Atlas Kỹ Thuật Hút Mỡ (Atlas of Liposuction)

(Trang không có chữ)

Adrien E Aiache MD
9884, Little Santa Monica Boulevard
Beverly Hills, California, USA
Email: aaiachemd@sbcglobal.net
Melvin A Shiffman MD JD
17501, Chatham Drive
Tustin, California, USA
Email: shiffmanmdjd@gmail.com
JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD
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Foreword
Pierre F Fournier

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Atlas of Liposuction
First Edition : 2013
ISBN: 978-93-5090-345-2
Printed at Ajanta Offset
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It is with great pleasure that, I accepted the offer of Adrien E Aiache to write
a foreword to his book on liposculpturing. I consider this to be a privilege
and honor for two reasons, the quality of the author and the quality of the
book.
It was in Rio de Janeiro in February of 1972 at the first meeting of
Aesthetic Plastic Surgeons that I met Adrien and we became friends at once
for medical as well as social reasons; both of us had a similar professional
education, a double medical education consisting of basic medicine acquired
in France and specialization abroad. Throughout the years, Adrien has been
able to preserve and develop his French clinical education and associate it
with the exceptional theoretical and practical education offered to plastic
surgeons in the United States.
If his “graft” to California has fully succeeded, he has also maintained a cultural bridge with his
country of origin and it is because of this “French Connection” that he has been among the pioneers
of liposculpturing and been able to share this knowledge with his American colleagues.
In February 1982, as I was returning from Lake Tahoe, after my first presentation in North America
of a new defatting procedure in esthetic surgery of the head and neck, Adrien and I met in Los Angeles
and discussed the new possibilities offered by this procedure. Soon after, Adrien accompanied by some
other plastic surgeons, flew to Paris to attend the first course on liposculpturing, even in Paris, with
YG Illouz, the great simplifier and popularizer of the original technique of Giorgio Fischer. Upon his
return to California, he passed-on his experience with “surgery from within” and actively participated
in its development in the States, both solely and working with other surgical groups.
Although this new procedure of closed body contouring was a significant advance on the
conventional open techniques, in 1982, we were only at the stage of lipoextraction. It is only with
years of practice that we have advanced to the era of true liposculpturing. As a matter of fact, even
if we had all the proper instruments needed to extract the excess adipose tissue at that time, we did
not yet know (and had to develop) the procedures needed to perform this new surgery safely and with
as few complications as possible. In a word, the surgeon has to shift from the position of a miner
and become an architect.
Adrien has been a witness to an actor in all these improvements including the development of the
better understanding of the operation, the refinements which he describes today in his book,
miniaturization of the instruments, study of the static and dynamic morphology of the patient, patient
selection, external and internal cryoanesthesia, the routine use of vasoconstrictors, the accomplishment
of the peripheral mesh undermining, the direct approach, the combined procedures and cases of the
treatment of zones previously considered taboo, the first cases of circular lipoplasty, microlipoextraction
and injection, histological studies, etc.
Adrien is not only a winner but also a leader and, in 1986, he founded ASPER capably assisted
by his wife Sylvie. The first meeting of this group was very successful as were those following. By
carefully selecting his faculty members, the students were presented with the latest advances in esthetic
plastic surgery and in the field of liposculpturing. The lipoplastic surgeon was shown for the first time
such subjects as incremental liposculpturing, autologous collagen, microlipoextraction and injectable soft
tissue implants.
Foreword

This book of high quality, written by a highly qualified lipoplastic surgeon, describes step by step the history,
basic theory and a very thorough study of all special areas of the body and the different cases coming to the
lipoplastic surgeon.
Breast reduction with suction lipectomy, one of the author’s earlier contributions to liposculpturing is given
special attention as well as gynecomastia combined techniques, face-lift combination with suction lipectomy and
arm lipectomy.
Autologous fat re-implantation, which was at that time a very controversial subject, is evaluated and its goals
explained.
Complications are also described and the study of those chapters will properly educate the reader.
The book should be read not only by beginning lipoplastic surgeons but also by the well-trained operator. He
will learn many refinements, finesses, tricks and unusual procedures that Adrien has accumulated over the years,
through his own extensive experience and through the experience of visiting professionals, and is now sharing
with the surgical community.
Thank you, Adrien, for presenting such an insightful, useful and carefully written book to your colleagues,
who with you, are fighting in the battle of body contouring, modifying the human body without scars and with
a minimum of complications. Since you waited so many years before writing this book, the readers are assured
that it is a reliable one, the full experience of an experienced plastic surgeon who is also an outstanding lipoplastic
surgeon in the most recent and significant advances in esthetic plastic surgery. I praise you for your wonderful
contribution to liposculpturing, for your honesty and for your loyalty about this new exciting and difficult “surgery
from within” as well as for increasing the circulation of the cultural bridge connecting Europe to America, which
gave to your book its quality.
Finally, you demonstrate with the work, you have achieved that you are a living example of one of the famous
quotes of Mario Gonzales Ulloa:
“The essentials in life are:
Not in having but in giving,
Not in knowing but in teaching,
Not in being able but in accomplishing.”
Pierre F Fournier MD
Past President of the French National Society of Aesthetic Surgery
55 Boulevard de Strasbourg, 75010 Paris, France
Email: pierre.fournier27@wanadoo.fr
vi
Atlas of Liposuction

Atlas of Liposuction presents an exhaustive survey of the current techniques in suction lipectomy. This
new operation was devised for removal of localized fat deposits. After a short introduction covering
basic theory, preoperative procedures and general techniques, use of the liposuction on each specific
area of the body is discussed in detail. These discussions cover the exact modus operandi, including
such matters as incisions, positions and instruments. Many color photographs and illustrations showing
actual clinical cases are included as an integral part of the text.
Through these volumes, the reader will be completely apprised of the techniques involved in
liposuction and can then refer back to specific chapters for help in solving problems or reviewing any
areas of special interest. Because of the number of different cases presented and the various techniques
used, we feel that this book will be of interest to even the well-versed surgeon in this area, as well
as to the operating surgeon with relative modest experience in liposuction and the student wanting to
learn the entire procedure. For any practitioner, regardless of experience, this book will serve as a
complete guide to the full range of techniques used in liposuction.
Note that a significant new advance in the field—the re-introduction of fat into the depressed areas
and wrinkles—has been included at the end of the Atlas. While this technique took a while to be
accepted by the general plastic surgery practitioner, we feel that it is likely to become a precious and
effective tool in body and facial contouring.
Other significant improvements such as superficial liposuction, laser liposuction and ultrasound
liposuction are discussed in this book since they have been emerging as the last improvements in the
technique of liposuction.
Adrien E Aiache
Melvin A Shiffman
Preface

(Trang không có chữ)

1. History of Liposuction
1
Melvin A Shiffman
2. Preliminaries
7
Adrien E Aiache
3. The Setup
17
Adrien E Aiache
4. Saddlebags
38
Adrien E Aiache
5. Suction Lipectomy of the Buttocks
52
Adrien E Aiache
6. Suction Lipectomy of the Thighs
61
Adrien E Aiache
7. Liposuction of the Inner Thighs
66
Adrien E Aiache
8. Combination of Techniques: Liposuction with
Trochanteric Lipectomy
72
Adrien E Aiache
9. Liposuction of the Knees
78
Adrien E Aiache
10. Abdominal Liposuction
85
Adrien E Aiache
11. Combination of Abdominal Liposuction and
Abdominal Lipectomy
97
Adrien E Aiache
12. Liposuction of the “Love Handles”
109
Adrien E Aiache
13. Iliac Crest Liposuction
115
Adrien E Aiache
14. Lumbar Bulge Liposuction
122
Adrien E Aiache
Contents

15. Breast Liposuction
126
Adrien E Aiache
16. Breast Reduction Combined with Liposuction
135
Adrien E Aiache
17. Back and Scapula (Upper Back and Thoracic Rolls)
138
Adrien E Aiache
18. Arm Liposuction
144
Adrien E Aiache
19. Combined Brachioplasty and Liposuction of the Arms
153
Adrien E Aiache
20. Liposuction of the Calves and Ankles
159
Adrien E Aiache
21. Facial Liposuction
171
Adrien E Aiache
22. Facial Liposuction Combined with Rhytidoplasty
185
Adrien E Aiache
23. Contour Liposuction
192
Adrien E Aiache
24. Autologous Fat Reconstruction
197
Adrien E Aiache
25. Non-cosmetic Liposuction
204
Adrien E Aiache
26. Combination of Liposuction and Body Implants
207
Adrien E Aiache
27. Modalities Beyond Simple Liposuction
214
Melvin A Shiffman
28. Medicolegal Aspects of Liposuction
219
Melvin A Shiffman
Index
229
x
Atlas of Liposuction

1 History of Liposuction
Introduction
The liposuction surgeon should be able to adjust to new
developments and improve his/her own technique.
History
Dujarrier (1921)1 reported a case of using a sharp curette
to remove fat of calves and knees that resulted in blood
vessel injury, and necessitated amputation. Pangman2
performed curettement of the submental fat using a small
uterine curette in 1940s.3 Schrudde used a sharp curette
to remove fat through small incisions.4 The technique
resulted in complications including bleeding and seromas.5,6
Vilain curetted fat in the medial knee through a small
incision with good results.7,8 Kesselring developed a metal
suction cannula designed like a ski that was attached to
a low vacuum pump (0.5 atm) and was used only for the
trochanteric area.9 The fat was shaved out in a modified
curette fashion. Teimourian and Fisher (1981)10 produced
an instrument from a fascia lata stripper that was similar
to the curette used by Kesselring. Early removal of
abnormal fat deposits was performed by surgical excision
trying to keep the resultant scar in a line or fold of the
body.11
Liposuction
The concept of reducing fat deposits without leaving large
scars was started by Arpad and Giorgio Fischer in 1972,
and by 1974, a prototype machine called the
cellusuctiotome (Fischer G, personal communication,
September 13, 2008) (Figures 1-1A to D) was developed.
This device was a motor-driven cannula with a rotating
cylinder inside which was used to cut fat and was
connected to a suction machine.
The cutting cylinder inside the cannula could be used
by pressing a lever. Fischer, in 1975 and 1976, reported
utilizing a 5 mm incision to remove fat with suction using
a blunt hollow cannula to aspirate subcutaneous fat.13,14
The cellusuctiotome was produced in a portable and a
nonportable form.15 There were complications such as
hematoma, seroma and pseudobursa, reported in 1977.16
The Fischers can be credited with other developments
A B S T R A C T
The history of how liposuction developed and progressed
allows the surgeon to see what the problems were and
understand how they were solved. This is necessary to
be able to develop further improvements in the future.
The author will follow the changes in fat removal, step
by step, so that the liposuction surgeons can understand
how to avoid the problems that have been resolved by
improved instruments and techniques.
Melvin A Shiffman

2
Atlas of Liposuction
FIGURES 1-1A TO D
(A) First prototype suction machine with a motor-driven cannula; (B) Second prototype motor suction machine; (C) Motor-driven
cannula with cutting and rotating cylinder inside; (D) When thumb released there is no aspiration
(Courtesy: Giorgio Fischer)
such as tunneling and the use of cross-tunneling
technique, in which the fat is aspirated from multiple entry
sites. The planatome was brought into use in 1977 for
trying to solve the problem of skin irregularities due to
blunt liposculpturing (Figure 1-2).17 The planatome
dissector created a layer of adipose tissue 8–13 mm thick
under the skin and regular liposuction was used for the
deeper layers using a guide.15 In 1982, a guided cannula
was produced with a second overlying slide that moved
over the surface of the skin, while the suction cannula
worked at a depth of 1.5 cm.12 At the same time, the
swan-neck cannula was developed to make it easier for the
surgeon to maintain a constant depth in the fatty layer12
(Figure 1-3).
Fischer introduced liposuction at Fournier’s clinic in
1977 (Figure 1-4). Illouz, having seen the technique at
Dr Fournier’s clinic, favored a “wet technique”, in which
hypotonic saline combined with hyaluronidase was
infiltrated into the adipose tissue prior to suction
FIGURE 1-2
The planatome
(Courtesy: Giorgio Fischer)
removal.18 He felt this would reduce trauma and decrease
bleeding. He mistakenly thought that the solution ruptured
the fat cells. His techniques also included the use of the
Karman cannula and abortion suction machine.
A
B
C
D

3
History of Liposuction
FIGURE 1-3
Swan-neck cannula and guided cannula (first prototype)
(Courtesy: Giorgio Fischer)
FIGURE 1-4
Clinic where the first liposuction operation was performed
with Fournier in 1977
(Courtesy: Giorgio Fischer)
Fournier developed the syringe technique of lipo-
suction19,20 that reduced bleeding and prevented
indentations.
Gasparotti and Toledo21-24 championed the technique
of superficial liposuction to smooth out excess fat and
to improve skin retraction.
Orthostatic liposuction was originated in 1990s by
Fischer; in order to perform liposuction more accurately
with the patient in a standing position.25 He developed a
table, that could bring the patient from supine position to
an upright position. This allowed reversing the table to
supine position, if the patient became dizzy or fainted.
Variations in instrumentation have also been deve-
loped. Ultrasonic liposuction was introduced by Zocchi.26
The concept was that adipose cells could be treated with
ultrasound energy, presumably breaking up their cell walls
and facilitating fat aspiration. The American Society of
Plastic and Reconstructive Surgery quickly adopted
ultrasonic liposuction; however, over time, problems were
found with this technique. Internal ultrasound (ultrasound
tips contained within cannulas) increased the risk of
cutaneous burns and seroma formation.
Newer powered liposuction devices have been
developed using reciprocating cannulas that facilitate the
fat removal and decrease the work of the surgeon.
Powered liposuction devices are largely electrically operated
but some air-driven devices are also available.27 There is
an increase in the rate of fat harvesting and the ease of
use. Powered liposuction is particularly useful for difficult
fibro-fatty areas such as male pseudogynecomastia or male
love handles.
Elam proposed lower vacuum pressure that is
successful in preventing or reducing bleeding during
liposuction.28
External percussion massage-assisted liposuction was
reported in 2005,29 as a substitute for expensive devices
for emulsifying fat and making liposuction easier. The
$30.00 double-headed massager caused emulsification of
the fat.
The earliest book on liposuction was written by
Morgan and Berkowitz (1984),29 and this was followed by
later books.19,20,24,30-39
Guidelines of care for liposuction were approved by
the American Academy of Dermatology in 1989 and were
published in 1991.40 Additional guidelines of care for
liposuction were published by the American Academy of
Cosmetic Surgery, the American Society for Dermatologic
Surgery in 2000,41 the American Academy of Dermatology
in 200142 and the Indian Academy of Dermatology,
Venereology and Leprology in 2008.43
Tumescent Technique
In the early days of liposuction, the dry technique was
used with general anesthesia. The technique used had no
fluids injected into the tissues and resulted in 20% to
45% blood loss.40,43-47 Liposuction was limited to 2,000–
3,000 ml because of the blood loss and patients were
frequently given transfusions.44
The wet technique relies on infusions of 100–300 ml
of normal saline into each site but has blood loss of 15%
to 30%.48-52 With epinephrine added to the fluid, the
blood loss is reduced to 20% to 25%.

4
Atlas of Liposuction
The tumescent technique has improved the problem
of blood loss reducing it to 1% to 7.8%.53-55 The term
“superwet anesthesia” has been used to describe the same
fluid injection as with the tumescent technique.56 This
technique consists of an infusion of saline with
epinephrine and an aspirate removal of approximately 1:1.
Local tumescent anesthesia usually has a fluid infusion to
aspirate ratio of 2:1 or 3:1.
Local Tumescent Anesthesia
There appears to be much confusion in the medical
literature concerning Klein’s solution. No one is certain
as to what the so-called Klein’s solution contains and what
a modification of Klein’s solution is.
Klein first reported the use of local tumescent
anesthesia in 1987.57 The report described solutions used
that consisted of:
„
For general anesthesia:
–
Normal saline: 1,000 ml
–
Epinephrine: 1 mg
„
For local tumescent anesthesia:
–
Normal saline: 1,000 ml
–
Epinephrine: 1 mg
–
Lidocaine: 1,000 mg
The amount of tumescent solution compared to
removal of aspirate was 1:1. This is Klein’s solution and
all the rest are modifications.
Klein, in 1990,58 showed that 35 mg/kg was a safe
amount of lidocaine to be used for local tumescent anes-
thesia. The solution utilized at that time consisted of:
„
Normal saline: 1,000 ml
„
Epinephrine: 1 mg
„
Lidocaine: 500 mg
„
Sodium bicarbonate: 12.5 mEq
Klein, in 1993,54 had changed the local tumescent
anesthesia solution to:
„
Normal saline: 1,000 ml
„
Epinephrine: 0.5 to 0.75 mg
„
Lidocaine: 500 to 1,000 mg
„
Sodium bicarbonate: 10 mEq
„
Triamcinolone: 10 mg (optional)
The mean tumescent solution compared to total
aspirate was 4609 ml: 2657 ml or almost 2:1.
By 1995, Klein59 had changed the tumescent formula
to:
„
Normal saline: 1,000 ml
„
Epinephrine: 0.5 to 0.65 mg
„
Lidocaine: 500 to 1,000 mg
„
Sodium bicarbonate: 10 mEq
„
Triamcinolone: 10 mg
In 2000, Klein60 described a variation of drugs, in the
local tumescent solution, according to the area being
liposuctioned. The basic solution to be changed after
checking for anesthesia completeness was:
„
Normal saline: 1,000 ml
„
Lidocaine: 500 mg
„
Epinephrine: 0.5 mg
„
Sodium bicarbonate: 19 mEq
If the anesthesia was not adequate then a variety of
formulations were proposed for each area of the body and
ranged from lidocaine of 750 mg to 1,500 mg,
epinephrine from 0.5 mg to 1.5 mg,54,56-65 and sodium
bicarbonate of 10 mEq.
Local tumescent anesthesia is used as the anesthetic
for performing liposuction, especially with small cannulas
(microcannulas). The same fluid can be used with
conscious sedation to provide the necessary local
anesthesia.
Ostad (1991)66 proposed that the maximum safe
tumescent lidocaine dosage was 55 mg/kg.
Gross et al (1995)67 introduced a soft tissue shaving
cannula that shaves the fat in an open fashion under direct
vision.
References
1. Grazer FM. Historical perspective. In: Grazer FM (Ed). Atlas
of Suction-assisted Lipectomy in Body Contouring. New York:
Churchill Livingstone; 1992. pp. 1-4.
2. Pangman WJ 2nd, Wallace RM. Cosmetic surgery of the face
and neck. Plast Reconstr Surg Transplant Bull. 1961;27:544-50.
3. Gurdin M. Personal communication. In: Grazer FM (Ed). Atlas
of Suction-assisted Lipectomy in Body Contouring. New York:
Churchill Livingstone; 1992.
4. Schrudde J. Lipexeresis in the correction of local adiposity. Rio
de Janeiro: Proceedings of the First Congress of the
International Society of Aesthetic Plastic Surgery; 1972.
5. Flynn TC, Coleman WP 2nd, Field LM, et al. History of
liposuction. Dermatol Surg. 2000;26:515-20.
6. Dolsky RL, Newman J, Fetzek JR, et al. Liposuction history,
techniques, and complications. Dermatol Clin. 1987;5:313-33.
7. Vilain R. Surgical correction of steatomeries. Clin Plast Surg.
1975;2:467-70.
8. Vilain R. In: Illouz YG, DeVillers YT (Eds). Body Sculpturing
by Lipoplasty. Edinburgh: Churchill Livingstone; 1989. pp. 9-
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9. Kesselring UK, Meyer R. A suction curette for removal of
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1978;62:305-6.
10. Teimourian B, Fisher JB. Suction curettage to remove excess fat
for body contouring. Plast Reconstr Surg. 1981;68:50-8.
11. Pitanguy I. Trochanteric lipodystrophy. Plast Reconstr Surg.
1964;34;280-6.

5
History of Liposuction
12. Fischer G. Personal communication September 13, 2008.
13. Fischer G. Surgical treatment of cellulitis. Rome, Italy; Third
Congress International Academy of Cosmetic Surgery; 1975.
14. Fischer G. First surgical treatment for modeling body’s cellulite
with three 5 mm incisions. Bull Int Acad Cosm Surg. 1976;2:35-7.
15. Fischer G. History of my procedure, the harpstring technique
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ture: The Syringe Technique. Paris: Arnette; 1991. pp. 9-21.
16. Fischer A, Maurice GM. Revised technique for cellulitis fat
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18. Illouz YG. Une nouvelle technique pour les lipodystrophies
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19. Fournier P. Body Sculpturing Through Syringe Liposuction and
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20. Fournier PF. Liposculpture: The Syringe Technique. Paris:
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21. Toledo LS. Superficial syringe liposculpture for the treatment
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22. Gasparotti M. Superficial liposuction for flaccid skin patients.
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23. Gasparotti M. Superficial liposuction: a new application of the
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24. Gasparotti M, Lewis CM, Toledo LS. Superficial Liposculpture:
Manual of Technique, New York: Springer-Verlag; 1993.
25. Fischer G. Orthostatic liposculpture. In: Shiffman MA, Di
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26. Zocchi M. Ultrasonic liposculpturing. Aesthetic Plast Surg.
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27. Coleman WP 3rd. Powered liposuction. Dermatol Surg.
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28. Elam MV, Packer D, Schwab J. Reduced negative pressure
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29. Mirrafati S: Vibrotumescent liposuction of the abdominal wall.
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33. Pitman GH. Liposuction & Aesthetic Surgery. St. Louis; Quality
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34. Cook WR Jr, Cook KK. Manual of Tumescent Liposculpture
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& Wilkins; 1999.
35. Klein JA. Tumescent Technique: Tumescent Anesthesia &
Microcannular Liposuction. St. Louis: Mosby; 2000.
36. Narins RS. Safe Liposuction and Fat Transfer. New York: Marcel
Dekker Inc.; 2003.
37. Wilkinson TS, Paradise LA. Atlas of Liposuction. Philadelphia:
Elsevier Saunders; 2005.
38. Hanke CW, Sattler G. Liposuction. Philadelphia: Elsevier
Saunders; 2005.
39. Shiffman MA, Di Giuseppe A. Liposuction: Principles and
Practice. Berlin: Springer; 2006.
40. Drake LA, Ceilley RI, Cornelison RL, et al. Guidelines of care
for liposuction. Committee on Guidelines of Care. J Am Acad
Dermatol. 1991;24:489-94.
41. Lawrence N, Clark RE, Flynn TC, et al. American Society for
Dermatologic Surgery Guidelines of Care for Liposuction.
Dermatol Surg. 2000;26:265-9.
42. Coleman WP 3rd, Glogau RG, Klein JA, et al. American
Academy of Dermatology Guidelines/Outcomes Committee.
J Am Acad Dermatol. 2001;45:438-47.
43. Mysore V. IADVL Dermatosurgery Task Force. Tumescent
liposuction: standard guidelines of care. Indian J Dermatol
Venereol Leprol. 2008;74 Suppl:S54-60.
44. Dillerud E. Suction lipoplasty: a report on complications,
undesired results, and patient satisfaction based on 3511
procedures. Plast Reconstr Surg. 1991;88:239-46.
45. Courtiss EH, Choucair RJ, Donelan MB. Large-volume suction
lipectomy: an analysis of 108 patients. Plast Reconstr Surg.
1992;89:1068-79.
46. Ersek RA. Severe and mortal complications. In: Hetter GP (Ed).
Lipoplasty: The Theory and Practice of Blunt Suction
Lipectomy, 2nd edition. Boston: Little Brown; 1990. pp. 223-
5.
47. Hetter GP. Blood and fluid replacement for lipoplasty
procedures. Clin Plast Surg. 1989;16:245-8.
48. Courtiss EH, Kanter MA, Kanter WR, et al. The effect of
epinephrine on blood loss during suction lipectomy. Plast
Reconstr Surg. 1991;88:801-3.
49. Goodpasture JC, Bunkis J. Quantitative analysis of blood and
fat in suction lipectomy aspirates. Plast Reconstr Surg.
1986;78:765-72.
50. Gargan TJ, Courtiss EH. The risks of suction lipectomy: Their
prevention and treatment. Clin Plast Surg. 1984;11:457-63.
51. Clayton DN, Clayton JN, Lindley TS, et al. Large volume
lipoplasty. Clin Plast Surg. 1989;16:305-12.
52. Dolsky RL. Blood loss during liposuction. Dermatol Clin.
1990;8:463-8.
53. Hetter GP. Blood and fluid replacement. In: Hetter GP (Ed).
Lipoplasty: The Theory and Practice of Blunt Suction Lipectomy,
2nd edition. Boston: Little Brown; 1990. pp. 191-5.
54. Klein JA. Tumescent technique for local anesthesia improves
safety in large-volume liposuction. Plast Reconstr Surg.
1993;92:1085-98.
55. Pitman GH. Tumescent liposuction: operative technique. Oper
Tech Plast Reconstr Surg. 1996;3:88-93.
56. Matarasso A. Superwet anesthesia defines large-volume
liposuction. Aesthet Surg J. 1997;17:358-64.
57. Klein JA. The tumescent technique for liposuction. Am J Cosm
Surg. 1987;4:263-7.

6
Atlas of Liposuction
58. Klein JA. Tumescent technique for regional anesthesia permits
lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg
Oncol 1990;16(3):248-63.
59. Klein JA. Tumescent technique chronicles: Local anesthesia,
liposuction, and beyond. Dermatol Surg. 1995;21:449-57.
60. Klein JA. Tumescent formulation. In: Klein JA (Ed). Tumescent
Technique: Tumescent Anesthesia & Microcannular Liposuction.
St. Louis: Mosby; 2000. pp. 187-95.
61. Greco RJ. Massive liposuction in the moderately obese patients:
a preliminary study. Aesthet Surg J. 1997;17:87-90.
62. Hanke CW, Bernstein G, Bullock S. Safety of tumescent
liposuction in 15,336 patients. National survey results. Dermatol
Surg. 1995;21:459-62.
63. Kaplan B, Moy RL. Comparison of room temperature
and warmed local anesthetic solution for tumescent liposuction:
A randomized double-blind study. Dermatol Surg. 1996;22:
707-9.
64. Lillis PJ. Tumescent technique for liposuction surgery. Dermatol
Clin. 1990;8:439-50.
65. Matarasso A. Superwet anesthesia redefines large-volume
liposuction. Aesthet Surg J. 1997;17:358-64.
66. Ostad A, Kageyama N, Moy RL. Tumescent anesthesia with a
lidocaine dose of 55 mg/kg is safe for liposuction. Dermatol
Surg. 1996;22:921-7.
67. Gross CW, Becker DG, Lindsey WH, et al. The soft-tissue
shaving procedure for removal of adipose tissue. A new, less
traumatic approach than liposuction. Arch Otolaryngol Head
Neck Surg. 1995;121:1117-20.

2 Preliminaries
The Patient’s Point of View
Curvaceous lines are and have usually been considered an
asset to the feminine body. Many women, however, are
not actually happy with their own “lines” and are seeking
ways to reduce their round shapes in order to remain
fashionable. Even moderate areas of fat deposits are
presently regarded as unattractive by many patients. The
trend in fashion and beauty care is towards the very slim,
thin, and even muscular silhouette.
Never before have exercise rooms and programs
been so prevalent and numerous. The health and fitness
craze is expanding continuously. Young people spend a
great deal of time and effort in body improvement
programs. This interest in image improvement has opened
new areas for plastic surgeons, who are now seeing in
A B S T R A C T
Preliminary aspects of liposuction cover discussions on
subjects such as the patient’s point of view, historical
background, scientific and esthetic basics for successful
liposuction, basic principles, patient selection, candidates
for surgery, physical examination, esthetic considerations,
preparation of the patient, preoperative laboratory tests,
anesthesia, blood and fluid replacement, and surgical
technique.
their offices the kind of patients who were never asking
for help before.
Before the development of liposuction, all that plastic
surgeons could offer such patients was a series of
mutilating operations. In attempting to contour the
body, their surgery resulted in extremely large, ugly,
troublesome scars. The arms, the thighs and the abdomen
were often the location of such scars. For other areas,
such as the knees and the ankles, no treatment at all was
available, while for some areas such as the breasts and the
neck, the treatment available was inadequate.
Today, liposuction has added an entirely new
dimension to body contouring treatment, making great
changes in body contour possible without leaving the
horrible scars caused by past treatments. As such,
liposuction must be considered the most important
development in body contouring in the past decade.
Historical Background
In the early part of the twentieth century, attempts were
made using a uterine curette to scrape out fat deposits
in the leg and knee areas. These attempts often mitigated
the build-up of fat. However, for the most part, this
surgical approach to fat excesses required large excisions
of skin and fat (called dermolipectomy) resulting in large
scars.
In 1972, Schrudde1 reintroduced the procedure of
curetting for fat ankles. Then in 1977, Fischer and
Adrien E Aiache

8
Atlas of Liposuction
Fischer,2 and Kesselring and Meyer in 19783 improved on
the technique by introducing a new element: liposuction.
It was not until Illouz, in 1977,4 that the procedure
became less prone to complications due to the new idea
of using a strong suction through a blunt opening without
incisions. Many minor modifications in that technique have
subsequently developed and the procedure has enjoyed
tremendous expansion becoming the most practiced
cosmetic operation. This atlas expands on the basic
principles of liposuction in an attempt to teach the
different aspects of the procedure to the uninitiated and
to present the basic knowledge of this surgical technique.
Scientific and Esthetic Basics
for Successful Liposuction
„
There is a difference between metabolic fat, which is
gained and lost easily, and blocked fat which is difficult
to lose easily. Blocked fat in men is found around the
waist and it is found around the hips and the saddlebags
in women.
„
Bjorntorp5 has determined that fat cells do not multiply
and in cases of removal of the “reserved fat”, there is
no return making this removal definitive.
„
After suction, which creates tunnel-shaped extractions of
fat and respects the septae, there is a certain amount of
skin retraction which is possible due to the contracting
elements below the skin.
The additional belief is that the superficial suction,
which is done immediately under the dermis, will be an
important factor in skin retraction. The fat is soft and
relatively poorly vascularized, allowing its removal with
blunt suction without the necessity of cutting, and
without too much blood loss. This has been the most
startling and positive contribution—since this is the only
tissue in the body that can be removed by aspiration,
making use of the knife unnecessary.
Basic Principles
When looking at the skeletal shape and fat distribution,
one realizes a fact that all human beings are essentially
built the same way, however, differences are present in
shapes and are either racial or ethnic or are due to
excessive fat deposits.
The surgeons can do little to correct skeletal body
contours as determined by genetics. However, with
liposuction the surgeons can in many ways alleviate the
deformities that people have brought upon themselves by
overeating and failing to exercise.
The simple aspiration of excess fat in some areas will
improve the beauty of a body in a permanent fashion.
This is due to the properties of fat cells; although the
fat cells can grow, it is understood that after puberty their
number is determined and they are unable to multiply.
This simple removal prevents the recurrence of an ugly
deformity.
The special characteristics of fat tissue (its softness and
the little amount of connective tissue) makes it relatively
easy to aspirate and allows for preservation of the
important structures such as arteries, veins, nerves and
lymphatics. This is an important fact in view of the “new”
techniques such as laser and ultrasound that destroy tissues
indiscriminately.
Some important factors that allow the technique to
work are:
„
The fat is soft and is contained in a loose tissue network
„
Strong suction causes avulsion of the fat from its bed
„
Using blunt instruments preserves vital structures
(nerves, arteries, etc.)
„
The retractive properties of the skin allow it to collapse
over its new surface
„
Preservation of most of the skin vessels and veins allows
good vascularization and the possibility of even
restructuring over a new bed.
Liposuction, however, cannot be successfully used to
treat a number of conditions such as:
„
Striae, which consist of epithelial tears caused by sudden
expansion of the skin (as with obesity or pregnancy,
Figure 2-1).
„
Skin flabbiness and redundancy will not only fail to
improve after liposuction but can often take a worse-
looking appearance. An obese woman who has the
beginning of an apron or a sagging face will show an
accentuation of the apron and of the nasolabial
grooving. For any case in which there is an excess of skin,
the liposuction technique will result in deeper folds and
more flabbiness, and only by returning to the older
method of dermolipectomy can the surgeon improve this
problem of skin laxity, excesses and folding. In a limited
number of cases, superficial liposuction can help in the
retraction of the skin and it may sometimes prevent the
necessity of using dermolipectomy (Figures 2-2 and
2-3).
„
Liposuction cannot be used thoroughly for what the
French call cellulite. A superficial layer of fat deposits,
which have increased in size and are under tension
because they are retained by skin and subcutaneous
connective strands, distort the surface causing the
cellulite’s typical appearance. This layer responsible for
cellulite formation is more superficial than the usual fat

9
Preliminaries
FIGURE 2-1
Stretch marks will not improve after suction lipectomy,
however, the abdomen can be flatter
FIGURE 2-2
Liposuction alone is not indicated in this type of excess skin
and flabbiness. Only an abdominal lipectomy is the solution
FIGURE 2-3
The technique of abdominal lipectomy does not satisfactorily
deal with the problems of excessive scarring and both body
distortion and usually ends up with a deformed abdomen
that is suctioned surgically. The new technique of
superficial liposuction with a cutting cannula, for the
cellulite strands and the autologous fat implantation
under the defect, is helpful in a moderate number of
cases and can correct the cellulite in a relatively modest
percentage of cases (Figure 2-4).
FIGURE 2-4
Patients with cellulite respond poorly to liposuction, unless it
is associated with superficial liposuction and cellulite release
using a sharp instrument to release the cellulite bands

10
Atlas of Liposuction
It is always a good idea and a good practice to
indicate on the schematic drawing the exact extent of the
fat deposits to be treated and to record these drawings
photographically. An informed consent associated with the
markings will often help in protecting the physician in any
medical-legal problems.
Selection of Patients
A key to success is proper patient selection. First and
foremost, a psychological evaluation in addition to a
physical evaluation will help to avoid problematic cases.
The psychological evaluation should consist of analyzing
the patient: avoiding the unstable, the psychologically sick
and especially the patient who has unrealistic expectations.
The patient with unrealistic expectations, although
psychologically normal, might present problems just as
severe as the psychologically abnormal patient.
It is important to ask proper questions from these
patients in order to evaluate their psychological and
emotional makeup. Often the physician is too eager to
perform the surgery, not realizing that an untoward result
or a result that is not completely satisfactory to the patient
will cause problems that could have been avoided in the
first place. Proper questioning will orient the surgeon by
allowing him to assess the amount of knowledge that the
patient has accumulated concerning the surgery, and will
allow proper evaluation of the amount of expectation that
the patient has (the hopes that they have placed in the
potential improvement that they may think could change
their life). Though there are exceptions, it is the experience
of the author that this type of surgery does not change
anyone’s life and does not solve the problems that the
patient had before the surgery.
An ideal patient is less than 35 years of age, relatively
thin with a localized contour deformity consisting of
excess fat with smooth and tight skin coverage. Cellulite,
skin sagging, skin with striae and irregularities from
contour defects constitute poor indications for the surgery.
In stretching the indications for surgery somewhat, one
may treat some patients over 35 years of age who are
slightly overweight, and present cellulite, striae and sagging
skin, provided that they understand that the surgical result
will be less than ideal. This specific point is often a cause
of misunderstandings and dissatisfaction, and should be
clearly explained before surgery (Figure 2-4).
Candidates for Surgery
Candidates for surgery may possess any of the problems
that are listed in Table 2-1.
Problem areas encountered in candidates for surgery
Face:
™ Fatty “turkey gobbler” neck
™ Fat cheeks
™ Nasolabial fat (or melolabial)
™ Jowls
™ Nape of the neck fat
™ Malar bags
Body:
™ Fat breasts
™ Fat back—subscapular, dowager’s hump
™ Abdominal protrusion
™ Epigastric bulge
™ Lack of waist or love handles in males
™ Iliac crests
™ Lumbar bulge
™ Saddlebags excess
™ Fat buttocks
Extremities:
™ Fat inner thighs
™ Fat thighs, lateral medial and anterior
™ Fat knees, medially and anteriorly
™ Fat ankles
™ Arm redundancy, excess fat in the posterior part
™ Fat necrosis with “false fat bulges”
™ Post-traumatic
TABLE
2-1
Physical Evaluation
Many so-called “tests” have been devised to ensure a
better understanding in the decision-making process of
surgery. The appearance test, the palpation test and the
lifting test have all been described by Illouz.4 The poor,
wavy appearance of the skin may discourage the surgeon.
Palpation will show the turgor or the lack of it, predicting
possibly a poor result, even when the fat layers have been
reduced. The lifting test consists of elevating the buttock,
thus removing the excess of saddlebags. This will indicate
an excess of skin and droop of the buttock which will
respond poorly to liposuction.
The “buttock contraction” is similar to the lifting test
in its effect of reducing the saddlebags. The riding
britches do not disappear when the patient contracts her
buttock; these can be safely suctioned. The muscle
contraction that takes place in the buttock will actually
tighten the layers of fat by telescoping them on top of
the muscle and, thus, change the possibility of estimating
the right amount of fat to suction. The so-called dynamic
pinching test (with the muscle contracting) as opposed to

11
Preliminaries
the static pinching test (with the muscle relaxing) is, thus,
not to be used to decide on the amount of suction to
be performed.
Using the trimming test (lifting the buttock will reduce
the fatty deposits), the surgeon can direct his attention not
only to the riding britches but also to the buttocks, the
hips, or the iliac crests.
The reclining test will show how much of a deformity
is due to simple skin excess and redundancy by watching
the patient in standing and lying positions. This is a
phenomenon called pseudodeformity of the saddlebags,
apparently secondary to the excess of the buttocks. To
correct this deformity, only buttock suction will help.
Pinching the skin between the thumb and the index
finger will actually define the amount of fat present in
any area of the body. This test is extremely useful and
stable and will be as efficient as computed axial tomo-
graphy (CAT) scans, ultrasonography, and magnetic
resonance imaging which are also useful but only in an
academic environment for the documentation of the fat
layers. The criteria for selection of patients is listed in
Table 2-2.
The patient who is older with redundant flaccid skin
should either be rejected or relegated to an associated
treatment consisting of a suction associated with
dermolipectomy. However, one has to keep in mind that
possible improvement can be obtained by superficial
liposuction and cellulite release.
The alternatives prior to liposuction involved
procedures such as trochanteric lipectomy (Figures 2-5 to
2-8), abdominal lipectomy, brachioplasty and dermato-
crurolipectomy. These procedures had a number of
drawbacks: scars were extensive and hard to hide,
deformities were not fully corrected, and they produced
secondary deformities such as dog-ears and expressionless
abdomen. There was also an inability to prevent localized
recurrences with increased obesity and also areas could
increase or recur in spite of surgery. Some of the words
of wisdom are given in Table 2-3.
TABLE
2-2
Criteria for selection of patients
Select patients with:
™ Good skin tone
™ Smooth skin surfaces
™ No waves, depressions or cellulite
™ Moderately hypertrophic area to be treated
™ Older patients willing to settle for a modest
improvement
TABLE
2-3
Some words of wisdom
Some don’ts
™ Cellulite improves only moderately after liposuction
if it is associated with a cellulitis release technique
™ Sagging skin occasionally responds to liposuction by
shrinking-down, but most often it does not although
the superficial liposuction is most useful
™ Striae and stretch marks do not improve after
liposuction
™ Wrinkled skin does not respond to liposuction
The new techniques of superficial suction and cellulite
release help somewhat in improving the conditions
mentioned above that were impossible to correct in the
past.
Esthetic Considerations
Removal of fat deposits by liposuction should not be
considered as a treatment for obesity, however, lately this
treatment has been used in very obese patients and has
increased the number of fatalities which was extremely low
with pure liposuction. If it is obvious that the patients
are candidates for liposuction even if they are relatively
obese, their shape will be helped by this technique.
The location of the excessive fat determines the
ultimate success of the operation. Localized, well-defined
excesses present under a taut, firm and young skin will
give optimal results if the technique is well performed by
the surgeon. Removal of excess of fat present under soft,
old, redundant and flabby skin will often result in a poor
esthetic result even if it is performed by a well-trained
operator.
Preparation of the Patient
The first contact with a new patient will allow the surgeon
to recommend a few procedures and assess the potential
risks that this patient presents from the physical,
psychological and even financial standpoint.
The usual checkups, especially for bleeding problems
and for potassium deficiencies, in patients who are dieting
or who are on thyroid treatment, should be performed.
Patients with medical problems as well as patients who
have poor skin tone or inordinate degree of obesity and
whose preoperative tests show deficiencies, such as low
potassium, bleeding disorders or cardiovascular
abnormalities, should be excluded. Obesity itself, although

12
Atlas of Liposuction
FIGURES 2-5A TO C
(A) Markings made for trochanteric lipectomy. This surgical excision is rarely performed nowadays; (B) Lateral view of markings
for trochanteric lipectomy; (C) Large lipodystrophy excision
A
B
C
FIGURE 2-6
Postoperative scars after lipectomy
FIGURE 2-7
Postoperative result of trochanteric lipectomy. Notice the
notching at the scar line and the remaining bulges over an
area below that scar

13
Preliminaries
„
Potassium (K+): Particularly important is its deter-
mination in older patients with cardiac disorders who
have been on diuretics or on thyroid medication, since
these medicines are notorious for having an impact on
the potassium level.
„
Dibucaine number: Also obtained to detect many
cholinesterase deficiencies.
„
Fibrinogen level: Important in the preoperative bleeding
workup in patients taking anabolic steroids who
sometimes have a deficiency.
Health risks are listed in Table 2-4.
FIGURE 2-8
Even properly placed thin scars can present a cosmetic
disfigurement in the era of high-strung bathing suits
not a contraindication, will not be corrected by this treat-
ment alone except if it is performed as a megaliposuction,
which is a procedure limited to patients in good shape
and is performed by a very small number of very
knowledgeable surgeons in this subject.
The patient’s age is the single most important factor
since an old skin will not shrink as much as a younger
one and an excessively redundant skin will not drape over
the defatted area.
Preoperative Laboratory Tests
„
Complete blood count (CBC): Borderline anemia should
be considered a possible contraindication to the
procedure since the condition will be worsened by the
blood loss inherent with the procedure (20–50% of the
aspirated material can be blood).
„
Fasting blood sugar (FBS): Diabetes, although not a
contraindication in itself, will have to be stabilized in
order to avoid postoperative problems.
„
SGPT, HBSA: To detect hepatitis since it is as prevalent
and as dangerous as AIDS.
„
HTLV-III: Determination to detect AIDS antibodies.
„
Bleeding workup
„
PTT and bleeding time: Any abnormality in this test will
be a definite contraindication to the procedure since no
hemostasis can be performed except for actual pressure
on the bleeding area.
TABLE
2-4
Health risks
The factors listed below should be considered when
screening a potential patient.
Age:
™ Under 50 preferred
Hypertension:
™ Poorly controlled hypertension
™ Coronary artery disease
™ Six months following a myocardial infarction
Common cause:
™ Superficial skin infections
Coagulation profile:
™ PTT
™ Aspirin intake
™ Obscure clotting problems (history, dental experience)
™ Hypercoagulation status
™ Diabetes
™ Obesity
Habits and risks:
™ Smoking
™ Alcoholics
™ Skin pigmentation
™ Ready vomiters
™ Steroid use
™ History of narcotic use
™ Tranquilizer use
™ Allergies
™ Topical reactions
Anesthesia
Anesthesia can be general but even under complete
anesthesia, whenever possible, the operator should also
infiltrate the area to be operated upon with a diluted
solution of xylocaine and epinephrine. A normal amount
of bleeding comes to approximately 15–25% of the total
amount of fat and fluid removed during the suction

14
Atlas of Liposuction
procedure but this amount can be significantly decreased
by vasoconstrictive solutions injected before surgery such
as epinephrine. Although the dilution of the solution has
been subject to discussion, an appropriate dilution of
1:400,000 of epinephrine is the most diluted solution that
can be used with appreciable results in terms of
vasoconstriction. More concentrated solutions are more
helpful. On the other hand, the tumescent technique is
a new way of infiltrating the tissues with a large amount
of fluid reducing blood loss and in these cases the
dilution of epinephrine comes to 1:1,000,000. However,
it seems to be successful in preventing blood loss.
The anesthesiologist should bear in mind the fact that
in addition to the process of removing fat and blood
from the area, a large amount of fluid shifting will result
after the procedure. This process has been compared to
a burn with fluid migration towards the injured area.
Proper understanding of this fluid movement and
proper replenishment of the fluid loss avoids potential
problems. Replacement fluids consist of saline solutions,
such as Ringer’s lactate, associated sometimes with colloid.
If the amount of aspirate reached 2000 cc and no
tumescent infiltration has been done, a transfusion can
sometimes be necessary. For this purpose, the author has
been satisfied with autologous transfusion which involves
collecting the patient’s blood approximately ten days prior
to surgery and reinjecting it during the procedure.
Improvements in the autologous transfusion process have
been noted all over the country. People are able to
“donate” their own blood two or three times prior to
surgery and the blood is frozen and then reinjected at the
time of surgery.
Possible complications under general anesthesia are
given in Table 2-5.
TABLE
2-5
Possible complications under general anesthesia
Anesthesia complications
™ Hypoxia
™ Hypovolemia
™ Anemia
™ Transfusion complications
™ Myocardial infarction (cardiac failure)
™ Excess fluid intake with pulmonary edema and
pulmonary failure with right heart failur
Autologous Transfusion
Autologous transfusion is the collection and reinfusion of
the patient’s own blood. The technique has become
popular due to the fear of acquiring transfusion-
transmitted diseases from homologous blood transfused
from sick donors. Human immunodeficiency virus, and
hepatitis B and C are still potential hazards in spite of
donor screening and testing measures. The surgeon has
to decide in advance who is a potential candidate for
blood replacement in cases where the likelihood exists for
such procedures, i.e. large suctions on obese patients or
multiple areas suctioned on patients with a normal weight
range.
If transfusion is likely for the planned procedure, there
are three options for autologous transfusion: (1)
Preoperative autologous blood donation; (2) Perioperative
blood salvage; (3) Acute normovolemic hemodilution.
Standards exist for proper handling, storage and
transfusion of collected blood.
Preoperative Autologous Blood Donations
A preoperative autologous blood donation is given to a
patient who is likely to require transfusion during or after
surgery.
Selection of patients: The ideal patient for a preoperative
donation is one who has two or three weeks before
surgery and has an adequate hemoglobin and hematocrit.
Patients with possible bacteremia are not eligible for
autologous transfusion because bacteria may proliferate
during blood storage or transfer. Among other procedures,
such as orthopedic procedures and cardiac and vascular
procedures, liposuction is now becoming a more common
procedure for autologous transfusion. Most individuals can
well tolerate phlebotomy loss equal to 10% of their blood
volume.
Procedure: After patients are advised of the process they
can give blood frequently, however, the optimal donation
period begins 4–6 weeks prior to surgery. The risk of
preoperative autologous blood donation includes vasovagal
reactions or surgical delay. Some of the autologous blood
components can be transfused instead of the whole blood.
Perioperative Blood Salvage
This is a collection and reinfusion of blood lost during
and immediately after surgery. The major benefit of blood
salvage is the reduction of donor exposure for patients
undergoing major surgical procedures such as extensive
liposuction.
Perioperative blood salvage consists of intraoperative
and postoperative blood salvage. Autologous blood
There are many ways of readministering blood and
although at this time the techniques are not uniformly
used, they are, however, helpful and can be used safely.
The techniques include:

15
Preliminaries
collected by intraoperative blood salvages represents an
excellent source of red cells during surgery and can reduce
homologous blood used in surgical procedures.
Commercially available equipment is used for this
technique. In the particular case of liposuction, it is
necessary to washout the blood to prevent the multiple
fat particles formed being reinfused. This technique is
rarely used at the present time.
Acute Normovolemic Hemodilution
This is the removal of blood through an arterial or
venous catheter immediately before surgery. Cell-free
solutions are infused simultaneously to maintain
normovolemia. At the conclusion of surgery, the patient’s
blood is reinfused. Hemodilution is a transfusion option
for patients who can tolerate repeated withdrawals of
several units of blood before the period of surgical blood
loss. The procedure is usually performed by the attending
anesthesiologist. The safe lower limit of posthemodilution
hematocrit is still unknown so the procedure should be
performed carefully.
Many options for using autologous blood have been
discussed. These options, although risky in themselves, are
nevertheless safer than homologous blood transfusions.
However, they deserve more study and more use.
Replacement of Fluids during
Liposuction
Colloid recommendations for fluid replacement during
liposuction are given in Table 2-6.
Hespan or Hetastarch is a synthetic colloid derived
from amelopectin. Hetastarch increases plasma volume by
up to 100% to 230% of the infused volume and the
volume expansion persists for 24–48 hours. Approximately,
70% to 80% of an administered dose is eliminated renally
by glomerular filtration. In situations where this colloid
is considered to be inadequate for volume expansion,
Hetastarch in amounts up to one liter should be used as
the initial colloid. After the infusion of 1 liter of Hespan,
consideration can be given to the use of albumin or even
blood.
The Tumescent Technique
Prior to liposuction the area to be improved is infiltrated
with large amounts of fluids. The fluid usually consists
of a solution of saline 0.5% or a diluted solution of
Ringer’s lactate. The saline is infiltrated with a long thin
cannula with multiple openings and introduced from one
area and injected in a fan-type procedure all over the area
TABLE
2-6
Replacement of fluids during liposuction
Amount of fat and blood loss
Ringer’s lactate blood
500 ml
1000–1500 ml
500–1000 ml
500–1000 ml
Dry
1000–-2000 ml
Bloody
Add 500 ml colloid
1000–1500 ml
1500–3000 ml
Dry
Add 1000 ml colloid
Bloody
2500–4000 ml
1500–2000 ml
Dry
Bloody
Add 1000–1500 colloid
2000–2500 ml
Dry
2 x Volume of Loss
Bloody
1 unit autologous blood
2500–3000 ml
Dry
2 x Volume of loss
Bloody
2 units autologous blood
to be suctioned. The movements of infiltrations are
similar to the movement of suction lipectomy and the
infiltration of the tissue is done to a point where the
tissues are well-distended and show turgor. In order to
reduce the bleeding, a solution of 1% xylocaine with
epinephrine in the ratio of 1:100,000 is diluted to
approximately 10 times and is injected in the same area.
This allows continuous infiltration of the tissues and
reduction of the bleeding. The long needle is connected
to a syringe that is made specially and connected to
intravenous (IV) tubing and to an IV solution. In addition
to this system, multiple pump systems have been
developed to increase the velocity of the infiltration.
According to its proponents, the technique allows large
amounts of fat to be aspirated without the need for
transfusion.
Although local infiltration of the tissues before surgery
is helpful, it has its problems such as spotty areas of
infiltration and risk of overdosage of lidocaine in addition
to blood loss, necessitating replacement and overdosage
of fluid that could end up in pulmonary edema.
This technique can be used with success above 2500 cc
of aspirate.
As described by Klein, the tumescent technique
obviates these problems somewhat. It can reduce or
eliminate the preoperative medications, general anesthesia
or even IV fluids since in some cases the infiltration in
itself is sufficient without the recourse to IV medications
or IV fluids.

16
Atlas of Liposuction
Surgical Technique
Marking of the area is done as usually for liposuction.
The upper and lower markings are made with solid
markings and the areas of feathering with stippled
markings. The areas of entry for liposuction are marked.
Usually two entry points are necessary to perform the
crisscrossing during liposuction. These same incision areas
are used for the introduction of the tumescent needles
and then later for the liposuction. The point of infiltration
is itself infiltrated with xylocaine and epinephrine in order
to reduce the pain of needle infiltration.
Then the tumescent infiltration (Table 2-7) is done
until a tight turgor in skin surface is obtained. Attention
is turned towards the actual liposuction cannula and an
incision is made or enlarged at the original point of
infiltration and the cannula is used through this entry for
the liposuction.
TABLE
2-7
Tumescent anesthesia technique
Klein’s formula
™ Normal saline 1000 cc
™ Lidocaine 50 cc, 1% plain
™ Sodium bicarbonate, 10 cc of 8.4%
™ Epinephrine 1 mg
Hunstad’s formula
™ Lactated Ringer’s 1000 cc
™ Lidocaine 50 cc 1%
™ Epinephrine 1 cc (1:1000)
™ Warmed to 38° centigrade
™ Final concentration of both solutions is lidocaine
0.05% and epinephrine 1:1,000,000.
burning sensation obtained by the lidocaine infiltration.
Warming of the solution has allowed less refrigeration of
the body and helps in reducing the shivering, and oxygen
demands of the patient.
This technique has been used in cases of ultrasound
liposuction since the ultrasound works its best in a more
fluid environment. A blood pump can be wrapped around
the intravenous bag to create approximate pressure for the
fluid injection.
Surprising facts that the tumescent technique is
working have been noted, in particular, the upper limits
recommendation of the lidocaine that can be injected have
been completely shattered by the findings that a very large
amount of xylocaine can be accommodated while the
tumescent technique is being used. It is mostly due to the
fact that after these large amounts of fluid containing the
lidocaine have been injected, the release in the blood
stream is extremely slow and never reaches the toxic levels
that are known to occur when large amounts of xylocaine
are injected. In the past, an average upper dose of 500 mg
of 1% xylocaine was recommended. The study of the
release of the xylocaine has found that there is an
extremely slow release and larger doses can be used.
Intravenous solutions can be injected, however
carefully, since pulmonary edema can result if excess fluid
has been infiltrated. The urinary output can be observed
as well as the blood pressure, the venous pressure, and
other vital signs useful for estimation of the capacity of
the vascular system and its potential overload. It is the
anesthesiologist who carefully evaluates all these parameters
in order to avoid difficulties during or after surgery.
References
1. Schrudde J. Lipexeresis in the correction of local adiposity. Rio
de Janeiro: Proceedings of the First Congress of the
International Society of Esthetic Plastic Surgery; 1972.
2. Fischer A, Fischer G. Revised technique for cellulitis fat
reduction in riding breeches deformity. Bull Int Acad Cosm
Surg. 1977;2:40-3.
3. Kesselring UK, Meyer R. A suction curette for removal of
excessive local deposits of subcutaneous fat. Plast Reconstr Surg.
1978;62:305-6.
4. Illouz YG, de Villers YT. Body Sculpting by Lipoplasty.
Edinburg: Churchill Livingstone; 1989.
5. Björntorp P, Karlsson M, Gustafsson L, et al. Quantification
of different cells in the epididiymal fat pad of the rat. J Lipid
Res. 1979;20:97-106.
In short, the liposuction can be done usually using a
diluted solution of lidocaine with a concentration of
epinephrine and this solution is diluted more often three
times, or ten times since the tumescent technique is used.
The most important characteristic of this technique
has been the relative lack of blood loss. The findings have
shown that the tumescent technique is able to provide
enough local anesthesia and decrease the blood loss during
the procedure. In addition to the solution used, some
sodium bicarbonate can also be added to minimize the

3 The Setup
The Machine
The simple and direct concept of extracting fat by its
curettage was worked out by Schrudde since 1964.1 Arpad
and George Fischer2 then used a motor-driven chopping
curette with an original additional idea—suction of the fat.
Illouz simplified the technique by using suction alone,
as he imagined the now proven wrong concept of lique-
fying and destroying the fat with a hypo-osmotic solution.
Luckily, he was provided a strong suction machine
(Medicalex) that remained the first and best instrument for
an extended period of time (Figure 3-1).
With the popularization of the technique, many
companies sponsored by plastic surgeons developed their
own suction machines and cannulas (Figures 3-2 to 3-8).
Heated discussions occurred during medical conven-
tions concerning the “right technique, cannulas and
machines”. These instruments were varied although
A B S T R A C T
The setup for performing liposuction includes an
understanding of the machine, the cannula including its
type and size, dressings and garments, technique of
liposuction, preoperative and postoperative photography,
and markings. There is a discussion of each of the above
topics in this chapter.
FIGURE 3-1
The original Medicalex suction machine, a quiet and sturdy
machine developing maximum negative pressure in a short
time
basically similar. This book will concern itself with cases
performed with varied machines and using rounded
cannulas of many styles. Each surgeon gets a slightly
different exposure in his training and his preferences may
be different too. He will have to make a partly original
Adrien E Aiache

18
Atlas of Liposuction
FIGURE 3-2
The Dean suction machine with disposable canisters,
excellent for office or hospital use. The added fumes filter is a
requisite for any new machine (Dean Instruments, Carson,
CA)
FIGURE 3-3
Dean cannulas with glass bottles with metallic sterilizable top
allowing fat transplantation
decision as to which instruments and the machines he will
use.
The basic components of the machine consist of a
vacuum cleaner with an aspirating pump and a special
container for the acceptance of the fat that has been
FIGURE 3-4
Grams aspirator, which is a very sturdy and reliable machine
FIGURE 3-5
The Sklarvac Multipurpose Suction Unit

19
The Setup
FIGURE 3-6
The Medco Aspirator
FIGURE 3-7
Tubing for Medco
FIGURE 3-8
The Davol tubing is disposable and light enough to allow fine
liposuctioning in areas such as the face or the knees. It is
inexpensive
aspirated. This concept lies in the fact that a vacuum can
be created down to zero and there are no machines that
can deliver a better figure. Thus, even the syringe
technique can achieve the same level of vacuum and this
concept has helped the development of the technique of
syringe liposuction.
The Cannula
A cannula is a long metallic tube with an opening at its
end. The size of the cannula, its length, the position of
its opening, and the sharpness of the edges of the
opening are varied and have been the subject of many
discussions (Figure 3-3).
Criteria for Proper Cannula Selection
A proper cannula should have blunt edges at the opening;
the opening distance from the tip should be 1 cm or
more if one wants to avoid a too superficial liposuction.
If the openings are close to the end, one should be care-
ful of not reaching a spot too close to the skin surface.
Proper size handle: this depends on the size of the
hand of the surgeon and companies provide different
sized instruments.
Round smaller tips to allow nontraumatic, non-cutting
perforations of the fatty tissue and preservation of the
denser anatomical deeper elements. This concept can be
proven wrong sometimes when a Robles cannula is used
and it shows that it does not injure any of these
structures.

20
Atlas of Liposuction
Modifications are made constantly and some interesting
features have been added to the already available variety
of shapes such as the flat cannulas, the curved cannulas,
the multiple-holed cannulas and the different size and
shape of the openings.
Cannula Sizes
Originally, a #10 cannula (10 mm) was used for large hips,
saddlebags and abdomen; #8 for saddlebags, abdomen,
thigh, flank and iliac crests; and #6 for neck, breast,
abdomen, epigastrium, knee, thighs and for feathering the
areas mentioned above. As time went on, it was
discovered that the larger cannulas were taking out large
chunks of fat with the potential complications of leaving
dents and deformities. Lately, the most common cannulas
used are #4 and #3. These numbers represent the inside
diameter of the cannula (Figures 3-9 to 3-13).
The thicker the cannula, the harder it is to penetrate
the fat layers and the tissues, and to utilize the to-and-
through movements since strong suction is holding back
on the cannula. The new, smaller cannula makes this
FIGURE 3-9
4 mm and 3 mm suction cannulas. Note the blunted tips and
the size of the openings
FIGURE 3-10
An assortment of diverse cannula used for suction
FIGURE 3-11
The #4 angled Aiache cannula useful for chin liposuction with
its 30 degree angle facilitating positioning of the surgeon
FIGURES 3-12A AND B
(A) Small caliber cannulas such as this 4 mm cannula can have a great power of aspiration enhanced by the presence of
multiple openings; (B) The 3-holed cannula was originally developed by Fournier

21
The Setup
the liposuction is not possible at the right level, grasping
the skin between the fingers and around the cannula will
allow more controlled suction.
Dressings and Garments
After the process of liposuction, a vacant space is left
under the skin. This space is created by the aspiration of
fat leaving only the nerves, vessels and lymphatics, which
come through the muscle and go towards the skin surface.
The existence of these connections has been shown on
videotape as well as on actual operative sites when an
open incision is made in an area which has been
suctioned. The space which is left behind does not actually
consist of tunnels or bee wax, it actually consists of an
empty space which is traversed only by the nerves and
vessels, and some connective ligaments.
It is easy to understand why following liposuction
some type of compression should be applied in order to
allow healing of the two new surfaces. This compression
is best accomplished by using either an elastic bandage or
using a garment. Originally, elastic tape alone was used,
however, the elastic garments played the same role, and
prevented the inconveniences and complications caused by
elastic tape such as tape burns, allergies and pain on
removal.
Technique
The elastic bandages should actually be applied with the
idea in mind that the vascular returns should not be
interrupted (Figures 3-15A and B). After the operative site
has been properly closed and the incisions covered with
some type of dressings, the skin is washed and the garment
is then put on immediately after the surgery. Excessive tape
is dangerous circumferentially, especially in the area of the
knees since it could cause deep vein thrombosis.
FIGURE 3-13
Example of multiple cannulas developed by a company for
the different aspects of liposuction
problem less difficult and the power cannulas activated
with a back-and-forth movement have been even more
useful in alleviating the fatigue of the surgeon.
Much has been written about holding the opening of
the cannula down, however, it is only important in
realizing the exact level of suction because in most areas
(except for the neck and the malleoli), it is necessary to
preserve a layer of fat and to avoid penetrating the
superficial fat layers, thus avoiding depressions.
Introduction of the Cannula
The incision should be deep to allow the cannula tip to
go through the superficial fascia and to stay below it.
When the tip hits the muscle fascia the cannula is
angulated almost parallel to the skin (Figure 3-14).
Once the cannula is at the right tip level, the suction
is started carefully, avoiding suctioning near the incision
for fear of creating a dimple in the area. The suction
tunnels are done methodically in using the palm of the
opposite hand which is flattened against the skin in order
to feel the exact thickness of the fat layers. In cases where
FIGURE 3-14
The cannula is introduced down to the deep fascia going
through the superficial fascia system

22
Atlas of Liposuction
FIGURES 3-16A AND B
(A) Garments used after liposuction of the face, knees and arms; (B) Garments used after liposuction of the abdomen, iliac
crests, waist, saddlebags and inner thighs. The full body girdle depicted on the right is the most commonly used since, in
addition to its compression, it will help in prevention of deep venous thrombosis
FIGURES 3-15A AND B
(A) Typical application of the elastic tape after suction of the
hips and thighs. A garment is easier to use; (B) Elastic tape
applied after saddlebag, iliac crest, inner thighs, knees and
ankle liposuction
The garments are usually made of an elastic material
which allows good compression in the area that has been
operated on. They should fit relatively snugly and in some
cases they require special custom-made pieces. They are
commercially available for different areas, including the
neck, the breasts, the arms, the hips, the thighs, the ankles,
etc. (Figures 3-16A and B).
Preoperative and Postoperative
Documentations Photography
Photographs of patients showing different views are
necessary for proper evaluation. They should be taken
equally with markings in order to have a document of the
surgery. Photographs represent the most important tool
in preoperative and postoperative documentation of the
work accomplished. In the preoperative pictures, the areas
of suction are marked with ink for referral during surgery
and for evaluation. Markings can indicate the thickest
areas, the thinnest areas and the areas of feathering.
A
B

23
The Setup
Markings
Added shortly before surgery, the markings are of the
utmost importance. Any type of indelible ink can be used.
Markings are better made with the patients upright and
they are made with the following two goals in mind
(Figures 3-17A and B):
„
Circumscribing the area to be defatted. The markings can
be doubled. The inner circumferential line indicates the
exact area of demarcation between the suctioned and
unsuctioned area. A second outer marking will then
indicate an area of feathering, which is necessary to
obtain a proper draping of the skin around the
suctioned-out area, preventing a step-down effect at the
junction of the two zones of the skin. Feathering is
usually done by the to-and-through movement of the
cannula with mild suction applied to the tubing.
„
The second purpose of the markings is to indicate the
areas needing most of the treatment as well as the areas
needing little or no treatment. Careful appraisal of the
area to be suctioned-out is done at the time of the
markings. Rotation of the patient and the pinch test will
help determine the extent of the problem and the
particular area of correction. Rotation allows tangential
view of the area to be used over the full extent of the
extremity. For example, in checking the circumferential
surface of the outer thighs, the tangential view will be
useful.
The markings, being the result of physical examination,
should not be modified on the operating table since that
would create a problem after the skin has shifted to a
different position. An example is jowl suction that could
leave a depression in the mandible if not properly located
since the jowls gravitate down in the standing position.
The markings will appear on photographs and help the
postoperative understanding of the results. From the
scientific and medical aspect, the importance of
documentation is paramount. The surgeon should make
an effort to learn proper techniques and to obtain
satisfactory illustrations of his work.
Photographs Required
Face
„
Anteroposterior
„
Lateral right
„
Lateral left
„
Oblique right
„
Oblique left
„
Framing should go down to the clavicles.
Abdomen
„
Anterior or anteroposterior standing
„
Lateral right
„
Lateral left
„
Sitting oblique
„
Standing oblique
„
Framing from the clavicles to the knees.
Saddlebags/Thighs
„
Anteroposterior
„
Posterior view
„
Oblique posterior right
„
Oblique posterior left
„
Lateral right
„
Lateral left
„
Framing from the clavicles to the knees.
Iliac Crests
„
Anteroposterior
„
Posterior view
„
Anterior oblique
FIGURES 3-17A AND B
(A) Different incisions that can be used on the anteriorly.
These incision markings should be made carefully and
symmetrically to obtain similar symmetrical results; (B)
Posterior incisions. These incisions are used for liposuction
in any area of the body

24
Atlas of Liposuction
„
Posterior oblique
„
Lateral right
„
Lateral left
„
Framing from the clavicles to the knees.
Thighs
„
Anteroposterior
„
Posteroanterior
„
(Legs are slightly open)
„
Lateral right
„
Lateral left
„
Lateral with one foot elevated
„
Framing from the nipples to the ankles.
Knees
„
Anteroposterior
„
Posteroanterior
„
Lateral right
„
Lateral left
„
Framing from the hips to the toes.
Ankles
„
Anteroposterior
„
Posteroanterior
„
Both lateral with distant foot in front
„
Posteroanterior while the patient is climbing on his/her
toes
„
(Patient should be on an elevated stool)
„
Framing from the stool up to the crotch.
Areas of Surgery and
Special Positioning
Face and Neck
In these cases the supine position is most adequate.
Although in particular cases where the area present on top
and immediately behind the sternocleidomastoid muscles
has to be suctioned, the prone position can be useful.
Arms
The supine position is adequate. Posterior epitrochlear
markings combined with midarm incisions allow full
suctioning of the arms. The arms are held-up during the
procedure. Another position which is adequate is the
prone position in which the arm suction is performed in
conjunction with other posterior procedures. In these
cases, a combination of epitrochlear incision and axillary
incision can comfortably be used.
Breasts
The supine position is most adequate in these cases. In
particular cases, where the axilla and the chest area is
suctioned, the lateral decubitus position is very useful
allowing through an incision in the axilla and in the outer
posterior inferior mammary fold to perform the suction
on the fatty deposits.
Abdomen
The supine position is adequate for most cases of the
abdominal liposuction. In cases of waist suction lipectomy,
it may be of some help to either situp the patient during
the estimate of the removal and the lateral decubitus
position can also be useful when an important reduction
is necessary in the waist zone. Although the markings are
made standing taking into consideration the ptosis of the
abdominal wall, one may often see an unsightly result from
an improper defattening of this area. It has been found that
in many of these cases, the lateral aspect of the abdomen
should be suctioned in order to allow the anterior zone
situated over the rectus muscle to look more anatomical.
Iliac Crests
The surgery is started with the patient lying prone. The
markings have been made upright and are followed
faithfully. At the completion of the procedure the patient
is allowed to stand or kneel and the procedure is
continued in that position.
Once positioned, the patient is allowed to rest her
chest on the table during suction episodes. Re-estimation
is made with the patient erect. This process is continued
and repeated until a proper result and the desired contour
of the area is obtained. Checking the contour by multiple
angles, estimate and palpation, the surgeon works until a
smooth contour is obtained from all angles.
Saddlebags
After proper markings and after administration of local
anesthesia, the usual two or three incisions are performed,
and liposuction is performed in a crisscross fashion
bilaterally. At the completion of this procedure, the patient
is placed erect. Of the two positions that are available;
the standing position will be obtained by standing-up the
patient on the floor at the side of the table allowing the
patient to rest her chest on the raised table. Successive
changes of position in the torso will allow frequent
checking of the shape of the thighs. When or if the
patient becomes dizzy, she is allowed to lie on the table.

25
The Setup
It is obvious that the flattening of the thighs under
the pressure of its own weight could have precluded such
an exact estimate of results. A tangential look is afforded
from all angles around the thigh when the patient is erect.
In particular, one will often find that a more anterior
extraction will be necessary. Without the opportunity to
stand the patient up, this course of action is not possible.
One of the interesting suggestions by Giorgio Fischer3
is the orthostatic table in order to evaluate exactly the
amount of fat removed during liposuction and “finesse”
the results. While the patient is lying down, the gravity
will disrupt the shape of the thighs, the skin, the fat and
the muscle and this orthostatic table is devised for that
purpose. The author has used the kneeling position
(Figure 3-18) and even the standing position, either on
the knees or on the feet, to provide proper sculpturing
of the fat.
Two incisions are often necessary in the thighs. The
infragluteal thigh for the posterior approach of the thigh
and knee, and the anterior groin approach for the anterior
thigh area. In addition, the frog-leg position is used for
the exact removal of the inner and anterior thigh fat that
is difficult to evaluate without this special position.
Ankles
The prone position will often suffice since the leg is bent
and allows circumferential view of its contour.
A different level of approach to patient positioning is
advocated for better esthetic results in suction. Although
this particular approach will create a more difficult
situation from the sterilization point of view, it has, never-
theless, been a useful tool in obtaining superior results.
General Liposuction Surgical
Technique
General liposuction surgical technique is given in Table
3-1.
The technique consists of the following: an incision
is made down to the subcutaneous tissue and fat. It
measures approximately the same length as the caliber of
the cannula to be used. The incision should go deep and
straight in order to avoid the multiple superficial layers and
allow the cannula to reach the muscle fascia.
FIGURE 3-18
The patient is in the kneeling position and awake. Liposuction
and shaping of the thighs becomes more precise since it
shows the exact contour of the thigh without the distortion
caused by the prone or supine position
Inner Thighs and Knees
The prone position is used in the early stages of the
surgery. The patient is often turned sideways with the legs
spread allowing comfortable aspiration in the upper part
of the thighs and the knees.
Further aspiration of the area is done with the patient
kneeling. Often it is found that an anterior extension of
the suction will help in contouring the thigh.
TABLE
3-1
Proper technique to avoid complications
™ Stay deep (This dictum is not necessary any more
since the advent of superficial liposuction)
™ Do not remove too much
– 2 cm in forgiving areas, 4 cm in non-forgiving areas
™ Cannula holes down
™ No lateral movements
™ Proper instruments
™ Holes 2 cm from the tip which is a blunt tip
™ Crisscross technique
Technique
A cannula of the proper size is introduced perpendicular
to the skin through the incision and goes down to the deep
layers over the muscular fascia. Then the cannula is pushed
again parallel to the muscular fascia, and by a sawing
movement multiple back and forth movements are made
while the liposuction is turned on. Approximately, 15–20

26
Atlas of Liposuction
strokes are made in the tunnel that is created in that fashion.
The cannula then goes to a parallel neighboring area and
the same technique is repeated in a slightly oblique fashion
and the area is liposuctioned in a spoke-like fashion covering
the zone that has been demarcated by the markings. Each
tunnel is made in the same fashion until it is felt that they
have covered the whole area. The most important part of
the technique is to use a second incision in an opposite
zone in order to be allowed to crisscross the zone to be
liposuctioned by creating tunnels in a perpendicular fashion
to the previous ones.
Although the original concept developed by Illouz and
his coworkers was to make parallel diverging tunnels, keep
in mind that the work to be accomplished consists of
complete emptying of the fat layers contained between the
skin and the deep fascia layer over the muscle. The only
way to preserve some layers of thickness under the skin
is to stay relatively deep. Depending on the size of the
cannula, the depth of the tunnel will result in a thicker layer
of subcutaneous fat. The tunnels are made in a very
methodical manner for fear of missing or skipping an area
and with the aim of obtaining a very even surface. To that
effect, the second crisscrossing incision is helpful. One has
to remember that, if the zone that has been suctioned was
elevated as a flap, there would be actually no specific tunnels
but a completely emptied area with only multiple strands
of connective tissue, nerves and vessels connecting the
deeper muscular layer to the subcutaneous area.
Estimate of Removal
During the procedure a constant inspection by palpation
of the skin, both by flat palpation and by rolling of skin
folds, is performed to assess the level of thinning. A
combination of pinching and rolling the pinch along the
area worked on will be useful. If an area is found to be
too thick, it can be grasped as a sausage between the palm
and the fingers, and the cannula is introduced and directed
between the fingers to thoroughly defat the area (Figures
3-19A to E).
FIGURES 3-19A TO E
(A) The grasping left hand is clutching the tissues while the right hand holds the cannula and pierces the fat layer. This
technique is useful in obtaining an even liposuction result; (B) Use of the pinch test to determine the fat thickness. The two
pinches show the difference between a liposuctioned area and a non-liposuctioned area on the left; (C) Palpation of the fat
thickness between two fingers is useful throughout the procedure to assess the amount of fat that still needs removal. A
combination of rolling and pinching is used over the surface to be liposuctioned; (D) The pinch shows the fat doubling when it is
pulled-up, showing the exact thickness of the fat layers opposed by the fingers; (E) Pinch and aspiration

27
The Setup
Once the area has been satisfactorily defatted with
continuous palpation and pinching, the finessing process
is done, using a finer cannula, to defat the zone out of
the zone to be suctioned. In addition, the feathering
technique consists of suctioning the periphery of the area
with a finer cannula and to use the cannula to free the
tissues without suction.
Extent of Liposuction
The liposuction is used throughout the area which has
been marked for defatting. It is only extended slightly at
the periphery by feathering for a smooth transition.
Constant refinements using smaller cannulas is useful,
however, this should be done carefully in order to avoid
uneven areas.
Advantages of the Crisscross
Technique
The entire suction lipectomy procedure was once based
on the single approach especially for saddlebags. It soon
became apparent that it was causing postoperative
cosmetic problems. Indentations and depressions in the
outer edges of the treated area could be mainly blamed
on this approach from only one area. The horizontal
versus vertical approach became an issue and the crisscross
technique became more popular.
The care of the suction is the ultimate root to success.
A watchful eye in all tangential areas and a constant
palpation and pinching of the tissues which are suctioned
will help in determining the evenness of the procedure.
The final touches should be performed with finer
cannulas. The author favors the Robles cannula which has
a sharp beveled tip and is useful in electively suctioning
zones that could be easily missed with other types of
cannulas.
Although in the past it was suggested to stop the
movement of to-and-through with suction when blood
was appearing, it is obvious nowadays that a bloody
suction should not in itself be a reason for stopping the
suction although it becomes more difficult and more
dangerous if the amount of blood is larger than usual.
This is the reason why the superwet and the tumescent
techniques are so useful for proper liposuction.
Technical Hints (Table 3-2)
(Figures 3-20 to 3-25)
„
Penetrate deep and stay deep, riding the cannula over
muscular fascia (Figure 3-30 to 3-34).
Intraoperative controls
Tests:
•
Pinch
•
Rolling pinch
•
Compression test
•
Amount of fat to be aspirated
–
Tests of quality
–
Pinch (1 cm)
–
Blood in tubing appearance test
•
Appearance Tests:
–
Appearance test
–
Tests of regularity (comparison and rolling pinch
test)
–
Test of quality
-
Check if there is dimpling tumors or masses
-
Compression test which magnifies the defect
–
Tests of improvement
-
Appearance
-
Amount in the bottle
-
Pinch of the same size on both sides
–
Prognostic tests
TABLE
3-2
FIGURES 3-20A AND B
(A) The exact extent of the suction process is depicted by the
bruising of the tissues. This type of photograph should be
used as an illustration for patients requesting explanations.
The bruising will last approximately three weeks; (B) Lateral
view of the same patient showing the exact extent of the
suction
„
If one is to perform superficial liposuction, the zone of
suctioning should become more and more superficial
with thinner cannulas to obtain an even result.
„
Diverging tunnels are made close to each other in order
to remove the fatty layers without “missed areas”
(Figures 3-26A to C).

28
Atlas of Liposuction
FIGURE 3-21
The superficial fascia of the hip and saddlebags area shown
below the skin. This layer should not be entered by the
cannula to prevent dents and depressions. It is entered only
when superficial liposuction is contemplated
FIGURE 3-22
The most probable cause for dents and depressions is the
tenting-up of the skin by the cannula which transforms an
inferior cannula opening into a superior opening
FIGURE 3-23
Process showing the liposuction combined with the
penetrating action of the cannula resulting in superficial fat
removal and skin depressions unless the surgeon decides to
perform superficial liposuction
FIGURE 3-24
When one desires extreme thinning, the technique of
liposuctioning between the pinch will help in accomplishing
that goal. The superficial liposuction affected here is often
used for neck, knees and ankle liposuction and sometimes
for saddlebags as described by Gasparotti
„
Use the left hand to flatten the tissue during suction and
use the flat of the palm to ensure a uniform thickness
under the skin.
„
Use the left hand to grab areas in order to defat them
more thoroughly when they have been felt to be too
thick. The cannula is introduced between the grasping
fingers during suction.
„
Use the crisscross technique for thorough defattening.
„
Flatten the edges and be careful at the periphery of each
area by feathering and liposuctioning less fat.
Cellulite
The so-called cellulite is a skin condition which was
originally described by the French. Although it took some
time for this concept to be understood in this country,
it is at this time rather well-conceived and its treatment
is requested by many patients. A simple look at the
advertisements in magazines indicates the concerns of the
female about this special condition.

29
The Setup
FIGURES 3-25A AND B
(A) In abdominal suction, safe technique consists of elevating the tip of the cannula at all times in order to prevent an accidental
fascia penetration with abdominal organ injuries; (B) This is a great way to judge the fat thickness by observing its thickness
over the elevated cannula
FIGURES 3-26A TO C
Cut section showing the levels of depth in liposuction technique. The superficial liposuction is used to thin-out the subcutaneous
fat level as opposed to the deeper liposuction going under the superficial fascia system and liposuctioning the deep fat deposits
only

30
Atlas of Liposuction
FIGURE 3-27: CELLULITE
Superficial fat with appearance of “peau d’orange”, a
mattress-like skin surface. This was originally described
Nürnberger and Müller (1978).4 Under the microscopic the
subdermis shows some chambers of fat separated by septa
(retinacular cutis) in arches and raised and holding the
subepidermis chorion down to the superficial fascia below
FIGURES 3-28A TO C
(A) A 29-year-old woman with cellulite, more noticeable after suction lipectomy, and marked for surgical repair, using fibrous
septa cutting and liposuction-filling; (B) Postsurgical; (C) Three months after cellulite release with some improvement. Further
surgery is indicated for completion of the procedure
The cellulite from a medical standpoint does not
respond to its definition. Cellulite in French indicates an
irregular, bumpy skin surface with depressions, however,
in English cellulitis means an infection of the area of the
skin, so this definition does not apply really to the
condition described (Figures 3-27 and 3-28).
The condition consists of a bumpy skin surface
interspersed with areas of depression. This appearance is
difficult to understand, however, it could be related to the
appearance of a mattress with the multiple buttons that
are holding the mattress at different regular spaces. On
the patient, the area is tender to palpation and especially
to pinch. It seems to be a more sensitive skin than the
ordinary skin probably due to the congested, tense, fat
deposits in these areas. Cellulite, however, does not regress
with weight loss and is apparent in the hips, the thighs
and the buttock, especially, although it could be present
in many other areas.
For the longest time there was a paucity of medical
treatments and this has allowed all the paramedical
treatments to come into play. All types of claims are made
by many companies and all types of treatments are
advised such as massages, special diets, special baths, oils,
exercises, and so on. In reality, very little can be done
medically to improve this condition. The demographic
distribution is limited mainly to females and it is rare in
males. It appears from 15 years of age on.
Lately a new concept has emerged representing,
actually, two types of cellulite—the young-age cellulite and
the old-age cellulite. Young-age cellulite consists of this
particular appearance that has been described above.
Old-age cellulite consists mainly of a relaxation of the
skin in many areas ending in a wavy, rippled type of skin
appearance most likely due to the skin relaxation over tight
fascial bands. From a scientific point of view, cellulite of
young age can be described as the hypertrophic fat cells
that have overgrown their boundaries and are pulling
under the skin, thus imposing some tension on the many
ligaments that attach the skin to the deeper fascia. The
concept of superficial fascial system (SFS) shows that the
skin is actually holding to the body underneath by a
collagen network representing a large sheath all around the
muscles sending rope-like attachments to the skin and
holding it in its position preventing it from sliding away
from the muscles underneath. This superficial fascia

31
The Setup
system divides the fat into two areas, one situated above
it and just under the skin. The second one below it is
especially large in certain areas such as the saddlebags, the
buttocks, the inner thighs, the abdomen and the back of
the arms. This concept of deep and superficial fat makes
us understand why cellulite has not been amenable to
treatment in the past.
Liposuction has allowed the reduction of the fat layers
under the superficial fascia, however, it is a difficult
treatment above the fascia since it can result in unwanted
depressions giving the same appearance as the cellulite
appearance. After the original work of Zaki Ftaiha in
1988, the treatment of cellulite has evolved gradually
showing that it can be performed using a sharp square-
end cannula allowing the actual freeing of the skin by
cutting the ligaments attaching it below.
The author has added the additional technique of
injecting some fat in the same zones that have been
liberated in order to prevent a too quick reattachment of
the skin below and to allow some limited mattressing,
thus, preventing the full recurrence of the deformity. This
type of cutting and injection of fat just beneath the skin
surface can be adapted to treatment of inadvertent
superficial suction done during surgery ending up in
depressed areas.
Although it is understood that a large portion of the
injected fat will actually disappear since it depends on a
new circulation, it has been found, however, that some
of this fat will actually remain and will help in the
treatment of the so-called cellulite condition.
Superficial Aponeurotic Fascial
System
The superficial aponeurotic fascial system has been
described in the literature and in most anatomy books. Its
knowledge was useful only in cases of abdominal surgery
and in general principles of skin closure. After more
extensive studies by Lockwood, its importance is now
recognized and applications of its recognition are more
numerous.
Description
The interest in the SFS is related to its importance in
providing support to the skin and its subcutaneous fat—
especially in surgical repair of the skin and in the
movements as it allows some limited gliding of the skin
over the muscles below it.
The characteristic of the SFS is its adherence in some
areas, such as, groin, axillas, gluteal folds, inframammary
folds, nasolabial area, which limits the anatomical areas
and consequently allows the relaxing of skin between these
“fixed points” when the patients are the victim of obesity
or aging.
This relaxation of skin can consequently only be
corrected by excisions within these areas between the fixed
points (abdomen lipectomies, mammoplasties, trochanteric
lipectomies and so on).
Fat Layers and the Superficial
Fascial System
The understanding of the anatomy of the subcutaneous
fat shows that there are two layers of fat in zones, such
as, the hips, the abdomen, the posterior aspect of the arm
and that in some areas the two layers are fused, since the
“deep fat” does not exist in these locations (knees, ankles,
chest and forearms).
These two layers can be hypertrophied and it is the
understanding of the relationship that will help to avoid
irregularities, dimples and “streaks” seen when the fat is
removed too superficially. The SFS in some parts of the
body (saddlebags, abdomen) covers a deeper fat layer. The
suction process is directed under it preserving the
superficial fat layer that is cosmetically more acceptable
(saddlebags). In some areas thinning out is done over it,
between it and the skin, since there is no fat layer below
this superficial fascia (ankles, neck arms). The surgical
judgment in suction is more of an esthetic judgment than
a scientific one and sometimes when superficial suction
is performed, the fat situated above the SFS is then
removed.
Superficial Liposuction
In primary or secondary cases when an excess of skin is
present and exhibits a cascading surface the technique of
superficial liposuction using small cannulas (3 mm and 2.6
mm Robles cannulas) will allow the skin to retract
properly.
Two different processes are available. One process
consists of utilizing an all-level liposuction allowing skin
retraction. Another process consists of limiting the suction
to the superficial layer, ending up with the same skin
retraction eventually. The incision is similar to liposuction
incisions (infragluteal and hip). The patient is positioned
laterally since this facilitates the visualization of the results
of surgery.
Pushing the buttock down helps in determining the
amount of saddlebag remaining and its eventual
correction, which is usually difficult in the prone position.
Superficial liposuction is effected until the skin can be
grasped and elevated from the tissues below it, however,
the technique should not cut all the strands of the skin

32
Atlas of Liposuction
in a cellulite release maneuver, that is dangerous creating
large pockets, but the process should only extract the fat
cells and leave the connective strands intact.
After the work of Gasparotti, the superficial suction
technique has become popular since it is helpful in
obtaining better results.
The technique allows improvement of flaccid areas in
older patients, and obtaining a thinner and firmer looking
cutaneous surface. The process is based on the belief that
skin is endowed with a significant degree of retractile
possibilities; the technique reaches the fatty layer situated
immediately under the skin thus reducing the effect of
gravity. This surgery is performed using fine cannulas
between 2 mm and 3 mm and attempting a very thorough
and very even suction.
Indications
Patients who present skin irregularities, either post-suction
lipectomy or due to old age as well as young age cellulite,
are candidates. Cases of fat lipodystrophy wherever present
are good indications for superficial suction. In old patients
with flabby, redundant skin, deep liposuction would only
accentuate the superficial defects presented here. This skin
problem is sometimes called old-age cellulite. The patients
who have depressions and bumps as well as older patients
with flabby, relaxed skin are thus good candidates. Other
cases consist of the poor result after liposuction with skin
irregularities, depressions and unevenness. A last indication
consists of the young age cellulite which is the appearance
of a “peau d’orange” secondary to the retaining ligaments
of the retinacular cutis attached to the superficial fascia
system below the skin.
Caveats
Although superficial suction is especially devised for
irregular and bumpy skin surfaces, it is not, however,
always possible to obtain a smooth, regular skin.
Markings
The areas of suction are marked in the usual fashion.
Positioning
Some surgeons prefer the lateral decubitus position in
order to appreciate the degree of improvements obtained.
A 4 mm incision is made in the ordinary fashion in the
hip and in the subgluteal folds. The superficial suction
follows a 4 mm cannula liposuction by the use of a 2.6
or 3 mm cannula in the more superficial layers. This is
thoroughly connected with all the abnormal areas which
are still containing some residual fat.
Technique
After local infiltration of a tumescent solution, the
superficial liposuction follows the normal liposuction
performed in the area which is the subject of the surgery.
The technique is similar to the suction lipectomy
technique, however, the instruments consist of small
diameter cannulas. The area is defatted thoroughly with
a watchful eye and multiple periods of skin pinching in
order to ascertain the exact thinning of the skin.
In cases of old-age cellulite, the additional technique
of cutting the connections that attach the skin to the deep
surface is used with the additional deposition of fat in
depressed areas which have been deliberated. These cases
are done with a 10 to 20 cc cannula to use the fat that
has been harvested elsewhere.
Discussion
In primary or secondary cases when an excess of skin is
present and exhibits a cascading surface, the technique of
superficial liposuction using small cannulas will allow the
skin to retract properly. Two different processes are
available. One process consists of utilizing an all-level
liposuction allowing skin retraction. Another process
consists of limiting the suction to the superficial layer
ending up with the same skin retraction without
much reduction of the deep fat deposits. The incision is
similar to liposuction incision and position of the patient
is often a lateral decubitus. The superficial liposuction is
effected until the skin can be grasped and elevated from
the tissues below it showing the thinning of the
subdermal level.
This technique should not involve cutting all the
strands of the skin in the cellulite release maneuver which
is dangerous and creates large pockets, and the process
should only extract the fat cells and leave the connective
strands intact.
Cellulite Release Technique
In a similar technique to the superficial liposuction, the
cellulite release technique is useful in cases of cellulite
provided that the undermining is completely extensive and
is only done in some areas to prevent the creation of a
large pocket which then would end with complications
similar to the earlier liposuction cases with wide
undermining.

33
The Setup
FIGURE 3-29
Special equipment for the ultrasonic suction consists of a
machine which is the ultrasonic generator. This is a
piezoelectric hand-piece and a high power blunt tip probe
made by LySonix 2000
Anesthesia
General anesthesia is the procedure of choice, however, if
only a limited area needs improvement this can be infil-
trated with a diluted solution of xylocaine with epinephrine.
Markings
It is important to mark most of the deeper dimples
observed on the buttock, the hips and the thighs since
it will be necessary not only to sever accurately the
retaining ligaments responsible for the dimples but also
it will be necessary to fill these depressions with some
autologous fat.
Position
Any position can be useful. The prone position and the
lateral decubitus can be used easily.
Incisions
The same incisions used for liposuction can be reused for
cellulite treatment especially for the hips, the thighs, the
saddlebags and the buttocks. The lateral hip incision, the
inner gluteal incision and a posterior paraspinal incision
are adequate for this treatment.
Technique
A sharp-end square or a V-shaped cannula (Aiache) is used
to free the septa attaching the skin to the SFS and these
are freed by methodical action of the to-and-fro
movements used for suction. The cannula remains
superficial under the skin, and since it has a cutting effect,
using repeated to-and-fro motions is performed until the
retaining ligaments are severed.
Control of superficial freeing of the cellulite is similar
to the superficial liposuction technique. It is possibly a
similar action, however, the cutting cannula helps in freeing
the deep retaining ligaments.
In cases of old-age cellulite, the additional technique
of cutting the connections attaching the skin to the deeper
SFS is used. The fat has been harvested during the suction
procedure and it can be reinjected at the time of the
superficial cellulite release. Any cannula can be used for
this action. Many different instruments have been devised
for cutting the strands holding the scar tissue down to
the deeper layers or the fibrous retinacula holding the skin
down to the SFS. The superficial suction technique is then
used and moderated by palpation and lifting the skin of
the deeper layers trying to tear away the remaining septa.
This technique allows a smooth even layer of skin.
Closure of the wound is done as usual and compressive
garments are then used for a few weeks.
In short, this technique of superficial liposuction and
cellulite release has added a new dimension in the
liposuction technique allowing a better result and even
surface of skin.
Advances in Liposuction
Liposuction with Different Systems
After the technique of liposuction was tailored to become
conventional and to become more organized, many
authors have proposed advances in the technique and the
apparatus for this procedure. There are many new findings
and some of them have been more successful than others.
One of the examples include ultrasound liposuction which
is utilized to melt and dissolve fatty tissue by cavitation
(US patent 4-886-491). This technique is making progress
(Figures 3-29 to 3-33).
Another additional invention is the use of an auger
within the lumen of the cannula to help in the removal
of soft tissue (US patent 4-735-605).

34
Atlas of Liposuction
FIGURE 3-30
A company called Vibra-Surge has created the ultrasonic
surgical instrument and it consists of the same three parts: (1)
The power machine; (2) The hand-piece; (3) The cannula
surgical tip
FIGURE 3-31
A company making external ultrasound machines called
Rich-Mar
FIGURES 3-32A AND B
External ultrasound machine (Wells-Johnson)

35
The Setup
FIGURE 3-33
Vaser machine, excellent for ultrasound suction
Another instrument developed by Surgitek Corporation
is the use of a reciprocating tip cannula which was
developed by companies such as MicroAire and other
companies such as Vibra-Surge from Sonimedix, Inc.
(Figure 3-34).
Other additional work was done in using electrocautery
within a cannula tip or a high pressure saline jet spray
located at the tip of the cannula which was developed by
Val Lambros.
Since these systems have not been completely
investigated and developed aside from the ultrasound
technique, they are not going to be discussed.
Another system was developed by Thomas Dressel
who uses the Nd:YAG laser for improvement on the
liposuction. The cannula utilizes a quartz glass fiber
delivery system designed to deliver up to 100 watts at the
fiber tip (35,000 joules by CM2). The fat is then aspirated
by suction through the cannula side hole and it is then
cut and coagulated by the laser beam. A group of plastic
surgeons have been named as investigators in the
technique.
The first laser-assisted liposuction was performed on
January 2, 1990 within an IRP protocol on a 34-year-old
male with abdominal lipodystrophy. Other cases have been
included.
Operating Room Protection against
Vapor Contamination
Aerosols are an efficient mechanism by which infectious
agents normally unable to penetrate through the protective
skin will enter the respiratory tract and through it enter
the blood stream. The exposure of open wounds to the
aerosols can also cause infections if a pathogen is within
the aerosol.
The technique of liposuction vaporization creates an
aerosol of fat and small amount of blood which results
in a liposanguinous aerosol. These particles could
contaminate if they contain bacteria or viruses. Especially
since this is a potential hazard, a number of reports have
been shown correlating aerosols with infection. The use
FIGURE 3-34
The new machine by MicroAire making a vibrating cannula
with back-and-forth motion of 3 mm facilitating the action and
speeding-up the process the machine

36
Atlas of Liposuction
of a filter withstanding the flow rate achieved is a way
to control this contamination. This frequent cause of
acquired infections such as inhalation is suspicious and it
is advised to use filters in the cannula in order to protect
the surgeon, the nurses, and other people attending the
operating room.
Ultrasonic-assisted Lipectomy
Researchers have developed an ultrasonic generator with
a special probe made of titanium. This system ends up
with a fat liquefaction which is then followed by suction.
The cavitation caused by the ultrasonic energy acts on the
liquid within the fat cells and has no effect on nerves,
vessels or other connective tissue.
Physics
Ultrasound waves are produced by transforming a normal
electric energy into high frequency energy. This energy is
transmitted by piezoelectric quartz crystal or to a ceramic
transducer transforming it into mechanical vibrations. Over
12–20 KHz of energy is generated and although it is too
low to be perceived by the human ear, nevertheless has
the action in the tissues. The ultrasonic waves, like all
sounds waves, have an expansion and compression cycle.
The compression cycle exerts a positive pressure on the
fluid molecules and the expansion cycles exert a negative
pressure. A sound wave of this adequate intensity will end
up generating microcavities during its expansion cycle. In
low density tissues molecular cohesion being weak allows
the ultrasonic effects to occur.
When the tissues are exposed to negative pressure of
an expansion cycle of a sound wave, the gas in the empty
spaces expands until a little bubble is formed in the tissue.
If it is a large bubble, it tends to explode destroying the
fat cell and liberating the fat. If the microcavities are
overexposed to ultrasonic energy, they are affected by the
alternative expansion and compression cycles of the sound
waves making the bubble expand and contract. The
increase in size of the cavity depends on the intensity of
the sound waves. The surface of the microcavity produced
by low intensity ultrasound is slightly bigger during
expansion cycles and during compression thus the amount
of gas diffusing expands and exceeds the compression
cycle. The biologic effect of ultrasonic energy on adipose
tissue consists of: (1) a micro-mechanical effect breaking
up chromosomes and micromolecules; (2) effect connected
with the cavitation phenomenon, ending up in explosion
of the fat cells; (3) thermal effects which are sometimes
difficult to control during the liposuction performed on
patients.
Surgical Procedure
The technique of ultrasonic-assissted lipectomy (UAL)
consists of an infiltration with ultrasound waves and then
aspiration of the liquified fat. Very accurate preoperative
markings are made and a large volume of hypotonic fluid
is infiltrated into the treatment site as it is done with the
tumescent technique. Then the technique consists of
introducing, through strategically located incisions, a
hollow titanium probe connected to the ultrasonic
generator via a handle that contains the ceramic
piezoelectric conductor. The ultrasound is started at the
same time the suction is undertaken and the probe is
moved methodically throughout the tissue in a slow,
regular manner and in a crisscross pattern similar to the
liposuction technique. Liposuction is performed at the
same time as the fat destruction occurs by the ultrasound.
Completion of the treatment is done with what is
termed refinement consisting of simple suction without
ultrasound to equalize the areas that have been destroyed
and suctioned, in addition to feather the edges to prevent
sharp demarcation of the treated tissues in juxtaposition
to the non-treated tissues.
Comments
This technique of ultrasound-assisted lipectomy has given
the following advantages to liposuction: (1) because it
actually liquefies the fat, there is less surgeon’s fatigue
during the application; (2) when it is combined with
regular suction it accelerates the length of time to perform
this technique since before the hollow cannulas, the solid
cannulas were only dissolving the fat and a second pass
was necessary to aspirate the fat.
It is usually a procedure that produced less blood loss
than the regular techniques especially if a tumescent
infiltration is performed at the same time. Although there
has been no significant difference in the postoperative
period, i.e. bruising, swelling, irregularities, it is found that
the final results have been similar to the liposuction. The
only disadvantage of the technique consists of the price
of the machine and the cannulae which have to be
replaced after 30–40 hours since they breakdown, and the
potential for burns, which are usually occurring at the tip
of the cannula if it is not moved constantly and in the
zone of incision where the constant friction of the probe
can destroy the skin edges. Some preventive measures such
as the wound protection devices and the cooling of the
cannula has been of some help in this process.
External Ultrasound Assist with Liposuction
Although external ultrasound has been used for a long
time for many conditions, it has been shown by Silberg5,6

37
The Setup
that it can be used under the skin after the infiltration
of the zone to be suctioned is done in a tumescent type
of technique. The external ultrasound is used and
apparently will end up with a smoother liposuction and
a more even result. At this time, other surgeons are
claiming that the use of the external ultrasound machine
can in itself be sufficient to resolve some fat deposits
without any concurring internal suction and that the
simple administration of the ultrasound to the fat tissues
will help in dissolving them. These claims are still to be
proven by the test of time.
As far as the external ultrasounds are concerned in the
pre- and postoperative care of internal liposuction, there
seems to be a consensus of opinion that the liposuction
becomes easier to perform, it yields a bloodless liquid fat,
and apparently it makes the mechanical technique easier
to perform physically ending up in less fatigue to the
surgeon. Again, these claims are to be proven by the test
of time.
References
1. Schrudde J. Lipexeresis in the correction of local adiposity. Rio
de Janeiro: Proceedings of the First Congress of the
International Society of Aesthetic Plastic Surgery; 1972.
2. Fischer A, Fischer GM. First surgical treatment for modeling
body’s cellulite with three 5 mm incisions. Bull Int Acad Cosm
Surg. 1976;2:35-7.
3. Fischer G. Orthostatic liposculpture. In: Shiffman MA, Di
Giuseppe A (Eds). Liposuction: Principles and Practice. Berlin:
Springer; 2006. pp. 217-21.
4. Nürnberger F, Müller G. So-called cellulite: an invented disease.
J Dermatol Surg Oncol. 1978;4:221-9.
5. Silberg BN. The technique of external ultrasound-assisted
lipoplasty. Plast Reconstr Surg. 1998;101:552.
6. Silberg BN. The use of external ultrasound assist with
liposuction. Aesthetic Surg J. 1998;18:284-5.

4 Saddlebags
Introduction
The so-called “saddlebags” deformity consists of fatty
deposits just below the hips. The deformity continues
laterally and posteriorly under the buttocks often mixing
with the buttock excess resulting in a buttock without a
fold or in a deformed lower thigh. The infragluteal fold
is lost or deformed and will have a downward slant
laterally (Figures 4-lA and B).
In the past, the treatment for this problem consisted
of the trochanteric lipectomy which was leaving an
extremely extensive scar. This technique was developed by
Pitanguy. It is still performed on old patients with excess
skin that cannot be improved by simple suction.
These large excisions were also resulting in secondary
deformities and scar problems which were worse than the
original one.
A B S T R A C T
The so-called “saddlebags” deformity consists of fatty
deposits just below the hips. The deformity continues
laterally and posteriorly under the buttocks often mixing
with the buttock excess resulting in a buttock without
a fold or in a deformed lower thigh. The infragluteal fold
is lost or deformed and will have a downward slant
laterally. The indications for treatment and the techniques
are described in this chapter.
Indications
Unsightly lateral thigh area just below the hip, which does
not respond to dieting or exercises, is the major indicating
factor. Some patients with this condition will have tried
desperately to reduce weight but to no avail. All types of
treatments used by quacks such as body wrapping, herbs,
massages, and regimens with applications of creams,
ointments and liquids have been sold to a credible public.
Liposuction is the most successful treatment in correcting
this deformity.
The slightly obese female saddlebag problem is more
severe than of the more obese patients since the fat cells
FIGURES 4-1A AND B
General appearance of the violin deformity consisting of an
iliac crest excess and saddlebag excesses on the same
patient
Adrien E Aiache

39
Saddlebags
in this area are particularly prone to overdevelop and
accumulate. Thin patients with very minimal saddlebags
will nevertheless exhibit excellent results with these
exercises.
The Cellulite Question
Cellulite is a different entity and was confused in the past
with the saddlebag deformity. Cellulite itself can be
corrected with the techniques that have been described in
the preceding chapter.
Contraindications
Patients such as older women, especially those with soft
skin, irregularities, bumps, peau d’orange and depressions
should not be considered as the skin will not drape well,
leading to a “golf-pants” effect as a variation of the
saddlebags. Irregular bumpy skin with cellulite effect will
only improve slightly unless the cellulite treatment is
performed, especially with the new technique of superficial
liposuction and cellulite release technique.
Age
Age is important since patients over 40 often present
looseness of tissue with wavy and irregular multiple bumps
which is called cellulite of old age. This non-elastic skin
will remain bumpy and wavy unless a thorough superficial
liposuction is performed to improve the area. Patients who
are under 40 and who have good skin tone should be
selected for this type of surgery. If patients are in the
contraindication category, they must be warned of the
possible complications and problems associated with the
technique, i.e. irregularities and bumps of the skin, although
in some cases no warning can deter these patients.
Caveats
The saddlebag area could produce dents and bumps if the
suction is performed in a non-homogenous way. This area
is “unforgiving” of excessive liposuction since the fat lies
on a non-yielding portion of the body, covered by the
tensor fasciae latae (TFL), where any loss of fat in uneven
areas will show. To obviate this problem, superficial
liposuction is indicated and will help in correcting the early
problems created by uneven suction. The area of the
saddlebags contains fat in two compartments, one above
the superficial fascia system, and the other one below it
and above the muscle. This zone of deep fat can be
suctioned safely, however, in a lower part of the thigh,
at approximately the middle third outer area, the two
compartments will meet and the deep fat compartment
disappears. If the liposuction is done in continuation of
the deep extraction and it reaches this superficial level,
very severe depressions can be created.
Symmetry
An important factor is the possible difficulty in achieving
symmetry between the two sides of the thighs and the
buttocks. Often one side is larger than the other, a
condition which the patient may not notice until after
surgery. This is a known phenomenon, which people
discover only after surgery that they have some type of
asymmetry that they failed to notice previously. The
patient should be made obligated to pay more attention
to their asymmetry before surgery. One should proceed
in the following manner:
„
Prior to surgery point out the differences in the two sides
including the volume and location of the buttocks, the
outer thighs and the buttock folds as well as any
difference in shape, length and direction. Also, point out
the location (height) of the saddlebag, its extent and its
shape.
„
Try to correct the asymmetry during surgery, by removing
unequal amounts of fat, until a symmetrical correction
is achieved.
„
Relocate the buttock fold as shown in the following
chapters.
Markings
The patient is marked before surgery in an erect position.
This is the only position that will indicate the extent of
the abnormality. Preoperative pictures are taken in the
antero-posterior position, lateral position and oblique
position. These photographs are taken before and after
the markings.
The following procedure for making topographic
markings is recommended: first the area to be suctioned
is carefully marked off in the anterior-posterior position
by marking a line to demarcate where the excess fat starts
superiorly and inferiorly. Next, the anterior and posterior
estimate of excess is made while the patient is viewed in
the lateral position. Note that in this lateral position, the
anterior and posterior estimates are difficult to establish
but the pinch test is usually very helpful. These tests
indicate which areas contain a fully excessive amount of
fat as opposed to areas in which the fat digresses to a
more normal thickness. The occasional dales or valleys are
also carefully noted and marked off at this time so that

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Atlas of Liposuction
no excess liposuction will be done. The area of thickest
fat protrusion should especially be marked with crosses
to indicate the need for more concentrated suction. There
is a very elective spot in the outer posterior saddlebag part
that is the subject of extreme precaution since there is
a large excess of fat that can be corrected only if one
is actively aware of it. The patient is turned anteriorly,
posteriorly, medially, and in three-quarters in order to
assess the exact volume and shape of the excesses which
are then marked accordingly (Figures 4-2 to 4-8).
If infragluteal folds are to be made or improved, their
position should be precisely noted since patients will often
have different height gluteal folds due to a congenital
FIGURE 4-2
The topographic markings, although helpful in figuring out the
excesses in diminishing stages, do not really represent to be
done and in this particular case it would be insufficient
FIGURE 4-3
Markings for moderate saddlebags liposuction. Notice their
extent
FIGURE 4-4
The reality of liposuction is that it removes fat along the
trajectory of the tunnels and leaves fat in between those
tunnels. Crisscrossing ensures a more homogenous removal
of fat
FIGURE 4-5
Depiction of the crisscrossing from two different incisions for
liposuction in the determined area. Note the amount of lower
buttock suctioning encompassing an area above the gluteal
folds
problem, spinal scoliosis and unevenness. The lower part
of the saddlebags at a junction with the normal thigh must
also be carefully marked to prevent depression secondary
to suction below this point (Figures 4-9A and B). Too
aggressive an approach could result in problems difficult
to correct the fat area and it would endup with severe
depressions just over the TFL and below the saddlebag area.