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

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Part XII  Body Contouring
Power-Assisted Liposuction
An array of cannulas is also available for the PAL systems (Microaire Surgical In-
struments, Charlottesville, VA). These cannulas are small and malleable, which is very
useful when working along curved surfaces. They are comparable in length and di-
ameter to SAL cannulas, which permit the use of small access incisions.
Ultrasound-Assisted Liposuction
Ultrasonic technology uses either a hollow cannula or a solid probe. Vaser probes
(Sound Surgical Technologies, Louisville, CO) are solid and have rings circumscrib-
ing them. The rings allow lateral fragmentation; therefore the greater the number of
rings, the more lateral fragmentation that is possible.
Vaser-Assisted Liposuction
Two- or three-ring probes are generally used in areas that have soft, nonfibrous fat,
and the single ring probe is reserved for more fibrous secondary areas.

A cannula with a golf-tee–shaped tip allows greater fragmentation than a rounded
bullet-shaped tip.
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Chapter 78  Liposuction: Basic Techniques and Safety Considerations
Cannula Size
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
Treatment Areas
Arms
Upper arm contouring can be performed with any number of the modalities listed
earlier. Caution must be exercised when suctioning toward the ulnar aspect of the
elbow. The fatty layer is thin and mobile in this region, and the ulnar nerve courses
superficially just beneath the investing fascial layer; this can be inadvertently injured
during treatment, resulting in either temporary or permanent nerve injury. Arm thick-
ness and composition of fat and muscle are variable; however, fat is usually most
abundant in the posterior third of the arm.

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Part XII  Body Contouring
Ideally, the arm is lean and has a convexity overlying both the deltoid and biceps
muscles. On the posterior surface, the arm is slightly convex from axilla to elbow.
Poor skin quality and/or excess skin will likely require excisional surgery. For pa-
tients who lack definition overlying the biceps and deltoid region, a circumferential
approach to the arm may be preferable.
It is important to consider the area posteriorly where the arm joins the trunk. This re-
gion creates fullness with the arm in adduction and is often accentuated by a bra
and/or other clothing. Liposuction of the arms is usually suited for patients with an
excess of 1.5 cm of fat by the pinch test. Patients with less fat and more skin excess
may benefit from excisional surgery rather than liposuction. The role of LAL in these
patients has not been clearly defined.
Liposuction of the arms may be performed with the patient in either the supine or
prone position. Regardless, care must be taken to avoid injury to the ulnar nerve, es-
pecially when using UAL. With UAL, the access incision is placed more radially
around the elbow. Contouring on the ulnar side is reserved for SAL. If a patient re-
quires circumferential liposuction of the arms or excisional surgery, we prefer to po-
sition the patient supine.

Proximal access may be achieved through a posterior axillary incision. The area where
the arm joins the trunk may be accessed either through this incision or a back ac-
cess incision in the case where the back is being treated as well. Overall, the fat is
loose and areolar. The superficial nature of the fat requires the use of smaller can-
nulas. Evacuation begins with a 3.0 mm cannula and may transition to a 2.4 mm
cannula for further contouring and feathering. In our hands, UAL tends to be par-
ticularly useful in the posterior third of the arm and the area adjacent to the back,
because these areas tend to be more fibrous. PAL is also effective in these areas.
Back
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Chapter 78  Liposuction: Basic Techniques and Safety Considerations
The anatomy of the subcutaneous fat and skin in the back is uniquely different from
other regions of the trunk and extremities; it has a very thick dermis and a dense, fi-
brous characteristic to the underlying fat. For liposuction in the back, we prefer to
treat patients in the prone position with the bed in a head-down flexed position. UAL
or PAL tends to work well in the fibrous tissue of the back. The quantity of fat re-
moved can be moderate, but improved results are often observed with release of folds
and attachments to deeper tissue. Access incisions will depend on the distribution of
lipodystrophy and can be placed medially or laterally; the incisions should be placed in
the bra/bathing suit line for the best cosmetic result. Forceful excursion of the cannula
should be avoided, because fibrous areas may redirect the cannula to an unsafe loca -
tion. Suctioning from areas off the thoracic cage (the hip region) toward the posterior
back should not be performed to avoid intraabdominal penetration of the cannula.

Abdomen
The abdomen is bordered superiorly by the xyphoid process and costal margin, in-
feriorly by the pubis and inguinal ligament, and laterally by the anterior superior il-
iac spines. Lipodystrophy of the abdomen is predominantly seen in the infraumbili-
cal region. Careful preoperative evaluation and physical examination are vital, with
careful attention to the distribution of fat, scars, skin laxity, and the presence or ab-
sence of hernias. The physical examination may be challenging for patients who are
overweight, those who have a large pannus, or patients with extensive scarring ne-
cessitating preoperative imaging to rule out any abdominal wall defects or hernias. Pa-
tients with diastasis, abdominal wall laxity, or significant intraabdominal fat should
be counseled on the possible benefit and/or need for skin excision or plication to
achieve an optimal contour and aesthetic result.
Subcutaneous abdominal fat is amenable to all of the various modalities of liposuc-
tion and continues to be one of the most desired areas for liposuction. We reserve
superficial liposuction for the linea alba or for correction of secondary deformities.
There have been published reports of superficial sculpting of the abdomen, but we
strongly urge that this be attempted only in experienced hands. Overaggressive treat-
ment of the abdomen, as with other regions, may result in untoward contour irreg-
ularities and/or skin injury.
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Part XII  Body Contouring
Access to the abdominal region may be gained through an umbilical incision, bilat-
eral lower abdominal incisions, and/or suprapubic incisions.
It is also useful to extend the table at the waist up to 15 or 20 degrees to allow ex-
cursion of the cannula from the suprapubic region. In patients with a long torso and
a moderate degree of lipodystrophy overlying their costal margin, an inframammary
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 intraabdominal or thoracic penetration. In the abdomen, it is imperative that
short, controlled strokes be used to avoid the potential for inadvertent fascial per-
foration, particularly when working around scars.

Hips/Flanks
We often treat the hip/flank area with the patient in the prone position, although
some surgeons prefer the lateral decubitus position. This common area of suction-
ing in both men and women is accessible through the bilateral or single midline
paraspinous region and/or incision in the lateral gluteal fold. Suctioning in this area
can provide excellent results, and all modalities have proved effective. The fat is loose
and in some cases fibrous, with thick overlying skin. Significant striae may be seen
in patients with weight fluctuations or in women who have had a child. Liposuction
in these patients may reduce the lipodystrophy but can result in superficial contour
irregularities or skin redundancy. Knowledge of the differing aesthetic considerations
of the hips and flanks in men and women is crucial to preventing inappropriate mas-
culinization or feminization. In general, men tend to have fullness in the superior
and lateral region, whereas women usually have prominence more inferiorly and
posteriorly.
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Chapter 78  Liposuction: Basic Techniques and Safety Considerations
In male patients the term flank describes an area immediately superior and poste-
rior to the iliac crest. It begins in the paraspinous area and enlarges as it expands lat-
erally. Anteriorly, the flank blends with the tissue of the lower abdomen. The infe-
rior margin is defined by the zone of adherence along the iliac crest.
In contrast, the female hip is located more inferiorly and typically is centered over
the 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. The skin may be
attenuated by striae and have some degree of laxity.

It is essential to mark the lateral gluteal depression before liposuction, because vio-
lation of this important area can lead to irregular contours and deformity. Often this
adherent zone is a landmark to which both the hips and lateral thighs are reduced. In
other patients, this area may be an area of significant depression that may benefit
from autologous fat grafting.
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Part XII  Body Contouring
The hip and flank can be accessed through two inferiorly placed lateral paraspinous
incisions that are easily concealed by undergarments or a bathing suit. With more
laterally displaced lipodystrophy, incisions may be moved more laterally. In contrast,
patients with more posteriorly oriented fat may be adequately treated through a sin-
gle lower midline access incision. This may be moved more superiorly if the fat over-
lies the area of the inferior posterior costal margin. However, it should be noted that
this midline incision typically does not heal as well as paraspinous incisions do; this
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 an aesthetic blend-
ing between the lateral thigh and hip/flank area. This incision, in combination with
a single midline access site, facilitates effective contouring and avoids incisions over-
lying the buttock area, which may have a tendency to dimple. However, caution
should be used when contouring through the lateral gluteal fold incision, because
overzealous resection through the trochanteric adherent zone is very likely to result
in a contour deformity.
Thighs and Buttocks
Liposuction of the thighs is one of the more difficult procedures, where overaggres-
sive treatment may result in an unsatisfactory contour. For most patients, a circum-
ferential approach in the prone or supine position is best. Although patients may
present with an isolated medial or lateral deformity, it has been shown that superior
results are obtained with a circumferential approach, which provides the best con-
tour and the highest patient satisfaction. The degree of contouring of specific regions
of the thigh depends on the analysis and needs of each patient.

Because the majority of contour irregularities occur within the thigh region, again
it is of paramount importance to recognize and understand the significance of the
thigh zones of adherence: the lateral gluteal depression; the gluteal crease; the pos-
terior, inferior, and distal lateral thigh; and the mid–inner thigh. In addition to these
zones of adherence, the buttock area must also be approached with caution. A uni-
form reduction of the buttocks can be achieved through cautious treatment of the
intermediate layer, resulting in a decrease in anteroposterior buttock projection. Ac-
cess 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 are of critical importance. Overzealous treatment in the deep or su-
perficial plane may result in buttock ptosis. This area is most easily accessed through
paraspinous or gluteal access incisions. Excessive contouring of the lateral proximal
posterior thigh may result in an extension of the gluteal fold in women and mas-
culinization of the gluteal area.
The surgeon must exercise special care when addressing the proximal posterior thigh.
Aggressive suctioning in this difficult area may result in disfiguring skin rolls and re-
dundancy. These problems can be very difficult to correct, requiring either autolo-
gous fat grafting or skin excision. In women, overtreatment of this area may elon-
gate the gluteal fold, masculinizing the female silhouette. Suctioning of the lateral
thigh and posterior thigh is easily facilitated through the previously described lateral
gluteal fold access incision.
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Chapter 78  Liposuction: Basic Techniques and Safety Considerations
Lateral gluteal
depression
Mid–inner thigh
Gluteal crease
Inferior and
distal thigh
Posterior thigh
ZONES OF ADHERENCE

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Part XII  Body Contouring
This 36-year-old patient underwent previous liposuc-
tion elsewhere and was unhappy with the appearance
of her buttocks. Overzealous liposuction of the buttocks
and proximal posterior thighs resulted in elongation of
the gluteal fold and skin fold redundancy of the skin
just caudal to the gluteal fold.
For evacuation and further contouring of the lateral thigh, a small midlateral inci-
sion may be made if necessary. Treatment of the posterior medial thigh is accom-
plished through the gluteal access incision with the patient in the prone position. If
necessary, a second, more medial incision within the fold may facilitate treatment of
this region.
With the patient supine, the anterior and medial thighs may be contoured through
an inguinal crease incision and often an incision in the distal medial thigh. A shelf
between the lateral and anterior thigh is often created when contouring the lateral
thigh in the prone position. This transition should be treated and may be approached

through either the inguinal crease incision or a separate midlateral or anterolateral
access incision. The anterior thigh has superficially located, relatively compact fat
that has a tendency to develop contour irregularities. It is often necessary to treat the
anterior thigh to allow adequate blending of the lateral and anterior thigh to avoid
a shelf between the two regions. A more superficial approach within the femoral tri-
angle will avoid injury to the lymphatic structures and prolonged lymphedema.
The medial thigh can be unpredictable with regard to redraping of the skin after li-
posuction. It is important to maintain a uniform, superficial layer of fat to prevent
contour irregularities. Skin tone and quality need to be adequately assessed preop-
eratively so that the patient will have realistic expectations about liposuction of the
medial thighs. In our experience, this is the most difficult area in which to achieve
consistent results.
Knees
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Chapter 78  Liposuction: Basic Techniques and Safety Considerations
Treatment of the knees varies, depending on the patient’s anatomy. Isolated fat of
the knee medially is easily treated through a posterior incision with the patient in
the prone position. For patients with suprapatellar fullness, the incision is usually
placed within a skin fold anteriorly to adequately treat this fibrous area.
Neck
Liposuction in the neck region is often performed with traditional SAL and small
cannulas or hand syringe suctioning. Access is typically via a submental incision and
often is just posterior to the mandible on either side. Suctioning should proceed in a
controlled fashion, and the superficial dermis should be avoided. Continuous as-
sessment of contour is important. Overzealous treatment of this area may result in
hollowing and skeletonization of the neck or potential neuropraxia of the marginal
mandibular nerve. Fortunately, this is usually reversible and resolves within a few
weeks of the procedure.

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Part XII  Body Contouring
Results
This 36-year-old woman desired improvement in her abdomen, hips, and thighs. She
underwent liposuction with UAL. A total of 3825 ml was infiltrated, and 3650 cc
was removed. She is shown 5 months postoperatively.

This 60-year-old woman requested improvement in her abdomen, hips, and thighs.
She was in good overall health and had some areas of skin inelasticity. The possi-
bility of skin laxity was discussed with the patient, who wanted to look better in her
clothing; 6100 ml was infiltrated and 6600 cc was removed. The patient was moni-
tored overnight. She is shown 6 months postoperatively.
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Chapter 78  Liposuction: Basic Techniques and Safety Considerations

This 45-year-old patient had undergone liposuction of her abdomen and thighs ap-
proximately 10 years earlier. She had gained about 7 kg (15 pounds) since then and
desired further improvement in her abdomen, hips, and thighs. She had some skin
laxity of her abdomen but did not desire excisional surgery. She underwent second-
ary liposuction with UAL; 4300 ml was infiltrated and 4550 cc was removed. She is
shown 9 months postoperatively. Particularly noteworthy is the final result in the
posterior view.
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Part XII  Body Contouring
Preoperative
Imaging
9 months postoperatively

This 47-year-old woman requested circumferential body contouring of her arms,
back, hips, abdomen, and thighs. She underwent UAL/SAL of these regions. A total
of 4750 ml was infiltrated and 5035 cc was evacuated. At 6 months postoperatively,
her dress size has decreased from 12 to 8, and she has lost approximately 7 kg
(15 pounds). Her circumferential trunk and thighs are improved, and modest im-
provement is seen in her abdomen.
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Chapter 78  Liposuction: Basic Techniques and Safety Considerations

This 32-year-old man requested improvement in his trunk. He underwent liposuc-
tion of the abdomen and flanks. A total of 1900 ml was infiltrated, and 1350 cc was
evacuated. He is shown 1 year after surgery with improvement in the centralized
lipodystrophy of his abdomen and the fullness in his flanks.
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Part XII  Body Contouring

Adjunctive Uses of Liposuction
Breast Reconstruction
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Chapter 78  Liposuction: Basic Techniques and Safety Considerations
Liposuction can be a useful adjunct to many other procedures. During breast sur-
gery it is often necessary to contour the lateral chest area. Liposuction may improve
the contour and shape of the upper torso.

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Part XII  Body Contouring
Flap Debulking
Liposuction may also be useful in flap debulking, specifically in breast reconstruc-
tion, as seen in this woman, who had 150 cc of fat removed from her transverse rec-
tus abdominis musculocutaneous (TRAM) flap during a second-stage reconstruc-
tion. It is also very useful in treating TRAM flaps that have firm areas consistent
with fat necrosis. Treatment may proceed without resorting to direct excision, thereby
decreasing or minimizing skin incisions. In the past, these areas have not been
amenable to treatment with SAL.
Postoperative Care
At the conclusion of surgery, patients are placed in an appropriate compression gar-
ment; some type of compression foam may also be used. In general, patients who
have undergone any large-volume procedure (more than 5000 cc of aspirate), lipo-
suction of multiple areas, or liposuction in addition to abdominoplasty or other ex-
cisional body contouring procedure are kept overnight for 23-hour observation. Pa-
tients are asked to ambulate the night of the surgery; sequential compression devices
are placed on the patient in the preoperative holding area and are continued until
discharge. The patient is allowed to shower beginning 1 or 2 days postoperatively

and is instructed to wear the compression garment 24 hours a day for 2 weeks, re-
moving the garment only for bathing. Initial postoperative visits are scheduled for 5
to 7 days postoperatively; the patient may return to activity and work as early as 3
to 4 days or 2 weeks, depending on the procedure. Walking is encouraged immedi-
ately, and light exercise is allowed 2 weeks after surgery, unless the patient under-
went an associated abdominoplasty. Patients should expect to gain anywhere from
2.25 to 4.5 kg (5 to 10 pounds) after liposuction. Edema tends to peak 3 to 5 days
after surgery; bruising should be minimal and dissipate by 7 to 10 days after surgery.
Patients should begin to see contour changes in their waist by 2 weeks after the pro-
cedure and at 6 weeks be able to appreciate significant changes in their shape. As
their activity level improves and necessary lifestyle changes proceed, further changes
may be noticed. The final aesthetic result can be seen 3 to 6 months after surgery.
Postoperative lymphatic massage is encouraged to help with swelling and induration
and is often started before surgery and resumed shortly after the procedure.
Complications
Liposuction is not a procedure without risks. Much attention has been directed to-
ward outcomes and prevention in the past few years, with the ultimate goal of im-
proved results while maintaining patient safety. Complications can vary from mild
postoperative nausea and vomiting to deep venous thrombosis/pulmonary embolism
and even death. Complications can occur in the perioperative period, early postop-
erative period, and/or late postoperative period.
In a questionnaire to board-certified members of ASAPS, a significant increase in
complications was reported when liposuction was combined with other contouring
procedures, most notably when paired with abdominoplasty. Perioperative compli-
cations can include anesthesia and cardiac complications, cannula trauma to skin
and/or internal organs, and volume loss or overload from bleeding or excess fluid
administration. Cannula injury to blood vessels, bowel, and other solid intraab-
dominal organs has been reported in the literature. Although rare, these complica-
tions are related to incomplete preoperative examination (overlooking the presence
of a hernia, for example) and overaggressive suctioning or penetration by the infil-
tration cannula. Hypothermia occurs commonly in liposuction cases. Hypothermia
is generally defined as a core body temperature less than 36.4° C (97.5° F). It is com-
mon in anesthetized patients as a result of an interthreshold shift in thermoregula-
tion. Its risk is amplified in larger volume cases in which a greater surface area of
the patient is exposed at one time and patients are under anesthesia longer. The core
body temperature can drop up to 2.8° C (37° F) in the first hours of surgery as a re-
sult of the anesthesia effect on autonomic regulation of core temperature. Warming
of the wetting and preparation solutions, increase of the ambient temperature, and use
of warming devices (Bair Hugger, Arizant, Eden Prairie, MN) all help reduce tem-
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Chapter 78  Liposuction: Basic Techniques and Safety Considerations

perature loss. Prewarming the patient with forced air for 1 hour has also been shown
to significantly reduce the incidence of hypothermia.
Fluid management is crucial to the prevention of volume overload and anesthesia-
related complications. As stated previously, careful management of intraoperative
and postoperative fluids, as well as use of an intraoperative data sheet, helps prevent
volume-related complications from liposuction. The tumescent liposuction technique
has been implicated in volume overload and pulmonary edema; however, this can
often be attributed to incorrect patient selection and/or poor fluid management. Fluid
overload and untoward sequelae from large-volume liposuction (more than 5 L)
prompted a warning by the ASPS that physicians performing liposuction should
be trained in comprehensive fluid resuscitation and the physiology of large-volume
liposuction.
Other early postoperative complications can include venous thromboembolism, in-
fection, and skin slough or loss. The incidence of deep venous thrombosis in lipo-
suction has been reported at less than 1%, but a marked increase in this percentage
is demonstrated when liposuction is combined with other surgery (such as ab-
dominoplasty or belt lipectomy). Physicians should familiarize themselves with the
American College of Chest Physicians (ACCP) current recommendations and the
modified Davison-Caprini Risk Assessment models currently available. Administra-
tion of enoxaparin has resulted in a decreased incidence of deep venous thrombosis
but has been associated with an increased risk of perioperative bleeding and
hematoma. Clinical signs of lower extremity swelling, Homan’s sign, shortness of
breath, chest pain, and/or tachycardia should alert the provider to the possibility of
deep venous thrombosis/pulmonary embolism and warrant immediate evaluation
and treatment. Sequential compression devices are placed on all patients in the pre-
operative holding area and remain in place throughout the procedure and postop-
eratively while the patient is in bed until the time of discharge.
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Part XII  Body Contouring
UT Southwestern Modification of Davison-Caprini Model
Suggested Revisions to the Davison-Caprini Risk Assessment Model: Exposing Risk Factors
One Factor
Two Factors
Three Factors
Five Factors
Minor surgery
Major surgery
Previous MI/CHF
Hip, pelvis, leg fracture
Immobilization
Severe sepsis
Stroke
Central venous access
Free flap
Multiple trauma
Circumferential
abdominoplasty
CHF, Congestive heart failure; MI, myocardinal infarction.

Fortunately, wound infections and necrotizing soft tissue infections are rare but have
been reported following liposuction. Persistent postoperative fevers and/or cellulitis
should be closely monitored and aggressively treated. First-generation cephalosporins
are administered perioperatively at our institution within 30 minutes of the incision
unless the patient has a known history of methicillin-resistant Staphylococcus au-
reus (MRSA), in which case vancomycin is administered preoperatively.
Late complications of liposuction include delayed seroma formation, edema, ecchy-
mosis, paresthesias, and contour irregularities. Seromas following aggressive lipo-
suction are rare; they are thought to be caused by overzealous treatment of an area,
denuding the fascia. It appears to be technique dependent rather than technology
specific. A loose closure of cannula sites, postoperative compression garments, and
expressing residual fluid over liposuction areas at the end of the procedure can po-
tentially reduce the incidence of seroma formation.
Postoperative edema and ecchymosis occur to a varying extent in all patients. Pro-
longed edema may be present for up to 3 months after surgery and is best treated
with supportive care and lymphatic massage. 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. Paresthesias in newer technologies have not been investigated.
The most common postoperative complication from liposuction is contour defor-
mity or irregularities, which can occur in up to 20% of patients. Mild irregularities
are often present after suctioning; these are treated conservatively with lymphatic
massage as swelling and edema resolve. Once a contour deformity is identified, it is
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Chapter 78  Liposuction: Basic Techniques and Safety Considerations
Suggested Revisions to the Davison-Caprini Risk Assessment Model:
Predisposing Risk Factors
Number of Factors
Age 40-60 years
1
Age 60 years
2
History of venous thromboembolism
3
Current pregnancy
1
Current malignancy
2
Obesity
2
OCP/HRT
2
Hypercoagulable disorder
3
HRT, Hormone replacement therapy; OCP, over-the-counter progesterone.

best to determine the cause. Treatment can either be directed at reinjecting fat in the
overresected region or suctioning the adjacent areas to reduce the prominence of the
concavity and blending the adjacent areas. UAL has a decreased incidence of con-
tour deformities compared with traditional SAL in our hands. We prefer UAL for
secondary liposuction cases in which fat grafting is not indicated. Careful preoper-
ative analysis and planning help to minimize the risk of postoperative contour ir-
regularity, and thorough patient education about this potential and informed con-
sent are essential.
Emerging Technology
Mesotherapy or lipolysis is an emerging technology, the goal of which is a reduction
in fat by dissolution. The concept, which dates back to 1952, involves injection of
phosphatidylcholine, deoxycholate, and/or other agents to dissolve fat deposits. It
has gained popularity because of its “noninvasive” nature, and the marketing efforts
have reached mainstream media and patients. Park et al showed no discernible dif-
ference after treatment in lower extremities with mesotherapy by measurement or
CT evaluation. Lipodissolve is considered by some (but not all) practitioners to be a
variant of mesotherapy. It involves injection of a standardized solution into the sub-
cutaneous fat, rather than the mesoderm. The use of these products in the United
States is controversial and is not supported by the FDA. A stern warning from the
FDA cautions providers against its unproven use and false marketing claims. Several
studies on safety and efficacy are available for review. The common side effects listed
include hyperpigmentation and persistent pain; 12% of patients had cosmetic out-
comes that were less favorable than expected. Further study and evaluation of safety
on all forms of mesotherapy are warranted before clinical use can be endorsed.
Focused external ultrasound therapy is one of the most popular fat-reducing tech-
nologies currently being evaluated and has considerable popularity in Israel, Spain,
and Japan. Depending on the technology, it can be thermally or non–thermally me-
diated (by cavitation). There is no “evacuation” phase; the process relies primarily
on removal of fat by the body’s own phagocytic mechanisms. Preliminary data by
Brown et al have shown it to be effective in a preclinical porcine model, in which the
UltraShape device (UltraShape, Tel Aviv, Israel) was target specific for the adipocyte,
preserving the surrounding neurovasculature. Two clinical studies have validated its
safety. Currently the company is performing a multicenter, prospective, randomized,
blinded study evaluating its safety and efficacy.
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Chapter 78  Liposuction: Basic Techniques and Safety Considerations
LipoSonix technology uses high-intensity focused ultrasound (HIFU) to disrupt fat in
a thermally mediated mechanism. The device is currently undergoing clinical trials
outside the United States and is being marketed in Europe. LipoSonix disrupts fat
through a thermocoagulation-mediated mechanism (compared with UltraShape,
which acts by cavitation, causing disruption of fat cell membranes). Neither the
UltraShape nor LipoSonix is FDA approved or available in the United States.
Liposuction combined with radiofrequency ablation of fat cells is currently being in-
vestigated under the trade name BodyTite (New York). The purported benefits are
thermal destruction of fat cells, removal via aspiration cannula, and subnecrotic
heating of the dermis for skin tightening. This device is not currently approved by
the FDA.
Cryolipolysis is a new and vastly different technology currently being evaluated for fat
destruction under the trade name Zeltiq (Pleasanton, CA). The concept is a con-
trolled cooling of the subcutaneous fat, with destruction of selective fat cells with-
out epidermal or dermal injury. Zeltiq is currently undergoing evaluation but is not
FDA approved.
Unfortunately, the devices mentioned here are still in the preliminary stages of de-
velopment but represent exciting and novel approaches to noninvasive body con-
touring. We must keep in mind that until adequate scientific validation of these novel
devices is performed outside of the manufacturers’ influence, any discussion of po-
tential benefit is strictly advertisement and market driven. As new technology is con-
tinually being introduced, we must temper our enthusiasm and base our treatments
on solid, scientific evidence. Device manufacturers often provide scant, if any, ob-
jective data to support claims such as skin tightening, reduced pain, and improved
aesthetic results.
Concluding Thoughts
Liposuction has evolved tremendously over the years since its initial description by
Illouz. In the past 25 years there have been significant advances in the techniques
and technologies available, resulting in improved safety and outcomes. We are con-
fident that liposuction will remain one of the most popular procedures performed
in the years to come. As each new therapy is developed, plastic surgeons must remain
committed to the common goals of patient safety and improved aesthetic outcomes.

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Part XII  Body Contouring
Clinical Caveats
 It is useful to classify patients based on their degree of lipodystrophy and skin re-
dundancy.
 Recognition of the zones of adherence is essential. These areas are vulnerable to
contour irregularities.
 The patient’s taking over-the-counter herbal and diet medications may have un-
favorable interactions with anesthetics and/or consequences for surgical outcomes.
 The intermediate fatty layer is the most common layer treated.
 Superficial liposuction should be reserved for significant superficial irregularities
and be performed by those experienced in liposuction techniques.
 One should avoid treating convexities from adjacent concavities.
 The utilitarian access site for UAL is the lateral gluteal fold.
 Patients with surgical scars on their abdomen must be thoroughly examined to
rule out the presence of a hernia.
 Treatment with UAL begins superficially and ends in the deeper plane. In contrast,
evacuation proceeds from the deeper layers to the more superficial layers.
 The compression garment should first be removed with the patient in the supine
position to avoid a vagal response.
 Incorporation of a diet and exercise program in conjunction with liposuction will
allow patients to achieve their optimal shape and contour.
Annotated Bibliography
Prado A, Andrades P, Danilla S, et al. A prospective, randomized, double-blind, controlled
clinical trial comparing laser-assisted lipoplasty with suction-assisted lipoplasty. Plast
Reconstr Surg 118:1032-1045, 2006.
The only randomized, objective assessment of laser lipolysis of significance. A must-read
when considering this technology.
Young VL, Watson ME. Prevention of perioperative hypothermia in plastic surgery. Aesthet
Surg J 26:551-571, 2006.
This review of a very common problem has completely changed the way we practice. It
is not only educational but also something you can and should incorporate into your
practice.

Suggested Readings
American College of Chest Physicians. Antithrombotic and Thrombolytic Therapy: ACCP
Evidence-Based Clinical Practice Guidelines, 8th ed. Chest 133(Suppl 6), 2008.
American Society of Plastic Surgeons. Practice Advisory on Liposuction. March 15, 2003.
Available at:
Summary-on-Liposuction.pdf
Avram MM, Harry RS. Cryolipolysis for subcutaneous fat layer reduction. Lasers Surg Med
41:703-708, 2009.
Blugerman G, Schavelzon D, Paul MD. A safety and feasibility study of a novel radiofre-
quency-assisted liposuction technique. Plast Reconstr Surg 125:998-1006, 2010.
Broughton G II, Horton B, Lipschitz A, et al. Lifestyle outcomes, satisfaction, and attitudes
of patients after liposuction: a Dallas experience. Plast Reconstr Surg 117:1738-1749,
2006.
Brown SA, Greenbaum L, Shtukmaster S, et al. Characterization of nonthermal focused ul-
trasound for noninvasive selective fat cell disruption (lysis): technical and preclinical as-
sessment. Plast Reconstr Surg 124:92-101, 2009.
Coleman SR, Sachdeva K, Egbert BM, et al. Clinical efficacy of noninvasive cryolipolysis
and its effects on peripheral nerves. Aesthetic Plast Surg 33:482-488, 2009.
Coleman WP III. Powered liposuction. Dermatol Surg 26:315-318, 2000.
Coleman WP III. Tumescent anesthesia with a lidocaine dose of 55 mg/kg is safe for lipo-
suction. Dermatol Surg 22:919, 1996.
Coleman WP III, Hendry SL II. Principles of liposuction. Semin Cutan Med Surg 25:138-
144, 2006.
Coleman WP III, Katz B, Bruck M, et al. The efficacy of powered liposuction. Dermatol Surg
27:735-738, 2001.
DiBernardo B. Evaluation of skin shrinkage and skin tightening in laser lipolysis vs liposuc-
tion: a randomized blinded split abdomen study. Lasers Surg Med 41:80, 2009.
DiBernardo BE, Reyes J. Evaluation of skin tightening after laser-assisted liposuction. Aes-
thet Surg J 29:400-407, 2009.
Difonzo EM, Campanile GL, Vanzi L, et al. Mesotherapy and cutaneous Mycobacterium
fortuitum infection. Int J Dermatol 48:645-647, 2009.
Failey CL, Vernula R, Borah GL, et al. Intraoperative use of bupivacaine for tumescent li-
posuction: the Robert Wood Johnson experience. Plast Reconstr Surg 124:1304-1311,
2009.
Farkas JP, Kenkel JM, Hatef DA, et al. The effect of blood pressure on hematoma formation
with perioperative Lovenox in excisional body contouring surgery. Aesthet Surg J 27:589-
593, 2007.
Fodor PB. Wetting solutions in aspirative lipoplasty: a plea for safety in liposuction. Aesthetic
Plast Surg 19:379-380, 1995.
Gilliland MD, Coates N. Tumescent liposuction complicated by pulmonary edema. Plast Re-
constr Surg 99:215-219, 1997.
2793
Chapter 78  Liposuction: Basic Techniques and Safety Considerations

2794
Part XII  Body Contouring
Hanke CW, Coleman WP III. Morbidity and mortality related to liposuction. Questions and
answers. Dermatol Clin 17:899-902, viii, 1999.
Hanke W, Cox SE, Kuznets N, et al. Tumescent liposuction report performance measure-
ment initiative: national survey results. Dermatol Surg 30:967-977; discussion 978, 2004.
Hatef DA, Brown SA, Lipschitz AH, Kenkel JM. Efficacy of lidocaine for pain control in sub-
cutaneous infiltration during liposuction. Aesthet Surg J 29:122-128, 2009.
Hatef DA, Kenkel JM, Nguyen MQ, et al. Thromboembolic risk assessment and the efficacy
of enoxaparin prophylaxis in excisional body contouring surgery. Plast Reconstr Surg
122:269-279, 2008.
Hatef DA, Trussler AP, Kenkel JM. Procedural risk for venous thromboembolism in abdom-
inal contouring surgery: a systematic review of the literature. Plast Reconstr Surg 125:352-
362, 2010.
Kenkel JM, Brown SA, Love EJ, et al. Hemodynamics, electrolytes, and organ histology of
larger-volume liposuction in a porcine model. Plast Reconstr Surg 113:1391-1399, 2004.
Kenkel JM, Lipschitz AH, Luby M, et al. Hemodynamic physiology and thermoregulation
in liposuction. Plast Reconstr Surg 114:503-513; discussion 514-515, 2004.
Kenkel JM, Lipschitz AH, Shepherd G, et al. Pharmacokinetics and safety of lidocaine and
monoethylglycinexylidide in liposuction: a microdialysis study. Plast Reconstr Surg
114:516-524; discussion 525-526, 2004.
Klein JA. Intravenous fluids and bupivacaine are contraindicated in tumescent liposuction.
Plast Reconstr Surg 102:2516-2519, 1998.
Koehler J. Complications of neck liposuction and submentoplasty. Oral Maxillofac Surg Clin
North Am 21:43-52, vi, 2009.
Lipschitz AH, Kenkel JM, Luby M, et al. Electrolyte and plasma enzyme analyses during
large-volume liposuction. Plast Reconstr Surg 114:766-775; discussion 776-777, 2004.
Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept.
Plast Reconstr Surg 87:1009-1018, 1991.
Matarasso A, Pfeifer TM. Mesotherapy for body contouring. Plast Reconstr Surg 115:1420-
1424, 2005.
Matarasso A, Pfeifer TM. Mesotherapy and injection lipolysis. Clin Plast Surg 36:181-192,
v; discussion 193, 2009.
Mohammed BS, Cohen S, Reeds D, et al. Long-term effects of large-volume liposuction on
metabolic risk factors for coronary heart disease. Obesity (Silver Spring) 16:2648-2651,
2008.
Nelson AA, Wasserman D, Avram MM. Cryolipolysis for reduction of excess adipose tissue.
Semin Cutan Med Surg 28:244-249, 2009.
Park SH, Kim DW, Lee MA, et al. Effectiveness of mesotherapy on body contouring. Plast
Reconstr Surg 121:179e-185e, 2008.
Rittes PG. The lipodissolve technique: clinical experience. Clin Plast Surg 36:215-221, vi; dis-
cussion 223-227, 2009.
Rohrich RJ. Mesotherapy: what is it? Does it work? Plast Reconstr Surg 115:1425, 2005.
Rohrich RJ, Beran SJ, Kenkel JM, et al. Extending the role of liposuction in body contouring
with ultrasound-assisted liposuction. Plast Reconstr Surg 101:1090-1102; discussion 1117-
1119, 1998.

Rohrich RJ, Broughton G II, Horton B, et al. The key to long-term success in liposuction: a
guide for plastic surgeons and patients. Plast Reconstr Surg 114:1945-1952; discussion
1953, 2004.
Rohrich RJ, Leedy JE, Swamy R, et al. Fluid resuscitation in liposuction: a retrospective re-
view of 89 consecutive patients. Plast Reconstr Surg 117:431-435, 2006.
Rohrich RJ, Smith PD, Marcantonio DR, Kenkel JM. The zones of adherence: role in mini-
mizing and preventing contour deformities in liposuction. Plast Reconstr Surg 107:1562-
1569, 2001.
Rooijens PP, Zweep HP, Beekman WH. Combined use of ultrasound-assisted liposuction and
limited-incision platysmaplasty for treatment of the aging neck. Aesthetic Plast Surg
32:790-794, 2008.
Teitelbaum SA, Burns JL, Kubota J, et al. Noninvasive body contouring by focused ultra-
sound: safety and efficacy of the Contour I device in a multicenter, controlled, clinical
study. Plast Reconstr Surg 120:779-789; discussion 790, 2007.
Trott SA, Beran SJ, Rohrich RJ, Kenkel JM, et al. Safety considerations and fluid resuscita-
tion in liposuction: an analysis of 53 consecutive patients. Plast Reconstr Surg 102:2220-
2229, 1998.
Woodhall KE, Saluja R, Khoury J, et al. A comparison of three separate clinical studies eval-
uating the safety and efficacy of laser-assisted lipolysis using 1,064, 1,320 nm, and a
combined 1,064/1,320 nm multiplex device. Lasers Surg Med 41:774-778, 2009.
Zelickson B, Egbert BM, Preciado J, et al. Cryolipolysis for noninvasive fat cell destruction:
initial results from a pig model. Dermatol Surg 35:1462-1470, 2009.
2795
Chapter 78  Liposuction: Basic Techniques and Safety Considerations

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Screening and Safety Issues in the
Massive-Weight-Loss Patient

JOSEPH F. CAPELLA, MATTHEW J. TROVATO,
SCOTT WOEHRLE
CHAPTER 79

P
ostbariatric patients represent a distinct population of plastic surgery patients.
Unlike routine body-contouring candidates, who are usually healthy and have
relatively mild deformities, postbariatric patients frequently have a history of sig-
nificant illness and virtually all have major contour deformities. The techniques for
managing facial aging and characteristic body contour deformities of most post-
partum women have become well honed through decades of plastic surgery train-
ing. Many of the body-contouring procedures for treating patients after massive
weight loss are relatively new and are evolving quickly, and few plastic surgeons have
had significant exposure to them during training. It is also generally recognized that
postbariatric procedures are associated with higher rates of complications. The com-
bination of improved techniques in bariatric surgery and a worsening epidemic of
obesity in the United States has led to a significant increase in demand for body-
contouring procedures. Thus it has become increasingly important for plastic sur-
geons to have a protocol in place to screen and manage these individuals safely.
Effective evaluation of postbariatric patients requires some familiarity with morbid
obesity and the surgical procedures commonly available to treat this condition. Most
morbidly obese individuals have been obese since adolescence, and some even since
childhood. These patients often have a number of comorbidities, including hyper-
tension, diabetes mellitus, sleep apnea, and urinary incontinence.
2798
Part XII  Body Contouring
Conditions Associated With Morbid Obesity
 Asthma
 Back and disc disease
 Cardiac and peripheral vascular disease
 Cholelithiasis
 Depression
 Diabetes mellitus/impaired glucose
tolerance
 Dyslipidemia
 Fatty metamorphosis, cirrhosis, and
carcinoma of the liver
 Gastroesophageal reflux disease
 Hypertension
 Increased risk for carcinomas
 Intertriginous dermatitis
 Male and female endocrine and repro-
ductive disorders
 Obesity hypoventilation syndrome
 Peripheral osteoarthritis
 Peripheral venous insufficiency
 Pseudotumor cerebri and carpal tunnel
syndrome
 Sleep apnea

Following weight loss, these conditions may be cured, improved, or stabilized. Last
year more than 220,000 surgical procedures were performed in the United States to
treat morbid obesity. The present criterion (suggested by the National Institutes of
Health and adapted by health insurance providers) for surgery requires that patients
have a body mass index (BMI) of 40 or greater. Those with a BMI as low as 35 may
qualify if they have a disease-related comorbidity, such as hypertension or diabetes
mellitus. Many variations of bariatric procedures have been performed over the past
several decades. At present, gastric bypass surgery is the benchmark procedure and
is the most commonly performed. Ten years ago, gastric bypass was usually per-
formed as an open procedure; today it is commonly done laparoscopically.
2799
Chapter 79  Screening and Safety Issues in the Massive-Weight-Loss Patient
Esophagus
Duodenum
Cardiac orifice
Ileum
Ileum
Ascending colon
Cecum
Appendix
Jejunum
Fundus

A less common procedure is biliopancreatic diversion with duodenal switch (BPD-DS).
Each of these techniques is associated with different rates of weight loss and com-
plications. Therefore each procedure has separate implications for plastic surgeons.
Gastric bypass surgery produces rapid weight loss during the first 8 to 10 postoper-
ative months, with some patients reaching their lowest weight during this time. Gen-
erally, patient weights stabilize 12 to 18 months after the operation. Weight loss with
this procedure is achieved through the restriction of food intake and some degree of
malabsorption.
2800
Part XII  Body Contouring
Liver
Duodenum
Gallbladder
Cystic artery
Ileum
Ascending colon
Cecum
Appendix
Jejunum
Stomach
Ileum
Pancreas
Pyloric antrum
Esophagus
Lap-band
Cardiac orifice
of stomach
In recent years laparoscopic adjustable gastric band-
ing (LAGB) has gained popularity. In some centers,
it is now the most commonly performed bariatric
procedure.

Average weight loss following a standard gastric bypass procedure is 60% to 65%
of excess weight at 5 years postoperatively and 77% with the banded form of gas-
tric bypass. At 5 years, the typical patient has regained approximately 10% of the
excess weight lost. Particularly during the rapid phase of weight loss, gastric bypass
patients may have hypoproteinemia. Iron- and folate-deficiency anemias are very
common among women after gastric bypass, particularly menstruating women. These
side effects can be further complicated by abnormal and frequent vomiting. Supple-
mentation with multivitamins, iron, folate, thiamine (B1), B12, and calcium is usu-
ally prescribed.
After the open form of gastric bypass, incisional or ventral hernias can be found clin-
ically in as many as 10% of patients. This number may be slightly higher on explo-
ration of the abdominal wall fascia during a body-contouring procedure. These forms
of hernia rarely lead to bowel obstruction. Internal hernias are a concern after lap -
aroscopic gastric bypass surgery. Most likely because of minimal adhesion forma-
tion, after a laparoscopic gastric bypass operation the small bowel has a greater ten-
dency to herniate through mesenteric defects. The frequency of internal hernias
appears to be highest during the period patients usually reach their lowest weight,
18 to 36 months postoperatively—often when body-contouring procedures are be-
ing performed. A high index of suspicion is necessary to diagnose a hernia promptly.
Patients may present with episodic bouts of moderate to severe pain as the bowel be-
comes partially or completely strangulated in the hernia. Surgeons must not attrib-
ute pain of this nature to routine postoperative discomfort. A late diagnosis can lead
to necrotic bowel and possibly death.
2801
Chapter 79  Screening and Safety Issues in the Massive-Weight-Loss Patient
Esophagus
Duodenum
Cardiac orifice
Ileum
Ileum
Body
Fundus
Jejunum

Various forms of obstruction after gastric bypass surgery are shown: twisting of the
bowel around isolated bands or adhesions, incarcerated incisional hernia (trocar her-
nia), scar formation or fibrosis at the mesenteric defect, and bowel obstruction with-
out a closed-loop component caused by adhesions. Twisting of the bowel, incisional
hernia, and scar formation or fibrosis are more common after laparoscopic gastric
bypass surgery. Bowel obstruction without a closed-loop component caused by ad-
hesions is more common following open gastric bypass surgery.
2802
Part XII  Body Contouring
Stomach
Duodenum
Defect
Ascending
colon
Cecum
Appendix
Jejunum
Ileum
Small intestine
Adhesions
Mesentery
Adhesions
Small
intestine
Skin
Mesentery
Herniated
intestine
Subcutaneous fat
Abdominal muscle
Small intestine

In LABG, an adjustable silicone ring is placed around the stomach immediately be-
low the esophagogastric junction. A filler tube from the band traverses the abdom-
inal wall and is connected to a port that is secured to the abdominal fascia and is
accessed by transcutaneous injections. The gastric band is inflated and deflated by
adding and removing saline solution. Typically the port is placed in a paramedian
position, often subcostally. Weight loss is achieved purely through the restriction of
food intake and is much slower than with a gastric bypass procedure. A stable re-
duced weight may take as long as 3 years to achieve. On average, LAGB patients
have lost 30% to 54% of their excess weight at 5 years postoperatively. The nutri-
tional disorders described for gastric bypass patients are also associated with LAGB
but are generally less severe, unless there are complications. The band may move from
its desired position or cause a stricture, leading to excessive narrowing of the stom-
ach and subsequent vomiting. Some dilation of the esophagus may occur in many
gastric-banding patients. The plastic surgeon and anesthesiologist should be aware
of this, because aspiration may be of particular concern during intubation.
BPD-DS produces weight loss by some degree of food intake restriction and signifi-
cant malabsorption. The technique is effective, with patients averaging 73% loss of
excess weight at 5 years. However, this procedure is associated with more significant
nutritional deficiencies than the two previously described techniques. In particular,
the absorption of calcium, vitamin D, protein, and fat-soluble vitamins is more af-
fected. The relatively large gastric pouch resulting from this procedure may allow
patients to consume foods at their presurgical rate, leading to frequent, foul-smelling,
bulky stools and significant diarrhea.
Postbariatric patients will differ in their comorbidities and postoperative status; some
may have significant residual disease from morbid obesity, and others will not. In
addition, sequelae from bariatric surgery will vary from patient to patient. An un-
derstanding of morbid obesity and bariatric surgery will help the surgeon determine
the appropriate management of each massive-weight-loss patient.
Screening
My approach to screening and evaluating postbariatric patients involves a minimum
of two office visits: an initial consultation and a preoperative visit, and at least one
outside consultation. Throughout this process, patients are encouraged to commu-
nicate concerns to the office and to include family members, loved ones, and care-
givers.
2803
Chapter 79  Screening and Safety Issues in the Massive-Weight-Loss Patient

Initial Consultation
The initial consultation serves multiple purposes: I establish rapport with the pa-
tient, obtain a medical and social history, perform a physical examination, and gain
an understanding of the patient’s goals. Ideally, at the conclusion of this first visit, a
preliminary plan can be provided to the patient.
History
Along with a medical and social history, a detailed weight history should be obtained
(see p. 2805). Critical information includes the patient’s height, current weight, and
highest weight. The interval between his or her highest and current weights and the
length of time at the current weight should be documented. If weight loss was
achieved through bariatric surgery, the technique and when it was performed should
be noted. Other important information includes whether the individual is being fol-
lowed by a bariatric surgeon and the date of the patient’s last visit. If supplemental
medication was prescribed, is the patient taking it regularly? Problems potentially
related to bariatric surgery should be explored, such as frequent vomiting, abdomi-
nal pain, weakness, light-headedness, and frequent bowel movements. For patients
who have lost weight through lifestyle changes, how this was accomplished should
be documented—exercise, diet and exercise, or medication—and whether the patient
is being supervised by a professional.
Physical Examination
The examination of a postbariatric patient should be thorough, with particular at-
tention to areas typically affected by weight loss. A standardized examination form is
helpful (see pp. 2806-2807). The presence of intertriginous dermatitis should be
noted. Lymphedema and/or the stigmata of lymphedema are documented, as are vari-
cosities. Existing scars should be described, particularly abdominal scars. The sur-
geon should assess for abdominal wall hernias. This portion of the examination can
often be challenging because of the presence of a large pannus. Routine maneuvers
to identify hernias, such as having the patient attempt to sit up from a supine posi-
tion, can be very helpful.
Patient Goals
The average patient age in my postbariatric practice is 39. Most of these individu-
als are very active and eager to minimize their time off from work and time away
from family obligations. It is quite common for a patient to express concerns about
multiple areas of the body and to ask how quickly all of the areas can be addressed.
Perhaps the most important component of screening and minimizing risk in a post-
bariatric patient is the selection of the most appropriate procedure or combination
of procedures and their sequence.
2804
Part XII  Body Contouring

2805
Chapter 79  Screening and Safety Issues in the Massive-Weight-Loss Patient
PATIENT INTAKE FORM: WEIGHT INFORMATION
Patient name
Date
Height
Current weight
Highest weight
Length of time to achieve current weight
Length of time at current weight
METHOD OF WEIGHT LOSS
1. Bariatric surgery
Date of surgery
a. Gastric bypass:
Open
/ Laparoscopic
b. Laparoscopic gastric banding
c. Biliopancreatic diversion
d. Gastric sleeve
e. Vertical banded gastroplasty
2. Lifestyle change
a. Diet
b. Exercise
c. Medication
d. Other
e. Professional supervision
YES / NO
Last visit with bariatric surgeon
Do you have any problems that you believe may be related to your bariatric surgery? If so, please list:
Were supplemental medications prescribed?
YES / NO
Please list all medications and note whether you are currently taking them:

2806
Part XII  Body Contouring
PHYSICAL EXAMINATION FORM
Patient name
Date
ARMS
Striae:
Left:
Yes No
Right:
Yes No
Scars:
Left:
Yes No
Right:
Yes No
Skin excess:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
Lipodystrophy:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
AXILLA / FLANK
Skin excess:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
Lipodystrophy:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
BREAST
Current breast size:
Desired breast size:
Excess grams of breast tissue:
Left
Right
Diameter of NAC:
Left
Right
Distance from sternal notch to nipple (normal 23-25 cm):
Left
Right
Distance from IMF to nipple (normal 10-12 cm):
Left
Right
Distance from midline to nipple (normal 10-12 cm):
Left
Right
Scars:
Left:
None Biopsy Inverted T Vertical Periareolar IM Axillary
Right:
None Biopsy Inverted T Vertical Periareolar IM Axillary
Breast ptosis:
Left:
None Grade I Grade II Grade III Pseudoptosis
Right:
None Grade I Grade II Grade III Pseudoptosis
Lymphadenopathy: Left:
None Axillary Supraclavicular
Right:
None Axillary Supraclavicular
Palpable mass:
Left:
Yes No
Right:
Yes No
Nipple discharge:
Left:
Yes No
Right:
Yes No
Shoulder grooving: Left:
Yes No
Right:
Yes No
Baker capsular contracture:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
Gynecomastia:
Left:
Type:
I II III IV Hypertrophy:
A B C
Right:
Type:
I II III IV Hypertrophy:
A B C
Tuberous breast:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
ABDOMEN
Striae:
Yes No
Scars:
None Midline Epigastric Hypogastric Chevron
Lt Subcostal Rt Subcostal Lt Paramedian Rt Paramedian
Lt Inguinal Rt Inguinal Pfannenstiel Abdominoplasty
Laparoscopic Appendix
Hernia:
None Ventral Incisional Umbilical Lt Inguinal Rt Inguinal
Skin excess:
None Mild Moderate Severe
Lipodystrophy:
None Mild Moderate Severe
Fascial laxity:
None Mild Moderate Severe
Intertriginous dermatitis:
Yes No
HIPS
Striae:
Left:
Yes No
Right:
Yes No
Scars:
Left:
Yes No
Right:
Yes No
Skin excess:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
Lipodystrophy:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe

2807
Chapter 79  Screening and Safety Issues in the Massive-Weight-Loss Patient
PHYSICAL EXAMINATION FORM—cont’d
Patient name
Date
BACK
Skin excess:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
Lipodystrophy:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
Sacral fat pad:
Yes No
BUTTOCKS
Skin excess:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
Lipodystrophy:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
Ptosis:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
THIGHS
Vericose veins:
Left:
Yes No
Right:
Yes No
ANTERIOR
Cellulite:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
Skin excess:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
Lipodystrophy:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
POSTERIOR
Cellulite:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
Skin excess:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
Lipodystrophy:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
MEDIAL
Cellulite:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
Skin excess:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
Lipodystrophy:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
LATERAL
Cellulite:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
Skin excess:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
Lipodystrophy:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
LEGS
Skin excess:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
Lipodystrophy:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe
Lymphedema:
Left:
None Mild Moderate Severe
Right:
None Mild Moderate Severe

Formulating a Plan
The information gathered by the patient history and physical examination can now
be used to formulate a preliminary plan. The patient’s BMI at presentation is one of
the most important variables in determining the appropriate course to take in man-
aging a postbariatric patient’s contour deformities. My data from the body-lift pro-
cedure indicate that individuals with lower BMIs at the time of body-contouring sur-
gery have fewer complications.
2808
Part XII  Body Contouring
Total
425*
100.00
2.74
23
49.65
27.29
20.94
8.47
4.94
2.59
2.35
1.18
12.94
Women
361
84.94
2.70
22
40.94
27.42
18.56
9.14
4.99
2.22
2.22
1.39
11.91
Men
64
15.06
2.98
27
57.81
26.56
34.38
4.69
4.69
4.69
3.13
0.00
18.75
Type 1
207
48.71
2.44
21
44.44
25.60
16.91
10.14
3.86
1.45
0.97
0.00
8.21
Type 2
126
29.65
2.84
25
51.59
26.98
26.19
5.56
3.17
3.97
3.97
1.59
15.87
Type 3
92
21.65
3.29
25
58.70
31.52
22.83
8.70
9.78
3.26
3.26
3.26
19.57
Nonsmokers
363
85.41
2.75
23
47.93
26.17
19.83
7.44
5.51
3.03
2.75
1.38
14.05
Type 1 NS
172
83.09
2.35
22
41.86
25.00
15.70
6.98
4.07
1.74
1.16
0.00
8.14
Type 2 NS
110
87.30
2.92
25
50.91
25.45
26.36
6.36
3.64
4.55
4.55
1.82
17.27
Type 3 NS
81
88.04
3.37
25
56.79
29.63
19.75
9.88
11.11
3.70
3.70
3.70
22.22
Smokers
62
14.59
2.68
21
59.68
33.87
27.42
14.52
1.61
0.00
0.00
0.00
6.45
Type 1 S
35
16.91
2.91
20
57.14
28.57
22.86
25.71
2.86
0.00
0.00
0.00
8.57
Type 2 S
16
12.70
2.31
22
56.25
37.50
25.00
0.00
0.00
0.00
0.00
0.00
6.25
Type 3 S
11
11.96
2.73
24
72.73
45.45
45.45
0.00
0.00
0.00
0.00
0.00
0.00
BMI and Outcome Data Associated With Body Lift
Patients
Percentage
LOS (days)
Complications (%)
Dehiscence (%)
Seroma (%)
Drain Duration (days)
Skin Necrosis (%)
Infection (%)
Bleeding (%)
DVT (%)
PE (%)
Transfusions (%)
Type 1: BMI 28; type 2: BMI 28 and 32; type 3: BMI 32.
*Body lift: A simultaneous abdominoplasty with a thigh and body lift.
DVT, Deep venous thrombosis; LOS, length of stay; PE, pulmonary embolus.
I prefer to perform a body lift first as a single procedure, then follow with a combi-
nation mastopexy/flankplasty/brachioplasty at least 3 months later. A medial thigh
lift, if necessary, would be done at least 3 months after that. Although I think the
aesthetic results may be best with this combination and sequence of procedures, pri-
marily because opposing vectors of tension are avoided, many individuals request
that their management be limited to two operations, or even one. In an effort to ac-
commodate patient wishes and minimize complications, I make different options
available based on BMI. For individuals with a BMI of less than 28, I consider per-

forming upper body work along with a body lift and in some instances a medial
thigh lift. For those with a BMI between 28 and 32, upper body work is considered
with a body lift, and for those with a BMI above 32 and below 35, I advise a pro-
cedure limited to a body lift. Individuals with a BMI greater than 35 are usually can-
didates for an abdominoplasty rather than a body lift. In this heaviest group of pa-
tients, I often consider avoiding fascial plication to facilitate early ambulation.
2809
Chapter 79  Screening and Safety Issues in the Massive-Weight-Loss Patient
BMI criteria are less important for individuals seeking specific upper body proce-
dures alone, such as mastopexy, brachioplasty, and facial procedures. I avoid per-
forming facial procedures with extensive body contouring. A surgeon’s experience
as well as those assisting in the surgery should factor into what the appropriate ap-
proach should be.
Before a patient is considered for any procedure, certain criteria must be met and is-
sues addressed. The patient should be at a stable weight for at least several months.
This will vary, depending on the bariatric procedure. Operating during a period of ac-
tive weight loss may result in an early recurrence of soft tissue laxity, and from a
safety perspective, the patient’s nutritional and metabolic status is unlikely to be op-
timal. Patients with symptoms indicating problems related to bariatric surgery should
be evaluated by their bariatric surgeon. Those with a history of major or acute men-
tal illness are referred for evaluation by an appropriate health professional. Patients
are advised to maintain the supplemental regimen prescribed by their bariatric sur-
geon. Individuals who use tobacco are urged to stop as soon as possible. The risks
of tobacco regarding wound healing and thromboembolic disease are clearly estab-
lished in the literature and are explained to the patient. I prefer to have patients stop
taking any medications that are part of their weight-loss protocol. All patients are
referred for medical clearance. Although weight loss dramatically improves the health
of morbidly obese individuals, not all medical conditions are resolved by weight loss.
Neurologic problems are not uncommon following bariatric surgery, potentially af-
fecting both the central and peripheral nervous systems. Foot drop has been reported
following weight loss, and peripheral neuropathies have been described after rou-
Contouring Options Available to Appropriate Candidates
BMI 28
BMI 28 to 32
BMI 32
BMI 35
Body lift (combination
Body lift
Body lift
Abdominoplasty alone
abdominoplasty, thigh
Mastopexy/flankplasty
(possibly without
and buttock lift)
brachioplasty
fascial plication)
Mastopexy/flankplasty/
combination
Body lift alone (possibly
brachioplasty
without fascial
combination
plication)
Medial thigh lift

tine postbariatric body-contouring procedures in which standard positions and pre-
cautions have been used. A careful evaluation of their health is imperative. A con-
sultation with a general or bariatric surgeon may be requested if an abdominal wall
hernia has been found.
After I discuss the proposed plan with the patient, we review several topics together.
Many individuals are eager to lose more weight before they undergo surgery in the be-
lief that their surgery would be safer and that more skin could be removed if they
were at a lower weight. I think that most people whose weight is stable (variation
of less than 10 pounds for 3 to 6 months) at the time of consultation are at the weight
they are most likely to maintain over the long term. Although many postbariatric
patients can lose weight for relatively brief periods—several months, perhaps a year—
long-term additional weight loss after bariatric surgery or through lifestyle changes
is difficult to achieve. An individual losing weight in short period of time can have
several undesirable outcomes. First, he or she may become nutritionally and meta-
bolically unbalanced just at the time body-contouring surgery is to be performed.
Second, weight gain in the future will in most instances diminish the aesthetic re-
sults of a body-contouring procedure. I advise patients to eat a balanced diet and
maintain a stable weight.
I explain that a certain amount of excess soft tissue will be removed during surgery.
Their new weight after surgery should be their current weight minus the weight of
the tissue removed. If their weight at their 3-month postoperative follow-up is sim-
ilar to their weight at consultation, this suggests a significant weight gain. I also ex-
plain that there will inevitably be some recurrence of skin laxity and that the long-
term results of surgery are best maintained by weight stability, avoiding tobacco use,
and minimizing exposure to sun (UV light). Scars should not be exposed to UV light
while they remain pigmented; UV light will cause or prolong further pigmentation.
Once scars have faded to the color of the surrounding skin, they may be exposed to
UV light without risk of hyperpigmentation. In general, UV light always accelerates
the aging (or damage) of skin. I conclude by giving patients an overview of the most
frequent complications associated with each procedure and the relevance of BMI.
Laboratory Workup
A patient history can often suggest problems; however, a thorough laboratory workup
is essential for identifying existing deficiencies or abnormalities. It is not unusual for
menstruating women to have few if any symptoms despite having severe anemia af-
ter bariatric surgery. Along with a complete blood cell count and other studies, our
routine includes a complete metabolic panel. Abnormal laboratory values are acted
on as they are made available. Individuals found to be malnourished, with a total
protein level less than 6 g/dl and/or albumin level less than 3 mg/dl, may be referred
to their bariatric surgeon for reevaluation and possible nutritional supplementation.
Those findings may be corroborated by edema on physical examination. Protein-
depleted patients may have difficulty with wound healing. Severely anemic patients,
2810
Part XII  Body Contouring

those with a hemoglobin less than 10 g/dl, are referred to their primary physician
and/or a hematologist. Patients with a hemoglobin level above 10 g/dl are advised to
continue on iron, folate, and B12 supplementation and to have their blood cell count
repeated in a week. Our preference is for patients to have a hemoglobin level above
12 g/dl before surgery.
Patients are advised of the possible need for a blood transfusion after the operation.
I do not have patients bank their own blood. In most institutions, blood can only be
given within 1 month of surgery, and 1 month may not be adequate for an anemic
patient to replenish his or her blood levels.
Preoperative Visit
At the preoperative visit, usually 2 weeks before surgery, the planned surgical pro-
cedure is reviewed in detail, as are the potential complications. The results of re-
quested consultations and recommendations are discussed with the patient. Another
critical function of the preoperative visit is to review photographs taken at the first
consultation. Patients rarely have a completely accurate sense of their deformities.
Key elements of this discussion are to highlight existing asymmetries, which in some
cases cannot be completely corrected; review the extent of their deformities; and ex-
plain the degree to which the planned procedure or procedures will address their de-
formities. I prefer not to morph patient images on the computer but rather to show
examples of individuals with similar body types who have had the same procedures.
Restrictions and recovery guidelines are reviewed. Patients often have the sense that
recovery from surgery should involve a lengthy period of bed rest. I emphasize the
importance of frequent ambulation. Medications that should be avoided before sur-
gery are reviewed: those that increase the risk of bleeding, such as aspirin and non-
steroidal antiinflammatory agents, and those that increase the risk of DVT, such as
birth control pills or hormone replacement therapy. Patients are advised not to take
any of these medications for 2 weeks before or after surgery. I conclude with a plan
for DVT prophylaxis.
Deep Venous Thrombosis Prophylaxis
My approach to DVT prophylaxis is derived from my own data and currently sug-
gested guidelines. My experience confirms the published reports that abdominoplasty
creates a significant risk for DVT. Having performed routine lower extremity venous
Doppler studies on well over 400 postabdominoplasty patients, I have found a cor-
relation between the patient’s presenting BMI and the likelihood of thromboembolic
disease (see the table on p. 2808). Therefore, in my practice, patients undergoing an
abdominoplasty or body lift alone or with additional procedures and who have a
BMI of less than 28 on presentation are not given chemoprophylaxis preoperatively
or postoperatively. Instead, a lower extremity venous Doppler study is performed
before discharge from the hospital, typically 1 or 2 days postoperatively. Those with
a BMI between 28 and 32 are given enoxaparin 40 mg subcutaneously beginning
2811
Chapter 79  Screening and Safety Issues in the Massive-Weight-Loss Patient

approximately 12 hours after surgery and each day during their stay in the hospital
or recovery facility. Once again, a lower extremity venous Doppler study is performed
before discharge. Patients with a BMI above 32 who are undergoing abdominoplasty
and/or a body lift follow the same regimen as the previous group but are kept on
enoxaparin 40 mg subcutaneously for 10 to 14 days after surgery. Patients with a
BMI greater than 32 undergoing a single procedure, such as mastopexy, brachio-
plasty, or a combination of the two, are given a single preoperative dose of heparin
5000 units subcutaneously before surgery. I perform these procedures or the com-
bination of the two on an outpatient basis. For the combination of brachioplasty,
mastopexy, and medial thigh lift, patients with a BMI above 32 are given enoxaparin
40 mg subcutaneously 12 hours after surgery. These patients are typically observed
overnight. Lower extremity venous Doppler studies are not routinely performed in
non–abdominoplasty/body lift patients. I have chosen not to provide chemopro-
phylaxis to all patients because of anecdotal observations about increased bleeding
with these medications. For similar reasons, ketorolac tromethamine is not used.
Patients with a history of DVT and/or PE, a family history of thrombosis or blood-
clotting disorders, varicose veins, lower extremity swelling, and recent air travel
should be managed on a case-by-case basis.
2812
Part XII  Body Contouring
POD, Postoperative day; SQ, subcutaneously.
Deep Venous Thrombosis, Chemoprophylaxis, and Surveillance
BMI 28
BMI 28 to 32
BMI 32
Abdominoplasty or
No perioperative
Enoxaparin 40 mg
Enoxaparin 40 mg
body lift with or
chemoprophylaxis
12 hr postopera-
12 hr postopera-
without other
Lower extremity
tively
tively
procedures
venous Doppler
Lower extremity
Lower extremity
exam on POD 1
venous Doppler
venous Doppler
exam on POD 1
exam on POD 1
Enoxaparin 40 mg
SQ for 14 days
postoperatively
Brachioplasty, mam-
No perioperative
No perioperative
Heparin 5000 units
maplasty, thigh-
chemoprophylaxis
chemoprophylaxis
SQ preoperatively
plasty (any of the
(patient usually
procedures alone
discharged home)
or a combination
of two)
Brachioplasty/
No perioperative
No perioperative
Enoxaparin 40 mg
mammaplasty/
chemoprophylaxis
chemoprophylaxis
SQ postopera-
thighplasty com-
tively (patient
bination
usually observed
overnight)

Perioperative Management
Preoperative
Before surgery, patients are marked and scar locations are reviewed, usually for the
third time. In cases in which a mastopexy/reduction is being performed, I have the
patient reconfirm her desired breast size. If chemoprophylaxis is to be given, it should
be administered at this time. If shaving is to performed, usually the redundant mons
pubis, it should be done now. Patients are discouraged from shaving in the 48 hours
before surgery to diminish the risk of skin infections.
Intraoperative
Intraoperatively the focus is on minimizing the length of procedure, patient expo-
sure, blood loss, proper patient positioning, and DVT prophylaxis. The room is kept
at a comfortable temperature for the patient, usually at least 24° C (75° F). The pa-
tient’s skin is cleansed while standing with povidone-iodine (Betadine) to minimize
the time spent preparing and draping during a surgery involving multiple areas. Se-
quential compression devices are placed and activated before induction of anesthesia.
Intravenous antibiotics are given immediately after placement of the intravenous
catheter. Fluids are warmed, and a Bair Hugger and operative table warming blanket
are used whenever possible. Blood loss is kept to a minimum by meticulous hemo-
stasis and the use of two electrocauteries, for the surgeon and assistant, set to a rel-
atively high level. Pressure points are carefully padded, and extremities are positioned
cautiously during maneuvers to rotate the patient.
Certain circumstances may arise during surgery, some planned and others not, that
must be addressed. A post-LAGB patient will have a port that nearly always must
be moved to effectively address abdominal wall fascial laxity. Routine midline pli-
cation of the abdominal fascia in an LAGB patient may render the port inaccessible.
In these patients, the port should first be detached from the fascia by dividing the
nonabsorbable sutures. The plication should then be performed as usual, with care-
ful attention to the tube location and verification throughout the process that the
tube can move freely. After plication, the port should be resecured with nonabsorbable
sutures in a subcostal position. The prominence of the costal margin makes the port
less discernible. Lower-BMI individuals may have concerns about the perceptibility
of the port. In these patients, the outline of the port may be visible along the ante-
rior abdominal wall. The port may be exchanged for a lower-profile version. If this
is to be done, the lower-profile port should be available preoperatively, and obtain-
ing the assistance of a bariatric surgeon for the exchange should be considered.
2813
Chapter 79  Screening and Safety Issues in the Massive-Weight-Loss Patient

Ventral hernias may be discovered during elevation of the abdominal pannus that
were not evident during preoperative evaluation. I have found that for small inci-
sional fascial defects, where preperitoneal fat is adherent to the facial edges, no par-
ticular maneuver is necessary. The fascial plication can be performed as usual, with
the sutures carefully placed through the rectus sheath overlying the rectus muscle.
Rectus diastasis can be considerable in these patients. For larger fascial defects, par-
ticular those in which the hernia contents readily protrude through the defect, re-
pair is required. The hernia sac contents are separated from the hernia sac, the fas-
cial edges are approximated without tension, and a standard plication is performed.
Routine hernias (those not involving a loss of tissue) in a postbariatric patient rarely
require mesh for repair. An intraoperative consultation may be sought if an unex-
pected hernia is discovered.
Postoperative
In the immediate postoperative period, the patient should be assessed for anemia,
hypovolemia, and hypothermia. Warming techniques like those used during surgery
should be used. Vital signs, urine output, and drainage output should be monitored
closely. Only three postoperative doses of antibiotics are routinely given. Following
postbariatric body-contouring procedures, significant blood loss may occur from
oozing. Tissue surfaces with the potential for bleeding can be extensive. Drains can
help to monitor this. Ideally, the fluid in the drains should take on a watery consis-
tency and pinkish color soon after the procedure. A thick consistency and dark red
color is a reliable indicator of continued bleeding. Although a routine CBC may not
be necessary, blood should be drawn for this purpose if there is any question of ane-
mia and/or hypovolemia. The initial CBC usually does not reflect the actual blood
loss that has taken place. I prefer to maintain hemoglobin levels above 8 g/dl.
Aggressive DVT prophylaxis should be continued postoperatively. In addition to the
protocol just described, all patients should have sequential compression devices in
place until they are ambulating regularly. Ambulation with assistance is attempted
the evening after surgery. Some patients may experience light-headedness despite be-
ing adequately resuscitated; narcotics are the likely cause. Initial attempts at ambu-
lation should always be done with assistance—a syncopal episode without supervi-
sion can easily result in head trauma. Patients are strongly encouraged to shower for
the first time with supervision. A warm shower can induce a syncopal episode. Fol-
lowing discharge from the hospital, postbariatric body-lift patients remain at risk
for a wide array of complications; DVT and pulmonary embolism represent the most
important potential problems. A high index of suspicion is the safest approach to
thromboembolic disease. Physical findings or patient reports of lower extremity
2814
Part XII  Body Contouring

2815
Chapter 79  Screening and Safety Issues in the Massive-Weight-Loss Patient
swelling and/or discomfort, particularly unilaterally, should be evaluated promptly.
The signs and symptoms associated with DVT and pulmonary embolism are many
and should be familiar to all physicians.
It is not unusual for patients to become depressed several weeks after surgery; par-
ticularly after major procedures such as a circumferential body lift, the patient may
regret having chosen to have the operation. In some cases, patients remark that they
are not even sure why they are depressed. I have found it very helpful to inform pa-
tients that this is normal and will most likely resolve over the next several weeks.
Our patients are encouraged to contact other patients who have had similar proce-
dures to discuss their experiences. Discussions with other patients can be helpful for
understanding different emotional states following surgery.
Concluding Thoughts
Body contouring of the postbariatric patient can be a gratifying experience for both
the patient and plastic surgeon. To achieve this end, every effort must be made to
minimize risk and avoid complications. The surgeon must thoroughly understand
morbid obesity and the procedures to treat this condition and should implement a
screening protocol that identifies patients who are satisfactory candidates for sur-
gery. Candidates should then be offered the appropriate procedures in the appro-
priate sequence. The patient’s BMI should be considered as one the primary vari-
ables in the decision process. Finally, the perioperative care of these patients must be
meticulous and involve great dedication by the plastic surgeon.
Clinical Caveats
 A postbariatric patient’s BMI is the most important factor for determining ap-
propriate management of contour deformities.
 There is a correlation between a patient’s presenting BMI and the likelihood of
thromboembolic disease.
 A patient’s weight should be stable for several months before a body-contouring
procedure is performed.
 A thorough laboratory workup, including a complete blood cell count and a meta-
bolic panel, is essential before body-contouring surgery.

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