Geoffrey 2 C. Gurtner, Peter C. Neligan, Daniel Z. Liu – Plastic Surgery Principles. 2-Elsevier (2018)

530
SECTION I
CHAPTER 20 • Otoplasty and ear reduction
The dressing is left in place 3–5 days after an otoplasty
depending on when the most convenient day for an office
visit occurs. No further dressings are used. Since absorbable
skin sutures are employed, no sutures require removal in the
standard otoplasty case. In the case of ear reduction, there are
a few nylon sutures in the helical rim that require removal.
The patient is instructed to wear a loose headband at night
only. The goal is to have no pressure on the ear during the
day and only enough at night to prevent inadvertent pulling
forward of the repaired auricle. The nocturnal headband is
continued for 4–6 weeks, although most patients confess to
discarding it much sooner than that. Remember, the headband
should only be tight enough that it does not fall off.
Outcomes, prognosis, and
complications
Most patients who undergo otoplasty are satisfied with the
results, making the procedure gratifying for the surgeon as
well. The technique for standard otoplasty described above
largely eliminates the worst of the otoplasty complications:
overcorrection, sharp edges, unnatural contours, inharmoni-
ous setback, telephone deformity, and infection.
However, any technique has its complications, and the
technique recommended is no exception. Suture complica-
tions are relatively common. The nylon Mustarde sutures may
eventually protrude through the posterior skin. This may
occur within the first few weeks or not for years. In some
cases, the sutures are associated with inflammation or a
granuloma. Suture removal immediately cures any apparent
infection and does not seem to lead to recurrence of the
prominent ear.
The second complication that is more common with this
technique is undercorrection or recurrence. While this in not
ideal, it is far better in this author’s opinion than overcorrec-
tion or distortion. Although the literature suggests that the
Mustarde technique is associated with an unacceptable rate
of undercorrection/recurrence, the author has had three cases
of undercorrection/recurrence requiring reoperation in his
career.
Secondary procedures
Unfortunately, patients requesting secondary procedures are
not uncommon. The most common complaints of these
patients are:
1. Overcorrection
2. Visible cartilage irregularities or unnatural contours
3. Unpleasing shape of the ear (e.g., telephone ear,
protruding lobules)
4. Undercorrection, usually of the upper pole of the ear.
Overcorrection can usually be improved by removing sutures,
undermining skin, and occasionally placing a skin graft. Some
otoplasty techniques, however, do not lend themselves as
well as others to reversal. Visible cartilage irregularities are
extremely difficult to correct. Firmin6 has the best and most
impressive series of patients in this category in whom she has
removed the damaged cartilage and placed expertly carved
pieces of rib cartilage. Unpleasing shapes of the ear such as
Tragal deformities
Tragal deformities consist of either anterior traction on the
tragus, amputation of some of the tragal cartilage, or excess
facial skin at the bottom of the tragus that serves as an across-
the-room surgical signature. There is little that can be done
for the first two conditions, since too much tissue has been
removed. In fact, further lifting attempts may only make them
worse: when the facial skin is rotated cephalad, there may be
even less skin available for tragal coverage than there was
originally. The latter deformity, lack of definition of the caudal
tragus, however, can be corrected. As Connell has empha-
sized, the tragus should have a well-defined top and bottom.
Imperfect trimming of the facelift flap often results in an
oblique fold at the caudal edge of the tragus and a gradual
transition from the tragus to the lobule rather than the normal
right angle. Removal of a triangle of skin can correct the
problem and make it much less obvious that the patient has
had a facelift.
Retroauricular deformities
Surgeons seem to feel that it is necessary to place the facelift
incision up on the back of the ear. If that is excessive or is done
a few times, there may be little skin remaining behind the ear.
If the incision is placed in the sulcus or minimally on the
auricular cartilage, it will not migrate if the flaps are trimmed
judiciously. Once the deformity is created, there is no solution
except release of the ear and placement of a full-thickness skin
graft.
Scars
Unsightly scars can frequently be improved by excision
and additional facelifting maneuvers as long as no tension
is placed on the closure. Although axiomatic in facelifting,
it bears repeating: the facelift flap should be redraped and
trimmed so the edges are touching. While a few sutures are
placed, no sutures should really be necessary in the pre-
auricular region or the postauricular sulcus. Hypertrophic
scars are more problematic. If they are due to tension, they
may be improved. If they are due to the patient’s intrinsic
scar-forming idiosyncrasies, they will not be. The problem
is that a surgeon evaluating such scars may not know in
advance which category the scars fit in. Therefore, revision
of scars should be approached with trepidation. Kenalog
injection is helpful and eliminates the need for revision in
many cases. If recurrent hypertrophic scars or real keloids
develop, the author recommends scar revision with postop-
erative radiation beginning immediately on the day of the scar
revision.
Postoperative care
A piece of Xeroform and a soft bulky dressing are placed on
the skin. The purpose of the dressing is to protect the repair,
keep the skin of the ear moist, and to absorb drainage. No
attempt is made to put pressure on the ear. A doughnut of
gauze is placed around each ear specifically to avoid pressure.
The author has seen significant abrasions of the ear from
dressings that were excessively tight, in one case an ulceration
with exposed auricular cartilage.

531
Secondary procedures
substantially improved, however, if the upper third and lower
thirds are setback so that the overall impression is one of
harmony and, when viewed from behind, the helical rim
forms a straight line contour. Correction of the overcorrected
middle third of the ear requires wedging a piece of rib carti-
lage behind the auditory canal to unfurl it.
telephone ear can usually be improved significantly. Even if
the overcorrected areas cannot be completely repaired, the
disharmony can be corrected. In the case of telephone ear, i.e.,
where the middle third of the ear is overcorrected relative
to the upper and lower poles, there may be little that can
be done about the overcorrected portion. The ear will look
1. Thorne CH. Otoplasty. Plast Reconstr Surg. 2008;122:291–292. The
author of this chapter demonstrates his preferred otoplasty technique in a
video and emphasizes the role of endpoint visualization when performing
the procedure.
2. Luckett WH. A new operation for prominent ears based on the
anatomy of the deformity. Surg Gynecol Obstet. 1910;10:635–637.
3. Converse JM, Wood-Smith D. Technical details in the surgical
correction of the lop ear deformity. Plast Reconstr Surg.
1963;31:118–128.
4. Stenstroem SJ. A “natural” technique for correction of congenitally
prominent ears. Plast Reconstr Surg. 1963;32:509–518. The technique of
otoabrasion is described. The technique was fully embraced by a large
number of surgeons.
5. Matsuo K, Hirose T, Tomono T, et al. Nonsurgical correction of
congenital auricular deformities in the early neonate. A preliminary
report. Plast Reconstr Surg. 1984;73:38–51. This is the first report
showing the enormous potential for neonatal molding of congenital ear
deformities.
6. Firmin F. Ear reconstruction in cases of typical microtia. Personal
experience based on 352 microtic ear corrections. Scand J Plast
Reconstr Surg Hand Surg. 1998;32:35–47.
7. Furnas DW. Correction of prominent ears by concha mastoid
sutures. Plast Reconstr Surg. 1968;42:189–193.
8. Gosain AK, Recinos RF. A novel approach to correction of the
prominent lobule during otoplasty. Plast Reconstr Surg.
2003;112:575–583.
9. Webster GV. The tail of the helix as a key to otoplasty. Plast Reconstr
Surg. 1969;44:455–461. This paper describes a technique for repositioning
the lobule that is a classic but with which the author of this chapter has
not had success.
10. Mustarde JC. The correction of prominent ears using simple
mattress sutures. Br J Plast Surg. 1963;16:170–178.
Access the complete reference list online at

531.e1
References
References
1. Thorne CH. Otoplasty. Plast Reconstr Surg. 2008;122:291–292. The
author of this chapter demonstrates his preferred otoplasty technique in a
video and emphasizes the role of endpoint visualization when performing
the procedure.
2. Luckett WH. A new operation for prominent ears based on the
anatomy of the deformity. Surg Gynecol Obstet. 1910;10:635–637.
3. Converse JM, Wood-Smith D. Technical details in the surgical
correction of the lop ear deformity. Plast Reconstr Surg.
1963;31:118–128.
4. Stenstroem SJ. A “natural” technique for correction of congenitally
prominent ears. Plast Reconstr Surg. 1963;32:509–518. The technique of
otoabrasion is described. The technique was fully embraced by a large
number of surgeons.
5. Matsuo K, Hirose T, Tomono T, et al. Nonsurgical correction of
congenital auricular deformities in the early neonate. A preliminary
report. Plast Reconstr Surg. 1984;73:38–51. This is the first report
showing the enormous potential for neonatal molding of congenital ear
deformities.
6. Firmin F. Ear reconstruction in cases of typical microtia. Personal
experience based on 352 microtic ear corrections. Scand J Plast
Reconstr Surg Hand Surg. 1998;32:35–47.
7. Furnas DW. Correction of prominent ears by concha mastoid
sutures. Plast Reconstr Surg. 1968;42:189–193.
8. Gosain AK, Recinos RF. A novel approach to correction of the
prominent lobule during otoplasty. Plast Reconstr Surg.
2003;112:575–583.
9. Webster GV. The tail of the helix as a key to otoplasty. Plast Reconstr
Surg. 1969;44:455–461. This paper describes a technique for repositioning
the lobule that is a classic but with which the author of this chapter has
not had success.
10. Mustarde JC. The correction of prominent ears using simple
mattress sutures. Br J Plast Surg. 1963;16:170–178.
11. McDowell AJ. Goals in otoplasty for protruding ears. Plast Reconstr
Surg. 1968;41:17–27.
12. Spira M. Otoplasty: what I do now – a 30-year perspective. Plast
Reconstr Surg. 1999;104:834–840.
13. Argamaso RV. Ear reduction with or without setback otoplasty.
Plast Reconstr Surg. 1989;83:967–975.
14. Sinno S, Chang JB, Thorne CH. Precision in otoplasty: combining
reduction otoplasty with traditional otoplasty. Plast Reconstr Surg.
2015;135:1342–1348.
15. Tanzer RC. The constricted (cup and lop) ear. Plast Reconstr Surg.
1975;55:406–415.
16. Kajikawa A, Ueda K, Asai E, et al. A new surgical correction of
cryptotia: a new flap design and switched double banner flap. Plast
Reconstr Surg. 2009;123:897–901.
17. Kaplan HM, Hudson DA. A novel surgical method of repair for
Stahl’s ear: a case report and review of current treatment
modalities. Plast Reconstr Surg. 1999;103:566–569.

SECTION I • Aesthetic Surgery of the Face
21 
Hair restoration
Jack Fisher
SYNOPSIS
■ Techniques have evolved in the last 50 years, resulting in more natural
(and aesthetically pleasing) hair transplants. The discussion of
transplantation refers to micrografts or minigrafts or, more specifically
in current nomenclature, follicular grafts.
■ The true objective of hair restoration must go beyond artificial results
to a point where the patient who has had restoration does not look like
he has had any procedure done at all. The final result should be a
natural-appearing hairline with natural-appearing density.
■ Rather than continuing the trend of using techniques such as flaps,
microsurgery, tissue expansion, and scalp excisions, most surgeons
today have gone to refined, anatomic, naturally occurring miniature
grafts in the majority of patients.
■ Hair restoration is one of the most common aesthetic procedures
performed in the male population.
Introduction
In order to identify the ideal technique for hair restoration,
numerous methods have come and gone during the past
50 years. Most patients undergoing hair restoration today,
however, undergo hair transplantation because of the signifi-
cant refinements of this specific technique. When it is obvious
that a procedure such as hair transplant has been performed,
the result is less than satisfactory. Techniques such as flaps,
excision of bald areas, and expansion no longer dominate this
field in the era of small, natural-appearing grafts. The discus-
sion of transplantation refers to micrografts or minigrafts or,
more specifically in current nomenclature, follicular grafts.
Follicular units refer to the naturally occurring clusters of,
typically, one to three hairs that emerge from the scalp.1
In the past, results were frequently mediocre to poor,
and the use of technically challenging flaps and intricately
designed scalp excisions, rather than enhancing results,
caused an unnatural appearance that was often difficult to
correct. Although these patients had significant amounts of
hair transferred, the hair often looked artificial.
The true objective of hair restoration must go beyond these
artificial results to a point where the patient who has had hair
restoration does not look like he has had any procedure done
at all. The final result should be a natural-appearing hairline
and natural-appearing density.
Rather than continuing the trend of using techniques such
as flaps, microsurgery, tissue expansion, and scalp excisions,
most surgeons today doing hair restoration have gone to
refined, anatomic, naturally occurring miniature grafts in the
majority of patients. The reason for this change is not only
physician-directed: patients today are demanding and expect-
ing better results.
Another current issue is the large number of patients who
in the past had hair plug procedures and want corrective
surgery, which requires a sophisticated approach for correc-
tion of these difficult problems. Some of the least satisfactory
results of all types of male aesthetic surgery are in hair restora-
tion. This can be attributed to poor technique and poor selec-
tion of patients.
Successful hair restoration requires a sense of aesthetics just
as demanding as in any other aesthetic procedure. This
chapter discusses those factors necessary for a successful
outcome, focusing primarily on the status of current hair
transplantation. At the beginning of the 21st century, hair
transplantation with use of small grafts is where the field
appears to be headed, with less flap surgery and less scalp
excision.
Hair restoration is one of the most common aesthetic pro-
cedures performed in the male population.2,3 However, of all
the fields of aesthetic surgery, it has suffered one of the worst
reputations for producing unnatural results and unhappy
patients.
Basic science: anatomy of hair
The embryologic origin of hair is both ectodermal and meso-
dermal. The ectoderm forms the hair and pilosebaceous fol-
licle; the mesoderm forms the dermal papilla.
  Access video lecture content for this chapter online at expertconsult.com

533
Basic science: anatomy of hair
in which this rule has not been observed leads to an extremely
unaesthetic appearance, especially in the mature adult. Young
males usually do not have this recession, and this is one
characteristic that distinguishes the child from the adult
pattern. As baldness progresses, the frontal–temporal reces-
sion increases, forming an acute angle. Both women and
children tend to have a continuous line between the frontal
and temporal areas without this recession. Another important
characteristic of a natural hairline is the transition from fine
hair to more dense hair with a degree of irregularity along the
margin. Natural hairlines are not straight and regular. Many
of the unsatisfactory results in hair restoration demonstrate a
fundamental lack of knowledge of these critical points. Other
important factors are that the hair follicle sits about 3–3.5 mm
below the surface of the scalp and that scalp thickness varies
between 5.5 and 6.5 mm. These factors are important in con-
sidering the placement of the grafts in the scalp, the thickest
layer of skin on the human body.
Characteristics of hair
There are two primary types of normal adult hair. Vellus hair
is soft, short, lightly pigmented or hypopigmented hair that
can be almost invisible. It can be found over the entire body.
On the scalp, it is primarily seen in the frontal area on the
Hair consists of a shaft and a root. The shaft is the visible
portion above the scalp surface; its diameter varies from 60 to
100 µm. The three layers of the shaft – the cuticle, cortex, and
medulla – consist of keratinized cells. The root or bulb is the
follicle and sits at an oblique angle in the scalp (Figs. 21.1 &
21.2).
Hair grows at different angles, depending on the site of the
scalp, and the proper angulation of the hair is key in hair
restoration surgery to effect a natural result. In androgenic
alopecia, the follicle reduces in size and the number of dormant
follicles increases. These atrophic follicles take a more super-
ficial location, and the visible hair shaft thins. Hair follicles
are still present in these bald areas, but they are atrophic and
essentially non-functional.
The hair shaft itself is composed of keratin, a fibrous protein
produced by the hair follicle. The keratin is an end product of
the hair matrix, which exists at the base of the hair follicle
canal within the subcutaneous tissue. Within the matrix are
rapidly dividing cells, and above this area of rapid cell divi-
sion lies the zone of keratinization, which makes the hair
shaft. The layering of these newly keratinized cells at the base
of the shaft causes the process of hair growth as the shaft
moves up through the surface.
Anatomy of a normal hairline
A discussion of the anatomy of hair could not be complete
without also discussing the anatomy of the normal hairline.
A critical anatomic landmark in the mature male hairline
is the frontal–temporal recession. This landmark is formed by
the emergence of two convex lines making up the frontal and
the temporal hairlines. Design of the frontal–temporal reces-
sion is critical to a natural result (Fig. 21.3). A hair restoration
Fig. 21.1  Microscopic cross-section of a single hair follicle unit.
Fig. 21.2  Anatomy of hair unit with terminal follicles, sebaceous glands, and
insertion of erector pili muscle.

534
SECTION I
CHAPTER 21 • Hair restoration
to an unnatural appearance. In the frontal area, the hair is
angled forward; on the temporal and parietal areas, it tends
to be angled slightly forward and downward. In the vertex, a
spiral pattern is present; below the occipital area, the hairs are
angled downward toward the neck. The two factors, thickness
and density of hair per square centimeter, are important
variables in the visual appearance of the hair. Whereas dark
hair is effective in covering areas, fair hair is less effective. The
converse is true, however, in designing a natural appearance.
Blond or salt-and-pepper hair gives a more acceptable result
when it is transplanted versus dark hair, especially in light-
skinned individuals. This is especially obvious with dark plug
grafts, in which thick hair clusters give a particularly unnatu-
ral result in contrast with light-colored skin.
Hair growth cycles
A discussion of the hair follicle cycles of growth and degen-
eration is relevant in considering hair restoration surgery.
These cycles will have an impact on the time it takes for newly
transplanted hair to begin to grow and also on the period
necessary to see the final result.
There are essentially three cycles – anagen, catagen, and
telogen. During the growth phase, referred to as anagen, the
follicular cells are actively reproducing, and matrix keratino-
cytes are producing cells that differentiate into the different
hair components. It is estimated that approximately 90% of
the hair on the scalp is in the anagen phase, which lasts
approximately 2–5 years. During the regression phase, called
catagen, there is a degeneration of the keratinocytes, and
special mesenchymal cells, referred to as dermal hair papillae,
cluster and separate. This phase typically lasts 2–3 weeks (Fig.
21.4). The final resting phase, called telogen, lasts approxi-
mately 3 months. During the 3–4-month phase of telogen, the
follicle is inactive and hair growth ceases. Approximately 10%
forehead, and it also makes up a large area of the bald scalp.
Terminal hair is the coarser, long hair and is pigmented.
Within the terminal hair group are subgroups, such as those
on the scalp, pubic area, and eyebrows. As an individual who
is destined to lose hair ages, the terminal hairs can be replaced
by vellus hairs. It is usually a progressive evolution in which
the terminal hairs are lost and the thinner, shorter hairs slowly
replace them until it converts to a vellus-type pattern. This
process continues until, eventually, baldness is evident in the
area. It is an interesting phenomenon that biopsies, even of
bald areas, show that hair follicles are present, but they are
atrophic in nature and are no longer producing significant
amounts of hair in these individuals.
There is great variation in all aspects of hair, which is
determined in each individual on the basis of race, sex, and
area of the scalp. There is also variation in thickness between
races: whites have thinner hair than both blacks and Asians
do. The shape of the hair also varies greatly. The differences
correspond to cross-sectional characteristics. For example,
wavy hair is oval on cross-section, whereas stiff or straight
hair tends to be round. An important variable is the density
of hair per square centimeter. The density of adult hair can
vary between 200 and 400 hairs per square centimeter. In the
presence of androgenic alopecia, the number of hairs drasti-
cally drops off. Large plug grafts, in which 20–60 hairs could
be contained in each graft, often led to an unnatural appear-
ance in many patients, resulting in “cornrows”. The trans-
plantation of these grafts led to a clustering and unnatural
look. Normally, one to three hairs emerge from a single orifice,
and this fact is critical in obtaining a natural result in hair
transplantation. Once this number is exceeded, that is, more
than one to three hairs, there is the risk of a visible, unnatural
result, especially along the frontal hairline.
The other critical variable is the angle at which the hairs
exit the scalp normally. A violation of this principle also leads
Fig. 21.3  (A) Preoperative and (B)
postoperative appearance of a patient who
had undergone hair transplantation in the
frontal area in which the acute frontal–
temporal angles were maintained, resulting
in a normal-appearing recession.
Maintenance of this recession is critical for
a natural appearance.
A
B

535
Diagnosis/patient presentation
in the section on the role and effectiveness of medications,
below, it is on this mechanism that finasteride acts in attempt-
ing to reduce hair loss by blocking the formation of DHT.
Androgenic alopecia is under the control of a single dominant
sex-linked autosomal gene. However, this may be influenced
by other modifying factors, and there is probably a polygenic
component to the expression of male-pattern hair loss. In most
men with hair loss, the hair follicles in the frontal and crown
regions of the scalp appear most likely to be affected by
androgenic alopecia. Although there is considerable variation
among ethnic groups as far as the average number of hairs,
and also variation among the different hair colors, it is typical
that the average individual with a relatively full head of hair
has at least 100 000–150 000 hairs growing from the scalp.
Hair loss in women is frequently of a diffuse nature, and
thus, most women may not be ideal candidates for hair resto-
ration. The pattern of hair loss, because of its diffuseness,
often results in a lack of appropriate donor hair. However,
there is a subgroup of women who demonstrate hair loss
similar to the male pattern.4 The hair loss in these women
frequently begins at the vertex and progresses anteriorly as
they approach their 30s and 40s. The family history in these
women is also compatible with a male-pattern type of hair
loss, with many of the male and female family members
reporting balding in both the vertex and superior portions of
the scalp. It is this subgroup of women who may be the most
appropriate candidates for hair transplantation because the
posterior scalp area has adequate donor hair. The history
these women give is fairly typical and is one of slow but
progressive hair loss, and it is most evident on the superior
scalp with good density on both sides and posteriorly. The
other interesting characteristic in many of these women is that
they maintain a low frontal hairline with a margin of hair
of hairs are in telogen phase at any one time. In the telogen
phase, the dermal papilla releases from its epidermal attach-
ment, and eventually there is a reforming of a growing bulb.
The old hair is shed, and as the cycle goes back to anagen, a
new hair will come up and grow in this area. This information
is relevant in discussing hair transplantation with patients.
After the follicle has been transplanted, one usually sees a
resting or telogen phase, and the patient should not expect
any significant hair growth for 3–4 months. Although some of
the hairs transplanted occasionally seem to continue to grow
immediately after the surgical procedure, this can be mislead-
ing. This early growth frequently leads to a shedding of the
hair shaft before the telogen phase. Therefore, the patient
needs to wait several months before any significant hair
growth is seen.
Diagnosis/patient presentation
Types and patterns of baldness
The most common type of hair loss in both men and women
is referred to as androgenic alopecia. The mechanism of
androgenic alopecia is inherent in each individual hair follicle
as it responds to external stimuli, essentially androgens. The
progressive loss of hair is predetermined by genetic charac-
teristics associated with these responsive scalp follicles. In
regions of the scalp susceptible to androgenic alopecia, andro-
gens reduce the growth rate, the hair shaft diameter, and the
length of the anagen phase. The mode of action of androgens
on the target cells occurs at the bulbar region of the follicle.
Testosterone is converted to dihydrotestosterone (DHT) by
5α-reductase. DHT acts on the target cells and, as discussed
Fig. 21.4  The cycles of hair growth.
Catagen involution phase
(1–2 weeks)
Anagen active growth phase
(2–6 years)
Telogen resting phase
(3–6 months)
Return to anagen
Hair matrix forming
new hair
Secondary
germ cells
Dermal papilla
Club hair

536
SECTION I
CHAPTER 21 • Hair restoration
Hamilton’s classification (Fig. 21.5).10 Most of these classi-
fications divide the patterns of baldness into six or seven
main groups with subgroups. These classifications may be
difficult to apply because so many variations can be seen from
patient to patient. Another classification system developed
by Bouhanna and Dardour11 distinguishes three stages, with
variances in stage 1 and stage 2, thus defining five basic pat-
terns. Ludwig12 devised a classification system for types of
androgenic alopecia in women. All classification techniques
have some limitations but can be useful tools in planning
hair restoration.
Evaluation of the patient
Compared with other areas of aesthetic surgery, hair restora-
tion is unique in that hair loss is not only progressive but also
unpredictable. In aesthetic surgery there are generally areas
of the face where one can predict with some accuracy the
effects of the aging phenomenon. In male-pattern baldness,
although there is some ability to predict hair pattern changes
on the basis of family history, there is also a great deal
unknown as far as the evolution of any particular patient’s
hair loss is concerned. Therefore, patient evaluation must
consider the progressive nature of hair loss postoperatively
during the ensuing decades. It is critical in the early phases
of a patient’s evaluation to design a hair pattern that will be
appropriate not only as the patient ages but also on the basis
of progressive hair loss. It is not unusual for a young patient
in his late teens or early 20s who has significant hair loss to
wish to redesign the hairline to a juvenile appearance. It is
important that the physician explains to the patient the long-
term ramifications and problems that will occur if a juvenile
hairline is attempted and what the results will be as the patient
ages. Young patients can be dissatisfied on hearing that their
transplanted hairline should be placed high with a temporal
recession. Patients who demand an inappropriate hairline
should be rejected for surgery because they are unrealistic and
will be dissatisfied later when they realize that they are going
to undergo extensive further surgery. Many of these patients
wind up wearing a hairpiece for the rest of their lives to cover
an area that is unsatisfactory or that often looks bizarre
because of the progressive nature of the hair loss. As in any
area of aesthetic surgery, having a patient with realistic expec-
tations is critical, especially since many hair restoration
patients will be seen in a practice for years because of progres-
sive hair loss. The patient with hair loss in his 20s is going to
have to deal with the ramifications of surgical procedures for
the next 5–7 decades. Unfortunately, the young patient can
find someone who will do hair restoration for him. Typically,
such patients come back a decade later, now in their late 20s
or early 30s, often regretful, wishing to have the work either
undone or modified. Besides the young patient, one must also
be cautious with the extensive hair loss patient with only a
lateral and posterior fringe who wants complete coverage of
alopecia. These patients can be given an adequate framing of
the face; however, the posterior occipital area in some cannot
be grafted or at least should be grafted sparingly.
In the initial consultation, certain variables or parameters
can be evaluated that assist the physician in decision-making
and help the patient establish realistic expectations. A family
history, especially of the maternal side of the family, is useful,
anteriorly. This is unlike the male counterpart with progres-
sive elevation of the frontal hairline and increasing temporal
recession as the patient ages. Women with this primary type
of alopecia characteristically will maintain that frontal hairline
for life, and therefore transplantation needs to begin in this
relatively low frontal area and progress posteriorly.
In many women, however, the cause of hair loss is second-
ary to numerous factors, such as surgery, metabolic disorders,
chemotherapy, stress, and autoimmune disease. This type of
hair loss is often of an acute nature, and most of these patients
are not candidates for transplantation. On occasion, in the
patient who has had hair loss after chemotherapy, if enough
time has elapsed to allow recovery and there is still no
regrowth, transplantation may be appropriate. However, graft
take has not been ideal in these patients. In many women, the
cause of hair loss is secondary to cosmetic surgery, and the
mechanism is traumatic hair loss.
Traumatic alopecia is primarily secondary to ischemia of
the hair bulbs, although it can be secondary to direct tissue
loss, as in post-burn alopecia.5 Numerous factors can lead to
this ischemia. Prolonged pressure on the scalp in a single area,
such as in a patient who lies in a comatose position for hours
at a time, can cause enough ischemia to the scalp that there
can be hair loss without loss of the actual scalp soft tissues.
In addition, patients undergoing prolonged surgical proce-
dures under general anesthesia can sustain pressure in an
isolated area of the scalp, leading to hair loss.
One of the most common causes of traumatic hair loss is
aesthetic surgery of the face and scalp area. Temporal hair loss
is probably the most common of this group. It may be due to
damage of the hair bulb from a subcutaneous dissection in the
temporal area or excess skin traction with resulting ischemia.
This also is seen in patients undergoing a coronal forehead
lift, with hair loss in the area of a coronal scar. In most of these
patients, the alopecia is temporary, and hair will regrow after
several months. In some patients, however, the hair loss is
permanent, and hair transplantation may be appropriate.6,7 In
addition, the scar itself in the scalp or facial area may widen,
and because of the absence of hair follicles within the widened
scar, a visible area of hair loss is seen.
Significant ischemia, which reduces blood flow to the fol-
licles, can explain the temporary loss of hair in hair transplan-
tation. The same phenomenon is seen in patients undergoing
facelift and other aesthetic surgery, especially with closure
under tension or with compromised flaps. With severe ische-
mia, death of the bulb can lead to permanent alopecia. Inter-
estingly, an increase in growth due to enhanced blood flow
may explain the effects of minoxidil, in which there is vaso-
dilatation of the scalp and tissue surrounding the hair follicle.
Whatever the exact mechanism, decreased blood flow affects
hair loss, both temporarily and permanently.
Classification
Numerous classifications of hair loss have been described
on a morphologic basis, which compares the hair-bearing
with the non-hair-bearing areas. The first attempts to clas-
sify patterns of baldness were described in 1950 by Beek8 in
male white patients and in 1951 by Hamilton,9 who analyzed
patterns of hair loss in both white and Chinese patients.
Later, others, including Norwood, suggested modifications of

537
Evaluation of the patient
Fig. 21.5  Norwood classification of androgenic alopecia. (Reproduced from Unger MG, Cotterill PC. Hair transplantation. In: Achauer BM, Eriksson E, Vander Kolk C, et al.
(eds). Plastic Surgery, vol. 5. St. Louis, MO: Mosby; 2000:2487. Redrawn from Norwood OT. Male pattern baldness: classification and incidence. South Med J.
1975;68:1359–1365.)
I
II
III
III Vertex
IV
V
VI
VII
although hair pattern inheritance can represent a mosaic of
family characteristics. When a patient presents a history of
brothers, uncles, and a maternal grandfather with significant
baldness, one can predict with some certainty that this patient
is also likely to have extensive hair loss. Thus, designing the
hair restoration pattern for this patient should consider this
family history. Another factor is the great variation in avail-
able donor hair. One can see patients with an abundance of
donor hair ranging from 240 to 400 hairs per square centimeter
who can undergo multiple future procedures. There are also
patients with far less donor hair, and a conservative approach
must be entertained. This is particularly important in

538
SECTION I
CHAPTER 21 • Hair restoration
later, hair restoration may not be able to be repeated because
of limited donor hair.
A thorough examination of the patient requires an assess-
ment not only of the pattern of hair loss but also of character-
istics such as color, texture, density, curling, and straightness.
Curly hair tends to appear denser because it covers up the
underlying scalp. However, straight, dark hair, unlike curly
hair, may not appear to have as much density because of the
scalp’s visibility between the straight dark hairs, especially if
the skin is light. In addition, straight, dark, thick hair on
light-colored skin can look unnatural if several hairs exit at a
single site because of the contrast between the skin and hair.
The same number of fine or light-colored hairs exiting together
on light skin, however, may look natural because of this lack
of contrast. This phenomenon, in which multiple hairs exit at
a single site and appear packed together at the base, spreading
out distally, is called compression. This tufted look may occur
when a graft with several hairs is placed in a small or tight
recipient site, compressing the base of the graft. This problem
is more evident in black-haired individuals on light skin, and
micrografting is critical in these patients to avoid this problem.
White, blond, or salt-and-pepper hair has far less of a problem
with visible compression because of the lack of contrast. In
African Americans with dark hair against a dark skin back-
ground, compression is less likely because of little or minimal
contrast. All these variables must be taken into consideration
to give as natural-appearing a result as possible. Hair color,
hair texture, and skin color play important roles in the aesthet-
ics of the result.
The goal is to design a hairline in harmony with the mature
face and to re-establish a balance between the scalp and the
other facial features. A natural hairline should be aesthetically
invisible and age appropriate. In other words, the patient
should not look like a hair transplant has been done (Fig.
21.7). This is accomplished by a relatively high mature hairline
with temporal recession at the proper height. In addition,
graft direction is important for the correct angulation of the
individual hairs consistent with their location on the hairline.
Hair direction in different parts of the scalp is discussed
above.
During the aging process, there is simultaneous recession
of the frontal hairline upward or superiorly and movement
of the temporal hairline posteriorly. Maintenance of this
frontal–temporal angle is critical to a natural appearance
in hair restoration. Procedures, whether grafting or flaps,
that blunt or fill in the frontal–temporal angle not only will
cause an unnatural appearance but will lead to significant
problems later as the hairline recedes, leaving a bizarre
appearance.
In most patients, the anterior level of the hairline in the
midline should be at least 8–10 cm above the glabella. In addi-
tion, the anterior hairline appears more natural if it runs paral-
lel to the ground when viewed from a lateral vantage point
(Fig. 21.8). Some patients with significant hair loss maintain a
frontal forelock, and if it sits too low on the forehead, it may
be more appropriate to begin the grafting process slightly
posterior to the centrally located tuft of existing hair. Trying
to chase an isolated frontal forelock that is sitting low on the
forehead can result in too low a hairline with an unnatural
appearance. In addition, it is always possible secondarily to
place grafts lower if necessary; however, the converse is not
true. In other words, grafts originally placed too low because
Fig. 21.6  Marking a patient to demonstrate location of hairline during consultation.
Note the irregularity of the hairline to avoid an unnatural straight line appearance.
discussing replacement of occipital hair with the young
patient. This is one of the most difficult areas to deal with at
a later point in life after hair transplantation. The individual
who had overly aggressive occipital transplantation at a
young age and then proceeds to have significant hair loss
around the transplants, resulting in a halo of alopecia, pre-
sents with a bizarre appearance. These patients require either
further grafting, chasing the halo of hair loss, or possible
excision of the previously grafted areas. However, the indi-
vidual who has significant donor hair density and reports
stabilization of hair loss may be an appropriate candidate for
occipital grafting.
In young patients the best approach is to graft the frontal
and superior regions first and wait until their hair pattern is
more mature before working on the occipital area. This is
particularly important for patients with limited or fine donor
hair, when there is a finite number of grafting procedures in
the future. The amount of donor hair in the posterior scalp is
a critical component in the assessment of these patients.
It is useful to draw a specific pattern on the scalp to dem-
onstrate as the patient is looking in a mirror where you think
the most appropriate hairline pattern should be (Fig. 21.6). If
a high, appropriately designed hairline with temple recession
is unacceptable to the patient, this may be the patient who
should not be considered for any type of hair restoration.
Although you may make the patient happy initially, if both
the plastic surgeon and the patient live long enough, both will
have to deal with any problems that were caused by poor
design or poor planning.
The classification of hair loss is useful in planning the hair
pattern. The individual who has a Norwood II or III pattern
and has stabilized is more likely to obtain an excellent result,
without worrying about continually chasing further hair loss.
Because of the progressive nature of male-pattern hair loss, it
is critical to set goals for the patient so the patient understands
what may be required several decades later. Unlike facelifts
or other aesthetic procedures, which can be repeated years

539
Role and effectiveness of medications
are also patients with medical problems that can interfere
with grafting, such as hypertension, which can cause bleed-
ing, but this usually can be corrected with the appropriate
antihypertensives.
Role and effectiveness of medications
Both minoxidil in a local application and finasteride adminis-
tered orally have been used in the medical management of
hair loss.13 It is believed that minoxidil works primarily by
increasing blood flow, which promotes hair regrowth or hair
stabilization in those follicles that are being affected geneti-
cally by androgenic alopecia. Finasteride, which is an oral
medication, is a selective inhibitor of 5α-reductase type II. It
was originally developed for the treatment of benign prostatic
hyperplasia; however, it has been available in the US since
1997 for use in treatment of male-pattern baldness. The
mechanism of finasteride relates to the effect of androgens on
the hair follicles of patients with a genetic predisposition to
male-pattern baldness. Circulating testosterone is taken up by
scalp hair follicle cells. Here it is converted by the enzyme
5α-reductase to DHT. DHT binds to an androgen receptor. It
of chasing a low frontal forelock are difficult, if not impossible,
to modify.
An appropriate term to discuss with patients, especially
young patients, is what is referred to as “framing the face”.
Patients in their 20s and 30s frequently dislike going bald, not
because of the hair loss itself, but because they think they look
several decades older than their stated age. We tend to associ-
ate balding with the aging process. In many of these patients,
it is natural to transplant only half or a third of the area of
male-pattern baldness and give the patient an adequate result
without necessarily treating the posterior or vertex area.
Again, if the patient has limited donor hair, is relatively
young, and by family history is going to continue to have
progressive hair loss, a conservative approach is much safer.
There are several criteria that one can use when rejecting a
patient, including inadequate donor hair and too low a
density, especially in patients with class VI or VII Norwood
patterns. In addition, there are patients who may have little
available usable donor hair because of too much scarring from
previous grafting that was healed by secondary intention.
Finally, the patient who has unrealistic expectations, especially
if young and demanding a procedure that the physician
considers inappropriate, should be rejected for surgery. There
Fig. 21.8  A 40-year-old patient with salt-and-pepper hair who underwent a total of 2800 follicular grafts in two sessions. (A,B) Preoperative appearance. (C) Appearance
after the second session of follicular grafting. (D) The patient’s salt-and-pepper hair helps facilitate the naturalness of the frontal hairline. Other points include the
appropriate distance between the glabella and the anterior hairline, which should be at least 8–10 cm, and maintenance of the hairline parallel to the ground with a normal
temporal recession.
A
B
C
D
Fig. 21.7  (A) Preoperative view of a 46-year-old man who underwent two sessions of follicular hair transplantation. (B) Postoperatively, the patient has a hairline that is
appropriate for his age with a temporal recession at the frontal–temporal angle. The other important aspect is the design of irregularity of the hairline along the frontal
margin as well as placement of the finest available grafts anteriorly. Thin or light-colored hair also facilitates design of a natural appearance. A successful hair
transplantation should not be recognizable.
A
B

540
SECTION I
CHAPTER 21 • Hair restoration
posterior scalp. This technique as developed by Carlos
Uebel14,15 in Brazil and others has significantly simplified the
technical aspects of this method of obtaining donor hair.
The width of the strip can vary from 1.5 to 2 cm; the length
is purely dependent on the number of grafts needed and can
vary from 12 cm to more than 20 cm. Because of the mobility
of the posterior neck and lower scalp skin, it is relatively easy
to close this area primarily. Excision of the original donor scar,
when donor tissue is reharvested in subsequent procedures,
avoids the problem of multiple incisions and leaves the patient
with a single transverse donor scar. On occasion, if the patient
has had previous surgery or if there is scarring, it may be
necessary to elevate the flap inferiorly to allow closure without
tension. Hemostasis is obtained with cautery, and the incision
is approximated with several stay sutures for alignment.
Several strategic buried 3-0 Vicryl sutures are placed, and then
the closure is followed with a running 3-0 nylon suture. The
key in harvesting the donor site is proper angulation of the
knife to prevent inadvertent transection of the hair follicles
and damage to the donor grafts (Fig. 21.9). The donor strip is
cut into multiple bread-loaf sections, which are then cut by
the assistants into the grafts.
The other harvesting method gaining increasing popularity
is FUE. In this method, very small rotating punches typically
0.9–1.1 mm in diameter are used to harvest the donor hair. In
is considered that hair follicles in areas susceptible to male-
pattern hair loss are sensitive to the effects of testosterone.
Finasteride inhibits 5α-reductase, thereby having an impact
on DHT and the androgen receptors of the hair follicles.
Studies document that 1 mg/day finasteride not only reduces
hair loss but, in a limited percentage of patients, can cause
some growth of hair. This is usually more effective in the
younger population, and once true baldness has occurred, it
is unlikely that finasteride will have any significant effect.
The use of finasteride has clearly been shown to stabilize
hair loss, and there can be some reversal, although it primarily
has its best effects on the vertex area of the scalp. Although
both finasteride and minoxidil can be effective, finasteride
may be more useful in younger patients and therapy must be
long term. Most studies have shown that it requires at least 6
months to 1 year for some significant improvement to be seen.
Technique
Currently, two major methods of harvesting the donor hair
are employed. They consist of the strip harvesting method
and the follicular unit extraction (FUE) technique.
Harvesting the donor hair with the strip technique uses a
standard No.10 knife blade to remove the tissue from the
Fig. 21.9  (A) Proper angulation of the knife is important to prevent transection of the donor graft follicles. (B) Elevation of the donor tissue is performed in a subcutaneous
plane, taking care to avoid transection of the base of the hair follicles. (C) Closure with a running suture. The donor site is easily closed because of laxity of tissues in the
posterior scalp and neck area. (D) The harvested donor strip before it is cut into transverse bread-loaf sections. These are then cut into individual follicular grafts.
A
B
C
D

541
Technique
posterior or posteriorly proceeding up to the proposed ante-
rior hairline. This order of placement of grafts depends on the
surgeon’s preference.
The key to these techniques is training the surgeon and
assistant in proper graft handling. This method requires
development of the assistant’s dexterity to place the graft at
the edge of the small incision made by the No.11 blade.
With this technique, implantation of 1500–2500 grafts can
be performed quickly (Fig. 21.13). This transfer of large
order to employ this method, the donor hair is shaved with
an electric shaver, leaving enough visible hair shaft on the
skin surface to guide the proper angle of the device as it cores
out the follicular unit. Proper angulation is critical; otherwise
the follicle may be amputated.
Only 15–20% of the hair in any given area should be har-
vested with this technique, otherwise the donor area can look
sparse once the hair has grown back in. No suturing of the
donor site is required since these small holes rapidly epithe-
lize. For those individuals who wish to wear their hair short
after a transplant, this technique has many benefits, and some
hair transplant surgeons today employ this as their only
harvesting method (Fig. 21.10).
Numerous devices are currently on the market for harvest-
ing follicular units with the extraction method. They can
be simple hand-held rotary devices or more sophisticated
systems employing suction and automation to even robotic
technology. Whatever method is employed, the quality of the
donor grafts is the most important issue.
The remaining instrumentation for insertion of the hair
grafts with the technique published by Uebel requires nothing
more than a No.11 blade and a fine pair of pick-ups. In this
technique, an assistant is lifting the follicular grafts off a towel
or tongue depressor and positioning them for the surgeon,
who is making an incision with a No.11 blade. The key to this
technique is in the timing and the dexterity of the maneuver.
The assistant holds the small graft adjacent to the No.11 blade,
an incision is made, the blade is withdrawn, then the assistant
puts the graft at the beginning of the orifice that has been
made, and the surgeon finishes pushing it in (Fig. 21.11). With
two individuals who are experienced with this technique, it
is possible to put in 500 or more grafts per hour once the
technique is mastered.
The grafts are placed on a moist towel, which is sitting in
a metal tray with ice-chilled saline (Fig. 21.12). They are kept
cold during the entire process before implantation. In Uebel’s
technique, the assistant holds the grafts that have been pre-
sorted to size on the towel and hands them to the surgeon and
they implant them together. The recipient area has already
been anesthetized with both supraorbital and supratrochlear
blocks and tumescent solution. Typically, the grafts are placed
as close together as possible, working either from anterior to
Fig. 21.10  Appearance of donor site immediately after follicular unit harvesting.
These holes close rapidly.
Fig. 21.11  The Uebel technique of graft insertion. The No.11 blade is used to
make a small incision and then partially withdrawn as the assistant places the graft
at the beginning of the orifice. The surgeon then inserts the graft into the hole that
has been made.
Fig. 21.12  Follicular grafts that have been cut and sorted by the number of hairs
in each. The towel is soaked in ice-chilled saline kept in a metal tray. The grafts are
sorted in rows of 10. During the implantation process, the assistant holds the towel
and hands the grafts to the surgeon, following the Uebel technique.

542
SECTION I
CHAPTER 21 • Hair restoration
implantation, both supraorbital and supratrochlear blocks are
performed as well as recipient site tumescence. This gives
excellent anesthesia and hemostasis during surgery and may
not need to be repeated during the operation.
Outcome, prognosis, and complications
Number of procedures
An important issue to discuss with patients is the number of
sessions necessary to obtain the desired result. A patient who
thinks that one procedure is going to be the total solution will
be disappointed. An assessment of how many procedures
during what time period is important to establish a good
physician–patient relationship.
With current techniques of 1500–3000 grafts, many patients
with limited hair loss require only two procedures. The patient
with more extensive hair loss, however, may require as many
as three or four procedures. Some patients will be pleased
after only one procedure with limited hair loss; but usually
with one procedure, the frontal hairline lacks adequate
density. It is appropriate to prepare most patients for at least
two sessions to give a refined result.
Complications are relatively few for most patients. In
healthy individuals with unscarred recipient sites, it is reason-
able to expect 90–95% of the grafts to grow successfully.
Hematoma and infection are extremely rare in hair transplan-
tation and can be readily managed. Cysts can form after graft
implantation when the recipient scalp epithelium grows over
the transplant epithelium, forming an epidermal inclusion
cyst. Positioning the transplant epithelium level or slightly
above the surrounding recipient epithelium reduces this
problem. When cysts occur, unroofing and warm soaks
usually resolve the problem.
The patient who requires a great deal of evaluation and
thought, besides the young or potentially unrealistic patient,
is the one who has an unsatisfactory result and is seeking a
secondary revision. These patients are hair cripples and fre-
quently wear hairpieces for the rest of their lives to cover
either disfigurement or a bizarre appearance. Many of these
secondary revision patients had grafting at too young an age
with a low hairline and then went bald behind the grafted
area. Also, a high hairline or temple recession was not
designed, so the patient has a juvenile hairline in a mature
face. This disparity causes a disharmony between natural
facial aging and the hair pattern. Many of these patients can
be dramatically improved with regrafting or with a combina-
tion of excisions and reuse of the previously grafted hair.
Some of these patients can have their grafts removed along
the frontal hairline if they are bald behind this frontal fringe
as long as they understand that there will be some visible
scarring. This can often be preferable to a few rows of unsightly
plugs in an unusual location. The other possibility is to do an
excision with an aggressive forehead lift to put the scarring in
a more superior and natural location. During clinical evalua-
tion, especially with the secondary revision patient, it is useful
to draw the areas on the patient that you think should be
either treated or grafted. This is particularly important in
the patient who comes in wearing a hairpiece covering up
unsightly grafted areas. The patient can then return for a
second consultation to make sure not only that there is a
numbers of small grafts at one time is an important concept.
Limmer16 and others advocated covering the entire area of
alopecia with small grafts, and the technique described makes
the concept feasible. After insertion of the grafts, a dressing is
applied, usually for 24–48 h. Mineral oil covered by a Kerlix
dressing gives good protection for 24 h without any adher-
ence of the dressing to the grafted area. The patient is seen
the next day, the dressing is removed, and the patient is
instructed on careful hair washing. At approximately 10 days,
the patient is seen in the office, and the sutures in the donor
area are removed with the strip method. With follicular unit
extraction, there are no sutures to remove.
Anesthesia
Anesthesia used in hair transplantation is relatively simple.
Most procedures can be performed with just local anesthesia,
with use of nerve blocks in both the donor and recipient areas.
Both of these areas are also distended with a dilute saline–
lidocaine–epinephrine solution for hemostasis. Scalp blood
vessels do not contract well because of their attachment to the
surrounding connective tissue. Therefore, the scalp blood
vessels are less likely to undergo rapid spontaneous hemosta-
sis compared with other areas of the body.
In selected patients, it may be necessary to add sedation
with midazolam and fentanyl. Because it is not unusual to put
in 2000 or more grafts per patient, which can take 3–4 h,
selected patients can benefit from light sedation.
The anatomy of scalp nerves is relevant in hair restora-
tion in considering local anesthesia and reducing damage to
the nerve during the surgical procedure. The procedure is
begun with occipital nerve blocks in the donor area by use of
lidocaine with epinephrine, followed by a tumescent solution
that allows both adequate anesthesia and good hemosta-
sis. The supraorbital nerve, a branch of the frontal nerve,
provides sensory innervation to the forehead. During graft
Fig. 21.13  Appearance of the scalp immediately on completion of the placement
of approximately 1200 follicular grafts. Small incisions were made with the tip of a
No.11 blade, and the grafts were immediately inserted.

543
Secondary procedures
Correction of this problem requires a thorough analysis of
the deformity with a specific surgical plan. The patient’s
hairline is too low, and any further grafting around the exist-
ing patient plugs to disguise them would not correct this situ-
ation. The first step was elevation of the hairline by excision
of the anterior row of plugs combined with a superior
advancement of the forehead. The forehead was fixed to the
frontal bone by Mitek suture fixation to maintain the forehead
height. The removed grafts were recycled, and after the scar
healed, the patient underwent two sessions of grafting for a
total of 2700 follicular grafts.
Other patients may have problems related only to the
cornrow appearance, which can be corrected by plug reduc-
tion and recycling in association with follicular grafting along
the frontal hairline.17,18 Besides the cornrow problem associ-
ated with large grafts is the problem of compression. When
large grafts with multiple hairs are placed in small recipient
holes, constriction at the base of the graft leads to bouquet
formation (Fig. 21.15).
Even with proper attention to detail, problems will occur
because of the progressive nature of male-pattern hair loss.
realistic expectation but also that the physician is comfortable
the patient’s goals can be met.
The other important issue in the patient who has had
multiple previous procedures, especially with a plug coring
technique, is the scarring of the donor site that healed by
secondary intention. These can be some of the most difficult
reconstructions because of limited available donor hair sur-
rounded by dense scarring. A great deal of time and evalua-
tion is required to find the best available donor hair, and this
often requires an intricate design, taking donor strips from
multiple sites. An appropriate assessment of risk and compli-
cations with these patients is required. The morbidity from
hair transplantation in general is relatively low because bleed-
ing and infection are fairly rare. However, a major problem is
difficulty healing the donor area in patients who have had
multiple plug graft procedures with secondary healing of the
donor site. These patients are often badly scarred, and there
can be difficulty healing the donor site, even when it is har-
vested with the strip technique and closed carefully in a linear
fashion.
Secondary procedures
Most patients with an unsatisfactory result fall into three
major groups. The first is patients who had grafting at an
early age before a mature hairline was established in whom
the grafts were placed too low, with progressive hair loss
behind the grafts. The second group is those patients in
which the hairlines were poorly designed and showed little
knowledge of the natural evolution of androgenic hair loss.
The third group is those in whom the unsatisfactory result
was due to use of large hair plugs, causing the typical cornrow
appearance. Fig. 21.14 demonstrates a patient in whom all
three of these problems occurred. This patient had large plug
grafts inserted at an early age. The grafts were placed too
low on the forehead. No attempt had been made to design
a frontal–temporal recession, thus abnormally rounding off
the frontal–temporal angle. Finally, large plug grafts were
inserted, and the natural progression of hair loss posteriorly
resulted in the patient wearing a hairpiece to cover his sig-
nificant deformity.
Fig. 21.14  (A) This patient demonstrates all three problems of an unsatisfactory result. First, the patient had grafting at an early age before a mature hairline was
established and the grafts were placed too low, with progressive hair loss posteriorly. Second, the hairline was poorly designed and showed little knowledge of the natural
evolution of androgenic alopecia. Third, the patient had large hair plugs, which resulted in an unnatural cornrow appearance once the surrounding hair was lost. No attempt
was made to design a proper frontal–temporal recession, causing an unnatural rounding-off of the angle. (B) Excision of the frontal hairline with removal of the large plug
grafts and elevation of the forehead accomplished by suture fixation to the periosteum. (C) Closure of the defect. (D) Final result after a total of 2700 follicular grafts in two
sessions.
A
B
C
D
Fig. 21.15  Graft compression. Grafts containing multiple hairs are placed in tight
incisions, leading to bouquet formation.

544
SECTION I
CHAPTER 21 • Hair restoration
Correction of the unsatisfactory hair restoration requires a
systematic analysis for proper surgical correction. With the
techniques currently available, these patients can be signifi-
cantly improved.
One such problem is the development of a temporal alley. This
occurs when a patient who had transplantation in the frontal
and superior scalp undergoes hair loss laterally, leaving a gap
or alley between the frontal hair and temporal area. This can
usually be corrected by further grafting in the gap as long as
sufficient donor hair remains.
1. Bernstein RM, Rassman WR. Follicular transplantation, patient
evaluation and surgical planning. Dermatol Surg. 1997;23:771–784.
This paper identifies the basic units in which hair naturally grows; there
are 1–3 follicles in a unit.
4. Halsner U, Lucas M. New aspects in hair transplantation for
females. Dermatol Surg. 1995;21:605–610. The unique characteristics of
female hair loss are presented, including the specific pattern of hair
transplantation unique to creating a natural female hairline.
5. Barrera A. The use of micrografts and minigrafts for the treatment
of burn alopecia. Plast Reconstr Surg. 1999;103:581–584. The ability of
hair grafts to grow successfully in burn scar is presented. The specifics for
successful management of hair loss after burns are discussed in detail.
6. Seyhan A, Yoleri L, Barutçu A. Immediate hair transplantation into
a newly closed wound to conceal the final scar on the hair bearing
skin. Plast Reconstr Surg. 2000;105:1866–1870. The ability to place hair
follicles into acute incisions is presented in order to minimize visible scars.
The authors demonstrate that hair follicles will successfully grow when
placed directly into a fresh incision.
17. Vogel JE. Correction of the cornrow hair transplantation and other
common problems in surgical hair restoration. Plast Reconstr Surg.
2000;105:1528–1536. Various options and techniques are discussed for the
treatment of previous unsatisfactory hair transplantation. The author
details the different techniques available to the surgeon for the secondary
restorations.
Access the complete reference list online at

544.e1
References
References
1. Bernstein RM, Rassman WR. Follicular transplantation, patient
evaluation and surgical planning. Dermatol Surg. 1997;23:771–784.
This paper identifies the basic units in which hair naturally grows; there
are 1–3 follicles in a unit.
2. Cosmetic Surgery National Data Bank: Statistics 2014. New York, NY:
American Society for Aesthetic Plastic Surgery (ASAPS). Available
at:
3. ISHRS: 2015 Practice Census Results. Geneva, IL: International
Society of Hair Restoration Surgery. Available at: http://

4. Halsner U, Lucas M. New aspects in hair transplantation for
females. Dermatol Surg. 1995;21:605–610. The unique characteristics of
female hair loss are presented, including the specific pattern of hair
transplantation unique to creating a natural female hairline.
5. Barrera A. The use of micrografts and minigrafts for the treatment
of burn alopecia. Plast Reconstr Surg. 1999;103:581–584. The ability of
hair grafts to grow successfully in burn scar is presented. The specifics for
successful management of hair loss after burns are discussed in detail.
6. Seyhan A, Yoleri L, Barutçu A. Immediate hair transplantation into
a newly closed wound to conceal the final scar on the hair bearing
skin. Plast Reconstr Surg. 2000;105:1866–1870. The ability to place hair
follicles into acute incisions is presented in order to minimize visible scars.
The authors demonstrate that hair follicles will successfully grow when
placed directly into a fresh incision.
7. Barrera A. The use of micrografts and minigrafts for the correction
of the postrhytidectomy lost sideburn. Plast Reconstr Surg.
1998;102:2237–2240.
8. Beek CH. A study of extension and distribution of the human body
hair. Dermatologica. 1950;101:317–331.
9. Hamilton JB. Patterned loss of hair in man: type and incidence. Ann
NY Acad Sci. 1951;57:708–728.
10. Norwood OT. A classification of male pattern baldness. South Med J.
1975;68:1359–1365.
11. Bouhanna P, Dardour JC. Hair Replacement Surgery. New York, NY:
Springer Verlag; 1996.
12. Ludwig E. Classification of the types of androgenetic alopecia
(common baldness) arising in the female sex. Br J Dermatol.
1977;97:247–254.
13. Scow DT, Nolte RS, Shaughnessy AF. Medical treatment for balding
men. Am Fam Physician. 1999;59:2189–2194.
14. Uebel CO. Micrografts and minigrafts:a new approach to baldness
surgery. Ann Plast Surg. 1991;27:476–487.
15. Uebel CO. Hair Replacement Surgery: Micrografts and Flaps. New
York, NY: Springer-Verlag; 2000.
16. Limmer BL. Bob Limmer does it all one hair at a time. Hair
Transplant Forum. 1991;2:8–9.
17. Vogel JE. Correction of the cornrow hair transplantation and other
common problems in surgical hair restoration. Plast Reconstr Surg.
2000;105:1528–1536. Various options and techniques are discussed for the
treatment of previous unsatisfactory hair transplantation. The author
details the different techniques available to the surgeon for the secondary
restorations.
18. Epstein JS. Revision of surgical hair restoration: repair of
undesirable results. Plast Reconstr Surg. 1999;104:222–232.

SECTION II • General Aesthetic Surgery
22.1 
Liposuction: A comprehensive review of
techniques and safety
Phillip J. Stephan, Phillip Dauwe, and Jeffrey Kenkel
SYNOPSIS
■ Incorporation of a diet and exercise program in conjunction with
liposuction will allow patients to achieve their optimal shape and
contour. Patients who do not adhere to diet and exercise are least
happy with their results.
■ A thorough history and physical exam should be performed and a
preoperative clearance obtained, especially for large-volume or long
combined cases.
■ Marking the patient in front of a mirror allows both the surgeon and
patient to see and understand the areas of concern and intended
treatment. Cellulite and other contour irregularities can be pointed out
preoperatively to the patient.
■ Over-the-counter herbal and diet medications may have unfavorable
interaction with surgery and/or anesthesia and should be discontinued
3 weeks prior to surgery.
■ Knowledge of the differing thickness and consistency of fat throughout
the body is crucial to determining proper depth and technique for each
region of the body.
■ Superficial liposuction should be reserved for significant superficial
irregularities and be performed by those experienced in liposuction
techniques.
■ Wetting solutions should always be used, and a strict record of volume
infused and aspirated should be kept by the operating room personnel.
■ Surgical access sites should be concealed, often asymmetric, and
utilized to allow the best access and treatment results. Excessive use
of a single access incision may result in a deformity.
■ Patients with surgical scars on their abdomen must be thoroughly
examined to rule out the presence of a hernia.
■ There are many tools one can use to perform liposuction. Physician
experience and judgment supersedes any technology.
■ Contour irregularities are best diagnosed at the time of the surgical
procedure. If noted, strong consideration for immediate fat grafting
should be considered.
■ Postoperative contour deformities should be clinically evaluated and, if
mild, can respond to lymphatic massage or other non-invasive
methods. A systematic approach should be used to correct contour
deformities when they occur.
Introduction
Suction-assisted lipectomy, lipoplasty, or more commonly
referred to as liposuction, originally introduced by Illouz in
the early 1980s, continues to be one of the most popular means
of body contouring and overall treatment modalities offered
in aesthetic surgery today.1 Annually, according to the Ameri-
can Society of Plastic Surgery and American Society for Aes-
thetic Plastic Surgery, it consistently ranks among the top
procedures performed in plastic surgery for the last 10 years.2
With greater understanding of the biochemical and physiologic
properties of liposuction, as well as biomedical technological
advancements, suction-assisted lipoplasty has undergone
tremendous evolution leading to overall improvements in
technique, patient safety, and outcomes. Over the past two
decades, it has grown from a procedure that facilitates small
or spot reductions to one that has become an almost irreplace-
able tool in the aesthetic surgery armamentarium in neck,
breast, and circumferential body contouring. Liposuction has
become a useful adjunct to other areas of plastic surgery,
including breast reconstruction and postoperative contouring
in upper and lower extremity reconstruction. A number of
important innovations and modifications to the standard
suction-assisted liposuction (SAL) have progressively refined
the procedure; these include the use of wetting solutions;
advances in cannula design; ultrasound-assisted liposuction
(UAL); power-assisted liposuction (PAL); VASER-assisted
liposuction, and laser-assisted liposuction (LAL). There has
been a strong movement concentrated on defining appropri-
ate safety guidelines for liposuction and other body contour-
ing procedures focusing on deep venous thrombosis (DVT)
prophylaxis and fluid resuscitation ensuring safety and effi-
cacy of the different treatment modalities for our patients.
Even with these refinements, liposuction, as with all inva-
sive procedures, is not without risk. Aesthetic body contour-
ing with liposuction requires a complete knowledge of the
anatomic, biochemical, and physiological components of the
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546
SECTION II
CHAPTER 22.1 • Liposuction: A comprehensive review of techniques and safety
less compact.3 This is critical information for the aesthetic
surgeon in order to perform safe and appropriate suctioning
of the targeted area, while minimizing potential contour
irregularities and skin necrosis. The variation in fat consis-
tency and depth will be discussed further, as it relates to safe
suctioning techniques and the choice of modality for the most
effective treatment.
Anatomic “zones of adherence”,6 which are present in both
men and women, are important to identify and note during
the preoperative consultation. These are areas of relatively
dense fibrous attachments to underlying deep fascia, which
help define the natural shape and curve of the body. There are
gender-specific variations with respect to each of these zones
(Fig. 22.1.2). It is important to recognize these zones, as they
are identified as high-risk areas for contour irregularities after
surgical intervention if not properly respected. However,
these are not areas to avoid in all cases and, on occasion, help
guide the surgeon in establishing “contour goals” for surgical
intervention. Regardless of the tool used for liposuction, it is
helpful to consider the treatment area in terms of the three
surgical layers. These arbitrary layers help delineate areas of
safety when performing liposuction. The most common areas
treated are the intermediate and deep layer. Treatment of
these layers allows uniform reduction without risk of injury
to the subdermal plexus and unwanted skin injury.
Classification
It is helpful to classify patients based on the three types of
lipodystrophy and skin redundancy (Fig. 22.1.3):
■ Type I: localized lipodystrophy. Often younger patients with
good skin tone and minimal skin irregularities.
■ Type II: generalized lipodystrophy. These patients tend to
have slightly diminished skin tone with some skin
irregularities and circumferential lipodystrophy
throughout their trunk and extremities.
■ Type III: skin redundancy and lipodystrophy. Patients
displaying significant skin redundancy that would be
more amenable to excisional surgical techniques to
improve shape and contour. If necessary, liposuction may
be a useful adjunct in order to achieve an optimal result.
different modalities and their limitations and indications in
order to perform the procedure in a safe, controlled manner.
Using a coordinated approach along with a thorough under-
standing, liposuction can be performed safely with relatively
predictable results and outcomes.
Basic science and anatomic
considerations
Anatomy texts divide subcutaneous fat throughout the body
into superficial and deep layers or compartments separated
by Scarpa’s fascia, or the superficial fascial equivalent.3
However, for the purposes of liposuction and body contour-
ing, subcutaneous fat is arbitrarily divided into three layers:
superficial, intermediate, and deep (Fig. 22.1.1).4,5 The impor-
tance of this distinction is that the superficial layer is one that
should be approached with caution and by those with a strong
foundation and experience in liposuction. If this layer is
treated, there may be vascular compromise and/or a signifi-
cantly increased risk for contour irregularities. The relative
consistency and thickness of each of these separate layers
varies for different anatomic areas. For example, the fat of the
back has a more fibrous, compact superficial and intermediate
layer, with an underlying loose, areolar layer. This contrasts
with the fat of the inner thigh, which is not as fibrous and is
Fig. 22.1.1  Surgical layers of subcutaneous fat: superficial, intermediate, and
deep.
Superficial
Intermediate
Deep
Fig. 22.1.2  The zones of adherence are areas where the fibrous
support structures of the subcutaneous fat and skin are adherent to the
underlying deep fascia. These attachments create adherence and
depressions contributing shape of the body’s surface.
1. Lateral gluteal
depression
2. Gluteal crease
3. Distal posterior thigh
4. Mid medial thigh
5. Inferolateral
iliotibial tract

Type I patient
Type I patient
Type I patient
Type I patient
Type I patient
Type I patient
Type II patient
Type II patient
Type II patient
Fig. 22.1.3  Patient examples of three types of patients (I–III): first six images, patient type I; second six images, patient type II; third six images, patient type III.
Continued

Type II patient
Type II patient
Type II patient
Type III patient
Type III patient
Type III patient
Type III patient
Type III patient
Type III patient
Fig. 22.1.3, cont’d

549
Basic science and anatomic considerations
or who were already practicing a “healthy lifestyle” that
continued postoperatively, experienced the best self assess-
ment and satisfaction scores with liposuction postoperatively
(Fig. 22.1.4). A successful body contouring patient must
satisfy four key elements to achieve and maintain optimal
results:
1. Lifestyle change
2. Regular exercise
3. Well-balanced diet
4. Body contouring.
Appropriate candidates for liposuction are not morbidly
obese, are of a stable weight, and have incorporated the above
lifestyle changes into their preoperative regimen. It is prefer-
able for patients to commit to the necessary changes in diet,
exercise, and lifestyle modification before undergoing surgery.
It is the responsibility of the surgeon to address all concerns,
expectations, and goals prior to the procedure in order to
establish realistic expectations of the procedure to the patient.
Preoperative consultation with a dietician may prove benefi-
cial for long-term patient satisfaction. Liposuction is contra-
indicated in patients who are pregnant or in poor general
medical health. Patients with morbid obesity, cardiopulmo-
nary disease, body image perception issues, unrealistic
expectations, wound healing difficulties, or who have exten-
sive or poorly located scars should be excluded from consid-
eration for liposuction.
Cellulite is a skin condition that is often seen when evaluating
patients for liposuction. Cellulite is a dimpling of the skin,
particularly in the areas of thighs and buttocks. It has a poorly
understood pathophysiology but is thought to be related to
fibrous, dermal attachments to the underlying fascia and sur-
rounding hypertrophied fat.3,7 It has a hormonally mediated
component. There is no predictable, long-term treatment
of cellulite. Liposuction in areas of overlying cellulite may
soften or accentuate the superficial deformity. This should be
clearly delineated to the patient as the goals of surgery are
reviewed.8
Diagnosis, operative indications,
and patient selection
Liposuction patients often present with a variety of expec-
tations, concerns, and/or complaints. In order to achieve
optimal contour with liposuction, appropriate patient selec-
tion is imperative. As a general rule, liposuction is performed
in healthy patients who maintain realistic goals and expecta-
tions. Studies have shown that patients who undergo proper
long-term lifestyle changes will in fact achieve the highest
level of postoperative satisfaction from their liposuction-
assisted body contouring procedure. Rohrich et al.9 concluded
that those patients who were committed to a positive life-
style change involving a healthy diet and regular exercise,
Fig. 22.1.4  Patients committed to a healthy lifestyle are more likely to be satisfied with the result of liposuction. (From Rohrich RJ, Broughton G, Horton JB, et al. The key
to long term success in liposuction: a guide for plastic surgeons and patients. Plast Reconstr Surg. 2004;114:1945–1952.)
Eat healthy diet
35% chance and 2 × more
likely to have increased
productivity
Results in better
satisfaction
Long term success
96% chance and 15 × more
likely to have a decreased
clothing size
79% chance and 2½ × more
likely to have high
self-appearance score
43% chance and 3 x more
likely to have improved
health
83% chance to have
decreased productivity and
2 × more likely to be...
62% chance and to have an
increased clothing size
and 10 × more likely to be...
29% chance to have low
self-appearance score and
10 × more likely to be...
85% chance to have
unimproved health and
3 × more likely to be...
Exercise regularly
Eat healthy diet
Exercise regularly
Yes
Yes
Weight loss
Weight gain
No
No
2 × more likely to have...
1½ × more likely to have...
3 × more likely to have...
4 × more likely to have...
Dissatisfied
with your results

550
SECTION II
CHAPTER 22.1 • Liposuction: A comprehensive review of techniques and safety
technique has been described in the abdomen, arms, and
chest. For instance, in male arm contouring, the posterior
deltoid sulcus, tricipital tendon, and bicipital tendon are
regions of concavity, while the deltoid and triceps muscles
are regions of convexity.15 Regions of muscular concavity are
suctioned in a superficial plane, and regions of muscular
convexity are augmented with intramuscular fat injection.
Caution should be exercised in superficial liposuction, as
contour irregularities are more likely and these regions are
dynamic. An unnatural appearance may result if transition
zones to blend these dynamic areas are not marked and
treated appropriately.
Physical exam
A detailed physical exam is performed at the first visit and
consultation. Specific attention to prior scars, presence or
absence of hernias, evidence of venous insufficiency, and
presence of pre-existing asymmetry or contour irregularity
should be discussed and noted in the chart. At the initial and
subsequent visits, height and weight with calculation of body
mass index (BMI) is paramount for safety, as well as for
observation of long-term trends during follow-up. For lipo-
suction candidates, six key elements are documented4–6:
1. Evaluation of areas of lipodystrophy and contour
deformities
2. Skin tone and quality
3. Asymmetries
4. Dimpling and cellulite
5. Myofascial support
6. Zones of adherence.6
The physical exam is best performed in front of a full-length
mirror (Fig. 22.1.5). This allows an open dialogue between
patient and physician, wherein the patient’s concerns can be
addressed and previously unrecognized problem areas can be
Preoperative assessment
Initial evaluation
During this initial interaction, it is imperative that the plastic
surgeon be able to assess the patient’s goals of surgery and be
able to determine if the patient has realistic expectations
regarding outcome and postoperative body image. It may be
useful to have the patient prioritize the body regions that they
are most concerned with, while focusing on specific com-
plaints within these areas. A detailed medical history should
be obtained, including any medications, allergies, and tobacco
use. Especially important are notations in the medical history
of diabetes, massive weight loss, previous surgery, previous
liposuction, and a full detailed list of medications and supple-
ments. Any concerns about a patient’s medical suitability to
undergo anesthesia and/or an operative procedure should
result in referral for preoperative clearance with either an
internist or cardiologist. The patients need to be asked specifi-
cally about herbal and over-the-counter medications, because
these are frequently omitted. Non-essential medications
should be discontinued at least 3 weeks before surgery. In
selected patients, a preoperative evaluation by a primary care
doctor, internist, or cardiologist may be warranted. This typi-
cally includes anyone with a significant medical history, or
patients older than 50 years of age.
It is often prudent to notify the consulting physician of
expected operative times and the amount of expected aspirate
and infiltrate. Often, our medical consultants view liposuction
as a very benign operation with minimal operative time and
morbidity, when, in fact, a large-volume liposuction case can
have significant fluid shifts and time under general anesthe-
sia.10 Massive weight loss patients should undergo the same
preoperative evaluation and clearance for liposuction as they
would for any excisional-type body contouring procedure
(including nutrition, hemoglobin, iron, vitamin B12, etc.).11 It
is safest to refrain from operations until these lab results are
normalized. Herbal remedies and supplements are not regu-
lated by the Food and Drug Administration (FDA) and thus
may place the patient at potential risk of untoward complica-
tions, including bleeding or hypercoagulability and should
be avoided in the perioperative period.12 Avoiding aspirin,
NSAIDs, and hormonal therapy can help prevent such com-
plications as well. It is the authors’ policy for patients to dis-
continue use of all non-steroidal anti-inflammatory drugs
(NSAIDs), aspirin products, fish oil, and supplements 3 weeks
prior to surgery. Of course, if there is a medical indication and
necessity for these drugs, consultation with the primary
physician or appropriate specialist should be completed
before discontinuation of the medical therapy. A frank discus-
sion of the risk of oral contraceptives and estrogens is held
with the patient regardless of the magnitude of the procedure.
We strongly recommend that these medications be discontin-
ued 1 month prior to the operative procedure.13
Patient goals must be clearly elucidated, and realistic
expectations must be established. This is particularly impor-
tant when more superficial liposuction or “liposculpture” is
planned, which is a difficult and time-consuming procedure
with a high learning curve that is appropriate only for highly
experienced surgeons. Authors such as Hoyos and Millard
have popularized high-definition liposculpture in an effort to
contour a body region to its underlying muscular form.14 This
Fig. 22.1.5  Patient examination in front of a mirror.

551
Basic science and anatomic considerations
patients. During the initial consultation, when the patient is
in front of the mirror, it is important to point out potential
problem areas that may cause less than optimal results, so the
patient may visualize and appreciate these areas.
If superficial liposuction or “liposculpture” is planned, a
detailed exam of the subcutaneous fat distribution is essential.
Attention must be paid to “gender ideal” muscular shape/
mass and fat distribution. Additionally, dynamic areas must
be examined and marked in the full range of muscular contrac-
tion to yield natural results. Inattention to these details may
result in unnatural appearances and contour irregularities.
A follow-up visit is typically scheduled 2–3 weeks after the
initial consultation. During this visit, computer images (Fig.
22.1.7) are reviewed, which allows the patient to establish
realistic expectations. These objective images portray the
advantages, disadvantages, and limitations of body contour-
ing surgery. The patient should understand that imaging is
for educational purposes only and is not a guarantee of the
final result. The second visit allows further dialogue between
the patient and physician so that all questions may be
answered and issues addressed. For example, a second oppor-
tunity to address any last minute concerns by the patient in
regards to recovery time, pain control, bruising, and postop-
erative changes will help strengthen the patient’s confidence
in the procedure and decrease the likelihood of any uncertain-
ties or surprises within the perioperative period.
Patient education and informed consent
Patient education is stressed throughout the course of the
initial evaluation, physical examination, and follow-up visit
so that the patient has sufficient information about the proce-
dure, postoperative course, and long-term results to make a
truly informed decision. The patient and physician should
discuss the procedure itself, alternative treatments, financial
obligations (including further surgeries if required), and
assessed and addressed. Any areas of cellulite should be
pointed out to the patient, and a specific discussion of expected
outcome in these areas should be noted. At the initial evalu-
ation, high-quality medical images should be obtained, with
anterior, posterior, lateral, and oblique views. This will allow
for documentation of results, as well as objective evaluation
of outcomes by both patient and physician. Professional
medical photography can be a very useful tool for accurate
and consistent pre- and postoperative documentation.16
While the patient is in a supine position with the head
elevated, abdominal integrity is examined (Fig. 22.1.6). This
is helpful for detecting hernias or myofascial diastases. Find-
ings may be difficult to interpret in larger individuals, males,
or patients with multiple scars. An ultrasound examination or
computed tomography (CT) scan may further clarify this
region and prevent potential intra-abdominal injury in these
Fig. 22.1.6  Patient examination in the supine position confirming integrity of the
abdominal wall.
A
B
Fig. 22.1.7  Computer imaging aids in
preoperative discussion with the patient.

552
SECTION II
CHAPTER 22.1 • Liposuction: A comprehensive review of techniques and safety
influence this decision are the amount of expected lipoaspi-
rate, length and extent of procedure, patient positioning,
operating surgeon preference, anesthesiologist preference,
and overall health of the patient. Depending on the geographi-
cal location, there are differing regulations for the location of
liposuction procedures, usually based on the type of anesthe-
sia and the size of the liposuction procedure. For example, one
recommendation is to avoid epidural and spinal anesthesia in
office-based settings because of potential hypotension and
volume overload issues.17
As a general rule, small-volume liposuction cases can be
performed with local anesthesia, with or without mild seda-
tion. Complex, large-volume liposuction and combined cases
should be performed under general anesthesia or regional
block. Our institutional preference has been to perform the
majority of cases under general anesthesia. Deep-sedation
cases and general anesthesia procedures are performed under
supervision of board-certified anesthesiologists in licensed
surgery centers or hospitals. All prone cases are performed
with general endotracheal anesthesia for airway control.
Operative location should be determined after careful patient
evaluation, assessment of the complexity of operation, and
appropriate evaluation of medical comorbidities. The antici-
pated postoperative course and the need for possible overnight
observation both factor into choice between inpatient obser-
vation or outpatient hospital settings.
Awake liposuction has been performed in the office-based
setting with a tumescent technique. The authors prefer to do
such procedures only for single area treatments or in small
revisions. Detailed patient assessment and strict limitations
on volumes infiltrated and amount of lipoaspirate expected
should be reviewed prior to performing in an unmonitored
office-based setting18; this should be approached with caution
and the patient’s safety kept in mind.
complications and risks. The risks for liposuction include, but
are not limited to, bleeding, infection, pain, thermal injury,
seroma, dyspigmentation, paresthesias, contour irregularities,
and dysesthesias. Large-volume liposuction carries increased
risks of fluid shifts, volume overload, and anesthesia compli-
cations.10 These problems are discussed under “Complica-
tions”, below. Informed consent is vitally important in the
evaluation and management of liposuction patients, to protect
the surgeon and the patient from unexpected outcomes or
patient dissatisfaction. This important process should be
performed by the operative surgeon (not a nurse or staff) and
clearly documented in the medical record.
Operative considerations
Preoperative marking
Guiding marks are performed prior to surgery with the patient
in the erect position. In patients undergoing total body lipo-
suction or contouring in combination with excisional surgery,
marking can be done in the office the day before surgery.
This allows for a more private environment and ample time
to review the plan with the patient. Marking is done in front
of a mirror, thus allowing the patient to contribute to the
process, and further confirms exactly what will be addressed
during the procedure. Areas to be suctioned are marked with
a circle; zones of adherence and areas to avoid are marked
with hash marks. Asymmetries, cellulite, and dimpling are
marked for their respective treatment and to allow patients
to see problem areas. When complete, the marks are once
again reviewed with the patient to ensure that all areas of
concern are addressed.4,5 Access incisions are also marked
at this setting. Often two incisions are needed per area to
be suctioned; these incisions should be placed adjacent to
suctioned areas and not too distant. With liposuction, it is
beneficial to choose access points that can treat multiple
areas. That being said, incisions are small and typically heal
well so should be utilized liberally to achieve crosshatch-
ing of the area and an ability to contour from multiple sites,
allowing for more uniform reduction and decreasing the risk
for access site depression. Care should be taken to prevent
access incision placement in or adjacent to zones of adherence.
The suctioning may cross the zone and disrupt it. Incisions
should also allow each area to be treated from different
directions for optimal contouring. Incisions should be no
longer than 3–4 mm in length and placed in well-concealed
areas. Note that the incisions utilized for ultrasound-assisted
liposuction are slightly longer (5–6 mm) than for standard
liposuction to account for the placement of skin protectors
when utilized. The surgeon should not hesitate in placing
additional incisions if access is insufficient with the existing
markings.
Fig. 22.1.8 shows the preoperative markings and preferred
placement of access incisions based on areas to be suctioned.
Cosmetically, it is preferable to stagger incisions in an asym-
metric fashion to camouflage their appearance.4,5
Anesthesia technique/location of operation
It is up to the surgeon to determine the optimal surgical
setting for each patient undergoing liposuction. Factors that
Fig. 22.1.8  Patient has been marked prior to surgery. Markings demonstrate the
contours of the areas to be suctioned as well as the planned incision sites.

553
Operative considerations
with position changes not necessitating a reprep. We dislike
this technique as it may be embarrassing for the patient and
increases the likelihood of hypothermia. Once in the operat-
ing room, the compression devices are applied to the patient
before being placed under general anesthesia. In the majority
of our liposuction cases, we prefer to position the patient
prone first. A soft hip roll is placed beneath the iliac crests to
elevate the treatment areas off the bed, and either pillows or
longitudinal rolls are used to support the upper chest (Fig.
22.1.9). The breasts should be placed medially and nipples
protected.
The patient’s arms are extended on padded arm boards at
<90° from the long axis of the table. The face must be appro-
priately padded, including placing the cervical spine in a
neutral position and protecting the globes. Patients in the
prone position are subjected to pressure changes over the
forehead, malar areas, iliac crest, and bony prominences of
the arms and legs. Special attention also needs to be given to
the female and male genitals. In the prone position, up to 70%
of the contouring can be performed and may include liposuc-
tion of the arms, back, hips/flanks, lateral, posterior, and
medial thighs.
With the patient in the supine position, the remainder of
the trunk and extremities can be addressed. This may include
treatment of the arms, abdomen, anterior medial thighs, and
knees. This position does not have significant effects on the
cardiopulmonary systems. Brachial plexus injuries can occur
if the arm is abducted >90°. The hips and knees should be
flexed at approximately 30° with a pillow. Pressure points in
the supine position include the occiput, scapula, posterior
iliac crest, sacrum, and heels.
Lateral decubitus positioning
Although rarely used in our hands, the lateral decubitus posi-
tion can access the flanks, lateral back, buttocks, thighs, and
lower legs. A disadvantage of this method, in our experience,
is that a side-by-side comparison to the contralateral area is
not available to assess symmetry. That being said, each
surgeon should choose the positioning that allows him or her
to best accomplish the goals of the patient.
Special importance should be given to medical comorbidi-
ties such as obstructive sleep apnea. Current American Society
of Anesthesiology recommendations include the following:
for patients with signs or symptoms suggestive of moderate
to severe obstructive sleep apnea, surgery should be per-
formed in a hospital setting with extended recovery and
observation to prevent postoperative respiratory complica-
tions.19 It is recommended that liposuction procedures,
whether inpatient or outpatient, if under anesthesia care,
should be performed in an accredited facility with the capabil-
ity to manage any postoperative insult.20 During the liposuc-
tion procedure, it is useful to have the circulating nurse
maintain an accurate liposuction data sheet to facilitate con-
sistent and accurate communication between the surgeon, the
anesthesiologist, and the operating room team.
Maintaining core body temperature
and immediate preoperative care
The patient is placed in a forced air, warming blanket
30–60 min prior to the procedure. Additionally, pedal or calf
compression devices are also applied in the holding area. This
should be instituted as part of preoperative orders to assist in
DVT prophylaxis and prevent the patient becoming cold
during the procedure. During the procedure, all areas not
being treated should be covered by the forced warm air
blanket. The wetting solutions should be warmed and not
administered cold.
Patient positioning
Prone/supine
Once marked, the patient position is determined. The cadence
of the operation usually begins with the patient in the prone
position followed by supine. This necessitates prepping
and draping the patient twice. If the team works together,
turnaround time should be limited to <10 min. An alterna-
tive method is to prep the patient circumferentially while
standing and to then position the patient on a sterile table
Fig. 22.1.9  The patient in the prone position. A large
proportion of a liposuction procedure can be performed in
this position. Appropriate padding and arm position is
important to avoid intraoperative complications.

554
SECTION II
CHAPTER 22.1 • Liposuction: A comprehensive review of techniques and safety
of the lipoaspirate) when the superwet technique or tumescent
techniques are utilized.
Many authors have popularized different variations of
these solutions, but all formulations include some variant of
fluid (normal saline (NS)/lactated Ringer’s (LR)), epineph-
rine, and lidocaine.21–24 Marcaine should be avoided because
of its potential cardiac effects and duration of action; it has yet
to be proven clinically as a suitable anesthetic in wetting solu-
tions.26 The most common solution mixtures are shown in
Table 22.1.3.
Lidocaine
Most wetting solutions utilize lidocaine as the local anesthetic
component to be included in the wetting solution. It has been
reported to provide analgesia for up to 18 h postoperatively
when injected in dilute concentrations into the subcutaneous
space.27 Initially with the large volumes of solution injected,
there was concern about lidocaine toxicity. Toxicity from
lidocaine affects the heart and central nervous system most
commonly. The initial signs and symptoms of lidocaine
toxicity include circumoral numbness, tinnitus, and light-
headedness. Increasing levels can yield tremors, seizures, and
eventually cardiopulmonary arrest. Intraoperative findings
would include arrhythmias and cardiac irregularities.28 The
traditional recommended maximum dose of lidocaine with
epinephrine is 7 mg/kg29; however, in the liposuction setting,
numerous studies have documented the safety of lidocaine
in concentrations >35 mg/kg and as high as 55 mg/kg in
Wetting solutions and perioperative
fluid management
When first described, liposuction was performed without the
use of any infiltrated wetting solution, which resulted in
blood loss of up to 45% of aspirate in some areas.21,22 In an
effort to reduce blood loss, the practice of infiltrating wetting
solutions (saline or LR mixture with dilute amounts of epi-
nephrine and lidocaine) was developed. Liposuction has
continued to evolve to include the addition of infiltrating
subcutaneous wetting solutions prior to suctioning in order
to provide hydrodissection, improve hemostasis, and poten-
tially provide some perioperative analgesia.
There are four different terms used to describe the types of
wetting technique: dry, wet, superwet, and tumescent.21 These
terms are based on the volume of infiltrate as a ratio of the
volume suctioned (Tables 22.1.1 & 22.1.2). The dry technique
uses no wetting solution and has few if any indications
in liposuction. The wet technique involves pre-infiltrating
200–300 mL of solution per region to be treated, regardless of
the anticipated amount to be aspirated. The superwet tech-
nique employs an infiltration of 1 mL of solution per estimated
1 mL of expected aspirate, and finally the tumescent infiltra-
tion, popularized by Klein et al., involves extensive infiltration
of wetting solution that creates significant tissue turgor and
results in total infiltration of ~3 mL of wetting solution per
1 mL aspirated.21–25 Regardless of the technique used, the
infiltrate should be allowed to set for 10 min and no longer
than 30 min prior to suctioning because of the estimated onset
of action of the anesthetic and vasoconstrictor in the solution.
As detailed in Table 22.1.2, there is negligible blood loss (<1%
Table 22.1.1  Estimated blood loss with different liposuction
techniques21
Technique
Estimated blood loss as percentage
of volume aspirated
Dry
20–45%
Wet
4–30%
Superwet
1%
Tumescent
1%
(Data from Fodor PB. Wetting solutions in aspirative lipoplasty: a plea for safety
in liposuction. Aesthet Plast Surg. 1995;19:379–380.)
Table 22.1.2  Techniques of liposuction and infiltrates21
Technique
Infiltrate
Volume aspirate
Dry
No infiltrate
To treatment endpoint
Wet
200–300 mL/area
To treatment endpoint
Superwet
1 mL infiltrate : 1 mL
aspirate
1 mL aspirate/infiltrate
(treatment endpoints)
Tumescent
Infiltrate to skin turgor
2–3 mL aspirate/mL
(Data from Fodor PB. Wetting solutions in aspirative lipoplasty: a plea for safety
in liposuction. Aesthet Plast Surg. 1995;19:379–380.)
Table 22.1.3  The most common formulations of wetting
solutions
Wetting solution contents
Quantity
Klein’s formula
  Normal saline solution
1000 mL
  1% lidocaine
50 mL
  1 : 1000 epinephrine
1 mL
  8.4% sodium bicarbonate
12.5 mL
Hunstad’s formula
  Ringer’s lactate solution
1000 mL at 38–40°C
  1% lidocaine
50 mL
  1 : 1000 epinephrine
1 mL
Fodor’s formula
  Ringer’s lactate solution
1000 mL
  Aspirates <2000 mL 1 : 500 epinephrine
1 mL
  Aspirates 2000–4000 mL 1 : 1000
epinephrine
1 mL
  Aspirates >4000 mL 1 : 1500 epinephrine
1 mL
UT Southwestern formula
  Ringer’s lactate solution
1000 mL at 21°C
  Aspirates <5000 mL 1% lidocaine
30 mL
  Aspirates >5000 mL 1% lidocaine
15 mL
  1 : 1000 epinephrine
1 mL

555
Wetting solutions and perioperative fluid management
cardiovascular system. Most commonly, epinephrine in 1 mg
with 1/1000 dilution is injected into a 1-L bag of infiltrate
either NS/LR.
In a study evaluating the hemodynamic effects of epineph-
rine during liposuction surgery, the authors found a linear
correlation between epinephrine concentration and cardiac
index.10,31,35 While the doses of epinephrine are low and its half
life is <2 min, peak concentrations do not occur until around
5 h after infiltration. In larger-volume cases, it is recommended
that infiltration be staged decreasing the “peak” effect of
epinephrine and its subsequent effect on the cardiovascular
system. Regardless, a thorough patient evaluation with special
attention to the presence of cardiovascular disease should be
performed to avoid the untoward effects associated with
epinephrine infiltration in some patients.36
Although rarely used, halothane may sensitize the heart to
catecholamines, resulting in ventricular arrhythmias. Despite
the protective effect of lidocaine against arrhythmias, halo-
thane should not be used during liposuction procedures.
To maximize its effect, the infiltrate should be allowed to
set for a minimum of 10 min. McKee et al. found that epineph-
rine’s maximum effect in their hand surgery model was
27 min, so a time should be picked that will allow appropriate
epinephrine effect.37
Current recommendations for
perioperative fluid management
The intraoperative data sheet (Fig. 22.1.10) is useful, especially
in large-volume cases, to guide the intraoperative and
postoperative fluid requirements. Perioperative management
guidelines previously published were developed after a
thorough review of 100 consecutive procedures using the
superwet technique. Perioperative fluid management during
liposuction procedures requires attention to maintenance
intravenous fluids, third-space losses, wetting solution infil-
tration, and lipoaspirate.38–40 Liposuction is considered a
moderate surgical stress; therefore 3–5 mg/kg per hour of
crystalloid solution is adequate volume for maintenance
replacement and third-space losses. Additional fluid may be
given during procedures in which the lipoaspirate amount is
more than 5 L. The ratio of 0.25 mL of crystalloid solution for
each aspirated milliliter over 5 L is considered appropriate.
Fig. 22.1.10 appears online only.
Fluid resuscitation
Body contouring procedures can result in significant fluid
shifts and intravascular volume changes for the patient.
The operating surgeon should maintain a dialogue with
the anesthesia provider so that patients receive adequate
replacement volume and proper fluid resuscitation during
the intraoperative period. As mentioned above, awareness of
four key elements will guide the intraoperative fluid manage-
ment of liposuction patients: intravenous fluid maintenance
(body weight dependent), third-space losses, volume of
wetting solution infiltrated, and total lipoaspirate volume.
Large-volume liposuction patients can present an especially
difficult challenge for fluid resuscitation.41,42 Strong consid-
eration should be given for placement of a Foley catheter
in patients undergoing large-volume aspiration to assist in
resuscitation.
large-volume cases.24,30 These higher doses have proven to
yield peak plasma levels below the toxic range. It is theo-
rized that this margin of safety is due to the dilute nature of
lidocaine solutions used in liposuction, slow infiltration, the
avascular plane injected, and the high lipid solubility of lido-
caine. There are many other variables that one must consider
when incorporating lidocaine into a wetting solution. First
and foremost, the lidocaine absorption rate is extremely vari-
able and dependent on multiple factors including the activity
of the cytochrome P450 system, drug interactions, fluids, and
concentrations of the drug administered. Medications that
tend to increase lidocaine levels include oral contraceptives,
beta blockers, and tricyclic antidepressants.
Recently, there has been significant attention addressed to
the importance of monoethylglycinexylidide (MEGX). MEGX
is an active metabolite of lidocaine that is less protein-bound
and thus pharmacologically more active. It has been reported
to be up to 83% active, meaning that it will contribute to
the overall activity of lidocaine and ultimately its potential
toxic effects. Studies have been performed that show that
the peak levels of the metabolite MEGX occur within 8–32 h
after initial infiltration.31 The peak systemic levels were
greater than initially thought but still below the level of toxic-
ity. Based on a recent study, this may increase levels up to
1 mg/mL.
A recent study published showed that tissue levels of
lidocaine beyond 8 h postoperatively are sub-therapeutic. A
well designed study by Hatef et al.32 prospectively random-
ized liposuction patients to receive preoperative subcutaneous
infiltration of 10, 20, or 30 mg/kg of lidocaine wetting solu-
tion prior to the procedure observing intraoperative anesthesia
requirement, postoperative pain, and the need for postopera-
tive analgesia. Surprisingly, no significant difference was
evident between any of the three groups. Some people argue
this as a reason to eliminate lidocaine altogether in wetting
solutions, stating the possibility of minimal effect is not worth
the small risks it poses in patients under regional or general
anesthesia. Further studies are warranted. Danilla et al. pub-
lished their experience with lidocaine evaluated in a random-
ized, double-masked, controlled trial.33 Their study showed
that there is limited clinical benefit to adding lidocaine to
wetting solutions when performing liposuction.
Additionally, further investigation on the use of bupiva-
caine in low doses may provide another alternative for post-
operative analgesia. A recent publication by Failey et al.34
demonstrated no significant difference in the incidence of
adverse events or postoperative length of stay for patients
who underwent liposuction with bupivacaine, compared
with other wetting solutions.
Epinephrine
The epinephrine contained in wetting solutions, with its
vasoconstrictive properties, is the key to minimal blood loss
during liposuction. This effect also decreases the rate of vas-
cular absorption of lidocaine, potentiating the local anesthetic
effect. Epinephrine toxicity can result in tachycardia, hyper-
tension, and arrhythmias. Many investigators have studied
the doses of epinephrine in wetting solutions. It has been
reported to have an upper safety limit of 15 mg per surgical
procedure. Regardless, it is known that epinephrine, even in
small concentrations, may still have a profound effect on the

555.e1
Wetting solutions and perioperative fluid management
Fig. 22.1.10  The intraoperative data sheet records essential information from the operative procedure.
INTRAOPERATIVE DATA SHEET
Patient name
Surgeon
Sex
Skin assessment
Wetting solution
Areas treated with UAL
Areas treated with SAL
Ancillary procedures
UAL generator unit
Output setting
Canula No.
Specific
anatomic area
Left
Right
Left
Right
Left
Right
Left
Right
Left
Right
Size
Wetting solution
volume (mL)
UAL
SAL
External sheath
Yes
No
Normal
Flaccid
Dimpling
Stria
Other (note below)
Male
Female
Weight
Age
lb.
Date
Wetting
solution
Running
total
Volume
(mL)
Cannula
size
Cannula
size
Total
volume
UAL + SAL
(mL)
Volume
(mL)
Time
(min)
Time
(min)

556
SECTION II
CHAPTER 22.1 • Liposuction: A comprehensive review of techniques and safety
systems have multiple power settings; they can be pro-
grammed for a variety of areas, tissue types, and according to
the preferences of performing surgeon. Some of the disadvan-
tages of earlier PAL systems was the significant noise genera-
tion and the mechanical vibration experienced by the operating
surgeon. However, these modalities are now run on electrical
power sources, decreasing the degree of vibration and noise.
PAL is touted for its ability to reduce surgeon work in liposuc-
tion and perform liposuction in all body areas and types with
ease and speed above traditional liposuction, although the
hand pieces are a bit heavy and vibration can still be an issue
for some surgeons.
Ultrasound-assisted liposuction utilizes ultrasonic energy
to break down fat and facilitate suction-assisted removal. Its
mechanism of action is also primarily mechanical in nature,
but cavitation and some thermal effects are purported to
occur. With this technique, fat is emulsified, which allows
removal through traditional liposuction cannulas. UAL com-
prises three stages: (1) infiltration, (2) emulsification, and (3)
evacuation and contouring.45 Skin protection may be utilized
to help protect the skin from thermal injury. Industry efforts
in device innovation are aimed at reducing the required
acoustic energy to achieve adipocyte fragmentation while
avoiding injury to surrounding tissues. Initial ultrasound
devices consisted of solid ultrasound probes that were fol-
lowed by hollow suction cannulas. Later generation devices
offer combined probes and variable acoustic output modes
and frequencies. Limiting the application of energy and
bathing the access site with saline will help prevent untoward
injury to skin and dermis. A towel should cover the region
behind the access site to prevent direct contact of the probe
with the skin during excursion. As with the other technolo-
gies, a variety of probe tip configurations and lengths are
available, including hollow and solid technology. For UAL,
the treatment is begun at a depth of approximately 1–2 cm,
depending on the body area. The plane is treated uniformly,
beginning at one side of the area and moving in a radial
fashion to the contralateral side (Fig. 22.1.11). This is continued
in this manner until the endpoint is reached. When this occurs,
the probe is moved to a deeper plane. Most treatment sites
will have a minimum of two planes and sometimes three.
When the last plane is completed, evacuation begins in the
deeper plane (Fig. 22.1.12) to remove the emulsified fat. Next,
the operating surgeon begins final contouring, if necessary.
Standard cannulas for final contouring are used. Smaller can-
nulas are less efficient at evacuating fat but decrease the likeli-
hood of contour irregularities. It is important that UAL
endpoints be respected to avoid overzealous resection of fat.
As previously mentioned by Rohrich et al. in 1998 (updated
in 2006), the following formula aids in fluid management for
these patients.40
1. Replace losses from preoperative oral intake loss as
needed.
2. Maintain fluid throughout the procedure and manage it
based on vital signs and urine output.
3. Employ the superwet infiltration technique.
4. Administer crystalloid replacements, 0.25 mL for each
milliliter of lipoaspirate over 5 L.
As always, the fluid management of any patient should be
based on sound surgical judgment and with all intraoperative
considerations, patient factors, and comorbidities accounted
for. The safety of procedures, especially for large-volume
liposuction, demands vigorous attention to detail to keep
patient volume status appropriate and prevent instances of
severe fluid shifts during intraoperative and postoperative
resuscitation.
Treatment options
After appropriate preoperative planning and informed
consent, there are now multiple options for which type of
liposuction to perform. Selecting the appropriate modalities
requires a knowledge of and familiarity with the recent
advances in liposuction. Factors that influence the selection of
a particular type of treatment include surgeon preference,
target area, expected aspirate, and history of previous liposuc-
tion. Currently, the most commonly utilized options include
traditional liposuction, as popularized by Illouz,1 commonly
referred to as suction-assisted liposuction (SAL); power-assisted
liposuction (PAL); ultrasound-assisted liposuction (UAL); VASER-
assisted liposuction; and laser-assisted liposuction (LAL). The
traditional SAL still remains the most common and popular
modality for lipoplasty among plastic surgeons.
Suction-assisted lipoplasty uses a two-stage technique
whereby the site is infiltrated with a predetermined wetting
solution and then evacuated after allowing time for the solu-
tion to set and take effect. Patients are marked as previously
described and incisions 3–4 mm in size are made for access.
Advantages of this technique include the ease of use, mal-
leable cannulas, a wide variety of cannulas, and decades of
experience and results. The disadvantages of SAL include
being more difficult to use in fibrous areas and secondary
liposuction. There is more physical work involved to break
up and remove fat with traditional SAL.
Power-assisted liposuction uses an externally powered
cannula, which is variable in size and flex and oscillates in a
2–3-mm reciprocating motion at rates of 4000–6000 cycles/
min. Advocates of PAL contend that it is best used for large
volumes, fibrous areas, and revision liposuction.43,44 Because
the PAL cannula breaks up fibrous fat much more readily, the
procedure is significantly faster and less labor intensive for
the surgeon than traditional SAL. Suction is still a major
component of PAL, and most units are compatible with stan-
dard aspiration equipment. Both the power source and the
suction are attached to the proximal end of the hand piece. If
the surgeon prefers, syringe suction is a useful adjunct and
can be used with an adapter. As with SAL, a wide variety of
probe tip configurations and diameters are available. PAL
Fig. 22.1.11  Ultrasound-assisted liposuction: superficial to deep.

557
Treatment options
some vendors suggest skipping the evacuation phase, allow-
ing the body to absorb the liquefied contents. These devices
have been marketed for purported skin-tightening effects.
The belief is that the heating of the subdermal tissue may
provide a skin-tightening effect. No large, prospective trials
have been undertaken to examine the benefits of LAL over
existing technologies, so unfortunately, these reports remain
anecdotal and lack scientific validation. DiBernardo and col-
leagues evaluated skin tightening and skin shrinkage after
treatment with a 1064/1320-nm laser in the abdomen of five
patients and found a 26% improvement in skin elasticity and
an average reduction in area of 17%.50,51 While DiBernardo’s
studies do achieve statistical significance, the authors are not
convinced it yields clinical differences.
A previously published randomized, double-blinded,
controlled study by Prado et al.52 showed no difference in
the outcomes of LAL versus traditional SAL. In that study,
each patient served as their own control. Factors evaluated
included cosmetic result, postoperative pain, length of
operation, lipocrit, and free fatty acids. Besides the lack of
difference in the cosmetic outcome of LAL versus SAL, the
authors also reported a longer operative time with LAL, less
early postoperative pain with LAL, and elevated free fatty
acids/triglycerides in the laser-treated lipoaspirate. Regard-
less of its efficacy in tightening skin, we must recognize
that there is a fine line between dermal contraction and full-
thickness injury when applying heat to the subdermis. There
are manufacturer claims about tissue contraction and skin
tightening, but there have been no clinical papers supporting
this claim.
Surgical endpoints
Longstanding endpoints have been established for traditional
liposuction such as skin pinch, final contour, and volume of
aspirate. However, with the advent of new technology, the
operating surgeon must be aware of the differences in surgical
endpoints for this new technology in order to prevent signifi-
cant injury or complications and allow for the best aesthetic
results. These endpoints have been divided into primary and
secondary endpoints. Skin pinch and final contour are the
most critical endpoints in traditional liposuction and account
for the best determination of final result.5,53 A reduction in
convexity to a smooth contour is the ultimate goal with the
endpoint being surgical judgment. Other indicators such as
treatment time, blood in aspirate, and amount of aspirate are
important factors to consider. Measured volume aspirated is
a good indicator for bilateral procedures in order to judge
symmetry and contour, comparing each side to the opposite.
However, recognizing preoperative asymmetries is important
because lipodystrophy is not usually perfectly symmetrical.
In UAL, the most important endpoint is reached when one
encounters a loss of tissue resistance, which is appreciated
through the treatment as well as the non-dominant guiding
hand. Additionally, the aspirate, when used, may become
more blood tinged, indicating adequate emulsification of the
treatment site. Furthermore, experience helps dictate energy
application times in particular regions of the body. Secondary
endpoints for UAL include site-specific treatment time and
volume to allow for comparison of size and symmetry of
treatment on either side. Contour should not be judged during
emulsification or the evacuation phase. Once evacuation is
Advantages of UAL include less surgeon fatigue, as well as
improved results in fibrous areas and in secondary proce-
dures. By utilizing ultrasound-assisted liposuction, advocates
report more uniform treatment of fat layers and improved
contour with less revision. Disadvantages include increased
equipment cost, slightly larger incisions, longer operative
times, and the possibility of thermal injury.4 Thermal injury is
not typically seen with the application times currently being
used today. UAL requires a superwet environment and cannot
be performed without a wetting solution. Finally, UAL
requires continuous movement to prevent excessive exposure
of the tissues to heat (Fig. 22.1.13).
Fig. 22.1.13 appears online only.
VASER-assisted liposuction employs a newer generation
ultrasound-assisted liposuction device that incorporates less
energy with more efficient, solid probes. The grooved rings
on the end of probes allow for emission of acoustic energy
through the sides of the probe rather than solely through the
end of the cannula. This allows lateral fragmentation of tissue
with lower energy and reduced chance of skin injury associ-
ated with “end hits”. The probes come in an array of sizes and
grooving, depending on tissues in which they will be used.
The system uses less energy, decreasing its thermal component
to the tissues.46,47 After treatment with either continuous or
pulsed energy, the fat broken down is then evacuated with a
traditional liposuction cannulas. An article by Garcia and
Nathan advocates the use of VASER in large-volume liposuc-
tion to reduce blood loss, especially in fibrous fatty areas
where blood loss is likely to increase (Fig. 22.1.14).48
Fig. 22.1.14 appears online only.
Laser-assisted liposuction has been at the forefront of
marketing hype at the time of this publication. The treatment
involves insertion of a laser fiber via a small skin incision.
Depending on the manufacturer, the fiber may either be
housed within a cannula or as a separate fiber. There are
several commercially available lasers on the market under
different trade names. The most common available wave-
lengths in the United States are 924/975 nm, 1064 nm,
1319/1320 nm, and 1450 nm. Without a specifically targeted
chromophore for lipolysis, the laser energy is transferred to
tissues in the form of heat. Many of these devices utilize more
than one wavelength during treatment. Most companies and
physicians utilizing these devices employ a four-stage tech-
nique: infiltration, application of energy to the subcutaneous
tissues, evacuation, and finally subdermal skin stimulation.
The laser fiber purportedly acts to disrupt fat cell membranes
and emulsify fat.49 Evacuation then commences via traditional
liposuction cannulas. For smaller regions (such as the neck),
Fig. 22.1.12  Ultrasound-assisted liposuction: deep to superficial.

557.e1
Treatment options
Fig. 22.1.13  Liposonix ultrasonic liposuction machine.
Fig. 22.1.14  The VASER system.

558
SECTION II
CHAPTER 22.1 • Liposuction: A comprehensive review of techniques and safety
utilized for superficial deposits and final contouring. See
below for common cannula sizes for various areas.
Cannula length
Length of the cannula can vary from 10 cm to 30 cm. As the
length increases, the ability to finely control evacuation is
more limited. With greater cannula length, more areas can be
suctioned with fewer access incisions. However, the surgeon
should never compromise on number of access incisions to
allow adequate suctioning and contouring (Table 22.1.5).
Cannulas utilized in traditional SAL
Most traditional liposuction cannulas used for SAL have
rounded and somewhat tapered tips to allow easier move-
ment through the tissues. The majority of cannulas have
multiple distal openings that are set back from the tip to avoid
contour irregularities. These openings vary in size and are
generally proportionate to the diameter of the cannula. Mul-
tiple openings allow improved efficiency in fat removal.
Single- and double-aperture cannulas are safe because the
opening can be directed away from the skin; however, they
do aspirate fat at a slower rate. The most common cannula
type is the Mercedes type, which has three apertures set back
from the tip to allow efficient circumferential fat removal.
There are multiple variations with either larger or smaller
opening, which can be tailored to the surgeon’s preference or
the desired effect.
Cannulas utilized in PAL
An array of cannulas is also available for the PAL systems
(Microaire Surgical Instruments, Charlottesville, VA). These
cannulas are small and malleable, which is very useful when
working along curved surfaces. They are comparable in length
complete, contour may be assessed. Alternatively, treatment
with SAL or PAL uses final contour and symmetrical pinch
test results as their primary endpoints. Treatment time and
volume, similarly, can be used to help ensure that treatment
is symmetrical (Table 22.1.4).
The operating surgeon should not hesitate to add multiple
sites for evacuation and final contouring to create a smoother,
more uniformly treated area and minimize the risk for contour
deformities. As a general rule, superficial liposuction should
not be performed routinely and is reserved for patients who
have significant superficial irregularities. Only surgeons with
extensive experience in liposuction should perform this pro-
cedure due to the high propensity for skin injury and contour
irregularities of the superficial soft tissues.
Finally, when contour irregularities are recognized intraop-
eratively, they can be treated with autologous fat grafting
immediately at the site of the deformity. Trying to feather
edges of the defect most often leads to an even greater
problem, further complicating its treatment. This will be dis-
cussed more under complications.
Cannulas and probes
Suction of fat is achieved through cannulas (hollow tubes
with opening(s) at tips). Cannulas have changed significantly
over the years. They are available for multiple different pur-
poses, modalities, and specific regions. The cannulas come in
a wide variety of sizes (diameter of the tube), tip configura-
tions (number and location of holes at the tip), and lengths of
cannula. Each factor alters the amount, speed, and viability of
fat removed.54
Tip configuration
The tip of the cannula has a bearing on the speed, efficacy,
and safety of liposuction. Most tips are blunt with multiple
apertures (openings) set back from the end to allow suction-
ing. The sharper the tip of the cannula, the more likely the
operating surgeon is to penetrate unwanted structures, i.e.,
fascia, peritoneum, etc. Cannulas can be found with a variety
of openings and configurations.
Cannula diameter
The most common cannula sizes utilized in liposuction are
between 2.5 and 5.0 mm. However, cannula sizes are available
down to 1.8 mm and up to 1 cm in size. There are very limited
uses for the large or very small specialized cannulas. As
cannula size increases, the amount and speed of tissue removal
increases; however, the risks of causing contour deformities
and tissue damage also increases. In general, large cannulas
are used for deeper fat deposits and the smaller cannulas are
Table 22.1.4  Surgical endpoints for suction-assisted liposuction/power-assisted liposuction (SAL/PAL) and ultrasound-assisted
liposuction (UAL)4
Modality
Mechanism
Primary treatment endpoints
Secondary treatment endpoints
SAL/PAL
Direct tissue cutting/avulsion at cannula holes
Final contour and symmetrical
pinch test
Treatment time, number of cannula
strokes, and treatment volume
UAL
Cavitation to disrupt and emulsify tissue, followed
by aspiration. Direct cutting less important
Loss of tissue resistance and
appearance of blood in aspirate
Treatment time and aspiration
volume
Table 22.1.5  Typical cannula size and location utilized
Site
Evacuation (mm)
Contouring (mm)
Neck
2.4
2.4 and 1.8
Arms
3.7
3.0 and 2.4
Back
3.7
3.0
Hips
4.6 (deep plane only)
3.7 and 3.0
Abdomen
3.7 (deep plane only)
3.7 and 3.0
Thighs
3.7 (deep plane only)
3.0
Knees
3.0
2.4
Calves/ankles
3.0
2.4

559
Treatment options
Treatment areas
Arms
The liposuction of arms is covered in Chapter 27.
Back
The anatomy of the subcutaneous fat and skin is unique from
other regions of the trunk and extremities; it has a very thick
dermis and a dense, fibrous characteristic to the underlying
fat, more superficial in location. Beneath this, there lies a loose,
areolar plane of fat on top of the deep fascia. The preferred
position to treat these patients is in the prone position with
the bed in a head-down flexed position. The fibrous nature of
the fat and the dense tissue make the utilization of UAL and
PAL extremely useful for this area. The quantity of fat removed
can be moderate, but improved results are often observed with
release of folds and attachments to deeper tissue. Access inci-
sions will depend on the distribution of fat and/or skin rolls
and should often be placed medially and laterally; if at all
possible, the incisions should be placed in the bra/bathing
suit line for the best cosmetic result.53,54 Women will often
complain of fat rolls along the bra-line, and large pockets of
lipodystrophy can be seen (Fig. 22.1.15). This area responds
especially well to UAL allowing the fold to be broken up and
excess fat removed. When suctioning the back, forceful excur-
sion of the cannula should be avoided, as fibrous areas may
redirect the cannula to an unsafe location. Suctioning from
areas off of the thoracic cage (hip region) towards the posterior
back should not be performed to obviate intra-abdominal and
intra-thoracic penetration of the cannula (Fig. 22.1.16).4,5
Abdomen
Limitations and benefits of abdominal liposuction are often
misunderstood by patients. Contouring the body in any area
requires the physician to evaluate that area circumferentially.
This is particularly true in the lower trunk, where the final
contour not only depends on the abdomen but also the area
of the hips or flanks. Furthermore, many patients seeking
contouring of the abdomen may not be candidates for
and diameter to SAL cannulas, permitting the use of small
access incisions.
UAL
Ultrasonic technology uses either a hollow cannula or a solid
probe. VASER probes (Sound Surgical Technologies, Louis-
ville, CO) are solid and have rings circumscribing them. The
rings allow for lateral fragmentation; therefore, the greater
the number of rings, the more lateral fragmentation that is
possible.
Two or three ring probes are generally used in areas that
have soft, non-fibrous fat, and the single ring probe is reserved
for more fibrous secondary areas. The golf tee-shaped tip
cannula provides a sharp edge, allowing for a more aggres-
sive treatment of the tissues and great tissue fragmentation.
Fig. 22.1.15  Patient with back rolls.
Fig. 22.1.16  Patient in position for suction of back rolls.
A
B

560
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CHAPTER 22.1 • Liposuction: A comprehensive review of techniques and safety
liposuction alone and require excisional techniques to allow
them the best possible change in contour.
The abdomen is bordered superiorly by the xiphoid process
and costal margin, the pubis and inguinal ligament inferiorly,
and the anterior superior iliac spines laterally. Careful preop-
erative evaluation and physical exam is essential. This includes
detail pertaining to the distribution of fat, scars, skin laxity,
and the presence or absence of hernias. The physical examina-
tion may be challenging on patients who are overweight, with
a large pannus, or with extensive scarring, necessitating pre-
operative imaging to rule out any abdominal wall defects or
hernias. Patients with diastasis, abdominal wall laxity, or
significant intra-abdominal fat should be counseled on the
possible benefit and/or need for skin excision or plication, in
order to achieve an optimal contour and aesthetic result.
The subcutaneous abdominal fat is amenable to all of the
various modalities of liposuction and continues to be one of
the most popular and desired areas for liposuction. Suctioning
the deep two-thirds of the fat is safe and effective. The sub-
scarpal fat below the umbilicus is loose while the area above
the umbilicus tends to be more compact and fibrous.55 The
operating surgeon should reserve superficial liposuction for
the linea alba or for the correction of secondary deformities,
and only then with extensive experience and care. There have
been published reports of superficial sculpting of the abdomen,
but this should only be attempted by experienced hands.56
Access to the abdominal region may be gained through an
umbilical incision, bilateral lower abdominal incisions, and/
or suprapubic incisions. It is also useful to extend the table at
the waist up to 15 or 20° to allow excursion of the cannula
away from the suprapubic region and specifically the pubic
ramus. In patients with a long torso and a moderate degree
of lipodystrophy overlying their costal margin, an inframam-
mary fold incision can be made to access this fatty area. As
with other body regions, the surgeon should never approach
an area of convexity from an area of concavity, to avoid intra-
abdominal or thoracic penetration (Fig. 22.1.16). In the
Fig. 22.1.17  Difference in configuration of
the (A) female and (B) male hip region.
A
B
abdomen, it is imperative that short, controlled strokes be
used to avoid the potential for inadvertent fascial perforation,
particularly when working in and around scars. Finally, the
distribution of fat in the abdomen can vary; people with large
volumes of intra-abdominal fat will not respond well to
abdominal liposuction and should be counseled accordingly
to prevent unwanted outcomes and disappointment.
The skin of the abdomen can be prone to contour irregulari-
ties. Constant feedback from the tissues by means of manual
palpation, pinch, and symmetry assessment helps decrease
the likelihood of contour irregularities.55
Hips/flanks
As mentioned earlier in this chapter, the authors prefer to
treat the hips and flanks in the prone position, as this posi-
tion allows for simultaneous treatment of both sides and for
comparison. This is a common area of suctioning in males
and females and is accessible through the bilateral or single
midline paraspinous region and/or an incision in the lateral
gluteal fold. This is determined by the location of the fat.
On very rare occasions, in patients with only lateral fullness,
treatment can be adequately performed in the supine position
with the patient rotated. Suctioning in this area can provide
excellent results, and all modalities have proven effective. The
fat is loose and in some cases fibrous, with thick overlying skin.
Significant striae may be seen in patients with weight fluctua-
tions or in postpartum women. Liposuction in these patients
may reduce the lipodystrophy but may result in superficial
contour irregularities or skin redundancy. When performing
liposuction of the hips and flanks, knowledge of the differing
aesthetic consideration of the hips and flanks in males and
females is crucial to preventing inappropriate masculinization
or feminization. In general, males tend to have fullness in
the superior and lateral region, while females usually exhibit
prominence more inferiorly and posteriorly (Fig. 22.1.17).57
In male patients the term flank describes an area immediately

561
Treatment options
adherent zone has a high likelihood of resulting in a contour
deformity.4,55
Buttocks
The buttock area must also be approached with caution. There
are widely varying ideals on the appearance of an aestheti-
cally pleasing buttock. These change with time and vary
across age groups, ethnicity, and geography. It is important to
discuss preoperatively the expectations and outcomes desired
from a patient requesting buttock contouring/liposuction. A
uniform reduction of the buttock can be achieved through
cautious treatment of the intermediate layer resulting in a
decrease in buttock projection in an anterior/posterior dimen-
sion. Access incisions are placed asymmetrically, to avoid an
operated look. Avoiding deep, aggressive suctioning and
ensuring the length, position, and integrity of the inferior
gluteal crease is of critical importance. Overzealous treatment
in the deep or superficial plane may result in buttock ptosis.57
This area is most easily accessed via paraspinous or gluteal
access incisions. These should be well concealed by clothing
and/or bathing suits. Additionally, excessive contouring of
the lateral proximal posterior thigh may result in an extension
of the gluteal fold in the female patient and masculinization
of the gluteal area (Fig. 22.1.19). Often, patients requesting
buttock contouring actually desire increased shape and pro-
jection and will require augmentation and/or fat transfer.
This should be discussed thoroughly in the preoperative
evaluation to ensure both the patient and operating surgeon’s
expectations are identical. Augmentation of the buttock with
a variety of techniques is covered in Chapter 26.
Thighs
Males and females have varied distributions of fat in the thigh
region. Women tend to accumulate the fat either in a diffuse,
circumferential manner or in significant amounts medially
and laterally. Cellulite may also be seen in women, as are
superior and posterior to the iliac crest. It begins in the para-
spinous area and enlarges as it expands laterally. Anteriorly,
the flank blends with the tissue of the lower abdomen. The
inferior margin is defined by the zone of adherence along the
iliac crest. In contrast, the female hip is located more inferiorly
and typically centered over the posterior iliac crest. The hip
extends down to the level of the lateral greater trochanteric
adherent zone. The fat in this region is typically loose but
fibrous as it becomes more superficial, due to the thickness of
the overlying dermis. It is essential to mark the lateral gluteal
depression prior to liposuction, as violation of this important
area can lead to either a persistent or exacerbated irregular
contour and deformity. Often, this adherent zone is a land-
mark to which both the hips and lateral thighs are reduced.
In some patients, this area may represent an area of significant
depression and may benefit from autologous fat transfer
(Fig. 22.1.18).
Access to the hip and flank can be achieved via two inferi-
orly placed lateral paraspinous incisions that are easily con-
cealed by undergarments or bathing suits. With more laterally
displaced lipodystrophy, incisions may be moved more later-
ally. In contrast, patients with more posteriorly oriented fat
may be adequately treated through a lower midline access
incision. This may be moved more superiorly if the fat overlies
the area of the inferior–posterior costal margin. Alternatively,
the area overlying the distal, posterior costal margin can be
approached from a “bra-line” access site in patients undergo-
ing back contouring. The midline incision typically does not
heal as well as paraspinous incisions and thus should be
discussed with the patient. The lateral gluteal fold access
incision may also contour the more inferior portion of the
hip/flank, which allows for a nice blending between the
lateral thigh and hip/flank area. This incision, in combination
with a single midline access site, allows for effective contour-
ing and avoidance of incisions overlying the buttock area,
which may have a tendency to dimple. However, caution
should be used when contouring via the lateral gluteal fold
incision, as overzealous resection through the trochanteric
A
Fig. 22.1.18  The violin deformity may
require fat grafting to the zone of depression
in addition to liposuction of the surrounding
areas of excess fullness.
B

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CHAPTER 22.1 • Liposuction: A comprehensive review of techniques and safety
The prone position allows the operating physician to
work both sides and assess for symmetry. Incisions are often
placed in the lateral gluteal crease. Occasionally, a patient
may benefit from a midlateral incision. The lateral thigh is
amenable to all forms of liposuction; both the intermediate
and deep planes can be suctioned. The lateral thigh is likely
the site of the most contour irregularities in our experience;
the visibility of the lateral thigh as well as the possibility for
skin laxity contribute to this. Extreme caution is advised in the
superficial plane for fear of worsening pre-existing contour
irregularities. Cannulas in the 3.0–4.6 mm range are used for
lateral thigh suctioning. Often final contouring or transition-
ing from lateral to anterior is performed in the supine position
to remove any “shelf” that may exist following the prone
position.
Suctioning the posterior thigh should be approached with
caution. In many patients, the skin is adherent to the underly-
ing tissues with a paucity of fatty tissue. Overzealous suction-
ing in this area results in loss of the adherent zone and rolling
and redundancy of the skin. Special care should be taken
when addressing the proximal posterior thigh. Problems in
this area can be very difficult to correct, requiring either
autologous fat transfer or skin excision. In females, overtreat-
ment of this area may elongate the gluteal fold, masculinizing
the female silhouette. Suctioning of the lateral thigh and
posterior thigh is easily facilitated via the previously described
lateral gluteal fold access incision and or a more medial
gluteal fold access incision.57
Medial
The medial thigh is the most unpredictable and difficult
area to treat in our view. Patients often present with com-
plaints of legs rubbing together when walking or difficulty
with clothing in the medial upper thigh. Fat in the medial
thigh is loose and soft, and the overlying skin is thin and
often lax.55 The plane of suctioning is intermediate fat, and
smaller cannulas such as 3.0 mm and 2.4 mm are generally
utilized. This area can be treated in both the prone and supine
superficial irregularities and preoperative contour problems.
In general, men tend to accumulate more compact fat in the
proximal thighs. The fatty layer tends to be more fibrous. The
dense fibroconnective tissue tends to prevent extensive super-
ficial contour irregularities and cellulite. It should be noted
that these are generalizations and any patient can present
with either diffuse or focal accumulations of lipodystrophy,
and the operating physician should thoroughly evaluate
with exam and photographs. Common terms for deformities
related to the thigh and hips include saddlebag (a trochanteric
bulge lateral to gluteal crease); banana roll (preoperative or
postoperative roll inferior to the gluteal fold), and violin
deformity (female contour of narrow waist, full hips, full lateral
thighs, and depression in the zone of adherence between the
hips and thighs).
Cellulite is very common in the thigh region and may be
the presenting complaint of some patients; this needs to
be addressed early with patients. Informed consent should
include the fact that cellulite will not improve with suctioning,
may worsen, and that no improvement in superficial contour
irregularities is possible with liposuction. Cellulite has become
the target of multiple devices with varying levels of invasive-
ness; however, to date, there are no published studies suggest-
ing an effective treatment modality.
In many instances, patients undergoing contouring of the
thigh are best suited for a circumferential approach in the
prone/supine position.3,4,55 Although patients may present
with an isolated medial or lateral deformity, we have found
this less common in our patient population. The degree of
contouring of specific regions of the thigh is dependent on the
analysis and needs of each patient. The adherent areas of the
thigh to recognize include the gluteal crease; the lateral gluteal
depression; the posterior, inferior, and distal lateral thigh; and
the area of the mid-inner thigh (see Fig. 22.1.2).6
Lateral and posterior thighs
Suctioning the lateral thigh is done in the prone position or
occasionally the lateral decubitus position.
Fig. 22.1.19  Masculinization of the female
buttock.
A
B

563
Complications
Postoperative care
At the conclusion of surgery, liposuction patients are placed
in a compression garment, which is customized based on
surgeon preference and procedure performed. Some type of
compression foam may also be used under the garment for
the first week to assist in contouring; this also helps diminish
bruising and edema in our hands. In our practice, patients
who have undergone any large-volume procedure (>5000 mL
aspirate), liposuction of multiple areas, or liposuction in addi-
tion to abdominoplasty or another excisional body contouring
procedure are kept overnight for 23-h observation.57 Patients
are asked to ambulate the day of the surgery, and sequential
compression devices are placed on the patient in the preop-
erative holding area and continued until discharge. Patients
are allowed to shower as early as 1 or 2 days postoperatively
and are instructed to keep the compression garment on 24 h
a day for 2 weeks. The patient may remove the compression
garments for bathing. Initial postoperative visits are sched-
uled for 5–7 days postoperatively; return to activity/work can
occur as early as 3–4 days or at 2 weeks, depending on the
procedure. Walking is encouraged immediately, and light
activity is allowed 2 weeks after surgery, unless the patient
has undergone an associated abdominoplasty or other inva-
sive procedure. Patients should expect to initially gain some
weight after liposuction due to volume shifts and postopera-
tive swelling. Edema tends to peak from 3 to 5 days after
surgery. Bruising should be minimal and dissipate by 7–10
days after surgery. Patients should begin to see contour
changes in their waist by 2 weeks, and at 6 weeks should be
able to appreciate significant changes in their shape. As
patients’ activity level improve and necessary lifestyle changes
proceed, further changes may be noticed. The final aesthetic
result can be seen 3–6 months after surgery, depending on the
patient. These postoperative volume changes and swelling are
often a source of angst for patients and are best discussed in
the preoperative consultation to alleviate any post-surgical
complaints/worries and allow for appropriate patient expec-
tations. Postoperative lymphatic massage is encouraged to
help with swelling and induration and is often started prior
to surgery and resumed shortly after the procedure.
Complications
Although viewed by many people as a simple and benign
procedure, liposuction, especially large-volume liposuction,
can be associated with significant morbidity and should be
performed by appropriately trained physicians. Much atten-
tion has been directed toward outcomes and prevention of
complications in the past few years, with the ultimate goal of
improved results while maintaining patient safety. Complica-
tions can vary from mild postoperative nausea and vomiting
to DVT/pulmonary embolism (PE) and even death. Postop-
erative complications occur in three different windows. These
are the perioperative period (0–48 h); early postoperative
period (days 1–7), and late postoperative period (1 week to 3
months). In a questionnaire to board-certified members of the
American Society for Aesthetic Plastic Surgery, a significant
increase in complications was observed when liposuction was
combined with other contouring procedures, most notably
position together or supine with legs “frogged”. Realistic
expectations must be established with the patient, and cer-
tainly the possibility of skin redundancy or laxity should be
reviewed.
Anterior thigh
The anterior thigh is characterized by compact fat of limited
thickness. Patients often have more fullness proximally com-
pared with the distal anterior thigh. Contouring of this area
helps eliminate step-off or transition points from the medial
and lateral thighs and helps decrease the projection of the
thigh in the posterior-to-anterior view. The anterior medial
thigh can often be addressed through the same access site as
the medial thigh. Laterally, we often make an accessory access
incision on the proximal anterior thigh. Fine cannulas should
be used in this area as it is compact and fairly thin. Irregulari-
ties can occur frequently in inexperienced hands.
Knees/ankles
Lipodystrophy around the knees is usually confined to the
areas of medial and anterior leg. Treatment is relatively
straightforward with small stab incisions to obtain easy access.
The posterior knee should be avoided. Suctioning proceeds
with small cannulas in the supine positioning/frog-leg posi-
tion. There is often a tendency to over-resect the medial knee
and not address the anterior portion; visualization is the best
way to determine the endpoint. Volume is usually small, and
the goal of contouring in this region should be to help improve
and taper the distal thigh.
The treatment of the calves and ankles remains challenging
and requires more prolonged recovery. Patients may complain
of a lack of definition and poor tapering from the bulkier calf
to the ankle. Patients must be aware of the increased morbid-
ity associated with treatment of this region. Specifically,
contour irregularities are much more common and difficult to
correct. In our experience, treatment of this region doubles the
recovery time of liposuction (from 3 to 6 months). Small, fine
cannulas are essential, utilizing multiple access sites to
decrease the risk for access site deformities.55
Neck
Patients with minimal to mild skin laxity and lipodystrophy
of the neck may be candidates for liposuction of this region.
All liposuction devices may be used in this region, but care
must be taken to avoid contour irregularities, skin injury, and
nerve injuries.
The patient is positioned with their neck hyperextended
with a shoulder roll or pill beneath the upper back. For cen-
tralized lipodystrophy, a single submental access incision may
be used. For most, lateral access with a lobular incision allows
for transitioning laterally.
An appropriate amount of wetting solution should be
placed and ample time utilized to allow for the epinephrine
effect. Direct subdermal suctioning should be avoided. In
our hands, key pinch is the critical endpoint allowing for
symmetry. Continuous assessment of contour is important.
Overzealous treatment of this area may result in hollowing
and skeletonizing the neck or potential neurapraxia of the
marginal mandibular nerve.58,59 Fortunately, this usually
resolves within a few weeks.

564
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CHAPTER 22.1 • Liposuction: A comprehensive review of techniques and safety
Other early postoperative complications can include
venous thromboembolism, infection, and skin necrosis. The
incidence of DVT in liposuction has been reported at <1%, but
a marked increase in this percentage is demonstrated when
liposuction is combined with other surgery (abdominoplasty/
belt lipectomy).66 Physicians should familiarize themselves
with the American College of Chest Physicians (ACCP)
current recommendations and a scoring system to assess risk
such as the University of Texas – Southwestern Modification
of the Davison–Caprini Risk Assessment model currently
available.13,66,67 Administration of enoxaparin has resulted in
a decreased incidence of DVT but has been associated with
an increased risk of perioperative bleeding and hematoma.66
Classical clinical signs such as lower extremity swelling,
Homan’s signs, shortness of breath, chest pain, and/or
tachycardia should alert the provider to the possibility of
DVT/PE and warrant immediate evaluation and treatment
(Table 22.1.6).
Wound infections, including necrotizing fasciitis, are
serious complications known to occur in lipsuction.68 Fortu-
nately, these types of complications are rare. Complaints of
persistent postoperative fevers and/or cellulitis should be
closely monitored and aggressively treated. As a preventative
measure, first-generation cephalosporins are administered
perioperatively within 30 min of the incision unless the
patient has a known history of methicillin-resistant Staphylo-
coccus aureus (MRSA), in which case vancomycin is adminis-
tered preoperatively. There is no indication for routine
postoperative antibiotics after the perioperative dose in stan-
dard liposuction.
Late complications of liposuction include delayed seroma
formation, edema and ecchymosis, paresthesias, hyperpig-
mentation, and contour irregularities. Seromas following
aggressive liposuction are rare and thought to be secondary
to overzealous treatment of an area, which denudes the fascia.
It appears to be technique dependent rather than technol-
ogy specific. A loose closure of cannula sites, postoperative
compression garments, and expressing residual fluid over
liposuction areas at the end of procedure all can potentially
reduce the incidence of seroma formation.57 Postoperative
edema and ecchymosis occur to a varying extent in all patients.
Prolonged edema can occur up to 3 months post-surgery and
is best treated with supportive care and lymphatic massage.
Significant ecchymoses may result in hemosiderin deposition
and ultimately hyperpigmentation. This can be challenging
to eliminate. Postoperative paresthesia/dysesthesia can
occur in all forms of liposuction. The sensory changes are
usually reversible and can take up to 10 weeks to recover,
but recovery is generally felt to be quicker with SAL than
with UAL.69 There is no current data addressing the sensory
changes associated with new technology or laser-assisted
liposuction.
With regard to aesthetic outcomes, the most common late
postoperative complication from liposuction is contour defor-
mity or irregularities. Up to 20% of patients can present or
will complain of some sort of contour irregularity.70,71 Mild
irregularities are often present after suctioning and are treated
conservatively with lymphatic massage as swelling and
edema resolve. Once a contour deformity is identified, it is
best to define the etiology. Blind suctioning of the surround-
ing areas is not often the correct treatment and can significantly
worsen the problem. Once a proper assessment of the etiology
when paired with abdominoplasty.60 Perioperative complica-
tions can include anesthesia and cardiac complications,
cannula trauma to skin and/or internal organs, and volume
loss/overload from bleeding or excess fluid administration.
Cannula injury to blood vessels, bowel, and other solid intra-
abdominal organs have been reported in the literature.57
Although rare, these complications may be devastating.
Thorough preoperative evaluation is essential but may be
challenging in higher BMI patients. If there is any suspicion
of the possibility of hernias, further imaging may help eluci-
date this (Fig. 22.1.20).
Liposuction surgery, especially when it involves multiple
areas, places the patient at risk for hypothermia. Hypothermia
is generally defined as a core body temperature of <36.4°C. In
anesthetized patients, the pathophysiology of hypothermia is
related to an inter-threshold shift in thermoregulation. Its risk
is amplified in larger volume cases, where a greater surface
area of the patient is exposed at one time and patients are
under anesthesia longer. Studies have shown that the core
body temperature can drop up to 2.8°C in the first hours of
surgery as a result of the anesthesia effect on autonomic regu-
lation of core temperature.61 Preventative measures include
warming of the wetting solutions and prep, increasing the
ambient room temperature, and use of preoperative and
intraoperative warming devices (Bair Hugger, Arizant, Eden
Prairie, MN). Prewarming the patient with forced air for 1 h
has also been shown to significantly reduce the incidence of
hypothermia and should be considered, particularly for longer
body contouring cases and those involving multiple areas.
In the perioperative period, fluid shifts occur, which, if
improperly managed, can lead to hypovolemia or volume
overload. As a general rule, we require our patients to obtain
preoperative medical clearance when they are over 50 years
of age or have any concomitant risk factors, such as cardio-
pulmonary disease. As stated previously, careful management
of intraoperative and postoperative fluids, as well as use of
an intraoperative data sheet,62 helps prevent volume-related
complications from liposuction. The tumescent liposuction
technique has been implicated in volume overload and pul-
monary edema; however, this can often be attributed to
incorrect patient selection and/or poor fluid management.63,64
Fluid overload and untoward sequelae from large-volume
liposuction (>5 L) prompted a warning by the American
Society of Plastic Surgeons that physicians performing lipo-
suction should be trained in comprehensive fluid resuscitation
and the physiology of large-volume liposuction.65
Fig. 22.1.20  Computed tomography scan showing a cannula injury to the spleen.
Cannula injury to spleen

565
Emerging technology
Injection lipolysis
The earliest version of non-invasive fat dissolution was
‘mesotherapy’, which is a general term that describes percu-
taneous injection of a medication or other agent into the
mesoderm. A variety of applications have been described, the
most popular of which has been reduction of subcutaneous
fat by dissolution.72 The concept dates back to 1952 and
involves injection of phosphatidylcholine, deoxycholate, and/
or other agents that are purported to dissolve fat. Widespread
marketing and patient desire to avoid anesthesia have allowed
mesotherapy and its variants to gain popularity because of
their “non-invasive” nature. However, large-scale studies are
not available for evaluation. Park et al.73 showed no discern-
ible difference in the treatment in lower extremities with
mesotherapy by measurement or CT scan evaluation.
“Lipodissolve” is considered by some, but not all, prac-
titioners to be a variant of mesotherapy. It is the injection
of a standardized solution into the subcutaneous fat, rather
than the mesoderm. The use of these products in the United
is made, then treatment can either be directed at re-injecting
the fat in the over-resected region or suctioning the adjacent
areas in order to reduce the prominence of the concavity and
blending the adjacent areas. The most comprehensive data on
treating contour deformity is from Chang, where he presents
a multimodality approach to assessing and treating contour
deformity to achieve long-term results.70,71 UAL has a
decreased incidence of contour deformities versus traditional
SAL in our hands. It is the preferred method for secondary
liposuction cases in which fat grafting is not indicated. Careful
preoperative analysis, planning, and proper informed consent
all help to minimize the risk of postoperative contour
irregularity.
Emerging technology
The non-invasive dissolution of fat is an extremely attractive
concept for patients. Many new technologies are being devel-
oped to facilitate this, with varied reports of success.
Table 22.1.6  UT Southwestern modification of Davison–Caprini model66
Step I: exposing risk factors
1 Factor
2 Factors
3 Factors
5 Factors
Minor surgery
Major surgery (general
anesthesia or time >1 h)
Immobilization
Central venous access
BMI >30
Previous MI/CHF
Severe sepsis
Free flap
Circumferential abdominoplasty
Hip/pelvis/leg fracture
Stroke
Multiple trauma
Step II: predisposing factors
Clinical setting (factors)
Inherited (factors)
Acquired (factors)
Age 40–60 (1)
Age >60 (2)
History of DVT/PE (3)
Pregnancy (1)
Malignancy (2)
OCP/HRT therapy (2)
Any genetic
hypercoagulable state (3)
Lupus anticoagulant (3)
Antiphospholipid antibody (3)
Myeloproliferative disorder (3)
HIT (3)
Homocystinemia (3)
Hyperviscosity (3)
Total of step I and step II________
Step III: orders
1 Factor
Low risk
Ambulate t.i.d.
2 Factors
Moderate risk
Intermittent pneumatic compression device and elastic
compression stocking on patient at all times while not
ambulating
3 Factors
High risk
Intermittent pneumatic compression device and elastic
compression stocking on patient at all times while not
ambulating
>4 Factors
Highest risk
Intermittent pneumatic compression device and elastic
compression stocking on patient at all times while not
ambulating
+
Lovenox 40 mg subcutaneously daily postoperative
BMI, body mass index; CHF, congestive heart failure; DVT, deep venous thrombosis; HIT, heparin-induced thrombocytopenia; HRT, hormone replacement therapy; MI,
myocardial infarction; OCP, over-the-counter progesterone; PE, pulmonary embolism.
(Data from Hatef DA, Kenkel JM, Nguyen MQ, et al. Thromboembolic risks assessment and the efficacy of Enoxaparin prophylaxis in excisional body contouring surgery.
Plast Reconstr Surg. 2008;122:269–279.)

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CHAPTER 22.1 • Liposuction: A comprehensive review of techniques and safety
recommended in guaranteeing reproducibility of these results
for two reasons. First, these devices did not gain popularity
because of scientifically documented results, but because of
industry sponsorship. Secondly, results in non-invasive body
contouring are exceedingly difficult to objectively quantify,
and reported results must be interpreted critically. These
technologies have varying levels of efficacy and can only be
adequately evaluated by well-designed clinical trials.
“Low-level laser therapy” has recently emerged as a treat-
ment for lipodystrophy. It is currently marketed under the
trade name Zerona. The proposed mechanism of lipolysis is
creation of transitory pores in the adipocyte membrane, from
which intracellular lipids egress.78 There are several studies
purporting its efficacy.79 However, these results vary and
further controlled clinical trials are necessary.
Focused external ultrasound therapy is one of the most
popular fat-reducing technologies currently being marketed
across the United States and the world. There are currently
two competing technologies attempting fat destruction by
thermal or non-thermal ultrasound-mediated mechanisms.
The UltraShape device delivers low-frequency non-thermally
mediated (cavitation) acoustic energy and is currently cleared
by the FDA for circumferential reduction of the abdomen.
Data by Brown et al.80 have shown it to be effective in a pre-
clinical porcine model, in which the UltraShape device pro-
duced lytic lesions in the subcutaneous fat while preserving
the skin and surrounding neurovasculature. Clinical studies
have validated its safety.81 Recommended treatment protocols
consist of three 40–60 min sessions every other week. Several
clinical trials have shown approximately 2–4 cm reduction in
circumference and 0.3–2 cm reduction in fat layer thickness
with stable patient weight. Side effects are generally mild pain
and irritation around treatment site with no long-term blister-
ing or skin erythema. The LipoSonix is the second FDA-cleared
ultrasound technology for fat reduction and uses high-
intensity focused ultrasound (HIFU) to disrupt fat with a
thermally mediated mechanism (versus UltraShape, which
acts via cavitation alone, causing disruption of fat cell mem-
brane). It is FDA cleared for waist circumference reduction,
and several clinical papers have demonstrated approximately
2–4 cm circumferential reduction after treatment. Pain during
treatment is more common with this device, likely due to its
thermal mechanism of action. Other side effects include
ecchymosis, edema, and lumps after treatment, which dis-
solve over 4–12 weeks.
Radiofrequency (RF) ablation of fat cells works by an oscil-
lating electromagnetic current delivering energy to the fat
cells, in turn, creating heat and causing destruction of the cells
and subsequent phagocytosis.82 There are currently several
companies with devices present and include Velasmooth,
which has been replaced by the Velashape (Syneron), Vanquish
(BTL Aesthetics), and Accent RF (Alma Lasers). Velashape
consists of a hand piece that draws tissue into its chamber via
intermittent negative pressure and treats the tissue with RF
energy, mechanical massage, and broadband infrared light.
Vanquish consists of non-contact 28 × 6-inch panels that are
positioned 1 cm above the patient’s abdomen or thighs and
delivers multipolar RF energy to the subcutaneous tissue.
Each device has had trials showing reduction of fat and, in
some cases, temporary improvement in cellulite appearance.
Side effects include mild burn, erythema, ecchymosis, and
edema.
States is controversial and not supported by the US Food and
Drug Administration (FDA). Warnings from the FDA caution
providers against its unproven use and false marketing
claim.74 Several studies on safety and efficacy are available for
review. Common side effects reported include hyperpigmen-
tation and persistent pain, and 12% of patients had cosmetic
outcomes that were less favorable than expected.75 Due to
lack of scientific data and adequate studies and outcome
results, the use of mesotherapy or its variants is not cur-
rently recommended, unless performed in conjunction with a
clinical trial.
The most promising of injectable lipolytic agents is Kybella
(Allergan Inc., Irvine, CA) or deoxycholic acid, which is a
cytolytic agent that physically destroys the adipocyte cell
membrane when injected. Kybella has gained FDA approval
for improvement of moderate to severe convexity or fullness
associated with submental fat in adults. Safety and efficacy of
use of Kybella outside of the submental region has not been
established and is not recommended. The cytolytic effect of
deoxycholic acid is powerful, and injection should only be
performed by experienced physicians with proper training in
injection technique. Knowledge of submental anatomy is
essential to avoid injury to neuromuscular, vascular, lym-
phatic, and salivary structures. Adequate preplatysmal fat is
assessed by skin pinch while the patient contracts the pla-
tysma muscle, and injection is administered in a grid pattern
with 1-cm intervals between sites. Injection should be admin-
istered midway into the preplatysmal fat layer, at least
1–1.5 cm below the inferior border of the mandible; special
attention should be paid to anatomical distortion due to prior
surgical or aesthetic procedures. Large randomized placebo-
controlled clinical trials have supported the safety and efficacy
of Kybella in submental contouring by means of clinical
observation and magnetic resonance imaging (MRI) evalua-
tion.76,77 Common adverse events include injection site reac-
tions, such as pain, swelling, induration, bruising, numbness,
and erythema. Less commonly seen adverse events are mar-
ginal mandibular neuropraxia, skin ulceration, and dysphagia.
Complications are related to injecting in proximity to vulner-
able anatomic structures, so injection technique is of utmost
importance.
Non-invasive devices
Available non-invasive “lipo-contouring” devices deliver
transcutaneous energy to the subcutaneous fat layer either by
ultrasound, radiofrequency, tissue cooling (cryotherapy), low-
level laser therapy, physical massage, or some combination of
these modalities. All devices have differing characteristics
that may influence suitability for a particular practice, such as
operator dependence, delegation capabilities, maintenance,
and consumables. These devices lack the evacuation phase
that is inherent to liposuction, so fat clearance is accomplished
by a physiologic macrophage-mediated phagocytic process.
All FDA cleared devices have demonstrated safety profiles fit
for use in the United States, and studies have demonstrated
no effect on serum lipid levels and hepatic function.
While these devices have shown to be safe, the non-invasive
lipo-contouring market is largely industry driven, with most
scientific data on device efficacy published after devices are
granted FDA clearance. While efficacy is shown in preclinical
and clinical studies for nearly all these devices, caution is

567
Conclusion
results, especially when compared to the gold standard of
SAL.
Conclusion
Over the past three decades, the procedure of liposuction has
evolved and become consistently one of the most popular
cosmetic procedures performed around the world. As evi-
denced by the large numbers of devices in clinical develop-
ment and active clinical use, there remains a duty by the
clinician to monitor not only the safety of the device but also
the true efficacy. Although touted as a relatively simple pro-
cedure, the process of liposuction/liposculpture is as much
an art as science. As such, the physician must understand the
pathophysiology of both the patient and disease process in
order to effectively treat the patient and achieve safe and
aesthetically pleasing results. The authors are confident that
liposuction will remain one of the most popular procedures
performed in the years to come, and we must thus remain
committed to the common goals of patient safety and
improved aesthetic outcomes.
“Cryolipolysis” has become a popular modality for non-
invasive fat reduction in the past 5 years. The concept is
controlled cooling of the subcutaneous fat, with selective
destruction of fat cells without epidermal or dermal injury
due to adipose tissue’s relative sensitivity to cold. Injured
adipocytes then undergo apoptosis and are cleared by a
macrophage-mediated process. Coolsculpt (Zeltiq Aesthetics,
Pleasanton, CA) has gained United States FDA clearance and
is currently approved for fat reduction in the thigh, abdomen,
and flanks in patients with BMI less than 30. Typical treatment
times are 1 h, and multiple hand pieces may be used concur-
rently. Studies have shown a 15–25% fat reduction in areas
treated, and potential side effects are transient neuropraxia,
induration, pain, erythema, and ecchymosis.83–86
Non-invasive fat removal has become a major player in the
area of body contouring. There is a clear role for it now and
in the future as technology continues to improve. We do not
believe it will replace liposuction, but will be another appro-
priate option that may be offered to patients with focal adi-
posity or who may not wish to undergo surgery. It is important
to keep in mind that until adequate scientific validation of
these devices is performed outside of manufacturer influence,
any discussion of potential benefit is strictly advertisement
and market driven. Physician oversight and patient evalua-
tion will be critical to determine which patients may be can-
didates for non-surgical contouring and which may benefit
from a surgical procedure. As new technology is continually
being introduced, we must temper our enthusiasm and base
treatment on solid, scientific evidence. Device manufacturers
often provide scant, if any, objective data to support claims
such as skin tightening, reduced pain, and improved aesthetic
Bonus images for this chapter can be found online at

Fig. 22.1.10 The intraoperative data sheet records: essential information from
the operative procedure.
Fig. 22.1.13 The Liposonix ultrasonic liposuction machine.
Fig. 22.1.14 The VASER system.
1. Illouz YG. History and current concepts of lipoplasty. Clin Plast
Surg. 1996;23:721–730.
3. Lockwood TE. Superficial fascial system (SFS) of the trunk and
extremities: a new concept. Plast Reconstr Surg. 1991;87:1009–1018.
This landmark paper describes anatomical studies detailing the anatomy of
the superficial fascial system. The findings of this report form the basis for
widely accepted surgical strategies in body contouring.
6. Rohrich RJ, Smith PD, Marcantonio DR, et al. The zones of
adherence: role in minimizing and preventing contour deformities
in liposuction. Plast Reconstr Surg. 2001;107:1562–1569.
9. Rohrich RJ, Broughton G 2nd, Horton JB, et al. The key to long
term success in liposuction: a guide for plastic surgeons and
patients. Plast Reconstr Surg. 2004;114:1945–1952.
10. Kenkel JM, Lipschitz AH, Luby M, et al. Hemodynamic physiology
and thermoregulation in liposuction. Plast Reconstr Surg.
2004;114:503–513. Hemodynamic parameters during large-volume
liposuction procedures were assessed. Metrics generally remained within
safe ranges, but low body temperature was uniformly observed.
17. Iverson RE, Lynch DJ. and the ASPS Committee on Patient Safety.
Practice advisory on liposuction. Plast Reconstr Surg. 2004;113:1478–
1490. This document represents the findings of the ASPS’s Committee on
Patient Safety with regards to liposuction.
22. Rohrich RJ, Beran SJ, Fodor PB. The role of subcutaneous
infiltration in suction-assisted lipoplasty: a review. Plast Reconstr
Surg. 1997;99:514–519.
24. Klein JA. Tumescent technique for regional anesthesia permits
lidocaine doses of 35 mg/kg for liposuction. Dermatol Surg Oncol.
1990;16:248–263. This paper addresses the pharmacokinetics that permit
the use of high concentrations of lidocaine in tumescent liposuction.
Tumescent liposuction is advocated as sustained analgesia and minimal
blood loss are achieved with this technique.
38. Rohrich RJ, Raniere J Jr, Beran SJ, et al. Patient evaluation and
indications for ultrasound-assisted lipoplasty. Clin Plast Surg.
1999;26:269–278, viii.
40. Rohrich RJ, Leedy JE, Swamy R, et al. Fluid resuscitation in
liposuction: a retrospective review of 89 consecutive cases. Plast
Reconstr Surg. 2006;117:431–435.
60. Hughes CE 3rd. Reduction of lipoplasty risks and mortality: an
ASAPS survey. Aesthet Surg J. 2001;21:120–127. This survey was
designed to examine changes American Society for Aesthetic Plastic
Surgery (ASAPS) member surgeons have made in response to the 1998
recommendations from the 1998 Lipoplasty Task Force. A major
complication rate of 0.2602% and a mortality rate of 0.0021% were
reported.
61. Young VL, Watson ME. Prevention of perioperative hypothermia in
plastic surgery. Aesthet Surg J. 2006;26:551–571.
Access the complete reference list online at

567.e1
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567.e2
SECTION II
CHAPTER 22.1 • Liposuction: A comprehensive review of techniques and safety
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recommendations from the 1998 Lipoplasty Task Force. A major
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82. Blugerman G, Schavelzon D, Paul MD. A safety and feasibility
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SECTION II • General Aesthetic Surgery
22.2 
Correction of liposuction deformities with
the SAFE liposuction technique
Simeon H. Wall Jr. and Paul N. Afrooz
SYNOPSIS
■ Liposuction is growing in popularity and technological sophistication
but sometimes results require revision.
■ Revision and secondary liposuction differ. Although much of the
information in this chapter pertains to both procedures, the focus will
be on secondary procedures.
■ When considering repeat liposuction, surgeons must accept that the
result will never be as good as could have been achieved from an
optimally performed primary liposuction, and the risk of serious injury
is greater.
■ In repeat liposuction, resistance may be due to an undesirable
structure but could also be fibrotic subcutaneous tissue secondary to
scarring.
■ The loss of differential resistance in repeat liposuction is the primary
reason that it is fraught with complications.
■ SAFE is an acronym for Separation, Aspiration, and Fat Equalization.
■ In repeat cases, a fourth step is frequently added that can include fat
shifting, fat grafting, and release processes to address any residual
defects or volume deficiencies.
Introduction
Liposuction is growing in popularity and technological
sophistication. It has become safer, faster, more effective, and
more predictable. Surgeons performing liposuction under-
stand the anatomy of fat and fluid management better.
Advances in instrumentation and technique yield more
predictable outcomes with less disruption of vascularity.
However, sometimes the results require revision.
Revision and secondary liposuction differ. Revision is a
repeat operation typically performed by the same surgeon to
improve the initial result, or deal with something not or
suboptimally addressed in the primary procedure. Secondary
liposuction is frequently performed by a different surgeon,
and is usually far more extensive than a revision. Secondary
procedures are usually performed more than a year after the
initial procedure, whereas revision procedures may fall within
a year of the original surgery. Although much of the informa-
tion in this chapter pertains to both procedures, the focus will
be on secondary procedures, both types falling under the
more generalized term of repeat liposuction.
An unfavorable result may not be the only reason patients
present for repeat liposuction. Many patients request repeat
procedures for further reduction of an area already treated,
having either gained weight or simply wanting further con-
touring of the area. Most commonly, however, patients are
dissatisfied with contour deformities from the initial proce-
dure. These can range from skin waviness, to divots and
depressions. Patients can also have skin damage associated
with these deformities in the form of hemosiderin deposition,
pigmentary changes, and scarring from thermal or avulsive
techniques. Internal scarring causes tethering, tightness, and
a worsening appearance with positional changes or skin
tension. External scarring is typically seen with thermal
liposuction, leading to entry site burns or internal burns to the
overlying skin, but can also be seen from non-thermal means,
as a result of overaggressive or avulsive liposuction that
devascularized the overlying skin (Fig. 22.2.1).
Challenges of repeat liposuction
Many surgeons avoid repeat liposuction altogether. However,
when considering repeat liposuction, surgeons must accept
(1) the result will never be as good as could have been achieved
from an optimally performed primary liposuction, and (2) the
risk of serious injury is greater.
Several factors contribute to the difficulty of repeat liposuc-
tion. Liposuction itself hinges on the premise that there is a
relatively low-resistance, subcutaneous adipose layer between
the higher-resistance overlying superficial fat and dermis and
the underlying musculoskeletal structures. Fat is less dense
and easier to disrupt than most surrounding tissues. Once this
plane has been manipulated or disrupted, it becomes scarred
and adherent, rendering navigation more difficult. For
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569
The dose–response curve
abdominal perforation or damage to deeper structures.
Cannula injury to skin and body structures, vascular disrup-
tion, major bleeding, musculoskeletal injury, and internal
organ perforation have all been reported and are underre-
ported in the literature. While these injuries are possible with
any liposuction, they are far more likely to occur in repeat
liposuction due to increased tissue resistance and scarred,
confluent tissue beds that require more passes of the cannula
with greater force.
The dose–response curve
The dose–response curve is applicable to liposuction, wherein
the dose is the amount of fat removed and the response is
example, in primary liposuction, when significant resistance
is encountered at the tip of the cannula, it generally indicates
that an unwanted structure has been encountered and the
cannula should be redirected. In repeat liposuction, resistance
may be due to an undesirable structure, but could also be
fibrotic subcutaneous tissue secondary to scarring. The
surgeon must be able to discern the cause of this resistance
and determine whether to continue with the high-resistance
pass or stop and redirect.
The loss of differential resistance in repeat liposuction is
the primary reason that this is fraught with complications
such as skin “end hits”. This is due to the surgeon’s tendency
to redirect the cannula superficially, preferring to err superfi-
cially rather than into deeper, more vital structures. Loss of
the low-resistance plane can also result in potentially fatal
Fig. 22.2.1  Examples of contour deformities
from liposuction. (© 2017 Simeon Wall Jr.,
MD, FACS.)
A
B
C
D

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CHAPTER 22.2 • Correction of liposuction deformities with the SAFE liposuction technique
subcutaneous irregularities until a threshold of contour defor-
mity is reached. Despite considerable progress, including
better safety in large-volume liposuction, no technologies
introduced thus far have been able to break this “dose–
response curve”.
The introduction of many internal thermal technologies
over the years has compounded this dose–response curve
with the addition of the thermal load on the tissues, contribut-
ing further to inflammation and fibrosis.
Repeat liposuction is usually significantly longer than
primary procedures, due to scarring and the necessity of more
passes to obtain a smooth result. Because the duration of
liposuction is also directly related to fat removal, the pro-
longed duration further increases the likelihood of creating
contour deformities due to excess fat removal. Frequently,
repeat liposuction patients also require fat grafting, adding
both complexity and additional procedure time. For all of
these reasons, the method of liposuction utilized for both
primary and secondary cases is crucial to obtaining satisfac-
tory results.
Adjunctive energy modalities
In traditional liposuction, the dose–response curve refers to
the propensity toward contour deformities as the amount of
Fig. 22.2.2  Examples of fibrotic and scarred areas after thermal liposuction.
(© 2017 Simeon Wall Jr., MD, FACS.)
A
B
Fig. 22.2.3  Examples of extensive subcutaneous scar tissue after liposuction of
the abdomen. (© 2017 Simeon Wall Jr., MD, FACS.)
A
B
fat removal increases. Thermal methods of liposuction (laser,
ultrasonic, radiofrequency, and others) can cause contour
deformities related to thermal injury varying with the type
and power of the device. Furthermore, thermal injury caused
by these devices is not restricted to targeted fat, but may affect
untargeted fat, as well as the supporting stromal network of
tissue (Figs. 22.2.2 & 22.2.3).
Particularly in repeat cases, fibrotic tissues require longer
treatment times. This is associated with more thermal
damage, fibrosis, scar formation, and often more contour
deformities. For these reasons, the senior author has
abandoned internal thermal liposuction technologies and
opted to use strictly fat-preserving techniques for all cases
(Fig. 22.2.4).
Paradigms for the treatment of fat
Two paradigms are proposed for treating fat in body contour-
ing. In fat grafting, effort focuses on optimal graft survival by
maintaining a healthy recipient bed through preservation of
supporting structures and vascularity. In contrast, in liposuc-
tion, the paradigm seems to be removal of fat with little regard
for supporting structures. On one hand, the recipient bed is
treated as delicately as possible, while on the other, liposuc-
tioned fat and its bed are treated differently. Non-selective fat

571
Surgical technique
Patient evaluation
Some patients have such a paucity of fat after their initial
liposuction procedure that it may not be possible to perform
a repeat procedure. Even with the SAFE liposuction (SAFE-
Lipo) process, some residual fat is necessary to create a smooth
and natural-appearing contour. Solely relying on fat grafting
to create a smooth appearance is difficult and should be
approached cautiously.
Preoperative planning and preparation
Sequential compression devices are applied to the lower
extremities prior to anesthesia induction and utilized
throughout surgery and until the patient is ambulatory.
Passive and active warming is employed from an hour
before surgery until discharge. A core temperature below
36°C at any time during surgery has been shown to increase
bleeding, postoperative nausea and vomiting, and wound
infection.
Surgical technique
Anesthesia
Repeat liposuction is typically performed under general
anesthesia. With the exception of minor refinements, repeat
liposuction is best not performed under local, tumescent, or
conscious sedation for many of the same reasons that these
methods are avoided for large-volume primary liposuction,
and for one additional reason – the dense scar tissue that is
frequently encountered limits the surgeon’s ability to pain-
lessly pass infiltration and liposuction instruments. However,
this may be dictated by surgeon preference.
Markings
Contrary to the simple topographical markings made in most
primary liposuction cases, repeat liposuction procedures typi-
cally require clearly delineated topographical markings of
hills, valleys, and other irregularities. Although a “spot
approach” is not used, it is still prudent to have a detailed
map of the areas to be reduced, blended, or augmented. Areas
are usually delineated with concentric black rings for reduc-
tion and cross-hatched markings in red for areas of redistribu-
tion or augmentation. Reference and orientation marks are
quite useful and aid in symmetry when changing positioning
(Fig. 22.2.5).
Patient positioning
Positioning for repeat liposuction is as for primary liposuc-
tion. We avoid the prone position and have found it unneces-
sary. Adequate padding of all pressure points is important, as
is careful prepping and draping. A single, whole body prep
with the sterile field extending from the neck down to the end
of the bed is utilized so that the patient can be turned during
the procedure without any additional prep.
Repeat liposuction using the SAFELipo process is typically
performed in three positions – supine, and left and right
Fig. 22.2.4  Process of repeat liposuction with thermal devices. UAL, ultrasound-
assisted liposuction; RF, radiofrequency.
Liposuction with laser / UAL / RF
Laser / UAL / RF creates thermal injury
Cell death, inflammatory response
Fibrosis and scar formation
Dermis adheres to fascia
Contour deformities
removal can be destructive to supporting structures while
lending itself to contour deformities and increasing complex-
ity of revision. Therefore, we believe in a single, comprehen-
sive paradigm in treating fat: to augment, redistribute, or
reduce to a desired contour, while preserving the remaining
fat and surrounding structures.
Indications and contraindications
Many of the indications and contraindications for repeat
liposuction are similar to those for primary liposuction.
Good candidates have a body mass index (BMI) of 30 or
below, good diet and exercise habits, and have reasonable
expectations. In patients seeking repeat liposuction due to
the re-accumulation of fat, these factors become even more
important.
Patients who were not adherent to their initial postopera-
tive care regimen, or who quickly gained weight following
previous surgery, may not be ideal for a repeat procedure.
Sometimes, patients requesting repeat procedures may not
have had a previous positive experience. In these situations,
one must explain the risks, benefits, and limitations of a
secondary procedure. Unreasonable expectations (i.e., those
unlikely to be achieved by available techniques) are a
contraindication.
It is recommended to wait at least 1 year and sometimes
longer prior to performing a secondary procedure. This time
is needed for the resolution of all swelling so that tissues are
optimally soft, pliable, and elastic. Furthermore, a stable bed
is necessary for the addition, redistribution, and subtraction
of fat. Typically, the longer the time interval between the
original surgery and the repeat operation, the better the
chances for successful improvement.

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CHAPTER 22.2 • Correction of liposuction deformities with the SAFE liposuction technique
procedures, volume expansion of the target zone is essential
to adequately traverse the tissue planes; therefore, a tumes-
cent approach with a ratio of 2 : 1 or even 3 : 1 is frequently
needed. In the past, this step was carried out using a Klein
needle for the infusion phase, followed by approximately
20 min of waiting to allow for maximum vasoconstriction
of the tissues before performing step 1 of the SAFELipo
process.
Dr. Daniel Del Vecchio and the senior author proposed the
utility of performing simultaneous separation and tumescence
(SST for short) in the course of applying the SAFELipo process.
Wall and Del Vecchio further refined this consolidation of
steps, finding an optimal set of instruments, flow rates, and
delivery techniques to ensure better and quicker vasoconstric-
tion, with the added benefit of simultaneously effecting a
significant amount of fat separation. In this technique, the
infiltration of the wetting solution is combined with step 1, fat
separation. This drastically reduced the time needed for
maximum vasoconstriction to take effect, while also stream-
lining the procedure by combining these two aspects of the
surgery.
Step 1: separation
Fat separation was originally carried out with an angled
variation of a Becker basket cannula but is more efficiently
performed with an angled exploded cage fat separator. This
step accounts for approximately 40% of the total procedural
time. Fat separation is performed using power-assisted lipo-
suction (PAL) without suction to maximize the movement
and effect of the wings on the exploded cage cannulas and
to minimize effort and surgeon fatigue during liposuction.
However, all aspects of SAFELipo can be accomplished manu-
ally without power, albeit much less efficiently. The angled
cannulas or dissectors have a blunt tip and “wings” or baffles
that create high- and low-pressure zones adjacent to the
wings of the cannula. These low-pressure zones allow fixed
fat globules to dislodge and detach from their surrounding
attachments, separating these droplets of fat from each other
and from their supporting networks of blood vessels and
stromal tissues without the disruption of these vessels and
stroma. This mechanical emulsification, or separation, process
changes the solid fat architecture into a more liquid, less
dense, environment in the targeted areas, creating a treatment
zone of low-resistance emulsified fat and higher-resistance
untreated areas above (skin) and below (musculoskeletal
structures) the target zone. This creates a differential resis-
tance in the treatment planes, which is crucial to safely and
easily navigate through the area during the second step of
aspiration.
In repeat liposuction, creating this differential resistance is
critical because the natural differential resistance between the
fat and surrounding layers has been obliterated due to scar-
ring and adhesions from prior procedures. This fibrotic bed
typically manifests as an inability to pass the infiltration or
liposuction cannulas through the tissues. This may lead to end
hits to the skin or damage to deeper structures, and in the past
has been almost unavoidable. The fat separation step allows
the surgeon to regain the lost differential resistance between
these planes, allowing the target zones to be navigated more
easily. Whether the goal is to remove more fat, redistribute
remaining fat, or add more fat to the area, the resistance
lateral decubitus positions. In addition to access, it is postu-
lated that turning the patient into the lateral decubitus posi-
tions may reduce the risk of deep vein thrombosis and
pulmonary embolism, as venous pressure is decreased on the
elevated side, thereby decreasing pooling and improving
pelvic venous drainage.
Performing liposuction from these three positions can
prevent contour deformities, including “shark bites” in the
mid-buttocks and other liposuction stigmata. The lateral
decubitus position most closely resembles the normal, stand-
ing position. This allows contouring to match the position the
patient sees themselves in a mirror. Furthermore, this position
allows for treatment of the upper abdomen, while the supine
position may not, due to the hyperextended supine position
of the abdomen, interference from the underlying ribcage, and
adherence of the tightened abdominal skin to the underlying
framework. In lateral decubitus, the patient’s upper abdomi-
nal skin can be pulled away freely from the underlying ribs,
which are not as protuberant in this position given increased
abdominal flexion.
Technique
SAFE is an acronym for Separation, Aspiration, and Fat
Equalization, representing the steps carried out in primary
liposuction and offering comprehensive fat management. In
repeat cases, a fourth step is frequently added that can include
fat shifting, fat grafting, and release processes to address any
residual defects or volume deficiencies.
Liposuction requires the adequate infusion of wetting solu-
tion to minimize blood loss, provide additional anesthesia,
and increase the working space by volume expansion. In
primary cases, a typical superwet infusion is utilized, with a
ratio of 1 : 1 or 1.5 : 1 infusion to aspiration. However, in repeat
Fig. 22.2.5  Example of preoperative marking. (© 2017 Simeon Wall Jr., MD,
FACS.)