Fat Injection From Filling to Regeneration

800
Part III • Clinical Applications • Upper Extremity
Preoperative
A
B

C
2 years postoperatively
D
E

F
Fig. 43-17, A-F
T is 4 -year-old man presented with dif use subcutaneous atrophy o the dorsal hands and what he
perceived as inadequate orearm and wrist size. Fat or gra ing was harvested rom various areas o the
patient’s abdomen with a blunt Coleman harvesting cannula.

801
Chapter 43 • Hand and Forearm Rejuvenation
8 years postoperatively
G
H

I
Fig. 43-17, G-I
With the use o a Coleman type I cannula, 5 cc o structural at were placed into the right orearm and
wrist, and 52.5 cc were placed into the le orearm and wrist. T e ull area o the dorsum o the right
hand was then addressed. Using a blunt Coleman cannula, cc were removed and centri uged to yield
cc. T e hands were dressed with Micro oam tape and urther secured with stockinets. Increased girth
and def nition o the treated areas remain visible years postoperatively.
C om p l i ca ti on s
EDEMA
T e hundreds o passes with a cannula create substantial swelling in the dorsum o the hand, but bruis-
ing is surprisingly minimal. In act, I have never seen signif cant bruising o the hand a er inf ltration o
at with a type I blunt Coleman cannula. Within 2 to weeks a er the procedure, much o the swelling
has subsided and although the hands may be a little pu y, they usually look natural and presentable.
However, observant patients may notice changes in the amount o swelling or 6 to 2 weeks or more.
LUMPS
Be ore 992 I used sharp 6-gauge needles to inject lumps o at into the dorsum o the hand and then
massaged the at into a smooth layer. My patients be ore that time experienced unpredictable results,
and there were two complications. Some small but noticeable lumps occurred, perhaps caused by un-
even spreading o at or by at migration. None o the irregularities bothered the patients enough to
have the lumps removed. Irregularities and migration have not been a problem with at placed into the
dorsum o the hand since 992, when I changed the placement technique.

802
Part III • Clinical Applications • Upper Extremity
SCARRING FROM TOPICAL THERAPY
T e only other complication in the hand that I have experienced in my cases was unilateral scarring o
the dorsal hand during a simultaneous chemical peel.
INFECTIONS
I have not seen any bacterial or viral in ections in patients with at gra s to the upper extremity.
DAMAGE TO UNDERLYING STRUCTURES
No signif cant hematoma or even signif cant bruising in the dorsum o the hand has occurred when
blunt cannulas are used, and my patients have not complained o sensation changes. However, I have
seen several patients in consultation a er placement o at into the dorsum o the hand by other phy-
sicians. Some o these patients had gra ed at located deep to the tendons, and at even appeared to be
present in the intrinsic muscles o the hand. Presumably, in these patients at had been injected in a lump
into the dorsum o the hand, and the physician had then attempted to push the lump into a atter mass,
during which process the at was displaced into the deeper planes o the hand.
D i scu ssi on
Placing at in a structured ashion with many minuscule parcels o at over the dorsal hand creates un-
derlying support as well as a radial expansion o the skin. Purpose ul placement o atty tissue so that it
orms a structured layer can restore a long-lasting, youth ul ullness to the dorsum o the hand. Gradual
improvement in the quality o skin with thickening and improved elasticity play an important role in the
rejuvenation o the dorsal hand skin. T e physical presence o a thin layer o atty tissue and the e ect
o thicker, more elastic skin will not only decrease the blue o the dorsal hand veins and the white o the
extensor tendons but also obscure or so en the shape o veins and tendons. T e overall e ect is to create
a thickening and improve elasticity o the aging skin o the dorsal hand with an underlying youth ul-
appearing subcutaneous ullness that is the primary site o wrinkling o the dorsal upper extremity.
A video relevant to this topic can be found in the Video Contents list on p. xxvi.
RECOMMENDED READING
Abergel PR, David LM. Aging hands: a technique o hand rejuvenation by laser resur acing and autologous at
trans er. J Dermatol Surg Oncol 1 5:7 5, 19 9.
Aboudib JC, de Castro CC, Gradel J. Hand rejuvenation by at f lling. Ann Plast Surg :559, 199 .
Abrams HL, Lauber JS. Hand rejuvenation: state o the art. Dermatol Clin :553, 199 .
Charles-de-Sá L, Gontijo-de-Amorim NF, Maeda akiya C, Borojevic R, Benati D, Bernardi P, Sbarbati A,
Rigotti G. Antiaging treatment o the acial skin by at gra and adipose-derived stem cells. Plast Recon-
str Surg 135:999, 15.
Coleman SR. Hand rejuvenation with structural at gra ing. Plast Reconstr Surg 11 :1731, .
Coleman WP. Fat transplantation. Dermatol Clin 17: 91, 1999.
Fenske NA, Lober CW. Structural and unctional changes o normal aging skin. J Am Acad Dermatol 15:571,
19 6.
Fournier PM. Who should do syringe liposculpturing? J Dermatol Surg Oncol 14:1 63, 19 .
Glogau RG, Beeson WH, Brody HJ, et al. Re: Obagi’s modif ed trichloroacetic acid ( CA) controlled variable
depth peel: a study o clinical signs correlating with histological f ndings. Ann Plast Surg 3: 9 , 1997.
Jimenez G, Spencer JM. Erbium:YAG laser resur acing o the hands, arms, and neck. Dermatol Surg 5: 31,
1999.

803
Chapter 43 • Hand and Forearm Rejuvenation
Lauber JS. Application o the tumescent technique to hand augmentation. J Dermatol Surg Oncol 16: 69,
199 .
Lewis CM, Toledo LS. Contour augmentation. In Gasparotti M, Lewis CM, Toledo LS, eds. Superf cial Li-
posculpture. New York: Springer, 199 .
Mojallal A, Lequeux C, Shipkov C, et al. Improvement o skin quality a er at gra ing: clinical observation
and an animal study. Plast Reconstr Surg 12 :765, 2 9.
Obagi ZE, Obagi S, Alaiti S, et al. TCA-based blue peel: a standard procedure with depth control. Dermatol
Surg 1 :77 , 1999.
Skouge JW, Ratner D. Autologous at transplant. In Coleman WP, Hanke CW, Alt TH, Asken S, eds. Cosmetic
Surgery o the Skin: Principles and Techniques, ed 2. St Louis: Mosby–Year Book, 1997.
Teimourian B, Adham MN, Chiaramonte MF, et al. Rejuvenation o the hand: at injection combined with
TCA peel. Aesthetic Surg J 2 :7 , 2 .

(Trang không có chữ)

Per cut aneous Aponeur ot omy
and Lipo il l ing
as a Regener at ive r eat ment
Alt er nat ive or Dupuyt r en s
Disease
Steven E.R. Hovius, Hester J. Kan, Jenni er S.N. Verhoekx,
Christianne A. van Nieuwenhoven, Roger K. Khouri
D
f b h
x f h .1 I
b b h h z b
h h f b b h f b -
.2 D b x ,
(LF), - h (NA)
j . NA w b L x , z h U
S , b F h R j .3-5 T -
b h , h h h
.6,7
I h h h w h NA,
x percutaneous aponeurotomy and lipof lling (PALF).8
T h q h f b h h f k
h k h b . T h
f b x wh h w j . T h
b f , b b b w h ,
h b k h .9
I h w h , h b f h -
.10 F h , h h
w h
f b .11,12
C h a p t e r 4 4
805

806
Part III • Clinical Applications • Upper Extremity
We have shown that stem cells derived rom adipose tissue inhibit proli eration o contractile myo-
f broblasts.13 Myof broblasts are the key cells leading to f broproli eration causing exion contrac-
tures.14 T ere ore inhibiting these myof broblasts using lipof lling containing adipose-derived stem cells
(ADSCs) represents a treatment strategy in inhibiting Dupuytren disease.
In this chapter, we will describe the benef t o at gra ing in conjunction with extensive percutaneous
aponeurotomy as a treatment strategy or Dupuytren disease. We will discuss the basic scientif c re-
search on the e ects o ADSCs on Dupuytren myof broblasts and review the clinical results o our PALF
procedure.
BASIC SCIENCE RESEARCH
Fig. 44-1
o study the e ects o stem cells on Dupuytren myof broblasts, we obtained tissue samples ollowing
in ormed consent (MEC-2 -29 ). Dupuytren myof broblasts were isolated rom nodular tissue rom
patients undergoing surgery, and human dermal f broblasts were isolated rom ull-thickness skin sam-
ples. T is actin cytoskeleton was visualized with a-SMA (red) and F-actin stain using phalloidin (yellow),
and the nucleus was stained with DAPI (blue). ADSCs were purchased rom Lonza (Berkshire, UK).
Co-cultures o di erent cell proportions o myof broblasts ( %, 75%, 25%, %) combined with ADSCs
or control dermal f broblasts were cultured or up to 5 days to evaluate proli eration rates. For exper-
iments to examine the e ect o soluble actors on proli eration, supernatants o myof broblasts, AD-
SCs, and direct contact cultures (5 % myof broblasts combined with 5 % ADSCs) were harvested a er
2 hours, and myof broblasts were cultured or up to 5 days in these supernatants.
Cell proli eration was measured using a 5-ethynyl-2′-deoxyuridine microplate assay, which incorporates
into DNA during active DNA synthesis, and assessed with a uorescent microplate reader by measuring
excitation/emission at a wavelength o 5 to 5 5 nm. o assess DNA content or proli eration studies,
cultures were stained with Hoechst 25 dye and analyzed with a uorescent microplate reader by mea-
suring excitation/emission at a wavelength o 5 to nm.

807
Chapter 44 • Percutaneous Aponeurotomy and Lipo illing
Fig. 44-2
0
25
50
75
100
P
e
r
c
e
n
t
a
g
e
Myofibroblasts
Conditioned medium
Myofibroblasts
Conditioned medium
ADSCs
Conditioned medium
Myofibroblasts + ADSCs
10,000
12,500
15,000
17,500
C
e
l
l

n
u
m
b
e
r
C
e
l
l

n
u
m
b
e
r
Myofibroblasts
75% Myofibroblasts + 25% human dermal fibroblasts
25% Myofibroblasts + 75% human dermal fibroblasts
Human dermal fibroblasts
10,000
12,500
15,000
17,500
Myofibroblasts
75% Myofibroblasts + 25% ADSCs
25% Myofibroblasts + 75% ADSCs
ADSCs
1

2
1
2
3
NS
A
B
C
Co-cultures o myof broblasts combined with ADSCs led to a reduction in cell number at day 5 com-
pared with myof broblasts cultured without ADSCs (p < . 5) (A), whereas co-cultures o myof broblasts
combined with control dermal f broblasts demonstrated no di erence in proli eration (B).
Supernatants taken rom ADSCs led to decreased myof broblast cell number at day 5 (p < . 5), whereas
supernatants taken rom myof broblast cultures had no e ect (p = .9 ) (C). Subsequently we tested
whether direct contact cultures in uenced soluble actors produced by ADSCs by culturing myof -
broblasts in supernatants taken rom direct contact cultures (5 % myof broblasts combined with 5 %
ADSCs). Supernatants o direct contact cultures led to decreased myof broblast cell number at day
5 (p < . ), a signif cant decrease compared with supernatants rom noncontact ADSC cultures
(p < . 5).13

808
Part III • Clinical Applications • Upper Extremity
P a ti ents a n d M
ethod s
PATIENT SELECTION
Ideal candidates or this technique are patients who want to minimize recovery time and have multiple a -
ected digital rays. Young women with a recurrent proximal interphalangeal (PIP) joint contracture or with
severe diathesis are less suited. PIP joint contractures, especially when they are o long-standing, are di cult
to ully release because o inherent joint contractures and attenuation o the central slip extensor tendon.
We do not recommend the PALF procedure or treating patients who have undergone previous ap sur-
gery in the a ected area, because the scarred neurovascular bundles are no longer loose and there ore as
vulnerable to be severed by the needle as the recurrent cord and the surrounding scar tissue.
PALF PROCEDURE
o harvest the at, the designated donor area (typically the abdomen or anks) is inf ltrated with a
mixture o 5 ml .9% sodium solution combined with 2 ml o lidocaine and .5 mg epinephrine
1:2 , and sodium bicarbonate. T e harvested at is not centri uged but is simply processed by grav-
ity sedimentation. T e sedimentation takes approximately 1 minutes per 5 ml. T e tumescent uid is
drained away, and the at is not strained and is minimally exposed to air.
Fig. 44-3, A and B
Preoperative primary Dupuytren disease
A
Affected third, fourth, and part of fifth finger
B
T e PALF procedure can be per ormed in an outpatient clinic with proper acilities or in daycare acili-
ties. Patients are placed in the supine position, and the a ected arm is placed on an arm board. Several
orms o anesthesia may be used:

1. A locoregional block or the upper extremity, combined with a local anesthetic or the area to be
liposuctioned to harvest at

2. General anesthesia

3. Peripheral isolated or combined nerve block, together with a local anesthetic or the area to be
liposuctioned

4. Local superf cial anesthesia o the a ected f ngers, combined with a local anesthetic or the area
to be liposuctioned
A er complete exsanguination o the a ected digital ray, it is placed under maximal orced extension
with a rather sti but still pliable hand retractor.

809
Chapter 44 • Percutaneous Aponeurotomy and Lipofilling
Superficial nicks with 19-gauge needle—maximum depth
bevel of needle
C
End stage of needle aponeurotomy
D
Curved needle creates space for fat graft
E
F
G
At end stage webspace is again opened

Hyperextension is possible
H
I
Needle with a fat graft

Fat injected
J
Fig. 44-3, C-J
A 1 -gauge needle is used to make multiple staggered punctures along the whole cord in an orderly fash-
ion, starting proximally and moving distally as the cord is severed by gentle lateral oscillation of the needle
tip. Control of the penetration depth is gauged by the bevel of the needle, since this will prevent damage to
the arteries and nerves of the digit. Proximal to the transverse palmar crease, a puncture depth of 2 to 3 mm
can be used; beyond that level, a depth 1 to 1.5 mm is appropriate, depending on the thickness of the skin.
A blunt-tipped 1 -gauge cannula is used to inject the harvested lipoaspirate into the palm and digits
through two or three needle puncture sites. On average, a total of 1 to 15 cc of very loose decanted li-
poaspirate per digital ray is injected. Some of the lipoaspirate will escape through the needle release sites.
Slight ballooning of the palmar skin is acceptable, because the injected fat is very dilute.

810
Part III • Clinical Applications • Upper Extremity
During surgery the contracted f ngers should remain under constant strong extension with a lead hand
retractor. T is tension is necessary to localize residual restricting bands until the contracture is ully
released. T e surgeon must be aware that the needle will cause the taut restrictive f bers to snap while
sparing the looser neurovascular bundles. T is constant tension will ensure the selective cutting ability
o the needle tip and the sa ety o this procedure. A er longitudinal release o the cord, an angled needle
is introduced and with a sweeping windshield-wiper arc o motion in the subdermal plane, the cutane-
ous insertions o the cord are urther released.
K
Injection complete

Plaster splint/dressing for 1 week
L
Fig. 44-3, K and L
A er surgery, a plaster extension splint with an incorporated dressing is applied to the operated hand.
T e splint is removed in to days in the outpatient clinic, and the patient is allowed to return to his or
her normal activities. Patients are advised to wear night extension splints or up to 4 months, but many
patients are noncompliant. A er open surgery no benef cial e ect o a postoperative extension splint has
been demonstrated; there ore it could be debated whether a posttreatment splint is necessary or PALF
patients.
T e duration o a PALF procedure is typically the same time as or an LF surgery; this o course depends
on the number o f ngers involved and the extent o the disease. A signif cant advantage o this technique
is the ability to treat all rays in one procedure, in contrast to open surgery, where rarely more than two
rays can be sa ely treated in one session.7
R esul ts
Our current clinical experience with PALF in Rotterdam and Miami includes more than 3 patients
treated over the past years. Our published retrospective cohort study o these patients reported data on
9 patients (99 hands); o these patients were measured with goniometry (with an average ollow-up
o 44 weeks).8 MP joint contractures could be released ully, rom 3 degrees to – degrees (an improve-
ment o 4%), whereas PIP joint contractures improved signif cantly, rom degrees to 2 degrees (an
improvement o %). Almost all patients returned to their daily activities within 2 to 4 weeks and were
very satisf ed with the results.8
A randomized controlled trial was initiated in 2 at the Erasmus University Medical Center (Rotter-
dam) to compare LF with PALF.15 T e study revealed the same contracture correction a er surgery or
the PALF group and the LF group, and at year a er surgery, no di erence was seen in the relapse o
the contractures. T e most striking di erence, however, was that PALF patients were able to return to
normal use o the hand within 9 days, compared with days or the LF-treated patients.
Recurrence rates are di cult to document, since these results depend considerably on various investiga-
tors’ def nitions and descriptions o a recurrence. We have per ormed a review o the di erent def nitions
used or recurrence o Dupuytren disease and conducted a Delphi study among experts to acquire a
broad supported def nition o recurrence in Dupuytren disease.16

811
Chapter 44 • Percutaneous Aponeurotomy and Lipo illing
C om p l i ca ti on s
O the 00 patients we have treated with PALF over the past years, we have encountered only one
permanent nerve lesion, two transient neurapraxias, and our complex regional pain syndrome (CRPS)
cases. One patient had a tendon rupture, which was treated with an additional surgical procedure. One
in ection occurred a er the operation and was treated with antibiotics.
T e overall complication rate was lower than with the standard LF procedure, especially when one con-
siders that we were o en dealing with severe multiple digital ray contractures that would normally have
required multiple Z-plasty aps or skin gra s.
D i scussi on
PALF is a radical departure rom conventional excisional surgery. Our procedure releases the contrac-
ture through a percutaneous mesh expansion o the restrictive tissue and helps prevent recurrence o
the f brosis by adding tissue with regenerative potential and inhibitory e ect on disease progression.8,17
Stem cells have therapeutic applications in regenerative medicine and have been shown to downregu-
late in ammatory cytokines and reduce myof broblast expression in f brosis.11,18 Our basic science study
shows that ADSCs inhibit myof broblast proli eration through cell-to-cell contact-dependent signaling and
through the release o soluble actors.13 Dupuytren myof broblasts are the key cells driving the pathologic
f brosis; there ore our f ndings represent a translational strategy in the treatment o Dupuytren disease.
Following extensive percutaneous needle aponeurotomy, aggregates o myof broblasts still remain that
are likely to rebuild the contracture. Fat gra ing provides ADSCs with regenerative potential and that
has an inhibitory e ect on the contractile myof broblasts. T is might explain why our experience with
this minimally invasive regenerative alternative has recurrence rates comparable to the more invasive
and more complication prone LF procedure. Our clinical results with the PALF technique show that this
is a sa e and satis ying strategy or the treatment o Dupuytren disease.
reatment o Dupuytren disease with PALF relies on two critical components:

. Applying a strong extensile traction: ension is crucial or the selective cutting ability o the
needle point. Just like a needle that will only snap the violin strings placed under tension, the
needle here pre erentially severs the taut f bers that restrict extension o the joint. T is selective
cutting ability o a needle tip or structures under tension provides the sa ety needed to spare the
precious looser neurovascular bundles. Furthermore, the multiple nicks in icted to the f bers o
the cord rupture it by attrition, creating a recipient sca old or the at gra s, and mesh expands
the skin def ciency to release the tightest o contractures without gra s or aps.

2. Fat gra ing: Autologous at gra ing is a critical component o this procedure or the ollowing
reasons. First, stem cells in the lipoaspirate have regenerative potential and inhibit the contractile
myof broblasts.13 Second, interposed gra s are reported to prevent the recurrence o Dupuytren
disease.19 T ird, at gra ing restores the subdermal at def ciency and restores normal pliability.8
When we compared our outcomes with the PALF procedure with those o the more conventional tech-
niques such as LF and NA, we ound that LF has a high complication rate (up to 0%) because o the
invasiveness o the procedure. However, the minimally invasive NA and collagenase are known to have
associated high recurrence rates.6,7 PALF is a minimally invasive technique comparable to NA, while the
recurrence is comparable to LF when assessed at year postoperatively.8 T ere ore one might say PALF
produces the best o both worlds in the treatment o Dupuytren disease.

812
Part III • Clinical Applications • Upper Extremity
C oncl usi on
PALF is a minimally invasive treatment strategy or Dupuytren disease that o ers ast recovery, minimal
complications, and a high rate o patient satis action. PALF treatment or Dupuytren disease represents a
drastic departure rom conventional excisional surgery. Without in icting any incision, this regenerative
procedure turns the diseased tissue into a loose recipient structure or gra s with regenerative potential
to achieve a result at least as satis actory as the conventional alternative.
We have shown that ADSCs inhibit proli eration o the contractile myof broblasts. Because myof bro-
blasts are the key cells leading to the development o f brosis and exion contractures in Dupuytren
disease, inhibiting myof broblasts using lipoaspirates containing ADSCs may help to avoid or reduce the
development o recurrent contractures.
Our clinical results show that patients treated with PALF can return to their daily activity in just over a
week, with results and recurrence rates comparable to the invasive LF procedure, and with lower com-
plication rates. T us it is comparable to the NA and collagenase technique, and is minimally invasive.
REFERENCES
. McFarlane R, McGrouther DA, Flint MH, eds. Dupuytren’s Disease. Edinburgh: Churchill Livingstone,
990.
. Luck JV. Dupuytren’s contracture; a new concept o the pathogenesis correlated with surgical manage-
ment. J Bone Joint Surg Am 4 -A:635, 959.
3. Badois FJ, Lermusiaux JL, Massé C, et al. [Non-surgical treatment o Dupuytren disease using needle
asciotomy] Rev Rhum Ed Fr 60: 0 , 993.
4. van Rijssen AL, Werker PM. Percutaneous needle asciotomy in Dupuytren’s disease. J Hand Surg Br
3 :49 , 006.
5. Foucher G, Medina J, Malizos K. Percutaneous needle asciotomy in Dupuytren disease. ech Hand Up
Extrem Surg 5: 6 , 00 .
6. van Rijssen AL, ter Linden H, Werker PM. Five-year results o a randomized clinical trial on treatment
in Dupuytren’s disease: percutaneous needle asciotomy versus limited asciectomy. Plast Reconstr Surg
9:469, 0 .
7. Watt AJ, Curtin CM, Hentz VR. Collagenase injection as nonsurgical treatment o Dupuytren’s disease:
-year ollow-up. J Hand Surgery Am 35:534, 0 0.
. Hovius SE, Kan HJ, Smit X, Selles RW, Cardoso E, Khouri RK. Extensive percutaneous aponeurotomy and
lipogra ing: a new treatment or Dupuytren disease. Plast Reconstr Surg : , 0 .
9. Rayan GM. Clinical presentation and types o Dupuytren’s disease. Hand Clin 5: 7, 999.
0. Lexer E. Die reie etttransplantation. In Die ransplantation, eil . Stuttgart: Ferdinand Ecke, 9 9.
. Elnakish M , Kuppusamy P, Khan M. Stem cell transplantation as a therapy or cardiac f brosis. J Pathol
9:347, 0 3.
. Dazzi F, Horwood NJ. Potential o mesenchymal stem cell therapy. Curr Opin Oncol 9:650, 007.
3. Verhoekx JS, Mudera V, Walbeehm E , Hovius SE. Adipose-derived stem cells inhibit the contractile my-
of broblast in Dupuytren’s disease. Plast Reconstr Surg 3 : 39, 0 3.
4. omasek JJ, Gabbiani G, Hinz B, et al. Myof broblasts and mechano-regulation o connective tissue re-
modelling. Nat Rev Mol Cell Biol 3:349, 00 .
5. Kan HJ, Selles RW, van Niewenhoven CA, Zhou C, Khouri RK, Hovius SE. Percutaneous aponeurotomy
and lipof lling (PALF) versus limited asciectomy in patients with primary Dupuytren's contracture: a
prospective, randomized, controlled trial. Plast Reconstr Surg 37: 00, 0 6.

813
Chapter 44 • Percutaneous Aponeurotomy and Lipo illing
6. Kan HJ, Verrijp FW, Huisstede BM, Hovius SE, van Nieuwenhoven CA, Selles RW. T e consequences o
di erent def nitions or recurrence o Dupuytren’s disease. J Plast Reconstr Aesthet Surg 66:95, 20 .
7. Khouri RK, Smit JM, Cardoso E, Pallua N, Lantieri L, Mathijssen IM, Khouri RK Jr, Rigotti G. Percuta-
neous aponeurotomy and lipof lling: a regenerative alternative to ap reconstruction? Plast Reconstr Surg
2: 2 0, 20 .
. Semedo P, Correa-Costa M, Antonio Cenedeze M, et al. Mesenchymal stem cells attenuate renal f bro-
sis through immune modulation and remodeling properties in a rat remnant kidney model. Stem Cells
27: 06 , 2009.
9. Degree I, ejpar S, De Smet L. Improved postoperative outcome o segmental ascietomy in Dupuytren
disease by insertion o an absorbable cellulose implant. J Plast Surg Hand Surg 5: 57, 20 .

(Trang không có chữ)

LOWER EXTREMITY
AND GENITAL AREA
Aesthetic
S e c t i o n S e ve n

(Trang không có chữ)

C h a p t e r 4 5
L h ly d l d h w ld. C l -
l l l ll h l ,
b v d h k y dd l d , h
l l .
P w h d l l w h f y
(S.R.C.) wh I d , h y h w h wh I h v h d h
l x .
U l k h j v h h d, l b dy l
q h -d l v l z h bl d l .
A esth eti c C on si d era ti on s
L k bl h ’ l h
ly d ly h l d w ld. W h h d l -
h ly 9 0 , w h v h h h , bd , d l v ly d
d h lv “ ddl b ,” l b k , bd l b l , d h . B k
b v d “ l ” d h b k . I l v ly h
v l, l b h ly d l d h
w ld. A l d v l d h l 9 0 h d- 9 0 , w l l y, h
l d y, d . A y wh l -
w ll l ’ l : f l l .
S h x x l , ll l , d
wly d. T h h d bd l ly l , d hy
h v h d bl l .
Iat r ogenic Liposuct ion
De or mit ies
Sydney R. Coleman, David Cangello
817

818
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
However, postliposuction iatrogenic de ormities are not just limited to sur ace irregularities. Changing
the relationship between a woman’s thighs, hips, and abdomen can result in an unnatural and even
bizarre proportion. For instance, a dramatic decrease in the size o a woman’s lateral thighs without an
appropriate decrease in waist size can result in a boxy and even masculine appearance. Flattening the
lower abdomen without attention to the upper abdomen can add to this boxy appearance. Minor reduc-
tions in the volume o the buttock and/or lengthening and deepening o the buttock creases interrupts
the continuous ow o the lateral and posterolateral thigh into the buttock. Such maneuvers o en create
a buttock that would be considered unattractive i it occurred naturally.
In 9 7 I began treating iatrogenic liposuction de ormities with at gra ing, primarily ocusing on sur-
ace irregularities. As I became more prof cient at at gra ing, I began to address corporeal proportion
to restore a more natural aesthetic proportion a er liposuction and to reestablish a eminine relationship
between waist, hips, and thighs.
A

B

C
Fig. 45-1, A-C
T is 30-year-old woman presented 2 years a er liposuction had been per ormed on her lateral thighs,
buttocks, and love handles. She was distressed because the deepening o her buttock crease now wrapped
around her thigh. She elt that her legs looked shorter and her buttocks bigger and more ptotic a er the
procedure. She also noticed that her body appeared “boxy” and less eminine. When she complained to
the plastic surgeon about the appearance o her buttocks, she discovered that he had deliberately deep-
ened her buttock crease to make it more “aesthetic . . . smiling.”

819
Chapter 45 • Iatrogenic Liposuction De ormities
D

E

F
G

H

I
J
Preoperative
K
3 years after second
grafting procedure
L
4 years after second
grafting procedure
Fig. 45-1, D-L
T e patient is shown 3 and years af er her second procedure to restore a more normal appearance to
her body. Fat was harvested rom her waist, upper hip, and lateral buttocks then placed into her buttock
creases and lateral thighs to create a more eminine and natural relationship among the waist, hip, and
thigh.

820
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
By f lling in the deepened buttock crease and slightly expanding the thighs, a more normal buttock-thigh
inter ace was reestablished. By restoring the continuous ow o the buttocks into the thighs, a more at-
tractive and youth ul line o the leg is restored.
Restoration o this buttock-thigh inter ace can have pro ound e ects on the appearance o the lateral
thigh, with smoothing o apparent irregularities.
M

N

O
P
Preoperative
Q
3 years after second
grafting procedure
R
4 years after second
grafting procedure
Fig. 45-1, M-R
Expansion o the thighs and buttock creases creates the illusion o a vertical li . However, the vectors
are radial. Restoring the continuous ow o the buttocks into the thigh produces a more attractive and
youth ul leg contour.
Liposuction is a power ul tool or alteration o the proportions o the body, but the consequences o re-
moving elements o the body or adding artif cial elements must be recognized. Care ul planning with a
clear vision o the overall result is paramount or aesthetic excellence.

821
Chapter 45 • Iatrogenic Liposuction De ormities
P a ti ent S el ecti on
Patients who present with corporeal iatrogenic de ormities have usually had negative experiences with
aesthetic surgeons. How they perceive themselves is colored by those experiences, so it is o en di cult
to assess how realistic the patient is about his or her current appearance as well as his or her expectations.
T e surgeon should not agree to per orm a correction unless he or she is reasonably conf dent that the
patient’s de ormity can be rectif ed. T e patient should be clearly told that new de ormities may be cre-
ated by harvesting at to correct the existing irregularities.
T e surgeon must have a reasonable expectation that a positive correction o the patient’s de ormity can
be accomplished without creating unacceptable new problems (such as donor site irregularities or de-
ormities). Furthermore, the surgeon should believe that the positive correction will be demonstrable on
photographs and that the patient will be able to appreciate the positive change.
It is never productive to be disapproving o surgeons who previously per ormed surgery on a patient,
because these patients usually already have critical eelings about their previous procedures. I the cor-
rective surgeon contributes negative dialogue to the consultation process, the eelings o pessimism ex-
perienced by the patient can be exacerbated. T is can make it very di cult or the surgeon to ultimately
satis y the patient. Care should be taken to approach uture procedures constructively; I hesitate to op-
erate on a patient who has a negative attitude about the planned procedure.
M
a teri a l a n d M
eth od s
TECHNICAL GUIDELINES
Anesthesia
In the past, epidural or occasionally general anesthesia was used or these procedures. However, in an
e ort to minimize complications, my anesthesiologist now most commonly uses total intravenous an-
esthesia ( IVA) or these procedures. I am ortunate to work with an anesthesiologist who is highly
experienced with o ce-based surgery and administering this type o anesthesia, which consists mainly
o propo ol, ketamine, and a narcotic agent. T e benef t o this type o anesthesia is that patients awaken
rapidly, even a er prolonged procedures, which are not uncommon when gra ing large volumes o at
or extensive de ormities. In addition, postoperative nausea, lightheadedness, and grogginess, which can
occur with inhalant anesthesia, are rarely experienced.
In addition to IVA, local anesthetic is also used in both the donor sites and the areas to be inf ltrated.
Harvesting sites are inf ltrated with the same mixture o lidocaine, epinephrine, and lactated Ringer’s
solution as the sites to be gra ed. T e mixture consists o 0 ml o % lidocaine and . ml o epineph-
rine : 000 or every 00 ml o Ringer’s lactate solution. T e harvesting sites are inf ltrated with a :
ratio o wetting solution to volume o lipoaspirate.
Incisions
When harvesting rom the back, sacrum, or hip, the lateral sacral depressions are used as the main
incision sites. Incisions into the sacral depressions are much better tolerated than incisions anywhere
else in this region, because the resulting incisional scar is less visible, even i it does become depressed
or pigmented. Occasionally an incision in the midline over the spine is used as well. T is allows or
suctioning to take place rom two di erent directions. When harvesting rom the inner thighs, a groin
crease incision is made. Incisions that are mm long are placed around the recipient sites to allow at
placement rom at least two directions.

822
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
Harvesting and Fat Preparation
Harvesting sites are selected to enhance body contour, as there has been no clear correlation between
donor site location and longevity o the implanted tissue. Care must be taken to minimize the amount o
at suctioned rom any one area such that new de ormities are not created. Incisions are made with a No.
11 blade scalpel, and a blunt Lamis inf ltrator is used to inf ltrate the previously described wetting solu-
tion. T e harvesting cannulas are Coleman aspiration cannulas, which have been designed to minimize
trauma to the tissue to be gra ed. Only a minimal amount o negative pressure is applied by hand to the
10 cc syringe to which the cannula is attached, again to minimize damage to the parcels o at.
A er harvesting, the cannula is removed rom the syringe and replaced with a cap, and the plunger o
the syringe is removed. T e syringe is then placed into a sterilized sleeve and centri uged or minutes
at 1 00 g. T e oil layer is decanted, and then the aqueous component is drained.
Inf ltration Cannulas
Fig. 45-2
I connect 3 cc syringes to the longest Coleman cannulas, which are 14- to 16-gauge and vary in length
rom 7 to 15 cm. I pre er to use the shorter cannulas (usually 9 cm), but to avoid too many incisions, I
will switch to a 15 cm cannula so I can extend placement rom any one incision. When using a 15 cm
cannula I pre er to use one that is thin, but controlling the longest cannulas through f brous planes can
be di cult, so I switch to a 16-gauge cannula i there is much resistance. I alternate between straight
and curved cannulas, depending on the curvature o the underlying structures. Although I have some
cannulas with more dramatic curves, I requently will bend the longer cannulas to create a gentle curve
to ollow the body, such as in the back or thighs. Although cannulas with the curve pre abricated into the
sha can be help ul to navigate curvatures o the body, the new multiholed cannulas are slightly bend-
able. T ese can be adjusted to create a curved plane.

823
Chapter 45 • Iatrogenic Liposuction De ormities
Fig. 45-3
I f ll the syringes with . cc o processed lipoaspirate to make them easier to manipulate. Unlike the
1 cc syringes, these syringes can be reused repeatedly without the plungers sticking. T e technique o
placement in the body di ers rom that described or the ace and hands in that slightly larger amounts
are placed with each pass. However, even or a long pass, no more than 0. cc is ever intentionally placed
in a single withdrawal.
Level o Inf ltration
T e level o inf ltration depends on the desired outcome. o accomplish large contour changes to the
thighs or buttocks, at is layered into the deep planes. In those deeper at planes and especially i any tis-
sue is placed into muscles, the thicker 16-gauge 1 cm type I cannulas are used. T e blunt large cannulas
minimize the possibility o damage to vessels and nerves in the muscles.
For a specif c groove or depression, more tissue is placed superf cially. Placement should be perpendic-
ular to the grooves or depressions that are more linear in nature. T is helps to prevent the creation o a
sausagelike de ormity, which can occur i at is placed only in a direction parallel to the long axis o the
depression. o address superf cial problems, placement starts immediately subcutaneously and inf l-
trates layer by layer to a deeper plane, specif cally eathering as the placement deepens.
Volume Ranges
Volumes or correction o corporeal de ormities vary rom 1 cc placements into minuscule irregularities
to as much as 00 or 00 cc into a def cient thigh, buttock, or arm. Experience and accurate photographs
are the most valuable tools or determining accurate volumes. T e amount o at harvested is twice as
much as the amount estimated to be used or gra ing.
TECHNIQUE
Key to Technique
T e most important step in correcting corporeal de ormities is analysis o the de ect. I the surgeon can-
not adequately demonstrate a de ormity on f lm, it will be almost impossible to show that the procedure
resulted in a positive change.
Photography or corporeal proportion is relatively standard and needs little explanation, but photo-
graphic techniques to demonstrate sur ace irregularities are generally inadequate. Casual observation
and commonly practiced conventional photography will not clearly def ne the problem in a manner that
reveals the def ciency, especially to the degree that the patient sees it.

824
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
When a patient sees her body in a standard photograph, she will usually say that the photograph does
not accurately portray the ull extent o the sur ace irregularities that she sees when she looks at hersel
unclothed. T e primary reason or this discrepancy is that the patient is most o en looking down at
her body with downward lighting when she sees these irregularities, whereas standard photographs are
taken without this elevated perspective and with more di use light. As a result, it is di cult to appreciate
the patient’s de ormity with the standard views that plastic surgeons routinely take.
Fig. 45-4, A and B
A

B
For example, with this patient, standard photographs provided scant evidence o the large depression in
the le buttock that the patient complained o .
In an e ort to address this discrepancy, I tried to photograph the patient with down lighting, up lighting,
side lighting, and with the patient in many physical positions, but with little success. I f nally developed
a system o photography or analyzing corporeal de ects to more accurately re ect what the patient
perceives and desires to have corrected. Several years ago, one o my patients insisted that I take photo-
graphs o her body while I was standing on a stool so that the camera was a ew eet above her. From this
“bird’s-eye” perspective we were both able to appreciate the extent o her corporeal sur ace irregularities
much better than rom any o the standard views.
Fig. 45-4, C and D
C
D
With this bird’s-eye view o the patient, the de ect in the le buttock is clearly visible in the same way
that it is visible to her as she looks over her shoulder or in the mirror with down lighting.

825
Chapter 45 • Iatrogenic Liposuction De ormities
E
F
Fig. 45-4, E and F
Even large irregularities can be di cult to discern in the normal photograph compared with the bird’s-
eye view. I now stand on a stool and take about ten views o a patient’s body or almost any corporeal
procedure that I per orm. T is angle allows me to appreciate the patient’s sur ace topography much more
clearly than with the photographic techniques I used to use. By shooting a patient rom a bird’s-eye view
I am better able to see the problem that the patient wants corrected.
G

H
I

J
Fig. 45-4, G-J
Af er the patient is marked to demonstrate which areas will be harvested and where the structural at
will be placed, I photograph the patient. Be ore the procedure begins, I compare the marked and un-
marked photographs, both with the patient standing. T e photos are placed side by side so I can more
accurately determine the relationship o the marks to the actual de ormity while I am operating and the
patient is lying in a supine or prone position.

826
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
Fig. 45-4, K-P
K

L
M
N
Preoperative
O
Preoperative markings
P
At 5-month follow-up
Clear photographic visualization by the surgeon o the extent o the patient’s de ect is essential or mak-
ing a plan and evaluating the extent o correction. T is photographic maneuver gives me a standardized
method o evaluating my results so that I can better appreciate the volumetric changes in my patients.
T ese bird’s-eye views allow the surgeon to better understand the ef ect that volume changes have on the
body’s shape.
Fig. 45-4, Q and R
Q
Preoperative
R
At 5-month follow-up
T e at gra s have reshaped the buttock to almost provide a “li ” to the upper buttock.

827
Chapter 45 • Iatrogenic Liposuction De ormities
Being able to review the bird’s-eye photographs while I am transplanting at into the areas has proved
very valuable. T e photographs allow me to re er to the patient’s standing appearance while she is supine,
and I can more accurately address her topography during the operation. T is has been the most impor-
tant single tool or me to obtain predictable results with at gra ing to the body.
Technique Demonstrated
Fig. 45-5, A-C
A

B

C
T is 60-year-old woman presented with a depression that developed a er she had had multiple injec-
tions o steroids into her le hip. She has a signif cant de ect rom the bird’s-eye view, but one can barely
see the problem in most o the conventional views.
Fig. 45-5, D
D
T e procedure is planned on tracings o the patient’s body in many views. T e plan devised or this pa-
tient was to remove tissue above the de ect, ref ne that tissue, and place it into the depression.

828
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
Fig. 45-5, E-J
G
F
E
I
J
H
On the morning o the procedure, the planned areas o removal are marked with a purple marker, the
planned areas o placement o the ref ned atty tissue are marked with a green marker, and the planned
incision sites are marked in red.

829
Chapter 45 • Iatrogenic Liposuction De ormities
Fig. 45-5, K-N
K

L

M
N
In these photos the patient has already had tissue harvested rom her right side and upper love handle
on the le . T e f rst picture in the series shows the type o cannula I used to use to harvest tissue. Over
time, I redesigned the harvesting cannulas to have multiple holes; the last picture in the series shows the
current design. T e f rst step in correcting the depression is to remove tissue above the de ect. T is will
atten the sur ace superior to the de ect and will provide more harvested tissue to place into the de ect. I
began harvesting the portion nearest the contralateral incision using a 3 cm straight harvesting cannula
with access through the contralateral sacral incision.

830
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
O

P

Q
Fig. 45-5, O-Q
I then switch to the ipsilateral incision and continue removing tissue laterally using either a 15 or 2 cm
straight cannula. Lubricating the incision with the oil derived rom centri ugation o the at minimizes
riction trauma to the edges o the incision. T is is the single most important maneuver or minimizing
incisional scarring during harvesting o at.
Straight cannulas obviously cannot ollow curves during harvesting or suctioning so extra incisions are
o en made to better ollow the curvature o the torso with straight cannulas. O en those incisions must
be placed in less than desirable skin sur ace sites.
o decrease the number o incisions needed to ef ectively remove subcutaneous tissue in the torso, I be-
gin using curved cannulas connected to 1 cc syringes. A gently sloping curve on a cannula allows me to
ollow the natural curves o the patient’s body. For example, I can ollow this patient’s body contours all
the way to the ar ank and hip rom a sacral incision with a 2 cm curved cannula. T is helps prevent
any irregularities o the donor site that might occur rom a straight cannula inadvertently gouging the
area.

831
Chapter 45 • Iatrogenic Liposuction Deformities
R

S
T

U
Fig. 45-5, R-U
I removed 00 cc from the right love handle and 70 cc from the hip above the depression.

832
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
V
W
X
Y
Fig. 45-5, V-Y
Placement into the de ect begins with a type I blunt 15 cm inf ltration cannula through the ipsilateral
sacral incision. T is longer cannula allows placement rom a slightly more distal incision that I usually
use or corporeal placement. T e placement begins deep and progresses in layers to a superf cial level to
create an integrated volume.
T e barrel o the cannula is f rmly grasped between the f ngers (middle, ring, and little) and the thumb
while the cannula is inserted into the incision and advanced through the tissues. I use my index f nger
(or thumb in some situations) to push on the plunger while the cannula is withdrawn. Fat is forced
through the cannula into the donor site only as the cannula is removed, not while it is advanced. No pres-
sure is placed on the plunger o the syringe during advancement o the cannula. When f rst trying this
technical maneuver, it is probably best to avoid having a f nger on the plunger because this will avoid
inadvertently injecting while advancing the cannula.

833
Chapter 45 • Iatrogenic Liposuction De ormities
Z
AA
Fig. 45-5, Z and AA
Numerous layers o at are inf ltrated in the deep tissues, gradually moving superf cially to eventually
place a layer immediately subdermal. In the more superf cial planes, special attention needs to be paid to
avoiding linear placement or lumps. Placement in the immediate subdermal plane is especially impor-
tant in patients with atrophy rom steroids or other injections.
BB
CC
Fig. 45-5, BB and CC
I try to approach most areas or inf ltration o atty tissue in the body and ace rom at least two direc-
tions because this appears to give more structural integrity to the placed tissue. Here I made an incision
to allow placement perpendicular to the previously placed at. A er making the incision with a No. 11
blade, I will o en open the depth o the incision with a small scissors or type III cannula.

834
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
Fig. 45-5, DD
DD
Continuing to use a blunt cannula, I continue placement while emphasizing the area o greatest def -
ciency in the central circle, and eathering out into the surrounding areas.
Fig. 45-5, EE and FF
EE

FF
T e placement again begins deep against ascia and muscle through to the most superf cial planes. In
this patient, the area augmented easily with no interrupting connections between the skin and underly-
ing tissue. However, i an adhesion is noted in the de ect so that sur ace dimpling or isolated depression
results, an attempt should be made to disrupt it. Aggressive interruption o adhesions should be delayed
until a er most o the placement has been attempted to the area, because disruption o the scar or adhe-
sion will create more unstable tissue planes into which the at can migrate.

835
Chapter 45 • Iatrogenic Liposuction De ormities
I recommend disruption o subcutaneous adhesions or scars with a V-dissector. Disruption o the ad-
hesions with the more delicate V-dissectors that I use on the ace is pre erred because they cause less
trauma to the recipient site tissues. However, in the body a larger (16- to 1 -gauge) and longer (1 cm)
cannula may be more use ul and ef ective.
POSTOPERATIVE CARE
Special Dressings
No dressings or elasticized garments are placed over the gra ed site to avoid creating unintentional
irregularities.
Reston oam is placed over areas that are suctioned on the body. I sometimes will place Reston oam
around areas into which I have placed tissue even i no adjacent tissue was suctioned there; this is to
relieve pressure on the gra ed areas. T is precaution is particularly important i the gra ed area may
become weight bearing, such as the area around the ischium.
A girdle or abdominal binder can also be placed to apply gentle pressure on the Reston oam, but not
over gra ed areas.
Positioning
Because the ischium is weight bearing while sitting, a er gra ing o the buttock crease or lower buttock
the patient should be instructed not to sit directly on her “sitz bones.” Rather, she should sit ar orward
or lean backward to distribute her weight so that it is not directly on the area o recent gra ing.
Because the sacrum is weight bearing when supine, the patient should be encouraged to lie on the oppo-
site side, i possible, a er gra ing around the sacrum.
Massage
Although I usually encourage patients to massage donor sites as soon a er the procedure as tenderness
in the area will permit, I ask them to wait at least months to manipulate the recipient sites because it
takes that long or the gra ed tissues to become more stable.

836
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
R esul ts
CASE 1
A

B

C

D
E

F

G

H
I
Preoperative
J
10 months postoperatively
K
1 year postoperatively
L
10 years postoperatively
Fig. 45-6, A-L
T is 4 -year-old woman presented or correction o her upper arm de ormity a er having been severely
oversuctioned. Multiple irregularities are seen, along with partial skeletonization o the upper arms. Be-
cause o the large def cit o at in the upper arms, a staged procedure was planned.

837
Chapter 45 • Iatrogenic Liposuction De ormities
During her f rst procedure, 1 0 cc o at was placed into her le upper arm, and 2 cc o at was placed
into the right upper arm, since this arm had been oversuctioned more than the le . A very small amount
(10 cc o at) was suctioned rom each proximal orearm to minimize bulging o the orearm, because it
had a somewhat “Popeye” appearance. As with all cases, at was harvested using 10 cc syringes and man-
ual suction by applying traction on the plunger o the syringe and creating negative pressure.
T e patient is shown 10 months a er her f rst procedure. Admirable correction can be seen. However,
to add slightly more bulk to the upper arms and smooth depressions urther, a second procedure was
per ormed at one year postoperative.
During the second operation, 1 0 cc o at was placed into the le upper arm, and 2 cc o at was suc-
tioned rom the posterior axillary old. On the right side, 210 cc o at was placed into the right upper
arm, and 2 cc o at was suctioned rom the posterior axillary old. T e patient is also shown 1 year
a er the second operation. T is is her f nal result. T ere is a signif cant increase in volume in both upper
arms. In addition, the contour irregularities have been vastly improved. T ere are only minor residual
depressions. In the right column, the patient is shown 10 years a er two operations. Note the longevity
o the survival o the gra .
CASE 2
A
B

C
Fig. 45-7, A-C
T is -year-old patient presented months a er undergoing superf cial circum erential thigh lipo-
suction that le her with severe irregularities o the thighs as well as a generalized def cit o atty tissue,
which was especially obvious in her inner thighs. Because o the large def cit in her inner thighs, we
decided to stage the procedure.

838
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
Fig. 45-7, D
200 cc
150 cc
130 cc
60 cc
60 cc
50 cc
20 cc
D
VOLUMES HARVESTED

Left (cc)

Right (cc)
Love handle
Buttock
Posterior thigh
Lateral thigh
Medial knee
150
130
10
20
50
200
10
60
60
During her f rst procedure, 790 cc o subcutaneous tissue was harvested and then ref ned into 40 cc o
usable at.
E

F
70 cc
50 cc
90 cc
60 cc
50 cc
60 cc
G
16
cc
9.5 cc
60
cc
4.5 cc
3.5 cc
4 cc
90
cc
H
Fig. 45-7, E-H
Placement ocused on the inner thighs, where 1 0 cc was placed on the right and 140 cc on the le . Small
amounts were also placed into the right lateral hip, buttock divots, and posterior thigh irregularities.

839
Chapter 45 • Iatrogenic Liposuction De ormities
Fig. 45-7, I
10 cc
10 cc
80 cc
70 cc
Abdomen 80 cc
60 cc
60 cc
30 cc
I
VOLUMES HARVESTED

Left (cc)

Right (cc)
Abdomen
Upper and middle back
Lateral upper buttock
Buttock
Lateral thigh
Medial lower thigh
Medial knee
80
30
70
60
70
10
80
60
50
10
T e patient returned 6 months a er the f rst procedure with def nite improvement but wanting to pro-
ceed with the next stage. Another 20 cc o subcutaneous tissue was removed using 10 cc syringes, which
was ref ned down into 200 cc o usable at.
110 cc
50 cc
30 cc
10 cc
50 cc
J
Fig. 45-7, J
During the second procedure, 0 cc more was placed into the right thigh and 110 cc was placed into the
le . Small additional amounts were placed into small residual irregularities o the le anterior thigh.

840
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
70 cc
50 cc
90 cc
60 cc
50 cc
60 cc
K
110 cc
50 cc
30 cc
10 cc
50 cc
L
Fig. 45-7, K and L
wo relatively large-volume at graf ing procedures into the inner thighs were per ormed.
M
Preoperative
N
6 years 4 months after
second procedure
O
Preoperative
P
6 years 4 months after
second procedure
Fig. 45-7, M-P
T e patient is seen 6 years and months af er her last procedure. Note the improvement in the inner
thighs, with restoration o the missing volume. Lighting coming rom the lef side on the two photos on
the lef emphasizes the smoothing o irregularities o the inner thighs.

841
Chapter 45 • Iatrogenic Liposuction De ormities
Q

R
S

T
U
Preoperative
V
6 years 4 months after
second procedure
Fig. 45-7, Q-V
Closeup photography with a ring f ash can be help ul or analyzing sur ace irregularities on the body as
well as the ace.

842
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
W

X
Fig. 45-7, W and X
T is posterior view reveals that the addition o only 16 cc to the right hip de ect with the adjacent re-
moval improves the silhouette o the patient’s right hip.
Y

Z
AA

BB
Fig. 45-7, Y-BB
T e posterior and oblique views also show the extent o the correction o the inner thighs. T is patient
was o ered a third surgery to urther ref ne the result, but she re used because she elt that the results
were acceptable.

843
Chapter 45 • Iatrogenic Liposuction De ormities
Fig. 45-8, A
A
Many patients present with ar more subtle iatrogenic de ormities that need only smoothing o sur ace
irregularities without signif cant volume replacement. T is -year-old woman presented years a er a
lateral thigh liposuction complaining o minor irregularities.
Fig. 45-8, B and C
B
17.5 cc
2.5 cc
5 cc
5 cc
C
T is patient had almost no donor sites, so it was possible to harvest only minimal amounts o tissue, and
only 0 cc was placed into her right lateral thigh irregularities in the areas shown.

844
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
D

E
F

G
Fig. 45-8, D-G
She returned 2 years and 3 months a er her only procedure. T e modest amounts o structural at gra -
ing resulted in signif cant improvement and great patient satis action.
C om p l i ca ti on s
Fig. 45-9, A and B
A

B
A er one larger at gra ing procedure or the correction o iatrogenic liposuction de ormities, this pa-
tient experienced seromas and hematomas.

845
Chapter 45 • Iatrogenic Liposuction De ormities
C
D
Fig. 45-9, C and D
She had remarkable adhesions o the inner thigh, which were almost impossible to release without sig-
nif cant sharper dissection. T e patient developed large collections o serous uid that required another
procedure to drain. In ection, hyperpigmentation o the skin in suctioned areas, and at embolism are
other very rare complications.
MOST LIKELY TECHNICAL MISTAKE
T e most likely technical mistake is the creation o new de ormities during harvesting. o lessen any po-
tential donor de ect, the surgeon should minimize the amount o at suctioned in any one area. When at
is harvested rom only a ew areas, new de ormities are easily created in the smaller areas. Spreading the
donor de ect out over many areas and over a large sur ace area helps to decrease the potential or a de ect
in any one area. Care should also be taken not to overcorrect areas that are depressed. I this happens, the
opposite de ormity—a protrusion—can occur.

846
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
D i scu ssi on
All patients need to be prepared or their results. I warn patients with major de ormities that it may take
as many as our procedures to attain an acceptable result, although I have never per ormed more than
three procedures or the correction o iatrogenic liposuction de ormities on any one patient. I explain
to the patient that the f rst procedure or a major de ect is to restore volume; the second procedure is to
smooth out the area with “f nishing touches.” In extremely rare cases, a patient may desire a third proce-
dure to smooth the area more. For smaller irregularities, one procedure is o en su cient.
C oncl u si on
In iatrogenic liposuction de ormities a er simple liposuction, adhesions are not common. In my experi-
ence, de ormities a er ultrasonic and laser liposuction or liposuction complicated by seromas are more
likely to have scarring. Similarly, lipodystrophies induced by trauma or injections more requently have
subcutaneous adhesions. T e approach to recognized adhesions should be f rst to place as much tissue
as possible using blunt cannulas. Frequently this will be enough to release the adhesion. I the adhesion
persists, a V-dissector can be used to disrupt the scar. T e maneuvers necessary to release the scar are
o en gross movements, but it is essential that the adhesions be released as much as possible to attain a
satis actory result.
Some swelling remains or more than 5 or months a er at gra ing, and some subtle changes occur or
up to a year. I wait at least months be ore considering a second procedure.
A video relevant to this topic can be found in the Video Contents list on p. xxvi.
RECOMMENDED READING
Chamosa M, Abascal J. Proportional liposuction. Ann Plast Surg 1:107, 199 .
Dillerud E, Haheim LH. Long-term results o blunt suction lipectomy assessed by a patient questionnaire
survey. Plast Reconstr Surg 92:35, 1992.
Gargan J, Courtiss EH. T e risks o lipectomy: their prevention and treatment. Clin Plast Surg 11: 57, 19 .
Gasperoni C, Salgarello M, Emiliozzi P, et al. Subdermal liposuction. Aesthetic Plast Surg 1 :137, 1990.
Guerrerosantos J. Autologous at gra ing or body contouring. Clin Plast Surg 2 : 19, 199 .
Illouz G. Body contouring by lipolysis: a 5-year experience with over 3000 cases. Plast Reconstr Surg 72:591,
19 3.
Pitman GH, eimourian B. Suction lipectomy: complications and results by survey. Plast Reconstr Surg 7 : 5,
19 5.
Reed LS. Some thoughts on suction-assisted lipectomy. Plast Reconstr Surg 72: 2 , 19 3.
Regnault P, Daniel RD. Secondary thigh-buttock de ormities a er classical techniques. Prevention and treat-
ment. Clin Plast Surg 11:505, 19 .
Rohrich RJ, Beran SJ. Is liposuction sa e? Plast Reconstr Surg 10 : 19, 1999.
Stampos M, Xepoulias P. Fat transplantation or so tissue augmentation in the lower limbs. Aesthetic Plast
Surg 25:25 , 2001.
Stone A, Rispler J. Scars at cannula sites or liposuction. Plast Reconstr Surg 99:257, 1997.
eimourian B. Complications associated with suction lipectomy. Clin Plast Surg 1 :3 5, 19 9.
eimourian B, Adham MN. A national survey o complications associated with suction lipectomy: what we
did then and what we do now. Plast Reconstr Surg 105:1 1, 2000.
Vilain R. Prevention and treatment o waves a er suction lipectomy. Ann Plast Surg 17:19 , 19 .

847
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847

848
Part III • Clinical Applications • Lower Extremity and Genital Area: Aesthetic
I currently use the ollowing technologies:
• Power-assisted liposuction (MicroAire) machine
• Autoinjection power-assisted Wells Johnson at trans er machine
Box 46-1 Overview of Approach to Fat Harvest and Preparation
My harvesting approach employs the ollowing:
• Larger-bore cannulas or at harvest: 5 mm cannula
• Power-assisted liposuction in every case
• Closed Wells Johnson reinjection system
Power-Assisted Liposuction
Fig. 46-1
Range of probe configurations
Complete PAL system
PAL electric handpiece
I per orm all my cases with a power-assisted liposuction (PAL) machine (MicroAire, Charlottesville,
VA). T is equipment has an electrically powered reciprocating cannula ( 000 to 6000 cycles per minute)
that makes suctioning much easier and less tiring or the surgeon. T e machine works quite well and
speeds up the liposuction process. T e system does not use heat; however, i the operator is not care ul,
riction skin burns can occur that will not be detectable or at least 2 to 3 days a er surgery.
In my experience with the PAL system, it does destroy about 10% o the harvested at, but this is a
tradeo that I am willing to accept, since the benef ts ar outweigh the 10% loss.