK, Bostwick J 3rd, Bried JT, et al: TRAM flap breast
reconstruction after radiation treatment. Ann Surg 221:756,
1995.
260. Williams JK, Carlson GW, Bostwick J 3rd, et al: The effects
of radiation treatment after TRAM flap breast reconstruction.
261. Tran NV, Chang DW, Gupta A, et al: Comparison of immediate and delayed free TRAM flap breast reconstruction in
patients receiving postmastectomy radiation therapy. Plast
Reconstr Surg 108:78, 2001.
262. Rogers NE, Allen RJ: Radiation effects on breast reconstruction with the deep inferior epigastric perforator flap. Plast
263. Spear SL, Ducic I, Low M, Cuoco F: The effect of radiation
on pedicled TRAM flap breast reconstruction: outcomes
and implications. Plast Reconstr Surg 115:84, 2005.
264. Guerra A, Metzinger S, Bidros R, et al: Breast reconstruction
with gluteal artery perforator (GAP) flaps: a critical analysis
of 142 cases. Ann Plast Surg 52:118, 2004.
265. Guerra AB, Soueid N, Metzinger SE, et al: Simultaneous
bilateral breast reconstruction with superior gluteal artery
perforator (SGAP) flaps. Ann Plast Surg 53:305, 2004.
266. Clark CP 3rd, Rohrich RJ, Copit S, et al: An anatomic study
of the internal mammary veins: clinical implications for freetissue-transfer breast reconstruction. Plast Reconstr Surg
99:400, 1997.
267. Feng LJ: Recipient vessels in free-flap breast reconstruction:
a study of the internal mammary and thoracodorsal vessels.
268. Hefel L, Schwabegger A, Ninkovic M, et al: Internal mammary
vessels: anatomical and clinical considerations. Br J Plast Surg
48:527, 1995.
269. Vath SD, Dupin CL, Allen RJ: Internal mammary vessels as a
recipient site for free flap breast reconstruction. Semin Plast
Surg 16:109, 2002.
270. Shaw WW: Discussion of “The internal mammary artery and
vein as a recipient site for free-flap breast reconstruction: a
report of 110 consecutive cases,” by CL Dupin et al. Plast
271. Schwabegger AH, Gschnitzer C, Ninkovic MM: Contour
deformity at the internal mammary recipient site. Br J Plast
Surg 52:674, 1999.
272. Majumder S, Batchelor AG: Internal mammary vessels as
recipients for free TRAM breast reconstruction: aesthetic
and functional considerations. Br J Plast Surg 52:286, 1999.
273. Nahabedian MY, Momen B, Galdino G, et al: Breast reconstruction with free TRAM or DIEP flap: patient selection,
choice of flap, and outcome. Plast Reconstr Surg 110:466,
2002.
274. Hamdi M, Blondeel P, Van Landuyt K, Monstrey S: Algorithm
in choosing recipient vessels for perforator free flap in breast
reconstruction: the role of the internal mammary perforators. Br J Plast Surg 57:258, 2004.
275. Serletti JM, Moran SL, Orlando GS, Fox I: Thoracodorsal
vessels as recipient vessels for the free TRAM flap in
delayed breast reconstruction. Plast Reconstr Surg
104:1649, 1999.
276. Ninkovic MM, Schwabegger AH, Anderl H: Internal mammary vessels as a recipient site. Clin Plast Surg 25:213, 1998.
277. Evans GRD, David CL, Loyer EM, et al: The long-term effects
of internal mammary chain irradiation and its role in the
vascular supply of the pedicled transverse rectus abdominis
musculocutaneous flap breast reconstruction. Ann Plast
Surg 35:342, 1995.
278. Temple CL, Strom EA, Youssef A, Langstein HN: Choice of
recipient vessels in delayed TRAM flap breast reconstruction
after radiotherapy. Plast Reconstr Surg 115:105, 2005.
279. Nahabedian MY: The internal mammary artery and vein as
recipient vessels for microvascular breast reconstruction:
are we burning a future bridge? Ann Plast Surg 53:311, 2004.
280. Munhoz AM, Ishida LH, Montag E, et al: Perforator flap breast
reconstruction using internal mammary perforator branches
as a recipient site: an anatomical and clinical analysis. Plast
281. Haywood RM, Raurell A, Perks AG, et al: Autologous free
tissue breast reconstruction using the internal mammary
perforators as recipient vessels. Br J Plast Surg 56:689, 2003.
53
BODY CONTOURING
Andrew Trussler MD
[email protected]
Dept. of Plastic Surgery, UTSMC
1801 Inwood Rd, 5th Floor, Dallas TX 75390-9132
INTRODUCTION
The common perception of beauty in the human body
has undergone a dramatic change in the past three
centuries, culminating in a preoccupation not only
with body weight, but also with body contour. The
emphasis placed by modern society on a lean, youthful
appearance is largely responsible for the increased
demand for surgical procedures designed to produce
an ideal aesthetic shape.
Liposuction is the most common cosmetic surgical
procedure in the United States. According to the
American Society for Aesthetic Plastic Surgery, in 2004
there were 324,891 liposuction procedures performed
in the U.S.; in 2007, this number had climbed to
456,828, a 41% increase. These statistics highlight the
importance placed on body shape and weight by our
society.1
PHYSIOLOGY OF BODY FAT
Because adipocytes specialize in the synthesis and
storage of fat, they are an important source of energy
for the organism as well as an effective insulator.2,3 A
certain amount of adipose tissue is necessary to sustain
animal life during periods of food deprivation.
Catecholamines are responsible for lipolysis under
conditions of stress such as fasting.4 Adipocytes
possess two different chemical receptors for
catecholamines, epinephrine and norepinephrine.
Beta-1 receptors are lipolytic and secrete lipase, while
α-2 receptors block lipolysis and are direct antagonists
of the β-1 receptors. Alpha-2 receptors are numerous
and active in well-localized areas of fat deposition,
such as steatomas and trochanteric lipodystrophy,
which may explain these sites’ apparent resistance to
weight loss.5,6 Furthermore, adipocytes in the deep fat
layer are more receptive to glucose and incorporate
faster than superficial adipocytes, so that it takes less
time for the deep cells to enlarge.6
Throughout life fat cells multiply in number as
well as increase in size.7 Individual adipocytes triple in
size during the first year of life, continue to grow and
multiply for the next 5 years, and grow again during
adolescence, without significant weight gain by the
individual.8 After adolescence no new adipocytes are
formed.
The ultimate number of fat cells in the adult is
genetically determined and therefore unique to the
individual. It is only slightly influenced by
environmental and nutritional factors at an early age,
and remains stable in the face of changes in the basal
metabolic rate and other physiologic alterations in
later life. A person’s body habitus, therefore, depends
on (a) enlargement of the fixed number of adipocytes
he or she begins adult life with and (b) fat-cell
replication by postadipocytes.
SRPS Volume 10, Number 22, 2008
Salans, Cushman, and Weismann7 studied adipose
cell size and number in non-obese and obese patients.
As a group, obese patients have larger adipose cells
than do non-obese patients; cell size, however, varies
considerably among the fat depots of individuals of
either group. Cell size variations also exist within
subcutaneous and deep sites of fat accumulation. The
authors find two patterns of obesity with respect to the
cellular character of the adipose tissue mass:
hyperplastic, with increased adipose cell number and
normal or increased size; and hypertrophic, with
increased cell size alone. Hyperplastic obesity is
characterized by an early age of onset; hypertrophic,
by a late onset. They surmise that there are two distinct
periods in life during which hypercellularity of the
adipose tissue is most likely to occur: very early within
the first few years, and again from age 9 to 13 years.
A 4-year longitudinal study of 132 subjects by
Knittle and associates9 showed that the contribution of
cell number and size to the growth of the fat depot in
non-obese children varies with age. Deviations from
this normal development were observed in obese
children shortly after 1 year of age. By age 11, obese
children exceeded the mean cell number found in nonobese adults, and the earlier elevations in both cell
number and size were maintained throughout the
study.
Borkan and colleagues10 described changes in
adipose tissue distribution with age. Newborns and
children have about 20% the adipose cell concentration
of adults. The proportion of fat in the trunk generally
increases with age, and there also appears to be a
progressive internalization of fat. In particular, the
abdomen shows an increase in subcutaneous fat and
correspondingly higher intraabdominal fat content.
The extremities tend to lose fat from the subcutaneous
tissue with age, shifting to a pattern of intra- and
intermuscular fat deposition.
Most human fat deposits consist of white adipose
tissue, whose primary function is the storage and
mobilization of triglycerides and free fatty acids.
Alterations in the balance between the processes
dictate changes in adipose tissue mass and body
weight gain or loss. Brown adipose tissue is known to
play a role in thermogenesis of newborns, but its
function in adults is unclear.
2
METABOLIC EFFECTS OF LIPOSUCTION
Adipose tissue is a metabolically active tissue. Among
the important secreted products of fat cells are leptin,
resistin, tumor necrosis factor-alpha and adiponectin.
The first three products are increased in obese patients;
the fourth, adiponectin, improves glucose handling
and decreases with obesity. High levels of adiponectin,
as seen when a person loses weight, can lead to higher
levels of insulin sensitivity, a lessening of diabetic
symptoms, and a better cardiac profile.
Hypertrophic fat cells are less sensitive to insulin.
Ghrelin is a hormone that stimulates food intake in
humans. Ghrelin is produced by the gastric mucosa,
the pancreas, hypothalamus, kidneys and pituitary
gland. Schreiber and colleagues11 evaluated the effects
of liposuction and diet on ghrelin, adiponectin, and
leptin levels in an animal model and demonstrated a
significant decrease in ghrelin and leptin levels after
liposuction. No effect on adiponectin levels was
appreciated in this study, though the interim from
intervention to sacrifice was only 42 days. When
extrapolated to a human model, this period of time is
not long enough to see an effect.
Giugliano
and
coworkers12
prospectively
compared the metabolic sequelae of large volume
liposuction (mean 3540mL) in obese and non-obese
women. After 6 months of testing, the authors noted
signs of less insulin resistance, fewer circulating
markers of vascular inflammation, and increased
levels of adiponectin. They conclude that liposuction is
safe and beneficial to the patient.
Robles-Cervantes et al13 found significantly lower
levels of glucose, cholesterol, insulin secretion, and
adiposity in a non-obese population at 3 weeks after
liposuction.
Insulin
levels,
glucose-insulin
relationship, and insulin sensitivity remained
unaltered.
Samdal et al14 measured lipids, lipoproteins, sex
hormones, and insulin levels in 7 women immediately
before and 4 weeks after suction lipectomy. The
authors report significant increase in HDL cholesterol
and apolipoprotein A1 postoperatively, but no change
in sex hormones or glucose metabolism. On the basis
of an average increase in HDL cholesterol of
0.2mmol/L, they hypothesize that large-volume
suction lipectomy may reduce the risk of
cardiovascular disease by as much as 30%.
D’Andrea and associates15 evaluated 123 obese
women prospectively for the metabolic effects of largevolume liposuction (LVL) over a longer period of time.
During 3 months of follow-up, LVL resulted in
significantly improved insulin sensitivity, resting
metabolic rate, serum adipocytokines, and
inflammatory marker levels. These metabolic changes
correlated with a decreased fat mass and improved
waist:hip ratio. Interestingly, no difference was seen
after 6 weeks, paralleling the findings in the RoblesCervantes study.
Liszka and coworkers16 studied the effect of
lipectomy
on
growth,
fat
cell
number,
hyperinsulinemia, and hyperlipidemia on a Zucker rat
model of Type 2 diabetes. The authors report no
consistent changes in serum glucose or insulin levels.
A significant decrease in lipid levels was noted in the
operated group.
Further physiologic effects of surgical removal of
subcutaneous adipose tissue were evaluated in 14
women by Giese and colleagues.17 All patients
underwent large-volume liposuction. At 4 months
postoperatively there was a decrease in body weight,
body fat mass, systolic blood pressure, and fasting
insulin levels, suggesting that liposuction may be a
valuable tool for reducing some of the comorbidities
associated with obesity.
Rizzo
and
associates18 concluded
that
dermolipectomy had similar effects on BMI, insulin
mediated glucose uptake, and degree of inflammation
after just 40 days in a female population.
Klein et al19 evaluated the effect of large volume
liposuction in 7 Type II diabetic females and compared
it to 8 non-diabetic females. In contrast to the
aforementioned studies, the authors found no
significant effect on insulin sensitivity or other
metabolic markers for coronary heart disease after 12
weeks. Significant findings were a decrease in fat mass
and in leptin, a marker for fat mass.
Despite reports of the physiologic benefits of
liposuction in obese patients, Matarasso, Kim, and
Kral20 raise concerns about the effect of liposuction on
body fat. The importance of the subcutaneous adipose
tissue in helping to maintain nutritional and
thermodynamic metabolic functions is stressed. The
authors measured the amount of fat removed by largevolume (>1000mL) liposuction in 63 normal-weight to
mildly obese patients and monitored changes in total
TABLE 1
Body Composition and Blood Chemistry Profile Before and After Liposuction
(Modified from Giese SY, Bulan EJ, Commons GW, et al: Improvements in cardiovascular risk profile with large-volume liposuction: a pilot
study. Plast Reconstr Surg 108:510, 2001.)
3
body fat and visceral adipose tissue postoperatively.
“Although large-volume subcutaneous liposuction
removed relatively little body fat, it led to significant
increases in the proportion of visceral adipose tissue
[with respect to subcutaneous fat].” Their concern is that
one may actually increase the risk of metabolic
complications of obesity if large-volume liposuction is
undertaken. Clearly, further studies are needed.
More recently Ybarra and coworkers21 confirmed
the beneficial effects of abdominal liposuction on
carbohydrate and lipid metabolism. In a prospective
study of 20 healthy volunteers of normal or slightly
above-normal weight, the authors report significant
decreases in free fatty acids (-35%), glycerol (-63%),
very-low-density
cholesterol
(-15.2%),
and
triglycerides (-21.3%) at 4 months post-liposuction. At
the same time there were increases in HDL cholesterol
(+10%) and apolipoproteins B, AI, and AII. The serum
levels of glucose, insulin, adiponectin, and C-reactive
proteins were not significantly altered by liposuction.
ANATOMY
The patterns of fat distribution in the body vary with
sex, race, and age of the subject. Heredity is also a
factor.
Gender Differences
Vague and Finasse22 described the characteristic sites of
fat deposition according to sex. In general, women
have a proportionately higher percentage of total body
fat than men, manifested by thicker adipose tissue
throughout. Women typically accumulate fat in the
lower trunk, hips, upper thighs, and buttocks—a
gynoid pattern. In contrast, men tend to accumulate fat
evenly around the trunk, which is usually reflected by
increased abdominal girth and a thick torso, upper
abdomen, and nape—an android pattern. These gender
variations have been explained in terms of metabolic
and embryologic factors23 but are finally determined
genetically, as suggested by a study of identical twins
reared separately.24 The environment alone does not
appear to determine adult body weight.
A cross-sectional sample of more than 41,000
German subjects aged from birth to 62 years revealed
4
a pattern of sexual dimorphism in measurements of
height, weight, circumference, and body mass index.25
Girls are shorter at birth, but they increase in height at
higher rates than boys up to age 12. Thereafter, males
show an obvious growth advantage. Female
circumferences are always smaller, from birth to
senescence, while subcutaneous fat and total body fat
levels are always higher in females.
Racial Differences
Racial and ethnic differences in fat accumulation are
also evident.26 Compared with other races, blacks show
increased fat accumulation in the buttocks, a pattern
that is magnified by lumbar lordosis.27
As reported by Weinsier and colleagues,28 weightreduction programs achieved similar results for white
and black American women in terms of total weight
loss and losses of total fat, trunk fat, and waist
circumference. However, white women lost more
intraabdominal adipose tissue and less subcutaneous
abdominal adipose tissue than did black women.
A meta-analysis to test the hypothesis that
Japanese have a greater amount of abdominal visceral
fat (AVF) relative to abdominal subcutaneous fat (ASF)
than Caucasians29 compared mean values for AVF and
ASF areas for native Japanese, African-Americans, and
Caucasians of both genders. After adjusting for ASF,
age, and sex, the difference in AVF between Japanese
and Caucasian females was lower than that between
African-American and Caucasian females.
Age Differences
Another Japanese study tracked longitudinal changes
in subcutaneous fat distribution among Japanese
women in their 20s.30 Subcutaneous fat thickness was
measured at 14 points on the body using the B-mode
ultrasound method; each subject was measured twice,
once at baseline and again 5 years later. The results
showed that subcutaneous fat thickness tends to
increase with age except at the cheek, neck, bust, and
leg. Significant increases were detected, especially at
lower parts of the trunk such as the waist and
infragluteal region. Despite these increases, the
circumferences measured did not change, and weight
also tended to decrease with age. The authors found
three patterns of subcutaneous fat accumulation from
the early 20s to the late 20s: (1) on the whole trunk and
upper arm; (2) around the waist; and (3) on the
abdomen and hips.
The interplay of sex, ethnicity, and age in body
morphology and fat deposition is exemplified by the
Amsterdam Growth and Health Study, which tracked
the development of central patterns of subcutaneous
fat in adolescence and adulthood.31 In adolescence, a
decrease was seen in extremity skinfolds for men but
not for women. For both sexes, the trunk skinfolds
increased over the entire period of study. An increase
was found in trunk–extremity skinfold ratios in males,
but not in females. The authors conclude that a central
pattern of body fat accumulation, mainly seen in
males, seems to start in adolescence.
A comparison of body fat and skinfold
measurements between Chinese females from two age
cohorts 32 showed significant differences in the
distribution of subcutaneous fat between younger and
older Chinese females, with the major differences in
the abdominal and subscapular skinfolds. In addition,
the 20–30 years cohort had a more evenly distributed
subcutaneous fat than the 40–50 years cohort.
Working with an American male population,
Bemben and colleagues 33 demonstrated a gradual
decline in fat-free body mass with increasing age, with
a corresponding increase in fat mass, from the
youngest (20yo) to the oldest (79yo) age groups.
Subcutaneous body fat in the proximal trunk locations,
especially the abdomen, was significantly higher with
increasing age.
Wolanski 34 identifies the following stages of
subcutaneous fat tissue development in the United
States: preschool loss, prepubertal gain, adolescent
loss, stabilization, adult gain, top fatness, and age loss.
The same pattern of fatfolds growth was found in
different ethnic groups, except level of thickness and
age at turning points. Adolescent loss is characteristic
of boys and stabilization of girls. Top fatness in various
populations occurred between 45 and 55 years of age.
Relative to Peruvian natives, white and black
Americans, fat tissues became more abundant in
Mexican American and Puerto Rican subjects and was
most abundant in the native Mexican group. American
black females have thicker fatfolds than white, but
white males’ fatfolds are thicker than those of blacks.
Genetics
Ramirez 35 analyzed patterns of subcutaneous fat
distribution in healthy adolescents and their families.
The results showed a strong family resemblance for
the level of fatness and also between siblings of like
sex for the fat distribution patterns. These patterns are
apparent from early adolescence and are evidence of a
strong genetic component in fat deposition and total
body fat.
Fat Layers
The subcutaneous tissue in the torso and proximal
lower extremity is composed of two histologic layers,
a superficial and a deep.36 The superficial adipose layer
is made up of compact, dense pockets of fat contained
within well-organized fibrous septa. 37 The deep
adipose layer consists of looser, more areolar fat bound
by a haphazard network of partitions (Fig 1).37
Fig 1. Differences in subcutaneous tissues in various areas of
the body. (Reprinted with permission from Markman B, Barton
FE Jr: Anatomy of the subcutaneous tissue of the trunk and lower
5
extremity. Plast Reconstr Surg 80:248, 1987.)
More clinically significant are the “surgical fat
layers,”38 three levels of subcutaneous fat each
representing a zone of relative safety or caution during
suction lipectomy (Fig 2). The deep and intermediate
layers are always safe to treat, while the superficial
layer of densely compacted fat should be suctioned
with extreme caution because of the greater risk of
deformities and skin irregularities afterwards.
Fig 2. Surgical fat layers. (Reprinted with permission from
Rohrich RJ, Raniere J Jr, Kenkel JM, Beran SJ: Operative
principles for optimizing results in circumferential body
contouring with ultrasound-assisted lipoplasty. Clin Plast Surg
26(2):305, 1999.)
Rohrich and others 39 describe “zones of
adherence” that should be avoided to minimize
contour deformities during liposuction (Fig 3). In these
accentuate localized fat deposits. When these areas are
recognized preoperatively, significant contour
irregularities can be avoided during liposuction. The
zones of adherence are different in men and women.
Cellulite
Gynoid lipodystrophy is also known as cellulite, and
refers to the dimpling of the skin of the buttocks and
lower extremities most often seen in women. Illouz
believes that “cellulite is not a pathologic condition
but simply the mechanical result of hypertrophy of the
superficial fat cells.”6 He postulates the mechanism by
which cellulite is formed as follows:
The superficial [adipose] layer is
composed of fat within arches made
up of connective tissue...These arches
are
firmly
anchored
to
the
undersurface of the epidermis above
and
the
fascia
superficialis
below...Since [the septa] are firmly
attached at both extremities...they
expand and contract like an
accordion...As
fat
hypertrophy
increases, so does the tension
within...fat pockets...[and] cellulite
becomes apparent because the anchor
points do not give as the chambers
expand.
Illouz (1990)
Fig 3. Zones of adherence where liposuction should be
avoided. 1, Lateral gluteal depression. 2, Gluteal crease. 3,
Distal posterior thigh. 4, Medial midthigh. 5, Inferolateral
iliotibial tract. (Reprinted with permission from Rohrich RJ,
Smith PD, Marcantonio DR, Kenkel JM: The zones of adherence:
role in minimizing and preventing contour deformities in
liposuction. Plast Reconstr Surg 107:1562, 2001.)
areas the overlying skin appears to adhere more
tightly to the underlying fascia, which tends to
6
Lockwood40 finds two types of cellulite, a primary
kind that is due to hypertrophied fat cells in the
superficial fat (Illouz’s) and a secondary cellulite
related to skin laxity. The latter is seen in women 35
years or older, and results from age, sun damage,
massive weight loss, or liposuction. “With age and sun
damage, the entire skin–superficial fat–SFS [superficial
fascial system] relaxes and stretches, resulting in ptotic
soft tissues, pseudo-fat deposit deformity, and
cellulite.”40 The underlying mechanism is gravity
acting on the fibrous septa of the SFS. Unlike primary
cellulite, cellulite of laxity is correctable by surgically
tightening the skin and superficial fascia.
In a study of 51 female patients who underwent
medically supervised weight loss programs, Smalls
and coworkers41 demonstrated that weight loss does
improve thigh cellulite. However, they noted
worsening of cellulite in a subgroup with smaller
starting BMI, smaller reductions in weight with
minimal reduction in thigh fat, and significant
increases in tissue compliance. This correlates with
Lockwood’s observation regarding cellulite of laxity
and the need for skin tightening in conjunction with
weight loss.
SUCTION LIPECTOMY
HISTORY
Surgical procedures to contour specific areas of the
body were first described in the 1930s for the abdomen
and breasts.42 Since that time, the popularity of
abdominal and lower-extremity contouring steadily
grew as a result of contributions by Pitanguy,43,44
Regnault,45–47 and others.48,49 Although these procedures
were quite sophisticated, it was not until Schrudde,50
Kesselring,51 and Illouz52 began reporting their
experience with suction-assisted lipectomy that the
concept of body sculpting became a reality.
Grazer53 traces the origin of suction lipectomy to
Dujarrier, who in 1921 used a uterine curette to try to
remove fat from the knees of a well-known ballerina,
with disastrous consequences and eventual
amputation because of damage to the femoral artery.
During the 1960s Schrudde50 rekindled professional
interest in the removal of localized subcutaneous fat
deposits through a small stab incision. His method
consisted primarily of sharp curettage, with secondary
suction only to clear the resultant debris.
In 1978 Kesselring and Meyer54 added strong
suction to the sharp curettage method. Although their
results were generally excellent, others reported a high
incidence of complications,55–57 particularly seroma and
skin necrosis. Shortly afterwards Illouz52 as well as
Fournier and Otteni58 minimized the curettage element
of the procedure and replaced it with a blunt cannula
inserted subcutaneously and connected to a vacuum
pump to aspirate the fatty tissue. Illouz52,59,60 also
proposed irrigation of the subcutaneous space with a
hypertonic saline solution in the belief that the fat cells
would swell and rupture, but this process has never
been confirmed clinically.58
Hetter61 stressed the importance of adequate
suction pressures for complete lipolysis, which
resulted in standardization of the vacuum pump.
Teimourian62–64 popularized the use of small-diameter
cannulas to limit the amount of fat that could be
removed and minimize unsightly postoperative
depressions.
Modern innnovations in suction lipectomy include
syringe liposculpture,65–67 superficial liposuction,68 the
tumescent technique,69–71 suspension of the superficial
fascia to decrease tension on the skin,72 ultrasoundassisted
liposuction, 73–76 and
power-assisted
77,78
liposuction.
INDICATIONS AND EVALUATION
In 2004 Iverson,79 writing for the Committee on Patient
Safety of the American Society of Plastic Surgeons,
reviewed the scientific and clinical data on liposuction
and surveyed the practice of liposuction as performed
by ASPS members. This comprehensive article is not
meant to define the standard of care, but offers
guidelines for practitioners to assist them in making
educated clinical decisions in light of multiple reports
of deaths attributed to liposuction.
Conventional wisdom holds that the best results
with liposuction are obtained when treating minimal
to moderate localized fat deposits unresponsive to diet
and exercise in patients whose skin is moderately
elastic. In general, patients seeking body contouring
surgery should be in good general health and have
realistic expectations. Patients must not only be
committed to body contouring surgery, but also be
willing to undergo modifications in their diet, exercise,
and lifestyle.80
A thorough history should be obtained and
specific questions should be directed toward their diet
and exercise regimen. Patients are also asked about
their use of both prescription and over-the-counter
weight loss medications and/or dietary supplements.
The continued use of these substances during the
perioperative period may raise the surgical risk.80
Body dysmorphic disorder is an underrecognized
disorder that affects 7–15% of patients seeking
cosmetic surgery.81 These patients have an obsessive
7
compulsion focused on an area of the body. Treated
surgically, these patients are likely to remain
dissatisfied with the results and seek further
alterations. If the disorder is suspected during the
initial consultation, psychiatric referral is indicated.
A candidate for liposuction shows one or more of
the following on physical examination:38
1) deviation from the ideal male or female aesthetic
contour or silhouette
2) presence of asymmetries
3) presence of dimpling or cellulite
4) location of fat deposits (liposuction areas) and
zones of adherence (non-liposuction areas)
Standard photographs are taken to guide the
surgeon intraoperatively and to serve as a baseline for
postoperative assessment of results.38,82 The views must
be consistent for each anatomic area and of high
enough quality to allow comparisons of different
techniques and instrumentation.
An informed consent is a compulsory process
which protects both patient and physician. It is
imperative for the physician to explain the nature of
the procedure, alternative treatments, potential risks
and complications, and the financial responsibilities of
the patient with regard to any secondary procedures.38
TABLE 2
Techniques of Liposuction and Their Infiltrates
(Reprinted with permission from Rohrich RJ, Beran SJ, Fodor PB:
The role of subcutaneous infiltration in suction-assisted lipoplasty:
a review. Plast Reconstr Surg 99:514, 1997.)
The dry technique of liposuction was popularized
by Fournier and Otteni.58 Estimates of blood loss as a
percentage of the aspirated volume range from 5–54%
(mean 25%) in Goodpasture and Bunkis’s series83 to
30–46% (mean 35%) in Courtiss’ large-volume
liposuctions.84 (Table 3). The dry technique has fallen
out of favor due to the excessive blood loss associated
with it.
TABLE 3
Estimates of Blood Loss with Different
Liposuction Techniques
TECHNIQUE
Instruments
The tools used in body contouring have changed
markedly since the original large, sharp, single-hole
cannulas. Over the last several decades the
instruments have evolved toward smaller cannulas
with blunt tips and multiple holes. These cannulas
tend to be less traumatic to the tissues and result in
fewer superficial irregularities.
Wetting Solutions
The liposuction technique evolved along four different
paths: dry, wet, superwet, and tumescent (Table 2).71
The dry and wet techniques are now of historical
interest only.
8
(Reprinted with permission from Rohrich RJ, Beran SJ, Fodor PB:
The role of subcutaneous infiltration in suction-assisted lipoplasty:
a review. Plast Reconstr Surg 99:514, 1997.)
Illouz60 pioneered the wet technique of liposuction,
which consisted of infusion of 100–300mL of fluid into
each treatment site—regardless of the amount of fat to
be removed—and aspiration with blunt cannulas
aided by hydrotomy. Blood loss with the wet
technique is estimated to be 20–25% of the total
aspirate.85,86
In 1983 Hetter86 added 1:400,000 epinephrine and
0.25% lidocaine to Illouz’s formula and reported a
smaller drop in the hematocrit postoperatively.
Thereafter most series of liposuction by the wet
technique incorporated a dilute local anesthetic and
low-dose epinephrine in the subcutaneously injected
solution. Blood loss averaged <15% of the
aspirate.85,87–90 This was often reported as a smaller
decrease in the hematocrit, from a mean drop of 8.7
points without epinephrine to 6.6 when epinephrine
was added.91
The superwet technique was first advocated by
Fodor in 198692,93 and involves injection into the
subcutaneous tissue of a dilute solution of local
anesthetic and epinephrine in approximately equal
volume to the proposed volume of fat to be removed.
Blood loss with the superwet technique ranges from
1–4% of the aspirate.94–97
In the late 1980s Klein70 reported a tumescent
technique that also resulted in decreased blood loss
during lipoplasty. The technique is performed under
local anesthesia with or without sedation.98 The skin
and subcutaneous tissues are anesthetized by direct
infiltration of large volumes of a dilute solution of
0.1% or 0.05% lidocaine and 1:1,000,000 epinephrine in
physiologic saline. The ratio of infiltrate to aspirate is
approximately 3:1. The fluid engorges the targeted
fatty areas and makes for easier and more precise fat
removal. Blood loss from the tumescent technique is
estimated to be 1% of the aspirate.98–102
The relative merits of the superwet and tumescent
techniques continue to be debated. Proponents of the
superwet technique95,96 cite the following advantages:
• low blood loss, equivalent to that of the
tumescent technique
• low complication rate
• theoretically improved control of fluid,
epinephrine, and lidocaine administration96,103,104
Advocates of the tumescent technique,99,103,104 on the
other hand, believe that it
• enables improved safety
• improves aesthetic results
• decreases postoperative pain
• shortens convalescence
• needs minimal follow-up care by the physician105
Infiltration Technique
The two critical issues in subcutaneous infiltration are
fluid delivery (for maintenance and resuscitation) and
dosage of lidocaine–epinephrine. Kaplan and Moy106
note that patients experience considerably less pain
when the subcutaneous solution is warmed to 40°C
before infiltration.
Hunstad and Aitken107 review the background and
technical points of tumescent surgery, which is
associated with reduced blood loss and better pain
control and fluid management. Safety is ensured by
monitoring the volume of solution and amount of
lidocaine that is infiltrated.
The two critical issues in subcutaneous infiltration
are fluid delivery (for maintenance and resuscitation)
and dosage of lidocaine–epinephrine. Trott et al104
suggest the following guidelines for the superwet
technique:
• when aspirating <4L, maintenance intravenous
fluids and subcutaneous wetting solution alone
are adequate
• when aspirating >4L, it is safe to administer
maintenance fluids, subcutaneous infiltration,
and intravenous crystalloid at a rate of
0.25mL/mL of aspirate over 4L
In a retrospective study of intraoperative fluid
ratios, Rohrich and colleagues108 noted a lower
threshold for fluid replacement of up to 5L with
superwet infiltration liposuction in both small- and
large-volume cases. No adverse effects of volume
overload were appreciated in the 89 patients in the
study.
Matarasso96
states
that
patients
absorb
approximately 1mL of the injectate per mL of fat
aspirate, and roughly 20% of the injectate is removed
via liposuction. He therefore supplements his patients
so that the total amount of fluid given—injectate,
intravenous, and postoperative fluid combined—is
roughly 2–3mL per mL of aspirate. Close clinical
monitoring during high-volume aspirations, good
communication between surgeon and anesthesiologist,
and monitoring of urine output are essential factors in
safe liposuction.
Klein99,100 does not recommend any supplemental
intravenous fluid when using the tumescent
technique.
9
Epinephrine and Lidocaine
To reduce blood loss during liposuction, one must add
a dilute epinephrine solution to the subcutaneous
infiltrate.96,101,103–105,109,110 On the basis of normal endocrine
values, Burk et al111 recommend a maximum 10mg of
epinephrine. An injected solution containing
epinephrine in 1:1,000,000 concentration seems to
afford both hemostasis and safety.104
Brown and others112 found the peak plasma level of
epinephrine occurred 5 hours after infiltration and was
attributed to an exogenous source. Endogenous
norepinepherine levels remained stable throughout
their study. Total absorption was 25–32%. No toxic
levels were demonstrated despite peak levels
equivalent to major physiologic stress. The authors
recommend patient screening to ensure sufficient
cardiac reserve to tolerate the hemodynamic stress of
surgery.
When mixed with epinephrine in solution,
lidocaine is absorbed slowly by the subcutaneous
tissues and thus can be used in relatively high doses.
Klein81,113 believes a lidocaine dose of 35mg/kg of body
weight is safe. Peak plasma concentrations at 12h
never reached toxic levels in his series. Ostad and
colleagues 114 believe that lidocaine doses up to
55mg/kg are safe. Plasma levels of lidocaine ranging
from 0.9–3.6mcg/mL typically occur 8–14h after
surgery but can be detected for up to 24h (Table 4).115
TABLE 4
Plasma Lidocaine Levels and Symptoms of Toxicity
(Reprinted with permission from Matarasso A: Lidocaine in
ultrasound-assisted lipoplasty. Clin Plast Surg 26(3):431, 1999,)
Kenkel and coworkers116 prospectively tracked the
serum and lipoaspirate levels of lidocaine and its
metabolite, monoethylglycinexylidide (MEGX), in 5
10
women during liposuction. MEGX is an active
metabolite of lidocaine that has 80–90% potency and
roughly equivalent toxicity. The time to peak
concentration of lidocaine ranged from 8–28h after
infiltration; 64% of lidocaine was absorbed
systemically and only 9.7% was removed during the
procedure. The peak lidocaine + MEGX concentration
was within safe limits, with therapeutic tissue levels
declining after only 4–8h postoperatively. The authors
comment on the prolonged time to peak systemic
levels and relatively short duration of effect at the
tissue level.
In a series of prospective studies, the physiologic
effects of large-volume liposuction were evaluated by
Kenkel et al117,118 in 5 female patients. The average
volume of lipoaspirate was 4835mL. The patients’
heart rate, blood pressure, mean pulmonary arterial
pressure, cardiac index, and central venous pressure
were monitored. Serum epinephrine level and core
body temperature were recorded. The cardiac index,
heart rate, and mean pulmonary arterial pressure were
significantly elevated but CVP was not, indicating
adequate right heart compliance. The intraoperative
epinephrine level and cardiac index correlated well;
hypothermia was prevalent intraoperatively. 117
Electrolyte and plasma enzyme disturbance was also
evident during surgery, with patients exhibiting
hyponatremia, hypokalemia, hypoalbuminemia, and
hypoproteinemia. All measures returned to baseline
levels in 4–24h. Transient elevations in aspartate
aminotransferase and alanine transaminase levels
were likely due to local tissue trauma, not hepatic
toxicity, as creatine kinase was also elevated.118 The
authors recommend use of isotonic fluids to avoid
further hemodilution and stress the importance of
maintaining intraoperative normocarbia to prevent
complications.
Lidocaine Toxicity
The early signs of lidocaine toxicity are subjective and
may include circumoral numbness, drowsiness, and
light-headedness. In a patient who has had general
anesthesia, the first signs may be cardiac
abnormalities. The treatment of lidocaine toxicity
involves maintenance of airway, ventilatory and
circulatory support, and possible cardiopulmonary
resuscitation. Valium may help control seizures by
raising the brain threshold two-fold. Some patients
may require specific medications to control cardiac
abnormalities.
Because of the risks involved with the use of
lidocaine, some have questioned whether it is
necessary in liposuction. An intraindividual
comparison of pain when lidocaine was used on one
side of the body only showed no statistically
significant difference in postoperative pain at 5, 30, 60,
and 120 minutes whether lidocaine was used or not.119
The authors recommend eliminating it because of its
potential toxicity. Their study was limited in design
and number of patients (10), but it raises an interesting
point that should be investigated further.
Traditional (Deep) Liposuction
The objective in suction lipectomy is to avulse
subcutaneous fat through a mechanically induced
negative pressure. The maximum vacuum that any
pump can produce at a given time and location is
equal to the current atmospheric pressure. Hetter61
described the vacuum pump and how to calibrate it so
that it can be used at any elevation.
The distance between fat and vacuum source
includes the length of flexible tubing connecting the
pump to the cannula. Courtiss120 underscored the
significance of cannular diameter and reminded us of
Poiseuille’s law: For each unit increase in radius of a
tube, flow through the tube rises exponentially; the
longer the tube, the smaller the flow.
Superficial Liposuction
Having presented his concept of superficial
liposuction at an international symposium in Brazil 3
years earlier,68 in 1992 Gasparotti121 published his
experience with superficial liposuction in 2500 patients
of all ages and sizes. After the conventional technique
was performed in the deep adipose layer, the
cutaneous fat layer was thick, heavy, and susceptible
to sagging from the effects of gravity and edema. The
level of suction was then shifted to the superficial
areolar layer of fat, making multiple, closely spaced
tunnels. A thin cannula is used in the subdermal fat,
undermining without aspiration is carried out in
neighboring areas, and any remaining irregularities
are smoothed manually. The author states that
superficial liposculpting is “based on the controlled
scar retraction of the thin cutaneous adipose flap
remaining after the [deep] treatment.” The patient
population consisted of “young people with slight
adiposities; young, very fat patients with flaccid skin;
elderly patients either with aged or very relaxed skin;
[and] secondary liposuctions.” Superficial liposuction
is of particular benefit in defects of the outer thigh, in
the so-called banana deformity, and for secondary
liposuction.
Working
independently
from
Gasparotti,
122,123
Gasperoni and Salgarello
introduced superficial
liposuction to the congress of the International Society
of Aesthetic Plastic Surgery in Zurich, also in 1989.
Five years later they published their results with
massive all-layer liposuction (MALL) combining deeplevel aspiration and subdermal defatting.124 In this
technique the subdermal fat is suctioned using thin, 3hole Mercedes cannulas with diameters up to 2mm.
The authors’ experience consists of 404 procedures in
293 patients treated primarily for large lipodystrophy
and sagging skin in the abdomen, inner thighs, and
arms. The reported results were excellent. In their
opinion, massive liposuction of all fat layers is
necessary “to reduce as much as possible the thickness
of all the adipose layers and to promote effective skin
retraction.”
In a follow-up article, the authors125 describe the
superficial fat layer, which is separated from the deep
fat layer by the superficial fascial system. The
superficial layer has vertical septa that can tether the
skin to cause dimpling or cellulite. The superficial fat
is more structural and contributes more to definition
rather than to thinning areas of the body, though
subdermal liposuction can be combined with deeper
aspirations in specific zones. The authors emphasize
proper patient selection: ideally, a patient who is not
obese and has good skin quality. Skin irregularities
may be corrected with external ultrasound or by
internal release of tethering fascial bands. The
procedures can be performed under local or general
anesthesia. External ultrasound can be used prior to
the procedure to soften the fat and make it more
regular and even.125 Small-gauge, 1.8–2mm Gasperoni
Multipurpose
Mercedes
tip
cannulas
with
11
circumferential openings are used for subdermal
suctioning. The same cannulas are used in the deeper
fat prior to using the larger, 2.5–3mm cannulas for
scavenging; this poses less risk of postoperative
contour abnormalities and eases passage of the larger
diameter cannulas later. The advantages of this
technique are 1) effective skin retraction; 2)
progressive removal of fat for predictable results; 3)
ability to treat thin areas; 4) better treatment of
cellulite; 5) applicability to all patient types. Skin
irregularities are common complications in the
immediate postoperative period and can be treated
with fat grafting.125
Superficial liposuction has been recommended for
the treatment of flaccid skin, for rippling irregularities
after deep aspiration, and for cottage-cheese or peau
d’orange skin deformity (cellulite). Whether
subdermal liposuction helps with skin retraction
depends on the treatment site, patient age, and volume
of fat removed.126
Matarasso127 confirms the importance of anatomic
site as a factor influencing the results of superficial
suction lipectomy. Patients who have flaccid,
pseudoptotic skin (type A) obtain maximum benefit
from superficial liposuction of the neck, dorsal rolls,
outer thighs, and banana deformity. Patients who have
cellulite (type B) respond best to superficial suction
lipectomy of the outer and anterior thighs. Generally,
areas in which substantial volume can be removed
show the most improvement.
The buttocks are not amenable to treatment by
superficial liposuction. Where skin needs to be lifted—
eg, the inner thighs—the procedure indicated is
excisional dermolipectomy rather than superficial
liposuction.
De Souza Pinto and associates128 offer an excellent
overview of the superficial technique of liposuction
and highlight the benefits of skin detachment in
correcting skin imperfections and enhancing
secondary skin retraction.
Syringe vs Vacuum Aspiration
In the late 1980s Fournier129 and Toledo65 independently
reported superficial fat aspiration by syringe for the
correction of skin contour deformities. The method
was recommended for smoothing out superficial
12
irregularities after conventional liposuction and for the
treatment of patients with flaccid skin or cellulite.
Toledo66,130 later updated his experience with syringe
liposculpture combined with superficial liposuction,
lysis of fibrous adherences, and subcutaneous fat
injections.
Lewis67 compared the syringe technique to the
traditional pump aspiration method of suction
lipectomy in 6 patients, one technique on either side.
He used a Tulip® aspirator system with a larger
opening (Toomey) and a lock to hold the syringe with
vacuum to free one of the surgeon’s hands. Lewis
reports less blood in the fat aspirate from the syringe
side and less postoperative bruising and morbidity
with the syringe technique on follow-up. He
speculated that the fluid added to the cannula may act
as a hydrotomy and provide a cushion that decreases
trauma to the adipose tissue.
Mandel131 assessed the results of syringe
liposculpture and conventional liposuction in matched
groups of 10 patients each. He reports less blood loss
in syringe-treated patients, who also “appeared to heal
faster, return to work in a shorter period of time, and
have less pain.” Mandel concludes that the advantages
of syringe liposuction are that the fat can be removed
accurately and in precise quantities from different
areas, the aspirated material is not vaporized, blood
loss is decreased, the operating room environment is
quiet, and patient recovery is accelerated. The main
disadvantage of syringe liposculpture is prolonged
operating time.
Ultrasound-assisted Liposuction (UAL)
In 1993 Professor Zocchi of Modena, Italy, published
his researches on ultrasonic energy to liquify excess
body fat. After treatment with a solid probe, the
emulsified fat was aspirated with a syringe instead of
being removed by a cannula attached to a vacuum
pump. All practitioners of UAL trace their enthusiasm
for the technique to these initial breakthroughs by
Zocchi.73,74,76,132
UAL has expanded the indications for suction
lipectomy in body contouring, enabling surgeons to
treat areas that were previously considered to be outof-bounds because of inconsistent results with other
techniques.133–135 Candidates for UAL range in age from
late teens to mid-70s and should be in general good
health, of reasonable body weight, and with at least
moderate skin tone.76,133–135
Kenkel et al136 compared the tissue effects of
ultrasound-assisted liposuction to traditional
liposuction in a domestic pig model. They found the
ratio of hemoglobin to triglycerides was lower after
UAL with or without the sheath than after traditional
liposuction. Moreover, radiographic dye studies of the
postperfusion vasculature in the treated areas showed
significantly less vascular disruption with UAL than
with traditional techniques.
The effects of traditional and ultrasound
liposuction on adipose tissue were also evaluated by
Grippaudo and coworkers,137 who obtained aspirates
from 15 patients and measured triglycerides and free
fatty acids in the samples. Triglyceride levels were
higher following ultrasound-assisted liposuction; free
fatty acids were similar in the two groups.
Song138 demonstrated that hypotonic solution can
significantly increase human adipocyte cell diameter.
The use of 25% normal saline in the solution may
facilitate ultrasonic lipoplasty by causing the
adipocyte to swell, thinning its cell membrane and
becoming more fragile.
While ultrasonic frequencies by definition are
outside the range of normal human hearing, during
ultrasound-assisted liposuction procedures one hears
a distinct, audible sound. Kenkel et al139 studied sound
intensity during UAL and found that all
measurements obtained with two different machines
were within acceptable standards as defined by the
U.S. Occupational Safety and Health Administration
(OSHA). The authors conclude that UAL does not pose
a risk to patient, surgeon, or operating room
personnel.
Zocchi76 reports a large clinical experience with
UAL encompassing more than 1000 patients operated
on between 1989 and 1996. After an initial learning
curve, the author reports minimal complications from
the procedure despite treating patients of all ages in
almost every anatomic area. Two precepts considered
essential for the safe use of UAL are: 1) never apply
energy to dry tissue; and 2) never apply energy
without motion of the probe or cannula.
Scheflan and Tazi140 as well as Kloehn141 also report
enhanced skin contraction and selectively improved
results with ultrasound-assisted liposuction. They
used early-model solid probes and endured a steep
learning curve. The hollow cannula for UAL was
developed in America by Maxwell133 and adopted soon
thereafter by Fodor142 and Rohrich.134 All authors
emphasize the initial learning curve with its attendant
risks of dysesthesias, thermal injury, and contour
deformity.
Rohrich et al143 review the process of selecting
access incisions for UAL, which are confirmed with the
patient (Table 5). The incisions are only 3–5mm long
and are made asymmetrically so as not to look like
surgical scars. The UAL procedure is considered to
have three stages:38
Stage I — subcutaneous infiltration of fluids to
decrease blood loss and tissue density
Stage II — ultrasound treatment to emulsify
subcutaneous fat
Stage III — evacuation of emulsified fat and final
contouring
TABLE 5
Access Incisions for UAL by Anatomic Area
(Reprinted with permission from Rohrich RJ, Beran SJ, Kenkel JM:
Ultrasound-assisted Liposuction. St Louis, Quality Med Pub,
1998.)
A perioperative log sheet is used to accurately
document events during liposuction. This record helps
in maintaining appropriate fluids and blood pressure.38
The authors143 stress the importance of primary and
13
secondary endpoints for assessing completion of UAL
(Table 6).
TABLE 6
Primary and Secondary Endpoints
for UAL and SAL
(Reprinted with permission from Rohrich RJ, Beran SJ, Kenkel JM:
Ultrasound-assisted Liposuction. St Louis, Quality Med Pub,
1998.)
Graf and colleagues144 present a series of 348
patients treated with a 3-stage technique consisting of
infiltration, ultrasound-assisted sculpturing, and
suction-assisted liposuction. The flanks and back were
the most common areas treated. Seromas were more
frequent with tumescent infiltration and became less
frequent with a superwet technique. The authors
describe their technical evolution to cases with smaller
volumes of liposuction and higher energy settings and
expressed themselves satisfied with the resultant
improved contour.
Perez and van Tetering145 review 350 consecutive
cases of UAL for body contouring. They applied the
basic rules of Zocchi—no regard to energy times, body
areas, or tissue planes—in a two-stage technique
consisting of tumescent infiltration followed by UAL
and simultaneous aspiration. The advantages of this
technique were selective destruction of adipose tissue
and preservation of soft-tissue elements, which led to
less bruising and pain, fewer skin irregularities, and
faster postoperative recovery than with conventional
techniques. No burns were seen despite prolonged
energy times. Disadvantages included the procedure’s
cost to the patient and additional training for the
surgeon.
A common mistake by surgeons just learning the
UAL technique is to overtreat and carry out UAL to
final contour. Since much of the already-destroyed
tissue is still in the subcutaneous space awaiting
evacuation, overtreatment invariably produces a
14
contour deformity. Adherence to the endpoints
mentioned above is critical to the success of UAL.
Over the last few years the trend has been toward
the use of solid probes and away from hollow
cannulas. Beckenstein and Grotting146 review their
experience with solid-probe UAL in 100 consecutive
cases, including advantages and disadvantages of the
technology.
Jewell and coauthors147 report their experience
with the second-generation ultrasound technology for
liposuction—the VASER device. The VASER system
“uses small-diameter solid probes . . . with grooves
near the tip to increase fragmentation efficiency. The
grooved probe design redistributes the ultrasound
energy, transferring some of the vibration energy from
the front of the tip to a region just proximal to the
tip.”147 The device in VASER mode emits pulsed energy
rather than continuous energy. With the vibration
energy “off” more than 50% of the time, the potential
for thermal injury at the treatment site is decreased.
The probes are smaller and lighter than previous UAL
probes. The probes’ various sizes and grooves produce
different pit configurations for different soft tissues. By
increasing the number of rings, one sees an increase in
lateral fragmentation. The authors review their results
in 77 patients and find the VASER system to be safe
and efficient for body contouring surgery.
De Souza Pinto and associates148 present their
experience with VASER liposuction. To increase fat
emulsification and use less energy, probe selection
should correlate with the consistency of the fat to be
treated. At a given diameter, probes with more grooves
emulsify fat tissue more efficiently, although they do
not penetrate fibrous tissue as well. Probes with fewer
grooves and smaller diameter penetrate fibrous tissue
more easily. Pulsed energy delivery further reduces
the power needed and is indicated for use in more
delicate areas or to achieve a finer contour. The authors
describe their technique, including power and time
limits and complementary use of SAL and PAL, with
case examples. They claim 70–90% cellular disruption
with the VASER and fewer complications as a result of
the lower applied energy.
A series of VASER liposculpture cases by Hoyos
and coworkers149 is testimony to the wide range of
patients that can be treated with this 3-stage technique.
The authors apply VASER in multiple modes to
different fat layers—eg, continuous mode in the
intermediate fat; low-energy pulse mode for
superficial definition. The reported seroma rate was
6.5%, with a 2.94% port burn rate and a steep learning
curve. The results presented are impressive.
External Ultrasound-assisted Liposuction
The standard device for external UAL delivers energy
in the range of 1–1.5W/cm2 and is used in conjunction
with subcutaneous infiltration. The combination of the
two modalities delivers power in the range of 3W/cm2.
Either a 5- or 10cm head is used following
subcutaneous infiltration. A surgical coupler must be
used for proper transmission of ultrasound energy and
safety. Times range from 2–10 minutes depending on
treatment site (Table 7).150 Once the application of
energy is completed, traditional liposuction is used for
fat removal.38 The safety of external ultrasonic
lipoplasty was confirmed by Rosenberg and Cabrera150
in a review of 160 consecutive patients.
TABLE 7
UAL Times by Body Area
(Reprinted with permission from Rosenberg GJ, Cabrera RC:
External ultrasonic lipoplasty: an effective method of fat removal
and skin shrinkage. Plast Reconstr Surg 105:785, 2000.)
The benefit of external ultrasound in body
contouring has been questioned. Rohrich and others151
compared lipoaspirates of four body regions in 6
women treated for 7 minutes with a) traditional
liposuction; b) internal UAL; c) external ultrasoundassisted liposuction; or d) external massage. Histologic
analysis of the specimens showed 70–90% cellular
disruption with internal UAL and no significant effect
of external ultrasound or massage on adipocytes.
These findings were confirmed clinically by
Lawrence and Cox,152 who evaluated 19 patients (25
sites) in a double-blind study of external ultrasound vs
traditional tumescent liposuction. The results were
assessed 1 month postoperatively by patients through
a questionnaire and by physicians using a visual
analog scale. Histologic specimens were also
inspected. Although 4/19 patients saw an advantage
in the external ultrasound side, the doctors found no
difference between treatment and control sides in
14/19 patients.
Power-assisted Lipoplasty
Power-assisted lipoplasty (PAL) is the latest
technology said to further refine suction lipectomy.153
Introduced in the 1990s, power liposuction used
compressed
air
and
has
been
called
“vibroliposuction,” though it now operates by means
of a gas or electric turbine.154 The majority of PAL
systems currently rely on electricity and a variablespeed motor to generate a reciprocating motion and
produce a cannula excursion of 2–4mm, which is
supposed to mimic the surgeon’s hand movement.
This is its main advantage: The surgeon exerts less
force to complete a case and is thus less fatigued. Its
major disadvantage is the vibration of the handpiece,
which can translate to the surgeon’s hand. There is also
noise associated with some of the PAL systems.
Reporting the results of an intraindividual
comparison of PAL vs traditional SAL in 30 patients,
Fodor and Vogt155 found no difference between sides
with regard to speed of recovery or aesthetic result. Fat
extraction was easier with PAL than with conventional
SAL.
Laser Liposuction
Laser lipolysis or lipoplasty has been used extensively
in Europe and Latin America and only recently in the
United States and Japan. The technique uses a pulsed
1064nm Nd:YAG laser to transmit low-level energy to
adipocytes, which expand and rupture.156 A flexible
fiberoptic light is inserted into the tissue through a
1mm cannula under local anesthesia. The position of
the cannula is monitored via transillumination from a
red guiding beam. Histologic analyses of the effects of
the pulsed Nd:YAG laser on human fat tissue have
demonstrated
reversible
cellular
damage
(tumefaction); irreversible tissue damage (lysis); and
15
reduced bleeding compared with conventional
lipoplasty.156
Ichikawa157 traced the histologic effects of the
pulsed Nd:YAG laser on human tissue. Excised human
skin and subcutaneous fat were irradiated with a
1064nm laser at 40Hz and 150mJ and 100ms-long
pulses and compared with non-irradiated tissue. An
increased destruction of human adipocytes was
appreciated in the irradiated human tissue, which
showed degenerated cell membrane, vaporization,
liquefaction, carbonization, and heat-coagulated
collagen fibers. The acute thermal effect in vivo was
evaluated by laser liposuction of the rat liver, which
demonstrated areas of necrosis 1mm in diameter—ie,
energy scatter and a thermal conduction effect by the
tissue.
Interestingly, Brown et al156 reported no effect on
human and porcine adipocytes by the 635nm low-level
laser using similar techniques, contradicting the
previous studies.
Mordon et al158 compared a pulsed 1064nm
Nd:YAG and CW 980nm diode laser. The advantage of
the diode laser is better efficiency, higher power, and
smaller size and weight than the Nd:YAG laser, yet
with similar absorption coefficient. The authors found
similar histologic effects on adipocytes with the two
lasers at similar energy settings, but infer an
advantage to the higher-power diode laser. Further
safety studies are indicated.
A comparison study by Kim and colleagues159
evaluated the safety and efficacy of a 1064nm Nd:YAG
laser in a group of patients with small focal areas of fat.
The authors report 37% clinical improvement and 17%
reduction in fat volume on quantitative MRI compared
with controls. The higher the energy, the greater the
volume of reduction. A 5cm3 reduction of fat volume
was observed with 3000J and a 20cm 3 volume
reduction was obtained with 12000J. Common side
effects were mild bruising and swelling. Large-volume
areas may require high amounts of total energy.
Goldman160 reported a series of 82 patients who
underwent submental treatment of lipodystrophy with
an Nd:YAG laser at 1064nm wavelength using 6W
power, 40Hz frequency, 150mJ energy, and 100ms
pulse width, followed by standard suction to remove
the laser lipolysis debris. The author notes a significant
16
cosmetic improvement. Comparative histology of
samples taken immediately after the procedure and 40
days after showed initial rupture of adipocyte
membranes as well as collagen coagulation and
channels in fatty tissue. Small blood vessels were
coagulated. Clinical skin tightening effects and
collagen reorganization was noted on follow-up.
Complications included two instances of asymmetry.
Suction Lipectomy in Men
In his first survey, Dillerud 161 found that
proportionately more men (15%) than women (2.8%)
were dissatisfied with the outcome of suction
lipectomy procedures, and speculated that stricter
criteria might be needed for liposuction in men.
Dillerud’s later survey, 162 however, recorded no
appreciable difference in satisfaction with suction
lipectomy between the sexes.
Men who request abdominal suction lipectomy
must be examined with particular care, since much of
the abdominal protruberance may be caused by
intraabdominal fat that cannot be corrected by suction
lipectomy.163 Periumbilical hernia must also be ruled
out.
Mentz and coworkers164 described differential
liposuction of the abdomen to better delineate the
musculature in male athletes. In a technique they call
etching, the authors perform localized superficial
liposuction to deepen the natural grooves and furrows
and enhance muscle definition. They report good to
excellent results and minimal risks in 8 men. Caution
should be used when applying this technique, as it can
lead to an excessively high rate of contour
irregularities.
Large-volume Liposuction
Large-volume liposuction was defined by the
Liposuction Task Force of the American Society of
Plastic Surgeons as lipoaspirate volume greater than
5000mL. As the liposuction technique became more
refined over the next 15 years, more and more patients
(and their physicians) sought larger and larger
lipoaspirates. Large-volume liposuction is a safe procedure
if performed in properly selected, healthy patients in the
appropriate environment. Because of the magnitude of
the operation and amount of fluids infiltrated and
removed, special attention must be paid to
resuscitation to avoid volume overload. Rohrich,
Beran, and Kenkel 38 recommend maintenance
intravenous fluids for the first 5L of aspirate and
replacement of further losses with 0.25mL IV for every
1mL aspirated over 5L. Additionally, lidocaine is
decreased to 15mL of 1% xylocaine/L and a Foley
catheter is used.
A couple of outcome studies of large-volume
liposuction are reviewed. Cardenas-Camarena and
coworkers165 treated 161 patients during a 4-year
period. Lipoaspirate volumes ranged between 5L and
22.3L with a mean of 8.7L. The average reduction of
hemoglobin and hematocrit at 1 week was 3.8% and
12%, respectively. No major complications were noted.
There were 2 cases (1.2%) of superficial cutaneous
necrosis, 18 (11.2%) seromas, 24 (14.9%) palpable
irregularities, and 92% patient satisfaction.
A similar study by Albin and de Campo166
encompassed 181 patients. Two patients (1.1%)
developed pulmonary embolism and one patient
(0.6%) had deep venous thrombosis.
Other Applications of Liposuction
McEwan and colleagues167 as well as Dowden et al168
report suction lipectomy in the management of
hematomas and fat necrosis developing after facelifts
and other nonsurgical trauma. Several authors169–174
have also used liposuction to remove lipomas.
Spinowitz175 and Collins et al176 cite reports of suction
lipectomy
for
the
correction
of
axillary
hyperhidrosis,177–179
buffalo
hump, 180
and
179,181–183
lymphedema.
To these we can add benign
symmetric lipomatosis (Madelung’s disease), 179
cherubism,184 and flap debulking and defatting.179,185,186
The reader is encouraged to study these reports before
embarking on suction lipectomy for special
applications.
As the number of patients who use HIV protease
inhibitors increases, and the drugs are taken for everlonger times, syndromes involving abnormal fat
distribution may be seen. These syndromes include the
presence of a cervicodorsal fat pad, centralized
lipodystrophy of the trunk and face, and hypertrophy
of adipose tissue in the breasts of women. Wolfort and
colleagues187 describe suction-assisted lipectomy in the
treatment of lipodystrophy syndromes attributed to
HIV-protease inhibitor use. Their study showed that
these areas are amenable to treatment with liposuction.
Rohrich and Kenkel 188 described the use of
ultrasound-assisted liposuction for the management of
these patients who they deem as “more fibrous.”
Complications
Gargan and Courtiss189 characterize the risks of suction
lipectomy as undesired sequelae, such as surface contour
irregularities, hypesthesia, edema, ecchymosis, and
discoloration, and potential complications such as
excessive blood loss, hematoma, seroma, infection,
thrombosis, fat emboli, and skin necrosis. Hypesthesia
of the treated areas is not considered a complication
but an inevitable consequence of the procedure.
Normal sensation usually returns within 3 to 6 months
of suctioning.
The most common postoperative sequelae of
suction lipectomy are contour irregularities. There
frequency is inversely related to the surgeon’s
experience with the procedure. Visible waviness or
ridging on the surface after liposuction can be kept to
a minimum by proper patient selection and thorough
preoperative evaluation; use of small cannulas
inserted through multiple incisions; cross-radial
tunneling; combined superficial and deep suction; and
feathering of the treatment areas.
Because contour irregularities may respond to
massage, they should be treated conservatively for at
least 6 months after the initial surgery. Chang190–192 uses
multiple techniques for correction of postliposuction
contour deformities. Methods of correction include
liposuction in the area of protruberance, liposuction
around the area of depression, simultaneous fat
grafting, dermolipectomy for sagging skin, and grid
pattern markings for liposuction. For mild
irregularities, limited additional liposuction is used;
for more severe defects, liposuction is directly applied
to areas of protuberance and around areas of
depression in combination with fat grafting or
dermolipectomy. Scar release with pretunneling,
planning the incision location, fat harvest, and
injection techniques are discussed. The technique of
autologous fat grafting in the treatment of iatrogenic
abnormalities or aesthetic improvement will be
17
discussed later in this review. More recently the
author192 advocates liposuction following grid pattern
markings, which in his experience yields fewer
contour irregularities.
A survey of US and Canadian plastic surgeons
published by Pitman and Teimourian193 in 1985
disclosed an overall complication rate of 9.3% after
suction lipectomy. An additional 20.7% of patients
were judged to have unfavorable results as manifested
by superficial waviness (from overly aggressive fat
removal) and asymmetry (from insufficient suction
within an area).
Unfortunately, despite the popularity of
liposuction and its well-documented safety record,
reports of fatalities related to liposuction continue to
emerge. Rao, Ely, and Hoffman194 identified 5 deaths
after tumescent liposuction among 48,527 deaths
referred to the Office of the Chief Medical Examiner of
the City of New York between 1993 and 1998. Critical
review showed that 3 patients died as a result of
intraoperative hypotension and bradycardia. One of
these patients had a postmortem lidocaine
concentration of 5.2mg/L. One patient died of fluid
overload and one died as a complication of deep
venous thrombosis. While the above analysis suggests
that lidocaine contributed to the deaths, there was no
objective evidence of this.195,196
Hughes197 sent out a questionnaire to 1432 boardcertified plastic surgeons, all active members of the
American Society of Aesthetic Plastic Surgery. The 754
respondents (53%) reported 94,159 lipoplasties among
them: 66% liposuction alone, 14% lipoplasty with
abdominoplasty, and 20% lipoplasty with other than
abdominoplasty. The reported complications of
lipoplasty are listed in Table 8. Combining liposuction
with other procedures dramatically increases the
mortality rate (Table 9).
In 2003 Matarasso198 surveyed members of the
American Society of Plastic Surgeons and reported a
15% response rate, representing the experience of 497
board-certified plastic surgeons who performed 20,029
abdominal contouring procedures over a 12-month
period: 55% full abdominoplasties; 35% liposuction;
and 10% limited abdominoplasties. The risk of
complications did not rise with increasing volumes of
fat removal, at least with respect to wound infection,
18
blood
transfusion,
anesthetic
complications,
pulmonary embolism, and malpractice actions.
Contour irregularities were reported in 9.2% of 7010
abdominal liposuction procedures—the most common
local complication.
TABLE 8
Nonfatal Complications from Lipoplasty Alone and
in Combination with Abdominoplasty
(Reprinted with permission from Hughes CE 3rd: Reduction of
lipoplasty risks and mortality: an ASAPS survey. Aesthetic Surg
J 21:120, 2001.)
TABLE 9
Deaths from Lipoplasty, 9/1/98 to 8/31/2000
(N=94,159)
J 21:120, 2001.)
On the basis of the findings by a lipoplasty task
force, many ASAPS members have modified their
technique to enhance aesthetic outcomes and patient
safety (Table 10). The importance of operating in an
accredited surgical facility cannot be understated and
is clearly emphasized in this review.197
TABLE 10
Changes in Lipoplasty Technique
(33% of Respondents)
J 21:120, 2001.)
Grazer and de Jong’s199 reported the results of a
survey of 1200 actively practicing, board-certified
plastic surgeons. There were 95 fatalities in nearly
500,000 lipoplasties, for a mortality rate of 1 in 5,224, or
roughly 19 in 100,000. Of these deaths, 23% were due
to pulmonary thromboembolism. The fact that this
was a random survey makes it difficult to estimate
morbidity and mortality associated with the
procedure. In his discussion of this paper, Rohrich200
lists guidelines for safety in liposuction (Table 11).
Reported complications of the tumescent
technique include pulmonary edema201 and several
cases of acute median nerve compression from
injection of fluid in the arm.202,203 In early 1998 the
American Society of Plastic Surgeons issued a warning
based on the findings of the lipoplasty task force. The
statement defined large-volume liposuction as that in
which more than 5 liters of aspirate is removed.
Members were cautioned to carefully balance the
volumes of infusion fluid and suction aspirate in these
cases because of the longer operating times and the
potential for life-threatening complications. The report
recommends that physicians performing the
procedure be properly trained in lipoplasty surgery
and that instructional courses on lipoplasty “include
comprehensive fluid resuscitation information and the
physiology of fluid diffusion pertaining to largevolume lipoplasty.”204
TABLE 11
Safety Guidelines in Liposuction
(Reprinted with permission from Rohrich RJ: Discussion of “Fatal
outcomes from liposuction: census survey of cosmetic surgeons”
by FM Grazer and RH de Jong. Plast Reconstr Surg 105:447,
2000.)
Several problems are associated specifically with
UAL,
including
seroma
formation,
hyperpigmentation,
thermal
injury,
and
134
dysesthesias. Measures to minimize or eliminate
complications include adopting a 3-stage technique,
skirting areas prone to hyperpigmentation (eg, the
medial thigh), and guiding treatment time by the
previously mentioned endpoints.
Other complications such as infection can be
minimized by maintaining a sterile field and not
touching the barrel of the suction cannula. The most
likely site of infection (eg, the inner thigh) should be
treated last, and incisions around the anus and vagina
should be avoided because of the risk of
contamination. Skin loss is rare; more common is some
ulceration or friction injury to the skin at the entrance
site from incorrect use of the cannula, tension on the
skin margins, or an incision that is too small.
Pardo Mateu and Chamorro Hernandez205 present
3 cases of cutaneous hyperpigmentation following
19
liposuction. They believe the etiology to be
multifactorial, from a combination of hemosiderin
deposition by ecchymosis, the pressure of the bandage,
and possibly friction in the inlet holes of the cannula.
Oral iron therapy, exogenous drug administration
(particularly estrogen), and sun exposure may be
contributing factors in the development of
hyperpigmentation after liposuction.
Goddio126 studied skin retraction in 458 subjects
representing 500 suction lipectomy procedures. The
neck seemed to be the site most amenable to
liposuction, which alone improved or eliminated
preexisting skin looseness better than in any other part
of the body. The results of liposuction in the face
deteriorated over time, and the author advocates a
combination of facelift and suction lipectomy when
there is skin and fat ptosis in the face.
Pitman, Aker, and Tripp 206 reviewed their
experience with 147 patients (136 women, 11 men)
who had outpatient liposuction by the tumescent
technique with >1000mL of aspirate (mean 2229mL)
and no other concurrent procedure. All areas of the
body were treated, and most patients had
simultaneous treatment of multiple areas. The average
fraction of aspirate was 78% fat, 7.8% blood. The
average estimated blood loss for all patients was
180mL, and the average decrease in hematocrit was
1.7%. Swelling and bruising were minimal and
complications were nil. Patients experienced little or
no pain postoperatively and were discharged 1 or 2
hours after surgery.
Dillerud 161 analyzed the complications and
undesired results of suction lipoplasty in more than
2000 patients (3511 procedures). As a rule only healthy
patients were operated on, although stable diabetics
and patients with well-controlled hypertension were
accepted for surgery, as well as moderately obese
patients. A body mass index greater than 35 was a
contraindication to suction lipectomy. The overall
complication rate in Dillerud’s series was 1.2% and
included excessive bleeding, allergic skin reaction or
dermatitis, anesthesia-related complication, superficial
phlebitis, pneumonia, hypertrophic scar, and
persistent dysesthesia. Undesired results were
reported in 10.8% of patients and consisted largely of
asymmetry, underresection, and skin irregularities.
20
The medial thigh, buttocks, ankle, and face were least
amenable to suction as reflected by the high
percentage of complications and undesired results in
these areas.
Dillerud 162 later surveyed long-term patient
satisfaction with the results of blunt suction lipectomy
by questionnaire. The authors found an overall
satisfaction rate of 76%; 6% of patients were
dissatisfied, 14% were less satisfied, and 4% were
unsure. Liposuction of the buttocks was the cause of
the greatest dissatisfaction, and patients were most
pleased with the outcome of treatment for
pseudogynecomastia and in the submental area. There
was no significant difference in subjective assessment
of outcome between men and women.
Illouz 207 summarizes his vast experience of
liposuction and its complications in a Clinics review.
Broughton and coworkers208 reported satisfaction
data provided by liposuction patients operated on by
two plastic surgeons. The majority of respondents
were satisfied with their results, particularly in the
neck, hip and buttocks. Weight gain and fat return was
reported in 43% and 65% of patients repectively; the
abdomen was the most common site of fat return. Most
patients said they would have the procedure again and
would recommend it to others. Most patients also
reported having less than one week of discomfort and
narcotic use. Dissatisfaction related to pre-existing low
self-esteem.
In another patient satisfaction study, Rohrich and
associates209 conclude that weight gain after liposuction
did not significantly affect satisfaction with the
procedure. Among patients who gained weight
postoperatively there were no appreciable lifestyle
changes such as diet and exercise, which factored into
the results of surgery and their opinion on selfappearance. In conclusion, the liposuction patient
should embrace positive lifestyle habits, and this
lesson should be reinforced by the plastic surgeon.
The question of whether pregnancy permanently
reverses the positive effects of suction lipectomy was
addressed by Ahkami.210 The author found that the
measurements achieved by suction lipectomy are
unaffected by pregnancy assuming the patient has a
normal gravid weight gain and maintains a proper
diet after giving birth.
Retroperitoneal
and
paraspinous
muscle
hemorrhage and necrotizing fasciitis have been
reported following liposuction.211–213
Mesotherapy
Mesotherapy was first described by Michel Pistor in
1952 in the context of multiple, local, superficial
injections of procaine. Mesotherapy is defined as the
treatment of the mesoderm and simply describes the
method of drug delivery.214
Intralesional injections of phosphatidylcholine
were first presented in 1988 as treatment of
xanthelasma. Currently phosphatidylcholine is
combined with deoxycholate for the treatment of
adipose tissue. 214 Rotunda et al215 differentiate
mesotherapy from phosphatidylcholine injections
through an extensive comparative review of the
literature. They seek to distinguish between the
techniques and conclude that neither is substantiated
by clinical studies.
The PSEF Device and Technique Assessment
(DATA) Committee reviewed the scant literature on
the safety and efficacy of mesotherapy for body
contouring, along with the use of isoproterenol and
phosphatidylcholine and the mechanism of lipolysis.216
The technique described includes multiple-site
injection of phosphatidycholine in typical doses of
100mg for every 5x5cm area. Three to 6 treatments are
usually required, with a 2-week interval between
sessions.
Rittes and colleagues217 studied 50 patients of ideal
weight who had injections of phosphatidylcholine into
focal fat deposits in various sites. Seventy percent of
patients had 4 treatments, 20% had 2 treatments, and
10% had one treatment. The interval between
treatments averaged 15 days. Bruising, edema, and
erythema were evident for 48–72 hours, with
postinflammatory nodules and hematomas seen for up
to 30 days. Pre- and postprocedural photographs were
compared. All patients showed improvement that
lasted up to 4 years.
Multiple reviews of mesotherapy urge further
scientific evaluation until its clinical use can be
endorsed.218
Gynecomastia
Ultrasound-assisted liposuction (UAL) plays a major
role in the treatment of gynecomastia. Rohrich and
colleagues219 refined Simon’s classification system220
and incorporated UAL into the management algorithm
(Table 12).
The
etiology
of
gynecomastia
includes
developmental
and
drug-induced
causes,
hypogonadism, tumors, systemic illnesses, congenital
disorders, and familial, idiopathic, and miscellaneous
causes221, 222 (Table 13). The common drugs that may
lead to abnormal breast enlargement in men are listed
in Table 14.
The authors classify gynecomastia based on the
degree of hypertrophy, whether the tissue is glandular
or fibrous, and the degree of ptosis. They successfully
treated 53/61 patients (87%) with liposuction alone.
Skin excision is reserved for extreme cases with severe
ptosis. Their technique consists of a lateral
inframammary crease incision, obliteration of the zone
of adherence at the inframammary fold, and tapering
TABLE 12
Classification and Management of Gynecomastia
(Reprinted with permission from Rohrich RJ, Ha RY, Kenkel JM, and Adams WP Jr: Classification and management of gynecomastia:
defining the role of ultrasound-assisted liposuction. Plastic and Reconstructive Surgery® 111:909, 2003.)
21
of the boundaries to avoid a depression under the
nipple–areola complex. An anterior axillary incision is
used only with extreme caution because this site
typically has little adipose tissue and can result in
either a burn or skin retraction from the scar.223
TABLE 13
Causes of Gynomastia
incision was needed. Technical details include plastic
ports, continuous saline irrigation, a probe sheath,
continuous movement, and avoidance of end-hits. The
inframmary fold was disrupted. The average volume
of lipoaspirate was 504mL per breast. No
complications were reported. Patient self-assessment
scores were excellent, and only one patient requested a
secondary procedure.
TABLE 14
Drug-Induced Gynecomastia
(Reprinted with permission from Glass AR:Gynecomastia
endocrinol Metab Clin North Am 23: 825, 1994.)
(Adapted from Glass AR Gynecomastia Endocrinol Metab Clin
North Am 23:825, 1994; and Neuman JF:Evaluation and
treatment of gynocomastia Am Fam Physician 55: 1835, 1997.)
Hodgson and others224 reviewed 13 men who were
treated for gynecomastia with ultrasonic liposuction.
An inframammary incision was used in most cases;
occasionally an additional anterior axillary fold
22
Rosenberg225 used traditional liposuction for the
treatment of gynecomastia. Later the author
recommended a combination of 7mm and 2.4mm
cannulas to remove the relatively heterogeneous fattyfibrous tissue.226 Patients returned to full activities in 48
hours and were left with minimal scars from the
procedure.
Several multimodal one-stage approaches have
been described. Bracaglia and coworkers227 applied a
multimodal approach in 45 patients with various
degrees of gynecomastia. Standard liposuction was
performed via three incisions, two lateral axillary and
one central, with a pull-through technique. The
authors report a 4.4% hematoma rate.
Ramon and associates228 reviewed a 17-patient
experience with gynecomastia of variable severity.
They used a multimodal approach consisting of crosschest, power-assisted liposuction via a contralateral
periareolar incision combined with endoscopicassisted pull-through technique. The advantages of
cross-chest access are scar placement in the periareolar
border and not traveling across the convex chest wall,
as with the inframammary and lateral axillary
incisions. The endoscope allows removal of fibrous
tissue under direct vision. There were no
complications reported.
Hammond and coworkers223 reviewed their
experience with single-stage, combined ultrasonic
liposuction with the pull-through technique in 15
patients. A periareolar incision was used for the entire
procedure. The overall complication rate was 18.5%.
Tashkandi and others229 report using a single-stage
subcutaneous mastectomy and circumareolar
concentric skin reduction with deepithelialization in
24 consecutive patients with high-grade gynecomastia.
A 3-0 polypropylene, intradermal, circumareolar
pursestring suture is used for skin closure. Mild skin
redundancy was noted in all patients postoperatively,
but no secondary procedures were deemed necessary.
Aiche230 describes an excisional technique for the
treatment of residual deformities of gynecomastia after
traditional liposuction. The author cautions against
removing central or peripheral adipose tissue without
addressing the underlying mammary tissue.
GLUTEAL AUGMENTATION
The gluteal area has received increasing attention in
body contouring surgery, particularly after massive
weight loss. Cuenca-Guerra and colleagues231 analyzed
more than 100 anatomic measurements in 1320
photographs to try to define the characteristics of an
aesthetically pleasing gluteal region. Four important
aesthetic areas were identified in the attractive
buttock: a lateral depression, an infragluteal fold,
supragluteal fossettes, and a V-shaped crease.
Anthropometric analysis of gluteal projection yielded
five gluteal types for which treatment plans could be
defined: Type 1 was corrected with liposuction; a
combination of liposuction and various designs of
submuscular gluteal implants was used to correct
Types 2 to 4; and Type 5 was corrected by
dermocutaneous adjustments.
Centeno and others232 describe eight aesthetic units
of the gluteal region that should be considered when
formulating the preoperative plan, for the placement
of the incision, and in the postoperative evaluation.
They include two symmetrical “flank” units, a “sacral
triangle” unit, two symmetrical gluteal units, two
symmetrical thigh units, and one “infragluteal
diamond” unit.
Many authors have described modalities to
augment the buttocks for increased projection and to
decompress the surrounding areas with liposuction to
sculpt the gluteal region. Mendieta233 divides the
buttocks into an upper, a middle, and a lower zone,
each with its own subdivisions. His evaluation takes
into account buttocks volume, shape, and skin
quality/laxity to determine the appropriate modality
of treatment, including liposuction, fat grafting, skin
excision, and gluteal implants. The author reviews his
technique and experience with intramuscular
placement of solid silicone implants.
Gonzalez234 reviews the surface anatomic
landmarks to keep in mind for the safe placement of
intramuscular gluteal implants based on his
experience with 746 patients. Infection was less
frequent with the use of drains, antibiotics, and a
drape over the perianal area. The most common
complication was small superficial wound dehiscence,
which occurred in 14% of patients and was managed
conservatively.
The safety of gluteal implants has been questioned
and has led to the development of autologous
modalities for buttocks augmentation in the United
States. Autologous flaps and fat injections have
become popular due to the rising number of patients
who seek body lift procedures after massive weight
loss.235 The gluteal region in these patients tends to be
already deflated and flattens further with elevation.
The autologous flaps used for correction are based on
regional perforating vessels and typically derive from
tissue that would otherwise be discarded.236
23
Rohde and colleagues237 describe their technique to
improve gluteal contour in 62 post-bariatric surgery
patients. A medially based axial flap is designed in the
upper buttock and lumbar area. This is a random flap
with perforators from the superior gluteal artery,
lateral sacral artery, and fourth lumbar artery. The flap
is rotated into a prefascial pocket and sutured while
advancing the buttock skin superiorly. Drains and
fibrin sealant complete the closure. Wound dehiscence
and seroma were the most common complications in
their series; one patient had fat necrosis.
The loss of gluteal projection and shape is
proportional to the amount of lower body lift
performed. Sozer et al238 present 20 patients who
underwent circular (belt) lipectomy in combination
with dermal fat flaps for body contouring after
massive weight loss. The superomedially based
dermal fat flap is rotated caudally 180° into a
subcutaneous pocket on either side. This refinement
adds 30 minutes to the operative time, but the shape
and projection of the buttocks is much improved.
Patient satisfaction was high despite minor
complications in 7 cases.
Raposo-Amaral and others235 describe their
experience with bilateral dermal fat rotation flaps in 9
women. The flaps are designed on the hip and rotated
into the buttocks; they are based on gluteal artery
perforators with deepithelialized extensions from
posterior and flank incisions. After 11 months of
follow-up, buttock projection was maintained. CT
scans of 2 patients at 6 months showed viable flaps.
Three patients (33%) had complications: a hematoma,
a seroma, and widened scars.
Colwell and associates236 used superior gluteal
artery perforator flaps for autologous gluteal
augmentation in 18 patients who underwent body lift
procedures after massive weight loss. Perforating
vessels were identified preoperatively along a line
extending from the posterior superior iliac spine to the
greater trochanter; two large perforators were usually
seen 6–9cm from the midline. The central tissue was
excised between the two deepithelialized oval flaps to
decrease central bulk, and the flaps were rotated and
inset 5cm above the inferior gluteal crease in a
suprafascial plane. The autologous augmentation
required an additional 60 minutes to complete. Wound
24
dehiscence was the most common complication. One
flap suffered major fat necrosis.
Autologous fat injections have been applied to
multiple anatomic areas as a volumetric filler.
Murillo239 describes a 7-year, 162-patient experience
with fat injections in the buttocks. The average
injection was 700cc. The fat was harvested from
multiple sites with a 5mm cannula, decanted and then
injected with the same cannula into the upper twothirds of the gluteus muscle. Six patients were
followed with serial MRI studies and showed
retention of the intramuscular fat for up to 12 months.
Clinically there was only 20% volume loss and high
patient satisfaction.
ABDOMINOPLASTY
INDICATIONS
The goals of abdominoplasty are to improve the
contour and external appearance of the abdominal
wall while leaving well-concealed scars and a naturallooking umbilicus. Redundant skin, excessive adipose
tissue, musculoaponeurotic diastasis and scar
deformities including striae are seen to variable
degrees in patients seeking abdominoplasty.
Adipose deformities of the abdomen may be
concentrated primarily above the umbilicus, below the
umbilicus, or at the waistline.45 Generalized obesity
with increased intraabdominal fat is typical of male
patients, while elderly women usually present with a
lower abdominal apron of skin and fat.
General contraindications to abdominoplasty are
significant medical comorbidities, gross obesity with a
BMI >30, future pregnancy, and supraumbilical
abdominal scars.
CLASSIFICATION
Matarasso240 classifies abdominal deformities based on
severity of the skin, fat, and muscular flaccidity, and
selects the most appropriate surgical technique for
abdominal contouring. Rohrich and colleagues38 use a
modified Matarasso classification that is based on
clinical assessment of the degree of skin redundancy,
amount of abdominal fat, skin thickness and tone, and
status of the abdominal musculature.
SURGICAL ANATOMY
Huger241 studied the changes in blood supply of the
abdominal wall after abdominoplasty and recognized
three vascular zones:
Zone I,
midabdomen, supplied by the deep
epigastric arcade
Zone II,
lower abdomen, supplied by the
external iliac artery
Zone III, lateral abdomen, supplied by the
intercostals, subcostal, and lumbar
arteries
Depending on the technique employed, one or two
zones may be sacrificed, leaving the resulting flap
perfused via Zone III. Current lipoabdominoplasty
techniques may preserve Zones I and III with limited
discontinuous undermining of the abdominal flap.
Matarasso initially gave technical guidelines for
safe concomitant liposuction and abdominoplasty, and
recommended caution when suctioning the upper
central flap.240,242 Graf243 demonstrated preservation of
abdominal perforators 1mm in diameter after
lipoabdominoplasty with limited upper abdominal
undermining. This was evaluated with color Doppler
flowmetry in 20 patients 15 days after surgery.
Blondeel et al244 compared the effects on blood vessels
within the subcutaneous tissue of the abdomen seen
with UAL versus conventional liposuction. Both
cadaver tissue and fresh abdominoplasty specimens
were examined. There was no difference between the
groups, though extravasation was seen in both. The
low rate of central flap necrosis in the
lipoabdominoplasty literature may show that this
extravasation may not be clinically relevant.
Grazer245 emphasizes the relation of the superficial
nerves to various abdominoplasty incisions, and notes
that the lateral femoral cutaneous nerve is susceptible
to injury during the flap sculpting incisions near the
groin, where the nerve emerges from the inguinal
ligament at a point close to the anterior–superior iliac
spine.
TECHNIQUE
Preoperative markings are made with the patient both
supine and upright to document the status of the
rectus muscle and the effect of gravity on the
abdominal wall. Most patients require as much or
more lateral resection than medial resection during
abdominoplasty to reverse the pattern of truncal skin
relaxation. The specific pattern of excision in any given
case ultimately depends on the location of most of the
fat.47 The trend is to accommodate bathing-suit
preferences by modifying the lateral limb angles,
which helps preserve maximum blood supply to the
abdominal flap. Liposuction and/or posterior dart
incisions in-continuity with the abdominoplasty may
be used for a more circumferential reduction of the
trunk.
The basic steps of the classic abdominoplasty
procedure are as follows: skin flap undermining to
xiphoid from symphysis pubis, midline fascial
plication in a diamond pattern for waist definition,
and lower abdominal skin resection. The umbilicus is
placed at the intersection of a line connecting the
highest point of the iliac crests with another line
bisecting the abdomen from sternum to pubis.246 The
skin is closed in layers with absorbable suture
material. Closed suction drains are placed under the
abdominal flap.
Lockwood247 presents his technique of lateral
tension abdominoplasty and body lifts. It includes
limited direct undermining, increased lateral skin
resection with highest-tension wound closure along
the lateral limbs, two-layer superficial fascial system
(SFS) repair, and significant truncal liposuction. This
technique improves waist contour, decreases central
tension, and maintains scar position. The author
thoroughly reviews his intraoperative and
postoperative management for both abdominoplasty
and body lifts.248,249 Of note is his use of postoperative
drains, permanent suture in the SFS to maintain scar
position, and patient position in lateral decubitus for
body lifts.
Pollock and Pollock250 present their technique of
abdominoplasty with liposuction and progressive
tension sutures to reduce the risk of seroma and
necrosis without drains. The deep sutures advance and
25
anchor the abdominal flap, distributing tension and
reducing dead space. No drains were used in his series
of 65 patients and no seromas were reported.
A lipoabdominoplasty combines aggressive
abdominal and flank liposuction with central
undermining for midline fascial plication and
superficial skin resection. Saldanha and coworkers251
report
on
125
patients
who
underwent
lipoabdominoplasty combining liposuction of the
upper abdomen with limited upper abdominal
undermining and standard infraumbilical skin
excision while maintaining a thin layer of tissue
beneath Scarpa’s fascia. Midline fascial plication is
performed by means of a narrow retractor. The
advantage of this technique is that it preserves the
perforating vessels, nerves and lymphatics. Two
seromas were aspirated.
Brauman 252
published
his
results
with
lipoabdominoplasty in a series of 43 patients. The
surgical technique employed was similar to other
reports. Preoperatively the author determined the total
volume of intraabdominal fat by radiographic means,
and concluded that, in cases of small intraabdominal
fat volume, diastasis repair is indicated only when
there is significant abdominal wall laxity. The
procedure is performed using local anesthesia with
sedation.
describes
his
technique
of
Avelar 253
abdominolipoplasty
without
continuous
undermining. Topographic evaluation of every patient
with diastasis helps to define the distance between the
muscles. Liposuction is uniformly performed over the
entire abdomen while preserving the perforating
vessels. Midline plication is selectively performed. The
skin is resected full thickness with a star-shaped
neoumbilicus and the wound is closed in multilayered
fashion with absorbable sutures. The most common
complication was seroma.
Cardenas-Camarena254 recounts a 7-year experience
with circumferential liposuction–abdominoplasty in
310 women. His technique involves suction-assisted
lipectomy combined with abdominoplasty and limited
central undermining. The average amount of
lipoaspirate was 3700cc; 86% of patients were
considered to be overweight. Minor complications
26
occurred in 20% and major complications in 1.3%; 46
patients (15%) required autologous blood transfusions.
Lipoabdominoplasty was applied to 60 patients
after massive weight loss by Espinosa-de-los-Monteros
and colleagues.255 The average BMI in this population
was 31. The author reports a 22% wound complication
rate and no patient requiring rehospitalization.
Increased weight and dimension of the pannus and a
BMI of≥35 significantly worsened the complication rate.
A fleur de lis excision is indicated for lower
medial obesity with significant panniculus adiposus.
This pattern of resection incorporates Castanares’s
vertical wedge incision in the upper abdominal
midline256 with Regnault’s shallow-W excision in the
lower quadrants.45,46 The vertical component can be
carried as high as the xiphoid and as low as the
perineum for simultaneous reduction of the mons
pubis.256,257 The operation improves the abdominal
contour and redefines the patient’s waist.
Persichetti and colleagues 258 describe their
abdominoplasty technique in 42 patients with
preexisting median or paramedian incisions. An
anchor-like incision is preferred. Seromas occurred in
7% of patients, all of whom were obese and diabetic.
Minor skin necrosis was seen in one case.
Fernando da Costa and others259 present their
results with a modified vertical abdominoplasty
technique in 48 patients after massive weight loss. The
advantages of the technique are improved abdominal
contour with vertical and horizontal correction of
redundancies; minimal lateral undermining; and
decreased operative time, bleeding, and cost thanks to
the rapid en bloc resection. The authors applied the
technique to patients without a preexisting vertical
scar. The most common complication was
epidermolysis at the inverted T-junction and umbilicus
in 8%.
MUSCULOFASCIAL REPAIR
Regnault46 believes that most women who have had
multiple pregnancies have some laxity of the
musculoaponeurotic fascia, if not true diastasis recti,
and therefore performs anterior sheath plication in
90% of patients requesting abdominoplasty. Likewise
Pitanguy 43
routinely
reinforces
the
musculoaponeurotic
wall
as
part
of
the
abdominoplasty procedure, even though he
documented only 3% of patients with diastasis recti in
his series of 539 consecutive abdominoplasties.
Nahas260 developed an objective classification for
abdominoplasty based on the musculoaponeurotic
deformity. The author recommends specific treatments
to optimize correction of the abdominal deformity.
Talisman and colleagues261 analyzed the results of
abdominoplasty in a series of 18 patients, 3 of whom
had significant diastasis repair (>12cm). These 3
patients
had
bladder
pressures
>24cmH20
intraoperatively and >20cmH20 postoperatively,
compared with mean bladder pressures of 8cmH20
intraoperatively and 15cmH20 postoperatively in
patients who did not have diastasis repair. All diastasis
repair patients had varying degrees of respiratory
distress postoperatively, and one required reintubation.
Two of them had history of previous pulmonary
thromboembolic events and were treated with
anticoagulants after their respiratory difficulties. The
author cautions against aggressive correction of large
diastasis with ensuing increased intraabdominal
pressure.
Van Uchelen and associates262 assessed the long term
durability of vertical plication of the anterior rectus
sheath after abdominoplasty. Questionnaires were sent
to 70 women who had undergone diastasis repair with
absorbable suture material as part of an
abdominoplasty, and 63 responded. Of these, 40 were
willing to attend a follow-up consultation and submit to
an ultrasound to gauge the competence of the fascia. At
a mean 64 months postoperative, 40% of patients had
residual or recurrent diastasis. The authors recommend
against the use of absorbable material for
musculofascial plication. Alternative techniques
consisting of vertical and lateral plication may improve
the waistline and prevent epigastric bulging.
Nahas263 reports 2 cases of recurrent diastasis recti
after abdominoplasty. Preoperative CT scans
demonstrated wide lateral insertion on the costal
margins. Correction was by posterior rectus sheath
imbrication, anterior rectus sheath advancement, and
rectus muscle mobilization to the midline. Postoperative
CT scans verified correction of the diastasis.
UMBILICOPLASTY
The aesthetically pleasing navel shows a pronounced
dimple, invagination of the surrounding tissue, and
slight superior hooding. Dubou and Ousterhout246
studied 100 subjects of normal weight and found that,
regardless of sex or race, the umbilicus lay at the level
of the superior iliac crests and midway between the
xiphoid and pubis.
After periumbilical defatting and rectus plication,
the umbilical pedicle is shortened as necessary and
affixed to the midline fascia in its new position.46,264
Two to four transfixing sutures are taken through the
skin flap, rectus fascia, and umbilical island. Pascal265
emphasizes high tension superiorly above the
umbilicus with caudal tension placed on the superior
abdominal flap to create invagination of the
periumbilical tissue and decrease tension on the lower
abdominal flap.
Akbas and colleagues266 describe a technique of
neoumbilical formation with a vertical elliptical
incision, incorporating the umbilical stalk into the
fascial plication and suturing the umbilical skin to the
rectus fascia. This is combined with midline upper
abdominal liposuction to maintain an umbilical
dimple and midline sulcus. They report 2
complications in 15 female patients (13.3%), one
dehiscence and one umbilical prolapse.
Baroudi264 describes techniques for correction of
secondary deformities and construction of a new
umbilicus. Typically a 4–6cm circular plug of fat is
resected from the chosen site for the new navel and
sutures are placed through the skin and fascia to create
a depression. A bolster is fitted and sutures are tied
over it for compression. These are removed in 12–16
days.
Sugawara and colleagues267 reconstruct the
umbilicus with a single V-shaped flap elevated around
the newly excavated umbilical fossa. The flap is
shaped into a cone, inverted into the fossa with the
skin side down, and anchored at the bottom. The skin
defect is closed primarily, leaving dog-ears at the
margin of the umbilicus.
Hypertrophic periumbilical scars usually
disappear by 18 months. No revision should be
contemplated before this time.
27
MINI-ABDOMINOPLASTY
In 1986 Wilkinson and Swartz268 described a limited
abdominoplasty for body contouring in patients who
had mostly infraumbilical excess of skin and fat. The
defining characteristics of the limited technique are
short, upturned incison lines; skin resection; plication
of the fascia; liposuction; umbilical stalk separation;
and closure of the umbilicus in the midline. 269
Wilkinson269 now applies the limited abdominoplasty
procedure to patients who formerly required full
abdominoplasty with relocation of the umbilicus.
Undermining at the fascial level allows the umbilicus
to descend about 2cm (umbilical “float”), which
eliminates skin laxity in the upper abdomen.
Greminger270 reported a mini-abdominoplasty to
correct lower abdominal flaccidity and regional fat
deposition. The procedure was based on the theory
that musculofascial support below the semicircular
line is weaker than above the line because of absent
posterior rectus fascia. The surgical technique consists
of a single incision, shorter than for the classic
abdominoplasty, and limited undermining to the level
of the umbilicus. The author recommended the miniabdominoplasty for patients whose deformity was too
slight to be corrected by standard abdominoplasty and
too severe for suction lipectomy.
Gradel271 advocated abdominoplasty through a
limited incision for patients with mild to moderate
abdominal lipodystrophy, flaccidity or bulging of the
abdominal wall, and mild to moderate infraumbilical
skin excess. The flap is developed through a
suprapubic incision 12–16cm long. Superior dissection
and muscular plication are facilitated by transecting
the umbilical pedicle.
Shestak272 adopted a technique that combines
aggressive superwet liposculpture of the abdomen
with modified open technique to address skin excess
and fascial plication. This “marriage” abdominoplasty
can be tailored to fit the patient’s needs; a full
abdominoplasty is not required in every patient.
Redundant abdominal fat and skin are addressed by
umbilical float for minimal supraumbilical skin excess
and endoscopic upper midline plication. This
technique helps shorten the scar length, sensory
28
changes, and the recovery period in abdominal
contouring surgery.
Occasionally the distance between a dropped
umbilicus and a high mons veneris is too short, in
which case mons reduction is indicated to lengthen the
hairless abdominal flap and to place the scar within
the pubic hair.269
The use of liposuction without skin resection has
been evaluated and can be applied to a select patient
population. Omranifard and colleagues273 compared 40
class II abdominoplasty patients who were randomly
assigned prospectively to one of two groups, a miniabdominoplasty with rectus plication and a matched
UAL group. The mean weight of tissue removed in
both groups was 2kg. The UAL group had significantly
longer operative times but shorter recovery and less
analgesic requirement. Complications were more
frequent in the UAL group, with 80% of patients
experiencing minor complications. After 6 months,
90% of the UAL patients were satisfied with their skin
laxity improvement.
Dabb 274 followed 32 patients who underwent
circumferential ultrasound-assisted liposuction and
direct abdominal wall plication through a
periumbilical incision as an alternative to conventional
abdominoplasty. These patients had minimal skin
laxity, moderate fatty tissue, midline diastasis, and no
concerns about striae. The total amount of lipoaspirate
averaged 2400cc. Patient satisfaction was acceptable
and surpassed their expectations. One patient desired
further skin excision and another requested further
liposuction. There was a 15.6% seroma rate despite the
use of drains.
ABDOMINOPLASTY IN MALES
Mladick 275 reviews body contouring in men and
describes technical points specific to the male
abdominoplasty. Men generally have thicker, less
elastic skin than women. Except in cases of massive
weight loss and a redundant skin apron, the soft-tissue
excision during abdominoplasty in a male patient is
less extensive than in a woman. Also because the male
pubic hair is not as well defined, the lower incision
should be placed higher in men.
Matarasso276 reviews his experience with male
body contouring and distinguishes between the male
and female torso. Men tend to have more
intraabdominal fat and thicker, less distensible skin
than women, which makes men better candidates for
SAL; 84% of the author’s male patients had SAL-only
for abdominal contouring. Full abdominoplasty or a
panniculectomy is more common than limited
excisional surgery in men seeking body contouring.
Lockwood277 believes that men with prominent
abdomens who are both diet- and exercise-resistant
may have familial fat deposits and significant rectus
diastasis. If examination reveals a rectus diastasis, he
considers it the primary indication for endoscopically
assisted abdominoplasty without skin resection.
Liposuction of any fat deposits can be done at the same
time.
abdominoplasty. Each group consisted of 10 women
who had full abdominoplasty with midline rectus
plication. The infusion pump group resumed normal
activities sooner, required less narcotic administration,
and rated their recovery as better than the control
group.
Patient satisfaction after abdominoplasty is
generally high. Bolton et al281 evaluated 30 consecutive
female
abdominoplasty
patients
preand
postoperatively in terms of body self-image,
psychological investment in appearance, and general
psychosocial function. Body image was significantly
improved, with positive changes in the patients’
assessments of their overall appearance, selfconsciousness levels, and how often they avoided
body exposure during sexual activity. No differences
were recorded in psychological investment in
appearance or psychosocial function.
PERIOPERATIVE MANAGEMENT
COMPLICATIONS
Kryger and coworkers278 review a 6-year experience
with 153 consecutive abdominoplasties, 92% of which
were performed with the patient under conscious
sedation with local anesthetic infiltration. There were
80% adjunctive cosmetic procedures and 8%
abdominal hernia repairs. No medical complications
or conversions to general anesthesia were reported;
73% were discharged home after their procedure; and
3 patients were readmitted to the hospital for
postoperative nausea. Minor complications were
noted in 11%, seroma being the most common (6.5%).
Patient satisfaction was high, recall was minimal, and
most were likely to request conscious sedation for
further procedures. The authors claim the benefits of
rapid recovery and a high margin of safety.
Mast and associates279 present a retrospective study
of 35 full abdominoplasties; 17 cases were done as
inpatient and 18 as outpatient surgeries. No difference
in complication rate was noted. Postoperative pain
and nausea were controlled adequately in either case
and patient satisfaction was similar.
Mentz and others280 compared the use of a regional
infusion pain pump plus standard oral/intramuscular
pain medication versus standard oral and
intramuscular
pain
medication
alone
in
In 1977 Grazer and Goldwyn282 published the results of
a survey of members of the American Society of Plastic
Surgeons on complications of abdominoplasty. The
report is based on 958 replies representing a minimum
10,490 abdominoplasties. In decreasing order of
occurrence were wound infection, dehiscence,
hematoma, and skin loss. Hematomas developed in
more than 600 cases. Almost half of all respondents
had to drain serum or blood from at least one patient,
and 39% of surgeons reported skin loss in at least one
patient. In addition, 47% of surgeons reported that
postoperative contracture of the umbilicus was a
frequent occurrence. Not surprisingly, the frequency of
complications was inversely related to the surgeon’s
experience.
An updated survey of members of the American
Society of Plastic Surgeons on abdominal contouring
received 15% responses, representing a total of 20,029
cases including abdominal liposuction, limited
abdominoplasty, and full abdominoplasty.283 Ninetytwo percent of respondents had been in practice longer
than 5 years and 57% classified themselves as aesthetic
surgeons. The complication rates of abdominoplasty
were similar to those reported in the literature and did
29
not vary with years in practice. The deep venous
thrombosis (0.04%) and pulmonary embolus (0.02%)
rates were lower than in previous studies. No deaths
were reported.
Hensel and others284 reviewed the records of 199
abdominoplasty cases performed over a 15-year
period in an attempt to identify factors that affected
the outcome. The overall complication rate was 32%;
1.4% were major complications. The revision rate was
43%. Minor complications were significantly higher in
smokers and in patients with diabetes or hypertension.
There was no statistically significant difference
between
patients
who
had
concomitant
intraabdominal procedures with abdominoplasty and
patients
who
had
abdominoplasty
alone.
Complications were magnified in obese patients (86%).
Similarly, Vastine and colleagues 285 note 80%
complications of abdominoplasty in obese patients.
The complications were mainly wound related.
Kim and colleagues286 compared the results in
patients who had abdominoplasty with and without
flank liposuction. Liposuction patients were
substratified into standard or ultrasound-assisted
liposuction. The average amount of lipoaspirate was
763cc. Seroma occurred in 38% of the abdominoplasty
group and 29% of the abdominoplasty+liposuction
group; seroma rates were no higher in UAL than in
conventional SAL. Obesity was the only factor that
contributed to seroma in both groups.
Chaouat and coworkers287 reviewed the records of
258 women who had abdominoplasty at their clinic
over 5 years. The authors report a significant higher
rate of skin necrosis for patients who had a T type
abdominoplasty (35.5%) than for those with
infraumbilical plasties (1.4%) or full abdominoplasties
with horizontal scars (4.6%). The revision rate was 29%
and highly dependent on the patient’s willingness and
the surgeon’s judgment. The authors stress the
importance of proper informed consent and lengthy
discussions with patients prior to surgery.
Manassa et al288 reviewed the results of 132
abdominoplasties in 71 smokers and 61 non-smokers.
Even though all patients were asked to refrain from
smoking perioperatively, only 14% stopped before and
41% (temporarily) after surgery. Wound dehiscence
was 3.2X more frequent in smokers, who also had
30
significantly longer hospital stays. Seroma, hematoma,
and infection were not significantly affected by
smoking. The number of cigarettes smoked had no
effect on wound healing.
A review of 101 consecutive abdominoplasties by
Van Uchelen et al,289 with long-term follow-up of 86
patients, found an alarming 10% incidence of injury to
the lateral femoral cutaneous nerve.
Pitanguy’s analysis of his 40+ year experience with
body
contouring
surgery,
including
1300
abdominoplasties, reveals seroma to be the most
common complication (Table 15).
TABLE 15
Complications of Abdominoplasty at the Ivo
Pitanguy Clinic, 1955-98 (%)
(Reprinted with permission from Pitanguy I: Evaluation of body
contouring surgery today: a 30-year perspective. Plast Reconstr
Surg 105:1499, 2000.)
Pitanguy discusses how refinements in the
technique, such as preventing seroma by avoiding
dessication of the dissected tissues, maintaining
rigorous hemostasis, and appropriate placement of
drains, reduced the frequency and severity of
complications. He also incorporates a “plaster shield”
for the first 2 postop days to maintain firm pressure
over the abdominal flap and promote adhesion.
REVISION SURGERY
Matarasso and others291 present a group of 24 previous
abdominoplasty patients who underwent revision
procedures (6% revision rate). The patients were
grouped into those who were operated within 18
months and after 18 months from the abdominoplasty.
Liposuction was the most common secondary
procedure in both groups and this did not change with
the type or invasiveness of the primary operation.
There was a 4% complication rate on revision.
COMBINATION PROCEDURES
Reporting the results of a survey, Voss, Sharp, and
Scott292 found higher morbidity, longer operative times,
and longer hospital stays when abdominoplasty was
combined with other common gynecologic operations
than when either procedure was done separately.
Perhaps more significantly, 6.6% of patients who had
combination surgery had a pulmonary embolus within
18 days of the operation, whereas no pulmonary
emboli occurred in patients who had single
procedures.
Hunter and colleagues293 confirmed a high risk of
pulmonary embolus in patients with combined
abdominal lipectomy and intraabdominal gynecologic
procedures and urged caution when using this
approach. The use of perioperative warfarin may
reduce the incidence of pulmonary embolism in these
patients and does not promote increased bleeding.
Pitanguy and Ceravolo294 believe there is no
difference in the frequency of clinical complications
whether abdominoplasty is done by itself or in
combination with gynecologic surgery except for an
increased need for blood replacement with combined
procedures. In their experience, the aesthetic results
are also similar in either situation.
Shull and Verheyden295 noted apparent safety of
combined plastic and gynecologic surgical procedures
in a series of 33 patients, each of whom was matched
with two controls. Other than a significantly greater
requirement for blood transfusion in the combinedsurgery group, the authors found no increased
morbidity and the hospital length of stay was shorter
by 2 days when the surgeries were combined. To avoid
complications the authors recommend continued
pressure monitoring; warmed inspired gases and
intravenous fluids as well as warming blankets to
prevent hypothermia; autologous blood replacement
as needed; and concerted preoperative planning of the
procedures by both surgeons.
Gemperli and associates296 analyzed the medical
records of 103 patients who had abdominoplasty at the
time of other intraabdominal procedures. Of these, 24
had mini-abdominoplasty with or without liposuction
and the rest had a standard full abdominoplasty.
Autologous blood transfusions were required in only 3
patients; the maximum blood loss was 500mL. One
seroma and one minor skin slough developed, but
there were no infections, embolism, or other major
complications.
The
authors
conclude
that
abdominoplasty in combination with intraabdominal
operation is a safe procedure when performed by a
well-schooled surgical team.
Hester at al297 reviewed the records of 563 patients
who underwent abdominoplasty alone (117) or in
combination with other major surgical procedures,
either aesthetic (216) or intraabdominal/pelvic (230).
They found similar morbidity and complication rates
among the three groups regardless of the complexity
of the procedure. The only identifiable risk factor in
predicting major morbidity (pulmonary embolism)
from the surgery was patient obesity.
Cardoso de Castro and Cupello298 analyzed 60
cases of simultaneous abdominoplasty and breast
reduction surgery and report a complication rate
similar to that of either procedure alone. Likewise
Stevens and colleagues299 retrospectively evaluated
two populations: One group of 264 patients underwent
abdominoplasty alone and a second group of 151
patients had simultaneous breast surgery. There were
no major complications reported and no differences in
minor complications between the groups. The type of
breast operation and the BMI had no effect on
complications.
Wallach et al300 combined abdominoplasty with
other procedures through the abdominoplasty incision
in 29 patients. There were 30 ancillary procedures via
the same incision, including flank liposuction in 23,
breast augmentation in 6, and rib harvest for
rhinoplasty in one. The inferior mammary fold was
repaired in all cases of breast augmentation. The total
complication rate was 4.3%, seroma being most
common. The authors also used the abdominoplasty
specimen as a source of autologous filler material and
for fat, fascia, and dermis grafts. The advantages are
minimal scarring and distant donor sites.
Yoho and others301 review the risks of cosmetic
surgical procedures including abdominoplasty.
31
BARIATRIC SURGERY
Morbid obesity has become an epidemic in the United
States, one that places a large financial stress on
medical insurers and public health resources. The
classic treatment consists of diet and exercise,
although a person’s genetic makeup and complex
behavioral issues blunt their effects. Medical
management with pharmacologic intervention has
been generally unsuccessful. Multimodality weight
loss through diet and exercise and/or pharmacologic
intervention has short-term success at best.
Bariatric surgery is currently the only effective
therapy for morbid obesity, producing rapid weight
loss along with measurable improvement or resolution
of comorbidities. Bariatric procedures are typically
classified as restrictive, malabsorptive, or a
combination of both. Purely malabsorptive procedures
that interrupt the digestive process, such as jejunoileal
bypass and biliopancreatic diversion, bring about
significant weight loss but at the risk of eventual
nutritional deficiencies, and require careful, long-term
patient follow-up. Restrictive procedures alter the size
of the stomach, limiting volume of intake. Vertical
banded gastrioplasty and adjustable gastric bands fit
into this category. They pose less operative and
postoperative risk, but the rate of weight loss is slower.
The more common techniques used in the U.S. today
are a combination of restrictive and malabsorptive
procedures, such as a Roux-en-Y gastric bypass. This
procedure can be performed either laparoscopically or
via an open approach and consists of creating a small
gastric pouch that is anastomosed to a Roux limb, with
the biliopancreatic limb attached distally to reduce the
absorptive surface area of the bowel.
Massive weight loss patients present a very
different profile than those who have not been obese.
In conjunction with their extreme physical deformity
after weight loss, the physiologic impact of bariatric
surgery is prevelant throughout the postbariatric state.
Nutritional deficiencies are more common in gastric
bypass patients. The incidence of anemia is >50% and
vitamin and mineral deficiencies occur in up to
30–40% of patients following gastric bypass.
32
Rubin and coworkers302 review the management of
the postgastric bypass patient presenting for body
contouring surgery. Patients are considered for body
contouring surgery approximately 12–18 months after
a bariatric procedure and must maintain a stable
weight for a minimum of 2 months to ensure
nutritional and metabolic homeostasis. The operative
risk is increased in obese patients, therefore a goal BMI
of 30 to 35 is appropriate. Laparoscopic bariatric
procedures decrease the risk of herniation, yet open
techniques are still common. Simple hernia repair can
be done in conjunction with body contouring surgery,
but a large hernia necessitating component separation
and ample undermining for correction should not be
combined with aggressive body contouring
procedures.
Medical issues may affect surgical outcomes.
Despite an initial loss of 10% of body weight, which is
associated with improvements in blood pressure,
plasma glucose, lipid levels, and hemostatic factors,
unresolved conditions the surgeon should be aware of
include psychosocial dysfunction, diabetes mellitus,
cardiac disease, sleep apnea, pulmonary disease,
gastroesophageal
reflux,
and
concurrent
medications.302 Prophylaxis for deep vein thrombosis is
essential because obesity is an independent risk factor
for deep venous thrombosis and pulmonary
embolus.302 Nutritional adjustments depend on the
type of bariatric procedure that was performed.
Patients should be tested for subclinical protein
deficiency, cobalamin deficiency, iron deficiency, and
folate deficiency; if a feficiency is present, the levels
should be corrected prior to undertaking body
contouring. Fluid management should be monitored
intraoperatively with a urinary catheter, and the use of
colloid and autologous blood products should be
considered.302 Wound complications can be avoided by
allowing the bariatric patient to reach his/her ideal
weight and stop smoking, and by using drains,
conservative
undermining,
and
prophylactic
antibiotics.
Cavallini and colleagues303 studied the effects of
intraoperative warming on coagulation in two
matched patient groups undergoing elective plastic
surgery. All patients had a complete coagulation
profile drawn 1 hour preoperatively and immediately
after surgery. One group was covered with only sterile
drapes and the other was covered with a forced-air
skin warming blanket and had warmed fluids infused.
Core temperatures were significantly different at the
conclusion of the 2-hour operation. Activated partial
thromboplastin times and bleeding times were
significantly elevated in the control hypothermic
group. No difference in hematoma rate or blood loss
was seen.
PANNICULECTOMY
In most cases panniculectomy is medically indicated to
remove the excessive amount of lower abdominal
tissue that overhangs the pubic area. This pannus
predisposes the patient to chronic skin infection,
lymphedema, and postural difficulties. The procedure
consists of direct excision of the redundant pannus
without undermining or fascial plication. Prayer and
collegues304 review the preoperative, intraoperative,
and postoperative care of a very complex patient
undergoing panniculectomy. The authors present a
safe, complication-free procedure based on a precise
plan and team effort.
Manahan and Shermak305 review their experience
with panniculectomy after massive weight loss in 23
patients with average BMI of 43.7. The authors define
panniculectomy as an abdominal skin resection of
more than 10lbs, pannus suspension, horizontal fascial
plication, and layered closure over drains. The average
weight of the pannus in their series was 16.1lbs.
Multiple other procedures were performed in
conjunction with panniculectomy. Results: 20%
received a blood transfusion; 20% had wound healing
complications; seromas occurred in 28%; and
uncomplicated healing was seen in 44%. There were no
thromboembolic events or deaths.
Aly306 states that most patients who do not lose
enough weight after bariatric surgery will not lose
more after interim operations. Combination
panniculectomy procedures impose additional risk to
the massive weight loss patient secondary to increased
operative time and poor aesthetic outcomes. A
recurrent hanging panniculus can occur after a
panniculectomy for chronic panniculitis or
lymphedema. Recurrent hernias from excessive weight
are common after panniculectomy, and infection rates
tend to be high.
Olejek
and
Manka’s307 experience
with
panniculectomy in combination with gynecologic
cancer surgery included 90 patients with an average
BMI of 47kg/m. The goal of the study was to show that
a panniculectomy performed in the same setting as the
oncologic procedure gives better exposure in obese
patients without increasing the number of operative
complications. The average weight of the pannus
excised was 4900gm. Use of the harmonic scalpel
resulted in 8% delayed healing vs 17% without the
harmonic scalpel. There were 2 deaths in this very
difficult population: one myocardial infarction and
one pulmonary embolus.
BODY LIFT
A belt lipectomy is indicated for patients with
generalized adiposity encircling the torso and
including the back and upper buttocks. Belt
lipectomies are commonly used to treat patients after
massive weight loss, but also can be applied to other
aesthetic patients with defined areas of skin excess.
Carwell and Horton308 described a circumferential
torsoplasty indicated for patients after considerable
weight loss. The authors believe the technique helps
improve the buttocks and lateral thighs as well as the
trunk and abdomen.
Aly and coworkers309 review the University of
Iowa experience with belt lipectomy in 32 consecutive
patients, stressing the importance of accurate
preoperative markings. The authors’ operative
technique incorporates both lateral decubitus
positions and supine position. Not surprising in a
procedure of this magnitude, they report 37.5%
seromas, 9.3% pulmonary embolus, and one
dehiscence requiring surgery. Nevertheless, their
patients demonstrated significant improvement. This
operation is not recommended for obese patients.
Nemerofsky and coworkers310 review 200 body lifts
performed over a 4-year period. The patients were
classified into three types depending on body mass
index before the body lift: type I, <28 BMI; type II,
33
between 28 and 32; type III, >32. The surgical
technique and preoperative markings are illustrated.
Posterior markings were made in the flexed position to
limit tension in the buttocks area. Nonabsorbable SFSdermal sutures were used to evert the incision edges.
The senior author uses a circumferential standing
preparation to facilitate an efficient, three-position
technique: supine and lateral decubitus. A 2-day
hospital stay, prolonged drain care (5 weeks), and
lower extremity venous Doppler study are standard.
The overall complication rate was 50%, the most
frequent being skin dehiscence (32.5%). Higher
maximum BMI, larger changes in BMI, history of
smoking, and male gender were associated with more
frequent complications. BMI at body lift did not affect
complications though it did lengthen the hospital stay
and correlated with poor aesthetic outcome.
Nemerofsky altered his technique during the study to
reduce complications and believes that both the
markings and suture technique (above) contributed to
his success, though no data were provided.
Rohrich et al311 present a large series of 151 patients
who underwent central body lifting over a 12-year
period by means of liposuction and extended
abdominoplasty. The average preoperative weight was
130kg and 25.2% were classified as massive weight
loss. The area of excision is estimated with a “grasp
test.” An aggressive deep venous protocol consisting
of enoxaparin and pneumatic compression devices to
the calves was applied in all cases. Patients were
operated while prone and then changed to a supine
position. Ultrasound-assisted liposuction and
conventional SAL by super-wet technique were used
circumferentially in all. The average lipoaspirate
volume was 4 liters. An extended abdominoplasty and
midline plication with permanent suture were
performed. Absorbable sutures were used for deep
closure because of suture extrusion and lack of scar
improvement with nonabsorbable sutures. The
average operative time was 3.4 hours and length of
stay was 2.1 days. The total complication rate in the
series was 28.5%, the most common being seroma in
14.6%. The seromas were treated by sclerosing the
cavity with doxycycline if drain output after 14 days
was
still
high.
The
deep
venous
thrombosis/pulmonary embolus rate in their series
34
was 1.9%. Skin dehiscence and necrosis occurred in
2.6%.
Pascal and Le Louarn312 describe a technique of
body lift with high lateral tension. They emphasize
preoperative markings, high superior tension above
the umbilicus, a dermal fat flap for buttock
augmentation, and multiple suspension sutures at the
trochanteric region between the SFS and the
underlying fascia. Complications were minimal in 40
cases.
Single-stage Resections
Lockwood72,248 described an extended resection
anteriorly and inferiorly on either side of the pubis to
add medial thigh lift to lower body lift in one
operation. The markings are made with the patient’s
hips flexed and abducted to allow overcorrection. The
incision lies in the perineal crease and extends along
the lateral mons pubis curving into the bikini line.
Posteriorly the incision curves downward to the top of
the gluteal crease and may cross the midline.
Undermining in the upper thigh avoids the femoral
lymphatics. The author stresses the importance of
complete SFS and dermal suspension.
A retrospective study by Hurwitz313 of single-stage
total body lift after massive weight loss traces the
course of 8 patients. The procedure combines lower
body lifts, upper body lifts, and circumferential
abdominoplasty. Ultrasound-assisted lipoplasty,
medial thighplasty and brachioplasty were performed
concurrently. To ensure accurate markings, the patient
is placed in the standing and recumbent positions to
draw the incisions for the lower body lift, medial
thighplasty, and circumferential abdominoplasty. A
Wise-pattern skin excision is marked for the breast
portion of the procedure and the IMF is moved
superiorly. A reverse abdominoplasty in which the
incisions do not cross the anterior midline and the
lateral extensions continue posteriorly to remove the
upper back redundancy is then performed, as well as
liposuction of specific areas.
The procedure begins in the prone position for the
posterior lower body lift, then the upper body lift is
completed and the mid-back skin excess is removed
with minimal undermining. Large braided absorbable
sutures are used for closure. The patient is then turned
supine and the abdominoplasty is completed with
minimal lateral undermining. For the anterior upper
body lift, an upper abdominal incision is made and the
lift area below the incision is excised or
deepithelialized to use in breast autoaugmentation.
The abdominal flap is elevated and secured to the sixth
rib periosteum with mulptiple permanent #0 braided
polyester sutures. A mastopexy and either
autoaugmentation or implant augmentation can be
employed in women, while UAL and tissue removal
are indicated in male patients with gynecomastia. All
patients received at least 1 unit of autologous blood;
one patient received 4 units of blood. Operative times
ranged 7–12 hours, and hospital length of stay was 3–4
days. The most common complications were skin
dehiscence (50%) and wound seromas (40%).
Endermologie was used in all patients postoperatively
for edema reduction.
scar widening, scar migration, and need for further
excision were noted as complications.
The traditional Lockwood horizontal excision does
not address the circumferential tissue excess seen in
most massive weight loss patients, and therefore a
vertical excision has been added. Two philosophies
exist regarding the vertical excision. One relies on the
same vertical vector of lift combined with a horizontal
vector. Through further refinements, the vertical lift is
replaced with a horizontal oblique pull which
completely eliminates the tension in the groin,
theoretically minimizing scar migration and vulvar
distortion 316 (Fig 4). Liposuction and superficial
dissection planes preserving the lymphatic channels
and saphenous veins limit postoperative edema.
LOWER EXTREMITY
Medial Thigh Lift
As surgical experience with postbariatric body
contouring mounts, the technique of medial thigh lift
continues to evolve. Many medial thigh lift techniques
have been proposed over the years, but the procedure
has not gained wide acceptance because of
postoperative problems such as inferiorly displaced
and wide scars, vulvar distortion, and early relapse.
Wound healing problems are unfortunately too
common in the postbariatric population.
The
fascial
anchoring
technique
of
Lockwoood’s72,247,248,314 is recommended to reduce the
frequency of wound complications. Le Louarn et al315
modified it to include a short horizontal scar combined
with suction lipectomy of the upper inner thigh,
excision of a crescent of redundant skin, and anchoring
of the inferior thigh flap to the deep layer of the
superficial perineal fascia (Colles’) without
undermining or deepithelialization of the flaps.
Lockwood reports no problems related to inferior
scar migration, labial separation, or early recurrence of
ptosis in 18 patients followed for up to 24 months.248 Le
Louarn’s group present a 2-year, 25-patient experience
with the short-scar technique. Delayed wound healing,
Fig 4. Markings for a horizontal and vertical resection.
(Reprinted with permisssion from Mathes DW and Kenkel
JM:Current concepts in medial thighplasty. Clinics in Plastic
Surgery 35: 151, 2008.)
The combined horizontal and vertical excision for
medial thigh lift relies on Colles’ fascia dissection and
suture fixation. The dissection plane for vertical
excision traverses only the superficial fascia and uses
the saphenous vein as a marker. Both techniques
depend on meticulous layered closure with sutures of
various sizes. Some surgeons do not use drains.
UPPER EXTREMITY
Glanz and Gonzalez-Ulloa317 reviewed the effects of
aging on the female arm and attributed the soft-tissue
descent and flaccidity to a loss of adipose tissue and
stretching of the anchoring septa. Working with
radiographs and measuring at midhumeral level, the
authors calculated a ratio of upper to lower soft-tissue
mass, or coefficient of Hoyer. The 1:1 ratio seen at age
35
Fig 5. Algorithm: patient with upper arm lipodystrophy. UAL, ultrasound-assisted liposuction; SAL, suction-assisted
liposuction. (Reprinted with permisssion from Appelt EA, Janis JE and Rohrich RJ: An algorithmic approach to upper arm contouring.
Plastic and Reconstructive Surgery® 118:237, 2006.)
10 gradually increases with age and gravitational
descent, so that by the age of 40 it is 1:1.4 and by age
70 it is 1:2.2.
Lockwood318 believes upper arm flabbiness is the
direct result of a “loosening of the connections of the
arm superficial fascial system to the axillary fascia
itself, with age, weight fluctuations, and gravitational
pull that yields a ‘loose hammock’ effect, resulting in
significant ptosis of the postero-medial arm.”
Classification systems of aesthetic arm deformities
abound. Regnault319 denotes the skin excess as mild,
moderate or major. Teimourian320 recognizes four
groups of patients according to the degree of skin
laxity and fat present; his recommendations for
management are group-specific and range from
liposuction to excisional techniques to a combination
of both. Appelt and colleagues 321 present a new
classification system for evaluation of the upper
extremity in the massive weight-loss patient and
36
suggest an algorithm for selecting the appropriate
technique of upper extremity contouring (Fig 5).
The classification system takes into account the
quantity of skin and fat excess and the location of skin
excess. Liposuction is recommended for fat excess in all
groups that have a pinch test >1.5cm. Skin excess is
treated by limited brachioplasty when proximal; by
traditional brachioplasty when involving the entire
extremity; and by continuing the excision to the lateral
chest wall for severe redundancy, as seen in the massive
weight-loss population. Staged liposuction with
excision or single multi-modality therapy is
recommended for the most severe types. A Z-plasty is
used for every incision crossing the axilla to prevent
scar contracture. The authors routinely use closed
suction drains and compressive garments. The most
common complication in their series was hypertrophic
scarring.
Most authors recommend direct elliptical excision
of the redundant tissue and place the incision medially
along a line connecting the axillary dome to the medial
epicondyle.322–324 In contrast, Knoetgen et al325 place the
incision within the intermuscular septum. In a review
of their brachioplasty experience in 40 patients, the
authors report a 5% rate of medial antebrachial
cutaneous nerve injury. Cadaver dissections of 10
upper limbs revealed some variability in the course of
the medial antebrachial cutaneous n., though it tended
to run in close proximity to the intermuscular septum.
The nerve penetrated the deep fascia a mean 14cm
proximal to the medial epicondyle, divided into an
anterior and posterior branch, and the anterior branch
continued onto the anterior forearm. The medial
brachial cutaneous nerve consistently ran posterior to
the basilic vein and could be injured with more
posterior incisions.
Lockwood modified the brachioplasty procedure
by anchoring with braided nylon sutures the
superficial fascia of the arm flap to the axillary fascia in
the proximal edge of the wound.318 The aesthetic results
in 5 patients followed for 6–12 months were
considered good. Simultaneous liposuction of the arm
was done in 4 patients. Complications included a
seroma and one case of underresection.
The technique described by Pascal and
coworkers326 combines circumferential liposuction and
superficial skin excision to protect underlying nerves
and lymphatics. Their markings aim at maximum
lymphatics preservation. Liposuction is performed
throughout the arm, with superficial liposuction only
in the area of planned excision. The excision is
superficial and no undermining is performed. A threelayer closure and an axillary Z-plasty complete the
procedure; no drains are used. There were no seromas
or nerve injuries reported in 21 cases.
Additional techniques have been described for
both distal excess about the elbow327 and proximally
along the chest wall.328 These can be combined with
standard brachioplasty techniques.
Baroudi322 and Guerrerosantos324 list the potential
complications of brachioplasty, which include highly
visible scars, persistent vascular congestion, edema
and lymphedema from excessive skin resection and
tension on closure, and cutaneous nerve injury from a
dissection that strayed below the superficial fascia.
Current refinements using limited incisions,
liposuction, and posteriorly oriented scars may help
prevent these complications.
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