The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

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Part XII  Body Contouring
Upper Arms
The options for recontouring the upper arms range from liposuction to the standard
arm lift, with the long incision extending from the axilla to the elbow. An extended
brachioplasty, which combines simultaneous excision of redundant posterior axil-
lary fold tissue, is best suited for individuals who have lost massive amounts of
weight. Selection of technique, as with almost all body contouring, is based on the
patient’s skin excess and skin quality. Individuals with excess fat but minimal or no
skin excess and with normal skin elasticity are ideal candidates for liposuction. Their
skin has enough elasticity to redrape and contract after liposuction. In these patients,
my preference is ultrasound-assisted lipoplasty (UAL) over suction-assisted lipoplasty
(SAL). The patient illustrated in the top image is a candidate for liposuction; the pa-
tient in the lower right image will require a full brachioplasty.
Patients with significant skin excess with loss of skin elasticity are clear candidates
for brachioplasty with the classic incision. There is a small group of patients with
excess fat who also have moderate skin excess with normal or minimal loss of skin
elasticity. These patients may be candidates for a modified limited-scar brachioplasty
combined with liposuction. In this group, the skin excision is limited to a horizon-
tal excision within the axilla, with or without a short vertical extension along the
medial border of the arm. I evaluate candidates for this modified approach by pinch-
ing and pulling the skin within the axilla and observing the effect on the arm. If the
skin tightening appears sufficient and the patient, who observes this maneuver in the
Liposuction
Modified brachioplasty
Full brachioplasty

mirror, indicates that he or she will be happy with such a result, then I would rec-
ommend this modified approach.
Thigh Lift
Options for recontouring the thighs range from liposuction to body lift combined
with abdominoplasty.
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Chapter 76  Clinical Decision-Making in Body Contouring
The patient on the left, who has already had liposuction, has skin excess and skin
irregularities, especially in the medial and distal thigh. She is a candidate for a me-
dial thigh lift through a groin crease incision. The patient in the center is a candidate
for abdominoplasty combined with a medial thigh lift, with the scar limited to the
groin crease. The patient on the right represents the extreme; she is a candidate for
a combined abdominoplasty, medial thigh lift, and body lift. In addition to the groin
crease incision, the medial thigh lift will require a vertical skin excision and resul -
tant scar along the medial surface of the thigh. The distinguishing factors among the
three women are the volume of fat excess and the quality and amount of skin excess.
The patient on the left has the least amount of excess fat, the least amount of excess
skin, and the skin with most elasticity.
Liposuction
Ideal candidates for liposuction have minimal to moderate amounts of excess fat
with minimal or no skin laxity or skin excess, and their skin will have normal or
near-normal elasticity.

Medial Thigh Lift
The classic medial thigh lift scar in the groin crease extends from the anterior supe-
rior iliac spine along the inguinal ligament running adjacent to the labia majora or
scrotum and ends in the gluteal crease. Through this incision, a variable-sized crescent
of skin and excess fat is excised from the upper inner thigh with the maximal skin
excision centrally located over the upper inner thigh. The best candidates are those
with moderate amounts of fat and mild skin excess and laxity, especially involving
the upper medial thigh. It is safe to combine this procedure with liposuction of the
anterior thigh and knee, as needed.
Medial Thigh Lift Combined With Abdominoplasty
This combined approach is best for patients who have the thigh changes described
previously, plus abdominal changes that require a full abdominoplasty. The lateral
part of the thigh lift and abdominoplasty incision meets at the medial end of the in-
guinal ligament. The combined procedure results in improvement of the abdomen
and thighs, especially the medial and anterior thigh. This procedure may safely be
combined with liposuction of the anterior thigh and knee.
Medial Thigh Lift With Groin Crease
and Medial Thigh Scar
Patients with extreme skin laxity and skin excess, especially along the medial thigh,
will respond minimally to skin excision through the crescent at the upper end of the
thigh. In addition to that crescent, they will require a variable amount of skin exci-
sion vertically along the medial axis of the thigh, a triangular skin excision with the
base of the triangle placed superiorly.
This procedure can safely be combined with an abdominoplasty or with a full lower
body lift. However, combining it with too many other body-contouring procedures
may increase the risk and should only be undertaken on a highly selective basis. This
procedure may be safely combined with liposuction of the anterior thighs.
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Chapter 76  Clinical Decision-Making in Body Contouring
Clinical Caveats
 The patient’s goals and expectations must be matched with the realities of his or
her tissues.
 Decision-making in body contouring, especially for massive-weight-loss patients,
requires taking into account the balance between the quality of the results and
safety issues.
 Recontouring must be distinguished from skin tightening.
 Skin, fat, muscle, fascia, and adjacent areas are evaluated before selecting proce-
dures for abdominal contouring.
 Body contouring in a massive-weight-loss patient is a high-risk procedure.
 Multiple procedures may need to be staged to minimize risk.
 The patient’s nutritional state should be assessed, especially in massive-weight-
loss patients.
 Chemoprophylaxis is important for massive-weight-loss patients and when com-
bining abdominoplasty with other procedures.
Choosing the Best Option
Medial
Thigh Lift 
Medial
Groin Crease
Thigh Lift 
Medial
Incision 
Morphologic
Liposuction
Groin Crease
Thigh Lift 
Medial
Changes
Only
Incision
Abdominoplasty
Vertical Scar
Fat Excess
Moderate



Extreme




Slin Quality
Normal elasticity



Poor elasticity



Skin Quantity
No excess

Moderate


Extreme


Adjacent Areas
Normal contour



Requires recontouring



Thigh-Contouring Options

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Noninvasive and Minimally Invasive
Body Contouring

JASON N. POZNER, BARRY E. DIBERNARDO
CHAPTER 77

W
eight loss in the United States is a $30 billion industry that encompasses phar-
maceuticals, gyms, diet aids, books, and surgical and nonsurgical interven-
tions. Obesity and weight reduction are global issues; current data show that one
third of adults in the United States are obese and another third are overweight. Es-
timates indicate that these numbers are increasing worldwide. Plastic surgeons have
long been involved in fat reduction and body-contouring procedures. According to
data from the American Society for Aesthetic Plastic Surgery, liposuction is currently
the second most frequently performed aesthetic surgical procedure in the United
States, with approximately 283,000 operations performed by core specialists in 2009.
This number may be far greater when laser liposuction procedures are factored in,
performed by the emerging market of non–core specialists.
Nonsurgical fat reduction is part of the noninvasive body-contouring industry and
includes devices for fat reduction, cellulite treatment, and skin tightening. There is
some overlap of these devices, because some are marketed for multiple clinical uses.
Medical Insight, a California-based aesthetic market research company, forecast that
when data are available for 2009, the global market for all body-shaping platforms
will be $361.9 million and that the market will expand by 21% per year, on aver-
age, to reach $752.9 million in 2012.
At this writing there are no devices expressly approved by the FDA for noninvasive
fat reduction, although the devices discussed in this chapter are approved for non-
surgical fat removal in many countries outside the United States. We will explore
nonsurgical technologies used for fat reduction and examine some of the current de-
vices touted as fat reducers. We will also discuss laser liposuction in depth.
NONINVASIVE FOCUSED ULTRASOUND
Physicians are most familiar with the use of diagnostic ultrasound for imaging; they
are less familiar with therapeutic ultrasound, but most have heard of the use of
lithotripsy for kidney stones. The actual use of ultrasound in medicine started in
1927, and therapeutic use began in the 1930s with low-energy, unfocused devices.
Focused ultrasound was used clinically in the 1950s for treating Parkinson’s disease
and other brain-related disorders. There was a period of relatively few developments
in ultrasound therapy until 1994, when high-intensity focused ultrasound was in-
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Part XII  Body Contouring

troduced to treat prostate cancer. Since that time, focused ultrasound has been used
to treat many different organs, including, very recently, adipose tissue.
Ultrasound is an interesting medium for fat removal: it can be focused below the skin
without causing injury to the skin. This differs from the use of lasers, in which light
energy traverses the skin and may be absorbed, scattered, transmitted, or reflected.
Ultrasound physics is a bit different from laser physics; a brief overview will help dif-
ferentiate ultrasound fat removal devices. Ultrasound waves are defined as frequen-
cies higher than the audible spectrum (20 to 20,000 Hz). These are used in medicine
and industry, from imaging systems with low energy to focused high energy forms.
Terms used to describe ultrasound waves are frequency, sound velocity, and wave-
length, which are related by this equation:
Velocity  Wavelength  Frequency
The frequencies of the devices may differ, which may have an impact on the treated
tissue. The goal of focused ultrasound technology is similar to that of targeted laser
therapy: to maximize energy accumulation at the target area to induce a significant
biologic reaction without causing collateral damage to the intervening tissues, such
as skin and the tissues and structures surrounding and within the target area. The
specific goal of ultrasound fat removal devices is to destroy adipose tissue without
disruption of nonadipose tissue. The therapeutic devices discussed here are referred
to as high-intensity focused ultrasound (HIFU) devices; these use high-energy ultra-
sound waves that are focused on a small spot. The sound intensity (SI) (energy) is
measured in Watts/cm2. High-intensity ultrasound generally refers to ultrasound with
SI higher than 5 W/cm2. This type of ultrasound, if used in continuous mode, can
cause coagulation necrosis of tissue and is usually used for ultrasonic surgery (such
as cancer therapy), as opposed to low-energy physiotherapy ultrasound devices (SI
less than 3 W/cm2), which cause nondestructive heating with stimulation or accel-
eration of physiologic responses to injury.
There are currently two major companies manufacturing noninvasive focused ul-
trasound devices for body contouring: UltraShape (Tel Aviv, Israel) and LipoSonix
(Medicis, Scottsdale, AZ). Other companies have devices in development. There are
differences among the devices, and only time and further clinical trials will deter-
mine which device is safest and most effective.
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Part XII  Body Contouring
UltraShape
The UltraShape device uses nonthermal selective focused ultrasound technology. It
received its CE mark in 2005, Canadian approval in 2007, and is currently available
in 57 countries. The UltraShape device operates at 200  30 kHz and uses a pulsed
ultrasound wave to deliver maximal intensity (580 W/cm2) and pressure (4.0 MPa)
per “burst” of energy. This pulsed ultrasound limits temperature increase and deliv-
ers mechanical effects to target and selectively destroy fat cells without harming sur-
rounding structures. UltraShape introduced a new model, Contour I Ver3, in early
2010 with a smaller footprint and higher efficacy.
The original device focused energy at 1.5 cm below the skin surface; the updated de-
vice has a multifocal mode. The fat cells within the focal volume are immediately dis-
rupted, and the triglycerides and cellular debris are released into the interstitial space.
The triglyceride debris is then cleared through the body’s natural metabolic and phys-
iologic pathways. It is thought that the disrupted adipose tissue is absorbed through
the lymphatic system.
Courtesy UltraShape, Yokneam, Israel
UltraShape mode of action

The UltraShape procedure is performed by placing a transducer on the skin surface.
No topical anesthetic or tumescent solution is used. A real-time computer tracking
and guidance device tracks the ultrasound pulses directed into the adipose tissue.
The operator moves the transducer along the skin according to a computer-guided
treatment algorithm, and the tracking mechanism ensures complete, uniform treat-
ment and smooth results. There is minimal or no patient discomfort.
Outcomes
The UltraShape device has been used extensively around the world, with more than
150,000 patient treatments performed to date. The safety profile is excellent, with
very few adverse events reported. The initial device delivered a 3-second pulse of en-
ergy, but recent technologic advances have shortened this to a 1-second pulse, which
reduces the overall treatment time with no change in device efficacy. The latest de-
vice combines a radiofrequency head into the machine, along with suction to in-
crease the efficacy of the treatment.
More than 20 clinical studies have been published and presented around the world
with this device. Circumferential reductions averaged from 2.0 cm in a single treat-
ment to 6.3 cm in a three-treatment series. Patient satisfaction varied from 86% to
93%. Early studies used a single treatment protocol, whereas later studies used mul-
tiple treatments. Measurements of blood lipid levels in all studies showed no increase
after treatment. An FDA IDE clinical trial was completed in six U.S. sites, including
our clinic. Our study involved a 125-patient randomized, double-blind study with a
sham control. Patients were treated three times at 2-week intervals, and blood
chemistries, MRIs, and photographic evaluations were performed. All safety end-
points were met, with no serious adverse events reported; blood chemistry and lipid
profile data were normal. At present, final efficacy data are not yet fully analyzed.
The newest version appears to be more efficacious in early series, but no published
studies are available yet.
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Chapter 77  Noninvasive and Minimally Invasive Body Contouring
UltraShape tracking system
Courtesy UltraShape, Yokneam, Israel

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Part XII  Body Contouring
Case courtesy Mark Lupin, MD
Results
These three patients are shown before and after three treatments with UltraShape.
Note the change in abdominal contour.

LipoSonix
LipoSonix is a high-intensity focused ultrasound device for fat reduction. It operates
at a frequency in the 2 MHz range. The LipoSonix device is available in Europe and
Canada at present and has its CE mark. This device’s transducer is placed on the
skin, and a scanner similar to a laser scanner delivers a series of pulses into the tissue.
The handpiece is moved manually by the operator using a grid pattern, and the
process is repeated over the treatment area. The depth of damage is selectable be-
tween 1.1 and 1.8 cm. The LipoSonix device has been extensively studied in both
animals and humans. The adipose tissue disruption is thought to occur through a
thermal mechanism very similar to HIFU treatment of cancers. After destruction of
a layer of adipose tissue, the body’s natural wound-healing response occurs and clears
the thermally damaged tissue through the lymphatic system. As with the UltraShape
system, there is no evidence of serum lipid level changes. Clinical studies with this
device are ongoing.
According to the manufacturers, the major differences between the UltraShape and
LipoSonix devices are that the UltraShape device uses a mechanical effect on the adi-
pose tissue, whereas the LipoSonix system employs a thermal effect. The UltraShape
device produces nonthermal stable cavitation to selectively disrupt fat cells without
harming surrounding critical structures such as skin, blood vessels, nerves, and con-
nective tissue. The UltraShape device operates at low average intensities to achieve
the maximal negative pressure needed to create the purely mechanical effect of cav-
itation. The nonthermal aspect of the UltraShape device delivers a comfortable treat-
ment with no downtime for the patient. The LipoSonix device relies on the mecha-
nism of thermal necrosis to destroy the subcutaneous tissue. It uses time-averaged
high-intensity continuous ultrasound energy delivery to create this thermal effect.
The protocol for the UltraShape device is for three treatments 2 weeks apart, whereas
the LipoSonix protocol is for one treatment. Initial comparisons suggest that the Lipo-
Sonix device may be more efficacious but more painful. Further comparative stud-
ies are necessary.
CRYOLIPOLYSIS
Another device that was introduced for nonsurgical fat removal is from Zeltiq Aes-
thetics (Pleasanton, CA). This noninvasive device is not yet FDA cleared for fat layer
removal but does have FDA approval for skin cooling during dermatologic treat-
ment. This means that this device may be used in the United States for nonsurgical
fat reduction as an FDA off-label use. The Zeltiq device works on the scientific prin-
ciple of cryolipolysis, by which fat cells are naturally more vulnerable to the effects
of cold than surrounding tissues are. This principle is used to selectively destroy and
eliminate fat cells without harming the skin. The concept stems from early research
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Part XII  Body Contouring
performed by Manstein and Anderson and colleagues of Wellman Center for Pho-
tomedicine and Massachusetts General Hospital, a teaching affiliate of Harvard Med-
ical School. Their original theory and research stemmed from observations of frost-
bite patients, who had fat layer reduction without skin injury. This led to animal
studies that confirmed that when fat cells are exposed to controlled cooling, it trig-
gers apoptosis, a process of natural fat cell removal that gradually reduces the thick-
ness of the fat layer. The fat cooling causes crystallization of the fat and fat cell death
without injury to adjacent structures. The fat is gradually removed through a
macrophage-mediated process similar to that observed through thermally induced
fat cell death.
The device consists of an applicator with cooling panels and mild suction, which is
placed directly on the tissue being treated. The fat is cooled over a period of 1 hour
per procedure site. No anesthesia is used, and patient discomfort is mild to none.
There may be transient erythema and a transient decreased sensitivity to touch fol-
lowing the procedure. The patient can resume normal activities the same day. Fat
loss occurs over a 2- to 4-month period. The treatment may be repeated 60 to 90
days later for even greater efficacy.
This device was extensively studied with animal models, followed by human trials.
Initial reports of the human trials show very promising results, with 84% of patients
showing noticeable improvement. Ultrasound measurements of fat reduction aver-
aged 22.4% for one treatment. Lipid blood levels showed no changes during the
postprocedure period. We have had the device in our practices for a few months, and
one of the authors (J.N.P.) was treated, with excellent results.
Zeltiq device
Zeltiq applicator head unit
Courtesy Zeltiq, Pleasanton, CA

The patient is shown before and 3 months after one Zeltiq treatment of the abdomen.
OTHER NEW TECHNOLOGIES
Other devices that manufacturers claim may cause fat reduction include radiofre-
quency energy, such as the Alma Accent (Caesarea, Israel) and Thermage (Solta, CA).
These devices are used for nonsurgical skin tightening and cellulite treatment. Some
reports have suggested that there may be some fat removal when these devices are
used at high enough energies. Further research is ongoing.
Another device that has been promoted for nonsurgical fat removal is the Zerona
laser (McKinney, TX). This device is a low-level light therapy device (laser 650 nm)
that has FDA approval for pain control following liposuction. The claims from the
Zerona manufacturer are that an adipose cell has a pore that is opened with expo-
sure to this low-level light. The adipose cell then extrudes its contents, which are ab-
sorbed by the body. Initial studies of a predecessor of this device showed no efficacy.
Further studies are ongoing.
LASER-ASSISTED LIPOSUCTION
As we have seen, technology has presented several ways of attacking fat. Laser has a
unique position in this armamentarium. The fat practice of the future will most likely
have three divisions: completely noninvasive for mild cases, minimally invasive for
moderate cases, and invasive, reserved for larger patients. Laser-assisted liposuction
(LAL) uses a small laser fiber (300 to 1000 microns) delivered through a small can-
nula of approximately 1 mm. The distinct advance in laser delivery over the past 10
to 15 years is the delivery of laser energy under rather than through the skin. This
allows more energy to be placed directly at the target instead of passing through epi-
dermis and dermis, with concomitant cooling mechanisms for protection of the sur-
face from intense heat. The advantages reserved for laser at this point in research are
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Chapter 77  Noninvasive and Minimally Invasive Body Contouring

the proven efficacy in skin tightening, and the safety mechanism has been defined
and delineated. Another advantage, because the cannula is small, is the ability to
treat scarring, dimpling, and cellulite in the superficial layers without the higher risk
of contour irregularity seen with larger cannulas. Disadvantages are the high cost of
the equipment, the need for exact temperature measurement, and the potential for
burns or blisters without this monitoring. Previous disadvantages were related to time
of the procedure; however, as technology progresses, additional wavelengths have
been proved to be 40 times more efficient in fat disruption, yet keeping the same
small cannula size. This is how technology can advance our treatments in ways me-
chanical or analog devices could not in the past.
Indications and Contraindications
The indications for LAL take into account analysis of the fat thickness, the physical
area in square centimeters to be treated in one setting, and the loss of skin elasticity
with increased laxity. Therefore indications include biolysis in patients with mild to
moderate thickness of the adipose layer (1 to 6 cm), although larger volumes can be
undertaken with the new wavelengths. Patients with mild to moderate skin laxity
can now be considered liposuction candidates; in the past, mechanical suction alone
would have produced an unpleasant result in these patients. This enhances the age
and skin quality range of potential lipoplasty candidates. Those with contour irreg-
ularities, scar tissue, or dimpling in the superficial layers of the skin have few other
choices for fat removal.
Contraindications include patients with severe skin laxity requiring a surgical solu-
tion, patients with a tremendous volume of fat by thickness of area to be treated at
one session, and patients with cardiac or similar medical conditions that preclude
the use of epinephrine.
Patient Profiles
Good Candidate
A woman in her mid-fifties with moderate fat thickness across 5 cm of the upper and
lower abdomen is an example of a prime candidate for LAL. She will have had pre-
vious liposuction approximately 10 years ago to the lower abdomen and has residual
scar tissue and mild contour irregularity. Her upper abdomen has significant fibrous
tissue. Most significant is a mild to moderate skin laxity with loss of elasticity. She
is a good candidate because she meets the area and thickness guidelines, and her de-
fects—namely skin laxity and superficial contour defects—are precisely those that
can be improved by LAL.
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Part XII  Body Contouring

Poor Candidate
A young woman weighing 100 kg (220 pounds) with 10 cm of fat excess in the ab-
domen as well as excess in the flanks and hips is an example of a poor candidate for
this procedure. There is a pannus of skin and fat hanging 4 cm in the lower aspect.
She is a poor candidate because of the amount of tissue requiring treatment, and the
skin excess, which is far beyond the capabilities of the laser.
Pertinent Anatomy
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Chapter 77  Noninvasive and Minimally Invasive Body Contouring
Epidermis (0.07 mm)
Dermis (0.3-3 mm)
Superficial fat (3-5 mm)
Deep fat (20 mm)
Fascia
Superficial and deep treatment planes for laser lipolysis
The pertinent anatomy for LAL treatment is the skin and just below it. The laser ini-
tially treats the deep fat. The next zone of treatment is just below the dermis. The
third and final step is small cannula suction removal of any debris, oils, and fat cell
remnants in the superficial and deep layers.
Pretreatment Assessment
Physical examination is consistent with the patient descriptions noted earlier. Oth-
erwise, general liposuction rules apply.
Patient education focuses primarily on the fact that the skin-tightening effects are
variable and that the stimulation of fibroblasts making more collagen and elastin
will not be evident until approximately 3 months after the procedure.

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Part XII  Body Contouring
Pretreatment Planning
Immediately before the procedure, the areas of fat to be removed are marked. In ad-
dition, 5 by 5 cm areas, as measured with a ruler, are marked over the treatment
area. This ensures that specific energy levels will be supplied to the deep fat as well
as discrete areas for application of heat for stimulation and subsequent tightening
of the skin. Incision points (1 to 2 mm) are marked in specific areas to maximize can-
nula access to the grid, taking into account cannula length and the curvature of the
tissue. Treatment becomes more difficult at a distance of more than two or three sec-
tors away from the incision.
If local anesthesia only is used, then the incision points are anesthetized with lidocaine
1%, just forming a wheal in the area; then photographs are taken of the new mark-
ings, and oral medications are given. Oral diazepam (Valium) 20 mg and oxycodone/
acetaminophen (Percocet), two tablets of 5 mg/325 mg, are used in local cases.

Technique
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Chapter 77  Noninvasive and Minimally Invasive Body Contouring
Once the patient is positioned on the table and the monitoring equipment has been
placed, additional lidocaine 1% with epinephrine 20 to 30 ml is given via a spinal
needle through the previously anesthetized incisions to provide additional comfort
before the tumescent fluid is administered. The patient is then prepared and draped.
Before tumescent fluid is injected, the skin and fat in the area to be treated are pinched
and measured for thickness; this information will be used for energy administration
guidelines. The surgeon can use the tumescent formula of choice. To ensure proper
reaction with the laser, approximately 50 to 100 ml of fluid is given per 5 by 5 cm
sector. The next step is the first laser application in the deep tissue. From the previ-
ous thickness measurement, 1000 to 2000 Joules of energy are given per centimeter
of pinched thickness. Therefore if 3 cm was determined, the deep energy level would
be 3000 Joules for normal soft adipose tissue and up to 6000 Joules of energy in
thick fibrous or scar tissue. This amount of energy is given to all deep sectors first.
The wavelength used for this layer is currently 1440 nm, combined with 1064 nm.
In this instance, 1440 has a higher affinity for the fat tissue by approximately 40
times. The mechanism is a higher absorption in fatty tissue, translating to a more in-
tense photomechanical effect. The power density concentrated at the tip of the can-
nula creates pressure-filled microbubbles that eventually collapse, creating both a
mechanical as well as a thermal disruption on the adipocyte cell wall.
Next, the laser settings are changed to 1320 nm and 1064 nm; hence the 1320 wave-
length has a high absorption coefficient for water, thus enhancing the dermal heat-
ing component.
5
77-1 Laser
liposuction

Temperature Monitoring
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Part XII  Body Contouring
Safety requires precise temperature monitoring for the skin-tightening phase. The ba-
sis of the temperature goals and safety parameters were published, establishing the
42° C (107.6° F) temperature goal in this layer. Too little heat will not achieve the
clinical goals; too much heat will risk blistering or burning with subsequent scars.
Currently there are three methods for monitoring temperature:
1. A handheld, laser-guided thermometer (least accurate)
2. A thermistor placed at the tip of the operating cannula
3. An overhead infrared thermal camera
The latter two have the capability to be tied into the laser computer to stop the laser
from firing as goal temperatures are achieved. These systems, although highly accu-
rate and safe, come at a significantly higher cost.
Once laser applications have been completed in all sectors, the last phase is to re-
move fat oils, cell fragments and other debris with small liposuction cannulas.
Wounds are either closed or left open in the dependent positions. Foam and a com-
pression garment are placed, and the rest of the postoperative care is similar to that
for other liposuction procedures.
Courtesy Cynosure, Westford, MA
Laser device, temperature monitor, and cannula

Posttreatment Care
Although posttreatment care is similar to that in other liposuction protocols, laser
treatment patients can usu ally return to sedentary work in 2 to 3 days. Although the
laser and the 1064 nm wave length help to coagulate small vessels, which results in
less bruising, swelling is still a factor. Therefore routine compression, massage, and
limitation of activity are required.
Problems and Complications
As with any liposuction, associated complications are similar to the laser procedure.
Complications can occur in three categories: systemic, local, and device based. The
box lists the complications per category.
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Chapter 77  Noninvasive and Minimally Invasive Body Contouring
Potential Complications
Systemic
Local
Device-Based
Infection
Undercorrection (insuffi-
End hits
Hemorrhage
cient fat removal)
Blisters
Hypovolemia
Overcorrection (excess
Burns
Third space fluid shift
fat removal)
Blowholes
Deep vein thrombosis
Contour irregularities
Prolonged edema
Fat embolism
Unevenness
Heat/pressure problems
Pulmonary embolism
Seroma
Neurapraxia
Abdominal perforation
Hematoma
Permanent nerve damage
Necrotizing fasciitis
Incision scarring
Hyperlipidemia
Lidocaine toxicity
Cutaneous slough
Contour irregularity
Epinephrine toxicity
Hyperpigmentation
Insufficient effect
Visual loss (idiopathic intra-
Poor skin tone
cranial hypertension)
Death

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Part XII  Body Contouring
Outcomes
Patient outcomes are very closely related to the efforts by the surgeon to apply ap-
propriate energy in the deep layers, obtaining a temperature as close as possible to
the 42° C (107.6° F) goal and performing a thorough suction at the end. These pro-
cedures require time and work, but the results should be worth the efforts. Ten con-
secutive patients were presented at an American Society of Plastic Surgeons meet-
ing: there was high patient satisfaction, safety, and a minimum of complications.
One patient was noted to have had a temporary postinflammatory hyperpigmenta-
tion. In the initial few months of use of the device, some blisters and burns were re-
ported, but these occurred before we gained experience with the technique and with
proper temperature monitoring.
Results
This 29-year-old woman is shown before and 2 months after a SmartLipo MultiPlex
(Cynosure) treatment on the neck, with a total of 16,198 Joules. Note the fat removal
and skin tightening.

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Chapter 77  Noninvasive and Minimally Invasive Body Contouring
This 55-year-old woman is shown before and 2 months after a SmartLipo MultiPlex
treatment on the arms, with a total of 31,684 Joules. Regular liposuction would not
have been able to provide this tissue contraction.
This 50-year-old patient is shown before and 3 months after SmartLipo treatment
on the neck. Note the skin contraction.

This 47-year-old patient is shown before and 1 month after a SmartLipo treatment
on the lower abdomen and flanks. She has excellent skin contraction.
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Part XII  Body Contouring

Concluding Thoughts
Nonsurgical fat removal is still in its infancy. The nonsurgical devices in use today
differ in their mode of operation—cryolipolysis versus ultrasound—and differ in their
efficacy and the level of pain the patient experiences. Future technology may make
it possible to visualize and remove specific fat deposits with greater efficacy and min-
imal pain. We have proved that laser liposuction destroys fat and tightens skin; how-
ever, the biologic mechanism of tightening needs to be elucidated. We need further
study to ascertain the time and temperature levels that lead to new collagen forma-
tion. We believe the questions will be answered in the ensuing years.
Clinical Caveats
 Proper patient selection is critical.
 The safety and efficacy of the laser device selected must be researched thoroughly.
 There are no shortcuts to proper energy application.
 The face and neck have much thinner skin and require additional caution.
2743
Chapter 77  Noninvasive and Minimally Invasive Body Contouring
Annotated Bibliography
DiBernardo BE, Reyes J. Evaluation of skin tightening after laser-assisted liposuction: pre-
liminary results. Aesthet Surg J 29:400-407, 2009.
This paper was the preliminary report and study designed to quantitatively assess clin-
ical skin tightening and skin shrinkage after laser-assisted liposuction.
DiBernardo BE. Recognition and management of complications of fat and cellulite treat-
ments. In Katz BE, Sadick NS, eds. Body Contouring. Procedures in Cosmetic Derma-
tology Series. St Louis: Elsevier, 2010.
This chapter is a comprehensive review of complications that can occur in liposuction
with particular focus on energy-based devices.
DiBernardo BE, Reyes J. Randomized blinded split abdomen study evaluating skin shrink-
age and skin tightening in laser-assisted liposuction vs liposuction control. Aesthet Surg
J (accepted for publication 2010).
This paper is a blinded prospective internally controlled study comparing liposuction
alone to laser-assisted liposuction in the same patient.

DiBernardo BE, Reyes J, Chen B. Evaluation of tissue thermal effects from 1064/1320-nm
laser-assisted lipolysis and its clinical implications. J Cosmet Laser Ther 11:62-69, 2009.
This paper reviews the basis of the initial safety and physics information acquired to
support the temperature reference levels of 42° C superficial and 47° C deep to safely
perform the laser-assisted liposuction procedure.
Suggested Readings
DiBernardo BE, Pozner JN, Codner MA. Lasers and Non-Surgical Rejuvenation. Techniques
in Aesthetic Plastic Surgery Series. Philadelphia: Elsevier, 2009.
Manstein D, Laubach H, Watanabe K, Anderson RR. A novel cryotherapy method of non-
invasive, selective lipolysis. Lasers Surgery Med 40(Suppl):S20-S104, 2008.
Moreno-Moraga J, Valero-Altés T, Riquelme AM, et al. Body contouring by non-invasive
transdermal focused ultrasound. Lasers Surg Med 39:315-323, 2007.
Teitelbaum S, Burns J, Otto J, et al. Noninvasive body contouring by focused ultrasound:
safety and efficacy of the Contour I device in a multicenter controlled clinical study. Plast
Reconstr Surg 120:779-789; discussion 790, 2007.
2744
Part XII  Body Contouring

Liposuction:
Basic Techniques and Safety Considerations

JORDAN P. FARKAS, PHILLIP J. STEPHAN,
JEFFREY M. KENKEL
CHAPTER 78

S
uction-assisted lipectomy, or lipoplasty, more commonly referred to as liposuc-
tion, originally introduced by Illouz in the early 1980s, continues to be one of
the most popular body-contouring and overall treatment modalities offered in aes-
thetic surgery today. According to the American Society for Aesthetic Plastic Surgery,
in 2009 more than 283,000 liposuction procedures were performed in the United
States, which placed it second among all types of invasive cosmetic procedures. With
greater understanding of the biochemical and physiologic properties of liposuction as
well as biomedical technologic advancements, suction-assisted lipoplasty has un-
dergone a tremendous evolution, leading to overall improvements in technique, pa-
tient safety, and outcomes. Over the past two decades, it has grown from a proce-
dure that facilitates small or spot reductions to one that has become an almost
irreplaceable tool in aesthetic surgical procedures of the neck, breast, and circum-
ferential 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. Important innovations and modifications
to standard suction-assisted lipoplasty (SAL) involving the introduction and/or re-
finement of wetting solutions and cannulas have assisted in refining the procedure,
and other novel technologies have been introduced, including ultrasound-assisted li-
posuction (UAL), power-assisted liposuction (PAL), vaser-assisted liposuction (VAL),
and laser-assisted liposuction (LAL). There has been a strong movement toward defin-
ing appropriate safety guidelines for liposuction and other body-contouring proce-
dures, with a focus on deep venous thrombosis prophylaxis and fluid resuscitation.
Even with these refinements, liposuction, as with all invasive procedures, is still not
without risk. Aesthetic body contouring with liposuction requires a comprehensive
knowledge of the anatomic, biochemical, and physiological components of the var-
ious modalities and their limitations and indications to perform the procedure in a
safe, controlled manner. Using a coordinated approach along with a thorough un-
derstanding, liposuction can be performed safely with relatively predictable results
and outcomes.
Pertinent Anatomy
Anatomy texts divide subcutaneous fat throughout the body into superficial and deep
layers or compartments separated by Scarpa’s fascia, or the superficial fascial equiv-
alent. However, for the purposes of liposuction and body contouring, subcutaneous
fat is arbitrarily divided into three layers: superficial, intermediate, and deep.
2746
Part XII  Body Contouring

The importance of this distinction is that the superficial layer is rarely violated. If
this layer is treated, there is a significantly increase risk of vascular compromise and/or
contour irregularities. The relative consistency and thickness of each of these sepa-
rate layers vary in 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 less compact. This information is crucial for an aesthetic surgeon to perform
safe and appropriate suctioning of the targeted area and to minimize potential con-
tour irregularities and skin necrosis.
In this chapter we will discuss the variation in fat consistency and depth as it relates
to safe suctioning techniques, and which modalities may be preferred for the most
effective treatment.
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Chapter 78  Liposuction: Basic Techniques and Safety Considerations
Superficial
Deep
Intermediate
ZONES OF ADHERENCE
• Inferolateral iliotibial tract
• Gluteal crease
• Lateral gluteal depression
• Middle medial thigh
• Distal posterior thigh
Previously described anatomic zones of adherence (see Chapter 77), which are pres-
ent in both men and women, should be identified and marked during the preopera-
tive consultation. These are areas of relatively dense fibrous attachments to the un-
derlying deep fascia that help define the natural shape and curve of the body. There
are sex-specific variations with respect to each of these zones. It is important to rec-
ognize these zones, because they are high-risk areas for contour irregularities after
surgical intervention if not properly respected.

However, these zones of adherence are not areas to avoid in all cases, and on occa-
sion they help to guide the surgeon in establishing contour goals. Regardless of the
type of liposuction selected, it is helpful to consider the treatment area in terms of
the three surgical layers. These arbitrary layers delineate areas of safety during lipo-
suction. The most common area treated is the intermediate layer, and often the deep
layer. Treatment of these layers allows uniform reduction without risk of injury to
the subdermal plexus and skin.
Indications and Contraindications
Liposuction patients often present with a variety of expectations, concerns, and/or
complaints. 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 expectations. Studies have shown that patients who un-
dergo appropriate long-term lifestyle changes will in fact achieve the highest level of
postoperative satisfaction from their liposuction-assisted body-contouring proce-
dure. Broughton et al found that patients who were committed to positive lifestyle
changes involving a healthy diet and regular exercise or who were already practic-
ing a healthy lifestyle that continued postoperatively scored the best on self-assess-
ment and satisfaction evaluations after liposuction. To achieve and maintain optimal
results, a body-contouring patient must satisfy four key elements: (1) lifestyle change,
(2) regular exercise, (3) a well-balanced diet, and (4) body contouring.
Appropriate candidates for liposuction are not morbidly obese, are at a stable weight,
and have incorporated the above lifestyle changes into their preoperative regimen.
It is preferable for patients to commit to the necessary changes in diet, exercise, and
lifestyle modification before undergoing surgery. It is the responsibility of the sur-
geon to address all concerns, expectations, and goals with the patient before the pro-
cedure to establish realistic expectations of the procedure. Preoperative consultation
with a dietician may prove beneficial for long-term patient satisfaction. Liposuction
2748
Part XII  Body Contouring

is contraindicated in patients who are pregnant or in poor general medical health.
Patients with morbid obesity, cardiopulmonary disease, body image perception is-
sues, unrealistic expectations, wound-healing difficulties, or with extensive or poorly
located scars should be excluded from consideration for liposuction.
Patient Profiles
There are three types of lipodystrophy and skin redundancy.
TYPE I: LOCALIZED LIPODYSTROPHY
Type I patients tend to be younger, with nor-
mal skin tone and minimal skin irregularities.
2749
Chapter 78  Liposuction: Basic Techniques and Safety Considerations
This 21-year-old woman is in good health but has mild lipodystrophy in her ab-
domen, hips, and thighs.
This 20-year-old man is an extremely active cyclist who has refractory lipodystro-
phy and mild skin redundancy in his lower abdomen.

2750
Part XII  Body Contouring
TYPE II: GENERALIZED LIPODYSTROPHY
Type II patients tend to have slightly di-
minished skin tone with some skin irregularities and circumferential lipodystrophy
throughout their trunk and extremities.
This 33-year-old woman has diffuse lipodystrophy in her abdomen, hips, and thighs
that has been resistant to diet and exercise.
This 27-year-old woman has diffuse lipodystrophy and some mild skin laxity in her
abdomen.

2751
Chapter 78  Liposuction: Basic Techniques and Safety Considerations
TYPE III: SKIN REDUNDANCY AND LIPODYSTROPHY
Type III patients have signifi-
cant skin redundancy that would be more amenable to excisional surgical techniques
to improve shape and contour. If necessary, liposuction may be performed as an ad-
junct procedure to achieve an optimal result.
This 59-year-old woman is interested in truncal rejuvenation. She is unhappy with
the central lipodystrophy that has recurred after menopause. She will benefit from
liposuction to her thighs and back as well as circumferential abdominoplasty.
This 47-year-old woman has lost more than 45 kg (100 pounds) and desires im-
provement of her central trunk. She has minimal lipodystrophy and will benefit from
circumferential abdominoplasty.

Preoperative Assessment
Initial Evaluation
During this initial interaction, it is imperative that the plastic surgeon be able to as-
sess the patients’ goals from surgery and be able to determine whether the patient
has realistic expectations regarding outcome and postoperative body image. It may be
useful to have the patient prioritize the body regions that he or she is most concerned
with, focusing on specific complaints within these areas. A detailed medical history
should be obtained, including any allergies, and whether the patient uses tobacco.
Especially important data include a history of diabetes, massive weight loss, previ-
ous 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 by
an internist or a cardiologist. Patients should be asked specifically about herbal and
over-the-counter medications, because they frequently fail to mention these. Nonessen-
tial 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 typically 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 colleagues view li-
posuction as a very benign operation with minimal operative time and morbidity,
when in fact a large-volume liposuction procedure can involve significant fluid shifts
and time under general anesthesia. Massive-weight-loss patients should undergo the
same preoperative evaluation and clearance for liposuction as they would for any
excisional type of body-contouring procedure (including nutrition, hemoglobin and
iron assays, B12, and so on). Herbal remedies and supplements are not regulated by
the FDA and thus may place the patient at potential risk of untoward complications,
including bleeding or hypercoagulability; these products should be avoided in the
perioperative period. Avoiding aspirin, NSAIDs, and hormonal therapy can help pre-
vent such complications as well. We advise patients to discontinue use of all NSAIDs,
aspirin products, fish oil, and supplements 3 weeks before 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 the medical therapy
is discontinued. A frank discussion of the risk of oral contraceptives and estrogens
is held with the female patients, regardless of the magnitude of the procedure.
We strongly recommend that these medications be discontinued 1 month before the
procedure.
2752
Part XII  Body Contouring

Physical Examination
A detailed physical examination is performed at the first visit. Specific attention to
prior scars, the presence or absence of hernias, evidence of venous insufficiency, and
any preexisting asymmetry or contour irregularity should be discussed and noted in
the chart. At the initial and subsequent visits, the patient’s height and weight are
measured and BMI calculated. This is of paramount importance for safety as well
as to track long-term trends during follow-up. For liposuction candidates, six key el-
ements are documented:
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
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Chapter 78  Liposuction: Basic Techniques and Safety Considerations
The physical examination is best performed with the patient in front of a full-length
mirror. This allows an open dialog between the patient and physician during the
exam so that the patient’s concerns can be addressed, and previously unrecognized
problem areas can be assessed and discussed. Any areas of cellulite should be pointed
out to the patient, and the expected outcome in these areas should be discussed. At
the initial evaluation, high-quality medical photographs should be obtained, with ante -
rior, posterior, and lateral views as well as anterior and posterior oblique views. These
images will allow documentation of results and aid objective evaluation of outcomes
by both the patient and physician. Professional medical photography can be a very use-
ful tool for accurate and consistent preoperative and postoperative documentation.

2754
Part XII  Body Contouring
With the patient facing away from the physician, the spine is assessed for abnormal
curvature. This is more easily appreciated with the patient bending at the waist with
the hands held forward and together in front of the body. This is often the first clue
that significant asymmetries may exist. Skin tone and quality are assessed using the
pinch test. The patient is examined from the anterior direction, both lateral direc-
tions, and finally in the supine position.
While the patient is in a supine position with the head elevated, abdominal integrity
is assessed. This is helpful for detecting hernias or myofascial diastases. Findings may
be difficult to interpret in larger individuals or in patients with multiple scars. An ultra -
sound examination or CT scan may further clarify findings in this region and prevent
intraabdominal injury. 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 can visualize and appreciate these areas.

A follow-up visit is typically scheduled 2 to 3 weeks after the initial consultation.
During this visit, computer images are reviewed, which allows the patient to estab-
lish realistic expectations. These objective images portray the advantages, disadvan-
tages, and limitations of body-contouring surgery. The patient should understand
that imaging is for educational purposes only and is not a guarantee of the final re-
sult. During the second visit, the patient can ask any remaining questions, such as
concerns about recovery time, pain control, bruising, and postoperative changes.
Such discussions help to strengthen the patient’s confidence in the procedure and de-
crease the likelihood of any uncertainties or surprises in the perioperative period.
Patient Education and Informed Consent
Patient education is stressed throughout the course of the initial evaluation, physi-
cal examination, and follow-up visit so the patient has sufficient information about
the procedure, postoperative course, and long-term results to make a truly informed
decision. The patient and physician should discuss the procedure itself, alternative
treatments, and 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. The informed consent process
is necessary to protect the patient and surgeon. The patient coordinator explains fi-
nancial obligations (including those for further surgeries if required).
Preoperative Planning
Markings
Preoperative marking is essential to perform successful liposuction. Patients should
be marked in the standing position and in front of a mirror, if possible. This allows
the patient to contribute to the process and further confirms exactly what will be
addressed during the procedure. The four-position stance is preferred. 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 respec-
tive treatment. When complete, the marks are once again reviewed with the patient
to ensure that all areas of concern are addressed.
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Chapter 78  Liposuction: Basic Techniques and Safety Considerations

2756
Part XII  Body Contouring
Access incisions are also marked at this
setting. With liposuction, it is beneficial to
choose access points that can treat multi-
ple areas. Incisions should also allow each
area to be treated from different directions
for optimal contouring.
The preoperative markings and preferred placement of access incisions based on ar-
eas to be suctioned are shown.
Incisions should be no longer than 3 to 4 mm in length and placed in well-concealed
areas. The surgeon should not hesitate in placing additional incisions if access is in-
sufficient with the existing markings.

Cosmetically, it is preferable to stagger incisions asymmetrically to camouflage their
appearance.
Anesthesia Technique/Location of Operation
The choice of anesthesia technique for liposuction varies based on multiple factors:
operating surgeon preference, anesthesiologist preference, amount of expected
lipoaspirate, length and extent of procedure, patient positioning, and overall health
of the patient. Local anesthesia, various forms of sedation (mild, moderate, heavy)
and general anesthesia are described in the literature. No single anesthesia technique
has proved superior over another. However, the practice advisory on liposuction
does recommend avoiding epidural and spinal anesthesia in office-based settings be-
cause of potential hypotension and volume overload issues.
Small-volume liposuction cases can be performed with a local anesthetic, with or
without mild sedation. Complex, large-volume liposuction and combined cases
should be performed with the patient under general anesthesia. We perform the ma-
jority of cases with a general anesthetic. Deep-sedation cases and general anesthe-
sia procedures are performed under the supervision of board-certified anesthesiolo-
gists in licensed surgery centers or hospitals. All cases in which the patient is in a
prone position are performed with general endotracheal anesthesia for airway control.
The operative location should be determined after careful patient evaluation, as-
sessment of the complexity of the procedure required, and appropriate review of
medical comorbidities. The anticipated postoperative course and the need for possi-
ble overnight observation both factor into the choice among inpatient, observation,
or outpatient hospital settings.
Special importance should be given to medical comorbidities, such as obstructive
sleep apnea. The current American Society of Anesthesiology recommendations are
that for patients with signs or symptoms that suggest moderate to severe obstructive
sleep apnea, surgery be performed in a hospital setting with extended recovery and
observation to prevent postoperative respiratory complications. It is recommended
that liposuction procedures, whether inpatient or outpatient, be performed in an ac-
credited facility equipped to manage any postoperative insult or sequela.
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Chapter 78  Liposuction: Basic Techniques and Safety Considerations

2758
Part XII  Body Contouring
It is useful to have the circulating nurse maintain an accurate liposuction data sheet
to facilitate consistent and accurate communication among the surgeon, the anes-
thesiologist, and the operating room team.
Patient Positioning
The patient is placed in a forced-air warming blanket 30 to 60 minutes before the
procedure. Pedal or calf sequential compression devices are also applied in the hold-
ing area at this time.
Prone/Supine
Once the patient is in the operating room, the compression devices are reapplied and
the patient is placed under general anesthesia. We prefer to position the patient prone.
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. The
breasts should be placed medially and the nipples protected.
The patient’s arms are extended on padded arm boards at less than 90 degrees from
the long axis of the table. The patient’s face must be appropriately padded, the cer-
vical spine is placed in a neutral position, and the eyes are protected. 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 genitals. In the prone position, up to 70% of the contouring can be per-
formed and may include liposuction of the arms, back, hips/flanks, and lateral, pos-
terior, and medial thighs.

With the patient transferred to the supine position, the remainder of the trunk and
extremities can be addressed. This may include treatment of the arms, abdomen, an-
terior medial thighs, and knees. This position does not have significant effects on the
cardiopulmonary system. Brachial plexus injuries can occur if the arm is abducted
at greater than a 90-degree angle. The hips and knees should be flexed at approxi-
mately 30 degrees with a pillow. Pressure points in the supine position include the
occiput, scapula, posterior iliac crest, sacrum, and heels.
Wetting Solutions and Perioperative Fluid Management
At one time, 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. Lipo-
suction has since evolved to include the addition of infiltrating subcutaneous wet-
ting solutions before suctioning to provide hydrodissection, improve hemostasis, and
potentially provide some perioperative analgesia.
The current options for wetting solutions are dry, wet, superwet, and tumescent. The
dry technique uses no wetting solution and has few if any indications in liposuction.
The wet technique involves preinfiltrating 200 to 300 ml of solution per region to
be treated, regardless of the anticipated amount to be aspirated. The superwet tech-
nique employs infiltration of 1 ml of solution per estimated cubic centimeter of ex-
pected aspirate. Finally, the tumescent infiltration popularized by Klein involves ex-
tensive infiltration of wetting solution that creates significant tissue turgor and results
in total infiltration of 3 to 4 ml of wetting solution per cubic centimeter aspirated.
Regardless of the technique used, the infiltrate should be allowed to set for 7 min-
utes and no longer than 30 minutes before suctioning is initiated because of the es-
timated onset of action of the anesthetic and vasopressor agents in the solution. Neg-
ligible blood loss, less than 1% of the lipoaspirate, is observed when using either the
superwet or tumescent technique.
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Chapter 78  Liposuction: Basic Techniques and Safety Considerations

Some authors have popularized different variations of these solutions, but all of the
formulations include some variant of fluid (normal saline solution or Ringer’s lac-
tate solution), epinephrine, and lidocaine. Bupivacaine (Marcaine) should be avoided
because of its potential cardiac effects and duration of action; it has yet to be proved
clinically as a suitable anesthetic in wetting solutions. The most common solution
mixtures are shown in the table on p. 2761.
Lidocaine
Lidocaine is the local anesthetic that most surgeons choose to include in the wetting
solution. It has been reported to provide analgesia for up to 18 hours postoperatively
when injected in dilute concentrations into the subcutaneous space. The recommended
maximum dose of lidocaine with epinephrine is 7 mg/kg, according to the Physi-
cians’ Desk Reference; however, numerous studies have documented the safety of li-
docaine in concentrations greater than 35 mg/kg and as high as 55 mg/kg in large-
volume cases. These higher doses have proved to yield peak plasma levels below the
toxic range. It is thought that the dilute nature of lidocaine and slow infiltration de-
lay absorption and reduce the peak plasma concentration. Additionally, the inclu-
sion of epinephrine, the relative avascularity of fatty tissue, and the high lipid solu-
bility of lidocaine all seem to contribute to the delayed absorption. There are many
variables to consider when incorporating lidocaine into a wetting solution. First, the
lidocaine absorption rate is extremely variable 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.
2760
Part XII  Body Contouring
Estimated Blood Loss With Different Liposuction Techniques
Estimated Blood Loss as a
Technique
Percentage of Volume Aspirated
Dry
20-45
Wet
4-30
Superwet
1%
Tumescent
1%
Techniques of Liposuction and Infiltrates
Technique
Infiltrate
Volume Aspirate
Dry
No infiltrate
To treatment endpoint
Wet
200-300 ml/area
To treatment endpoint
Superwet
1 ml infiltrate:1 cc aspirate
1 cc aspirate/infiltrate (treatment endpoints)
Tumescent
Infiltrate to skin turgor
2-3 cc aspirate/ml

One area that is still under investigation is the importance of monoethylglycinexy-
lidide (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% ac-
tive, meaning that it will contribute to the overall activity of lidocaine and ultimately
its potential toxic effects. It has been demonstrated that the peak levels of the metabo-
lite MEGX occur within 8 to 32 hours after initial infiltration. The peak systemic
level was greater than initially thought, but still below the level of toxicity. Based on
a recent study, this may increase the concentration of active metabolite up to 1 mg/ml.
At our institution, a concern about the volume of infiltrated lidocaine and possible
toxicity levels led to a modification in the mixture of wetting solution in large-volume
liposuction cases. In cases with aspirate greater than 5000 cc, the initial five bags of
solution are mixed in a standard UT Southwestern protocol (see the table above).
After 5 L of infiltration, the remaining bags of infiltrate contain lidocaine 1% plain
at half the volume (15 ml).
However, a recent study at our institution showed that tissue levels of lidocaine be-
yond 8 hours postoperatively are subtherapeutic. A well-designed study by Hatef et
al prospectively randomized liposuction patients to receive preoperative subcuta-
neous infiltration of 10, 20, or 30 mg/kg of lidocaine wetting solution before the pro-
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Chapter 78  Liposuction: Basic Techniques and Safety Considerations
Most Common Wetting Solution Mixtures
Ingredient
Amount (ml)
Klein’s Formula
Normal saline solution
1000
1% lidocaine
50
1:1000 epinephrine
1
8.4% sodium bicarbonate
12.5
Hunstad’s Formula
Ringer’s lactate solution
1000 at 38° to 40° C
1% lidocaine
50
1:1000 epinephrine
1
Fodor’s Formula
Ringer’s lactate solution
1000
Aspirates 2000 cc 1:500 epinephrine
1
Aspirates 2000 to 4000 cc 1:1000 epinephrine
1
Aspirates 4000 cc 1:1500 epinephrine
1
UT Southwestern Formula
Ringer’s lactate solution
1000 at 21° C
Aspirates 5000 cc 1% lidocaine
30
Aspirates 5000 cc 1% lidocaine
15
1:1000 epinephrine
1

cedure, observing patients’ intraoperative anesthesia requirement, postoperative pain,
and need for postoperative analgesia. Surprisingly, no significant difference was found
among any of the three groups. We have since eliminated lidocaine in our wetting
solutions and have noted no difference in our patients’ postoperative recovery or pain
levels.
Further investigation on the use of bupivacaine in low doses may provide another
alternative for postoperative analgesia. A recent article by Failey et al demonstrated
no significant difference in the incidence of adverse events or postoperative length of
stay for patients who underwent liposuction procedures in which bupivacaine was
administered, compared with other wetting solutions.
Epinephrine
The importance of epinephrine in subcutaneous infiltrates has been well recognized.
In addition to its vasoconstrictive effect, it also decreases the rate of vascular ab-
sorption of lidocaine, potentiating the local anesthetic effect. Epinephrine toxicity
can result in tachycardia, hypertension, 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
cardiovascular system.
In a study to evaluate the hemodynamic effects of epinephrine during liposuction
surgery, we found a linear correlation between the epinephrine concentration and
cardiac index. Although the doses of epinephrine are low and its half-life is less than
2 minutes, peak concentrations do not occur until about 5 hours after infiltration.
In larger-volume cases, we recommend that infiltration be staged, decreasing the peak
effect of epinephrine and its subsequent effect on the cardiovascular system. Re-
gardless, a thorough preoperative patient evaluation with special attention to the
presence of cardiovascular disease should be performed to avoid the untoward ef-
fects associated with epinephrine infiltration in some patients.
Although rarely used, halothane may sensitize the heart to catecholamines, result-
ing in ventricular arrhythmias. Despite the protective effect of lidocaine against ar-
rhythmias, halothane should not be used during liposuction procedures.
Regardless of the technique used, the infiltrate should be allowed to set for a mini-
mum of 7 minutes and no longer than 30 minutes before suctioning because of the es-
timated onset of action of the anesthetic and the vasopressor in the solution.
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Part XII  Body Contouring

Current Recommendations for Perioperative
Fluid Management
Guidelines were developed by Rohrich et al in 1998 (and updated in 2006) after a
thorough review of 100 consecutive procedures using the superwet technique (see
the box below). Perioperative fluid management during liposuction procedures re-
quires attention to maintenance intravenous fluids, third-space losses, wetting solu-
tion infiltration, and volume of lipoaspirate. We tend to diminish any preexisting
fluid deficits, because our current preoperative guidelines allow patients to consume
clear liquids up to 2 hours before surgery. Liposuction in our hands is considered a
moderate surgical stress; therefore 3 to 5 mg/kg/hr 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. A ratio
of 0.25 ml of crystalloid solution for each aspirated cubic centimeter over 5 L is used.
Fluid Resuscitation
Body-contouring procedures can result in significant fluid shifts and intravascular
volume changes for the patient. The operating surgeon should maintain a dialog with
the anesthesia provider so that patients receive adequate replacement volume and
proper fluid resuscitation intraoperatively. Awareness of four key elements will guide
the intraoperative fluid management of liposuction patients: intravenous fluid main-
tenance (body weight dependent), third-space losses, the volume of the wetting so-
lution infiltrated, and total lipoaspirate volume. Large-volume liposuction patients
can present an especially difficult challenge for fluid resuscitation. We routinely place
Foley catheters in patients undergoing large-volume aspiration to assist us in resus-
citation.
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Fluid Management
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 cubic centimeter of lipoaspirate
over 5 L.
These recommendations serve as a guideline for fluid management of these compli-
cated patients and are not meant to replace sound clinical judgment based on spe-
cific patient needs.

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Treatment Options
Once having determined that lipoplasty would be the best treatment option to ac-
complish the planned aesthetic goals, the surgeon focuses on selecting the appro-
priate modality. Factors that influence the selection of a particular type of treatment
include surgeon preference, target area, expected volume of aspirate, and history of
previous liposuction. Current options include traditional liposuction, as popularized
by Illouz, which today includes SAL, PAL, UAL, VAL, LAL. Traditional SAL remains
the most common and popular modality for lipoplasty among plastic surgeons.
SAL is a two-stage technique in which the site is infiltrated with a predetermined
wetting solution and then evacuated after allowing time for the epinephrine to take
effect. The advantages of this technique include the ease of use, wide variety of can-
nulas, availability of malleable cannulas, and decades of experience and results. The
disadvantages of SAL include its being more difficult to use in fibrous areas and typ-
ically requiring more effort to perform than other liposuction modalities.

PAL uses an externally powered cannula, variable in size and flexible, and oscillates
in a 2 mm reciprocating motion at rates of 4000 to 6000 cycles per minute. Advo-
cates of PAL contend that it is best used for large volumes, fibrous areas, and revi-
sion liposuction. Because the PAL cannula breaks up fibrous fat much more readily,
the procedure is significantly faster and less labor intensive for the surgeon than tra-
ditional SAL. Suction is still a major component of PAL, and most units are com-
patible with standard aspiration equipment. Both the power source and the suction
are attached to the proximal end of the handpiece. If the surgeon prefers, syringe suc-
tion is a useful adjunct and can be used with an adapter. As with SAL, many probe
tip configurations and diameters are available. PAL systems have multiple power set-
tings, especially the computer-controlled systems that can be programmed.
Some of the disadvantages of earlier PAL systems, which ran on compressed air, in-
cluded significant noise generation and the mechanical vibration experienced by the
operating surgeon. However, these modalities now run on electrical power sources,
decreasing the degree of noise and vibration. We find that the PAL system is bulky
and somewhat cumbersome, making fine contour changes more difficult.
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Chapter 78  Liposuction: Basic Techniques and Safety Considerations
PAL electric handpiece
Complete PAL system
UAL applies ultrasonic energy to break down fat and facilitate suction-assisted re-
moval. Its mechanism of action is also primarily mechanical in nature, but cavita-
tion and even thermal effects are purported to occur. With this technique, fat is emul-

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sified, which allows removal through traditional liposuction cannulas. UAL com-
prises three stages: infiltration, emulsification, and evacuation and contouring.
To help protect the skin from thermal injury, some operators limit their application
of energy and bathe the access site with saline solution. A towel should cover the re-
gion behind the access site to prevent direct contact of the probe with the skin dur-
ing excursion. As with the other technologies, a variety of probe tip configurations
and lengths are available, including hollow and solid devices.
For UAL, we begin at a depth of approximately 1 to 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. We continue in this manner until the end-
point is reached. Then we move to a deeper plane. Most treatment sites will have a
minimum of two planes and sometimes three. When the last plane is completed, evac-
uation begins in the deeper plane to remove the emulsified fat. Next, we begin final
contouring, if necessary. We are fairly conservative in our choice of cannulas. Smaller
cannulas are less efficient at evacuating fat but decrease the likelihood of contour ir-
regularities. It is important that UAL endpoints be respected to avoid overzealous
resection of fat. The advantages of UAL include less surgeon fatigue as well as im-
proved results in fibrous areas and in secondary procedures. We have found that our
revision rate over the years has dropped from just under 10% to less than 3%. We
think that UAL allows a more uniform and homogenous treatment of the fatty lay-
ers. The disadvantages have been reported to include the need for larger incisions,
longer operative times, and the possibility of thermal injury. Although there is a po-
tential for thermal injury, this does not typically occur with the application times
we use today. UAL requires a superwet environment and cannot be performed with-
out a wetting solution. Finally, UAL requires continuous movement to prevent ex-
cessive exposure of the tissues to heat.
VAL employs a newer-generation ultrasound-assisted liposuction device that incor-
porates less energy with more efficient solid probes. The probes come in an array of
sizes and grooving, and their selection depends on the tissues in which they will be
used. The system uses less energy, decreasing its thermal component to the tissues.

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Chapter 78  Liposuction: Basic Techniques and Safety Considerations
Images courtesy Cynosure, Westford, MA
Left, Smartlipo system; center, ThermaView; right, ThermaGuide probe
LAL has been at the forefront of marketing efforts for the past several years. The
treatment involves insertion of a laser fiber through a small skin incision. Depend-
ing on the manufacturer, the fiber may either be housed within a cannula or stand
alone. There are several commercially available lasers on the market under different
product names. The most common available wavelengths in the United States are
924/975 nm, 1064 nm, 1319/1320 nm, and 1450 nm.
Most companies and physicians using these LAL devices employ a four-stage tech-
nique: infiltration, application of energy to the subcutaneous tissues, evacuation, and
subdermal skin stimulation. The laser fiber purportedly acts to disrupt fat cell mem-
branes and emulsify fat. Evacuation then commences through traditional liposuc-
tion cannulas. For smaller regions, such as the neck, some manufacturers suggest
skipping the evacuation phase, allowing the body to absorb the liquefied contents.
These devices are being heavily marketed for their purported skin-tightening effects.
The belief is that the heating of the subdermal tissue may in fact be the contribut-
ing factor for LAL’s possible skin-tightening effect. No large prospective trials have
been undertaken to examine the benefits of LAL over existing technologies, so un-
fortunately, these reports remain completely anecdotal. DiBernardo and Reyes eval-
uated skin tightening and skin shrinkage after treatment with a 1064/1320 nm laser
in the abdomens of five patients and found a 26% improvement in skin elasticity
and an average reduction in area of 17%.

A randomized, double-blind, controlled study by Prado et al showed no difference
in the outcomes of LAL compared with those of traditional SAL. In that study, each
patient served as his or her 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 reported a
longer operative time with LAL, less early postoperative pain with LAL, and ele-
vated free fatty acids/triglycerides in the laser-treated lipoaspirate. Regardless of its
efficacy in tightening skin, we must recognize that there is a fine line between der-
mal contraction and full-thickness injury when applying heat to the subdermis.
Surgical Endpoints
The surgical endpoints for UAL are different from those of SAL and PAL; these have
been divided into primary and secondary endpoints. In UAL, the most important
endpoint is reached when one encounters a loss of tissue resistance, which is appre-
ciated through the treatment hand as well as the nondominant guiding hand. Addi-
tionally, the aspirate may become more blood tinged, indicating adequate emulsifi-
cation of the treatment site. Experience helps dictate energy application times in
particular regions of the body. Secondary endpoints for UAL include site-specific
treatment time and the 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 complete, the contour may be assessed. Alter-
natively, treatment with SAL or PAL uses final contour and symmetrical pinch test
results as their primary endpoints. Similarly, treatment time and volume can be used
to help ensure that treatment is symmetrical.
We do not hesitate to add multiple sites for evacuation and final contouring to create
a smoother, more uniformly treated area and to minimize the risk of contour defor-
mities. As a general rule, we reserve superficial liposuction for patients who have sig-
nificant superficial irregularities. Only surgeons with extensive experience in lipo-
suction should perform this procedure because of the significant potential for skin
injury and contour irregularities of the superficial soft tissues.
Finally, when contour irregularities are recognized intraoperatively, they are treated
at this setting with autologous fat grafting at the site of the deformity. Trying to
feather the edges of the defect most often leads to an even greater problem, further
complicating its treatment.
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Part XII  Body Contouring