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

The patient is shown preoperatively with a bulging pubic fat pad and hanging labia
majora. Ten months postoperatively, an excellent result is seen. She could benefit
from more pubic liposuction, but she is not concerned about this.
3120
Part XII  Body Contouring

Concluding Thoughts
Aesthetic genital surgery can be very successful if the guidelines are followed metic-
ulously. As more women become aware that safe, successful operations are avail-
able, the number of procedures performed will continue to increase.
Clinical Caveats
 During preoperative assessment for all procedures, the patient should hold a mir-
ror while she is shown the tissue to be excised and her expected postoperative re-
sult is discussed.
Labia MinoraReduction
 The excision should not be closed with tension.
 A good subcutaneous closure, usually in two layers through most of the length,
is essential to prevent dehiscence. The labium is thus closed in four layers.
 5-0 Monocryl on an atraumatic TF needle is ideal to prevent a tissue reaction and
trauma that can lead to wound separation.
 Vertical mattress sutures at the leading edge of the labium minus help to prevent
wound separations.
 The surgeon should confirm that two fingerbreadths can be inserted in the vagina.
 The glans clitoris should not be overexposed if some of the clitoral hood is being
excised vertically or horizontally. The glans exposure should remain the same as
before surgery unless the patient requests otherwise.
Labia Majora Reduction
 The eventual scar line should be as inconspicuous as possible, usually just lateral
to the medial hairline.
 The symmetry of the markings should be checked with the patient both standing
and lying down; the appearance of the labia can be assessed by imbricating the
marked areas with cotton swabs.
 Overresection of the skin must be avoided, because this can cause a gaping introi-
tus, especially if an inner thigh lift has been done or is contemplated.
 A subcuticular closure should be used.
3121
Chapter 86  Female Aesthetic Genital Surgery
Continued

Clinical Caveats—cont’d
Mons Pubis Lift
 The anterior labial commissure should not be overelevated.
 Care must be exercised so that the escutcheon is not too narrow.
 The pubic flap is primarily thinned by liposuction. An adequate amount of fibro-
fatty tissue should be left on the flap to prevent a concavity. The peripheral areas
are liposuctioned for wound contouring.
 Usually three horizontal rows of three symmetrical, strong tacking sutures are
placed from the pubic flap to the rectus fascia.
 The thickness of the two sides of the skin closure are matched and adjusted as
needed.
3122
Part XII  Body Contouring
Annotated Bibliography
Alter GJ. Aesthetic labia minora and clitoral hood reduction using extended central wedge
resection. Plast Reconstr Surg 122:1780-1789, 2008.
The indications and techniques for central wedge labia minora and clitoral hood reduc-
tion are described. A large series with results are described. The pros and cons of other
labia reduction procedures are explained in detail.
Alter GJ. Management of the mons pubis and labia majora in the massive weight loss pa-
tient. Aesth Surg J 29:432-442, 2009.
The indications and techniques for lifting the mons pubic and reducing the labia majora
in a massive weight loss patient are described.
Alter GJ. A new technique for aesthetic labia minora reduction. Ann Plast Surg 40:287-290,
1998.
The author’s first report on the wedge resection for labia minora reduction.
Suggested Readings
Alter GJ. Aesthetic labia minora and clitoral hood reduction using extended central wedge
resection. Plast Reconstr Surg 124:337-338, 2009.
Alter GJ. Aesthetic labia minora reduction with inferior wedge resection and superior pedi-
cle flap reconstruction. Plast Reconstr Surg 120:358-359, 2007.
Alter GJ. Central wedge nymphectomy with a 90-degree Z-plasty for aesthetic reduction of
the labia minora. Plast Reconstr Surg 115:2144-2145, 2005.
Capraro VJ. Congenital anomalies. Clin Obstet Gynecol 14:988-1012, 1971.

Chavis WM, LaFerla JJ, Niccolini R. Plastic repair of elongated, hypertrophic labia minora.
A case report. J Reprod Med 34:373-375, 1989.
Choi HY, Kim KT. A new method for aesthetic reduction to the labia minora (the deepithe-
lialized reduction labioplasty). Plast Reconstr Surg 105:419-422; discussion 423-424,
2000.
Felicio YA. Labia surgery. Aesthetic Surg J 27:322-328, 2007.
Giraldo F, González C, de Haro F. Central wedge nymphectomy with a 90-degree Z-plasty
for aesthetic reduction of the labia minora. Plast Reconstr Surg 113:1820-1825; discus-
sion 1826-1827, 2004.
Girling VR, Salisbury M, Ersek RA. Vaginal labioplasty. Plast Reconstr Surg 115:1792-1793,
2005.
Gowen RM, Martin VL. Labia minora reduction in an iron-lung disabled woman. Obstet
Gynecol 71(3 Pt 2):488-489, 1988.
Hodgkinson DJ, Hait G. Aesthetic vaginal labioplasty. Plast Reconstr Surg 74:414-416, 1984.
Hunter JG. Considerations in female external genital aesthetic surgery techniques. Aesthetic
Surg J 28:106-107, 2008.
Kato K, Kondo A, Gotoh M, et al. Hypertrophy of labia minora in myelodysplastic women.
Labioplasty to ease clean intermittent catheterization. Urology 31:294-299, 1988.
Laub D. Discussion of Choi HY, Kim KT. A new method for aesthetic reduction to the labia
minora (the deepithelialized reduction labioplasty). Plast Reconstr Surg 105:423-424,
2000.
Maas SM, Hage JJ. Discussion of Alter GJ. A new technique for aesthetic labia minora re-
duction. Ann Plast Surg 41:685-686, 1998.
Maas SM, Hage JJ. Functional and aesthetic labia minora reduction. Plast Reconstr Surg
105:1453-1456, 2000.
Munhoz AM, Filassi JR, Ricci MD, et al. Aesthetic labia minora reduction with inferior
wedge resection and superior pedicle flap reconstruction. Plast Reconstr Surg 118:1237-
1247; discussion 1248-1250, 2006.
Radman HM. Hypertrophy of the labia minora. Obstet Gynecol 48(1 Suppl):78S-79S, 1976.
Rouzier R, Louis-Sylvestre C, Paniel BJ, et al. Hypertrophy of labia minora: experience with
163 reductions. Am J Obstet Gynecol 182(1 Pt 1):35-40, 2000.
3123
Chapter 86  Female Aesthetic Genital Surgery

This page intentionally left blank
This page intentionally left blank

Evaluation and Treatment of
Iatrogenic Deformities

SYDNEY R. COLEMAN
CHAPTER 87

S
tructural fat grafting is an essential tool for all aesthetic surgeons performing li-
posuction, because it provides a successful way to treat iatrogenic liposuction
deformities. Patients with liposuction deformities were the first patients in my prac-
tice in whom I attempted fat grafting and therefore the patients with whom I have
the longest experience. Unlike the use of fat to rejuvenate the hand, successful treat-
ment of surface irregularities in the body requires a three-dimensional visualization
of the problems and solutions.
Aesthetic Considerations
Any surgeon performing liposuction will undoubtedly experience the most common
complication of liposuction—superficial surface irregularities. Some are exaggera-
tions of preexisting irregularities, some consist of cellulite, and some are newly cre-
ated. The thigh and abdomen are particularly prone to irregularities. Postliposuction
iatrogenic deformities are not limited to surface irregularities. Changing the rela-
tionship between a woman’s thighs, hips, and abdomen can result in unnatural and
even bizarre proportions.
In 1987 I began treating iatrogenic liposuction deformities with fat grafting, primar -
ily focusing on correction of surface irregularities. As I became more proficient at fat
grafting, I began to address corporeal proportion to restore a more natural aesthetic
symmetry after liposuction.
3126
Part XII  Body Contouring
This 30-year-old woman presented 2 years after liposuction to her lateral thighs, but-
tocks, and love handles. She was distressed by the deepening of her buttock crease,
which now wrapped around her thigh. She felt that her legs looked shorter and her
buttocks bigger and more ptotic after the procedure. She also noticed that her body
appeared boxy and less feminine. When she complained to the plastic surgeon about

the appearance of her buttocks, she discovered that he had purposely deepened her
buttock crease to create a more aesthetic “smiling” crease.
3127
Chapter 87  Evaluation and Treatment of Iatrogenic Deformities
The patient is shown 3 years after her second procedure, which restored a more nor-
mal appearance to her body. Additional fat was removed from her waist, upper hip,
and lateral buttocks and placed into her buttock creases and lateral thighs to create a
more feminine and natural relationship of the waist, hip, and thigh. By filling in the
deepened buttock crease and slightly expanding the thighs, a more normal buttock-
thigh interface was reestablished. By restoring the continuous flow of the buttock
into the thigh, a more attractive, youthful line of the leg was restored.
Patient Selection
Patients who present with iatrogenic body deformities have usually had previous ex-
periences with aesthetic surgeons, and they view these experiences as negative. Their
perception of their bodies is colored by that experience, and it is often difficult to as-
sess how realistic these patients are about their current appearance as well as the de-
gree of satisfaction they will attain with treatment.
The aesthetic surgeon should not agree to perform a correction unless he or she has
a reasonable expectation that a positive correction of the patient’s deformity can be
done without creating unacceptable new problems (such as donor-site deformities).
Furthermore, the surgeon should believe that the positive correction will be demon-
strable on photographs and that the patient will be able to appreciate the positive
change. It should be clearly explained to the patient that new deformities might be
created by harvesting fat to correct the current irregularities.
Preoperative
3 years after
last grafting procedure

Patient Education
These patients need to be prepared for the result. For major deformities, I warn pa-
tients that it may take as many as four procedures to attain a result that they will
find acceptable (although I have never performed more than three procedures on any
one patient’s body). I explain to the patient that the first procedure for a major defect
is to restore volume; the second is to smooth out the area with “finishing touches.” On
an extremely rare occasion, a patient may desire a third procedure to smooth the
area even more. For smaller irregularities, one procedure is often sufficient.
Patient Evaluation
The most important step in correction of iatrogenic deformities is analysis of the de-
fect. If the surgeon cannot adequately demonstrate a deformity on film, it will be al-
most impossible to show that the procedure has produced a positive change.
Photography for corporeal proportion is relatively standard, but photographic tech-
niques to demonstrate surface irregularities are more challenging and require a dif-
ferent approach. When patients see their bodies in standard photographs, they often
comment that the image does not accurately portray the full extent of the surface ir-
regularities they see when they look at their unclothed bodies. I have come to real-
ize that the primary reason for this discrepancy is that patients are most often look-
ing down at their bodies with downlighting when they see these irregularities,
whereas standard photographs are taken without this elevated perspective and with
more diffuse light. Therefore it is difficult to appreciate patients’ deformities with the
standard views that plastic surgeons routinely obtain.
After much experimentation with lighting, I have finally developed a system of pho-
tography for analyzing corporeal defects to more accurately reflect what the patient
sees and wants corrected. This system came about when one of my patients insisted
that I take photographs of her body while I was standing on a stool so that the cam-
era was a few feet above her. From this “bird’s-eye” perspective, we were both much
better able to appreciate the extent of her body surface irregularities than from any
of the standard views.
3128
Part XII  Body Contouring

3129
Chapter 87  Evaluation and Treatment of Iatrogenic Deformities
With this bird’s-eye view of a patient, the defect in her left buttock is clearly visible,
in the same way that it is visible to her as she looks over her shoulder or in the mir-
ror with downlighting.
Even large irregularities can be difficult to discern in the standard photograph taken
of this patient compared with the bird’s-eye view. I now stand on a stool and obtain
approximately 10 views of a patient’s body for almost any corporeal procedure that
I perform. By shooting from a bird’s-eye view, I can more effectively see the problem
that the patient wants corrected.
After the patient is marked to demonstrate the areas of harvesting and placement of
structural fat, I then photograph the patient standing with the marks. Before the pro-
cedure begins, I have the photographs printed to compare the marked and unmarked
photographs, both with the patient standing. With the photographs placed next to
each other, I can more accurately determine the relationship of the marks to the actual
deformity while I am operating on the patient, who is in a supine or prone position.

Technique
Anesthesia
Epidural and occasionally general anesthesia are most commonly used. No solution
is placed into the areas to be infiltrated.
Incisions
When harvesting from the back, sacrum, or hip, the lateral sacral depressions are
used as the main incisions. Incisions into this anatomic structure are much better tol-
erated than incisions anywhere else in this region.
Infiltration Cannulas
3130
Part XII  Body Contouring
The syringes are connected to cannulas, which range from 18 to 16 gauge and vary
in length from 7 to 15 cm. I prefer to use the shorter cannulas (usually 9 cm), but to
avoid making too many incisions, I will often switch to a 15 cm cannula to extend
placement from any one incision. When using the 15 cm cannulas, I prefer to use the
thinner cannulas. I will switch to a 16-gauge cannula if there is much resistance. I al-
ternate between straight and curved cannulas, depending on the curvature of the un-
derlying structures.

The body is the only place that I use 3 cc Luer-Lok syringes for infiltration of fatty tis-
sue. I fill the 3 cc syringes with 2.5 cc of refined fat to make them easier to manipu-
late. Unlike the 1 cc syringes, these syringes can be reused repeatedly without the
plungers sticking. The technique of placement in the body differs from that described
for the face and hands in that slightly larger amounts are placed with each pass, but
no more than 0.25 cc is intentionally placed in a single withdrawal.
Level of Infiltration
The level of infiltration depends on the desired outcome:
 Fat is layered into the deep planes for large contour changes to the thighs or
buttocks. In those deeper fat planes, especially if any tissue is placed into mus-
cles, the thicker 16-gauge 15 cm style I cannulas are used. The blunt large can-
nulas minimize the possibility of damage to vessels and nerves in the muscles.
 More tissue is placed superficially to fill a specific groove or depression. Place-
ment starts in the immediately subcutaneous plane and infiltrates layer by layer
to a deeper plane, specifically feathering as the placement deepens.
Volume Ranges
Volumes for correction of corporeal deformities vary from 1 cc placements into min -
uscule irregularities to as much as 300 or 400 cc into a deficient thigh, buttock, or
arm.
3131
Chapter 87  Evaluation and Treatment of Iatrogenic Deformities

3132
Part XII  Body Contouring
Procedure
This 60-year-old patient presented with a depression that developed after she had
multiple injections of steroids into her left hip. A significant defect is visible from the
bird’s-eye view, whereas I could barely see the problem in most of her conventional
photographs.
The procedure is planned on tracings of the patient’s body in many views. The plan
devised for this patient was to remove tissue above the defect and refine it, and then
place it into the depression.

The areas of planned removal were marked with a purple marker, the areas of
planned placement of the refined fatty tissue with a green marker, and the planned in-
cision sites with red markers.
3133
Chapter 87  Evaluation and Treatment of Iatrogenic Deformities
This patient has already had tissue harvested from her right side and her upper love
handle on the left. The first step in correcting the depression was to remove tissue
above the defect to flatten the surface superior to the defect and provide additional
harvested tissue to place into the defect. I began harvesting the portion nearest the
contralateral incision using a 23 cm straight harvesting cannula with access through
the contralateral sacral incision. I then switched to the ipsilateral incision and con-
tinued the removal of tissue laterally using either a 15 or 23 cm straight cannula.

3134
Part XII  Body Contouring
To decrease the number of incisions that are needed to effectively remove subcuta-
neous tissue in the torso, I began using curved cannulas connected to my 10 cc sy-
ringes. A gently sloping curve on a cannula allows me to follow the natural curves
of the body. For example, in this patient I could follow her body contours all the way
to the far flank and hip from a sacral incision with a 23 cm curved cannula; 100 cc
was removed from this patient’s right love handle and 70 cc from the hip above the
depression.
Placement into the defect begins with a style I blunt, 15 cm infiltration cannula
through the ipsilateral sacral incision. This longer cannula allows placement from a
slightly more distal incision. The placement begins deep and progresses in layers to
a superficial level to create an integrated volume. The barrel of the cannula is firmly
grasped between the fingers (middle, ring, and little) and the thumb while the can-
nula is inserted into the incision and advanced through the tissues. I use my index
finger (or thumb in some situations) to push on the plunger while the cannula is
withdrawn. Fat is forced through the cannula into the donor site only as the can-
nula is removed, not while it is advanced.
Numerous layers of fat are infiltrated in the deep tissues, gradually moving superfi-
cially to place a layer immediately subdermally. In the more superficial planes, the
surgeon must pay special attention to avoiding linear placement or lumps. Placement
in the immediate subdermal plane is especially important in patients with atrophy
from steroids or other injections. I try to approach most areas for infiltration of fatty
tissue in the body and face from at least two directions to provide more structural
integrity to the placed tissue. In this instance I made an incision to allow placement
perpendicular to the previously placed fat. After the incision with a No. 11 blade,
I often open the depth of the incision with a small scissors or style III cannula. Place-
ment continues, emphasizing the area of greatest deficiency in the central circle above,
and feathering out into the surrounding areas.

The placement again begins deep against fascia and muscle through to the most su-
perficial planes. An attempt should be made to disrupt an adhesion that causes sur-
face dimpling or an isolated depression. This should be performed after most of the
fat placement has been attempted to avoid creating unstable tissue planes in which
the fat can migrate. I recommend disruption of subcutaneous adhesions or scars with
a V-dissector. In the body, a 14- to 16-gauge cannula and a 15 cm cannula may be
more useful and effective.
Posttreatment Care
One or two layers of Microfoam tape are placed over any areas into which fat has
been grafted. Bulky dressings or foam rubber is never positioned over grafted areas.
However, Reston foam can be placed over areas that are suctioned on the body to
relieve pressure on grafted areas. Over the Microfoam tape and Reston foam, a gir-
dle or abdominal binder can placed to apply gentle pressure on the Reston foam and
to secure the Microfoam tape.
If grafting is performed in the buttock crease or around the sacrum, the surgeon must
consider positioning of the patient after the procedure. Because the ischium is weight
bearing when the patient is sitting, he or she is instructed not to sit directly on the
“sitz bones.” Rather, the patient should sit far forward or lean backward to distrib-
ute the weight while sitting so that the weight is not directed to the area of recent
grafting. Because the sacrum is weight bearing when the patient is supine, the pa-
tient should be encouraged to lie on the opposite side, if possible, after grafting around
the sacrum. Patients are also asked to wait at least 2 weeks before massaging the re-
cipient sites to allow sufficient time for grafted tissues to become more stable.
3135
Chapter 87  Evaluation and Treatment of Iatrogenic Deformities

3136
Part XII  Body Contouring
Complications
Undercorrection and overcorrection are the two most frequent complications after
corporeal fat grafting. Friction from the many passes of the harvesting and infiltration
cannulas can create incisional complications, such as hyperpigmentation and de-
pressed scars. Use of the lipids decanted after centrifugation to lubricate the cannu-
las can significantly improve the appearance of the incisions. Paresthesia and tran-
sient anesthesia are also common in both the recipient and donor sites. Patients rarely
complain about them for more than a few weeks.
Results
Many of the patients who are seen for correction have subtle surface irregularities
requiring only smoothing without significant volume replacement. This 35-year-old
patient presented 3 years after lateral thigh liposuction complaining of minor irreg-
ularities.

3137
Chapter 87  Evaluation and Treatment of Iatrogenic Deformities
Because she had almost no viable donor sites, it was possible to harvest only mini-
mal amounts of tissue. Therefore only 30 cc was placed into her right lateral thigh
irregularities in the areas demonstrated above.
The patient returned at 2 years and 3 months after the only procedure. The modest
amounts of structural fat grafting resulted in significant improvement and great pa-
tient satisfaction.
17.5 cc
2.5 cc
5 cc
5 cc

Clinical Caveats
 The most important step in correction of corporeal deformities is analysis of the
defect. A photograph from a bird’s-eye view is invaluable for accomplishing this
purpose.
 To lessen any potential donor defect, the surgeon should minimize the amount of
fat suctioned in any one area.
 Use of the oils decanted after centrifugation to lubricate the cannulas can signifi-
cantly improve the appearance of the incisions.
3138
Part XII  Body Contouring
Annotated Bibliography
Regnault P, Daniel RD. Secondary thigh buttock deformities after classical techniques: pre-
vention and treatment. Clin Plast Surg 11:505-516, 1984.
The authors discuss correction of supratrochanteric depressions, trochanteric bulges,
scars, contour irregularities, perineal bands, and flat buttocks.
Suggested Readings
Coleman SR, Mazzola RF, eds. Fat Injection: From Filling to Regeneration. St Louis: Qual-
ity Medical Publishing, 2009.
Stampos M, Xepoulias P. Fat transplantation for soft tissue augmentation in the lower limbs.
Aesthetic Plast Surg 25:256-261, 2001.
Teimourian B. Complications associated with suction lipectomy. Clin Plast Surg 16:385-394,
1989.
Teimourian B, Adham MN. A national survey of complications associated with suction lipec-
tomy: what we did then and what we do now. Plast Reconstr Surg 105:1881-1884, 2000.
Vilain R. Prevention and treatment of waves after suction lipectomy. Ann Plast Surg 17:194-
205, 1986.

Correction of Contour Deformities
After Liposuction

KRISTOFFER NING CHANG
CHAPTER 88
Smooth contour
established via fat transfer
Fat injected
in multiple
tunnels
Protuberant
area reduced

W
ith the introduction and popularization of suction-assisted lipectomy (SAL)
in the 1980s, the concept of body contour surgery was dramatically trans-
formed, offering surgeons a new tool to improve outcomes and reduce morbidity.
Since that time, subsequent refinements and developments, including the use of wet-
ting solution, large-volume liposuction, ultrasound-assisted liposuction (UAL), and
power-assisted liposuction (PAL), have further enhanced our ability to contour the
body. Today, liposuction’s popularity and appeal have made it one of the most fre-
quently performed aesthetic operations in the United States. Despite the excellent re-
sults often obtained with liposuction, this procedure is not trouble free and may pro-
duce aesthetically unsatisfactory results. Aesthetic problems resulting from liposuction
can be grouped into four general categories:
1. Skin problems
2. Surface or contour irregularities
3. Disproportions
4. Skin excess
Skin problems include pigmentation changes, discoloration, loss of smoothness and
sheen, textural changes, atrophy, wrinkling, and scarring. Surface or contour irreg-
ularities include visually distinct depressions, grooves, waves, dents, divots, dimples,
ridges, and protuberances. Aesthetic disproportion is characterized by altered pro-
portion in various parts of the body, rendering a disharmonious, displeasing look.
For example, excessive removal of fat of a woman’s thighs may result in an emaci-
ated or a masculinized appearance. Excessive skin results from a discrepancy between
the overlying skin envelope and the underlying subcutaneous tissue and fat. The junc-
tion of the lower buttock and upper posterior thigh is an area prone to this type of
problem.
These changes are referred to as postliposuction contour irregularities or iatrogenic
deformities, and they are familiar to any surgeon who performs liposuction. This
chapter presents postliposuction deformities and strategies for their prevention and
treatment.
Avoiding Deformities From Liposuction Procedures
A number of variables influence the outcome after liposuction and should be care-
fully considered when planning liposuction. These variables include the patient’s age
and skin condition, the composition and extractability of the fat, the equipment to
be used (SAL, UAL, or PAL), the infiltration of wetting solution, artistic planning
and surgical execution, and postoperative care. Careful planning is the key to pre-
venting postliposuction deformities. The surgeon must understand the potential pit-
3140
Part XII  Body Contouring

falls to be avoided and must individualize treatment to take into consideration the
particular anatomic situation for each patient. Major factors that contribute to poor
aesthetic results include overresection, underresection, removal of fat from the wrong
location or from the incorrect depth of the subcutaneous layer, excessive fibrosis,
scarring, loss of tissue elasticity and support, and skin excess.
Factors That Contribute to Poor Aesthetic Results
Overresection
Although we have strategies for correcting problems related to liposuction, it is al-
ways best to avoid them. Understanding the causes of these problems will help pre-
vent them. Contour irregularities are among the most common deformities after lipo -
suction. A common cause of these deformities is overresection of adipose tissue,
which may result from employing a cannula that is too large or by making too many
passes with the cannula in the same location. In some patients, especially fair, thin-
skinned women, the adipose tissue may be loose and prone to overresection. The use
of wetting solution containing epinephrine and lidocaine promotes hemostasis, pro-
vides analgesia, and makes the fat more easily removable. When an excessive amount
of wetting solution is used in an area where the fat is loose and nonfibrous (for ex-
ample, the buttocks or lateral thighs), fat extraction can easily exceed what is needed
to achieve the desired result. Excessive infiltration of wetting solution, combined with
the use of the cannula in the subdermal layer, may result in diffuse, multicentric con-
tour irregularities. To ensure a good surgical outcome, there must be a smooth, un-
scarred layer of adipose tissue remaining beneath the skin and dermis.
In some patients, the aesthetic limit of fat extraction may be exceeded. Too much fat
removal from the thighs may transform a desirable female shape into a more mas-
culine appearance. The midsection of the medial thigh is particularly susceptible in
this regard. Overresection may occur when the underlying bony prominence causes
the surgeon to erroneously assess the remaining amount of adipose tissue to be re-
moved. The medial condyle of the femur can mask overresection while the patient
is in a supine position with the knee extended. This soft tissue deficiency becomes
evident when the patient assumes a sitting position.
Uneven Resection
Uneven resection may occur where more fibrous adipose tissue is juxtaposed with
looser adipose tissue. For example, in the periumbilical area, dense subcutaneous tis-
sue around the umbilical stalk changes into the softer adipose tissue of the lower ab-
domen. Similarly, a preexisting abdominal surgical scar may cause interference with
smooth fat extraction near the scar. Careful patient examination and planning for
these anatomic variants can help prevent potential problems in these areas.
3141
Chapter 88  Correction of Contour Deformities After Liposuction

Incision Placement
Suboptimal incision placement may also yield unsatisfactory results. Ideally, an in-
cision should permit easy access for execution of a series of unhindered, smooth,
and radiating cannula movements appropriate for the three-dimensional configura-
tion of the adipose tissue to be modified. When the cannula is torqued, forced to go
around a curved surface, or its movement is impeded, the results may be subopti-
mal. To ensure smooth coverage of the area to be aspirated, two incisions may be
placed 90 degrees from each other to allow the surgeon to make crisscrossing pat-
terns. In circumferential liposuction or liposuction of extensive body surfaces, grid-
pattern markings of variable sizes can be drawn on the skin surface intraoperatively
to assist with placement of incisions and to facilitate unimpeded cannula movement.
The Level of Subcutaneous Tissue
Removal of adipose tissue from an inappropriate subcutaneous level may contribute
to unsatisfactory results. For example, when fat is removed from the deep subcuta-
neous layer of the lower buttock and the upper posterior thigh region, support is lost
and the buttock becomes ptotic. Improvement of the upper posterior thigh (sub-
gluteal region) and the anterosuperior knee is accomplished by removal of more su-
perficial fat.
Markings
The body’s contour changes as the patient moves from a standing to a recumbent
position, or when wetting solution is infiltrated. These changes must be considered
when markings are being made preoperatively. The appropriate surgical markings
guide the surgeon to prevent compromise of the extraction of fat. Lack of proper
feathering at the periphery of the liposuction site may lead to a visible demarcation
between the treated and untreated areas.
Use of Ultrasound-Assisted Liposuction
When UAL is being used, care must be taken to carefully regulate the amount of ul-
trasound energy applied. Excessive ultrasound energy may result in overresection,
prolonged edema, and tissue damage from mechanical impact or the thermal effect.
3142
Part XII  Body Contouring

Compression
Appropriate application of postoperative compression is important to prevent de-
formities. Uneven compression may lead to temporary or permanent deformation
of the skin and subcutaneous tissue. Prolonged and tight postoperative compression
may accentuate tissue ischemia associated with the use of epinephrine and tissue
trauma from fat extraction, thereby resulting in more fibrosis and scarring.
Liposuction is a very effective tool for body contouring. Its successful execution is
highly dependent on sound surgical judgment based on careful patient evaluation,
meticulous preoperative planning, an understanding of anatomic landmarks, and
knowledge of one’s own surgical skills.
Secondary Procedures for Treating Postliposuction
Deformities
Secondary procedures are performed after liposuction to remove residual fat excess
and contour irregularities. Residual fat excess with a smooth, normal-appearing con-
tour is amenable to additional liposuction. Protuberances in contour that appear vi-
sually distinct and do not blend into the surrounding surface contour require addi-
tional liposuction. Minor contour irregularities can be treated by limited additional
liposuction, which is often performed under local anesthesia. The more severe and
complex cases of postliposuction contour irregularities require a systematic approach
that includes combinations of the following:
1. Liposuction of areas of protuberance
2. Liposuction around the areas of depression
3. Simultaneous fat grafting
4. Dermolipectomy for redundant skin
The technique of corrective liposuction and fat grafting has been available since the
late 1980s. It has the advantage of being simple and safe. Fat collection, processing,
and injection require commonly available supplies and instruments. Most patients
have ample amount of fat available for harvesting to further modify and improve
the contour.
3143
Chapter 88  Correction of Contour Deformities After Liposuction

3144
Part XII  Body Contouring
Indications and Contraindications
Autologous fat grafting is indicated for the replacement of volume deficiencies and
for filling postliposuction irregularities and indentations in the thighs, abdomen,
hips, waist, buttocks, chest, and arms.
Patient Profiles
Liposuction of this 54-year-old woman’s thighs and abdomen resulted in indenta-
tions in her anterolateral thighs, distal medial thighs, left groin, and lower abdomen.
She is a good candidate for corrective liposuction and fat grafting because she has the
following characteristics: (1) abundant subcutaneous fatty tissue around areas of de-
pression, (2) gentle slopes in areas of indentation, (3) preservation of good skin qual-
ity in the areas of indentation, and (4) an absence of dense subcutaneous scarring.
Some patients develop extensive skin changes and subcutaneous fibrosis with mul-
tiple diffuse indentations. These problems are less responsive to corrective liposuc-
tion and are better treated with fat grafting.

Dermolipectomy is indicated for patients with redundant skin or extensively affected
skin. This 45-year-old woman is a candidate for dermolipectomy. She developed loose
skin in the medial thighs with uneven contours in the medial and anterior thighs af-
ter liposuction.
She was first treated with corrective liposuction and fat grafting, which was followed
by medial thigh dermolipectomy after 1 year and 8 months. Postoperative results
show a smooth contour and less flaccid skin 10 months later.
3145
Chapter 88  Correction of Contour Deformities After Liposuction
The same patient also developed an extra crease in the left upper posterior thigh and
buttock junction after her original liposuction. This deformity was improved with
posterior thigh dermolipectomy, which was an extension from and continuous with
the medial thigh dermolipectomy.
The location of redundant skin determines where dermolipectomy is indicated. Der-
molipectomy procedures include but are not limited to medial thigh lift, transverse
flank-thigh-buttock lift, lower abdominal dermolipectomy, abdominoplasty, upper
abdominal dermolipectomy, and brachioplasty.
In 2001 Saylan described liposhifting as a technique for the treatment of postlipo -
plasty irregularities. More recently, Wall has advanced the technique he refers to as
separation and fat equalization and applied its use to both secondary and primary
lipoplasty. In this technique, the fat is separated with a cannula that has an expanded,
basket-shaped tip.

3146
Part XII  Body Contouring
The fat is shifted and redistributed by manual massage and back-and-forth cannula
movements without suction. Thus the fat is redistributed and equalized between ar-
eas of relative excess and deficiency. Wall’s technique uses a power-assisted device.
The fat transfer is internal, without leaving the body.
Liposhifting complements the “external” fat transfer technique. It does not replace
external transfer of fat from a distant site if there is a significant deficiency of fatty
tissue. In some cases in which the deformity is irregular, multicentric, and complex
in shape, or if there is tight and localized subcutaneous scarring, liposhifting may
have some unique advantages. Certainly liposhifting and fat grafting by an external
route can be combined for synergistic effect.
This 30-year-old woman had a history of prior liposuction of her circumferential
thighs, with a contour deformity in the mid-buttock extending into the right lateral
thigh. SAFELipo of the circumferential trunk and thighs was performed, with uni-
form foam compression postoperatively to maintain a smooth contour. She is seen
1 year postoperatively.
Case courtesy Simeon Wall, Jr., MD

Clinical Anatomy of the Subcutaneous
Adipose Tissue
For liposuction, the extractability of fat varies, depending on the individual, sex, and
anatomic location of the fat. In general, it takes more effort to extract fat in men
than in women. A ranking of body regions in order of increasing difficulty of fat re-
moval includes the medial knees, buttocks, lateral thighs, central lower abdomen,
medial thighs, upper arms, hips, calves, ankles, flanks, chest wall, and back.
3147
Chapter 88  Correction of Contour Deformities After Liposuction
This 39-year-old woman had a history of prior liposuction of the trunk, thighs, and
buttocks, with a resultant deep contour deformity in the upper lateral buttock. SAFE-
Lipo of the circumferential trunk was performed, using some liposhifting to further
equalize the contour. Uneven (nonuniform) foam compression was used postopera-
tively, consisting of 1-inch Reston foam with a cutout in the center to allow the de-
pressed area to expand and maintain the shifted fat. Today, with a defect that is par-
ticularly depressed and/or scarred down such as this, I usually add some fat grafting
to the standard fat equalization/fat shifting (SAFELipo) techniques to ensure that
these areas are fully elevated. This approach is in contrast to wider areas of uneven
contour, where correction does not usually require formal fat grafting, as seen in the
previous case.
Case courtesy Simeon Wall, Jr., MD

Varying zones of adherence of the superficial fascial system extend over the trunk
and extremities. The encased fat produces bulges, valleys, plateaus, creases, and folds.
The most adherent zones are found in skin creases and valleys, such as the infra-
mammary fold, groin crease, gluteal crease, the anterior and posterior midline, and
lateral gluteal depressions. Zones of least adherence are the bulges of the truncal area
and the extremities, where the superficial fascial system forms a roof over the local-
ized deep fatty layer. Intermediate zones of adherence exist in all areas of the trunk
and extremities without significant deep fat. Surgical alteration within certain zones
of adhesion, such as the lateral gluteal depression and buttock crease, may predis-
pose the patient to postliposuction contour irregularities.
3148
Part XII  Body Contouring
ZONES OF ADHERENCE
• Inferolateral iliotibial tract
• Gluteal crease
• Lateral gluteal depression
• Middle medial thigh
• Distal posterior thigh
Paralumbar deep
adipose layer
Rectus
abdominis
muscle
External oblique
muscle
Muscular fascia
Abdomen deep adipose layer
Superficial (subcutaneous) fascia
Superficial adipose layer
The subcutaneous adipose tissue of the trunk and extremities is organized into a con-
tinuous fatty layer or superficial layer and a localized, deep fatty layer that is also
present in the abdomen, paralumbar area, and gluteal–upper thigh regions. The sub-
cutaneous fascia, or superficial fascial system, is the fibrous connective tissue net-
work that, depending on the location, contains single or multiple horizontal mem-
branous layers and vertically oriented extensions attaching to the subdermal layer
above and the deep fascia layer below.

Extractability of the fat depends on its density and the strength of its encasing con-
nective tissue. Loosely organized deep fat tends to be more easily removed than the
more compact superficial fat. In lipoplasty, depending on the aesthetic goals, the su-
perficial fatty layer and the deep fatty layer are targeted for fat extraction. However,
it is important to leave a smooth, healthy layer of fat beneath the skin after liposuc-
tion. To treat postliposuction contour irregularities, corrective liposuction and fat
grafting are directed toward modification and restoration of the superficial and deep
fatty layers, as needed.
Preoperative Assessment
During the consultation with a patient regarding secondary procedures to correct
postliposuction contour irregularities, the surgeon obtains information about the
patient’s preoperative body appearance, the changes that resulted from the primary
surgery, any postoperative complications, the anesthetic technique used, and details
of the surgery, if known.
The areas of fat excess and fat deficiency are located, the ideal contour is visualized,
and sites of fat harvesting are determined.
3149
Chapter 88  Correction of Contour Deformities After Liposuction
Physical examination includes assessment of the thickness of the subcutaneous fatty
layer with a skin pinch test. Underlying musculoskeletal contour is assessed by pal-
pation as the patient contracts and relaxes the muscles. Laxity and sagging of the
skin are evaluated by lifting the skin up against gravity and observing the body con-
tour as the patient assumes upright, reclined, sitting, and flexed positions.
The surgical plan is discussed with the patient. Areas of fat excess and deficiency can
be marked on the patient’s skin as the surgical plan is discussed. Photographs are
taken during the initial visit to identify areas for correction. Variable retention of the
fat graft, realistic expectations, limitations, financial cost, and the potential need for
additional procedures are discussed fully with the patient. For major contour irreg-
ularities, both early (3 to 6 months) and late interventions appear to be effective.
Fibrotic area
Ideal plane
Fat grafting to areas of depression
Muscle
Fascia
Adipose layer
Liposuction of areas of protuberance

Preoperative Planning
Markings
3150
Part XII  Body Contouring
A detailed topographic contour map is essential to the
planning and execution of corrective surgery. Photo-
graphs without flash, using only overhead ceiling light-
ing, are routinely taken. Areas of maximal depression,
areas of maximal protuberance, and the adjacent tran-
sition zones are indicated precisely. Markings should re-
flect differences in the amount of fat to be removed and
injected in different areas.
Although skin markers of different colors provide added
contrast, all markings can be performed with a black
skin marker. Areas of maximal depression are colored
black. Areas of maximal protuberance or fat excess are
marked with multiple Xs or crosshatching. Transition
zones between the two extremes are left unmarked. For
complicated cases, I routinely perform the markings the
day before surgery. This gives the patient ample oppor-
tunity to fully inspect the operative sites, including the
donor sites, and ensures that the patient and the sur-
geon agree on the surgical plan.
The marking is performed with the patient in a standing position. Digital photo-
graphs of the surgical markings are used intraoperatively. Areas of maximum de-
pression may be tattooed with methylene blue at the start of surgery to help main-
tain accurate surgical markings intraoperatively.
Incision Placement
Cannula entry sites for corrective liposuction should be selected to ensure the most
direct approach to the areas to be aspirated. Attempts to hide the incision may com-
promise cannula movement and the final results.

Operative Technique
For fat harvesting, infiltration of wetting solution is minimized or avoided to obtain
fat of maximum solidity. Lidocaine 0.25% with 1:400,000 to 1:800,000 epineph-
rine is injected with a 22-gauge spinal needle. Infiltration into the operative site re-
quiring correction is minimized or avoided to facilitate intraoperative evaluation of
the contour as fat is aspirated or added. Patients undergoing more extensive and com-
plex procedures are given a general anesthetic.
3151
Chapter 88  Correction of Contour Deformities After Liposuction
The fat is collected by pouring directly from the
patient end of the liposuction tubing or with an
interposed sterile specimen trap. Pretunneling be-
fore fat removal facilitates localization of the ex-
cess fat, helps to establish correct cannula path-
ways, avoids unwanted fat removal, and maximizes
the accuracy of fat extraction. It is important to
avoid excessive or full vacuum pressure when har-
vesting fat for reinjection. I limit the vacuum set-
ting to 26 to 28 mm Hg.
The fat is allowed to settle and the liquid portion is discarded. No special process-
ing is required. If the fat is dilute or if the amount is small, a centrifuge or absorbent
gauze can be used to concentrate the fat. A blunt-tipped cannula without suction is
passed beneath areas of dense subcutaneous adhesion to make multiple tunnels be-
fore fat injection.

3152
Part XII  Body Contouring
Fat is injected with a small blunt-tipped cannula with an outside diameter of 1.5 to
1.8 mm. A blunt-tipped cannula is preferred, because it is less likely to cause bleed-
ing during fat injection. Alternatively, a 16- or 18-gauge hypodermic needle may of-
fer the advantage of more precise and effective fat deposition, especially in densely
fibrotic areas.
The process is repeated. The fat is injected in small increments, in multiple passes,
and at multiple depths. The pathways of fat injection may be parallel or crisscrossed,
as needed. Fat injection may be carried out as a reversal of fat extraction in liposuc-
tion. During the injection, incremental change in the contour is correlated with the
amount of fat injected. A skin pinch test is used to assess the thickness of the opera-
tive sites. Although a small degree of overcorrection is acceptable, excessive tissue
turgor or overcorrection should be avoided.
Postoperative Care
The postoperative care of patients who have undergone corrective liposuction and
fat grafting is similar to that given to patients who have undergone primary lipo-
suction. If there is any chance that a compression garment may apply uneven pres-
sure to the area that has received fat grafting, such a garment is not used. Postoper-
ative manual massage is applied to areas with prolonged induration and firmness.
Smooth contour
established
via fat transfer
Fat injected
in multiple
tunnels
Protuberant
area reduced

Outcomes
In most properly selected patients, secondary procedures for postliposuction con-
tour irregularities are expected to correct or improve deformities. I reported on 22
patients with 43 areas of postliposuction contour irregularities; 2 areas were treated
with dermolipectomy, 22 areas were treated with liposuction only, and 19 areas were
treated with fat grafting in combination with liposuction. Ninety-five percent of the
areas showed improvement, nearly complete correction, or complete correction. Five
percent of the areas had overcorrection consisting of minor depressions. The qual-
ity of the outcome was also related to the severity of the postliposuction contour ir-
regularities. Thirty-one percent of the areas with major contour irregularities (de-
fined as an area greater than 100 cm2, with greater difficulty of correction and
increased severity of visual impact) had nearly complete or complete correction.
Forty-seven percent of areas of minor contour irregularities had nearly complete or
complete correction. Most patients required one or two corrective procedures; two
patients required three procedures. The average number of procedures required was
1.4 per patient. The only complication noted was hyperpigmentation in the skin of
one patient.
Results
Correction of Contour Irregularities, Protuberances,
and Depressions
3153
Chapter 88  Correction of Contour Deformities After Liposuction
This 55-year-old woman underwent simultaneous liposuction of the abdomen and
mini-abdominoplasty. Her surgeon performed additional liposuction to correct con-
tour irregularities. She presented with multiple contour irregularities in the abdomen
31⁄2 years after the initial operation. Examination revealed an uneven contour, pro-
tuberant areas in the lower abdomen, and areas of depression below the umbilicus.

3154
Part XII  Body Contouring
A corrective procedure was performed with the patient under general anesthesia. No
wetting solution was used in the abdomen. Umbilical incisions and three lower ab-
dominal incisions were made. A 3 mm Mercedes-type cannula was used to aspirate
areas of protuberance in the lower abdomen and around the periumbilical and su -
praumbilical areas. Liposuction was tapered from the point of maximal protuber-
ance into areas of maximal depression. The adhesions beneath the areas of depres-
sion were freed by passing a liposuction cannula without suction to create space for
fat grafting.
To obtain fat for grafting, liposuction of the medial thighs and the medial knees was
performed after infiltration with 0.25% lidocaine with 1:400,000 epinephrine. With
an intravenous catheter, 35 cc of fat was injected into the areas of depression. Addi-
tional minor liposuction was performed around the periumbilical area 5 months later.
Improvement is evident 22 months after the major corrective procedure. The result
remained stable 9 years and 10 months later, when the patient was 68 years of age.
In the meantime, she had an upper abdominal dermolipectomy to correct upper ab-
dominal skin laxity.

Correction of Contour Irregularities, Disproportion,
Protuberances, and Indentations
3155
Chapter 88  Correction of Contour Deformities After Liposuction
This 55-year-old woman had multiple areas of postliposuction contour irregulari-
ties, including bilateral posterior iliac regions, her lateral thighs, and the lateral hip
areas. Her surgical correction consisted of liposuction around the areas of indenta-
tion and autologous fat grafting. The amount of fat grafting to each area was as fol-
lows: 60 cc each to the right and left posterior iliac crest areas, 110 cc to the left lat-
eral hip, 95 cc to the left upper lateral thigh, and 95 cc to the right upper thigh.
Two years and 4 months after the corrective procedure, the indentations in the right
and left iliac crest areas, the left lateral hip, and upper thighs were improved, as seen
in the posterior and lateral views.

Correction of Areas of Linear and Circular Depression
3156
Part XII  Body Contouring
This 38-year-old woman had undergone liposuction of the thighs, and 21⁄2 years later
she presented for corrective surgery. At the time of our consultation, she had already
undergone one corrective procedure. On physical examination, we noted linear de-
pressions in the posterior thighs and circular depressions in the lateral thighs.
The preoperative markings include solid red areas, which indicate areas of maxi-
mum depression and indentation. Areas of protuberance are indicated with multiple
black X’s. Transitional zones were noted between the areas marked red and black.
Surgery was performed with the patient under general anesthesia and in the prone
position. No local anesthetic was injected. Several incisions were made in the but-
tock crease, lateral thigh, and distal posterior thigh in the midline. Areas of protu-
berance were aspirated with a 3.7 and 2.4 mm Mercedes-type cannula. A total of
20 cc of aspirated fat was injected into the areas of depression and indentation. Both
a blunt-tipped cannula and a sharp needle were used to inject the fat into the de-
pressed areas. Three additional minor corrective procedures were performed over the
next several years, and the patient underwent liposuction in the hip area.

3157
Chapter 88  Correction of Contour Deformities After Liposuction
Her improvement remained stable 11 years and 10 months postoperatively.

3158
Part XII  Body Contouring
Correction of Indentation in Male Breasts
This 54-year-old man underwent reduction of gynecomastia with UAL. He devel-
oped indentations of the right and left breasts; the right side was more pronounced
than the left. He also had adhesion of the nipple-areola complex, manifested by re-
traction during voluntary contraction of the pectoralis major muscle. The adhesion
resolved spontaneously. He underwent corrective surgery 31⁄2 years after the original
surgery.
The procedure was performed with the patient under intravenous sedation. The fat
was aspirated from the right and left flank with a 3 mm cannula; 9 cc was aspirated
from the right and left chest with a 1.8 mm cannula, and 35 cc of fat was infiltrated
into the right breast, including the subareolar area, with both an 18-gauge needle and
a blunt-tipped cannula. At 15 months postoperatively, good correction is evident.

Correction of Large Soft Tissue Deficiency of Thighs
and Buttock Ptosis
3159
Chapter 88  Correction of Contour Deformities After Liposuction
This 46-year-old woman underwent liposuction of the lateral, medial, and anterior
thighs and lower leg. She developed contour irregularities at multiple sites. She was
particularly concerned with changes in the lateral and medial thighs, around the
knees, and in the posterior calves.
Corrective surgery was performed with the patient initially positioned supine. Ap-
proximately 200 cc of 0.125% lidocaine with 1:800,000 epinephrine was injected
into various sites before fat was aspirated. The recipient areas were pretunneled be-
fore the fat was injected with a blunt cannula. Liposuction was performed in the up-
per medial thighs, medial knees, and anterior-superior knees. The fat was injected
into the right anterior thigh (23 cc), right and left midmedial thighs (10 and 55 cc,

3160
Part XII  Body Contouring
respectively), and the abdomen (25 cc). The patient was then placed in a prone posi -
tion, and liposuction was performed on the posterior thighs. Fat was injected into the
right and left posterior lateral thighs (90 and 100 cc), posterior gluteal folds (40 and
20 cc), and the calves (25 and 28 cc). The total amount of fat aspirated was 480 cc;
the total amount of fat injected was approximately 420 cc.
Twenty-five months later, improvement of the contour in the medial, lateral, and
posterior thighs, and around the knees is evident. The patient returned to the oper-
ating room for additional improvement in the outer thighs, buttocks, knees, and legs.
Liposuction was performed in the abdomen, anterior and medial thighs, anterior-
superior knee, and anterior proximal legs. The arms, waist, hips, and the right mid-
posterior thighs were aspirated as additional fat donor sites. Fat was injected into

the abdomen (40 cc), right anterior thigh (60 cc), left anterior thigh (30 cc), left leg
(20 cc), right leg (10 cc), right and left lateral thigh, gluteal folds and right posterior
upper thigh (400 cc). A blunt cannula was used for fat grafting at all the sites. At the
right lateral thigh, upper posterior thigh, and gluteal fold, 16- and 18-gauge needles
were used in addition to the blunt cannula.
3161
Chapter 88  Correction of Contour Deformities After Liposuction
The postoperative result 13 months after the second procedure shows that there is
more fullness in the lateral and upper posterior thighs. There is reversal of the soft tis-
sue deficiency and improvement in the sagging at the buttock–upper thighs junction.

3162
Part XII  Body Contouring
Correction of Contour Irregularities and Depressions
This 44-year-old woman underwent liposuction of the thighs, knees, and buttocks
1 year before presentation. Circular, linear, and irregularly shaped depressions were
noted in the medial, lateral, and anterior thighs.
Preoperative surgical markings of areas of maximal indentation were made (solid
red). Intermediate areas of indentation were marked with parallel red lines. Red cir-
cles indicated areas with a smaller degree of indentation. Areas of protuberance were
crosshatched or marked with X’s. Anteromedial thighs and knees were aspirated with
the patient in the supine position under general anesthesia. The aspirated fat was in-
jected into the area of depression using 14- and 16-gauge intravenous catheters. The
patient was then placed in the prone position, and 1400 cc of fat was aspirated from
the thighs; 200 cc was injected into various areas of indentation and depression.

Fourteen months after the first corrective procedure, several areas of the thighs ap-
peared full and out of balance with other areas of the thighs and the body. Some ar-
eas of the thighs had received less liposuction than others up to this point; her hips
and abdomen also appeared full. Additional liposuction without fat grafting was per-
formed 14 months later.
3163
Chapter 88  Correction of Contour Deformities After Liposuction
The patient is shown 4 years and 10 months after the first corrective procedure. Good
improvement is noted in the anterior, medial, and lateral thighs and in the knees.
A slight indentation persisted in the left lateral thigh.

The patient’s results remain stable 13 years and 4 months postoperatively.
Correction of Diffuse Irregular Indentations,
Protuberances, and Skin Excess
3164
Part XII  Body Contouring
This 45-year-old woman underwent liposuction of multiple body areas; the tumescent
technique was used. She underwent subsequent revision. A total of 1500 cc of aspi-
rate was removed from the abdomen during the two previous procedures. At our
consultation, we noted diffuse, irregular, circular, and oval indentations in the lower
abdomen, with redundant skin on the upper abdomen.

Preoperative surgical markings identified areas of protuberance in the right lower
lateral abdomen, suprapubic area, supraumbilical areas, and multiple areas of in-
dentation in the lower abdomen. The protuberant regions were infiltrated with 0.25%
lidocaine with 1:800,000 epinephrine and treated with SAL. An internal ultrasound
device was used to create space for fat grafting in the densely fibrotic tissue. The
LySonix 2000 cannula at a power setting of 2 was introduced into the subcutaneous
space of the lower abdomen caudal to the umbilicus after wetting solution was in-
filtrated. The use of an ultrasound cannula permitted breakthrough of the scar, which
was confirmed by passing a blunt 2.4 mm cannula without suction. No fat was as-
pirated during application of the ultrasound. Fifteen cubic centimeters of fat was
transferred into the lower abdomen. The deeper level was injected using a blunt-
tipped cannula. Sharply circumscribed indentations were injected with an 18-gauge
needle at the superficial (subdermal) level. Postoperatively, the abdomen was cov-
ered with nonsticky foam and an elastic garment.
3165
Chapter 88  Correction of Contour Deformities After Liposuction
Twenty months postoperatively, some improvement in contour is evident. (NOTE:
UAL is rarely used in corrective liposuction to maximize fat preservation.)

Concluding Thoughts
The best treatment of postliposuction contour irregularities is prevention. The op-
timal method of fat collection, processing, and transfer remains to be determined.
The technique described in this chapter is relatively simple, practical, and does not
require elaborate equipment. With appropriate patient selection and proper appli-
cation of the various surgical techniques, most cases of postliposuction contour ir-
regularities can be improved by various degrees. Multiple procedures may be required
for complicated cases.
Clinical Caveats
 In patients with complex postliposuction contour irregularities with volume defi-
ciency, surgical correction consists of liposuction of areas of protuberance and
around areas of depression with concurrent fat grafting.
 Dermolipectomy is indicated for patients with redundant or extensively altered
skin.
 A detailed contour map delineates areas of maximal protuberance and depression
and adjacent transitional zones.
 Pretunneling before corrective liposuction facilitates accurate fat extraction.
 A blunt-tipped cannula without suction is passed beneath the area of depression
to make space for fat grafting if there is dense fibrosis.
 Incisions are placed to create the most direct approach to areas requiring correction.
 The solidity of the material for fat grafting is maximized by avoiding or minimiz-
ing the injection of wetting solution.
 During secondary or primary liposuction, if overresection of fat is observed, the
volume deficiency should be replaced with immediate fat grafting.
 A submaximal vacuum setting (26 to 28 mm Hg) is used to obtain fat for grafting.
 Avoid or minimize injection of wetting solution into areas requiring correction so
the existing contour can be better visualized.
 In densely fibrous areas, fat may be more precisely deposited using sharp needles.
3166
Part XII  Body Contouring

 Fat is injected superficially or deep, depending on the location of the soft tissue
deficiency.
 Overresection should be avoided in secondary lipoplasty.
 Multiple procedures may be required for treatment of postliposuction contour ir-
regularities.
 Liposhifting offers alternatives to fat grafting in some deformities.
3167
Chapter 88  Correction of Contour Deformities After Liposuction
Annotated Bibliography
Chang KN. Long-term results of surgical correction of postliposuction contour irregulari-
ties. Plast Reconstr Surg 109:2141-2145, 2002.
Long-term surgical results, ranging from 5 years to 13 years and 4 months, are presented
in five patients. The beneficial results of the procedures, which have been previously re-
ported, continue to be observed during the follow-up.
Chang KN. Surgical correction of postliposuction contour irregularities. Plast Reconstr Surg
94:126-136; discussion 137-138, 1994.
Surgical treatment of postliposuction contour irregularities with secondary liposuction
and fat grafting and the outcome in 43 areas of the body in 22 patients are presented.
The surgical results involving the lateral, posterior, and medial thighs and the abdomen,
hips, and waist in 5 patients are illustrated.
Fodor PB. Secondary lipoplasty. Aesthet Surg J 22:337-348, 2002.
The author presents a clinical classification of candidates and indications for secondary
lipoplasty. The results of secondary liposuction, dermolipectomy, and fat grafting in the
abdomen, lateral buttocks, and thighs in three patients are detailed.
Rohrich RJ, Smith P, 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.
This article identifies five zones of adherence to avoid in the trunk and extremities to
prevent contour deformities when performing circumferential liposuction. These zones
are the lateral gluteal depression, gluteal crease, distal posterior thigh, midmedial thigh,
and infralateral iliotibial tract. Two patients who underwent fat grafting in the buttocks
and posterior, lateral, and medial thighs are presented.
Saylan Z. Liposhifting instead of lipofilling: treatment of postlipoplasty irregularities. Aes-
thet Surg J 21:137-141, 2001.
Saylan presents a technique in which the subcutaneous fat adjacent to the area of de-
pression is loosened with a specially designed cannula and shifted to adjacent areas of de-
pression by external pressure. No fat is removed from or reintroduced into the patient.

Wall S. SAFE circumferential liposuction with abdominoplasty. Clin Plast Surg 37:485-501,
2010.
The author presents his separation, aspiration, fat equalization (SAFE) liposuction tech-
nique and associated instruments, which are used in both primary and secondary lipo-
suction. The fat is loosened and redistributed with a power-assisted device.
Suggested Readings
Beckenstein MS, Grotting JC. Ultrasound-assisted lipectomy using the solid probe: a retro-
spective review of 100 consecutive cases. Plast Reconstr Surg 105:2161-2174; discussion
2175-2179, 2000.
Chang KN. The use of intraoperative grid pattern markings in lipoplasty. Plast Reconstr Surg
114:1292-1297, 2004.
Coleman SR, Mazzola RF, eds. Fat Injection: From Filling to Regeneration. St Louis: Qual-
ity Medical Publishing, 2009.
Illouz YG. The fat cell “graft”: a new technique to fill depressions. Plast Reconstr Surg 78:122-
123, 1986.
Kenkel JM, Hughes CE, Mladick RA. Lipoplasty complications—panel discussion. Aesthet
Surg J 25:57-65, 2005.
Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept.
Plast Reconstr Surg 87:1009-1018, 1991.
Markman B, Barton FE Jr. Anatomy of the subcutaneous tissue of the trunk and lower ex-
tremity. Plast Reconstr Surg 80:248-254, 1987.
Teimourian B. Repair of soft tissue contour deficit by means of semiliquid fat graft. Plast Re-
constr Surg 78:123-124, 1986.
Toledo LS. Secondary liposculpture. In Gasparotti M, Lewis CM, Toledo LS, eds. Superficial
Liposculpture: Manual of Technique. New York: Springer-Verlag, 1996.
White DJ. Ultrasound-assisted liposuction in 2002. Oper Tech Plast Reconstr Surg 8:133,
2002.
3168
Part XII  Body Contouring