The Art of Aesthetic Surgery_ Principles and Techniques -Foad Nahai, Farzad Nahai, Jeffrey Kenkel, Grant Stevens, William Adams Jr. (3 Volume Set)-Thieme (2020)

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XII Body Contouring
Fig. 84.10 (a,c,e) Pre- and (b,d,f) 4 months post–cool sculpting.

84 Clinical Decision Making in Body Contouring
1325
Fig. 84.11 (a,d,e,g) Pre- and (b,d,f,h) 8 months postliposuction to the thighs.
Fig. 84.12 (a,c) Pre- and (b,d) 5 months postthighplasty in a patient with major weight loss.
a
c
b
d

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XII Body Contouring
Clinical Caveats
• The patient’s goals and expectations must be matched with
the realities of his or her tissues.
• Decision making in body contouring requires taking into account
the balance between the quality of the results and safety issues.
• Discussions including surgical and nonsurgical options should
be reviewed with the patient in front of a mirror.
• A partnership is created between the surgeon and the patient
whereby the final result is dependent on proper execution by the
surgeon and on the patient’s embracing the necessary lifestyle
changes needed for recovery and optimization of the result.
• Skin, fat, muscle, fascia, the presence of intra-abdominal fat,
and adjacent areas are evaluated before selecting procedures
for abdominal contouring.
• A risk assessment should be performed to determine the extent
of the procedure, safety measures, and the need to stage.
• Nutritional assessment should be included in the preoperative
assessment of major-weight-loss body contouring patients.
• Skin evaluations are important prior to arm contouring
procedures.
• It is preferred to avoid combining thighplasty procedures with
abdominoplasty procedures, because together these can
alter surrounding structures and result in poor scarring.
Suggested Reading
[1] Agha-Mohammadi S, Hurwitz D--P. Potential impacts of nutritional deficien-
cy of postbariatric patients on body contouring surgery. Plast Reconstr Surg
2008;122(6):1901–1914
[2] Cosmetic Surgery National Data Bank Statistics. Aesthet Surg J 2017;37(Suppl 2):1–29
[3] Kenkel JM, Eaves FFJP III. Medial thigh lift. Plast Reconstr Surg 2008;122(2):621–622
[4] Levy AS, Dinesh A, Ahmed L, Morrison N, Engdahl R. Management of incidental
hernia discovered during abdominal contouring in post-bariatric surgery pa-
tients. Ann Plast Surg 2018;81(5):591–593
[5] Matarasso A, Wallach SGJASJ. Abdominal contour surgery: treating all aesthetic
units, including the mons pubis. Aesthet Surg J 2001;21(2):111–119
[6] Matarasso AJ. Abdominolipoplasty: a system of classification and treatment for
combined abdominoplasty and suction-assisted lipectomy. Aesthetic Plast Surg
1991;15(1):111–121
[7] Momeni A, Heier M, Bannasch H, Stark GB. Complications in abdominoplasty:
a risk factor analysis. J Plast Reconstr Aesthet Surg 2009;62(10):1250–1254
[8] Rohrich RJ, Broughton G II, Horton B, Lipschitz A, Kenkel JM, Brown SA. The key
to long-term success in liposuction: a guide for plastic surgeons and patients.
Plast Reconstr Surg 2004;114(7):1945–1952, discussion 1953
[9] Rohrich RJ, Lowe JB, Hackney FL, Bowman JL, Hobar PC. An algorithm for
abdominal wall reconstruction. Plast Reconstr Surg 2000;105(1):202–216,
quiz 217
[10] Strauch B, Greenspun D, Levine J, Baum T. A technique of brachioplasty. Plast
Reconstr Surg 2004;113(3):1044–1048, discussion 1049

85 Noninvasive and Minimally Invasive Techniques for Body Contouring
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85 1RninYDViYe Dnd 0inimDOOy ,nYDViYe 7eFKniTueV IRr %Rdy
Contouring
Lawrence S. Bass, Jason N. Pozner, and Barry E. DiBernardo
Abstract
A multitude of technologies are designed to contribute to improved
outcomes in body contouring. The devices in one group are used
as adjuncts to surgical procedures like liposuction to enhance or
simplify fat removal or increase skin redraping, thereby broaden-
ing the scope of acceptable candidates for liposuction versus an
open body contouring procedure like abdominoplasty. Devices
in a second group are used in place of a surgical procedure in
patients who require a smaller degree of improvement or who are
unwilling or unable to undergo a surgical procedure. This latter
circumstance is a compromise but one that an increasing propor-
tion of patients are selecting. Realistic expectations on the part of
patients and appropriate selection and application of technologies
by surgeons are the keys to success in achieving patients’ aesthetic
goals. The role and capability of body contouring technologies will
continue to grow as further refinements of existing technologies
and combination therapies progress.
Keywords
fat, liposuction, cryolipolysis, laser lipolysis, HIFU, adipocytolysis
85.1 Introduction
There is an almost universal desire for body contouring in the pop-
ulation. Open surgical body contouring procedures have several
inherent drawbacks, including the need for anesthesia, possible
hospitalization, substantial cost, lengthy scars, pain, swelling, and
prolonged recovery. Over the past four decades, body contouring
has transitioned from the exclusive use of open procedures like
abdominoplasty, thighlift, brachioplasty, and buttock lift to
liposuction to noninvasive options. Today, noninvasive options are
the most common, performed in large numbers that have grown
in double digits annually for nearly the past decade. Liposuction
remains one of the two most popular surgical procedures in
aesthetic plastic surgery. The quality of results with liposuction
has been amplified and refined with a number of energy-based
devices that provide some advantages in many specific circum-
stances to enhance the completeness of fat removal; the evenness
of the result, especially in reoperative cases; and as an aid in skin
tightening and smoothing, which have always been the Achilles’
heel of minimally invasive body contouring (liposuction). Major
open surgical procedures continue to be an essential part of ideal
body contouring and have evolved in ways that limit recovery time
and enhance results but are the predominant choice only in major-
weight-loss and postpartum circumstances. Body contouring
through noninvasive means has become one of the most alluring
areas in aesthetic surgery, with technologies that can consistently
produce contour tailoring and subcutaneous fat reduction. Patient
expectations and demands for no recovery, minimal discomfort,
and increasingly efficacious noninvasive procedures will continue
to drive industry development efforts to provide improvements
and novel options for noninvasive body contouring.
This chapter describes the technologies currently available to
perform body contouring noninvasively or minimally invasively in
lieu of surgical approaches or as a modification of traditional sur-
gical procedures with some potential advantage or improvement
in outcome. Several broad classes of technologies are available.
Detailed outcomes data are not available for most of these, although
some technologies have very specific outcome data that exceed the
kind of data available for surgery, with its broad individual vari-
ability based on patient and surgeon attributes. Comments about
potential benefits of technologies will be based on the subjective
experience of the authors as well as an understanding of the tissue
effects and mechanism of action of the technology.
:here the authors have some specific techniques for applying
these technologies that they consider particularly useful, these will
be delineated. However, each manufacturer generally provides a
variety of instructional experiences to allow surgeons to become
familiar with preferred techniques, such as webinars, preceptor-
ships, and written materials. This chapter does not attempt to
reproduce such teaching. In addition, even with three authors, it is
impossible to have extensive hands-on experience with all available
technologies. Finally, we caution that exposure parameters cannot
be readily transferred from one device to another, even if the
fundamental mechanism or energy modality is the same or seem-
ingly identical. In most devices produced today, energy parameter
regimes are unique and proprietary to the device. Settings that may
be safe on one device could produce serious tissue damage with a
roughly comparable device. Specific training and familiarity with
appropriate settings is essential for safe operation of devices.
Efficacy also relies on multiple factors intrinsic to the individual
technology and the treatment technique. Selection of proper energy
settings in terms of both intensity and total dose is essential to
place the treatment over the threshold of efficacy. To some extent,
these issues are known or have been adequately developed by the
equipment manufacturer in clinical trials. For other devices, few
clinical data exist, and clinicians are required to develop their own
effective approach to treating patients. In all cases, the individual
patient areas requiring treatment and assessment of severity and
appropriateness of a minimally invasive or noninvasive option
require the judgment of an experienced clinician.
85.2 Energy-Assisted Liposuction
Although liposuction has performed admirably for contour reduction,
the technique can require significant labor on the part of the surgeon.
Fibrous areas such as the male chest, the flanks, the bra strap, or reop-
erative sites with fibrosis and scar can be particularly challenging.

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XII Body Contouring
Devices using laser, ultrasound, water, and radiofrequency energy
have been employed as adjuncts to tumescent liposuction in order to
facilitate adequate fat removal and contouring with reduced surgeon
effort, improve contour smoothness, and enhance the natural tailor-
ing of skin laxity that occurs during healing.
85.2.1 Laser-Assisted Liposuction
Laser-assisted liposuction uses a small fiber delivered through
a narrow cannula of approximately 1 mm or smaller to deliver
energy to tissues. This allows delivery of large amounts of energy
directly to subcutaneous adipose and connective tissue elements
without the concern for skin safety that is intrinsic to transcuta-
neous laser delivery. More energy can be placed directly at the
target instead of passing through the epidermis and dermis, with
the requirement for concomitant cooling mechanisms for protec-
tion of the surface from intense heat. The principle advantage is
the enhancement of skin laxity correction compared to conven-
tional tumescent liposuction due to laser exposure of both the
deep surface of the dermis and the fibrous septa running between
the dermis and the muscular fascia. In addition, laser exposure
to fat creates a loosening of tissues, which allows aspiration with
greater ease and smaller cannulas. Thus laser-assisted liposuction
can more easily be used to treat scarring, dimpling, and cellulite
in the superficial layers with the small cannula. This reduces the
risk of contour irregularities seen with larger cannulas. Some
disadvantages include the higher cost of equipment, the need for
exact temperature measurement, and the potential for burns or
blisters without this monitoring. Previous disadvantages were
related to duration of the procedure; however, as technology
progresses, exposure to multiple wavelengths allows shorter
treatment times with comparable energy exposure and fat dis-
ruption while maintaining a similar cannula size.
Preoperative Planning
Patients are evaluated for potential fat reduction and skin laxity
improvement. :hen treating specific areas, these areas of adipos-
ity are marked in a standard fashion, in addition to 5 × 5 cm squares
representing the areas of skin laxity targeted for energy application
(Fig. 85.1). Approximately 50 to 100 mL of tumescent fluid is admin-
istered per 5 × 5 cm2 sector. This procedure is routinely performed
with oral and local anesthesia only but may be supplemented with
intravenous sedation, epidural block, or general anesthesia.
It is essential to manage patient expectations during the initial
consultation. Patients must understand that the skin-tightening
effect hinges on several variables, including age, genetics, and skin
condition from environmental factors, such as smoking and sun
exposure. The effect is highly variable and takes several months
to fully manifest.
2SerDWiYe 7eFKniTue
Various laser systems are available from different manufacturers,
offering different laser wavelengths and combinations of these
wavelengths. It is beyond the scope of this chapter to discuss the
attributes and provide comparisons of the systems. The most used
laser-assisted liposuction system is the Triplex (Cynosure Triplex).
It allows individual as well as sequential emission of 1,064-nm,
1,320-nm, and 1,440-nm wavelengths (Fig. 85.2). Energy is
delivered to the subdermal tissue through a 600- or 1,000-mm
fiber threaded through a 1-mm microcannula that extends 2
to 3 mm beyond the distal end of the microcannula. When the
microcannula is inserted into the tissue, the laser is activated and
the microcannula is moved slowly and evenly through the deep fat
layer with a 1,064- to 1,440-nm combination or through the super-
ficial subdermal layer with a 1,064- to 1,320-nm combination. For
ideal absorption and performance, wavelength combinations are
used for preferential target affinity of fat and water, respectively.
Sciton manufactures a competing device, Allura, which is a
laser liposuction device using blended 1,064- and 1,319-nm
wavelengths. The device is similar in use to the Cynosure device
but lacks an accelerometer and differs in its skin temperature
monitoring. Its clinical use and postoperative management are
similar to those of the Cynosure laser.
Using the biplanar technique, adipose cells are disrupted,
resulting in a more liquefied material that can be removed through
a smaller cannula. This refines the removal, particularly close to
the surface, thereby reducing potential contour irregularity that
can be seen with larger instrumentation. To achieve increased
skin elasticity and tightening, surface temperature goals of 40 to
42ƒC superficially and deep temperature goals of 47 to 52ƒC are
delineated. Achieving and uniformly maintaining these tempera-
ture goals are paramount to achieving optimal efficacy.
Safe energy delivery is monitored via an accelerometer delivery
system attached to the laser handpiece, used to minimize the
occurrence of localized thermal damage during treatment. The
handpiece contains a motion-sensing feedback chip that provides
constant information of cannula movement to the laser device.
Slower movement of the handpiece triggers a reduction in laser
power. If the handpiece stops, energy delivery ceases within 0.2
seconds. This safety feature prevents excess accumulation of
energy in a given area. Temperature safety is measured with an
embedded thermistor probe at the tip of the cannula, which is
Fig. 85.1 Marking grid used to subdivide the area to be treated in
order to control energy delivery to each area.

85 Noninvasive and Minimally Invasive Techniques for Body Contouring
1329
set for a safe range according to the aforementioned parameters.
:hen the threshold is reached, the laser automatically stops firing.
A two-layer/two-step technique is used in which the deep fat layers
(1–3 cm below the epidermis) within the premarked squares are
treated first. Insertion of the microcannula is facilitated with the use
of 1-mm incisions made with a No. 11 blade for appropriate access to
the treatment area. The superficial subdermal layer (0.5 cm below the
epidermis) is treated in the second step of the two-layer technique.
Aspiration is then performed with a standard 3-mm suction cannula
to remove any remaining fat, disrupted cells, and free fat oils.
Optimization of this procedure hinges on proper delivery
of energy while maintaining an appropriate safety margin.
Inadequate tightening can often be the result of insufficient
temperature attainment necessary to achieve the desired effect.
Too much energy applied in one area can result in excessive heat
buildup and fat necrosis, which manifest as protracted induration
and palpable nodules. If too much heat is applied superficially, the
result will be skin blistering, burns, or pigmentation changes. If
used properly, the built-in safety mechanisms will help control
temperature and avoid a harmful buildup of heat.
Another device on the market is the LipoFlow, a laser liposuction
system (Alma Lasers). The LipoFlow uses a 1,470-nm laser fiber
that is encased in a liposuction cannula. The laser helps break up
the fat and makes fat removal easier, but this device differs from
other laser liposuction devices in that the fat has been shown to
be over 97% viable. Alma Lasers includes a fat collection device
with this system and markets the device as a fat-grafting system.
Further studies with this device are ongoing.
Postoperative Care
Firm pressure dressings are applied to the wounds upon comple-
tion of the aspiration, and compression garments are worn for 3
to 4 weeks postoperatively. Dependent incisions may be left open
for drainage or closed, depending on surgeon preference, and
oral antibiotic prophylaxis is administered. Garments are used as
in traditional liposuction cases and use varies among surgeons.
Skin and tissue firmness is examined during the healing period.
Excessive swelling or dense edema may be treated with the use of the
Triactive Device (Cynosure) or some other external radiofrequency
or equivalent massage, edema reduction, or lymphatic drainage
system. Patients are reminded of the time necessary for skin changes
to occur during the dynamic fibroblast stimulation period (90 days).
If further enhancement of skin is desired after 3 months, acceptable
external skin devices can be applied, and additional treatments in
adjacent areas can be performed after tissue effects have subsided.
Outcomes
Ecchymosis tends to be less pronounced with laser lipolysis, but
edema and induration may be greater or take longer to resolve.
:ith healing and tissue remodeling, an amplification of skin
tightening and smoothness, variable in amount, is typically
observed (Fig. 85.3). Complications of laser-assisted liposuction
include blisters, end hits, burns, blowholes, prolonged edema,
heat/pressure problems, neuropraxia, permanent nerve damage,
contour irregularity, palpable or visible nodules or induration,
skin tethering, minor asymmetries, and insufficient effect. These
complications are rare in procedures that are properly performed.
Laser-assisted liposuction has evolved over the past decade
with improvements in the laser hardware and delivery systems,
including more power and greater feedback control for enhanced
safety and efficacy. At the same time, clinical study has provided
more information about adequate dosing, and demonstration of
outcome advantages in laxity reduction.
85.2.2 Ultrasound-Assisted Liposuction
Systems to deliver therapeutic levels of ultrasonic energy are
decades old but have undergone development and refinement
Fig. 85.2 Laser lipolysis devices can have temperature and motion feedback to ensure adequate and safe energy exposure.

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XII Body Contouring
to provide predictable effects safely and without excess energy
exposure. The third-generation VASER system (Sound Surgical
Technologies) was introduced in 2001 and is currently the most
commonly used ultrasound-assisted liposuction (UAL) technology.
Ultrasound interacts with tissue by three basic mechanisms:
thermal, mechanical, and cavitation. Cavitation is the tissue
interaction most responsible for causing fat emulsification with
current UAL devices. Noninvasive ultrasound devices that will be
discussed here create tissue effects thermally or with cavitation.
Wetting solution delivered into the target tissues is essential to
create the cavitation effects of UAL, separating fat cells within the
fat tissue matrix, which subsequently mix with the tumescent
solution by means of acoustic streaming to create an emulsion.
This emulsion is subsequently harvested by means of a suction
cannula.
Preoperative Planning
Even though UAL has expanded the parameters for selecting
liposuction patients, one criterion that remains unchanged is the
patient’s candidacy to undergo an elective surgical procedure.
Once this has been established, preoperative preparation may
proceed.
Preoperative markings are performed in the standing position.
There are five distinct anatomical areas that should be avoided
in patients undergoing UAL. These areas—termed the zones of
adherence—include the gluteal crease, the lower lateral thigh
area of the iliotibial tract, the posterior distal thigh above the
popliteal crease, the midmedial thigh area, and the lateral gluteal
depression area. Violation of these areas often leads to iatrogenic
contour deformities. During the preoperative marking process,
it is essential to carefully plan the placement of access incisions.
UAL requires a greater number of slightly longer access incisions
to accommodate the skin protectors and avoid placing torque on
the ultrasonic probe over curved anatomical areas.
VASER probe selection must consider the characteristics of
localized fat in the region to be treated. The characteristics of fat
cells in different regions of the body differ with respect to collagen
structure and conjunctive septi among the fat cells, as described
by de Souza Pinto. .nowledge of these differences is essential for
probe selection in order to achieve optimal outcomes.
Penetration of various tissue is influenced by the probe
diameter and the number of grooves at the tip. For a probe of a
given diameter, more grooves emulsify fat tissue more efficiently.
However, they do not penetrate fibrous tissues easily due to vibra-
tory energy that is transferred to the sides of the probe as opposed
to the front surface. Fibrous tissues are better addressed with
probes with fewer grooves. Smaller-diameter probes also pene-
trate fibrous tissue more easily. The 3.7-mm probes achieve rapid
debulking and contouring of medium to large volumes of soft to
fibrous tissues. The number of grooves at the tip of the probe will
vary according to the fibrous nature of the anatomical area. For
treating smaller, soft to extremely fibrous localized fat deposits in
sensitive areas, fine contouring is achieved with 2.9-mm probes.
Fig. 85.3 Smart lipo (a) before and (b) after.
a
b

85 Noninvasive and Minimally Invasive Techniques for Body Contouring
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In general, the continuous mode should be used for fibrous
tissue, for faster fragmentation, and when tissue emulsification
is not readily achieved in the VASER mode. The VASER or pulsed
ultrasonic mode is more suited for delicate work, finer sculpting,
or softer tissues. The device must be adjusted such that the probe
moves smoothly through tissue.
Experience and practice have delineated application times. In
general, 1 minute of application time may be used per 100 mL of
infused solution in the VASER or continuous mode. Loss of resis-
tance to probe movement in all intended areas can be considered
the surgical end point. Following emulsification, aspiration can be
performed with suction-assisted or power-assisted liposuction.
SurgiFDO 7eFKniTue
The prone position provides good access to the back, flanks, lateral
thighs, and superior posterior thighs. General endotracheal anes-
thesia is preferred for patients requiring prone positioning and for
large-volume aspirations. Many surgeons also prefer the lateral
decubitus position, which requires one additional patient reposi-
tioning. Despite additional repositioning, some authors maintain
that the lateral decubitus position offers better access with less
trauma and is particularly helpful for evacuating large volumes
from the flanks and back with the goal of creating more aesthetic
waistlines. Supine positioning offers access to the abdomen, ante-
rior and medial thighs, knees, calves, arms ankles, breasts, and face.
Maintaining core body temperature is best accomplished by run-
ning intravenous fluids through a fluid warmer in addition to the use
of forced warm air by means of a Bair Hugger (Arizent). The access
incisions are placed in previously marked areas using a No. 11 blade
and must be long enough to accommodate the fluid-infiltrating can-
nula. The rate of flow is controlled on the infusion pump according to
the anatomical area. Generally, a wetting solution is prepared with 1
mL of epinephrine added to 1 L Ringer’s lactate at room temperature
(1:1,000,000 dilution). In cases not utilizing general anesthesia, lido-
caine may be added to the wetting solution. The dose of lidocaine
should not exceed 35 mg/kg, although some authors routinely use
doses exceeding 50 mg/kg while maintaining a safety margin.
Treatment Recommendations
Posterior Trunk
• The 3.7-mm two-ring probe is used at 80% energy level in
continuous mode for most of the back.
• The 3.7-mm one-ring probe is used at 80% energy level in
continuous mode for tight fibrous back rolls.
• Posterior trunk areas require slightly longer ultrasound appli-
cation, usually between 12 to 14 minutes on average.
• Aspiration is accomplished with a small-diameter cannula.
Abdomen
• The 3.7-mm three-ring ultrasonic probe is used at an energy
setting of 80% in VASER mode.
• Continuous mode is used for the area above the costal margin.
• Average ultrasound time is 8 to 9 minutes.
• Aspiration is accomplished with a small-diameter cannula.
Extremities and Buttocks
• The 3.7-mm three-ring ultrasonic probe is used at an energy
setting of 70% in VASER mode for the superior medial thigh.
• Around the knees and superior posterior thigh, a short 3-mm
three-ring probe is used in 80% VASER mode.
• Depending on how fibrous the subcutaneous layer may be, the
3.7-mm three-ring probe is used in 80% VASER or continuous
mode for the anterior and lateral thigh areas.
• Average ultrasound time is approximately 3 minutes for both
knees, 5 minutes for both superior medial thighs, 8 minutes
for both anterior thighs, 6 to 7 minutes for both lateral thighs,
and 4 minutes for both superior posterior thighs.
• For the axillary area, a 3-mm three-ring probe is inserted into
the subcutaneous space through a small access incision in the
axillary fold.
• The energy setting is 70% VASER mode, applied for approxi-
mately 2 minutes per arm.
• Aspiration is performed through a small-diameter cannula.
Gynecomastia
• The 3.7-mm one-ring probe or the gynecomastia arrow probe
can be used efficiently in this area.
• Energy levels are set at 80 to 90% at continuous mode at an
average of 3 to 4 minutes per breast.
• Aspiration is performed through a small-diameter cannula.
HIV-Associated Cervicodorsal Lipodystrophy
• The 3.7-mm one- or two-ring probe is used depending on the
fibrous nature of the area.
• The energy setting is 80% continuous mode, and the time will
vary according to the volume of fat being treated.
• Aspiration is performed with a fine cannula.
Optimizing Outcomes
• Apply the least amount of ultrasound energy necessary to
obtain fat emulsification.
• The clinical end point of ultrasound application is loss of tissue
resistance against the probe.
• Incision placement must be planned appropriately to facilitate
access to the treatment area while avoiding torque on the
ultrasonic probe.
• Small-diameter cannulae provide the greatest precision, par-
ticularly in the aspiration of superficial fat.
• Liberal use of wetting solution dispersed evenly through the
fat maximizes efficiency of ultrasonic cavitation, minimizes
blood loss, and provides added protection against thermal
effects of UAL.
• Circumferential contouring provides a more harmonious
result than local fat extraction.
• Postoperative use of foam compression garments, lymphatic
drainage massage, and skin-moisturizing regimens can opti-
mize UAL outcomes and decrease recovery times.

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XII Body Contouring
Postoperative Care
Following large-volume UAL procedures, close monitoring of
fluid replacement and urine output is required. Postoperatively,
most patients with large-volume aspirations continue to leak
fluid through the incisions for 24 to 36 hours. A significant volume
of the infiltrating solution does get absorbed during the first 12
hours following major UAL, and this must be considered when
planning fluid replacement. Oral intake of fluids is permitted
upon waking, early ambulation is encouraged, and patients are
discharged on the first postoperative day. Foam and compression
garments can be applied to most UAL patients in the immediate
postoperative period. Lymphatic drainage and skin-moisturizing
regimens are helpful as soon as the patient can tolerate them.
Outcomes
The most common complications of liposuction procedures are
underextraction, overextraction, or irregular contour. In general,
these complications are prevented by the use of intraoperative
flow sheets documenting infusion and aspiration volumes for each
anatomical area. Underextraction is usually corrected by revi-
sionary extraction while overcorrection may require fat grafting.
Paresthesias, edema, and ecchymosis are usually self-limiting.
The vibrating ultrasonic probe generates heat, which could lead to
thermal injury, particularly around the incision site. The use of skin
protectors is essential, along with the use of a wet towel adjacent
to the incision to provide added protection. The most important
factor in preventing skin burns is avoiding torque on the probes.
Seromas are the result of too much ultrasonic energy applied to the
tissues either as a result of increased generator settings or prolonged
application. It is seldom necessary to use energy settings above 80%
applied for 1 to 1.5 min/100 mL of wetting solution to a particular area
in order to achieve proper tissue fragmentation and emulsification.
Water-based liposuction (Bodyjet, Human Med) is a device that
provides pressurized water to help break up fat deposits. This
device is also marketed for simultaneous fat removal and harvest
as the water pressure is gentle enough to enhance liposuction
but not destroy the fat cells. Pre- and postoperative care with this
device is similar to traditional liposuction.
Internal fiber–delivered radiofrequency devices have supplanted
laser liposuction devices in many practices. The first device to gain
U.S. Food and Drug Administration (FDA) approval and clinical
acceptance was the Thermi device (Thermigen). Use of this device
was very similar to that of laser lipo except that an internal radiof-
requency probe was used rather than a laser fiber. Tumescent
anesthesia was used, and the device was grounded using an
external pad. The monopolar probe was then used under the skin,
and thermistors at the tip measured temperature and the device
also measured impedance. An external forward-looking infrared
camera is used to measure external skin temperature. The goal of
treatment was to achieve confluent skin temperatures between 42
and 47°C. Liposuction was then used to remove dead fat cells as
well as for contouring similarly to that with laser lipo devices. The
device works very well for neck and small-volume body tightening
but was very slow for larger areas. A newer version called Arvati
was introduced by the same company late in 2018. This device
offered much higher power and solved the larger-area issues.
A Thermi/Arvati competitor was FDA-approved in late 2016
but had been used outside the United States since 2009. This
radiofrequency device, Bodytite (Inmode), is a bipolar device with
internal and external electrodes. A grounding pad is not required,
and internal and external thermistors provide real-time tempera-
ture feedback. Goals are similar to those with the Thermi/Arvati,
with achieved skin temperatures optimized at 40 to 42°C. Pre- and
postoperative care with the radiofrequency devices is very similar
to the care provided with laser liposuction devices (Fig. 85.4).
85.3 Noninvasive Modalities
85.3.1 Cryolipolysis
Cryolipolysis is a noninvasive technology that takes advantage
of the higher freezing point of lipids and greater sensitivity of
adipocytes to cold injury compared with surrounding skin or
muscle tissues. Fat can be selectively targeted and eliminated.
Cryolipolysis is performed as part of the CoolSculpting pro-
cedure (=eltiq Aesthetics). Adipocytes respond differently to
cooling than other cell types. Precisely controlled cooling causes
lipid crystallization (freezing) above the temperature at which
water would freeze and triggers apoptosis in adipocytes, while
non-lipid-storing cells are left undamaged. Lipids released by
apoptotic fat cells are removed gradually through the lymphatic
system, thereby reducing tissue volume.
Planning
The areas to be treated must be evaluated for size and shape, after
which the appropriate applicators are selected that best match the
area to be treated in the fewest cycles (Fig. 85.5). For thicker areas
or if a greater degree of correction is required, a second series of
cycles or a complementary pattern of cycles should be planned.
Manufacturer-provided templates aid in marking the application
areas and anticipating how much tissue will be drawn into the
applicator. The original cup-shaped applicators with parallel-facing
flat cooling plates and a 60-minute cycle length have largely
been replaced by cup-shaped applicators with a curved cooling
surface. The newer applicators have a 35-minute cycle length and
improved patient comfort. A flat applicator is available typically for
upper abdominal and outer thigh areas. A small overlap between
applicator placement is typically used in adjacent cycles.
A gel pad provides thermal contact between the patient’s skin
and the applicator and should be placed over the center of the
treatment site.
7eFKniTue
The treatment regimen is selected from the instrument’s touch
screen console. Some regimens include a short massage session,
which enhances the selective injury to the adipocytes.
Once the applicator is properly placed and the patient is
comfortably positioned, the clinician may begin the cooling cycle.
Vacuum pressure is used to draw the target tissue into the appli-
cator for optimal cooling.
Aftercare
Following the procedure, the treated areas may feel cold and firm
with a red and raised appearance. These effects are transient and
usually resolve within a few minutes to hours. Massage of the

85 Noninvasive and Minimally Invasive Techniques for Body Contouring
1333
Fig. 85.4 Abdominal liposuction with InMode Bodytite radiofrequency treatment. (a) Before and (b) 6 months after.
Fig. 85.5 The cryolipolysis applicator provides hands-free treatment once applied but must be used in a pattern of cycles that covers the intended
area of treatment.
a
b

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XII Body Contouring
frozen mass for several minutes or treatment with shockwave
generators have shown enhanced clearance of fat compared
with control patients undergoing cryolipolysis alone. Numbness
in the treated area is expected for several weeks. Bruising, sore-
ness, tenderness, cramping, and tingling occasionally occur but
usually resolve within a few days to weeks.
Outcomes
Proper patient selection for cryolipolysis is essential to achieving
successful outcomes. For optimal results, patients should be at
or near their ideal body weight with good skin tone and minimal
laxity. Ideal candidates have distinct pockets of fat that are resis-
tant to diet and exercise.
A visible reduction in the thickness of the fat layer is typically
achieved with each treatment. Though results are visible with a
single procedure, multiple procedures may be recommended to
achieve the aesthetic goals (Fig. 85.6). Although results may be
observed as early as 3 weeks following treatment, final results
are visible in 2 to 4 months. Some have reported skin tightening
or smoothing after cryolipolysis, but these results have not been
consistently demonstrated. Patients with visible skin laxity
are particularly poor candidates for cryolipolysis and should be
directed to other modalities.
Some patients may experience significant pain following
cryolipolysis. This seems to be associated with abdominal area
and inner thigh treatments, is self-limiting, and usually resolves
within a few days to 2 to 3 weeks. Paradoxical fat hyperplasia is
also rarely seen. This can be treated with some difficulty as the fat
mass tends to be fibrous and resistant to the suction lipectomy,
which is required to treat it. The zone of fat hyperplasia does not
respond to repeat cryolipolysis.
Cryolipolysis is a novel, safe, and effective option for patients
who desire a noninvasive procedure to reduce distinct areas of
adiposity, such as fat in bulges, rolls, or other small areas that are
resistant to diet and exercise. While reduction in local adiposity
can be achieved, cryolipolysis should not be relied on to consis-
tently produce tightening in the skin or deeper layers.
85.3.2 High-Intensity Focused
Ultrasound
High-intensity focused ultrasound (HIFU) body contouring devices
UltraShape (Louisville, KY) and Liposonix (Solta Medical, Hayward,
CA) are novel technologies that result in noninvasive adipocyte
death, creating a reduction in the fat layer and body contouring.
A low-energy-density beam of sound energy is transcutaneously
applied, focusing down to a smaller spot size and consequently higher
energy density at a defined depth, creating a therapeutic effect.
UltraShape operates at 0.2 MHz, creating cavitation rupturing the
Fig. 85.6 Coolsculpting treatment of the abdomen (a) before and (b) 3 months after treatment.
a
b

85 Noninvasive and Minimally Invasive Techniques for Body Contouring
1335
cell membrane of adipocytes in the target zone. Lipsonix operates
at 2 MHz, creating tissue heating to the point of adipocyte necrosis.
Lipids subsequently released are removed gradually through the
lymphatic system, thereby reducing tissue volume.
Planning
Patient assessment should be performed in the standing position so
that the fat is subject to gravity. The clinician should assess the fat
thickness; a minimum of 1.5 cm of fat is generally needed for efficacy,
although advances in this technology may allow smaller volumes to
be treated. The areas to be treated are marked in a standard fashion.
7eFKniTue
Most patients are able to undergo treatment without the need
for analgesics or sedation. The transducer is placed on the skin,
which is lubricated with oil to enhance conduction. The opera-
tor follows a pattern on the device screen, which ensures that
the target area receives even treatment without overlap. The
transducer dwells for a specific time per area while delivering
the ultrasonic energy, and the tracking system keeps track of the
area treated. The protocol for UltraShape calls for three sessions,
2 weeks apart, with radiofrequency treatments at the same time
and during the untreated weeks, whereas the Liposonix device
requires only one treatment per area.
Aftercare
There are no posttreatment limitations following HIFU, and
patients may resume all activities immediately. The treated areas
may be slightly ecchymotic and edematous, but these changes
resolve within a few days. Sensory changes may also occur but
usually resolve in a few days to weeks.
Outcomes
Patient expectations must be addressed preoperatively, and
there must be an understanding that these devices are less
efficacious than liposuction. In rare cases a burn may occur with
treatment. The majority of patients will see results, but results
are highly variable. Results may be observed as early as 3 weeks
posttreatment, but final outcomes are visible in 2 to 4 months.
85.3.3 Noninvasive Laser Lipolysis
A noninvasive approach to laser lipolysis is available that applies
1,060-nm laser light transcutaneously (SculpSure, Cynosure).
Simultaneous skin cooling from the faceplate of the applicator
prevents injury to the skin even in dark-skinned individuals.
This is one of the few laser treatments that is colorblind. Four
applicator heads can expose multiple areas during a single cycle,
which lasts 25 minutes. The laser wavelength is selected for
preferential absorption in fat-bearing tissues compared with
water-bearing tissues, although this is only a relative selectivity.
During the 25-minute cycle, the laser is on continuously during a
warm-up phase designed to bring the tissue to a target tempera-
ture of 43 to 47°C. This temperature is known to cause apoptosis
in adipocytes after a few minutes. The laser cycles on and off for
seconds at a time during the remainder of the treatment in a
preset algorithm designed to maintain the target temperature in
the fat while avoiding heating of the skin.
Indications
Patient selection for laser body contouring is similar to that for
other noninvasive fat reduction or body contouring treatments.
Patients who need only a small size reduction, have an isolated
area of excess contour, or cannot be considered for a surgical
procedure due to medical history or patient preference are typ-
ically the most suitable candidates. Skin laxity does not prevent
treatment but often masquerades as contour excess, reducing
the appearance of improvement despite success at destroying
some of the fat depot. Additionally, patients with scarcely any
excess fat may paradoxically also be poor candidates due to the
minimal fatty substrate to target with the energy. Counseling the
patient about the expected degree of contour reduction with a
single treatment and the number of treatments required to meet
the patient’s individual aesthetic goals is essential to appropriate
treatment selection and patient satisfaction. Treatment over the
umbilicus, surgical or traumatic scars, or bony prominences must
be avoided. Cooling cannot be directly applied to the skin at the
depth of the umbilicus, creating a high risk for skin burn. Scars
may conduct cooling and heating differently than normal tissues,
again risking a burn. Bony prominences such as the iliac crest
seem to preferentially absorb laser light, possibly at the level of the
periosteum, with pronounced sensitivity for patients, although
treatment over the ribs in the bra strap areas is well tolerated.
Planning
As an applicator-driven technology, planning involves selection
of the contours to be treated and matching the smallest collection
of applicators to cover this area in an efficient fashion. The size
and shape of each applicator-driven treatment are somewhat
different, making the process unique to each technology. The
1,060 nm laser system can be expected to expose fat over the
entire zone of contact with the applicator and to the edges of the
framing system used to hold the applicators in place. As a prac-
tical issue, various frames are typically held in place against the
areas selected for treatment to see which will give the best fit.
The variety of frames and orientations gives a greater degree of
flexibility than other applicator-driven systems. :ith the patient
in a standing position, a small ink mark is made at each strap
attachment point on the frames to delineate proper positioning
for all cycles planned at that sitting.
7eFKniTue
The selected frames and retaining straps are applied and
snugged into position while the patient is standing. The patient
then assumes the position to be maintained during treatment.
Abdominal and inner thigh areas are usually treated in the supine
position. Flank and bra strap areas may be treated in the sitting
position with the patient facing away from the machine to allow
treatment of both sides simultaneously, or in the lateral position
if this allows better contact or if more than two applicators are
being used on each side. Outer thigh areas are typically treated
in the lateral position. An oil-based lotion is applied to the skin

1336
XII Body Contouring
once the frames are in place to facilitate conduction of light into
the skin. The applicators are then snapped into the frames and
stable positioning is insured. The starting energy density (flu-
ence) is set on the machine, typically in the middle of the avail-
able range, and the cycle is initiated. After the warm-up phase,
fluence is adjusted to match patient sensation. The treatment
should feel hot but not painful (typically a 3–4 out of 10). Usually,
fluence is increased to the point where pain is experienced and
then slightly reduced. This ensures that the tissue temperatures
are in the middle of the therapeutic range. A small reduction in
fluence often produces a significant improvement in comfort.
Alternatively, some operators start at a high fluence during
warm-up and reduce the energy as needed for tolerability during
the cycling phase of the treatment. The operator may leave the
patient unattended.
Aftercare
Immediately after the cycle, the straps and frames are removed,
and any remaining lotion is wiped from the skin. The patient
can dress and immediately resume full activities. A faint bruised
feeling accompanied by minimal edema is typical for 1 to 2 days
after treatment.
Outcomes
Contour reduction occurs over approximately 3 months. Assessment
at 6 weeks is made to determine if further treatment should be
planned. Patients approaching the desired contour by 6 weeks
will probably have reached their goal by 3 months. If there is still
a desire for significant additional contour reduction, more treat-
ments should be planned (Fig. 85.7). Treatment is often repeated at
Fig. 85.7 A 26-year-old man treating the abdominal area with noninvasive laser lipolysis. (a) Before treatment. (b) Twelve weeks after three treat-
ments, weight change of 3 lbs.

85 Noninvasive and Minimally Invasive Techniques for Body Contouring
1337
the 6-week point for patients who are not yet close to their contour
goals. Complications are infrequent, but an occasional nodule in
the subcutaneous fat can be seen, probably representative of fat
necrosis, which resolves over a few weeks to a few months. Skin
burns are possible but again infrequent with a properly functioning
machine with working sensors on the applicator heads. Treatment
in contraindicated areas can produce a skin burn, which heals in a
fashion similar to most laser cutaneous burns.
Contour reduction is stable in the absence of weight gain,
having been confirmed in studies out to a year and congruent
with the histological observation of apoptosis, adipocyte death,
and removal by macrophages. Multiple treatment applications are
associated with modest skin tightening or smoothing (Fig. 85.8).
This is more likely due to thermal effects creating remodeling
and neocollagenesis in the fibrous septae transiting through the
exposed fat than to any direct effect on the dermis, which experi-
ences minimal tissue heating during treatment.
85.3.4 0uOWiSRODr 5DdiRIreTuenFy
Radiofrequency has been used transcutaneously in a number of
fashions as well as being delivered into or beneath the skin using
electrodes in a minimally invasive fashion. The coupling of the
energy into the skin varies with the impedance of the tissues,
which vary widely from patient to patient based on multiple fac-
tors. A technology has been developed (Vanquish, BTL Industries)
that houses an array of electrodes in a treatment bay that is
Fig. 85.8 A 66-year-old woman treating the infraumbilical abdomen with noninvasive laser lipolysis. (a) Before treatment. (b) Twelve weeks after
three treatments, weight change of 1 lb. In addition to contour reduction some skin smoothing has occurred.

1338
XII Body Contouring
lowered over the patient’s torso or extremity. The device transmits
energy into the tissue from electrodes on one side of the bay with
absorption on the other side. The device has impedance-matching
capabilities to help produce a uniform field effect. This allows
exposure of most of the anterior abdomen, or waist area posteri-
orly, or extremity (arm, thigh) nearly circumferentially in a single
treatment. Multiple treatment sessions are needed to obtain a
result comparable to cryolipolysis or laser lipolysis.
Indications
As for similar noninvasive devices, the ideal patient requires a
modest contour reduction. The ability to expose most of the abdo-
men or waist in a single treatment makes the technology more suit-
able for patients who want a small but global size reduction in the
torso or an extremity compared with applicator-driven treatments
and stamping treatments. Because of the use of radiofrequency
energy, patients with metal prostheses in the zone of treatment or
an implanted pacemaker or defibrillator may not be treated.
Planning
The treatment area must be selected in conjunction with the
patient. Areas amenable to this therapy include the upper abdo-
men, lower abdomen, flanks, bra strap, extremity, or chest along
with the upper thigh or arm. Three 45-minute treatment sessions
are planned at weekly intervals for each zone being treated.
7eFKniTue
The coupling of energy into the tissue is critically affected by the
treatment bay’s positioning relative to the surface of the patient’s
skin. The patient must be in a position that can be comfortably
maintained during the treatment. The treatment bay is lowered
to the appropriate distance from the skin surface, and the lateral
arms of the treatment bay are adjusted to bring them to an appro-
priate distance from the skin surface. The patient should not be
wearing any metal objects and must be careful not to touch
the treatment bay during exposure. The operator monitors the
energy coupling during the treatment, and the power is adjusted
to maximize energy coupling. The patient experiences a feeling
of warmth and tissue heating, which is generally pleasant. Hot
spots or pain should be promptly reported and responded to by
repositioning the applicator or adjusting the power.
Aftercare
At the conclusion of the treatment the patient may immediately
dress and resume all normal activities. Slow contour reduction
occurs over a period of about 90 days after the final treatment.
Outcomes
Invested time is greater than with other contouring treatments,
but a larger area is exposed in each treatment. Efficacy is
dependent on meticulous positioning and energy monitoring
during treatment. This is a much easier treatment for patients
to undergo, the only restriction being the need to stay in one
position with minimal motion for the duration of the treatment.
The safety profile of the treatment is very high, but occasional
nodules are seen from hot spots and the resultant fat necrosis.
85.3.5 Low-level Laser Therapy
Low-level laser therapy (LLLT) is characterized as treatment with
a dose rate that causes no immediate detectable rise in tissue
temperature and no macroscopically visible changes in tissue
structure. The Zerona (Erchonia), a low-level laser device that
emits a wavelength at 635 nm, has shown efficacy as a thera-
peutic strategy for circumferential reduction of the waist, hips,
and thighs.
The mechanism of action of LLLT remains somewhat contro-
versial, but it is thought that in body sculpting, the 635 nm LLT
=erona laser penetrates the first few millimeters of fat and creates
a temporary pore in the adipocyte cell membrane through which
lipids are released. Lipids are subsequently released into the inter-
stitial space and gradually removed by the lymphatic system, and
tissue volume is subsequently reduced.
The =erona laser is a device with five rotating, independent
diode laser heads, each emitting 17 mW of 635 nm of laser light.
It was the first noninvasive aesthetic device to receive FDA market
clearance in the United States for circumferential reduction of the
waist, hips, and thighs following completion of a placebo-con-
trolled, randomized, double-blind, multisite clinical investigation
evaluating 67 participants. Results of this study showed an aver-
age reduction of 3.51 inches across the patient’s waist, hips, and
thighs in as little as 2 weeks.
Planning
Patient assessment should be performed in the standing position
so that the fat is subject to gravity. The areas to be treated are
marked.
Between treatments, patients are asked to walk 30 minutes per
day, drink 1 L of water, and take a supplement called Curva that
contains niacin among other homeopathic substances, which are
designed to increase lymphatic flow. Cessation of smoking and
alcohol consumption should be encouraged.
7eFKniTue
The commercial Zerona unit has an array of diodes, which are
adjusted to within 6 inches of the patient’s body. The patient is
treated for 20 minutes in the waist, hips, and thighs in both the
supine and the prone positions. The center diode is positioned 4
to 12 inches above the abdomen, centered in the midline, and the
four remaining diodes are positioned above the lateral abdomen
and thigh regions. The diodes are repositioned in a similar fashion
in the prone position. In order to optimize the transitory pore, it is
important that treatments are conducted 48 hours apart.
The current Zerona protocol calls for 6 to 12 treatments,
depending on the habitus of the patient. On average, patients
undergoing Zerona treatment receive a total of 9 treatments
every 48 hours over a period of 2 weeks. It is possible to combine
Zerona with other more focal, ablative, fat reduction technologies
to enhance general slimming and local fat reduction.
Outcomes
Complications with LLLT can include thermal skin injury.
However, complications are rare and mainly include patient
dissatisfaction due to unrealistic expectations.

85 Noninvasive and Minimally Invasive Techniques for Body Contouring
1339
85.3.6 Muscle Bulking with
Electromagnetic Pulsed Energy
A recent development in body contouring is the addition of
treatments with electromagnetic pulsed energy (Emsculpt, BTL
Industries), causing muscular contraction and a training or bulk-
ing effect. Unlike electrical muscle stimulation, electromagnetic
stimulation is much more comfortable, allowing 20,000 contrac-
tions in the targeted muscle in 30 minutes. After four treatments
spaced out by 2 to 3 days each, the muscle shows more definition.
Some fat reduction in the overlying or adjacent area has also
been demonstrated in early studies. The durability of the effect
has not been defined, but this technology is rapidly becoming
one of the mainstay treatments in noninvasive body contouring
and is likely to be employed in concert with various noninvasive
fat reducing technologies going forward. The main areas treated
include the abdominal wall musculature and buttocks.
85.3.7 Pharmacologic Adipocytolysis
Injection Therapy
Mesotherapy is the injection of various agents into the subcu-
taneous tissue to promote adipose tissue reduction. Agents
can include a combination of homeopathic and pharmaceutical
medications, plant extracts, and vitamins that are injected
into the mesoderm layer targeting the adipose fat cells, dermal
vasculature, and connective tissue septae. The selection of
medications and herbal extracts is generally at the discretion
of the practitioner. It is important to choose medication based
on treatment goals, and the formula for each patient will differ
based on these goals. Historically, theophylline tends to be the
drug of choice for lipolysis in Europe, whereas in the Americas it
is usually phosphatidylcholine.
More recently, investigation of mesotherapy cocktails has
identified deoxycholic acid, a bile salt, as a major active ingredi-
ent responsible for adipocytolysis and fat reduction. A synthetic
form of this compound has been FDA-approved for submental
fat reduction, with off-label use taking place elsewhere on the
body. There are significant limitations with using this medication
for body applications. Treatment is dose-limited to 100 mg or 50
injections. The high cost of the medication also limits use to small
contour issues, such as residual contour asymmetry or a small
bump of retained fat after liposuction.
Planning
Proper selection of patients for mesotherapy is paramount for
successful treatment and patient satisfaction. Patients with a
body mass index greater than 30 are not ideal candidates for
mesotherapy and will likely be dissatisfied with inadequate
results.
7eFKniTue
Use of the formulation as delivered (10 mg/mL) is essential to
produce maximum efficacy. Proper spacing is also essential to
maintain efficacy and minimize risk. After marking the area to
be treated, an injection grid is placed over the marked area and
transferred onto the skin by moistening. The requisite amount
of medication is drawn up and injected using a 30-gauge needle.
The needle should be directed in at each grid-marked injection
point to the midpoint of the fat layer thickness, and 0.2 mL of
solution (2 mg) is injected at each point. Local anesthesia is often
infiltrated prior to injection to minimize treatment discom-
fort. Cool compresses are applied after treatment to minimize
discomfort and edema. Treatments are repeated at intervals
of 4 to 8 weeks. Several treatments are typically required to
achieve contour reduction. Various injectors have used dilution
or threading techniques with this product, but the dosing and
spacing are difficult to control in this fashion, creating unpre-
dictability in the treatment.
Outcomes
The initial reaction to injection is typically a burning and itching
sensation associated with flushing and swelling. After 1 to 2
hours this gives way to mild tenderness and edema, which can
be pronounced. Numbness in the skin overlying the treated area
typically lasts for several weeks. During healing, induration
slowly dissipates, producing a flatter contour with reduced fat
compared with pretreatment. Skin smoothing and tightening
have been postulated given the inflammatory nature of the heal-
ing process, with the removal of necrotic fat in the area, but there
are no data on this in other body areas. The compound is not
exclusively selective for adipocytes and can create tissue injury
if injected into skin or deeper structures. Neuropraxia occurs if a
nerve is infiltrated with the medication.
85.4 Concluding Thoughts
The strong patient demand for safer, less invasive body contour-
ing procedures will inevitably drive technology toward more
effective modalities that minimize downtime and recovery
while improving results. The future of body contouring will
likely stratify patients into more distinct categories, such as
those requiring aggressive surgical excision, minimally inva-
sive liposuction techniques with adjunctive energy-delivering
modalities or mesotherapy, and noninvasive techniques achiev-
ing volume reduction and skin tightening through additional
energy-delivering modalities.
:ith proven safety and efficacy, the future of minimally inva-
sive and noninvasive body contouring is very promising. However,
judicious patient selection cannot be overemphasized, and these
procedures should not be overpromoted. Currently, the most
ideal candidates for these types of procedures are those who are
accepting of a mild to moderate result.
These technologies, incorporated into a plastic surgery prac-
tice, provide a multifaceted approach to body contouring that
will ultimately lead to greater patient and physician satisfaction.
This is undoubtedly an emerging model of minimally invasive
and noninvasive body contouring surgery given that body con-
touring is a recurrent or perhaps even continuing process for
most patients; thus major surgery cannot be the only available
option.
The future of body contouring will most likely involve entirely
noninvasive procedures for mild cases and minimally invasive
procedures for moderate cases, with invasive procedures
reserved for massive-weight-loss and larger patients. Acquisition

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XII Body Contouring
of noninvasive technologies is designed not to supplant surgical
procedures but rather to offer a broader range of patients an
appropriate option for their needs. Patient expectations must be
based on the realistic capabilities of the available technologies,
which is key to patient satisfaction and achievement of their
aesthetic goals.
Clinical Caveats
• Patients must be stratified into candidates for surgical con-
touring, nonsurgical contouring, and medical weight loss.
• Realistic patient expectations for each option must be estab-
lished at the outset.
• Noninvasive contouring technologies will require multiple
rounds of treatment for significant results.
• Noninvasive contouring technologies will cost more and pro-
duce less than liposuction procedures but avoid anesthesia
and recovery time and have a very low complication risk
profile.
• Although many noninvasive technologies can be provided
by nonprofessional staff in your office (subject to regulations
in your state), careful planning by an experienced aesthetic
plastic surgeon is essential to optimizing results.
• A detailed understanding of the energy–tissue interactions
and outcomes data is essential to selecting technologies that
will work in your practice.
• Manufacturer-provided training and coaching from expe-
rienced users substantially enhances deployment of a new
technology in your practice.
• Minimally invasive energy application devices contribute to
enhanced outcomes but have a variable response based on
the individual patient’s remodeling ability.
Suggested Reading
[1] Ascher B. Safety and efficacy of UltraShape Contour I treatments to improve the
appearance of body contours: multiple treatments in shorter intervals. Aesthet
Surg J 2010;30(2):217–224
[2] Avci P, Nyame TT, Gupta GK, Sadasivam M, Hamblin MR. Low-level laser therapy for
fat layer reduction: a comprehensive review. Lasers Surg Med 2013;45(6):349–357
[3] Bass LS, Doherty ST. Safety and efficacy of a non-invasive 1060 nm diode laser
for fat reduction of the abdomen. J Drugs Dermatol 2018;17(1):106–112
[4] DiBernardo BE. Randomized, blinded split abdomen study evaluating skin
shrinkage and skin tightening in laser-assisted liposuction versus liposuction
control. Aesthet Surg J 2010;30(4):593–602
[5] DiBernardo BE, Reyes J. Evaluation of skin tightening after laser-assisted liposuc-
tion. Aesthet Surg J 2009;29(5):400–407
[6] Duncan D, Rotunda AM. Injectable therapies for localized fat loss: state of the art.
Clin Plast Surg 2011;38(3):489–501, vii
[7] Garibyan L, Sipprell WH III, Jalian HR, Sakamoto FH, Avram M, Anderson RR.
Three-dimensional volumetric quantification of fat loss following cryolipolysis.
Lasers Surg Med 2014;46(2):75–80
[8] Jewell ML, Baxter RA, Cox SE, et al. Randomized sham-controlled trial to evaluate
the safety and effectiveness of a high-intensity focused ultrasound device for
noninvasive body sculpting. Plast Reconstr Surg 2011;128(1):253–262
[9] Jewell ML, Weiss RA, Baxter RA, et al. Safety and tolerability of high-intensity
focused ultrasonography for noninvasive body sculpting: 24-week data from a
randomized, sham-controlled study. Aesthet Surg J 2012;32(7):868–876
[10] Jones DH, Carruthers J, Joseph JH, et al. REFINE-1, a multicenter, randomized,
double-blind, placebo-controlled, phase 3 trial with ATX-101, an injectable drug
for submental fat reduction. Dermatol Surg 2016;42(1):38–49
[11] McRae E, Boris J. Independent evaluation of low-level laser therapy at 635 nm
for non-invasive body contouring of the waist, hips, and thighs. Lasers Surg Med
2013;45(1):1–7
[12] Nassab R. The evidence behind noninvasive body contouring devices. Aesthet
Surg J 2015;35(3):279–293
[13] Robinson DM, Kaminer MS, Baumann L, et al. High-intensity focused ultrasound
for the reduction of subcutaneous adipose tissue using multiple treatment
techniques. Dermatol Surg 2014;40(6):641–651
[14] Schilling L, Saedi N, Weiss R. 1060 nm Diode hyperthermic laser lipolysis: the
latest in non-invasive body contouring. J Drugs Dermatol 2017;16(1):48–52
[15] Solish N, Lin X, Axford-Gatley RA, Strangman NM, Kane M. A randomized,
single-blind, postmarketing study of multiple energy levels of high-intensity focused
ultrasound for noninvasive body sculpting. Dermatol Surg 2012;38(1):58–67

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1341
86 /iSRVuFWiRn Dnd +igK-'eÀniWiRn /iSRVFuOSWure
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Alfredo Hoyos and Mauricio Perez
Abstract
Since the advent of the liposuction apogee after Ilouz and
Fournier’s first description, many variations on the original
technique have been made and improved. However, some basic
principles remain the same, while others had to be changed or
updated to allow better outcomes.
The most important updates have been the tumescent tech-
nique and added technologies for removing more adipose tissue
and increasing stem cell harvest with less bleeding and fewer
complications. There are now as many variations of the original
method as there are tech-assisted devices.
For high-definition body sculpting we use third-generation
ultrasound. We take advantage of this technology to perform a
smooth, deep, and superficial lipoplasty that provides a natural,
athletic, and muscular appearance without curbing the functional
and dynamic appearance of the underlying anatomy.
One of the foremost objectives of cosmetic surgery is to
minimize complications, which requires consideration of many
factors. The process begins with preoperative preparation, then
moves to intraoperative procedures, and ends with postoperative
control and follow-up. Strict adherence to each of the protocols of
this three-step task will decrease the incidence of postoperative
complications.
Keywords
liposuction, high-definition liposculpture, complications,
ultrasound-assisted liposculpture, VASER, fat grafting, stem cells
86.1 Introduction
Inasmuch as any corporal zone was susceptible to liposuction, it
rapidly became one of the most important aesthetic procedures
around the world. There have been many variations of and mod-
ifications to the original technique over the past several decades.
Improvements in technology have allowed important advances.
The safety of liposuction as well as a desire to improve one’s
appearance have pushed aesthetic surgeons toward standards
of care, optimization, and development. For those fatty deposits
resistant to exercise and diet, liposuction was used as a surgical
solution. For decades, it has been the most frequent procedure
in aesthetic surgery, second only to breast implants in some
countries. After many conventional procedures, the introduction
of the tumescent technique by Klein in the 1990s transformed
the safety of suction-assisted lipoplasty, allowing surgeons to
remove larger amounts of adipose tissue with less blood loss.
Meanwhile, the development of new technologies also
impacted the outcomes and the way liposuction was performed.
Ultrasound was introduced in the medical field many years before
it became popular in aesthetic surgery; for example, Kelman
introduced phacoemulsification for cataracts in 1967 after being
inspired by his dentist’s ultrasound device for descaling. Also,
neurosurgeons started using it for selective destruction of tumors,
and general surgeons for cutting and coagulating tissues during
laparoscopic surgery. In the late 1980s and early 1990s, Scuderi
and Zocchi pioneered the application of ultrasound for selective
emulsification and removal of fat for body contouring. After that,
the SMEI Company developed the first-generation ultrasound-
assisted device for liposuction in Italy, which consisted of large 4-
to 6-mm solid probes that emulsified fat at a frequency of 20 kHz.
By the mid-1990s, two second-generation ultrasound-assisted
lipoplasty devices were introduced, which were very similar to
the first device but differed in that emulsification was intermit-
tent rather than continuous. The success of the first-generation
devices led to a surge in the development of many new devices.
Lysonix 2000 (Misonix) featured hollow ultrasonic cannulas of
4.0-mm and 5.1-mm diameter in the later 1990s to achieve fat
emulsification and aspiration simultaneously through a golf-tee
and bullet design, at a frequency of 22.5 kHz. In the meantime,
Mentor Corporation introduced their Mentor Contour Genesis
device, which employed 3.0- and 5.1-mm hollow cannulas at a
frequency of 27 kHz. Although there was significant improve-
ment from the first- to the second-generation devices, surgeons
began to realize that excessive ultrasound delivery to the tissues
with these devices, compounded with the elimination of pro-
tective wetting solution due to simultaneous aspiration during
ultrasound delivery, resulted in a significantly higher rate of
complications. In 2001, Sound Surgical Technologies introduced
a third-generation device, designed to improve safety by reducing
the power delivered to the tissues while maintaining efficacy.
They designed smaller-diameter solid probes (2.2–4.5 mm) and
a unique grooved tip design to emulsify fat efficiently at 36 kHz
while also preserving surrounding tissues and structures. This
new technology was patented with the name VASER (vibration
amplification of sound energy at resonance) and became the
dominant system for ultrasound-assisted lipoplasty.
We believe that the addition of VASER to body contour liposcu-
lpture has decreased the risk of thermal injury and intraopera-
tive and postoperative bleeding. It has also enabled stem-cell
harvesting from the extracted adipose tissue for later grafting in
areas that lack volume or projection. Studies have been published
supporting the use of ultrasound in cosmetic surgery, and VASER
is no exception. In 2002, Jewell et al published a multicenter,
single-blinded study that demonstrated the safety of VASER for
lipoplasty. No major complications were reported with its use.
Also, surgery time was shorter than with standard liposuction,
and the fatty tissue was more easily extracted after ultrasound
emulsification. Moreover, it is particularly effective for tight,
fibrous areas, such as the back and posterior flanks, areas where
increased blood loss would be expected with standard liposuc-
tion. In general, VASER reduces surgeon effort.

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XII Body Contouring
Although VASER-assisted lipoplasty typically takes longer
than standard suction-assisted lipoplasty due to the extra step
required for emulsification of adipose tissue before aspiration,
the technology has several advantages. Fine probes and tunable
power allow delicate and superficial tissues to be treated without
causing unwanted irregularities. The unique pulsed (VASER) mode
also halves the energy delivered to the tissues and represents an
important feature for subdermal clearance of fat without causing
complications. In order to treat fibrous tissue, such as the back
or male breasts, the power output is increased, continuous
ultrasound is selected, and a more aggressive probe, such as
the one-grooved or arrow probe, is selected. The cavitation and
mechanical forces that are produced by the VASER probes vibrat-
ing at ultrasonic frequencies disrupt relatively weak adipose tissue
much more readily than denser tissue, such as vessels, nerves,
and fibrous septae. As a result, there is selective emulsification
of fat with sparing of surrounding tissues. This translates to less
bleeding, less bruising, and an easier and more rapid recovery for
the patient than suction-assisted lipoplasty. The majority of fat
aspirated following treatment with VASER is viable. This is par-
ticularly important for high-definition body sculpting, in which
large volumes of fat grafts may be used to contour the buttocks,
hips, or breasts.
Consequently, this technology improved surgical procedures
and reduced complication rates, which led to a new era of body
sculpting.
86.2 Body Sculpting with the
9AS(5 7eFKniTue
86.2.1 Preoperative Markings
Preoperative markings are essential to recognize the different
zones and spaces that will be treated with superficial or deep
liposuction, as well as the smooth transition zones. A color code
is created for each feature that will need to be recognized during
surgery. We have created a code based on each characteristic:
(1) black for anatomical landmarks and gross liposuction (access
incisions), (2) red for dynamic zones and transition zones, (3)
green for negative spaces, and (4) blue for fat grafting. Sometimes
purple can also be used to mark some zones for extra definition
or thorough deep liposuction. Markings must always be made
with the patient in the standing position, allowing gravity and
muscles to rest in the anatomical position. Then, depending on
the zone we will treat, we ask the patient to make a voluntary
contraction of some muscles to mark the dynamic zones and also
the negative spaces: for example, triceps and biceps contraction,
rectus abdominis muscle and serratus contraction, pectoralis
major contraction, and contraction of the calves, hamstrings,
and quadriceps (Fig. 86.1, Fig. 86.2).
86.2.2 2SerDWiYe 7eFKniTue
After marking is completed, we start with the surgical prepa-
ration, after which the patient is placed over a sterile blanket
and anesthetic induction begins. One precaution is worth
mentioning: under the blankets there must be a heat-cooling
blanket exchanger in order to keep the patient warm during the
procedure. Some studies support its use in order to avoid hypo-
thermia, particularly in the presence of a cool operating room. In
addition, in body sculpting surgery we block some physiologic
protective mechanisms by tumescent solution infiltration, fat
pad removal, vasoconstriction, and sedation/relaxation. After
sedation, analgesia, and anesthesia are achieved, we initiate
surgery by placing ports over stealth incisions (Fig. 86.3). These
hidden incisions are explained later in this chapter.
Infiltration of tumescent fluid into the subcutaneous fat com-
partments is the first step in body sculpting (Fig. 86.4). Typically,
a large volume of saline, mixed with epinephrine, sodium
bicarbonate, and varying quantities of lidocaine, is infiltrated into
the subcutaneous treatment planes until the tissues are firm.
Tumescent anesthesia may obviate the need for sedation or gen-
eral anesthesia. When general anesthesia is used, the tumescent
infiltrate is usually prepared with a much smaller quantity of local
anesthetic. This initial step produces a relatively bloodless field
due to the profound vasoconstrictive properties of epinephrine.
The fluid environment is essential for the safety and efficacy of
ultrasound-assisted lipoplasty. For high-definition lipoplasty,
fluid must be infiltrated very superficially in the subdermal layer
as well as deeper layers to protect the tissues during the delivery
of ultrasound. A peau d’orange, or dimpled, appearance in the skin
is normal when the fluid is infiltrated very close to the dermis.
As soon as infiltration of tumescent solution has concluded and
once sufficient time has elapsed for vasoconstriction following
tumescence (a 20–30 min), an appropriately sized and grooved
VASER probe is selected depending on the volume of fat present
and on whether the tissues are soft or fibrous (Fig. 86.4). For
high-definition sculpting, the superficial subcutaneous fat should
be treated first in VASER mode. :e usually start with a 3.7-mm
two-grooved probe using an amplitude of 80%. Gentle but deliber-
ate, long to-and-fro strokes are made with the operating hand like
the bow movements of a cellist. Movements should be graceful and
continuous, with no torquing, which could conduct excessive heat
through the skin port and result in a burn. Although the skin port
protects the skin around the incision to some degree, wet towels
should be placed adjacent to the port during ultrasound delivery
to protect the skin from contact with the probe, specially when
removing it. The probe should be parallel to the skin and guided by
the nondominant hand. Some resistance is felt as the probe gently
creates tunnels through the fat, but it should not stop the probe in
its path or require grasping and pushing of the probe with the oper-
ating hand. If excessive resistance is experienced, energy should be
increased to 90%, or an alternative probe should be selected. One
should continue emulsification until no resistance is encountered
in the treatment area so that the skin is undermined and allowed
to redrape during the postoperative period. Ultrasound is delivered
only inside the patient and in an area where there is sufficient
wetting solution (Fig. 86.4). Since tumescence is a temporary
state, some reinfiltration of tumescent fluid may be required in
the superficial plane immediately prior to emulsification. As when
emulsifying fat in the ipsilateral side, the probes are long enough
to pass to the contralateral side, and this criss-crossing maneuver is
important for smooth, even results, especially in the rectus abdom-
inis muscle, where remarkable definition needs to be achieved. As
well as emulsifying all marked areas to a point of minimal or no
resistance, feathering should be done by emulsifying to a lesser
degree in border areas to create smooth transitions between

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contours. Once the superficial layer is completed, continuous mode
is used to emulsify the deeper fat. Approximately 60 to 90 seconds
of ultrasound delivery per 100 mL of tumescent fluid is infiltrated,
but the end point is primarily determined by the low resistance
of tissues rather than by the timing. Upon resuming, the VASER
system is employed to optimize safety and efficacy. Thorough
emulsification in the superficial subdermal plane is performed
first to redrape the skin and enhance the skin-tightening effect.
This is followed by a deeper emulsification to reduce the volume.
Slow, gentle but deliberate strokes are used to pass the titanium
probes through the fatty tissue until little or no resistance is felt.
The probes should not be forced or held tightly; an appropriately
chosen probe at the correct setting glides effortlessly through the
pearls and lobules of fat without harming blood vessels or nerves.
By the time emulsification is completed, the skin ports are
removed, and a suitably sized suction cannula is inserted. In
general, smaller cannulas are less likely to create postliposuction
defects and/or irregularities. We prefer 3.7-mm and 3.0-mm
vented cannulas, which have port sizes smaller than those on
3.0-mm and 2.4-mm Mercedes cannulas, respectively. Aspiration
of emulsified fat is easy and requires little force (Fig. 86.4). The
PowerX system (Sound Surgical Technologies LLC, Louisville, CO)
can be used to increase aspiration efficiency. This generates up
to 360° of alternating clockwise and anticlockwise rotation of
the cannula at a rate of up to 420 times per minute. Cannulas
with multiple orifice patterns are used for aspiration with the
PowerX system, including the standard, Mercedes, Spiral, and
Mendieta. The extent and areas of removal are dictated by the
preoperative markings. Where convexities are desired, less fat is
removed; where negative spaces are desired, fat is removed more
thoroughly. After debulking, the 3.0-mm cannula is used to treat
the superficial plane. In order to define muscle groups and create
shadows, it is necessary to create controlled deformities. These
are deliberate irregularities, created by removing almost all of the
Fig. 86.1 Markings in the male patient. (a) First we mark the negative
spaces and transition zones that will be treated with thorough and
smooth liposuction, emphasizing anatomical triangles (lights and
shadows concepts). (b) Then zones for superficial liposuction as well
as zones for fat grafting enhancement are also marked. Note: we are
describing general landmarks for the gluteal area, but there are many
more details beyond the scope of this chapter.
Fig. 86.2 Markings in the female patient. (a) Careful and very
descriptive markings need to be made in women’s negative spaces and
transition zones in the gluteal area. Anatomical triangles, adhesion
zones, and other specific landmarks need to be advised (lights and
shadows concepts). (b) Then zones for superficial liposuction as well
as zones for fat grafting enhancement are also marked. Although the
illustration depicts breast enhancement through fat grafting, it could
also be achieved with implants. Note: we are describing general land-
marks for the gluteal area, but there are many more details beyond the
scope of this chapter.

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XII Body Contouring
fat in the subdermal layer. During aspiration, the operating hand
moves forward and backward radially like the spokes of a wheel,
while the other hand stabilizes the skin over the tip of the cannula.
As suction continues, the pinch test is performed intermittently to
assess symmetry and reduction in the thickness of the fat layer. In
traditional body contouring, the end point is reached when the
desired amount of fat removal and improvement in body contour
have been achieved. In high-definition body sculpting, additional,
very superficial lipoplasty is performed with small cannulas to
create controlled irregularities and negative spaces.
Numerous incisions are required in order to perform high-
definition lipoplasty. However, consideration must be given to
the location of these incisions. For surgeons, the balance lies
between operating comfortably from easy access sites that leave
visible scars and hiding incisions in concealed folds or creases, at
the cost of working from awkward positions that may necessitate
additional incisions to reach all contours; moreover, small inci-
sions can leave conspicuous scars, particularly if they are hyper-
pigmented or hypertrophic. Various factors influence the healing
process, including age, race, presence of body hair in men, and
suturing method. When closure is indicated, we prefer subdermal
continuous sutures. The gentle manipulation of the incisions and
flaps is crucial to avoid hyperpigmentation and excessive scarring.
The ideal access points should not leave visible marks over the
abdomen or the back and should be hidden in the underwear
or over the natural folds of the skin. This helps avoid stigmata of
lipoplasty surgery, as even with good contouring results, some
patients are reluctant to wear a bikini or sunbathe if noticeable
scars are present. We have perfected the use of hidden or stealth
incisions and developed various long and curved cannulas to com-
fortably access the entire body (Fig. 86.3). From these access sites,
we are now able to perform superficial framing and definition of
the underlying muscle anatomy. Keeping an eye on our markings,
we start on negative zones (concavities) for superficial, thorough
Fig. 86.3 Stealth incisions. Note the different locations for (a) the male
patient compared with (b) the female patient. Remember that the
pectorals are more important in males, as the gluteal area is for females.
Fig. 86.4 General features of the high-definition liposculpture process. Note that the normal tissue (a) is infiltrated with the tumescent solution (b),
then emulsification (c) takes place, and finally liposuction (d) is performed.

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liposuction and then smoothly reach those positive spaces
(convexities). Transition zones between positive and negative
spaces need to be treated carefully so as to provide the enhancing
appearance of the underlying muscles. We prefer curved and thin
cannulas for small muscles and positive spaces but thicker and
straight cannulas for negative spaces and big fat pads. For exam-
ple, for arm high-definition liposculpture we use a short, straight,
thick cannula from the elbow stealth incision; for the pectoral
crease we use a curved, thin cannula from the axillary incision.
Where convexities are desired, less fat is removed; where negative
spaces are desired, fat is removed more thoroughly. After that, the
3.0-mm cannula is used to treat the superficial plane. In order to
define muscle groups and create shadows, it is necessary to create
controlled deformities. These are deliberate irregularities, created
by removing almost all of the fat in the subdermal layer.
The creation of controlled deformities occurs in the last phase
of high-definition body sculpting and is the most challenging
and least forgiving step in the procedure. These negative spaces
and controlled deformities are formed using compression and
pinching techniques. During compression, the tissue is pressed
down over the tip of the cannula with the guiding hand. A con-
cavity is gradually formed by repeated passage of the fine cannula
through the compressed tissue. Pinching facilitates the removal
of subdermal fat as the skin is grasped and squeezed around the
cannula tip (Fig. 86.5). This technique is particularly useful for
creating shadows along the linea semilunaris. As the sculpting
procedure progresses, the shadows begin to show, and the three-
dimensional forms are created. The deepest groove contains the
darkest shadow and represents the area that received the most
thorough liposuction. These grooves are blended with surrounding
forms by removing progressively less fat as the negative space rolls
toward a positive space. This tonal progression is achieved by reduc-
ing the compression over the cannula and by reducing the number
of strokes in each subcutaneous track. The end point for high-
definition body sculpting is the visual result. The surgeon should be
able to appreciate the definition at the end of the procedure.
Some specific zones, known as adhesion zones, are forbidden
for liposuction because they can lead to deformities or asymme-
tries due to their specific anatomy and poor fat content (Fig. 86.6).
These zones need to be carefully avoided, and we have already
identified them over time: trochanteric depression in the gluteal
zone; popliteal, medial, and lateral zone of the thigh; lower back
sacral depressions (Venus dimples); Cooper’s ligaments on the
breasts; and the inguinal ligament marking (iliac furrow). These
zones are also noticeable in the obese patient; however, their
surface anatomy limits are not so clearly identified.
There is another consideration as important and definitive for
body sculpting, called the dynamic state. The dynamic concept
was inferred after we noticed that most muscles have different
anatomical features in the resting position compared with the
movements they perform. Although high-definition liposculpture
was initially planned for muscles in their anatomical position,
we then considered making some additional markings after the
active movement of the muscle. The dynamic zones are referred
to as the ones that drastically change the appearance of certain
group of muscles from resting to active positions (Fig. 86.7). These
zones helped us to realize that results could be more natural than
before by avoiding the postop facade that most patients complain
about. Preoperatively, marks are carefully drawn (active vs. rest-
ing) over the triceps and biceps muscles, pectorals and deltoids,
rectus abdominis, serratus and obliques, and latissimus dorsi and
trapezius muscles. Other muscles, such as the quadriceps and
gastrocnemius are also marked if necessary. These dynamic zones
will be treated as negative spaces and exhaustive superficial lipo-
suction will be performed; however, smooth transitions within
the same zone must be cautiously achieved.
Consequently, each zone for body sculpting needs to be indi-
vidualized. Cannulas and incisions need to be carefully chosen to
reach the anatomical areas and landmarks in order to guarantee
natural and optimal results. Remember also the concepts of
negative spaces and transition zones as they relate directly with
dynamic zones (Fig. 86.1, Fig. 86.2).
Fig. 86.5 High-definition carving and sculpting. (a) Compression and (b) pinching maneuvers.

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86.3 Adipose Tissue Anatomy
and Fat Grafting
Fatty tissue is the largest body energy reserve. It is highly
metabolically active and helps us regulate a lot of biochemical
processes. It represents 17% of the body weight at birth; in ado-
lescence represents around 20% in girls and 10% in boys, with
some phenotypic variations; and reaches stabilization at 15 to
20% in adult men and 25 to 30% in adult women. Two types of
fatty tissue, white and brown, are described in the human body.
White fat cells (adipocytes) produce leptin, the key hormone in
the regulation of body weight. Starvation corresponds to low
leptin levels and obesity to high ones. The hypothalamus spe-
cifically controls the feeding process depending on the signals
received from the gastrointestinal tract cells and the leptin
levels. Brown fat cells play a thermoregulatory role in mammals.
In human beings, the function of brown fat cells is not well
known, though their main role is related to heat production, at
least in the perinatal period. The possibility of pharmacologi-
cally stimulating these fat cells makes them a potential point for
therapeutic intervention in obesity.
The subcutaneous tissue has a particular distribution that has
not been thoroughly described. It is composed of three layers,
divided by a membranous tissue, which is referred to as superfi-
cial fascia and the Scarpa, Coles, and Camper fascia, which actually
confuses the real meaning of the nomenclature. The three layers
(Fig. 86.8) are (1) the superficial adipose tissue (SAT), (2) the inter-
mediate membranous layer (superficialis fascia), and (3) the deep
adipose tissue (DAT). The SAT layer is characterized by fibrous
septa that define polygonal lobes of fat cells. The thickness of this
layer is relatively constant throughout the body and is the one that
correlates with the pinch test that is commonly used to gauge the
insertion depth of the cannula for liposuction. The membranous/
intermediate layer is a continuous fibrous membrane rich in elas-
tic fibers that give the skin recoiling ability and structure. In the
DAT layer, the fibrous septa are obliquely oriented, which defines
large and flat lobes of fat cells. The boundary between this layer
and the muscle consists of a filmy membranous sheet called the
innominate or Gallaudet’s fascia, which is tightly adherent to and
often indistinguishable from the underlying muscle fascia. This
layer varies significantly according to anatomical region; it is usu-
ally thicker in the periumbilical region over the rectus abdominis
sheath and tapers laterally as it approaches the external oblique
muscle. The thickness and proportion of these layers change
throughout the body according to the anatomical regions and the
patient’s characteristics (Fig. 86.9). These differences have been
studied and clearly characterized for some areas:
• The abdominal area has a prominent fascial plane, which make
this site the easier to distinguish between the two layers. The
SAT is thicker in the upper abdomen and thinner in the lower.
• In the leg the SAT/DAT division is not clear. There is an
attenuated fibrous membrane barely discernible beneath a
single layer of subcutaneous fat and separating it from the
underlying muscle fascia. The adipose tissue is similar to the
superficial fatty layer of the trunk in gross appearance, den-
sity, and structure.
Fig. 86.6 Adhesion (forbidden) zones in the thighs. 1, major trochanteric depression; 2, lateral thigh; 3, popliteal zone; 4, inner thigh; 5, inferior
rectus abdominis bellies. Remember also Cooper’s ligaments on the breasts, lumbosacral depressions (Venus dimples), and inguinal ligaments
described in the text.

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• In the buttock and thighs, the subcutaneous fascia fuses with
the gluteal crease and infragluteal fold medially and with the
iliac crest superiorly. Laterally and below, the subcutaneous
fascia continues uninterrupted into the thigh, where it merges
with the iliotibial tract. The SAT depth is quite constant
throughout the buttocks, while the DAT is mainly over the glu-
teal muscles and iliotibial tract, having a maximal thickness
of 5 cm below the iliac crest, less so over the trochanter, and
even thinner as it proceeds distally down the thigh. This layer
appears dense and rather compact, with regularly spaced fat
lobules bound by sturdy fibrous septa often indistinguishable
from the superficial layer.
• The paralumbar subcutaneous adipose tissue resembles that
of the abdomen with respect to the presence and extent of two
fatty layers. The subcutaneous fascia is especially distinct. The
SAT thickness is relatively constant throughout the region. The
DAT is always thicker.
86.3.1 )DW GrDIWing 7eFKniTue
Today there are as many techniques for fat grafting as there are
surgeons. Each group has adopted a preferred technique for har-
vesting and injection. There is no clear international consensus
about the best technique for autologous fat grafting. However,
the main concepts are well known and widely accepted:
• Best selection of the donor site
• Atraumatic method for harvesting
• Suitable postextraction management of the graft
• Injection procedure that maximizes structural integrity,
nutrition, and survival
86.3.2 Donor Site and Harvesting
At the present time, selection is mostly based on the surgeon’s
preference (common practice) or is just chosen by the patient.
The most commonly used sites are the abdomen, thighs, flanks,
buttocks, and breast. :e have not appreciated differences in the
viability of fat graft from these sites. However, recent publica-
tions support that adipose-derived stem cells can improve the
longevity and volume of the fat graft. These cells are mostly
found on the lipoaspirate from the inner thigh and lower abdo-
men, which makes these areas ideal sites for harvesting.
The optimal harvesting technique is still debatable. Two main
techniques are machine liposuction or syringe aspiration. For both,
the histological structure is conserved, but it seems that the cel-
lular function is better conserved when using syringe aspiration.
Moreover, controlling the vacuum pressure is essential; when it is
greater than 700 mm Hg, the tissue is damaged and the viability
is really compromised. The Coleman technique appears to achieve
a better level of cellular function than other techniques, due to
the careful management of the graft with small cannulas. The
ideal cannula for harvesting was once believed to be the one with
the highest diameter, but it is now known that the main factor is
to control the negative pressure and keep it to a minimum. We
prefer to harvest by liposuction after fat emulsification via VASER,
carefully controlling the negative pressure at 10 mm Hg and using
a 3-mm cannula.
86.3.3 Graft Processing
Different authors have created several methods to process fat
grafts. Actually, some surgeons prefer to have somebody process
the fat graft and prepare it before injection. Some devices have
also been designed to purify and clear the fat graft from detritus.
Fig. 86.7 Dynamic zones. This concept was created some time after the introduction of high-definition liposuction, when we noticed that results in
the resting muscle differed from those in the active muscle. We discovered some specific zones that were far from static while marking patients. The
illustrations show dynamic zones in (a) the arm and (b) the pectoral muscle, including zones for fat grafting in the chest. Remember some important
negative spaces: 1, interpectoral rhomboid; 2, subpectoral triangle; 3, latissimus dorsi triangle; 4, subclavicular triangle; and the pectorals line.

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XII Body Contouring
The three most commonly used methods are sedimentation,
filtering, and centrifugation.
Centrifugation allows for separation of fat, lipids, and cells in
different layers by simple gravity: the deepest layer contains the
white and red blood cells, the middle layer holds the fat, and the
upper holds the oil. The deepest portion of the middle layer con-
tains most of the viable adipose cells and many angiogenic growth
factors, whereas the upper part has detritus and nonviable fat
cells. The speed of centrifugation is critical, allowing for the high-
est yield of viable cells. The best survival rate is achieved between
1,500 and 3,000 rpm for up to 5 minutes. We suggest 3,000 rpm
for 3 minutes or the use of 1,200 G of optimal centrifugal force.
The graft obtained by this means also has a higher density, which
is associated with a better survival rate.
Fig. 86.8 Adipose tissue anatomy. (a) Notice the difference between intra-abdominal and extra-abdominal fat. (b) Subcutaneous tissue layers:
superficial adipose layer, intermediate membranous layer, and deep adipose layer, pre- and posttreatment.

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When the graft is decanted, more viable adipocytes are found
than with centrifugation, but there are fewer stem cells and there
is more contamination with blood cells. The centrifugation may
damage more adipocytes but holds a higher amount of stem
cells, which finally helps improve the survival of the fat graft.
We use the decantation process for most cases by removing the
infranatant and adding antibiotics (cephazolin). For high-volume
fat grafting (gluteus, pectorals, breasts) we use decantation, but
in small-volume fat grafting (deltoids, biceps, calves) we prefer to
use centrifugation to maximize the fat survival.
86.3.4 /iSRinMeFWiRn 7eFKniTue
Across most aesthetic plastic surgery groups, use of a single bolus
injection with large amounts of fat is generally discouraged, as it
results in unwanted results and higher rates of complications. The
thicker the graft, the higher the risk of failure, because the survival
depends on the plasmatic imbibition from the surrounding tissues.
The graft should be placed in multiple layers to increase graft
viability. Moreover, placing the graft inside the muscular layer
will promote graft longevity due to the increased blood flow
and nutrients that active cells have. The one exception is in the
buttock, where intramuscular injections are not performed due
to safety concerns. The grafts are placed using a 3-mm cannula
in small amounts injected as the cannula is in retrograde motion.
This must be done multiple times, in multiple tunnels, and at dif-
ferent tissue levels (Fig. 86.10). Once the required degree of defi-
nition has been achieved, harvested fat is used to augment convex
forms, particularly the buttocks, breasts, deltoids, male chest, and
calves. Large 60 mL and 20 mL syringes, and 3- to 4-mm Toomey
cannulas are used with a retrograde linear threading technique.
The subcutaneous and intramuscular planes receive the fat in
multiple fine strokes to ensure small parcels are left rather than
large boluses.
Once the desired volumes are grafted, a sequential comparison
may be performed from different points and angles in the surgery
room to ensure symmetry and proportions. Finally, we prefer to
leave some stealth incisions opened for lymphatic drainage in
slope points. Blake drains (Johnson & Johnson) are placed in the
subdermal layer to monitor drainage. The remainder are sutured
in a delicate fashion avoiding flap trauma with intradermal
stitches. Garments and foams are placed immediately in the post-
operative period, and the patient is discharged after recovering
from sedation and anesthesia.
86.4 Postoperative Care
Although the general population usually thinks that surgery
is what the patient needs in order to achieve excellent results,
surgeons acknowledge the importance and vital linkage that
postoperative care has with any procedure, and high-definition
liposculpture is no exception. In fact, high-definition body
sculpting must have a comprehensive postoperative care regi-
men prescribed.
Complications and suboptimal results arising from internal
ultrasound, extensive superficial and deep lipoplasty, and
large-volume fat transfer can be avoided or reduced by implement-
ing a plan of appropriate care and therapies in the postoperative
period. These include advice, medications, drainage, compression,
massage, and external energy-based procedures. To ensure suc-
cess, the importance of compliance with postoperative care and
attending postoperative visits must be explained to the patient
during preoperative consultations. One should make patients
aware of their commitment to postoperative care during the
preoperative evaluation and before beginning surgery, and it must
be carefully mentioned during the informed consent process.
Fig. 86.9 Abdominal fat distribution. Deep and superficial fat layers according to different corporal areas.

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86.4.1 Target of Therapy
• Treat the signs and symptoms of postsurgical bruising and
edema.
• Promote and monitor the healing process.
• Prevent and treat fibrosis, adhesions, or undesirable scar
tissue.
• Treat and control scars, keloids, and hypertrophic scars.
• Advise in aftersurgical care to ensure the success of surgery.
• Establish the complications to be treated.
86.4.2 Types of Postoperative
Basic Procedures
• Drainage: daily drainage must be performed by a technologist.
• Compression: garments and foams must be used for at least 2
weeks after the procedure. Then, depending on the surgeon’s
evaluation, their use is recommended for an additional 4 to 8
weeks.
• Ambulation
Another type of procedure that needs to be performed for some
patients is within the CARE system (cosmetic active recovery).
This program was designed to accelerate the recovery of the
tissue and thereby reduce convalescent time. There are many
treatments, but the combination of treatments in a specific
sequence provides the results we seek. The main purposes of this
therapeutic method are to reduce swelling, bruising, and pain
and to improve healing. The method is sometimes used before
surgery to prepare the tissue for intervention.
86.4.3 SRme GenerDO (̵eFWV
• Activates the lymph and lymphatic circulation
• Improves blood circulation
• Enhances immune system function
• Stimulates the parasympathetic nervous system (relaxation
effect)
• Helps the healing process (protects against hypertrophic scars
or keloids)
• Reduces fibrosis after liposuction
86.4.4 SeTuenFe 3rRWRFRO
1. Lymphatic drainage
2. External ultrasound
3. Pressotherapy
4. Diathermy
5. Radiofrequency
6. Moist heat
A thorough postoperative care regimen in patients undergoing
high-definition body sculpting helps avoid complications and
optimize the aesthetic result. In the immediate postoperative
Fig. 86.10 Fat grafting. The “multriple” technique: multiple layers,
multiple times, multiple tunnels. (a) The muscle pinch maneuver must
be done for multilayer chest fat grafting. (b) Breast fat grafting must
be performed in three layers: submuscular, intramuscular, and peri-
mammary. Two accesses are needed to avoid Cooper’s ligament injury.
(c) Diverse gluteal fat grafting has to be done to improve projection
and contour, also via two access points.

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phase, blood-tinged tumescent fluid is evacuated by compression
and open drainage. Bimodal compression, using specialized foam
and garments, reduces swelling, ecchymoses, and liposuction
edema. After 2 to 3 days, manual lymphatic drainage commences
in order to accelerate healing. Drains are removed and external
ultrasound is added after 1 week to soften tissues and reduce
edema further. Various other energy-based modalities, including
radiofrequency and radial extracorporeal shockwave therapy,
are useful adjuncts after 4 to 6 weeks, particularly if there is any
fibrosis, reduced skin tone, or cellulite.
86.5 Outcomes
High-definition and 4D liposculpture results can be noticed 6
months postop, but they can be noticeable by the first month (Fig.
86.11, Fig. 86.12, Fig. 86.13, Fig. 86.14). As we mentioned earlier,
use of garments and foam vests is crucial to obtaining optimum
outcomes: they will keep the skin adhered to the newly defined
anatomy and help the lymph draining and healing process by
preventing seroma and other complications. Noncompliant
patients have a higher likelihood ratio for complications than
those who clearly follow the recommendations.
Fig. 86.11 Male high-definition body sculpting surgery for a 38-year-old man. (a–e) Preoperative pictures show the 360° distribution of adipose
tissue accumulation.

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Since surgery is the first path to a new way of life, we always
instruct our patients and prescribe a diet for them, along with
nutrition plans, metabolic controls, and exercise routines, for
long-lasting results. We advise them that exercise and diet are
vital to good health and to improved outcomes by preventing new
fat deposition over the pads we have just removed.
Although we do our best and improve our techniques to achieve
long-lasting results in fat grafting, patients and surgeons need to
be aware of reabsorption and muscle mass decrease over time.
Muscles need to be continuously trained to enhance muscle mass,
and gym routines should be focused on those muscles lacking
projection and shape. Certainly, a multilayer technique, stem-cell
enrichment, and exercise are key points to improve the contour
and projection in high-definition body sculpting fat grafting.
86.6 Complications
The goals of high-definition lipoplasty are to optimize patient
contour and outcomes and diminish the risk to the patient.
Fig. 86.12 Male high-definition body sculpting surgery for a 38-year-old man. (a–e) Postoperative views at 6 months show a new athletic and
muscular appearance compared with the preoperative pictures (Fig. 86.11). Note the new definition of the chest and the gluteal area. (c,d) The arms
are also defined to improve the muscular anatomy.

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Sometimes iatrogenic and undesirable complications can occur.
A long learning curve and much practice are required to master
the high-definition technique in body sculpting surgery. This
supports our ongoing effort to teach and lead training worldwide
in high- and dynamic-definition liposculpture.
Fig. 86.13 Female high-definition body sculpting surgery for a 29-year-old woman. (a–e) Preoperative pictures show the adipose tissue accumula-
tion, predominantly in the thighs, the gluteal area, and the lateral abdomen.

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The patient should be made aware during informed consent
that high-definition lipoplasty is different from conventional lipo-
suction. Patients who may not be motivated to attend frequent
postoperative visits should be excluded, because postoperative
therapies play a critical role in optimizing the results and minimiz-
ing complications. The patient must also understand the impor-
tance of constant compression with foam vests and garments.
Most of the complications associated with high-definition body
sculpting can also arise following conventional lipoplasty tech-
niques. Even though VASER technology is important for successful
high-definition lipoplasty and may also reduce excessive blood
loss and prolonged edema, as well as stimulate skin retraction, it
is also prone to several complications due to the high energy it is
based on. The next sections list some frequent complications of
general liposuction and high-definition liposculpture with a brief,
description of each.
Fig. 86.14 Female high-definition body sculpting surgery for a 29-year-old woman. (a–e) Postoperative views at 7 months show a new slim figure
and the new contour in the abdominal region, compared to preoperative pictures (Fig. 86.13). (c) The arm definition and the gluteal enhancing
through selective fat grafting give a youthful and athletic appearance.

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86.6.1 General Liposuction
Complications
Bleeding
Excessive bleeding during or following high-definition body
sculpting is rare. Using the tumescent technique, saline with epi-
nephrine causes profound vasoconstriction so that the emulsifi-
cation and removal of fat is occurring in an almost bloodless field.
Although a creamy, bloodless aspirate is typical during tumescent
VASER lipoplasty, a bloody aspirate may be produced in very fibrous
areas, such as the back, upper abdomen, or male breasts. Patient
medical history and preoperative assessment should detect any
coagulopathy or blood disease. Preoperatively, patients should
not take any medications, vitamins, herbals, or supplements with
antiplatelet effects for at least 7 to 10 days. These include aspi-
rin, nonsteroidal anti-inflammatory drugs, vitamin E, ginseng,
ginger, ginkgo biloba, and garlic. The application of compression
garments is essential immediately postoperatively in order to
facilitate hemostasis and compress small vessels. Although some
ecchymosis is normal, extensive ecchymosis may occur in areas
where bleeding has occurred over large surface areas, particularly
in the thighs. Resolution of ecchymosis occurs without inter-
vention, although oral or topical Arnica montana may accelerate
healing. A small hematoma may resolve without intervention. A
large hematoma can be evacuated or aspirated once it liquefies.
Untreated, a large hematoma will become organized and form a
mass, seroma, and chronic pseudocyst requiring aspiration.
Infection
Infection is extremely rare following lipoplasty and high-defi-
nition body sculpting, though some severe cases have been
reported. Sterile technique, small incisions, and properly
sterilized instruments in selected patients greatly lower the
incidence of infection. Additionally, components of tumescent
fluid also have antimicrobial effects on bacteria, mycobacteria,
and fungi. Patients should be carefully evaluated to state optimal
immunological condition. Prophylactic antibiotics, such as a
cephalosporin, should be prescribed before surgery and should
be continued for 5 days.
Necrosis
Necrosis of tissue and skin may occur following aggressive
superficial lipoplasty if the subdermal vascular plexus is
compromised. This is more likely if the patient is a smoker or
if sharp cannulas are used. If the ultrasonic probe is not contin-
uously moving in the tissues, or if it is activated in dry tissues,
mechanical energy will be converted to heat, and a burn may
result. To minimize the incidence of necrosis, very superficial
maneuvers, such as pinching or compression, should be limited
to areas where shadows are required (e.g., over the linea alba or
linea semilunaris) and not performed extensively over the abdo-
men. Additionally, a burn or necrosis is rare when using pulsed
ultrasonic delivery to the superficial tissues through a gentle
dynamic technique in wet tissues. Postoperative compression
foam and garments should be tailored to fit the patient properly
so as to avoid excessive compression that may compromise
perfusion to the skin and superficial tissues (Fig. 86.15).
Seroma
Seroma formation is usually an inflammatory exudate but may
also consist of lymph. An untreated hematoma may also become
a seroma over time. Large seromas are uncommon following
high-definition body sculpting, because the patients are usually
not obese and continuous drainage is performed during the
CARE system. Seromas are more common in overweight or obese
patients. Diagnosis is either by clinical or ultrasound examina-
tion. Early seromas can be drained by needle aspiration followed
by compression.
Thromboembolism
Risk factors for deep venous thrombosis (DVT) and pulmonary
embolism (PE) should be identified during the consultation and
Fig. 86.15 Skin necrosis. A 36-year-old woman who underwent
high-definition lipoplasty experienced skin flap ischemia and superfi-
cial necrosis due to superficial vasculature injury in the lower lumbar
region when the gluteal area was being defined.

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XII Body Contouring
assessment. Prolonged surgery and postoperative immobiliza-
tion also increase the risk. For lengthy procedures performed
under intravenous sedation or general anesthesia, perioperative
antithrombotic prophylaxis will reduce the risk of DVT and PE.
In general, if the procedure is performed purely under tumes-
cent local anesthesia where the patient is moving during the
procedure, prophylaxis is not required. Patients should mobilize
as soon as possible postoperatively and stay well hydrated.
Measures to reduce the risk of thromboembolism associated with
high-definition body sculpting include discontinuing estrogens
for 3 weeks before and after surgery, ensuring the patient wears
thromboembolic deterrent (TED) or antiembolic/antithrombotic
stockings, administering subcutaneous low-molecular-weight
heparin toward the end of the procedure and postoperatively for
patients undergoing procedures estimated to last longer than 1
hour under sedation or general anesthesia, and excluding high-
risk patients from treatment. Several cases of fatalities due to PE
associated with liposuction have been reported. If suspected,
therapy may be commenced even before a definitive diagnosis
is made with imaging, such as a ventilation—perfusion lung scan
and CT pulmonary angiography.
Pulmonary Edema
The most common cause of pulmonary edema is preexisting car-
diac disease. An electrocardiogram, chest X-ray, and echocardio-
gram can be used to investigate cardiac function. Patients with
cardiac failure should not undergo tumescent lipoplasty due to
the large volumes of fluid infiltrated during the procedure. Even
in healthy (stable) patients, injudicious use of intravenous fluids
as well as large volumes of subcutaneously infiltrated fluid can
cause fluid overload and pulmonary edema. Fluid balance should
be monitored carefully during high-definition body contouring
where large surface areas are being treated and large volumes of
tumescent fluid are required. Usually intravenous fluids are not
required except to maintain a patent intravenous line.
Lidocaine Toxicity
Lidocaine can be administered safely in tumescent anesthesia
in doses up to 55 mg/kg. Reducing the maximum dose to 45
mg/kg is prudent in order to reduce the incidence of lidocaine
toxicity. Toxicity can be noticed as perioral tingling, numbness
of the tongue, dizziness, nausea, and vomiting in awake patients.
Allergic reactions can be triggered by lidocaine, which will be
correctly settled in the preoperative assessment. With increas-
ing plasma levels, cardiac toxicity can occur. The treatment of
lidocaine toxicity is supportive. It is important to remember
that since lidocaine is absorbed very slowly from the fat com-
partment, peak plasma concentrations occur only 12 to 18 hours
after administration. For high-definition body sculpting under
local anesthesia, a concentration of 0.1% is often required in the
superficial tissues. If the procedure is performed under general
anesthesia, the lidocaine dose is reduced to about 25% or even
less. Lidocaine administered to patients under general anesthe-
sia provides postoperative analgesia for several hours due to the
lipophilic nature of the lidocaine molecule.
Perforation
Penetration of the probe or cannula through the abdominal wall
can occur during any lipoplasty procedure on the abdomen, par-
ticularly if the procedure is performed under intravenous sedation
or general anesthesia. Several cases of intestinal perforation
following abdominal lipoplasty have been reported. Intestinal
perforation causes peritonitis and may lead to septic shock, nec-
rotizing fasciitis, and death. Perforation can be the result of the
cannula passing through a defect in the abdominal wall, into an
undiagnosed abdominal wall hernia, or careless movement of the
cannula in a vertical, rather than horizontal direction. A detailed
physical examination and medical history must be performed to
detect these issues during the preoperative assessment. An ultra-
sound scan of the anterior abdominal wall should be performed
in these cases or if a scar from previous surgery appears tethered
or depressed, in which cases the peritoneum could be adherent to
the skin. Particular care should be taken near the costal margin to
avoid penetration of the thoracic cavity. Treating the upper abdo-
men using access incisions in the inframammary crease ensures
the cannula to be oriented inferiorly over the costal margin, reduc-
ing the risk of inadvertent intrathoracic penetration. If a patient
experiences excessive abdominal pain during or after abdominal
lipoplasty, perforation should be suspected. Tachycardia, fever,
pain, and rebound abdominal tenderness are straightforward clin-
ical findings. An emergency exploratory laparotomy is required.
Penetration of the thorax causes a pneumothorax with chest pain
and dyspnea, requiring prompt tube thoracostomy. Necrotizing
fasciitis is a severe infective sequela of intestinal perforation that
requires cardiovascular support, surgical débridement, and, in
some cases, abdominal wall reconstruction.
Fat Embolism
When both fat and the vasculature are disrupted or injured
mechanically, some type of mobilization of fat droplets into the
systemic circulation occurs. Although lethal cases of fat embo-
lism are rare, some degree of embolization may commonly occur
during lipoplasty. Fat embolism syndrome is an uncommon con-
dition affecting the pulmonary system, cardiovascular system,
central nervous system, and skin. The patient develops dyspnea,
fever, tachycardia, and a petechial rash. The pathophysiology of
fat embolism syndrome includes an inflammatory reaction on
the endothelium caused by release of fatty acids from adipocytes
by tissue lipase activation. Treatment of clinically significant fat
emboli and fat embolism syndrome is supportive, with fluids,
electrolyte balance, and oxygenation or ventilation if required.
Systemic steroids, such as methylprednisolone, are prescribed in
some cases.
86.6.2 SSeFiÀF +igK-'eÀniWiRn
Liposculpture Complications
Burns
Burns can occur due to thermal injury using ultrasound devices.
The VASER device is energy-based and must be carefully manip-
ulated (Fig. 86.16). Depending on the port location, burns can be
divided as follows:

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• Behind-the-port burns
• Over-the-port burns (heating by frictional vibration)
• After-the-port burns (subdermally produced from the inside,
while using the probe superficially)
̑ Pointed burns (tip of the probe)
̑ Horizontal burns (excessive power or poor infiltration)
Contour Irregularities
Preoperative photographs detect preexisting irregularities,
cellulite, scars, and asymmetry. For this reason, markings must
be precise, as they will guide the surgeon during the procedure.
Unwanted contour irregularities may occur if excessive fat
removal is performed superficially. Also, if a thorough emul-
sification of fat is not performed superficially, irregularities
will appear and the skin will not retract and redrape properly
(Fig. 86.17). Retouch procedures may be planned to remove
superficial fat and eliminate the irregularities. Applying suction
with the cannula in one position without movement should be
avoided. Minor irregularities may improve with smooth, even,
postoperative compression garments and manual lymphatic
drainage. Larger defects require either lipectomy around the
defect or autologous fat transfer to fill the defect. If extensive
contour irregularities are present following an incomplete fat
removal procedure, thorough superficial lipoplasty may be
required to reduce the uneven contours and allow the skin to
redrape smoothly and evenly.
Skin Retraction
Although desired and controlled skin retraction is one of the
pillars of high-definition body sculpting, its predictability at
times can be difficult to determine. Undesired skin retraction
may occur when garments and foam are not routinely used and
postoperative recommendations are not followed. There are
areas (usually areas of thin skin) that are more prone to develop
abnormal fibrosis: the inner thighs, posterior arm, axilla and
lateral pectoral area (Fig. 86.18).
Asymmetry
Although some phenotypical asymmetry is normal, maintaining
symmetry is essential in high-definition and four-dimensional
liposculpture. Preoperative asymmetries should also be docu-
mented and brought to the attention of the patient. Asymmetry
due to uneven fat distribution can be improved or corrected
by removing more fat on the larger side, or shifting fat to areas
where it is deficient. Skeletal abnormalities may also cause asym-
metries. Although these cannot be corrected with lipoplasty, an
illusion of symmetry can sometimes be created. Excess fat can
be removed, whereas areas that have been excessively removed
may require autologous fat injections.
Unnatural Appearance
A careful appreciation of the morphology or muscles, their rounded
borders, the positive and negative spaces, and the dynamic and
tonal progression between spaces is required to produce a natural
result. Simply creating a frame around muscle groups with linear
depressions will cause a “wooden” appearance. Similarly, if the
appearance of muscles is etched upon an abdomen in an over-
weight patient, the result is the so-called fat fit man. Patients who
are overweight or obese may need staged procedures, initially
treating the torso and upper arms (Fig. 86.19).
Fibrosis and Nodularity
During the postoperative healing process, the skin and soft tissues
feel firm. Some inflammatory and fibrotic reaction is inevitable
following ultrasound-assisted lipoplasty. However, avoiding
unnecessary or excessive delivery of ultrasound to the tissues,
as well as minimal use of traumatic cannulae or an aggressive
technique, may reduce this consequence. The compression
Fig. 86.16 Port burn. A 32-year-old woman with prolonged swelling
and a skin port burn in the posterior axillary fold, which resulted from
definition of the deltoid area and the upper back during high-definition
lipoplasty.
Fig. 86.17 Contour irregularities from excessive fat pad removal
over the abdomen in a 58-year-old man. Notice the overresection in
the lower abdomen and the unnatural appearance in the 8-month
postoperative picture of the abdomen.

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XII Body Contouring
garment should be smoothly placed over the skin to prevent
subcutaneous fibrosis leading to irregularities. Subcutaneous
nodularity or masses may be inflammatory or the result of
seromas or hematomas. These can be assessed with ultrasound.
Although fibrosis normally softens over 6 months without inter-
vention, postoperative lymphatic massage, external ultrasound,
radiofrequency, pressure, and mechanical massage are useful
modalities to soften tissues and accelerate healing.
Unsightly Scars
Consideration should be given to the placement of incisions for
high-definition body sculpting, particularly in patients who are
prone to hypertrophic scars or postinflammatory hyperpigmen-
tation. Patients with dark skin types are more prone to develop
postinflammatory hyperpigmentation and hypertrophic or
keloid scars. Incision sites appear initially brown and can take
several months, or even years, to fade. Patients should be advised
to wear sunscreen and avoid sun exposure for 6 weeks following
the procedure. Various treatments can be used to try to improve
hypertrophic scars, including topical silicone gel or sheeting, top-
ical 5% imiquimod, vitamin E, and pressure/massage therapies.
Loose Skin
Skin laxity following any form of lipoplasty may occur if the skin
does not fully retract to fit the new contours. This is more likely in
certain areas, including the lower abdomen, periumbilical area,
upper arm, and above the knees (Fig. 86.20). The use of energy-
based devices may improve skin retraction in some targeted
areas. Patients with poor skin tone, striae, and large volumes of
fat are at increased risk of postoperative looseness and additional
procedures. Mini- or full abdominoplasty should be considered
artistic definition and enhancing of the human anatomy, in addi-
tion to high-definition and dynamic-definition body sculpting
procedures.
86.7 Concluding Thoughts
Many technologies have been developed in the new era of aes-
thetic plastic surgery liposuction procedures. All these advances
have a common purpose: ensuring patient safety and the best
overall outcomes. We have learned a great deal regarding
use of technology and techniques to improve our results with
lipoplasty.
Fig. 86.18 Unusual skin retraction in a 41-year-old woman who
underwent high-definition body sculpting surgery in addition to
abdominoplasty. The lack of skin retraction was due to incorrect use of
compression garments and foam.
Fig. 86.19 Fat-fit man. A 44-year-old man who underwent high-defi-
nition body sculpting surgery. The 2-year postoperative photo shows
lateral rectus abdominis muscle definition but a general overweight
appearance.

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VASER-assisted lipoplasty is a nice addition to the tools we
have for liposculpture and body sculpting. We have called the
procedure high-definition and dynamic-definition liposculpture,
since the aesthetic principles changed from just fat removal
and liposuction to include artistic definition and enhancing of
human anatomy. We use ultrasound and resonance to emulsify
and thereby ease the harvesting of adipose cells and decrease
bleeding and damage to the surrounding structures. In addition,
VASER technology enables us to perform liposculpture over the
subcutaneous layer, which is the basis for high-definition and
dynamic-definition body sculpting procedures.
Subsequently, these techniques are based on the essential con-
cepts of lights and shadows (positive and negative spaces), which
allow us to sculpt and carve the muscular and athletic appearance
of male bodies and the slim but defined female bodies. In most
cases, some anatomical regions must be enhanced through fat
grafting to improve projection and mass, in accordance with
the concepts of curvaceousness and proportions in standards of
beauty.
Clinical Caveats
• Remember the basic steps for high-definition liposculpture:
preoperative marking, intraoperative infiltration, emulsi-
fication (superficial and then deep), deep and superficial
liposculpture, smooth liposculpture for lights and shadows,
fat grafting, postoperative care (garments, foam, drainage).
• In high-definition body sculpting, the subdermal fat should
be treated first in VASER mode with graceful and continuous
movements. Try to avoid torquing, which could conduct
excessive heat through the skin port and result in a burn.
Towels folded twice should be placed adjacent to the port
during ultrasound delivery to protect the skin from contact
with the probe. The deep layers can be treated in continuous
mode for emulsification.
• Once emulsification ends, liposuction can be performed thor-
oughly over the negative spaces and smoothly toward the
positive spaces. Sculpt the body according to the concepts of
lights and shadows, always following the preoperative mark-
ings. Dynamic zones and negative spaces need to be carefully
defined to achieve the most natural results.
• Do not treat the adhesion zones that are naturally and ana-
tomically established in order to avoid fateful asymmetries
or complications.
• Donor sites and harvesting for adipose tissue should be
selected preoperatively, then carefully treated with decanta-
tion, centrifugation, or filtration.
• Fat grafting should be performed in a multilayered fashion,
hopefully enriched with stem cells, also in the muscular layer
to enhance the graft survival.
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Fig. 86.20 Residual skin laxity in a 36-year-old woman who underwent
body-sculpting surgery. The residual skin laxity is seen over the central
abdomen due to excess thinning of the superficial flap.

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stem cells. Mol Biol Cell 2002;13(12):4279–4295

87 Screening and Safety Issues in the Massive-Weight-Loss Patient
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87 Screening and Safety Issues in the Massive-Weight-Loss
Patient
Christopher K. Patronella, Stephanie Nemir, and Olivier A. Deigni
Abstract
Postbariatric surgery can be both immensely rewarding and
extremely frustrating for the patient and the surgeon. Excellent
outcomes in some patients may also be mixed, with less than
optimal results in others when significant complications occur.
Comprehensive preoperative preparation involves nutritional,
medical, psychiatric, and surgical disciplines in a collaborative
effort to optimize each patient’s treatment plan and outcome.
Adequate exploration of motivation and priorities for each
patient, while carefully outlining the limitations and potential
for complications and revision procedures, fosters a trusting
doctor–patient relationship before and after surgery. Clinical
and surgical recommendations outlined in this chapter provide
a foundation for developing a protocol that emphasizes safety,
more predictable outcomes, and enhanced patient satisfaction.
Keywords
bariatric surgery, massive weight loss, body contouring, safety,
comorbidities, procedure staging, DVT prophylaxis, nutrition,
fluid management, progressive tension sutures
87.1 Introduction
Obesity is on the rise in the United States and globally, with
more than 1 in 3 Americans meeting definitions for obesity and
1 in 13 meeting criteria for extreme obesity based on 2013–2014
National Institutes of Health data. There has been a concomitant
rise in bariatric procedures as these patients seek assistance with
weight loss, with an estimated 216,000 procedures performed in
2016 (Fig. 87.1).
Sleeve gastrectomy is the most common procedure performed,
accounting for 58.1% of procedures, followed by Roux-en-Y gastric
bypass (RYGB) at 18.7%. Less commonly performed procedures
include gastric band (3.4%), balloons (2.7%), and biliopancreatic
diversion/duodenal switch (BPD/DS, 0.6%). Though traditionally
requiring laparotomy, all these procedures can now be performed
laparoscopically, thus accelerating recovery and decreasing the
risks of hernia formation and wound healing complications.
Bariatric surgery is indicated for patients with a body mass index
(BMI) > 40 kg/m2 in the absence of comorbid conditions or > 35
kg/m2 in patients with one or more obesity-related illnesses and
the inability to achieve weight loss through medical therapy.
Fig. 87.1 Recent trends in bariatric surgery and body contouring procedures following massive weight loss from 2011 through 2017.

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XII Body Contouring
Most patients will go on to lose 50 to 75% of their excess weight
after a bariatric procedure, often resulting in a weight reduction of
100 lbs. or more. Weight loss has been shown to have substantial
health benefits for obese patients, including reduction in overall
mortality as well as improvement or resolution of obesity-re-
lated diseases, such as diabetes, hypertension, and sleep apnea.
However, massive weight loss may introduce new problems for
patients as they deal with excess skin causing intertrigo, difficulty
with hygiene, interference with physical activity, poor clothing fit,
and altered self-image.
Many of the patients who successfully lose large amounts of
weight, whether through diet and exercise or bariatric surgery,
will seek out body contouring procedures to remove excess skin
and adipose tissue and improve their cosmesis and quality of life.
American Society of Plastic Surgery data show that more than
55,000 of these procedures were performed by board-certified
plastic surgeons in 2016, a 10% increase over 2015 numbers, and
the numbers will likely continue to increase with rising obesity
rates and rates of bariatric surgery (Fig. 87.1). Abdominoplasty
was the most common procedure performed, followed by mas-
topexy, brachioplasty, and lower body lift. Patients undergoing
body contouring procedures after massive weight loss have been
shown to have significant and lasting improvement in body image
and quality of life.
Postbariatric body contouring can be an incredibly rewarding
experience for both patient and surgeon, but this patient popu-
lation has specific safety considerations that must be appropri-
ately managed to ensure the desired outcome. As our collective
experience has grown, postbariatric procedures have evolved and
outcomes have improved. Yet there is a continued need to develop
protocols aimed at reducing complications and optimizing
recovery in this higher-risk demographic. Careful assessment of
nutritional status, optimization of medical comorbidities (Table
87.1), and planning and execution of procedures are essential
for success. This chapter addresses specific safety concerns that
require special consideration in patients seeking improved cos-
mesis and function after massive weight loss.
87.2 Preoperative Optimization
87.2.1 Management of Comorbidities
Obesity is a chronic multifactorial disease with multiple causes
that include genetic, molecular, physiological, cultural, social,
behavioral, and environmental factors. It is associated with many
conditions that can lead to increased morbidity, early death, or
decreased life expectancy. Such conditions include type 2 diabe-
tes mellitus, gallbladder disease, hypertension, coronary artery
disease, osteoarthritis, skin infections, hernias, and infertility.
Additional health risks associated with obesity include gout, non-
alcoholic fatty liver, hyperlipidemia, pregnancy complications,
menstrual irregularities, bladder control problems and stress
incontinence, stroke, obstructive sleep apnea and respiratory
problems, gastroesophageal reflux disease, hygiene problems, and
psychological disorders, such as depression or eating disorders.
Obesity has significant economic implications, and most of the
costs associated with this condition are attributed to treatment
of type 2 diabetes, coronary heart disease, and hypertension.
Morbidly obese patients have an average of three to four major
comorbidities before massive weight loss. Many comorbidities
are improved with weight loss, but metabolic defects may not
be completely resolved and may increase the risk for surgical
complications.
Upon initial evaluation of massive weight loss patients, it is
important to elicit information regarding their weight history,
including maximum weight, current weight, method of weight
loss, type of bariatric procedure performed and length of time
since the procedure, weight stability, and desire for further weight
loss. Their contouring goals and priorities should be discussed,
and their specific complaints should be documented. Medical
comorbidities must be reviewed, including the status of each con-
dition. In women of childbearing age, plans for future pregnancies
and/or breast-feeding should be queried, and women desiring
breast surgery should be asked about personal and family history
of breast cancer and results of their most recent mammogram.
Patients should also be asked about any personal or family history
of stroke, blood clots (deep vein thrombosis [DVT], pulmonary
embolisms), or miscarriages, as these can affect their DVT risk
perioperatively.
Any patients with a history of hypertension or diabetes need
to have their blood pressure and glucose appropriately controlled
prior to surgery. Hemoglobin A1C is a reliable measure of the
patient’s glycemic control over the previous 3 months; a value of
6.5% or below is recommended prior to surgery as values higher
than this have been associated with an increased risk of complica-
tions with wound healing.
Consultations with cardiology, pulmonology, internal medicine,
nutrition, and psychiatry are followed as indicated to evaluate and
optimize medical issues prior to major surgery. Contraindications
to surgery include any systemic disease that precludes safe gen-
eral anesthesia.
Patient selection and appropriate timing of surgery are key to
a successful outcome. The patient should be at least 18 months
out from bariatric surgery, and his or her weight should be stable
for at least 3 months, and preferably 6 months, before any body
contouring is performed. These recommendations reflect the fact
that many patients will reach their maximal weight loss about 18
months after a bariatric procedure, and many will regain some
weight before reaching a plateau. It is also not uncommon for
patients to have periodic plateaus during their weight loss fol-
lowed by additional weight loss. The rapidity of weight loss will
Table 87.1 Conditions associated with morbid obesity
• Asthma
• Back and disk 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
reproductive disorders
• Obesity hypoventilation
syndrome
• Peripheral osteoarthritis
• Peripheral venous insufficiency
• Pseudotumor cerebri and
carpal tunnel syndrome
• Sleep apnea

87 Screening and Safety Issues in the Massive-Weight-Loss Patient
1363
depend on the type of procedure performed, with purely restric-
tive procedures having a longer period to maximal weight loss
than procedures with both restrictive and malabsorptive effects.
Additional weight gain or loss after body contouring will compro-
mise the final result, so waiting for weight stability is worthwhile.
For patients wishing to have their procedure(s) covered by insur-
ance, it is important to know that insurance companies will have
their own criteria for timing in order for procedures to be covered.
Current Medicare guidelines require that patients be 18 months
out from a bariatric procedure and have a stable weight for 6
months in order for panniculectomy to be a covered procedure,
and many other insurance companies have followed their lead.
Consideration should also be given to a patient’s BMI at the
time of surgery, since a BMI greater than 30 may increase the risk
of surgical complications. Ideally, weight will have stabilized and
plateaued below BMI 30 to allow thorough surgical planning of
multiple procedures for each stage. For a BMI 30 to 35, consid-
eration should be given to shorter procedures and more stages
to mitigate higher complication rates. In general, patients with
a BMI greater than 35 should lose more weight prior to surgery
unless there is chronic panniculitis or other conditions for which
a functional panniculectomy is indicated.
The physical exam should include evaluation of skin excess,
including both horizontal and vertical vectors of laxity. The
amount and distribution of remaining fat should be assessed.
The abdomen should be inspected for hernias. All previous scars
should be identified and documented, as should areas of extensive
striae. The presence of moisture, hyperpigmentation, or intertrigo
in skin folds must be noted, and active intertrigo should be treated
prior to surgery. Candidal intertrigo will typically respond to
topical nystatin in powder or cream form, with oral antifungals
reserved for patients who fail topical treatment. If bacterial
superinfection is suspected, treatment with topical or systemic
antibiotics may be indicated.
Hernias are common in patients who have had previous open
abdominal surgery. Consideration should be given to planning
a team case with the bariatric surgeon for adequate repair of
complicated abdominal hernias. The plastic surgeon must keep in
mind the length of time needed for hernia repair while planning
the body contouring approach. Staging of procedures is highly
encouraged to minimize the risk of complications and provide
adequate healing and recovery.
Psychiatric comorbidities are common in the massive weight
loss population, with an estimated 20 to 60% of patients who
present for bariatric surgery suffering from an Axis I disorder.
Because mental health evaluation is recommended as part of the
work-up for bariatric surgery, many of the patients presenting for
body contouring evaluation will have already had at least one pre-
vious assessment. Mood and anxiety disorders are most common,
with a smaller number suffering from personality disorders, body
dysmorphic disorder, substance abuse, or disordered eating. The
lifetime rate of major depression in patients with a BMI > 40 kg/m2
has been reported at nearly 5 times the rate seen in patients with
a normal BMI. Impacts of obesity on quality of life may contribute
to depression; patients reporting impaired physical function as a
result of their weight also scored higher on evaluation of depres-
sive symptoms.
Multiple studies have shown improvement in symptoms of
depression (though not in anxiety or bipolar disorder) in patients
after bariatric surgery. Unfortunately, patients may have contin-
ued complaints of body dissatisfaction after weight loss due to
the development of excess skin with attendant difficulties with
hygiene, clothing fit, and exercise. In addition, postoperatively
some patients will express continued dissatisfaction with residual
skin laxity after body contouring despite overall marked improve-
ment in body contour. It is important during evaluation of the
patient for weight loss surgery to assess the patient’s motivations
and expectations for surgery and any specific areas of concern.
Though body dysmorphic disorder is difficult to diagnose in
patients who have obvious reasons for concern, patients exhib-
iting preoccupation or distress out of proportion to the degree of
their deformity or those with unreasonable expectations should
prompt a closer look. Attentive and candid discussion regarding
the limitations of each surgical procedure, and the possibility of
revision surgery and associated cost, is a necessary prerequisite
before proceeding. Staging procedures provides an opportunity to
manage both expected and unexpected revisions in a cost-effec-
tive manner.
While resolution of all psychiatric symptoms prior to body
contouring surgery may not be a reasonable expectation, it is
important to ensure that psychiatric health is optimized before
introducing the added stressors of surgery and recuperation. Both
pharmaceutical therapy and cognitive behavioral therapy have
been shown to improve symptoms preoperatively. Consideration
should be given to contacting the patient’s mental health provider
prior to scheduling a body contouring procedure to ensure that
the patient is in an appropriate psychological state. This may offer
some protection against patients unhappy with their surgical out-
come referencing their psychiatric history in legal action against
their surgeon, alleging an absence of informed consent, as has
been reported by some authors.
In addition to counseling patients on what to expect from a
surgical standpoint, it is important to manage patient expecta-
tions with regard to the effects that their body contouring will
have on other aspects of their lives, such as romantic and sexual
relationships. While the majority of body contouring patients are
likely to receive support from friends and loved ones, a minority of
patients may experience unanticipated changes in their relation-
ship dynamics. Jealousy and attempts to undermine the patient’s
progress have been witnessed. Divorce rates after bariatric sur-
gery are higher than expected, though the reasons for this have
not yet been elucidated. Despite these risks, most studies find that
body contouring after massive weight loss improves quality of life,
body image, sexuality, physical functioning, and self-esteem in a
large majority of patients, though these positive effects may wane
over time.
87.2.2 Nutritional Assessment
Postbariatric patients are at risk for multiple nutritional defi-
ciencies, which may include many macro- and micronutrients
involved in wound healing and immune function. Questions
regarding current diet, use of dietary supplements, and history
of nutrient deficiencies can screen for patients at higher risk, and
diagnostic tools such as the mini nutritional assessment may yield
additional information. Understanding the different types of bar-
iatric procedures will help the surgeon predict which nutrients
are most likely to be affected (Fig. 87.2). Bariatric procedures can

1364
XII Body Contouring
broadly be classified into restrictive, malabsorptive, and combi-
nation procedures. Restrictive procedures such as laparoscopic
adjustable banding or vertical banded gastroplasty effect weight
loss mainly through limiting dietary intake, whereas malabsorp-
tive procedures work by limiting absorption of nutrients from
the shortened digestive tract. Roux-en-Y gastric bypass and
biliopancreatic diversion +/- duodenal switch have both restric-
tive and malabsorptive components. While these patients may
all suffer from malnutrition postoperatively, patients presenting
after malabsorptive procedures are particularly vulnerable to
nutritional deficiencies due to loss of absorptive surface of the
bypassed portion of bowel as well as discoordination between
gastric emptying and pancreatic enzyme release. Additionally,
although patients achieving weight loss through diet and exer-
cise do not undergo the same physiologic alterations in digestion
and absorption as those treated with bariatric surgery, they may
also develop macro- and micronutrient deficiencies from inade-
quate intake during caloric restriction.
Macronutrients
Protein is a necessary component of wound healing, required for
fibroblast function, angiogenesis, D1A production, and collagen
synthesis. Preoperative protein malnutrition has been shown
to predict adverse surgical outcomes, including poor wound
healing and increased susceptibility to infection. Because of this,
ensuring adequate protein stores and ongoing maintenance of
protein levels in patients seeking body contouring procedures is
critically important.
Protein malnutrition is common after bariatric surgery,
reported to affect as many as 25 of patients. It affects both
patients with restrictive and those with malabsorptive proce-
dures. Maintenance of appropriate dietary intake of protein (1.5
g/kg ideal body weight) can be challenging in the face of reduced
gastric volume and meat intolerance, so common in postbariatric
patients. This intolerance may be due in part to loss of pepsin,
renin, and hydrochloric acid production from the surgically
reduced stomach. Protein stores may also be consumed during
caloric restriction, as amino acids are used for gluconeogenesis.
Protein requirements increase further in the face of wound
healing following body contouring procedures, and patients with
preexisting deficiencies will find it difficult to achieve appropriate
protein levels without significant supplementation.
Laboratory assessment of nutritional status can serve as an
important adjunct to history and physical exam, though care
should be taken in interpreting these markers in the context of
the patient’s overall health. The primary laboratory markers used
to assess patient protein stores are albumin and prealbumin. Of
these, albumin gives the best assessment of protein intake over
the past 3 months, whereas prealbumin is indicative of protein
intake over the past 7 to 14 days. Both these levels may be affected
by physiologic stress, particularly prealbumin, which acts as an
acute phase reactant. Serum albumin > 4 mg/dL and prealbumin
> 20 mg/dL are ideal preoperatively, though slightly lower levels
may be acceptable in select patients.
Interestingly, protein stores alone may not adequately predict
successful wound healing. Barbour et al found that patients
presenting for body contouring after bariatric procedures had sig-
nificantly higher wound healing complication rates than similar
patients presenting after weight loss through diet and exercise,
despite the former group having a higher mean preoperative albu-
min. Clearly, protein is only one of many factors that may affect
healing in the postoperative period.
Fat malabsorption may also occur after malabsorptive bariatric
surgery, particularly BPD/DS and less commonly RYGB. This may
decrease absorption of fat-soluble vitamins and may also result in
steatorrhea. Carbohydrate malabsorption may lead to bloating but
has not been heavily studied. A small proportion of patients (4.7%)
will develop severe protein-calorie malnutrition after RYGB, and
these patients must be identified prior to body contouring so as to
prevent significant wound healing complications.
Fig. 87.2 Types of bariatric surgery include purely restrictive procedures, such as (a) gastric banding and (b) procedures with both restrictive and
malabsorptive components, such as Roux-en-Y gastric bypass.

87 Screening and Safety Issues in the Massive-Weight-Loss Patient
1365
Micronutrients
In addition to macronutrient deficiencies, massive-weight-loss
patients may have deficiencies of micronutrients important in
healing and immune function. In the early postoperative period,
intake of nearly all vitamins has been shown to be lower than the
recommended daily allowance (RDA) in the majority of patients.
By 1 year postoperatively, all vitamins except for K, niacin, and
B12 remain below (in many cases substantially below) the RDA.
In patients having undergone restrictive procedures and those
who have lost weight through diet and exercise, absorption of
nutrients is typically minimally affected, and deficiencies can
be overcome with dietary supplementation. In patients with
altered absorption after surgery, however, it may be difficult to
impossible to fully correct these deficiencies through standard
oral supplementation, as the primary site of absorption for many
vitamins is within the portion of the small bowel that is bypassed
during malabsorptive procedures.
Many vitamin and mineral deficiencies have implications for
surgeons through their effects on inflammation, wound healing,
and hematopoiesis. In general, all postbariatric patients should be
seeing their bariatric surgeon on a regular schedule and should be
taking supplements as directed. While a complete discussion of
micronutrient abnormalities in the massive weight loss popula-
tion is beyond the scope of this chapter, certain deficiencies bear
discussion. Several excellent resources are referenced at the end of
the chapter for those wanting to explore this topic in more depth.
Iron deficiency anemia is common after massive weight loss,
particularly in patients who have undergone malabsorptive pro-
cedures. Iron deficiency affects an estimated 30 to 50 of Rpatients and is likely caused by a combination of reduced intake
and altered absorption. Normal iron absorption from dietary
sources requires an intact duodenum and jejunum as well as
normal gastric hydrochloric acid production, all of which may be
altered after gastric bypass. Iron deficiency may persist despite
supplementation, and 3.5% of patients will require parenteral
transfusion to treat refractory deficiency. Because body contour-
ing procedures may result in significant blood loss, the presence
of anemia preoperatively should be identified and addressed to
prevent postoperative complications.
Vitamin B12 and folate deficiencies are also common following
bariatric procedures and may have compounding effects on eryth-
ropoiesis and anemia. Additionally, deficiencies in these factors
can contribute to hyperhomocysteinemia, increasing the risk of
cardiovascular and thromboembolic events. Poor mobilization
due to anemia-related fatigue and weakness following surgery,
combined with hypercoagulability from elevated homocysteine
levels, puts patients at high risk for DVT.
Vitamin B12 absorption requires the complex coordination of
multiple portions of the gastrointestinal tract. First, the vitamin
must be unbound from the food through the actions of gastric acid
and pepsin, followed by release from salivary binding proteins by
pancreatic enzymes. Intrinsic factor (produced in the stomach)
then promotes uptake of the vitamin within the terminal ileum.
All of these steps may be affected by the altered anatomy after bar-
iatric surgery. In fact, many patients after RYGB will be unable to
maintain B12 levels through oral supplementation alone and will
require monthly B12 injections. The incidence of B12 deficiency in
postbariatric patients is reported to be as high as 37%, with 3.6%
remaining deficient even after recommended supplementation.
Folate absorption requires hydrolysis by components of the
intestinal brush border, which may be inhibited in alkali envi-
ronments after reduction of gastric acid production. A portion
of the daily allowance of folate is excreted in the bile and then
reabsorbed in the small intestine. Folate deficiency after Rhave been reported to affect up to 35 of patients, and they may
require continuous folate supplementation to make up for defi-
ciencies in gastrointestinal absorption.
87.2.3 Laboratory Work-up
As part of our preoperative evaluation, we routinely obtain
a complete blood cell count as well as a complete metabolic
panel. Abnormal laboratory values are addressed. Patients with
total protein level < 6 g/dL or albumin level < 3 mg/dL may be
referred to their bariatric surgeon or a dietitian for reevaluation
and possible nutritional supplementation. Physical findings cor-
roborating protein deficiency include edema on physical exam.
Patients with a hemoglobin level less than 10 g/dL are referred
to their primary care physician or a hematologist. Patients with
a hemoglobin level above 10 g/dL are advised to continue on iron
and B12 supplementation. We prefer a hemoglobin level above 12
g/dL prior to surgery.
87.2.4 Medication Review
Part of the history should include a complete review of the
patient’s medications, including vitamins and supplements.
Many supplements, particularly those with herbal components,
can increase bleeding risk, either by direct effects on coagulation
or by potentiating other medications with effects on coagulation.
In addition, some supplements contain stimulants or appetite
suppressants, which results in suppression of adrenaline pro-
duction that may manifest with sudden hypotension during a
surgical procedure. The American Society of Anesthesiologists
recommends that supplements be stopped at least 2 weeks before
surgery to minimize the risk of interactions with anesthesia. In
addition, many surgeons recommend that patients stop any anti-
coagulant medications or medications with platelet-inhibitory
functions (including aspirin and other nonsteroidal anti-
inflammatory drugs) 2 weeks prior to surgery, if deemed safe to
do so by the patient’s cardiologist or primary care physician. In
cases in which patients are unable to come off of these medica-
tions, careful consideration should be given to the risk/benefit
ratio of performing the surgery on an anticoagulated patient, and
some surgeries may need to be postponed until anticoagulation
can be safely withdrawn.
87.2.5 Nicotine Cessation
Patients with active nicotine use should be counseled to abstain
from all nicotine-containing products for at least 1 month before
and 1 month after any procedure to reduce the risk of pulmonary
or wound healing complications, including flap ischemia. It is
important to specifically ask about use of any nicotine-contain-
ing products, including patches, gum, and electronic cigarettes,
as many patients will not report these if asked only about smok-
ing. Patients should be counseled that heavy secondhand smoke
exposure can also increase the risk of complications. If there is

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XII Body Contouring
a question about whether the patient is accurately reporting
nicotine use, point-of-care urine cotinine tests can give a semi-
quantitative assessment of recent nicotine exposure.
87.3 Perioperative Planning
87.3.1 Perioperative DVT
Chemoprophylaxis
DVT and venous thromboembolism (VTE) are known compli-
cations of body contouring procedures, particularly abdomino-
plasty (either alone or in combination with other procedures).
This increased risk is likely related to impaired venous return
from the lower extremities due to tightening of the abdominal
wall leading to increased intra-abdominal pressure as well as
decreased mobility both during and after the operation. When
combined with intimal damage inherent in surgical procedures,
two-thirds of Virchow’s triad are present. A recent retrospec-
tive review of the American Association for Accreditation of
Ambulatory Surgical Facilities database revealed that throm-
boembolism was the leading cause of mortality associated with
plastic surgery procedures, and in the majority of cases, DVT risk
was either not assessed preoperatively or assessed incorrectly.
Preoperative evaluation of risk factors, early postoperative mobi-
lization, and thoughtful use of chemoprophylaxis are critical in
prevention.
The most commonly used medications for DVT chemoprophy-
laxis are low-molecular-weight heparin (LMWH) and unfraction-
ated heparin. Both have been shown to reduce rates of venous
thromboembolism in high-risk populations. Both medications
have the downside of requiring the patient to self-inject, which
may affect compliance once patients go home.
Novel oral anticoagulants are direct inhibitors of factor Xa and
have been shown to be significantly superior in efficacy when
compared with LMWH. They are well absorbed in the gastroin-
testinal tract, and once daily dosing is possible. Apixaban, the
second factor Xa inhibitor introduced in the United States market
after rivaroxaban, has been approved for DVT chemoprophylaxis
after surgery. Studies in the orthopaedic literature have shown
apixaban to have similar adverse-event profiles but lower rates
of clinically relevant bleeding when compared with LMWH or
rivaroxaban. Apixaban offers the option for different dosages, is
primarily metabolized by the liver, and displays improved phar-
macokinetics. As an oral option, it may have increased compliance
in patients squeamish about self-injecting.
A 2012 American Society of Plastic Surgeons task force reviewed
available data regarding thrombosis risk management in cosmetic
surgery and recommended the use of preoperative risk stratifi-
cation, such as the 2005 Caprini Risk-Assessment Module, to
guide postoperative chemoprophylaxis, particularly for patients
undergoing inpatient aesthetic procedures with general anesthe-
sia. For patients undergoing body contouring procedures lasting
more than 60 minutes, chemoprophylaxis should be considered
for patients scoring a 3 or above, a low threshold considering
that surgery length alone awards the patient 2 points. Other
risk factors applicable to many body contouring patients are age
> 40 (1 point for age 41–60 years, 2 points for 60–74 years, and 3
points for 75+), BMI > 25 (1 point), and use of oral contraceptives
or hormone replacement therapy (1 point). Though a minimal
risk reduction with the use of prophylactic enoxaparin was seen
in patients with Caprini scores of 3 to 6, prophylaxis provided
significant risk reduction in patients with Caprini scores ! 7, with
4-week postoperative prophylaxis having increased risk reduction
compared with 1-week courses. When started 6 to 8 hours after
surgery, chemoprophylaxis was not associated with an increased
risk of reoperative hematoma or bleeding complications.
Use of postoperative anticoagulation is not itself a panacea, and
prevention of thrombotic and thromboembolic complications
after body contouring is best accomplished through a combina-
tion of mechanical prophylaxis with the use of intra- and post-
operative sequential-compression devices, early mobilization,
and chemoprophylaxis as indicated. Other preventive strategies
include limiting operating room (OR) time, particularly for high-
risk patients, and perioperative cessation of hormonal medica-
tions. Home sequential-compression devices ($200–$300) can be
a useful adjunct in high-risk patients.
We perform all of our body contouring procedures on massive-
weight-loss patients on an outpatient basis or 23-hour observa-
tion. Our approach to perioperative DVT chemoprophylaxis is
based on our personal experience as published in 2008 and 2016
in the Aesthetic Surgery Journal. Our current protocol for patients
who meet criteria for chemoprophylaxis is summarized in Table
87.2. We administer chemoprophylaxis for all patients undergo-
ing abdominoplasty or thighplasty, either alone or in combination
with other procedures, except for those undergoing a facelift in
the same procedure. Performing facial rejuvenation procedures
(without anticoagulation) in a separate stage for the high-risk
patient should be considered.
87.3.2 Total Procedure Time
:hile there is no definitive maximum procedure length estab-
lished or recommended, increasing OR time in body contouring
surgery is associated with increasing risk of DVT, hypothermia,
infection, blood loss, and a higher complication rate in many
studies. These potential sequelae should be factored into the
Table 87.2 Apixaban chemoprophylaxis recommendations for
massive weight loss patients undergoing body contouring
Deep venous thrombosis chemoprophylaxis
BMI < 30
BMI > 30
Brachioplasty,
mammoplasty, or
torsoplasty
No DVT
chemoprophylaxis
No DVT
chemoprophylaxis
Abdominoplasty, body
lift, or thighplasty
2.5 mg by mouth
twice a day × 7 days
5 mg by mouth twice
a day × 14 days
Facelift combined with
other procedure
No DVT
chemoprophylaxis;
consider staging if
high-risk for DVT
No DVT
chemoprophylaxis;
consider staging if
high-risk for DVT
Abbreviations: BMI, body mass index; DVT, deep vein thrombosis.

87 Screening and Safety Issues in the Massive-Weight-Loss Patient
1367
decision making when analyzing “how much can be done” in one
operative setting. Likewise, the skill of the surgical assistants
available and OR staff can dramatically affect OR time and should
be considered when selecting a facility and accurately assessing
the OR time estimate for the procedures planned. A limit of 6
to 7 hours has been a successful time constraint strategy in our
practice.
87.3.3 Staging Strategies and
Setting Priorities
Strong consideration should always be given to addressing
a patient’s top priorities during the first stage. This provides
immediate gratification, establishes the foundation of a strong
doctor–patient relationship, and inspires confidence and enthu-
siasm for future procedures. In addition, when financial consid-
erations create limitations, patient satisfaction will always be
higher if the primary concerns are treated first.
Major areas requiring treatment are often grouped to optimize
aesthetic results, minimize OR time, limit position changes during
surgery, and minimize blood loss. Common coordinated groups
include the following:
• Upper body (breasts, arms, axilla, back, bra line, lateral chest)
• Lower torso (abdomen, hips, buttocks, lateral thighs)
• Lower extremities (thighs and knees, gluteal folds)
• Face and neck, eyes
Natural procedure groupings should always be reviewed with
the patient to optimize procedure safety and aesthetic results.
This may occasionally require compromise on the part of patients
in order to safely meet their goals. For example, to optimize
aesthetic outcomes, it is advised to perform the abdominoplasty
and lower body lift with accompanying liposuction of associated
areas and autologous fat grafting of the buttocks during a single
operative setting. This may preclude performing another major
procedure, such as a medial thigh lift, that the patient may have
listed among the top two or three priorities. As another example,
DVT prophylaxis is often required in most major body contouring
procedures and not recommended in facial rejuvenation surgery,
therefore making it more difficult to combine those procedures.
Some procedures require two stages due to vascular perfusion
risk, such as first-stage mastopexy followed by second-stage breast
augmentation in the profoundly ptotic breast. Staging of other
procedures, such as first-stage ´debulkingµ liposuction followed
by second-stage skin excision (lifting) is not advised. Multilevel
adipose scar formation following liposuction will limit flap
mobility during secondary lifting procedures, thereby adversely
affecting aesthetic outcomes. Finally, consideration should be
given to avoiding combinations of procedures with opposing vec-
tors of force to minimize wound-healing complications and scar
migration. For example, an upper body lift procedure performed
simultaneous to a belt lipectomy may increase the tension on
both closures; therefore, staging should be considered.
A well-thought-out strategy for combining and staging pro-
cedures that synchronizes a patient’s priorities with optimal
aesthetic groupings from the surgeon’s perspective should be
created for each patient.
Attentive assessment of preexisting scars, particularly on the
abdomen and breasts, is an important step in planning. A right
subcostal abdominal scar creates additional vascular perfusion
concerns, and therefore may require a modified abdominoplasty
technique. Patient scar quality and tolerance of scars may also
affect planning. For example, a patient with a preexisting midline
vertical abdominal scar may be more accepting of a fleur-de-lis
abdominoplasty approach than would a similar patient with an
unscarred abdomen. Patients who form thin, pale, flat scars may
be less concerned with incision length than those with widened,
hyperpigmented, or hypertrophic scars. Some patients will be
very concerned about minimizing scarring, even if doing so limits
the degree of contouring performed, while others will express the
greatest concern with overall contour, arguing that scars can be
hidden with clothing.
Creative procedure planning generally requires removal of the
redundant skin along the natural folds where maximum skin
redundancy exists rather than along a preset “standard” or tra-
ditional design. Analyzing the effectiveness of proposed excision
choices with physical tissue manipulation and reviewing these
options with the patient should guide the decision for incision
location and orientation. =ones of adherence are difficult to
neutralize and therefore should influence the planning. Careful
patient education to review the rationale for the chosen incision
location and scar permanence is a necessary prerequisite.
87.3.4 Prevention of
Postoperative Infection
Preventing postoperative infection requires a comprehensive
approach to include decolonization of the patient preoperatively,
perioperative antibiotics, and prevention of wound contamina-
tion postoperatively. Our current strategy is as follows:
• Full-body chlorhexidine antiseptic wash (especially the umbi-
licus, perineum, and axilla) the night before and the morning
of surgery
• Methicillin-resistant Staphylococcus aureus prophylaxis when
appropriate (for those patients with prior history)
• Preoperative intravenous antibiotics > 30 min before incision
at an appropriate dose for BMI and redosing at 4-hour incre-
ments intraoperatively
• Surgical area wipe with chlorhexidine Sage cloth in preopera-
tive holding room
• Hair clipping (not shaving) in the preoperative holding room
• Frequent reprepping and redraping for each procedure
• Maintenance of normothermia during surgery
• Frequent hand washing and alcohol-based foam or lotion by
clinical staff and home caregivers
• Avoidance of contact with animals for 4 weeks postoperatively
• Patient education for wound care management
• Requiring an antibacterial soap shower daily and after each
bowel movement in all body lift and thigh lift patients

1368
XII Body Contouring
87.4 Intraoperative Strategies
87.4.1 Operating Room Logistics
The surgical staff should play an active and influential role
in organizing the sequence when multiple procedures are
performed in a single operative setting. Consistent attention to
maintaining sterility and optimizing time efficiency are empha-
sized. An experienced staff to coordinate the preparation for the
various procedures being performed in an efficient order, along
with additional support staff to set up subsequent procedures,
can have a significant impact on the total OR time, hypothermia,
and prevention of infection.
87.4.2 Circumferential Body Prep
As an additional measure of protection against contamination
and infection, all patients requiring circumferential procedures
(liposuction, thigh lift, body lift, bra line lift, etc.) receive a stand-
ing circumferential prep from neck to feet, followed by placement
of the patient on sterile draping on the operating table. Induction
of anesthesia then commences and sterile draping is completed.
Additional area prepping and sterile drapes are added for each
procedure performed in sequence.
87.4.3 Maintenance of Normothermia
Intraoperative hypothermia has been studied in a variety of
surgical fields, including plastic surgery. Risk of intraoperative
hypothermia is related to heat losses from large areas of exposed
skin as well as impairment of thermoregulatory controls during
general anesthesia. Studies have shown that 20% of patients
will become hypothermic during body contouring procedures
despite the use of forced-air warming devices, and rates may rise
as high as 90 in the absence of specific warming measures. Once
patients become hypothermic, return to normothermia may
take up to 4 hours of specific warming measures. In general, even
a small drop in intraoperative body temperature from 37 to 35°C
has been shown to increase rates of wound infection, seroma,
and blood loss requiring transfusion; decrease collagen depo-
sition near the wound; and increase length of stay. In addition,
greater need for opioids and longer time in recovery have also
been demonstrated in hypothermic patients. Looking specifi-
cally at postbariatric body contouring, intraoperative blood loss,
need for blood transfusion, and postoperative seroma formation
have been shown to be increased in hypothermic versus normo-
thermic patients, and seroma risk has been shown to follow the
degree of hypothermia in a dose-dependent manner.
The effects of hypothermia are likely multifactorial and in
many cases remain poorly understood. The increase in infection
following hypothermia has been postulated to occur as a result of
vasoconstriction both intraoperatively and postoperatively, lead-
ing to decreased partial pressure of oxygen in tissues. This in turn
has been theorized to reduce the efficiency of microbial killing
through oxidative burst as well as directly impairing immune cell
function. Changes in collagen deposition may also be related to
tissue oxygenation through effects on oxygen-dependent hydrox-
ylation of proline and lysine residues. Increases in intraoperative
blood loss and transfusion requirements are likely related to
decreased activity of clotting factors at lower temperatures, and
blood transfusions may also affect immune function and contrib-
ute to elevated infection rates.
As already mentioned, once hypothermia has occurred, more
than 4 hours of warming is often required to attain normother-
mia; therefore prevention of hypothermia is by far the best course.
Preoperative warming with a forced airflow device is the mainstay
of prevention. Intraoperative and postoperative maintenance
warming through underbody or forced air warmers, underbody
OR table warmers, use of warmed fluid for irrigation and fluid
resuscitation, limiting exposed surface area to the portions neces-
sary for the procedure, and maintaining ambient OR temperatures
above 70°F have all been recommended as measures to maintain
appropriate patient temperatures during the operation.
87.4.4 Anesthesia Considerations
Many of the anesthetic considerations for postbariatric body
contouring are the same as in other cosmetic surgical proce-
dures, with a few caveats. Depending on the combination of
procedures being performed, operative time may be significant.
Therefore, issues of appropriate patient positioning and padding
of pressure points are critical. If it is anticipated that patients will
need to be sat up and turned during the various procedures, then
particular care must be taken to protect and secure the arms
and shoulders. Some body contouring procedures require prone
positioning, and the protection of the eyes and airway (as well as
other dependent structures) is paramount.
The entire OR team should be aware of the areas being addressed
during the procedure so that the patient can be appropriately
prepared. IVs and blood pressure cuffs will need to be strategically
placed for operations involving the extremities.
Although many patients will report improvement in sleep
apnea after weight loss, this population often still has difficult air-
ways. Use of videolaryngoscopy during intubation may increase
the ease of airway management. All patients with diagnosed sleep
apnea are required to bring their apnea machine to the facility if
overnight observation is planned.
Gastroesophageal reflux is frequently seen in postbariatric
patients, particularly those presenting after restrictive proce-
dures. This likely puts them at higher than average risk of aspira-
tion perioperatively. Consideration should be given to performing
orogastric and nasogastric suction prior to extubation.
87.4.5 Fluid Management
1umerous strategies have been developed for fluid resuscitation
in the anesthesia and surgical disciplines. Attentive fluid man-
agement involves consideration of all input and output sources,
becoming more complex with the addition of tumescent infusion
and lipoaspirate, as is common in major body contouring proce-
dures. Fluid sources for the anesthetized patient include intrave-
nous fluids and tumescent infiltration, both of which are easily
measured. Fluid output includes blood loss, fat/fluid extraction
with liposuction, and urine output as well as the less easily mea-
sured insensible losses, third spacing, and preexisting fluid deficit
from being off oral feeding prior to surgery. To ensure appropriate
replacement without volume overload complications, a strategy
for fluid management for large body contouring procedures should

87 Screening and Safety Issues in the Massive-Weight-Loss Patient
1369
involve a collaboration between the surgeon and anesthesiologist
and should take into account all inputs and outputs.
A formula that we have used successfully for approximately 20
years at The Aesthetic Center for Plastic Surgery (ACPS) employs
the 4-2-1 rule for maintenance of intravenous fluids: 4 mL/kg/h for
the first 10 kg, 2 mL/kg/h for the next 10 kg, and 1 mL/kg/h for the
remaining kg. Lactated Ringer’s (LR) is used for volume replace-
ment. Patients who have been off oral feeding for surgery are
assumed to have arrived to surgery with a fluid deficit of approxi-
mately 8 hours, and this fluid deficit is replaced during surgery. In
addition, estimated blood loss is replaced using 3 mL LR for each
1 mL of blood loss. Estimated blood loss must take into account
not only direct bleeding from the surgical site but also the blood
removed within the lipoaspirate, assumed to be approximately 5
to 10% of the aspirated volume. A sample calculation is provided in
the box Estimating Intraoperative Fluid Requirements (Fig. 87.3).
In our strategy, there is a concerted effort to balance tumescent
infiltration volume with the lipoaspirate extracted; therefore,
there is no need for fluid replacement of the lipoaspirate. :hile
not part of our formula, if there is a marked disparity whereby the
lipoaspirate is significantly greater than tumescent infiltration
(> 1–2 L), consideration should be given to cautious replacement
of fat aspirate, guided by hemodynamics and urine output and
always cognizant of the potential for volume overload. Adequate
fluid replacement is our primary concern, thereby avoiding
insufficient replacement or overcorrection. Urinary output is
assessed for adequacy of fluid replacement, accelerating replace-
ment should urinary output drop < 0.5 mL/kg/h and reducing
replacement for urinaP output > 1.5 mL/kg/h.
87.4.6 SurgiFDO 7eFKniTue
Pretreatment vasoconstriction with tumescent solution infiltra-
tion (3 L loss replacement, 50 mL 1% lidocaine, 3 mL epinephrine
1:1000) for all flap procedures is highly recommended and affords
several advantages: clarification of tissue planes for easier,
faster, and more precise dissection; reduction of blood loss; and
reduction of general anesthesia requirements. If this technique
is employed, attentive hemostasis of less dramatic bleeding in
vasoconstricted tissue is required to neutralize the potential for
bleeding postoperatively. In our experience, hematoma rates are
equivalent with or without tumescent vasoconstriction.
Deep plane (beneath Scarpa’s fascia) suction-assisted lipectomy
prior to flap elevation for body lift, bra line lift, brachioplasty,
torsoplasty, and thigh lift procedures provides several advantages.
Reduction of fat thickness assists in assessing true skin redun-
dancy for more accurate resection. Discontinuous undermining
facilitates flap mobility, partially disrupts the fibrous connective
tissue zones of adherence, and lessens the direct undermining
required to facilitate a tension-free closure while preserving flap
vascularity. Obtaining contour uniformity and balanced upper
and lower flap thickness may also be easier to achieve.
87.4.7 Prevention of Seroma
Numerous studies have consistently demonstrated a lower inci-
dence of seroma formation in abdominoplasty when progressive
tension sutures are employed. As in abdominoplasty, progressive
tension sutures can be effectively used for all flap procedures
(body lift, thigh lift, bra line lift, brachioplasty, torsoplasty) to
improve outcomes by reducing tension along the incision line,
eliminating potential space, thereby reducing seroma formation,
and in many cases eliminating the need for drains altogether.
Reduction of seroma formation can also be achieved by leaving
liposuction access sites open at the completion of the procedure
to allow fluid egress. In our own experience, seroma occurred in
1% of patients with unsutured liposuction access sites versus 11%
of patients with sutured access sites.
87.5 Postoperative Care Strategies
While careful preoperative planning and meticulous surgical
technique are critical to successful outcomes, postoperative care
of the massive weight loss body contouring cannot be ignored.
These are large surgeries with potentially prolonged healing
Fluid management calculation
(VWimDWing ,nWrDRSerDWiYe )Ouid 5eTuiremenWV
Sample calculation of intraoperative fluid requirements for a 75
kg patient undergoing a 6-hour surgery after an 8-hour fast,
with estimated blood loss of 100 mL. Lipoaspirate volume is
not routinely factored in to fluid replacement unless there is a
large net removal of lipoaspirate (> 1 L) coupled with low urine
output (< 0.5 mL/kg/h).
Calculation of Maintenance IV Fluid
For the 75 kg adult:
• 40 (4 mL/kg/h for the first 10 kg of body weight)
• 20 (2 mL/kg/h for the second 10 kg)
• 55 (1 mL/kg/h for the remaining 55 kg)
• 115 mL/h maintenance IV fluid
• For a 6-hour case, MIVF = 6 h × 115 mL/h = 690 mL
&DOFuODWiRn RI 3reRSerDWiYe 'eÀFiW
For a 75 kg patient who has been
fasting for 8 hours:
• 8 h × 115 mL/h = 920 mL
Calculation of Blood Loss
Replacement
For 100 mL of blood loss:
• 100 mL EBL × 3 mL replacement/mL loss = 300 mL
Total IV Fluids
• 920 mL preoperative deficit
• 690 mL maintenance for OR time
• 300 mL blood loss replacement
• 1910 mL/6h = 318 mL/h replacement fluid
Fig. 87.3 Fluid management calculation.

1370
XII Body Contouring
times and a high risk of complications, so close follow-up and
frequent reassurance may be needed. Patients should receive
postoperative instructions on incision and drain care, as well as
activity restrictions, the need for bowel regimen while on nar-
cotics, and recognizing signs and symptoms that should prompt
a call to the office or an emergency room visit.
Use of compression garments and adjuncts postoperatively is
surgeon dependent. We prefer to use compression garments and
foam pad inserts for a period of 6 to 8 weeks postoperatively, as
we feel this assists in reducing swelling and potentially seroma
formation. In addition, there may be an advantageous effect on
shaping through tissue splinting. It is important, though, to
ensure that the garments are properly fitted so as to avoid vascu-
lar compromise in the short term or permanent creases (contour
depressions) in the long term.
The addition of multivitamin supplements is a useful adjunct
for optimizing wound healing in the postoperative period, espe-
cially for the massive-weight-loss patient, in whom multiple
vitamin deficiencies are common.
Massage, ultrasound, and radiofrequency treatments reduce
induration, nodularity, and early scar contraction, thereby
optimizing aesthetic outcomes. In addition, by interrupting the
inflammatory process, the recovery process is accelerated, and
most patients experience more rapid improvement in mobility
and reduction in discomfort. Once the wounds have adequately
healed, warm water (94–96°F) whirlpool tubs also have an
anti-inflammatory effect on indurated tissue. Very hot water and
heating pads are not advised, as surgical sites are more sensitive
to higher temperatures and more likely to sustain burns.
87.5.1 Analgesia
Body contouring procedures can be quite extensive, with large
areas of undermined tissue, extensive liposuction, and muscular
plication. These patients will typically require pain medication
postoperatively. Appropriate pain control will allow patients to
mobilize postoperatively and will prevent effects of catechol-
amine release on tissue perfusion. Overnarcotized patients are
at risk for falls, constipation, and respiratory suppression, so
careful titration of analgesic medication is key. As in other areas
in plastic surgery, the trend in body contouring is toward multi-
modal therapy to include some combination of long-acting local
anesthetics, anti-inflammatories, acetaminophen, gabapentin,
and opioids. By acting on different pain pathways, these medi-
cations are more effective in combination than in single-agent
therapy.
Local anesthesia can be obtained through direct injection of
the anesthesia into the surgical site, regional blocks performed
by either the plastic surgeon or anesthesiologist, or use of pain
pumps, in which catheters are left in place in the surgical site
and local anesthetic is infused into the surgical site over the
course of several days. More recently, a liposomal formulation of
bupivacaine has become available, which is injected at the time
of surgery and slowly releases bupivacaine over 72 hours. Use of
locoregional anesthesia can help minimize narcotic requirements
for patients after surgery.
The safety of nonsteroidal anti-inflammatory drugs periop-
eratively is a hotly debated topic. Concerns regarding their use
typically revolve around their effects on clotting and perceived
increased bleeding risk. A meta-analysis of ibuprofen use follow-
ing plastic surgical procedures failed to show any increased risk
of complications in patients taking ibuprofen perioperatively, but
many surgeons still err on the side of caution, particularly in body
contouring procedures, in which large dissected areas with risk
for significant blood loss may be the norm. One proposed alterna-
tive to nonselective Cox inhibitors such as ibuprofen is the use of
celecoxib, which is thought by many to have decreased effects on
clotting due to its selective effects on Cox-2. It is also important
to consider the mechanism of weight loss before prescribing
nonsteroidal anti-inflammatory drugs, as their use following
RYGB has been associated with increased risk for marginal ulcers
of the stomach and are therefore contraindicated. Some bariatric
surgeons will also advise sleeve gastrectomy or gastric banding
patients to avoid them.
Many bariatric patients suffer from chronic back and joint
pain, so it is important to screen for preexisting chronic opioid
use. Patients with a long history of opioid use may have higher
tolerance to opioid analgesics and are likely at increased risk of
prolonged opioid use postoperatively. In patients under a pain
contract, it is important to communicate with the patient’s pain
management physician regarding their surgical plan to avoid
duplications in prescribing.
87.6 Concluding Thoughts
Obesity affects a person in profound ways, both physically and
psychologically. Following massive weight loss, significant
contour deformities impact every part of the body, consistently
accompanied by emotional and psychological consequences.
Safe management of these patients with corrective surgical pro-
cedures requires a comprehensive strategy that involves consid-
eration of the high rate of comorbidities, the anatomical changes
that occur following weight gain and loss, and the nutritional,
psychological, and metabolic derangements that may make
surgery and recovery more challenging. Given the complexity
of surgical intervention, managing expectations becomes a
particularly critical element in this patient population. Priority
staging of procedures, accompanied by candid representation of
the limitations of surgery and the potential for complications,
improves the probability of patient satisfaction.
Clinical Caveats
• Comprehensive treatment protocols for preoperative, intra-
operative, and postoperative phases are required to manage
comorbidities, enhance safety, and reduce complications in
the massive-weight-loss patient.
• Our collective experience has demonstrated that treating
a patient’s primary concerns first (priority staging) is more
likely to result in a higher level of patient satisfaction.
• Pretreatment vasoconstriction with tumescent solution
infiltration for all flap procedures reduces blood loss, clarifies
dissection planes, and reduces surgical time.
• Liposuction prior to flap elevation preserves flap vascularity
through discontinuous undermining and optimizes accurate
assessment of skin redundancy.

87 Screening and Safety Issues in the Massive-Weight-Loss Patient
1371
• Using progressive tension sutures for all flap procedures
reduces seroma formation and the need for postsurgical
drains.
• Because the deformities are more dramatic and the proce-
dures more complex and demanding with higher complica-
tion rates, managing expectations in the massive-weight-loss
patient is more challenging and yet even more crucial.
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1372
XII Body Contouring
88 Brachioplasty
Sepehr Egrari
Abstract
The use of brachioplasty is rapidly increasing. Tremendous
variability in presentations has led to different types of arm
recontouring. From suction-assisted lipectomy, for appropriate
candidates, to minimal incision brachioplasty and more exten-
sive brachioplasty procedures, the objective is to reproduce
a proportional and functional arm contour. Patient selection,
preoperative assessment, and clear understanding of the arm’s
anatomical features are paramount. Preoperatively designed
markings of four major groups of brachioplasty—minimal
incision, standard, extensive, and thoracobrachioplasty—are
based on the position and proximal and distal involvement
of excess skin and fat and on preferred scar position in the
posterior–medial axis. Two intraoperative approaches to a safe,
predictable operation—the staple approximation technique and
the sequential resection and approximation technique—are
described. A three-pointed progressive closure reduces dead
space and obviates the need for drains. As scarring continues to
be a major concern, intraoperative and postoperative measures
are taken to reduce tension and create a better environment for
the eventual mature scar. Use of longer-absorbing sutures and
silicone products, as well as the passage of time, are primary
factors in the mature scar’s appearance. Selective ancillary pro-
cedures, such as breast recontouring and upper body lifts, can
be useful adjuncts to brachioplasty. Patients should be warned
about various anatomical limitations, such as posterior elbow
lipodystrophy and midarm constrictive bands, and the potential
need for secondary operations with recurrent arm laxity. But
with selection of the appropriate type of brachioplasty and a
well-planned execution, this operation’s results are predictable
and highly gratifying for patients.
Keywords
brachioplasty, drainless closure, extensive brachioplasty, hyper-
trophic scarring, intraoperative scar management, midarm
constrictive bands, minimal incision brachioplasty, posterior
elbow lipodystrophy, posterior–medial scar, postoperative scar
management, sequential resection and approximation tech-
nique, standard brachioplasty, staple approximation technique,
thoracobrachioplasty
88.1 Introduction
:ith the confluence of popular culture’s quest for a shapely arm,
and the rapid evolution of massive-weight-loss body contouring
has come a rapid increase in brachioplasty that addresses excess
skin and fat of the upper arm and its extension into the lateral
chest wall. Considering the diverse presentations of excess skin,
patterns of weight loss, and proximal and distal extension of the
deformity, different types of brachioplasty are used to address
this range of presentations. Brachioplasty has evolved primarily
through development of progressive and efficient intraoperative
techniques that translate into a harmonious and balanced arm
shape, taking into account scar position and regional proximal
defects, such as lateral chest wall excess. Also, a clear under-
standing of variability of presentation is paramount to produce
consistent outcomes in the face of the wide-ranging variations in
this patient population (Fig. 88.1).
Although suction-assisted lipectomy might be appropriate for
a select group of patients who retain sufficient skin elasticity,
an excisional approach to remove excess skin continues to be
the most common operation for a majority of patients. Since its
description in the mid-1950s in the literature, brachioplasty has
been considered the operation of choice in individuals with sig-
nificant excess skin and lipodystrophy of the arm. Various types
of brachioplasty, based on an algorithmic description of defects,
range from a minimal incision procedure, based on the axillary
fossa, all the way to thorachobrachioplasty that extends the exci-
sion of the arm’s excess into the lateral chest wall. At all times,
the goal of treatment is to create a harmonious, proportional,
and balanced arm with attention to aesthetics of the scar and,
ultimately, safety and reproducibility.
88.2 Indications and
Contraindications
Brachioplasty is indicated in patients who have significant excess
skin of the upper arm. Such patients present with loss of anatom-
ical features of the upper arm due to redundancy of skin. This
is accompanied by various degrees of lipodystrophy in different
regions of the upper trunk and arms. This skin redundancy can
extend below the elbow and to the lateral chest wall. In cases
where excess fat is present with minimal excess skin, usually in
younger individuals or persons who have not sustained weight
loss, liposuction alone can be used to contour the upper arm.
However, most patients with excess skin will require brachio-
plasty. An appropriate candidate for this operation is someone
with significant excess skin and fat, who is healthy, has stable
weight, and understands the realistic outcomes of this operation.
Candidates must also be familiar with the extent and nature of
scarring that accompanies brachioplasty.
Brachioplasty should be avoided in patients with poor health
and those who have not fully lost the necessary weight, are
active smokers, or have unrealistic expectations. It should also be
avoided in patients with a history of extensive lymphadenectomy
of the axilla or lymphedema and compromise of vascular anat-
omy and function and in those with restricted arm movement
and function due to immune, musculoskeletal, or traumatic
disease processes.