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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91.14c,d). Once the stalk is identified, it is sutured to the umbilical
opening with four inverted interrupted 4–0 absorbable monofil-
ament sutures to preliminarily inset the umbilicus. Any tendency
to now use any type of traditional running suture to finalize the
skin closure should be resisted, because this technique can result
in suture marks in the skin that create a very unaesthetic result
postoperatively. It is a better option to finalize the closure using a
standard subcuticular suture of 4–0 absorbable monofilament, as
this will provide long-term support of the wound without risking
the creation of stitch marks in the skin. This is accomplished by
running one subcuticular suture along the superior aspect of
the horizontal umbilical wound and then a second subcuticular
suture along the inferior aspect, keeping the free ends long and
then tying the loose ends together on either side of the umbilicus
once the wound is entirely closed. While the process of creating,
sighting in, and insetting the umbilicus is tedious and requires
great attention to detail, it is required to ensure that the aesthetics
of the final umbilical size and shape are maximized as much as
possible to achieve the desired overall result. In evaluating the
complications observed in other less than desirable results, it is
often a substandard umbilicus that is responsible for the dissatis-
faction of the patient. Such results include an umbilical opening
that is either too small or too big, with a visible scar; or is in a
misplaced location that is too high or too low or off center; or is
tethered, creating an unnatural contour. Because the umbilicus
rides up away from the scar, which can be concealed beneath
clothing, it is more plainly visible, a fact that makes creating an
aesthetic and natural-appearing umbilicus central to an aesthetic
result. All efforts to maximize the appearance of the umbilicus
in all forms of abdominoplasty are well worth the time spent to
achieve the desired result.
Once the umbilicus is inset and the deep tissues are approx-
imated, final closure of the skin incision is accomplished. Any
persistent gaps in the closure of the deep fatty layers are closed,
and dermal approximation with numerous interrupted 4–0
absorbable monofilament sutures is performed. If there is any
inequality in incision length in the remaining central third of the
wound, it is evenly distributed again using a tailor-tack stapling
technique to guide the placement of the intradermal sutures. Final
skin closure along the entire abdominal wound is accomplished
with a running subcuticular suture. A strong recommendation
can be made to use a barbed 3–0 absorbable monofilament for
this purpose. The barbs lock the skin edges into position during
the early wound healing period, thereby preventing micromotion
form occurring at the wound edge. This greatly diminishes the
inflammation that occurs in the skin closure, an advantage that
results in a very thin and fine-line scar once full healing has
occurred (Fig. 91.14e,f).
Final dressings are applied consisting of tape support of the
wound topped with a clear occlusive dressing. An abdominal
binder is applied and secured snugly enough to simply provide
support to the abdominal wall and help alleviate stress and
discomfort associated with the procedure. This provides an easy
and straightforward postoperative recovery, because there are
no dressings that require changing and no sutures need to be
removed.
In the vast majority of cases, abdominoplasty is performed as an
outpatient procedure. As an aid to this approach, several adjunc-
tive techniques have been described to assist in the rapid recovery
of the patient. Before final closure, the injection of a long-acting
local anesthetic, such as Marcaine, into the abdominal wall can
ease postoperative pain for up to 12 hours after the procedure. An
even more aggressive approach, albeit a very costly one, is to use
Exparel for this purpose. The ameliorating effects of this long-act-
ing local anesthetic on postoperative pain can persist for even
days after the procedure. Alternatively, some surgeons have also
Fig. 91.14 (a–d) By passing the index finger under the partially closed abdominal wound, the location of the umbilicus can be manually identified.
This point is transposed onto the skin of the abdomen, and an inferiorly oriented hemi-ellipse that is the same length as the original umbilical
incision is diagrammed and then incised. After the incision is made, the defect will spread slightly, creating a perfect defect for inset of the umbilical
stalk. (e,f) Final appearance of the abdomen after resection of the redundant skin and fat and plication of the abdominal wall.

91 Abdominoplasty
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reported on the use of indwelling catheters left in the wound for a
short period of time, through which a continuous dosing of a local
anesthetic is provided. This catheter is then removed after several
days, after which pain control is managed with standard pharma-
cological techniques. Postoperatively the patient is encouraged to
wear the abdominal binder for comfort. Drains are managed on
an outpatient basis and are removed when the drainage from an
individual drain is less than 30 to 40 mL in 24 hours. The occlusive
dressings are removed at 1 week postoperatively, and taping of the
incisions is begun, with the tape being changed once a week until
the 6-week mark is reached. This provides an external splint to the
wound that, in conjunction with the barbed suture, tends to create
a fine-line and aesthetic scar. Vigorous activity is restricted for 4
weeks, and return to athletic activity is allowed after 6 weeks.
Results
The results obtained after abdominoplasty tend to be among
the more dramatic results of the various aesthetic procedures
performed in plastic surgery. Removal of the excess skin and
fat in conjunction with repair of the abdominal wall flattens
and contours the abdomen, restoring a youthful and aesthetic
appearance. Also, the muscular plication combined with the
posterior liposuction tends to narrow the waist, restoring an
hourglass configuration to the torso. Overall, a consistent,
effective, and safe procedure is provided with a very high rate of
patient satisfaction (Fig. 91.15, Fig. 91.16, Fig. 91.17, Fig. 91.18).
91.7.2 Extended Abdominoplasty
Indications
In selected cases, the redundancy of the skin and fat of the
abdominal wall extends around to the back into the region of the
lateral abdominal wall and the posterior hips. The weight of this
tissue in conjunction with the redundancy leads to ptosis of this
tissue along the lateral hip area with variable shape distortion
and irregularity. Removal of this redundant tissue along with
tightening of the soft tissue envelope performed in continuity
with a full abdominoplasty can significantly rejuvenate the
entire area, improving not only the contour of the abdomen
but also the entire lateral abdomen, back, and thigh. However,
stopping short of a full circumferential approach by keeping the
midline back area untouched means the postoperative mobility
of the patient is less significantly affected, resulting in an easier
and more straightforward recovery for the patient. This proce-
dure is referred to as an extended abdominoplasty.
Marking
The markings for an extended abdominoplasty mirror those
applied for a conventional abdominoplasty in that the pattern
sweeps across the lower abdomen, identifying what can be an
impressive amount of skin that is destined for resection. The dif-
ference lies in the fact that the lateral extent of the pattern is dia-
grammed such that an additional amount of skin and fat from the
lateral abdominal wall with an extension onto the back is removed.
As with standard abdominoplasty, the pattern follows the relaxed
skin tension lines of the lateral abdominal wall as it outlines the
area of excess to be removed. As the pattern extends posteriorly,
it generally curves upward, ending variably short of the midline.
The markings are initiated by first identifying the area of redun-
dancy along the lateral hip area and estimating the amount of skin
and fat to be removed using a pinch test. This pinch of skin and
fat is centered directly over the area of maximal redundancy, and
the upper and lower limit of tissue removal is estimated. It is noted
during this maneuver that most of the tissue advancement comes
up from the lateral thigh, and this is the area that experiences the
most dramatic reshaping. Only minimal inferior advancement of
the tissues from the lateral abdominal wall is noted. Once this area
is marked, the pattern is tapered off posteriorly along the relaxed
skin tension lines to end short of the midline in the back. By viewing
the pattern from the back, symmetry in both the location and the
level of the posterior portion of the pattern can be assured. Once
Fig. 91.15 (a,b) Preoperative appearance of a 42-year-old woman in preparation for a full abdominoplasty along with abdominal wall plication and
liposuction to the posterior hips. (c,d) Preoperative marks. (e) Final intraoperative appearance. (f,g) Three-year postoperative result.

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the posterior and lateral portions of the pattern are completed,
the lateral marks are joined with the anterior marks for a standard
abdominoplasty to complete the pattern (Fig. 91.19).
7eFKniTue
Because of the extended nature of the pattern, the procedure
is initiated with the patient in the prone position (Fig. 91.20a).
This allows easy access to the more laterally and posteriorly
located markings. Attempts to resect this tissue with the patient
supine prove difficult, as accessing these areas to perform the
resection and then close accurately requires rolling the patient
from side to side. Even with reasonable exposure with the help of
multiple assistants, this approach is awkward and unnecessarily
complicates the technical aspect of performing the operation.
Additionally, the prone position also allows fat grafting to the
buttock to be performed if that is desired by the patient.
If liposuction is to be performed in conjunction with the soft
tissue resection, these areas are infiltrated with tumescent solu-
tion at the start of the case. Very often this will include the areas of
the posterior hips. Liposuction is then performed to the affected
areas of the posterior torso as needed prior to the resection of
any tissue. Once the desired contours have been created, the skin
incisions are made in the most medial aspect of the pattern near
the midline. A resect and tailor staple closed technique is used
to gauge how much tissue to remove. Typically, in this posterior
location, the upper skin edge is somewhat immobile compared
with the lower incision, which tends to have more laxity in the
Fig. 91.16 (a–c) Preoperative appearance of a 36-year-old woman in preparation for a full abdominoplasty along with abdominal wall plication and
liposuction to the posterior hips. (d–f) Preoperative marks. (g) After liposuction to the posterior hips, 1,150 mL of fat was removed. (h) Appearance
of the resected specimen. (i) Immediate intraoperative appearance. (j–l) One-year postoperative result.

91 Abdominoplasty
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Fig. 91.17 (a,b) Preoperative appearance of a 34-year-old woman in preparation for a full abdominoplasty along with abdominal wall plication and
liposuction to the posterior hips.(c) Preoperative marks in preparation for full abdominoplasty with three-line plication of the abdominal wall.(d,e)
Four-year postoperative result.
Fig. 91.18 (a,b) Preoperative appearance of a 40-year-old woman in preparation for a full abdominoplasty along with abdominal wall plication and liposuction
to the posterior hips. (c) Preoperatively a small fascial defect is present in the midline diastasis just above the umbilicus. Repair of this defect will be incorpo-
rated into the plication of the abdominal wall. (d) Preoperative marks. (e) Appearance of the resected specimen. (f,g) Seven-month postoperative appear-
ance. (h) When the abdomen is placed under stress, a stable repair of the fascial weakness and complete correction of the fascial defect is demonstrated.

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tissues. Therefore, the upper skin margin is incised first, with the
exact location of the lower incision adjusted as needed to allow
easy closure. This resection strategy is worked out laterally to
the midaxial line. The deep plane of resection is set just deep to
the deep fascia of the back. Only minimal undermining of the
upper flap is performed due to the relative lack of mobility in
these tissues. Inferiorly, however, limited undermining can be
performed as needed to maximize the amount of tissue resected
and still facilitate wound closure. Laterally the redundant tissue
is amputated using a V-shaped pattern, and the entire wound is
closed with temporary staples. Orientation lines are placed in the
skin margins and the staples are removed. The wound is irrigated,
hemostasis is obtained, and final wound closure is accomplished
using a quilting suture technique designed to close off the dead
space. A 2–0 absorbable monofilament is passed through the
upper and lower edges of the deep fascia with a third pass taken
through the deep fat. This closes off the dissection space and
negates the need for a drain in this portion of the resection pattern.
Final closure is performed with an intradermal approximation
using a 4–0 absorbable monofilament followed by a subcuticular
closure using a 3–0 absorbable barbed monofilament suture. The
back wound is dressed with Steri-Strips followed by a Tegaderm
dressing (Fig. 91.20b–g).
Once the back wound is closed, the patient is rotated into the
supine position, and the abdomen is prepped and draped as
for a routine abdominoplasty. Using the same techniques as for
abdominoplasty, the redundant tissue is removed in continuity
with the incisions that are running anteriorly from the back, such
that the anterior abdominoplasty closure then completes the
procedure (Fig. 91.20h,i).
Postoperatively, the recovery process is not much changed from
that associated with standard abdominoplasty. By stopping short
of the midline in the back, the morbidity with restricted motion
postoperatively is not as significant as that associated with a cir-
cumferential body lift. Drains are placed with the abdominoplasty
and are managed in the same fashion. Vigorous exertion is limited
for 4 weeks, after which, full return to activity is allowed.
Results
The results after extended abdominoplasty are often even
more dramatic than those seen with standard abdominoplasty.
Typically, an impressive amount of skin and fat is removed, and
the additional contouring effect of removing the lateral and
posterior excess of tissue reshapes this entire area with little
chance of forming a dog-ear. Overall, a procedure that is safe and
particularly effective in reshaping the abdomen of these difficult
patients is provided (Fig. 91.21a–k).
91.7.3 Circumferential Abdominoplasty
Indications
While standard abdominoplasty is indicated in most patients
seeking abdominal rejuvenation, there is a subset of patients
who present with fat and skin excess, laxity, and tissue ptosis
that extends circumferentially around the torso. In these situa-
tions, the abdominoplasty component of the surgical plan is very
effective at treating the abdomen; however, by completing the
excision pattern circumferentially around the torso, the excess
tissue is removed from the hips as well as the posterior back.
Fig. 91.19 (a–c) Preoperative appearance of a 24-year-old woman who presents for abdominal rejuvenation after undergoing a 30-pound weight loss.
(d–f) Preoperative marks are seen outlining a wide resection of skin and fat from the anterior abdominal wall, extending laterally to include a gen-
erous amount of tissue from the lateral hip and finishing around to the back in a symmetrical fashion, stopping just short of the midline. Orientation
lines on the pattern applied with the patient in the upright position allow accurate approximation of the superior and inferior flaps. These marks
become important, as the positioning of the flaps intraoperatively can appear distorted with the patient in either the prone or the supine position.

91 Abdominoplasty
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The rejuvenating effect this maneuver has on the lateral hip area
and buttock can be significant. Also, the addition of this circum-
ferential approach fits well with the lateral excision pattern of
the abdominoplasty, making it an easy addition to the overall
surgical plan.
Candidates for a circumferential abdominoplasty include those
where the tissue laxity is pronounced not only in the abdomen
but also in the lateral hip areas and buttocks. While some more
straightforward abdominal rejuvenation patients may present with
these findings, particularly after pregnancy, it is more common for
patients who have undergone a significant weight loss to be can-
didates for this procedure. In these patients, the circumferential
´body liftµ approach is often the first step in a staged treatment
plan designed to address all the areas of laxity these patients can
present with, including the medial thighs, arms, and face.
Strategically, these patients can be thought of as extended
abdominoplasty patients, with the resection pattern simply
continuing across the posterior midline. From a recovery stand-
point however, the procedure is more extensive than resection
patterns that are limited to the front or sides of the torso. A
typical abdominoplasty patient will favor the anterior abdominal
wall wound by adopting a slightly flexed posture for several days
postoperatively while the wounds heal. When a circumferential
approach is used, there is tightening both front and back; therefore,
body positioning as a means of alleviating stress on the surgical
sites during the early healing process is limited. Thus the recovery
after a circumferential approach proceeds more slowly than after
a more limited anterior abdominoplasty procedure. These factors
must be taken into account when counseling patients as to the
most appropriate surgical approach.
Patient Marking
The markings for a circumferential body lift are essentially those
of an extended abdominoplasty, with the caveat being that the
pattern is continued around to and past the midline as the marks
from each lateral hip area are joined together. Once the lateral
marks are applied, the redundancy of the soft tissues is assessed
as the tissue laxity is pinched between the fingers toward the
midline. Typically, as is noted in the lateral hip area, there is
Fig. 91.20 (a) The procedure is initiated with the patient in the prone position to allow easy resection of the posterior and lateral tissues as well as
liposuction of the posterior hips. (b,c) After resection of the posterior wedge of tissue, the back wound is closed up to the midlateral line. (d–f) The
redundant tissue is excised, leaving an anteriorly based V-shaped dart that is inset into the most lateral extent of the closure with temporary skin
staples. This allows the posterior wound to be dressed and the patient to be then rotated into the prone position in a clean fashion with no open
wounds being exposed during the position change process. (g) Final appearance of the completed closure in the back. (h) Final appearance of the
completed anterior abdominoplasty. (i) Appearance of the resected tissues from the lateral and anterior portions of the abdomen.

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limited excursion of the tissues from the upper portion of the
resection pattern, even with undermining. However, the inferior
tissues over the buttock will move superiorly even with only min-
imal undermining. Therefore, since the upper incision line will
be relatively stable in location, it is set first. The area of maximal
redundancy is estimated by pinching the skin together at various
levels just above the top portion of the intergluteal crease. Care
must be taken not to remove an excess of tissue above the crease,
as this will pull the top portion of the intergluteal crease too far
superiorly, creating a distorted appearance. Once the top line is
set, the bottom line is estimated, with the final resection pattern
determined intraoperatively. As a final nuance, a contoured
closure can be facilitated by incorporating a small, inferiorly
directed dart in the pattern just above the gluteal crease. This
adds a more aesthetically pleasing curve to the resulting scar by
breaking up the tendency for the back scar to adopt a straight-
line configuration. One very important marking maneuver to
include in the pattern is to add evenly spaced orientation marks
above and below the upper and lower incisions with the patient
standing upright. This will allow easy and accurate approxima-
tion of the wound edges intraoperatively after the skin and fat
are excised. Failure to include these marks can create difficulty
at the time of surgery as the tissue planes become distorted after
excision with the patient lying prone, making it difficult to accu-
rately close the wound without creating an unnecessary dog-ear.
This completes the marking sequence (Fig. 91.22).
Fig. 91.21 (a–c) Preoperative appearance of a 37-year-old woman in preparation for a full abdominoplasty along with abdominal wall plication.
(d–f) Preoperative marks in preparation for an extended abdominoplasty. (g,h) Intraoperative views demonstrating a three-line abdominal wall
plication as well as the final intraoperative result. (i–k) Final result at 6 months demonstrating a smooth and aesthetic abdominal wall contour.

91 Abdominoplasty
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7eFKniTue
As with the extended abdominoplasty, the procedure is begun in
the prone position. The upper incision line is made on either side
of the midline, then is extended laterally for several centimeters.
An estimate is made of the location for the inferior resection
line, and this incision is then made, being certain that the wound
edges will come together without excessive tension. Only min-
imal undermining is performed to facilitate this resection and
closure. The wound is tailor-tacked closed with staples, and
the pattern is similarly extended laterally as with an extended
abdominoplasty. In this fashion, the redundant tissue is resected
under direct control, being certain that the wound will be closed
easily and accurately, using the previously placed orientation
lines as guides. Closure proceeds without drains using a quilting
suture approach by incorporating the deep fat in the upper and
lower wound edge closure with a three-cornered stitch of a
heavy 2–0 absorbable monofilament suture material to close off
the dead space.
Fig. 91.22 (a–c) Preoperative appearance of a 50-year-old woman in preparation for circumferential abdominoplasty. (d) The redundancy of the soft
tissues is assessed in the midline, and a proposed resection pattern is outlined. The interior extent of the pattern is diagramed directly at the superior
aspect of the intergluteal cleft. A small, inferiorly oriented dart in the pattern is added to provide contour to the eventual closure. (e,f) Laterally the
extent of the soft tissue redundancy is assessed and diagrammed, with care being taken to ensure that the resulting wound will close easily. (g,h)
Once the extent of the posterior and lateral aspects of the pattern have been determined, the lines are joined into a smooth arc across the posterior
aspect of the torso. (i,j) The pattern is then joined anteriorly into the marks for a standard anterior abdominoplasty. (k) Final appearance including
marks for a proposed three-line abdominal wall plication.

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Resection of the redundant tissue and final posterior skin
closure is performed as with an extended abdominoplasty
(Fig. 91.23a–d).
The patient is then rotated into the supine position, where
the posterior lines of resection are continued anteriorly into the
previously diagrammed pattern. The abdominal wall is repaired
as needed, and final skin resection and closure proceed as for a
normal anterior abdominoplasty (Fig. 91.23e–h).
During the placement of the final wound dressings, care must
be taken to avoid placing tension on the skin edges with top-
ical Steri-Strips, dressing tape, or clear, waterproof, occlusive
dressings. Because the patient is in the prone position, there
is a slight flex to the back area; therefore, what looks like a
tension-free application of the topical dressing actually places
traction on the skin when the patent adopts a normal upright
position. This tension on the superficial surface of the skin
can result in blistering that can sometimes become significant
and even result in permanent scarring in patients with darker
pigmented skin. Therefore, when applying topical dressings,
care must be taken to ensure that no tension is placed on the
skin edges.
Results
As with the extended abdominoplasty, the results obtained
after circumferential abdominoplasty can be remarkable. A total
rejuvenation of the entire torso, front, and back, with extension
into the hips and buttocks, can be achieved (Fig. 91.24).
91.7.4 Fleur-de-Lis Abdominoplasty
Indications
In patients who present after massive weight loss, the degree of
stretch and excess associated with the redundant tissues over
the entire torso can exceed what can be excised using the single
Fig. 91.23 (a–d) The posterior wedge of tissue is incised, reflected laterally, and amputated in a fashion similar to that performed with an extended
abdominoplasty. The back wound is closed, and the lateral wedge is temporarily stapled shut to facilitate rotation into the supine position. (e–g)
The resection pattern is then carried anteriorly according to the previously applied marks. In this case, a three-line abdominal wall plication was
performed. (h) Final appearance after closure and inset of the umbilicus.

91 Abdominoplasty
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plane of excision afforded by simple abdominoplasty. In these
patients, excising tissues vertically in association with a horizon-
tally oriented excision pattern can more effectively treat the soft
tissue excess and improve the aesthetic result. The disadvantage
is related to the addition of a vertical scar running down the mid-
line of the abdomen. However, for the vast majority of massive
weight loss patients, improvement in contour is prioritized over
scar, and the additional vertical component is well tolerated.
Also, many patients present with a preexisting midline vertical
scar related to a previous procedure, often a gastric bypass pro-
cedure, making the inclusion of a vertical soft tissue excision an
even more attractive option, as the result is improved with no
additional scar burden (Fig. 91.25).
Patient Marking
The patient is marked standing upright with the hands held
down at the sides. The marks for a standard abdominoplasty are
applied, extending laterally and/or around to the back as indi-
cated. Once the upper abdominoplasty incision line is marked,
the redundant soft tissues in the midline of the abdomen are
pinched together vertically to give some guide for how much
can be removed while still providing for a stable closure. This
mark extends from the xiphoid process down to the upper
abdominoplasty mark along the midline, curving laterally along
the midline on each side of the umbilicus. It is important to real-
ize that this mark serves as a guideline only; the final pattern
will be determined intraoperatively once the flaps have been
undermined.
7eFKniTue
During the operative procedure, the abdominoplasty is per-
formed first, and the exact location of the upper line of resection
is determined. The abdominal wall repair is finalized so that the
final vertical resection can be performed once the shape of the
underlying muscular framework has been set. The proposed
line of vertical resection is tailor-tacked closed, along with the
horizontal component. Once the desired skin resection has been
determined, the vertical segment is marked and the redundant
soft tissues are resected, with care being taken to avoid any
undermining of the flaps during the resection of the fatty layers.
Closure is performed incorporating the umbilical stalk into the
midline of the vertical scar (Fig. 91.26).
Fig. 91.24 (a–c) Preoperative appearance of a 42-year-old woman who presents for rejuvenation of her torso after undergoing a 30-pound weight
loss. (d–f) Preoperative marks in preparation for a circumferential abdominoplasty or body lift procedure. (g–i) Six-year postoperative result demon-
strating smooth anterior and posterior contours and an overall aesthetic and proportional appearance to her entire torso.

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XII Body Contouring
Results
As is seen with circumferential abdominoplasty, the results
obtained by adding a vertical component to the pattern can
create a dramatic postoperative change in the aesthetics of the
entire torso. Not only is the horizontal excess treated, but by
resecting the redundant and what is often damaged midline
skin and fat, a narrowing of the waist is also accomplished that
enhances the quality of the overall result (Fig. 91.27).
91.7.5 Mini-Abdominoplasty
Indications
In assessing the patient for possible abdominal rejuvenation,
one of the most important relationships that must be recog-
nized is the position of the umbilicus in relation to the remain-
der of the abdominal wall. If the umbilicus is located higher
up on the abdominal wall, or if there is minimal laxity of the
skin in the lower abdomen, it becomes impossible to remove
all the skin between the umbilicus and pubis and still achieve
primary closure of the wound. In this situation, the upper
incision line would have to be located below the umbilicus,
thus obviating any possibility of translocating the umbilicus,
and the resulting scar would end up higher on the abdomen
in an unaesthetic and visible location. In these situations, a
technique referred to as a mini-abdominoplasty is used. In this
procedure, the redundant skin and fat in the lower abdomen
are removed, the fascia of the lower abdomen can be minimally
plicated, and liposuction to the abdomen or posterior hips
can be performed as needed to help reshape the abdomen.
Taken together, when applied appropriately, these technical
maneuvers can result in a pleasing improvement to the con-
tour of the abdomen in selected patients. One caveat to this
approach relates to patients who present with an umbilicus
positioned higher up on the abdominal wall. In these cases, all
the foregoing procedures can still be performed; however, as
an additional maneuver, the umbilical stalk is released from its
attachment to the abdominal wall. As the abdominal pannicu-
lus is drawn downward and the redundant tissue resected, the
new position of the umbilicus is identified, and the umbilical
stalk is reset into its new, lower position in the midline. This
umbilical float technique serves to lower a highly positioned
umbilicus while also allowing the tightening effect of the skin
and fat resection to be extended to the soft tissues above the
umbilicus as well as below. Taken together, all these changes
can be affected with a shorter scar than that associated with
a traditional abdominoplasty as well as incorporating less
operative morbidity into the procedure.
Patient Marking
The patient is marked in the upright position. The lower incision
is marked first by placing the incision low on the abdominal wall,
Fig. 91.25 (a,b) Preoperative appearance of a 65-year-old woman who presents for abdominoplasty with a previous history of an abdominal
procedure resulting in a midline vertical scar extending from the xiphoid process to the umbilicus. (c) Preoperative marks in preparation for an
abdominoplasty using an additional vertical fleur-de-lis extension. This strategy makes use of an already existing scar and affords an opportunity
to further shape and narrow the abdomen while at the same time revising the mildly widened previous vertical scar. (d,e) Six-month postoperative
result demonstrating improvement in the contour of the abdomen in both the horizontal and vertical dimensions.

91 Abdominoplasty
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just at the pubic hairline. The redundancy of the skin and fat of
the lower abdomen is assessed, and the amount of tissue to be
resected is estimated, with care being taken to avoid removing
so much tissue that a tethering effect is placed on the immobile
umbilicus. Once the vertical height of tissue to be removed is
determined, the marking pattern is extended laterally in either
direction as far as is needed to avoid a dog-ear once the tissue
resection is completed. Any areas of excess fatty deposition in
the abdomen or posterior hips are marked, and the marking
process is completed.
Fig. 91.27 (a) Preoperative appearance of a 53-year-old woman who presents with severe stretch marks extending from the pubis up to a point well
above the umbilicus. The skin damage to the central portion of the abdomen is severe; however, the skin laterally is unaffected. (b) To maximally
utilize the unaffected skin as cover for the abdomen and resect as much of the damaged skin as possible, a fleur-de-lis approach is diagrammed.
(c) The 7-year postoperative result demonstrates excellent coverage of the abdomen with undamaged skin and a well-healed and fine-line midline
abdominal scar. In this case, the vertical scar was a reasonable tradeoff to allow resection of the damaged and stretch mark–plagued skin.
Fig. 91.26 (a) Preoperative appearance of a 64-year-old woman who presents for abdominal rejuvenation using a combined horizontal and vertical
fleur-de-lis approach. Her previous lower midline abdominal scar makes this an attractive surgical option to maximally tighten and reshape the
abdomen. (b) Preoperative marks demonstrating the combined horizontal and vertical approach along with liposuction of the anterior abdominal
wall. (c,d) The proposed lines of skin resection are temporarily stapled into position to confirm the accuracy of the surgical markings. After removal
of the staples, the lines for incision can be seen. (e,f) After resection, the skin flaps are pulled together with a T-shaped closure in the midline just
above the level of the pubis. (g) Final immediate postoperative result. (h) Final result at 6 months.

1436
XII Body Contouring
7eFKniTue
At surgery, liposuction is performed as needed, after which the
lower incision is made and the soft tissue release is extended
down to the Scarpa’s fascia of the abdomen. While full-thickness
resection of the skin and fat can be performed at the level of the
abdominal wall, in many patients the soft tissue resection can
be stopped just at the level of Scarpa’s fascia and then extended
upward as far as needed to allow the removal of the redundant
tissue. Leaving behind the deep layer of fat below Scarpa’s fascia
limits the propensity of the wound to develop a seroma. After the
upper incision is made, a 2–0 absorbable monofilament suture
is used to join the upper and lower incisions to the deep fat in a
quilting suture type fashion. This closes off the deep space and
can eliminate the need for a postoperative drain.
In cases where the abdominal wall requires plication, the
dissection of the skin and fat is ideally performed at the level of
the abdominal wall fascia in the central third to allow easy visual-
ization of the abdominal wall fascia and accurate placement of the
sutures. Closure is then performed as before.
Results
Typically, the technique is best applied in thin patients who present
with limited soft tissue excess. In these situations, a full abdomi-
noplasty may involve much more operative morbidity than the
patient needs or wants, and the mini-abdominoplasty approach,
although somewhat limited in scope, can provide excellent results
in properly selected patients (Fig. 91.28, Fig. 91.29).
91.7.6 Male Abdominoplasty
Indications
All the benefits noted with abdominoplasty in women are also
noted in men. However, excess of abdominal skin and fat in men
is almost purely related to weight gain and loss as the effects of
pregnancy no longer apply. As a result, laxity of the abdominal
wall is a much less significant issue for men. Also, many male
patients present for abdominoplasty after undergoing a signifi-
cant body habitus change and can be dramatically toned prior to
surgery. For these reasons, male abdominoplasty tends to involve
soft tissue resection only, with no need to incorporate muscle
plication into the operative plan. Additionally, incorporation of
liposuction into the posterior hip or “love handle” areas on men
is a commonly applied adjunct to abdominoplasty, as this area
is resistant to fat loss, even in cases of dramatic weight change.
Patient Marking
Typically, the markings for abdominoplasty in men mirror those
used in women in every respect. However, great care must be taken
in placement of the location of the lower incision secondary to
differences in fatty deposition between men and women. Despite
the presence of a clear excess of skin and fat in the lower abdomen,
in men there is often a very clear zone of adherence running just
below this lower abdominal crease, with a very thin layer of skin
and fat being present. Once the excess lower abdominal tissue is
removed, the greater thickness of the inferiorly transposed upper
Fig. 91.28 (a,b) Preoperative appearance of a 49-year-old woman who presents with mild skin laxity with stretch marks to the lower abdomen along
with laxity to the abdominal wall. (c) Preoperative marks in preparation for a mini-abdominoplasty along with liposuction of the central abdomen and
three-line plication of the abdominal wall. In this case an umbilical float technique will be used to allow full repair of the abdominal wall without being
restricted by the presence of the umbilical stalk. (d,e) One-year postoperative result demonstrating improvement in the abdominal wall contour.

91 Abdominoplasty
1437
flap can be poorly matched to the thinner lower flap such that an
unavoidable step-off is created after closure (Fig. 91.30). To pre-
vent this, the lower incision mark must not be placed directly in
the lower fold but rather must be placed just slightly up onto the
thicker proposed lower skin flap. This will ensure that the match
between the thicknesses of the upper and lower flaps is sufficient
to ensure a smooth contour to the final closure.
7eFKniTue
The technique of abdominoplasty in men is identical to that used
in women in every respect. Care is taken to match the thickness
of the two incision lines during closure to ensure a smooth
contour postoperatively. Of note, however, is the fact that hemo-
stasis merits particular emphasis in men, as the blood vessels
can be more substantial in structure and can require fastidious
control during the dissection.
Results
The results in men after abdominoplasty can be very gratifying,
as the removal of excess skin and fat can augment the toned
musculature that many men will demonstrate after weight
loss. Additionally, hair distribution can often serve to mask the
resulting scar, leading to a significant improvement in the overall
appearance of the abdomen (Fig. 91.31).
91.7.7 Panniculectomy
Indications
Many patients may present with incomplete weight loss after
undergoing gastric bypass surgery and may eventually reach a
plateau where further weight loss becomes difficult. Despite fall-
ing short of complete weight loss goals, a point may be reached
where the hanging panniculus that results from the weight loss
that is registered becomes a problem with regard to limitations
to movement and exercise. Additionally, physical symptoms
such as subpanniculus intertrigo can develop. Alternatively,
some patients can present with a hanging panniculus who are
significantly compromised from a general health standpoint
and may be poor candidates with an unacceptably high surgical
Fig. 91.29 (a,b) Preoperative appearance of a 60-year-old woman who presents for mini-abdominoplasty along with liposuction to the abdomen and
posterior hips. She does not have enough skin laxity to allow full resection of the lower abdominal skin with transposition of the umbilicus; therefore,
a more limited resection of a wedge of skin and fat will be removed from the lower abdomen to provide a mild tightening effect. (c,d) Preoperative
marks outlining the areas of skin resection and liposuction. (e,f) The 7-year postoperative result, demonstrating long-term improvement in the
contour of the lower abdomen.
Fig. 91.30 When the thickness of the upper flap after resection of
the redundant soft tissue does not match the thinner thickness of the
lower flap, an unavoidable step-off results along the suture line that
significantly detracts from the quality of the overall result.

1438
XII Body Contouring
Fig. 91.31 (a–c) Preoperative appearance of a 37-year-old man who presents after the loss of 55 lbs. over the course of 1 year. Redundancy of the
skin and fat in the lower abdomen is associated with persistent fatty deposition in the posterior hip areas. (d,e) Preoperative marks in preparation for
the anterior abdominoplasty are placed, with care being taken to move the inferior incision line up onto the upper panniculus slightly so as to avoid
a step-off in soft tissue thickness at the time of wound closure. (f–h) An extended abdominoplasty technique is marked by assessing the redundancy
of the lateral soft tissues and working this resection pattern around to the back along the relaxed skin tension lines. Liposuction to the posterior
hips will also be performed. (i) As the lower incision is developed, an effort to angle superiorly is made, to create a lower flap of sufficient thickness
to evenly match the thickness of the upper flap once it is transposed. Here, the outline of the incised Scarpa’s fascia layer can be seen 2 to 3 cm
above the lower incision line. (j) Appearance after final closure demonstrating a smooth transition between the superior and inferior flaps. (k–m)
The postoperative result demonstrates smooth abdominal contours along the incision line with complete correction of the fatty deposition in the
posterior hips.

91 Abdominoplasty
1439
risk profile for a complete body contouring procedure. In these
types of patients, it is a reasonable approach to perform a simple
excision of the redundant tissue from the lower abdomen. In this
procedure, there is little to no undermining, and the umbilicus
is not transposed or can simply be removed. This procedure can
be a limited but reasonable alternative to alleviate some of the
symptoms associated with the hanging panniculus.
Patient Marking
The marking pattern is placed in a very similar fashion to that for
a full abdominoplasty. The lower mark is made along the lower
margin of the redundant tissue, and it is extended laterally far
enough to avoid the creation of a lateral dog-ear. The amount
of tissue to be removed is estimated, and the upper margin of
the pattern is marked at a point that will allow an easy and
tension-free closure. This mark is likewise extended laterally to
reach the lower mark.
7eFKniTue
At surgery, the goal is to excise the redundant tissue in an effi-
cient manner with limited blood loss. The lower incision is made,
and dissection carried down to the abdominal wall. Crossing
vessels of great size can be encountered, and these are best
controlled directly with suture ties due to their size. The upper
incision is then made, the dissection spaces are connected, and
the redundant tissue segment is removed. Little to no undermin-
ing is performed during this dissection, in an attempt to limit
the magnitude of the procedure. Drains are placed and a secure
wound closure is obtained.
Results
The results obtained after simple panniculectomy fall short of
the aesthetic results obtained with more extensive procedures;
however, the effect of the surgery can be life-changing. Simply
as a result of removing the mass of tissue from the lower abdo-
men, mobility is improved, symptoms are relieved, and patients
report an enhanced quality of life. For these reasons, and despite
the limited nature of the procedure, it is a procedure that is well
worth the effort (Fig. 91.32).
91.7.8 Isolated Abdominal Wall
Rejuvenation
Indications
A very interesting and challenging subgroup of patients who
present for abdominal rejuvenation are those who present with
isolated laxity to the abdominal wall but no excess of skin or
fat in the abdomen itself. Typically, these are younger patients
who have experienced severe stress to the musculoaponeurotic
tissues of the abdominal wall secondary to pregnancy, often
associated with a fetus of high birth weight. Many will present
with an isolated but very prominent diastasis recti. At times, the
deformity to the anterior abdominal wall can be quite striking.
These patients are excellent candidates for repair of the abdomi-
nal wall using standard abdominoplasty techniques without the
resection of any skin or fat.
Patient Marking
To provide access to the abdominal wall, a 10- to 12-cm incision is
drawn, placed low on the abdomen and centered on the midline.
This incision is the access portal through which the abdominal
panniculus will be undermined. :hile every effort is made to
keep this incision as short as possible, it does need to be long
enough to allow access to the abdominal cavity all the way up
to the xiphoid process. What’s more, after the abdominal wall
Fig. 91.32 (a,b) Preoperative appearance of a 71-year-old woman who presents with morbid obesity and a hanging panniculus with her fatty
excess concentrated centrally on the abdomen. (c,d) Preoperative marks in preparation for a panniculectomy utilizing a small fleur-de-lis extension.
(e,f) The 8-month postoperative result demonstrating a dramatic reshaping of the anterior abdomen and a greatly enhanced quality of life.

1440
XII Body Contouring
is repaired, a small excision of skin and fat from the upper flap
can be performed as needed to remove any redundant skin that
might become noticeable after the abdominal wall is repaired.
This skin is marked as well. The margins of the diastasis are then
outlined to complete the marking.
7eFKniTue
The patient is placed supine on the operative table and muscle
relaxation is used to facilitate the musculofascial repair. The
incision is made and the central third of the abdominal wall is
undermined to expose the fascial edges of the rectus abdom-
inis muscles. If the exposure is adequate, there is no need to
make a separate incision around the umbilicus as it will not be
translocated, and the fascia can simply be repaired above and
below the umbilical stalk. If exposure becomes problematic, an
umbilical float type of approach can be used to fully visualize
the fascial edges all the way up to the xiphoid process. Once
the fascia is repaired, the stalk is simply sutured back into
position.
At this point, the medial leading edge of each rectus muscle is
easily visualized. Starting at the xiphoid process, a 1–0 perma-
nent, nonabsorbable monofilament suture is used to plicate the
two medial edges together using a running locking technique.
Visualization with the aid of a lighted retractor can facilitate the
placement of this suture. In this fashion, the diastasis recti is com-
pletely and securely repaired. In cases where a more generalized
abdominal weakness is associated with the diastasis, additional
suture plication lines run along the lateral margins of the rectus
abdominis muscles can be passed as indicated to provide further
support to the abdominal wall as described earlier in the abdom-
inoplasty section.
Once the abdominal wall has been repaired, the umbilical stalk
is inset in the midline if the umbilical float technique was used,
and any redundant skin that is present in the upper panniculus
is resected. Drains are placed and the access incision closed to
complete the procedure.
Results
The improvement in the shape of the abdomen after repair can
be significant, as an aesthetic, flat anterior contour is created that
stands in stark contrast to the preoperative condition. Moreover,
by restoring a more normal resting muscle tone to the abdominal
wall, strength, function, and posture are often improved, with a
low scar burden leading to an overall high level of satisfaction
with the procedure (Fig. 91.33).
91.8 Complications
91.8.1 Dog-Ear Formation
Although purely aesthetic in nature, dog-ear formation at the
ends of the lower abdominal scar is one of the most common
complications after abdominoplasty. Certainly given the mag-
nitude of the procedure, to experience patient dissatisfaction
related to such a minor and preventable issue can be frustrating.
It is best to avoid such an error in preoperative planning by
making sure to extend the scar laterally as much as is necessary
along the relaxed skin tension lines, so as to ensure a smooth
postoperative contour. When a bulge of excess skin and fat
does develop at the ends of the abdominoplasty scar, it is easily
addressed with simple reexcision. This can be performed under
local anesthesia when the involved area is small. Larger excisions
may require the assistance of an anesthesiologist. Additionally,
any persistence of fatty accumulation can be treated with repeat
liposuction in an attempt to create a smooth aesthetic lateral
contour.
91.8.2 Seroma
The amount of undermining required to successfully perform
abdominoplasty naturally creates an effusion-producing wound.
In most instances, this drainage of fluid is easily managed by
drains placed in the wound for a period of time postoperatively.
The utilization of quilting sutures as well as Scarpa’s fascia–pre-
serving dissection techniques can also ensure rapid resolution
of abdominal wound drainage. However, in selected cases, after
the drains have been removed, it is not uncommon for fluid to
accumulate in the dissection space; this may occur to such an
extent that it becomes noticeable as a fluid wave across the lower
abdomen. :hen this fluid accumulation becomes excessive, it
can also become symptomatic by causing an achy discomfort
or even pain. Such accumulations are easily managed by weekly
percutaneous aspiration, even as many as four or five times,
as needed until the seroma resolves. Only in rare cases, after
repeated aspiration, does it become necessary to temporarily
place another drain. Eventually, any tendency for fluid accumu-
lation ceases, and the seroma resolves.
91.8.3 Delayed Wound Healing
It is not uncommon for patients to experience delayed wound
healing after abdominoplasty, particularly in the area just
above the mons pubis along the incisional edge. This is the
area that is farthest from the blood supply that enters the skin
and soft tissue from the periphery after the upper panniculus
has been undermined. Typically, a segment of skin will demon-
strate signs of ischemia that progresses over several days to
outright necrosis. In such cases, a variable amount of subcu-
taneous fat is also involved in the ischemic process. When
the involved area is small, meaning less than approximately 2
cm in length, it can be managed conservatively, as it will heal
by secondary intention. Larger areas are best managed with
dressing changes over a period of 1 to 2 weeks to allow the
wound margins to completely demarcate, followed by delayed
excision and closure. In rare circumstances, the involved area
of necrosis can be so large as to mandate a more aggressive
approach. Standard reconstructive techniques including dress-
ing changes, débridement, VAC therapy, and delayed wound
closure with flap readvancement or even skin grafting may be
required.
91.8.4 Scarring
While the results of abdominoplasty can be remarkable, they
do come at the expense of creating a long and at times unsightly

91 Abdominoplasty
1441
Fig. 91.33 (a,b) Preoperative appearance of a 37-year-old woman who presents with loss of abdominal tone after pregnancy. (c,d) Stress testing of
the abdomen reveals a pronounced diastasis recti with general laxity of the lower abdomen. (e) Preoperative marks demonstrating the proposed
suprapubic access incision along with a three-line plication of the abdominal wall. (f,g) A low suprapubic incision is used to provide access to the
abdomen. An umbilical float technique is used as the abdominal tissues are reflected away from the abdominal wall to facilitate muscular repair. (h,i)
The midline diastasis is repaired with a 1–0 nonabsorbable Prolene suture that is passed from the xiphoid process down to the pubis. (j) A separate
Prolene suture is used to plicate the lateral border of each rectus muscle so as to complete the three-suture-line repair of the abdominal wall. (k) Final
intraoperative appearance after repositioning and inset of the umbilical stalk. (l,m) Postoperative appearance demonstrating restoration of a normal
abdominal contour. (n,o) Stress testing demonstrates the integrity of the abdominal repair with complete correction of the diastasis deformity.

1442
XII Body Contouring
abdominal scar. During the early wound healing period, there
can be a significant amount of tension on the wound closure,
leading to a widened, erythematous, and hyper- or even hypo-
trophic scar. In these cases, revision after the scar has fully
matured can result in a fine-line and imperceptible scar as the
soft tissues accommodate to the new tissue dynamics created
after being rearranged after abdominoplasty. As well, a further
tightening of the skin can be performed as needed to improve
the aesthetic result. When performing the scar revision,
attention to techniques of proper skin incision, including the
creation of sharp, 90° wound edges with no beveling coupled
with layered and accurate subdermal wound support and final
skin closure with barbed sutures, can result in excellent aes-
thetic results.
91.8.5 Abdominal Wall Relaxation
After initial abdominoplasty, insufficient repair of the abdominal
wall or postoperative stretching of the fascial elements can
result in an unaesthetic bulging in the abdomen. Such contour
irregularities can be isolated to the midepigastrium, the lower
abdomen, or even the entire abdominal wall. Repair can be
accomplished; however, a reelevation of the entire abdominal
panniculus will generally be required to allow the musculofascial
elements to be properly supported with suture plication. Mesh
support can be added in selected cases to reinforce the repair.
Typically the results demonstrate an excellent improvement
in the appearance of the abdomen, despite what amounts to a
repeat of the initial dissection planes.
91.8.6 Fat Necrosis
In selected cases, even in the presence of a completely healed
wound with a stable skin scar, areas of firmness along the scar
may present as a result of fat necrosis. Typically these small
masses will shrink over time and in most instances will require
no further intervention. If they do become symptomatic by
making it difficult to wear belts or tight pants, for instance, these
areas can easily be excised along with a formal scar revision
followed by direct closure.
91.8.7 Recurrent Soft Tissue Ptosis
At the time of closure of the abdomen when the redundant
skin and fat of the upper panniculus is removed, an aggres-
sive approach is best used to estimate the amount of tissue
to be resected, to be certain that a flat and well-contoured
abdominal contour is created. Even with this approach, it is
not uncommon for the soft tissues to relax over time, resulting
in mild postoperative redundancy of skin and fat in the lower
abdomen. When such an event occurs, simple reexcision cou-
pled with scar revision can completely correct the problem. It
is rarely necessary to reelevate the abdominal panniculus or
manipulate the umbilicus as the soft tissue relaxation typ-
ically involves only the tissue in the central lower abdomen.
Although inconvenient, such revisions can dramatically and
in a long-term fashion restore the abdominal contour to an
aesthetic form.
91.8.8 Umbilical Necrosis
Although unusual, necrosis of a portion or all of the umbilical
stalk can occur after abdominoplasty. Predisposing factors for
experiencing this complication include excessive dissection of
the umbilical stalk, associated periumbilical hernia, excessive
length (> 5 cm) of the umbilical stalk, and excessive tightening of
the surrounding rectus fascia during abdominal wall plication.
Early on, when potential ischemia to the umbilicus is recognized,
immediate release of the sutures is best performed to remove
any tension on the closure. After complete demarcation, débride-
ment of any necrotic eschar followed by secondary healing with
dressing changes allows the wound to stabilize. Depending on
the defect, secondary umbilical reconstruction can then be
performed in a delayed fashion.
91.9 Concluding Thoughts
Abdominoplasty is an effective and gratifying aesthetic proce-
dure that can transform the appearance of the abdomen and
torso, sometimes in dramatic fashion. With proper attention to
preoperative markings, coupled with an organized and properly
applied surgical technique, excellent results with a low risk of
complications can be achieved.
Clinical Caveats
• Mark the patient standing prior to the procedure to ensure
accurate and symmetric placement of the incisions.
• When marking a patient for abdominoplasty, care must be
taken to extend the pattern far enough laterally to avoid a
dog-ear at the lateral end of the wound closure.
• Determine the final location of the superior resection margin
intraoperatively with the patient in a moderate flexed position
to be certain the maximal amount of tissue will be resected.
• Use a horizontal incision pattern to define the initial shape of
the umbilicus at the start of the procedure.
• Tack the umbilical stalk down to the abdominal wall before
inset to ensure an aesthetic umbilical depression after inset.
• Make sure the dimensions of the initial umbilical incision
match exactly the dimensions of the incision in the ante-
rior abdomen at the time to inset to maximize umbilical
aesthetics.
• Use more than one line of muscle/fascia plication as needed
to maximally reconstitute the integrity of the abdominal wall.
• Liposuction can be safely and effectively combined with
abdominoplasty.
• Do not hesitate to use an extended abdominoplasty approach
as needed to take up soft tissue redundancy along the lateral
and posterior torso.
• When the surgical pattern extends laterally and posteriorly,
start prone to allow these areas to be easily and fully treated
before turning back supine.
• Be certain the thickness of the upper flap matches the thick-
ness of the lower flap after the redundant tissue has been
resected to avoid a step-off at the suture line after closure.

91 Abdominoplasty
1443
Suggested Reading
Overall
[1] Friedland -A, Maffi TR. MOC-PS(SM) CME article: abdominoplasty. Plast Reconstr
Surg 2008;121(4, Suppl):1–11
[2] Gutowski KA. Evidence-based medicine: abdominoplasty. Plast Reconstr Surg
2018;141(2):286e–299e
[3] Lockwood T. High-lateral-tension abdominoplasty with superficial fascial system
suspension. Plast Reconstr Surg 1995;96(3):603–615
Combination with Other Procedures
[4] Winocour J, Gupta V, Ramirez JR, Shack RB, Grotting JC, Higdon KK. Abdomino-
plasty: risk factors, complication rates, and safety of combined procedures. Plast
Reconstr Surg 2015;136(5):597e–606e
Combining Abdominoplasty with SAL
[5] Matarasso A. Abdominolipoplasty: a system of classification and treatment for
combined abdominoplasty and suction-assisted lipectomy. Aesthetic Plast Surg
1991;15(2):111–121
[6] Vieira BL, Chow I, Sinno S, Dorfman RG, Hanwright P, Gutowski KA. Is there a
limit? A risk assessment model of liposuction and lipoaspirate volume on com-
plications in abdominoplasty. Plast Reconstr Surg 2018;141(4):892–901
[7] Samra S, Sawh-Martinez, R, Barry O, Persing JA. Complication rates of lipoab-
dominoplasty versus traditional abdominoplasty in high-risk patients. Plastic
and Reconstructive Surgery 2010;125(2):683–690
DVT Prophylaxis and Abdominoplasty
[8] Marangi GF, Segreto F, Poccia I, et al. Thromboprophylaxis in abdominoplas-
ty: efficacy and safety of a complete perioperative protocol. Arch Plast Surg
2016;43(4):360–364
No-Drain Abdominoplasty
[9] Pollock TA, Pollock H. Progressive tension sutures in abdominoplasty: a review of
597 consecutive cases. Aesthet Surg J 2012;32(6):729–742
Use of Quilting Sutures
[10] Pollock H, Pollock T. Progressive tension sutures: a technique to reduce local
complications in abdominoplasty. Plast Reconstr Surg 2000;105(7):2583–2586,
discussion 2587–2588
[11] Quaba AA, Conlin S, Quaba O. The no-drain, no-quilt abdominoplasty: a sin-
gle-surgeon series of 271 patients. Plast Reconstr Surg 2015;135(3):751–760
[12] Sforza M, Husein R, Andjelkov K, Rozental-Fernandes PC, Zaccheddu R, Jovanovic
M. Use of quilting sutures during abdominoplasty to prevent seroma formation:
are they really effective" Aesthet Surg J 2015;35(5):574–580
Mini-Abdominoplasty
[13] Greminger RF. The mini-abdominoplasty. Plast Reconstr Surg 1987;79(3):356–
365
%Rdy /iIW 7eFKniTue
[14] Hamra ST. Circumferential body lift. Aesthet Surg J 1999;19(3):244–250
[15] Lockwood T. Lower body lift with superficial fascial system suspension. Plast
Reconstr Surg 1993;92(6):1112–1122, discussion 1123–1125
Fleur-de-Lis
[16] Friedman T, O’Brien Coon D, Michaels J, et al. Fleur-de-lis abdominoplasty: a safe
alternative to traditional abdominoplasty for the massive weight loss patient.
Plast Reconstr Surg 2010;125(5):1525–1535
[17] Dellon AL. Fleur-de-lis abdominoplasty. Aesthetic Plast Surg 1985;9(1):27–32
Scarpa’s Preservation
[18] Costa-Ferreira A, Rebelo M, Vásconez LO, Amarante J. Scarpa fascia pres-
ervation during abdominoplasty: a prospective study. Plast Reconstr Surg
2010;125(4):1232–1239
[19] Tourani SS, Taylor GI, Ashton MW. Scarpa fascia preservation in abdominoplasty:
does it preserve the lymphatics? Plast Reconstr Surg 2015;136(2):258–262
Umbilicoplasty
[20] Joseph WJ, Sinno S, Brownstone ND, Mirrer J, Thanik VD. Creating the perfect
umbilicus: a systematic review of recent literature. Aesthetic Plast Surg
2016;40(3):372–379
[21] Rohrich RJ, Sorokin ES, Brown SA, Gibby DL. Is the umbilicus truly midline?
Clinical and medicolegal implications. Plast Reconstr Surg 2003;112(1):259–263,
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Plast Reconstr Aesthet Surg 2011;64(6):803–808

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XII Body Contouring
92 Gluteal Augmentation with Fat Transfer
Ashkan Ghavami and Vicky Kang
Abstract
Gluteal augmentation can be performed through a wide variety
of surgical techniques, but there are substantial advantages to
gluteal fat transfer compared with other methods. Principles of
gluteal augmentation with autologous fat transfer have evolved
from solely buttock augmentation to global, whole-body, 360°
contouring and shaping, thereby producing an optimal, highly
defined body/gluteal balance, without implant-related complica-
tions. The demand for gluteal augmentation with fat grafting is
rapidly increasing, but there is an unacceptably high morbidity
and mortality rate associated with fat embolic phenomena.
Despite the high prevalence of morbidities and fatalities asso-
ciated with gluteal fat transfer, this is a highly sought-out
operation that can be performed safely and effectively. This
chapter provides a comprehensive overview of patient selection,
surgical technique, and perioperative management with which
to maximize gluteal aesthetics while avoiding or minimizing
complications. The chapter also delineates anatomical features
and technical details that are critical to improving fat graft sur-
vival as well as reducing catastrophic adverse events.
Keywords
gluteal augmentation, autologous fat grafting, fat embolism,
patient safety, aesthetic surgery, body contouring, buttock aug-
mentation, fat transfer, S-curve butt lift, Brazilian butt lift
92.1 Introduction
Gluteal augmentation procedures have become more prevalent
over the past decade; specifically, the demand for gluteal fat
transfer has been unprecedented in aesthetic surgery. Popular
media (especially the social media platforms) have demonstrated
that the curvilinear body silhouette with a proportionately larger
buttock is becoming a more ideal female aesthetic today. Modern
popular culture has placed a growing emphasis on the female
buttocks as a defining characteristic of the ideal female form. The
ideal waist-to-hip ratio has evolved to favor pronounced curves
and aesthetic contour. Since Bartels first described the Cronin
round breast implant to correct asymmetry of left gluteal muscle
atrophy in 1969, techniques of gluteal augmentation have been
refined, resulting in fewer complications and more predictive
aesthetic outcomes. All modalities of gluteal augmentation have
evolved with a significant goal to reduce complications rates,
but most notably in gluteal augmentation with autologous fat
grafting. Recently there have been critical discussions as well as
formation of a Multi-Society Gluteal Safety Task Force regarding
the unacceptably high mortality rate seen with fat embolic phe-
nomena via gluteal fat transfer. The Aesthetic Surgery Education
and Research Foundation formed a task force dedicated to
evaluating fatal and nonfatal complications of gluteal fat grafting
and providing safety recommendations. The task force estimates
fatality rates to be as high as 3% and nonfatal fat embolism rates
to be as high as 7%.
The principles of buttock augmentation with gluteal fat grafting
started with Pitanguy and Regnault resecting tissue from the
gluteal fold and lateral trochanteric region to increase buttock
projection and volume. Gonzalez and Spina then performed
the first successful fat grafting procedure in 1986, but gluteal
lipoaugmentation in that decade was largely dismissed as a
simple operation requiring little technique and no unique instru-
mentation. :ith the advancement and refinement of surgical
techniques in the last decade, principles of gluteal augmentation
with autologous fat transfer have evolved from purely reduction
and liposuction to global contour and shaping with the combina-
tion of both lipoaspiration and fat transfer. Succeeding in gluteal
augmentation with fat grafting requires both surgical finesse and
comprehensive knowledge of the gluteal anatomy.
Augmentation gluteoplasty can be performed through a variety
of techniques, including autologous fat grafting, prostheses, fillers,
and local dermal fat flaps. There are numerous advantages of
gluteal augmentation through fat transfer compared with other
methods. Fat grafting uses only autologous tissue and avoids all
complications associated with an implant. Gluteal augmentation
with implants may be beneficial for patients who have signifi-
cant ptosis or asymmetry without adequate donor fat volume.
However, gluteal augmentation with implant placement is laden
with complications, including implant migration or rotation, cap-
sular contracture, implant-associated infections, wound-healing
complications, and thinning of native tissues. Filler injections are
costly, temporary, and frequently associated with foreign body
complications. The aesthetic results are inconsistent. In addition,
most fillers, both hyaluronic-based and silicone-based, can cause
permanent skin changes, including a purplish-blue pigmentation.
Fat harvesting allows a more comprehensive approach to body
contouring and produces an improvement in the global torso
aesthetic. Removing fat from supragluteal fossettes, the adjacent
torso, and the lateral trochanteric area with simultaneous injec-
tion of fat to the buttocks superiorly and medially provides the
enhanced 360° S-curve that is desired (Fig. 92.1). The combina-
tion of liposuction and fat transfer allows contour of the buttock
and surrounding hip and waist, creating the curvilinear body
silhouette. Gluteal fat transfer also enables the surgeon to tailor to
specific anatomical needs and patient preferences.
Despite the increasing demand and advantages of using fat
transfer for gluteal augmentation, the procedure has its limita-
tions. Patients may not have sufficient fat for the desired augmen-
tation. Additionally, a number of morbidities and fatalities as a
result of gluteal fat transfer have been reported.
There is a paucity of literature on the safety of this technique.
This chapter discusses refinements in patient selection and

92 Gluteal Augmentation with Fat Transfer
1445
positioning, surgical technique, and postoperative management,
including the prevention and management of complications. It is
of the utmost importance to adhere to these key principles and
understand the anatomy, in order to achieve aesthetically opti-
mized results and maintain patient safety.
92.2 Indications and
Contraindications
Appropriate patient selection and education are absolutely crit-
ical to the success of gluteal fat augmentation. The ideal patient
should have sufficient donor fat to allow for the desired gluteal
augmentation and global contouring of the buttock and thigh
region. Patients who do not want implant-based augmentation
or the significant morbidities associated with autoaugmentation
flaps are excellent candidates for gluteal fat augmentation.
Thin patients with lower body fat composition are generally
poor candidates for the procedure; however, modest liposuction
and fat augmentation to select zones of the gluteal region can
sometimes achieve dramatic global torso transformation. A small
volume of fat transfer can have a significant aesthetic impact
on thinner patients when placed in the proper locations. Thin
patients can also be instructed to gain weight with a diet targeted
toward increasing lipoaspirate yield. Patients with a personal or
family history of hematologic disorders, including deep venous
thrombosis and pulmonary embolism, need to undergo an appro-
priate hematologic evaluation and may be poor candidates for
the procedure. Patients with previous gluteal augmentation with
permanent agents, including silicone, hydrogel, and unknown or
illicit agents, may not be ideal candidates for the procedure.
Fig. 92.1 (a) The modern preference for an S-curvilinear female body contour. Patients will vary in their preference for waist-to-hip ratios. (b) Some
patients prefer a more athletic silhouette line, whereas other patients may want a wider lateral buttock/hip dimension. Inevitably, most do request as
narrow a waist as possible.

1446
XII Body Contouring
92.3 Pertinent Anatomy
92.3.1 Muscular Anatomy
A thorough understanding of the subcutaneous and deep
anatomy is essential to achieving beautiful results without
compromising patient safety. Intramuscular fat transfer should
be avoided, because fat may travel unchecked deep to the muscle
fibers and into the danger zone. The danger zone was defined by
Ghavami as a triangular medial zone adjacent to the intergluteal
buttock crease or cleft. This may be the most likely area where
depth is unforgiving, and ligamentous borders can misguide a
cannula deeper than intended. The larger vessels are located
here, as are vulnerable sciatic nerve segments (Fig. 92.2). There
are superficial and deep muscles in the gluteal region. Superficial
muscles include the gluteus maximus, gluteus medius, gluteus
minimus, and tensor fasciae latae. The deep muscles are smaller
and include the obturator internus, gemellus superior, gemellus
inferior, quadratus femoris, and piriformis. It is critical for the
surgeon to have a thorough understanding of the neurovascular
structures’ relationship to the muscular anatomy.
Direct injury to the neurovascular bundle and fat emboli can
occur more readily submuscularly and within the anatomical bor-
ders of the danger zone. In addition, fat may migrate when injected
intramuscularly to travel deeper, where it is left unchecked due to
a lack of posterior gluteus maximus muscle fascia.
92.3.2 Neurovascular Anatomy
The vascular supply to the gluteal region originates from the
superior gluteal and inferior gluteal arteries. The superior gluteal
artery travels with the superior gluteal nerve and exits through
the greater sciatic foramen above the piriformis muscle, before
dividing into the superficial and deep branches. The superficial
branch of the superior gluteal artery travels deep to the gluteus
maximus muscle, while the deep branch travels between the
gluteus medius and minimus muscles. (insert neurovascular
anatomy diagram vs muscles) The inferior gluteal artery runs in
close proximity with the sciatic nerve through the greater sciatic
foramen, below the piriformis muscle. The superior and inferior
gluteal veins eventually join the pelvic vein plexus and ultimately
drain into the femoral vein. The sciatic nerve is commonly found
in the plane between the superficial and deep muscles, lying deep
to the gluteus maximus and at the midpoint between the greater
trochanter and the ischial tuberosity. It is important to stay super-
ficial to the muscular fascia to avoid injuring these structures.
92.3.3 Ligamentous Anatomy
In addition to the bony, muscular, and neurovascular anatomy,
understanding the ligamentous and fascial anatomy is invaluable
for patient safety and optimizing the aesthetic outcome. Knowledge
of the ligamentous structures consistently found in the gluteal
region and their clinical implications is imperative for avoiding
morbidity and mortality. The sacrocutaneous and ischiocutaneous
ligaments are rigid tissue densities that have a tendency to inad-
vertently torque the cannula tip into or deep to the muscle (Fig.
92.3). The inferomedial buttock region also contains the densest
fascial and ligamentous attachments and are what. The combina-
tion of the ligamentous structures causing inadvertent “cannula
misguidance” and the presence of large vessels constitute the
danger zone, and proper technique based on thorough anatomical
knowledge is paramount in regard to safety. This increases the risk
of injection into adjacent neurovascular structures (e.g., the sciatic
nerve) resulting in morbid complications, including fat emboli-
zation or even death. When injecting medially, the surgeon must
first release both ligament and fascial condensations to prevent
inadvertent misguidance of the cannula tip into deeper planes.
Release is accomplished best using power assisted “basket” tip
cannulas in swiping, tangential motion. This can be accomplished
simultaneously or in-between fat injection. Fat injection can be
accomplished with Toomey syringe and/or power-assisted cannu-
las. The senior author (AG) uses a combination of Toomey syringe
(for initial and majority of fat injection sequence) and accomplishes
final fat contouring with 4 and 5 mm ´basketµ tip cannulas.
There are two osseocutaneous ligaments consistently found
in the gluteal region: the sacrocutaneous and ischiocutaneous
ligaments (Fig. 92.3) The sacrocutaneous ligament is located at the
Fig. 92.2 The danger zone of the buttock. This area is where neurovascular injury is most likely to occur, allowing for possible fat emboli.

92 Gluteal Augmentation with Fat Transfer
1447
superior border of the gluteal cleft. The ligament originates from
the lateral margins of the sacrum and extends laterally to interdigi-
tate with adhesions from the iliac crest to the dermis. The thickness
of the ligament seems to be unrelated to dermal or fat thickness.
The ischiocutaneous ligament, or the ligament of Charpy, is a broad,
fan-shaped ligament that originates at the ischial tuberosity and
merges superiorly with the natal cleft fasciocutaneous ligament
and inferolaterally with the infragluteal crease fasciocutaneous lig-
ament. This ligament is approximately 4 cm in length and does not
extend beyond the lateral half to two-thirds of the buttock width.
It is commonly the most difficult to pierce and pass the cannula
through. However, only the medial portion of the infragluteal crease
is invariably fixed by the ligament. The ischiocutaneous ligament
also determines the contour of the inferior medial third to half of
the inferior buttock. This is the most expansive and restrictive of
the ligaments. The senior author theorizes that this is responsible
for cannula misguidance untowardly deeper in the region of the
danger zone, which can cause catastrophic venous fat emboli.
Judicious release of this and other ligamentous attachments and
borders is critical for safety. Ligaments are released either by “stop
and go” with automated injection techniques (using roller pumps
on pedal control) or by sequential release–inject–release–inject
using a combination of high-vibration basket tip cannulas for
release and syringe methods for fat injection. Furthermore, proper
aesthetic contour expansion requires appropriate release of the
ligamentous borders to allow safer subcutaneous injection.
The natal cleft and infragluteal crease fasciocutaneous ligaments
also help define the depth and contour of the buttock. The natal cleft
ligament, or gluteal cleft fasciocutaneous ligament, defines the glu-
teal cleft and merges inferiorly with the ischiocutaneous ligament
and superiorly with the sacrocutaneous ligament (Fig. 92.3). The
infragluteal crease fasciocutaneous ligament defines the inferior
Fig. 92.3 The ligamentous anatomy of the buttocks must be thoroughly understood. Discriminate release is required to avoid cavitation from
overrelease, and cannula misguidance from underrelease. A balanced tactile feedback is created to each cannula stroke in which there is neither
excess resistance nor a complete lack of cannula resistance. (a) The important larger ligaments, of which the ischiocutaneous ligament is the most
important to properly release to avoid inadvertent deep fat injection in the danger zone. (b) The underlying bony and muscular anatomy. (c) With
proper ligament release and proper cannula angle, the danger zone and cannula misguidance are avoided.

1448
XII Body Contouring
border of the buttock and mimics the inframammary fold. It origi-
nates from the muscular fascia and extends as loose attachments to
the dermis. Selective release of the fascial densities and ligamentous
borders of regions of the buttocks is critical for achieving optimal
buttock aesthetics. Similar to scoring of the breast subcutaneous
plane and parenchyma for the release of a tuberous breast, buttock
soft tissue attachments require release for adequate expansion of
the injected fat. The basket cannula is best for these release maneu-
vers, as it acts as a sagittal saw on high vibration (Fig. 92.4).
92.3.4 The Danger Zones
In order to optimize the safety of gluteal fat transfer, we recom-
mend identifying the danger zone on each buttock. The apex of
the “danger triangle” is at the posterior superior iliac spine, and
the lateral and medial points are at the greater trochanter and
ischial tuberosity, respectively. Deep injection (submuscular)
within this danger zone increases the risk of both vascular
and nerve injuries. While any intra- or submuscular injection
outside the danger triangle may migrate to the danger zone,
direct deposit of even small volumes of fat within this area can
be catastrophic as well. Currently it is recommended that all fat
injections be at varying depths within the subcutaneous tissues,
whether inside or outside of the danger zones, as gluteal veins
are located in the medial third of each buttock, deep to fibrous
ligaments and deep to the gluteal musculature.
92.3.5 Zones of Adherence
Liposuction requires a three-dimensional understanding of
the anatomy and placement of fat deposits. Understanding the
underlying zones of adherence of the superficial fascial system
helps avoid contour irregularities and deformities. Zones of
adherence exist where the superficial fascial system is tightly
adherent to the deep compartment in conjunction with thin
overlying dermis and a minimal or absent fat layer. It consists
of the lateral gluteal depression, gluteal crease, medial thigh,
distal posterior thigh, and inferolateral iliotibial tract. The
subcutaneous fascia of the buttocks fuses with the infragluteal
fold medially and the iliac crest superiorly. It is important to note
the zones of adherence, because it accentuates the localized fat
deposits located between them and differs based on gender.
Men tend to accumulate weight in the flank areas superior to
the iliac crest, unlike women, who accumulate fat directly over the
iliac crest. The reason for this difference is because the men’s zone
of adherence is located along the iliac crest, defining the inferior
margin of the flank. In contrast, women’s zone of adherence overlies
the greater trochanter, causing fat to accumulate over the iliac crest.
Liposuction should be avoided over the five zones of adherence,
but if it is necessary to perform liposuction over these areas (i.e.,
large-volume liposuction cases), the surgeon should use varying
small cannula diameters as well as shapes. Off-suction liberation of
the superficial fat from deeper fat with basket cannula tips is highly
recommended to reduce inadvertent contour irregularities.
92.4 Preoperative Assessment
A preoperative discussion regarding realistic expectations based
on the patient’s anatomy is critical to both patient satisfaction
and the success of the procedure. The patient should have a clear
understanding of what gluteal fat augmentation can and cannot
accomplish. Preoperative and postoperative photos of other
patients, especially patients with similar body frame and tissue
characteristics, can demonstrate what the patient can expect but
also reveal limitations of the procedure. Patients should be able to
prioritize the areas for which they would like more projection and
Fig. 92.4 Intermittent release with an exploded type cannula tip on high vibration allows for relatively low-trauma tissue modification. An
intermittent release–fat injection–release–fat injection technique is critical to avoid a gluteal fat compartment “blowout.” Fat injection can also be
accomplished during release using the same canula on highest vibration (power assisted) mode. The senior author (AG) utilizes this simultaneous
technique more commonly during the final contouring phase rather than during the entire procedure.

92 Gluteal Augmentation with Fat Transfer
1449
fullness (e.g., upper buttock fullness vs. lateral hip to trochanteric
fullness). The ability to prioritize areas of importance is especially
important in the patient population with a paucity of donor fat,
when it may be challenging to augment all areas. There are gener-
ally two zones that patients with less donor fat availability should
prioritize. The senior author calls these zones A, B, and B1 for
simplicity (Fig. 92.5). This illustration can be drawn or shown to
patients as a guide to their preferences as far as percentage of fat
they would like allocated throughout one, a few, or all the zones.
The preoperative consultation should stress the risks associated
with the procedure along with the unpredictability of fat graft sur-
vival. In the current climate of photograph-altering applications and
social media ´filters,µ patient education and understanding of realistic
outcomes is more critical than before. It is the surgeon’s responsibility
to provide honest expectations for results. Patients with preexisting
medical comorbidities and patients who are older than 40 years need
to undergo appropriate medical preoperative clearance. All medica-
tions, vitamins, herbal supplements, and other substances should
be reviewed, including fish oil, vitamin E, aspirin, other nonsteroidal
anti-inflammatories, and weight loss supplements.
Smoking and nicotine use can greatly compromise fat viability and
impair wound healing, and it may increase the likelihood of sacral
and groin seroma formation. Tobacco induces vasoconstriction and
reduces neovascularization, both of which processes are critical for
fat graft survival. Patients should be instructed to stop tobacco use
for a minimum of 4 to 6 weeks prior to the procedure. Patients who
continue to have unrealistic expectations or are psychologically
compromised, even after a thorough preoperative consultation,
should undergo repeat consultations prior to proceeding with
the procedure. Surgeons should be wary of and strongly consider
refusing to perform the procedure on patients who continue to have
unrealistic expectations despite repeated consultations.
92.5 Preoperative Planning
and Markings
Successful technical planning and execution require a compre-
hensive preoperative evaluation. The patient’s skeletal frame
and preoperative shape should be carefully analyzed. There are
four general types of trunk–buttock shapes. Mendieta used the
relationship of the upper lateral hip, midbuttock, and lateral leg
to describe the A, V, H (square) and round gluteal frame classifica-
tion system. (Insert diagram of different frames). It is important
to note whether the patient desires a more enhanced hourglass
(S-curve shape) or a more athletic frame with less lateral fullness.
The optimal waist-to-hip ratio of the curvilinear or S-curve shape
is frequently less than or equal to 0.7, whereas the more athletic
frame typically has a waist-to-hip ratio greater than 0.7.
Preoperative markings should be made while the patient is
in the standing position. The markings should be made based
on several factors, including skin laxity, bony anatomy, fat, and
muscle fullness. Areas of planned liposuction should be marked
in the standard fashion while considering how areas adjacent to
the zones of liposuction will be affected. The previously discussed
danger triangle may be marked for less experienced surgeons
to help ensure avoidance of neurovascular injury and injection,
including to the posterior superior iliac spine, greater trochanter,
and ischial tuberosity. This will remind the surgeon of what
region of the ligamentous anatomy needs releasing to avoid direct
injection intra- or submuscularly in this zone or from a distance.
The iliac crest should be marked, as it serves as the lowest point
of liposuction and the most superior border of the gluteal region.
Laterally, the height, width, and shape of the iliac crest determine
the potential for waist definition. Areas of dimpling throughout the
gluteal region should be marked preoperatively for selective release
or augmentation during the operation. Liposuction should begin in
the midline sacral region and proceed laterally to the flanks, includ-
ing the soft tissue superior to the iliac crest and inferior to the 12th
rib. This transition area from lateral flank to lateral buttock and outer
thigh/hip is critical in creating a natural silhouette line. This is com-
monly the zone that requires revisional reshaping procedures when
they are initially performed incorrectly. Lipoplasty should continue
inferiorly to the lower lateral flanks and end over the lower lateral
thigh and lateral gluteal curve. The lower lateral buttock/thigh inter-
face requires a very careful, “less is more” approach to lipoaspiration.
To create a smaller waist-to-hip ratio, the distance between
the caudal ribs and the iliac crest should be increased as much as
possible. Liposuction in this area accentuates depth and decreases
the waist-to-hip ratio and can enhance the S-curve silhouette,
even when donor fat may not be as readily present to transfer
into the lateral buttock (“hip-dip”). It is also desirable to have a
concavity over the supragluteal fossettes, where the lumbosa-
cral aponeurosis and gluteus maximus insert. The concavity of
the supragluteal fossettes should transition gracefully into the
Fig. 92.5 Two main regions are important to prioritize, especially
when there is a relative paucity of donor fat. Zone A is the key main
area, which is mandatory, whereas zone B can be limited. Some
patients prefer enhanced waist-to-hip ratio over projection and
therefore will express prioritization of zone B as important if not more
than zone A. Zone B1 may also be desired in some who need greater
buttock lift and need lateral thigh width enhancement. A thorough
discussion is necessary preoperatively.

1450
XII Body Contouring
convexity and projection of the buttocks. The posterior superior
iliac spine serves as the desired height of the gluteus maximus.
Adding volume superior to this region will lengthen the appear-
ance of the gluteus maximus and further enhance the shape of
the buttock. The desire for lateral fullness and posterior projection
must also be discussed to properly identify the patient’s desires
and the surgical goals.
The surgeon must avoid overzealous injection overall and in
one zone. Excessive fat transfer can lead to cysts and third-space
cavities as well as a blowout phenomenon (first described in 2014
by the senior author). The lack of a substantial subcutaneous
scaffold in the lateral thigh makes this area tighter, and both graft
survival and graft capacity over the tensor fascia lata are low.
However, just medial to this is an area located where the gluteal
muscle is tapered, and deep large lobule fat rests in a recess
without a platform to build upon. This area is at the most risk
for contour problems and blowout issues (Fig. 92.6). The preop-
erative marking session is the best and last chance to delineate
areas of reduction and augmentation. The patient’s anatomical
morphology determines the amount of available donor fat, and
patients should prioritize which areas they feel the strongest
about augmenting.
Fig. 92.6 The blowout phenomenon, which can cause a drastic contour irregularity. This can be caused by excessive ligamentous release or overzeal-
ous fat injection into one particular area. Ligaments exist throughout the buttock and can be more dense in some patients. (a–d) Regardless, proper
release without overinjection into one region or overrelease will avoid a pooling of fat and a blowout phenomenon. (e) Note the saponified sterile fat
resting in an encapsulated subcutaneous cavity. Patient surface irregularity displays a classic blowout pattern of a “double-bubble” configuration.

92 Gluteal Augmentation with Fat Transfer
1451
92.6 2SerDWiYe 7eFKniTue
92.6.1 Preprocedural Protocol
The preprocedural protocol includes warming of the patient in
the preoperative holding area, intraoperative Foley catheter
insertion for accurate evaluation of fluid resuscitation status, and
use of sequential compression devices for deep venous thrombo-
sis prophylaxis. The appropriate dose of preoperative antibiotics
per surgical care improvement project recommendations is
given prior to the start of the case and redosed every 4 hours as
the surgical duration permits. General anesthesia allows greater
flexibility in the operation. :hen the patient is prone, a bump
should be placed under the iliac bones in addition to the “kidney”
position extension of the operating table to create an upward
angle from caudal to cephalad injection points. This positioning
makes it more difficult to inadvertently enter the deeper planes
and helps the surgeon avoid the venous and sciatic nerve spaces,
so long as the cannula tip location is always known and continu-
ally assessed and reassessed. It should be noted that we strongly
discourage the use of Luer lock cannulas, which can easily bend at
the hub. Their unpredictability and instability make unintended
injection planes more likely, especially in the ligamentous regions.
Other authors have also described placing patients in the lateral
decubitus position; however, we believe that the prone position
provides the best visualization of gluteal symmetry and avoids
tissue splaying. All pressure points should be protected with
axillary rolls, facial padding, and cushioning of iliac crests, knees,
and elbows. After the patient is prepared and draped in a sterile
manner, we infiltrate with tumescence and wait at least 15 min-
utes for hematologic epinephrine concentration to peak in order
to take advantage of its vasoconstrictive properties.
92.6.2 Lipoaspiration
Liposuction is performed using the surgeon’s preference for
tumescence and cannula. :e prefer the 4- and 5-mm flared
(exploded tip or “basket” tip) high-oscillation cannula tip (pow-
er-assisted) for fat lobule preinjection release and blunt 3-, 4-,
and 5-mm blunt multihole or traditional Mercedes-tip cannulas
for lipoaspiration. The 4- and 5-mm basket tips are then used
post aspiration for final donor site contour smoothing to shift and
evenly distribute fat lobules that remain. Massaging and rolling
of the soft tissue for the final contour can be performed to the
surgeon’s specification and preference.
Occasionally, smaller cannulas are used for thin patients with
areas of superficial lipodystrophy and cellulite (banana rolls). The fat
layers are approached in a superficial to deep fashion, and slower
strokes are used throughout the deeper layers and faster strokes
in the superficial layers to avoid dimpling and injury to the skin. In
general, the cannula tip should always be at least 1 cm deep to the
dermis. The nondominant hand assists in proprioception throughout
the case, palpating the position and depth of the cannula at all times.
It is critical to use multiple access incisions in a cross-hatched
pattern at multiple depths to avoid contour irregularities. The
surgeon should pay special attention to the lower back, sacral area,
and lateral flanks. Liposuction of the sacral area, or central fat pad,
accentuates the degree of upper-pole gluteal projection and creates
an illusion of greater lower back lordosis. However, caution must
be taken not to be overaggressive with sacral liposuction, as the
destruction of lymphatics in this area can lead to increased seromas
as well as deep skin rhytids and overly increased skin laxity.
92.6.3 Fat Preparation
The surgeon must not underestimate the importance of preparing
the fat for injection. There are multiple approaches to processing
of the lipoaspirate. Although the details may differ, the principle
remains the same: to separate the viable fat from the aqueous
component in a sterile fashion. We use a closed collection system
with processing in an open strainer. The authors’ preferred
method is to aspirate or drain the aqueous component after the
lipoaspirate is decanted in the closed liposuction canister system
(Fig. 92.7). We do not routinely centrifuge the fat, as this is not
common for large-volume lipoaspiration and lipofilling. The fat is
then strained through a commercial strainer to remove residual
aqueous components and obtain more purified fat lobules. Scar
and fibrous tissue will also need to be removed. The viable fat
ratio is approximately 30 to 50% of the aspirate volume.
The viscosity of the lipoaspirate should be consistent. Excess
aqueous solution or fibrotic tissue in the lipoaspirate can alter the
necessary tactile feedback required to judge the injected volume.
It is important not to touch the fat during this process. The purified
fat is then mixed with 300 mg of clindamycin solution and trans-
ferred into 60 mL Toomey syringes (Fig. 92.8). The strainers are
covered to avoid theoretical contamination in this open phase of
processing. Other processing systems include a completely closed
system without any exposure to the environment, minimizing
theoretical open-air contamination. Proponents of the closed
system claim that it reduces infection rates, but there has been no
evidence to suggest that our processing technique increases infec-
tion rates or reduces fat viability. This is not unlike leaving tissue
allograft, suture material, cartilage, implants, and other materials
out on the table prior to placement into the body.
92.6.4 Fat Injection
Gluteal fat transfer is the most critical component of the opera-
tion. The surgeon must optimize fat graft survival, while placing
the fat properly and avoiding neurovascular complications. Fat is
extremely susceptible to injury or death during the harvest and
transfer. The single most important principle to ensure success-
ful fat transfer is to inject fat in small aliquots with each stroke in
multiple planes, so that the fat grafts are surrounded by healthy
and well-vascularized tissue and not pooled into one large area.
Vibration can be used while prereleasing to release superficial
and deeper bands of attachment in the buttock zones. This will
liberate the scaffold availability and graft capacity. In addition,
tumescent infiltration prior to this will help in the preexpansion
required in some patients and in some buttock regions.
We use a 3.7-mm cannula to inject in both anterograde and
retrograde fashion. The strokes are rapid and in a fanning motion,
so as not to remain in a single location for too long. Typically, we
do not inject more than 5 to 10 mL of fat per pass. Large aliquots of
fat can result in fat necrosis or large cystic cavities of saponified fat
(blowout deformity). 1utrients and oxygen are unable to diffuse
long distances to the central core of large aliquots of fat, resulting
in loss of the central tissue.

1452
XII Body Contouring
The volumetric limits of fat transplant theoretically cannot
exceed a 1:1 ratio, based on multiple reports studying fat graft
survival. Carpaneda’s principle dictates that transferred fat must
be within an average radius of 1.5 mm to surrounding well-
vascularized tissue. The average volume maintained is approxi-
mately 53%, secondary to the adipocytes’ not surviving the period
of diffusion before angiogenesis and the adipocytes’ shrinking
during periods of ischemic stress. Constant massage and contin-
ual motion can prevent the coalescence of fat into large clumps.
Overcorrection is not recommended, because excessive injec-
tion overloads the graft capacity of the recipient site and may
reduce fat graft survival overall. Based on the graft-to-capacity
ratio, the preoperative volume of soft tissue determines the fat
graft capacity of the recipient site. Multiple studies have shown
that it is the fat quality and not the fat volume that increases fat
graft survival. Fat quality can be improved by protecting the fat
from shear, stabilizing the fat using cell protectants, increasing the
stem cell concentration, and using a small, uniform lobular size.
Standard wetting solution and low-pressure suction can minimize
blood loss and also improve adipocyte viability. It has also been
shown that there is no relationship between the amount of volume
injected and the satisfaction of the patient or surgical team.
Tactile feedback and proprioception should be used to determine
both the depth of the plane of injection and the changes in tissue
resistance. Graft capacity should be determined both preoperatively
and intraoperatively based on tactile feedback of tissue resistance.
Injection of an area should cease once there is tactile resistance, as
further injection into this area exceeds the site’s graft capacity and
can result in third spacing and future cyst formation. Overinjection
can also result in excessive pressure on the grafted fat, leading to
interstitial hypertension and its deleterious effects on nutrient and
oxygen diffusion. Additionally, excessive graft-fill pressure increases
the risk of fat entering the veins by increasing the pressure gradient.
Signs of increased recipient site pressure can also include a sudden
decrease in resistance and fat exiting the port incision.
Multiple passes should be performed in multiple directions and
planes to avoid contour irregularities and ensure an even and homo-
geneous fat distribution. The fat is injected into only the superficial,
intermediate, and deeper subcutaneous planes, starting with the
layer above the superficial muscular and fascial layer, progressing
to the deep subcutaneous layer, and ultimately in the superficial
subcutaneous tissue layer. Subcutaneous and suprafascial injection
is best for contouring and gluteal projection, while intramuscular
injection can increase the risk of fat emboli. Intramuscular fat
transfer is also not necessary for contour, because muscle does not
expand as required, even with larger volumes. If patients require or
desire release and expansion of the medial lower pole region (lower
portion of the danger zone), the surgeon should avoid deep injection
and prerelease as well as intermittent release (as dictated by cannula
stroke ease feedback) from the infragluteal crease access (VIDEO 1).
Also, it is possible in some patient morphologies to inject this region
from superiorly (either via the cleft access or lower back access).
While injecting near the upper lateral thigh and buttock areas, the
surgeon should point the cannula medially to laterally with the
access point either superior or lateral to the previously described
danger zones. Vertical traversion in this area is not as important for
maintaining injection safety. The lateral gluteal depression may be
injected from an intergluteal cleft incision or from a lower lumbar/
upper midbuttock access point. This is the region that is least
likely to create canula misguidance but is the hardest area in many
cases to expand. :e find this lateral region that extends into the
lateral thigh to be the area that benefits most from simultaneous
release-injection using the canula in high vibration mode.
Preinjection of tumescent or intermittent release of ligamen-
tous structures can aid the excursion of the cannula through
these structures. Additionally, ligamentous release can ensure
Fig. 92.7 Canister decanting. A “near-closed” system is used. Open
strainers or washing and separation by decanting alone may both be used
without any difference in infectious or other complication rates reported.
Fig. 92.8 A 60 mL Toomey syringe setup. Fat is not overly liquefied and
is dehydrated as much as feasible, with little to no excess oil or blood.

92 Gluteal Augmentation with Fat Transfer
1453
homogeneous fat distribution that avoids the “tombstone” defor-
mity (harsh square transition from flank/waist toward the lateral
buttock), when tissue is not adequately expanded and fat ends up
in areas with the greatest tissue compliance. Fasciocutaneous lig-
aments can be released with flared cannulas on high vibration (off
aspirate mode) and/or small pickle-fork cannula tips (for superfi-
cial dimples) for lower central fascial bands. Manual palpation and
tactile resistance assessment as to the ease of cannula excursion is
continually required to determine the end points.
There should always be a moderate to light degree of tissue
feedback resistance during lipoinjection. If it is too easy, the plane
must be changed, and if it is too difficult, the plane must be altered
and/or ligamentous release must be performed. It is critical to
balance the judicious release of ligaments without overreleasing
and rupturing the boundaries of the gluteal fat compartments.
92.6.5 Closure
Access incisions are closed using a layered technique that
maintains the sterility of the fat-grafted sites. The closures must
be watertight, specifically in the buttock and lumbar areas.
The authors do not recommend placing open drains to prevent
fluid collections. Instead, patients are placed in a compression
garment for 6 to 8 weeks to prevent seroma and ensure good
adherence of the superficial fat and skin layer to the underlying
musculoskeletal framework. We routinely place one or two foam
pads over areas of concavity, for example, over the central sacral
fat pad to enhance the lower back lordosis. We also place foam
pads over areas that have undergone liposuction, followed by a
compression garment. The compression garment should be loose
or open over the buttocks to take pressure off the grafted areas
and prevent adipocyte death.
92.7 Postoperative Care
Patients are encouraged to ambulate immediately after surgery,
and we do not routinely prescribe prophylactic anticoagulation
for venous thromboembolism prophylaxis. Patients are given
antibiotics for 5 days postoperatively. They are instructed to
avoid as much as possible lying or sitting on their buttocks for
the first 2 weeks and up to 8 weeks after the operation. The
senior author recommends that patients sit on special pillows
that place pressure only on the posterior thigh as the buttock
is floated. Patients should sleep in the prone position (and if
combined anterior ancillary procedures were performed, lateral
decubitus). Patients can apply pressure to their buttocks for only
20 to 30 minutes at a time for necessary tasks of daily living, such
as restroom use and eating.
Patients have to continue using the surgical compression gar-
ment for up to 2 months after the procedure. They will change
from the ´first-stageµ garment, with two zippers, to the ´sec-
ond-stage” garment, with one zipper, after 1 to 2 weeks. The foam
pads are removed 7 to 10 days after the operation and replaced
until patients are wearing their second-stage garment. Patients
should be educated on meticulous hygiene and are instructed to
increase caloric intake for the first to third week after surgery to
ensure nutrition and fat retention.
Patients can participate in light exercise 4 weeks after surgery.
The authors recommend muscle-building exercises (e.g., yoga,
Pilates, strength training, muscle bulking) rather than fat-burning
or cardiocentric programs in the first 6 months after surgery.
Patients should stay well hydrated and consume a low-sodium,
complex carbohydrate, and protein-rich diet. A low-sodium diet
will minimize postoperative edema. The final contour and volume
retention of autologous fat gluteal augmentation is not achieved
until at least 6 months after surgery.
Surgeons should have a very low threshold for seeing their
patients if they have any concerns or questions.
92.8 5eVuOWV&DVeV
92.8.1 Case 1
A 23-year-old woman desired a narrower waist line and fuller
buttocks. She also placed significance in =ones B and B1. She
is shown here 1 year postoperative (Fig. 92.9). Approximately
400 mL of fat was placed into each buttock. There were no
complications.
92.8.2 Case 2
A 28-year-old woman who had had one child desired an
abdominoplasty and buttock augmentation with fat transfer.
She had staged procedures. Stage 1 included an abdomino-
plasty with rectus diastasis repair and liposuction 360 minus
the midcostal region of the back (bra strap) to avoid injury to
abdominal skin flap perforators. Fat transfer was 720 mL into
each buttock. Six months later she had dog-ear repair and a
second round of fat transfer to the buttocks, with 420 mL into
each side, derived mostly from the abdomen, upper/midback,
and arms. She is seen here 1 year postsurgery from the second
stage (Fig. 92.10).
92.8.3 Case 3
A 22-year-old woman who was happy with her overall body
shape but desired larger buttocks. She complained of her buttock
asymmetry and boxy appearance from the posterior views.
She is seen 9 months postoperatively after liposuction of the
abdomen, inner thighs, arms, back, and flanks with 660 mL of fat
transferred to each buttock (Fig. 92.11). Of note: At 6 months, the
shape and size of the buttock is stable for evaluation. While the
buttock may feel less taut or dense after 1 to 2 years, the overall
scaffold and shape remain in the majority of patients.
92.8.4 Case 4
A 21-year-old woman who has overall thin skin and an athletic
silhouette requested fuller buttocks with a significant increase
in size. She had 540 mL of fat transferred to her buttocks after
liposuction in a ´Hi-Definitionµ 360° fashion. She is seen here 11
months postoperatively (Fig. 92.12). Note the preservation of fat
in the abdomen and the curvilinear definition lines created with
high-definition techniques.

1454
XII Body Contouring
Fig. 92.9 (a,c,e) Case 1. A 23-year-old woman desired a narrower waistline and fuller buttocks. She also placed significance in zones B and B1.
(b,d,f) She is shown here 1 year postsurgery. Approximately 400 mL of fat was placed into each buttock. There were no complications.

92 Gluteal Augmentation with Fat Transfer
1455
92.9 Complications
92.9.1 Fat Embolism and
Fat Embolism Syndrome
Based on recent reports of significantly higher morbidity and
mortality rates associated with gluteal fat grafting than with any
other aesthetic procedure, it is critical that surgeons adhere to
key principles of safety throughout gluteal fat augmentation. It
should be noted, however, that mortality rates are actually high-
est for abdominoplasty. The recent Aesthetic Surgery Education
and Research Foundation task force report on mortality from
gluteal fat grafting demonstrated that out of 198,857 cases of
gluteal fat grafting, there were 32 fatalities from pulmonary fat
emboli and 103 nonfatal pulmonary fat emboli. Comprehensive
understanding of the gluteal anatomical planes in relation to
the neurovascular structures greatly improves the safety of
this procedure. Fat should be injected into the subcutaneous
plane only, whether superficial, intermediate, or deep. Proper
placement of the cannula injection tip at fat graft sites is critical
to safety and to avoiding inadvertent injection or injury to adja-
cent neurovascular structures. In addition, proper ligamentous
release drastically reduces canula misguidance which create
inadvertent injection into subfascial and submuscular planes.
Fat embolism and fat embolism syndrome are two distinct
concepts with different pathophysiology and clinical presenta-
tion. Fat embolism is a result of mechanical blockage by fat in a
medium to large vessel. There is a significant risk for this com-
plication secondary to the high vascularity of the buttock region.
The consequences of fat embolism can range from permanent
blindness to pulmonary embolism to death. Patients who develop
fulminant thromboembolism during the surgery typically suffer
macroscopic fat embolism, whereas patients who die during the
first 24 hours after surgery suffer from embolism of small pulmo-
nary and/or cardiac vessels. The pathophysiology of macroscopic
and microscopic fat embolism is in contrast to fat embolism
syndrome, which is a systemic inflammatory response that often
does not have major sequelae.
Two theories of how macroscopic fat embolism occurs have
been proposed: cannulation injection theory and the laceration
siphon theory. The cannulation injection theory proposes that
a bolus of fat is directly and actively injected into a large vein.
The laceration siphon theory proposes that fat enters the venous
system slowly over time, after it has been injured as a result of
indirect shearing or direct venipuncture. This creates a pressure
gradient, and fat flows from the higher-pressure soft tissue to the
lower-pressure venous lumen. Therefore, to reduce the risk of fat
embolism, surgeons must avoid creating high-pressure states and
avoid direct venous injury.
Important safety factors include the use of a large-bore blunt
cannula (> 3.7 mm) and continuous motion while remaining in
the subcutaneous or superficial muscle plane and avoiding over-
grafting and excessively high recipient-site pressure. Large-bore
cannulas are more rigid and provide more precise anatomical
placement of the fat compared with flexible, small-bore cannu-
las. Flexibility misguidance occurs frequently with small-bore
cannulas and Luer lock hub interfaces. Continual motion prevents
direct and/or continuous injection into a vessel or nerve and can,
theoretically, never be in one location long enough to both injure
and bolus into an injured vein. Also critical are staying superficial
to avoid injuring the neurovascular structures that run inferior to
the muscular fascial plane as well as avoiding danger zones and
cannula misguidance via incomplete ligamentous release. Lastly,
avoiding excessive graft pressures (particularly subfascially)
decreases the risk of fat entering into a lower-pressure vein lumen
in the setting of a venous injury.
92.9.2 Poor Fat Survival
One of the most common complaints of gluteal fat transfer is
poor fat survival. We believe it is normal to lose 25 to 40% of
transplanted fat over 3 to 12 months. There are many surgical
factors that can minimize fat loss. Reducing the amount of time
Fig. 92.10 (a–d) Case 2. A 28-year-old woman who had had one child
desired an abdominoplasty and buttock augmentation with fat trans-
fer. She had staged procedures. Stage 1 included an abdominoplasty
with rectus diastasis repair and liposuction 360 minus the midcostal
region of the back (bra strap) to avoid injury to abdominal skin flap
perforators. Fat transfer was 720 mL into each buttock. Six months
later she had dog-ear repair and a second round of fat transfer to the
buttocks, with 420 mL into each side derived mostly from the abdo-
men, upper/midback, and arms. She is seen here 1 year postsurgery
from the second stage.

1456
XII Body Contouring
Fig. 92.11 (a–c) Case 3. A 22-year-old woman who was happy with her overall body shape but desired larger buttocks. She complained of her but-
tock asymmetry and boxy appearance from the posterior views. (d–f) She is seen 9 months postoperatively after liposuction of the abdomen, inner
thighs, arms, back, and flanks, with 660 mL of fat transferred to each buttock. Of note: At 6 months, the shape and size of the buttock are stable for
evaluation. While the buttock may feel less taut or dense after 1 to 2 years, the overall scaffold and shape remain in the majority of patients.

92 Gluteal Augmentation with Fat Transfer
1457
between fat harvest and fat transfer is critical to increasing
fat survival. The surgery should be performed with a sense of
urgency, with care to minimize any downtime. Decreasing
extracorporeal time reduces oxidative and ischemic injury to the
adipocytes. While the fat is out of the liposuction canister, the fat
should be kept covered by a barrier to prevent air exposure and
potential contamination. Proponents of the “closed” technique
warn that the “open” transfer from the donor to recipient site
creates a nonsterile environment and increases the risk for infec-
tion. However, surgeons leave instruments and other materials
(e.g., sutures, tissue matrices) exposed and open throughout the
case, yet infections do not occur.
It is also important to place fat in small aliquots in multiple
passes to optimize graft take. Typically, we place no more than
5 to 10 mL of fat per pass. Large aliquots of fat will result in
cyst formation and fat loss. The central core of large aliquots
is located too far from neighboring vascularized soft tissue to
receive nutrients and oxygen by diffusion and will be signifi-
cantly susceptible to graft loss. The surgeon must also pay care-
ful attention to not exceeding the graft capacity of the recipient
site. Excessive pressure on transplanted fat increases adipocyte
necrosis.
Similarly, patients should avoid sitting or lying on their but-
tocks for the first 2 weeks after the operation. The transplanted fat
should be nurtured as it transitions from a diffusion-dependent
graft to vascularized tissue. Patients are allowed to sit or lay on
their buttocks for a maximum of 20 to 30 minutes at a time, only
for necessary tasks of daily living.
Fig. 92.12 (a–d) Case 4. A 21-year-old woman who has overall thin skin and an athletic silhouette requested fuller buttocks with a significant
increase in size. She had 540 mL of fat transferred to her buttocks after liposuction in a “Hi-Definition” 360° fashion. (e–h) She is seen here 11 months
postoperatively. Note the preservation of fat in the abdomen and the curvilinear definition lines created with high-definition techniques.

1458
XII Body Contouring
92.9.3 Asymmetry and Contour
Abnormalities
Contour abnormality and asymmetries are related to many fac-
tors, including differential graft take, inherent donor site char-
acteristics, and preoperative native bony and tissue asymmetry.
The most important first step is to wait at least 4 to 6 months
prior to determining the final graft take. Additionally, managing
preoperative patient expectations is the most critical step of
managing postoperative asymmetry. It is important to clearly
point out preoperative asymmetries and native skin and soft
tissue irregularities. Preoperative photographs can be a critical
supplement for the preoperative discussion.
Although the surgical goal is to improve asymmetry, it is
impossible to achieve complete asymmetry, as in all bilateral
plastic surgery. The patient should be informed that there is no
guarantee that preexisting asymmetry and contour abnormalities
can be corrected. Correcting superficial skin contour is one of the
most challenging aspects of buttock augmentation. Skin irregular-
ities over the lateral or inferior buttocks are especially difficult to
correct secondary to the lack of native fat scaffold.
In addition to managing preoperative expectations, structural
differences can be noted and corrected intraoperatively with
release of fascial bands, superficial indentations, and ligamentous
borders. If the patient continues to have asymmetry 6 months after
the operation, revision fat injection can be considered but is rare.
Another fat transfer procedure to revise the asymmetry can be
performed as soon as 6 months after the surgery, but it is preferable
to wait until at least 1 year after the initial operation. In revision
augmentation, it is also preferable to augment only the anatomical
zones indicated and not the entire buttock. Revising buttock asym-
metry with liposuction is not recommended and commonly results
in buttock ptosis and significant contour irregularities.
Iatrogenic contour abnormalities of the buttock can result from
superficial fat injections, skin dimpling, fat necrosis/oil cysts, scar
tethering, and inadequate fat injections. Contour abnormalities
secondary to liposuction of the donor sites can be avoided by
practicing good liposuction technique. The liposuction cannula
should be appropriately sized for the region being treated and per-
formed in multiple directions and planes in a continuous motion.
As with buttock asymmetry, it is critical to wait 3 to 6 months
prior to addressing the defect. Superficial fat injection is treated
with localized liposuction or steroid injections. Inadequate fat
transfer is treated with additional fat transfer, and scar tethering
and skin dimpling are treated with percutaneous scar release and
additional fat injection.
92.9.4 Fat Necrosis and Cysts
Fat necrosis and cysts formation can be avoided with injection
of small aliquots in multiple passes in multiple planes. The
goal is to have all adipocytes surrounded by healthy and well-
vascularized tissue during the diffusion-dependent stage of graft
take. With injection of large aliquots of fat, the central core will
not receive adequate nutrition and will result in oil cysts or areas
of fat necrosis.
The best management of fat necrosis and oil cysts is by adher-
ing to the surgical principle of injecting small aliquots of fat to
allow adequate diffusion of oxygen and nutrients. Small areas of
fat necrosis may not need surgical correction. Large areas of cyst
formations or necrosis will result in soft tissue ptosis and depres-
sion that may benefit from small revision procedures. Complete
fat loss and full buttock ptosis are rare complications but may
require a superiorly based buttock lift. Secondary fat injection for
volume correction may be necessary after the initial lift procedure
to treat the ptosis.
92.9.5 Infection
Perioperative intravenous antibiotics, intraoperative antibiotics
mixed with the lipoaspirate, and postoperative oral antibiotics
are used to minimize buttock wound infections. Preoperatively,
patients are instructed to perform a chlorhexidine shower and
instructed to maintain good postoperative hygiene with anti-
biotic ointment on incisions, showers, and so forth. However, if
the patient develops localized erythema concerning for cellulitis
in the postoperative period, surgeons should have a very low
threshold for treating with antibiotics and draining a possible
abscess. :e typically prescribe 5 to 7 days of first-generation
cephalosporin or fluoroquinolones in penicillin-allergic patients.
All abscesses should be drained thoroughly and cultured, and
patients should be started on antibiotics immediately. A high
suspicion of drainage should be present with any erythema,
particularly between postoperative days 10 and 21. Follow-up in
this time period is critical. Fig. 92.13 shows a 15-day postoper-
ative patient seen in clinic and immediately scheduled for local
anesthesia, incision, and drainage. Mycobacterial and fungal
infections are rare after gluteal fat transfer, but patients should
be referred to infectious disease specialists for appropriate
Fig. 92.13 This patient presented in clinic 15 days postoperatively
(after a no-show for a visit on day 10) with complaints of increasing
pain. The pain level should be on the decline by day 15. The patient
was seen and immediately taken to the operating room and placed
under local anesthesia (sedation anesthesia may be required in more
progressive cases). The incision was drained, cultures were sent, and
a Penrose drain with Betadine packing was placed. Although cultures
came back negative, she was placed on 10 days of ciprofloxacin
empirically.

92 Gluteal Augmentation with Fat Transfer
1459
treatment and may require months of antibiotic therapy. Acid-
fast preparation cultures should be sent and body fluid mixed
with the tissue specimen. In these rare cases, surgical wound
exploration and washout may be necessary.
92.9.6 Seroma
Seromas are more frequently seen in donor sites and should be
treated by needle aspiration and continued use of compression
garments. Repeated drainage may be necessary and is usually
performed in the office setting.
92.10 Concluding Thoughts
Gluteal augmentation with autologous fat grafting has become
an increasingly popular procedure over the last decade. Fat
harvesting with liposuction in conjunction with augmentation
with lipoinjection allows a global and comprehensive contouring
of the entire torso and buttock region. Despite the many advan-
tages of gluteal augmentation with fat transfer, it is a procedure
that carries significant risks of morbidity and mortality without
surgical expertise. There are numerous technical and anatomical
considerations that must be carefully understood and analyzed
before it can be performed successfully. Success of the procedure
is dictated not only by the final aesthetic outcome but also by
maintaining patient safety throughout the perioperative journey.
Adherence to proper patient selection, perioperative protocol,
and surgical technique as discussed in this chapter allows gluteal
fat transfer to transform the patient’s entire body silhouette.
Clinical Caveats
• Patient selection and management of postoperative expecta-
tions with regard to volume and precise gluteal shape prefer-
ences are critical to surgical success and patient satisfaction.
• Gluteal fat transfer should be performed only in the subcuta-
neous plane. Period.
• Use of larger-bore cannulas (> 3.7 mm) as well as avoidance
of Luer lock cannulas will prevent flexibility misguidance and
reduce the risk of inadvertent tissue cannula misguidance of
the cannula tip into deeper planes.
• The zone of danger is an integral part of avoiding neurovascu-
lar injury during gluteal lipoinjection and must be thoroughly
understood anatomically.
• Lipoinjection should be performed in small aliquots with
constant cannular motion and tactile feedback of tissue
resistance, which should never be too easy or include high-
resistance difficulty during passes.
• Overcorrection should be avoided, because it can cause
decreased fat graft viability, increased risk of venous injury,
increased risk of a blowout, and increased risk of potential
buttock ptosis in the future.
• Patients should avoid placing pressure on the buttocks for 2
weeks postoperatively, and patient education/communica-
tion postoperatively with a low threshold for treatment of
infection are all important in the comprehensive treatment
approach.
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[45] Yoshimura K, Coleman SR. Complications of fat grafting. Clin Plast Surg
2015;42(3):383–388, ix

93 Evaluation and Treatment of Iatrogenic Deformities, Including Contour Deformities
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93 Evaluation and Treatment of Iatrogenic Deformities,
Including Contour Deformities
Jeffrey R. Claiborne and Simeon Wall Jr.
Abstract
Revision and secondary liposuction procedures are associated
with less than ideal outcomes compared with other revisionary
cosmetic procedures. Some areas of contour deformity will not
be amenable to repair. The levels of fibrosis and scarring seen,
especially in cases associated with previous thermal liposuction,
generally reduce the possibility that all residual deformity can be
successfully addressed.
SAFELipo is different than traditional liposuction and was
developed to overcome its shortcomings. Whereas traditional
liposuction is strictly a reductive procedure, SAFELipo is a com-
prehensive body contouring technique for adipose, skin, and
the fasciocutaneous network. In a previously treated area, the
technique allows the surgeon to regain the lost differential in
resistance between tissue planes, allowing for easy navigability
and treatment throughout the target zones, whether the goal is
to remove more fat, break up fibrous scar, redistribute what fat
remains, or add more fat to the area using expansion vibration
lipofilling (EVL). It allows for dramatic and thorough liposuction
without increasing the risk of contour deformities or damage to
the skin and blood supply. It is more than a reductive or additive
procedure, because it removes, redistributes, blends, and adds fat
as needed. It releases and equalizes disparities in skin distribution,
simultaneously providing for areas of skin retraction much wider
than traditional liposuction treatment areas. It also treats deep
and superficial tissues without disrupting vascular and stromal
networks.
Keywords
liposuction, SAFELipo, contour deformities, contour deformity,
body contouring, expansion vibration lipofilling, simultaneous
separation and tumescence
93.1 Introduction
The goal of liposuction is to precisely and evenly extract the
“desirable” solid fat matter, which is contained within a sandwich
of ´undesirableµ structures, exploiting the differential resistance of
these tissues. This concept has been the foundation of successful
liposuction since it was originally introduced by Illouz in 1977. Low-
resistance adipose tissue is more easily disrupted and aspirated
than the higher-resistance vessels, stromal supporting network,
overlying skin, and underlying musculofascial struc-tures. Tactile
feedback allows the surgeon to detect cannula misguidance and
keep the cannula in the safe, low-resistance adipose tissue. While
this simplified explanation allows for the avoidance of vital struc-
tures and for the aspiration of fat, it does not address the high rate
of uneven and nonuniform removal of fat as we have known it for
decades. Despite advances in the field of blunt cannula extraction
of fat (liposuction), most notably advances in patient safety, the
basic problem with liposuction was not overcome—what we call
the dose–response curve of liposuction (Fig. 93.1). The more fat
that is removed from an area (the dose), the higher the tendency
toward creating a contour deformity (the response). Surgeons have
subsequently become experts, or not become experts, at incom-
pletely removing fat to avoid creating contour deformities, or in
other words taking just enough fat to make patients happy while
not creating obvious contour deformities.
Many devices and technologies (laser, ultrasonic, radiofre-
quency, and others) have been proposed over the years that would
supposedly allow for the blunting, or even the elimination, of this
dose–response curve in liposuction, none of which appear to have
been effective. In fact, the opposite is true. These devices create an
unintended but significant scar burden, and as the skin redrapes
postoperatively, the fibrosis generated predisposes the patient to
unnatural contours and dermal adherences (Fig. 93.2, Fig. 93.3).
Thermal methods of liposuction dramatically reduce cannula
Fig. 93.1 Traditional dose–response curve in liposuction.
Fig. 93.2 Dose–response curve in liposuction, thermal with time.

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XII Body Contouring
resistance within the tissues indiscriminately, narrowing the
resistance differential between targeted and unwanted tissues. In
this way, surgeon precision is compromised as the tactile feedback
is blunted. To improve the safety and efficacy of liposuction, the
resistance differential needs to be widened and exploited max-
imally to allow greater precision of aspiration. :hen the differ-
ential is narrow, vessels and unwanted superficial fat are avulsed.
The goal is a controlled, smooth, laminar removal of a sheet of
subcutaneous fat so that the overlying superficial fat and dermis
redrape naturally over the deeper musculoskeletal structures—
without dermal adherence to the underlying tissues. However,
since the procedure is blind, we can approach, but never achieve,
perfectly even adipose removal. Acceptance of the imperfect
removal is critical to preventing iatrogenic contour deformities.
SAFELipo was introduced by the senior author in 2002 to address
the limitations of traditional liposuction, in concert with the
concepts of fat separation, fat equalization, and closed skin equal-
ization. SAFELipo is an acronym describing this comprehensive
process approach to fat and skin management: separation, aspira-
tion, and fat equalization. The foundation of SAFELipo is widening
the resistance differential, which gives the surgeon greater control
and precision in manipulating the adipose tissue and overlying
skin. The separation phase mechanically emulsifies and liquefies
the targeted adipose tissue prior to any suction (Fig. 93.4, Fig. 93.5,
Fig. 93.6, Fig. 93.7, Fig. 93.8, Fig. 93.9). “Liquefying” the targeted
adipose tissue differentiates this fat from the surrounding ´solidµ
fat and supporting vessels and stromal network. The targeted fat is
aspirated preferentially, leaving the superficial fat and supporting
structures intact, unlike typical liposuction, which avulses blood
vessels and supporting structures along with the relatively solid
fat. The process approach of fat separation followed by preferential
aspiration allows greater control, precision, and safety. In recog-
nition that perfectly even adipose removal can never be achieved,
the final step of SAFELipo, fat equalization, emulsifies some of the
remaining fat, which will remain and serve as local fat grafts to
fill in any imperfections. The equalization phase becomes more
critical in thinner patients when small discrepancies in tissue
thickness become more readily visible externally. By comparison,
traditional liposuction works by punching holes throughout
the adipose latticework to weaken and collapse the fat and then
hoping that the skin collapses evenly. With SAFELipo, even if some
irregularities exist after aspiration, the equalization phase will
correct and prevent deformities.
Separation and equalization also soften and relax the deep
septal stromal network that runs throughout the subcutaneous
layer and allows for recruitment or decruitment of the overlying
skin, seen externally as smooth skin without dermal or fascial
adherences. These rigid subcutaneous adherences tether the skin
and are another etiology of contour irregularities. By relaxing the
attachments of the skin to underlying structures, the skin can be
predictably manipulated and redistributed as needed from areas
of excess into areas of deficiency and vice versa. :hen properly
understood and utilized, SAFELipo can go beyond aspiration
lipectomy. The principles of SAFELipo have been extended to
comprehensively manage volume and control skin redraping.
expansion vibration lipofilling (EVL) was conceived of and
developed by the senior author in 2004 in conjunction with and
as a complement to SAFELipo to provide a more effective and
potentially safer way to transfer autologous fat in revision cases,
and was later systematized and automated to its current state
by the senior author and Del Vecchio. EVL allows for rapid and
comprehensive simultaneous internal expansion and fat grafting
of the target areas, a concept in complete contradistinction to the
wedging of very small aliquots of fat into tight spaces, as has been
proposed for decades. Using much larger, exploded-tip, Wall CAGE
cannulas attached to a reciprocating power unit and in continuity
with a fat reservoir, in-line preexpansion/fat grafting allows for
predictable volume maintenance and uniform dispersal of fat,
even in densely scarred areas from previous liposuction. SAFELipo
and EVL are ideally suited for the treatment of iatrogenic contour
deformities by using addition, subtraction, and redistribution
while controlling skin redraping.
Fig. 93.3 (a,b) Fibrosis from thermal liposuction.

93 Evaluation and Treatment of Iatrogenic Deformities, Including Contour Deformities
1463
93.2 Indications
Repeat procedures are performed for a variety of reasons, includ-
ing unsatisfactory results or the need for further improvement.
Frequently, a repeat procedure involves a patient who underwent
“spot” liposuction, commonly of the upper or lower abdomen
only or of the lateral thighs only. Because the entire anatomical
(circumferential truncal or circumferential thigh) unit was not
contoured comprehensively, the patient is dissatisfied with
the remaining area or areas of adiposity and therefore wants a
more comprehensive procedure secondarily. More commonly,
however, dissatisfied patients seek a secondary procedure to
correct one or many contour deformities that resulted from an
initial liposuction procedure. These contour deformities include
overall skin waviness, hills and valleys, strange contours, and
outright divots and depressions. In addition to these contour
deformities, many patients have skin damage in the form of
hemosiderin deposition, pigmentary changes, and scarring from
thermal, superficial, or avulsive liposuction methods. Internal
scarring is seen as an unnatural static or dynamic appearance
of the area, with tethering, tightness, and worsening appearance
with positional changes or skin tension. External scarring is
Fig. 93.4 SAFELipo sequence. Separation, before.
Fig. 93.6 SAFELipo sequence. Aspiration, before.
Fig. 93.8 SAFELipo sequence. Equalization, before.
Fig. 93.5 SAFELipo sequence. Separation, after.
Fig. 93.7 SAFELipo sequence. Aspiration, after.
Fig. 93.9 SAFELipo sequence. Equalization, after.

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XII Body Contouring
usually seen only with thermal methods of liposuction in which
there were entry site burns, or even internal burns so severe
that the overlying skin was burned and scarred. Rarely, though,
overlying skin damage or outright loss can result from superfi-
cial or overly aggressive, avulsive suction cannulas (Fig. 93.10,
Fig. 93.11).
Good candidates for repeat liposuction (patients who have
undergone liposuction in an area to be treated again but who do
not suffer from obvious contour deformities) generally have a
body mass index of 30 or below, good diet and exercise habits, and
reasonable expectations regarding outcomes. Patients noncom-
pliant with postoperative care after their first procedure or who
quickly gained weight after a previous body contouring procedure
are suboptimal candidates for a repeat procedure.
A repeat liposuction patient usually seeks only additional
reduction of an area, whereas patients requesting a revisionary
procedure due to contour deformities have already had a bad
experience and primarily need improvement or correction of
obvious deformities. In these revisionary patients, it is important
that the surgeon carefully explain what to expect from a correc-
tive revisionary procedure. Obviously, if the surgeon is not able
to substantially improve or correct the problem area(s), he or
she should explain that to the patient before a second or third
or more procedures are performed. Also, it is important to make
certain that the patient understands the limitations inherent in
revisionary procedures, as well as the likelihood that the result
will not be as close to optimal as could have been achieved with
a better-performed first procedure. This is particularly true if the
initial procedure involved the use of thermal liposuction because
of the excessive amounts of scarring and fibrosis seen in these
cases. In some cases, particularly when patients have undergone
one or more procedures using internal thermal liposuction,
significant improvements cannot be made, and these patients
should be counseled accordingly. If the patient’s expectations are
not likely to be met by any available techniques, or if the amount
or number of surgeries required becomes excessive to gain only a
modest improvement, it is best to walk away from the case.
In an approach similar to performing revision rhinoplasty, we
wait at least 1 year before performing a secondary liposuction
procedure. This time is needed to ensure that all swelling has
resolved and that the tissues are as pliable, soft, and elastic as pos-
sible. Additionally, because of the frequent need to add, redistrib-
ute, and subtract from an area, a stable and unchanging tissue bed
is required before a reoperation is planned. Most patients with
moderate to severe contour deformities, and all patients with a
history of thermal liposuction, need 18 months to 2 years to settle
before attempting a significant corrective liposuction operation,
and the longer the interval between the original surgery and the
repeat operation, the higher the chances for long-term improve-
ment and success.
93.3 Important Considerations
Some patients are left with so little subcutaneous fat after their
initial procedure(s) that it is nearly impossible to perform a
corrective procedure. Even with the SAFELipo process and EVL,
some amount of residual fat is required to create a smooth and
natural-appearing contour. Cases that rely on pure fat grafting to
create a smooth appearance are very difficult to execute, even by
experts, and should be approached with extreme caution.
Fig. 93.10 (a–k) Thermal abdominal liposuction referrals.
a
g
h
i
j
k
b
e
f
c
d

93 Evaluation and Treatment of Iatrogenic Deformities, Including Contour Deformities
1465
Repeat liposuction has been compared to operating in concrete.
Once a liposuction procedure has been performed in a given area,
the treatable tissue layer is scarred, adherent, or even obliterated,
making navigation and fat extraction more difficult and poten-
tially more dangerous. In a primary liposuction procedure, signif-
icant resistance encountered at the cannula tip is generally a sign
that the cannula should be redirected. In a revision or secondary
procedure, this is not necessarily the case, so the surgeon must
be able to discern whether the resistance is coming from a vital
structure or from fibrotic subcutaneous tissue that remains from
a previous procedure.
This loss of differential resistance seen in repeat liposuction
procedures is the main reason these procedures frequently result
in problems, such as skin “end hits,” resulting from the natural
tendency for the surgeon to redirect superficially, preferring
to err here rather than into deeper structures. The loss of this
low-resistance plane can also result in potentially fatal (and
likely underreported) abdominal perforations or damage to other
deeper structures.
Many competent and experienced body contouring surgeons
do not perform repeat liposuction procedures at all, perhaps
wisely. As plastic surgeons, we typically strive for beautiful
results that “do no harm” to the patient, but when considering
repeat liposuction, we are faced with two nearly universal truths
that distinguish these procedures from most other revision plastic
surgery procedures: first, the result will never be as good as the
result that could have been obtained from an optimally performed
primary liposuction procedure; and second, the risk of significant
or serious injury is greater and outside the usual scope of a pri-
mary liposuction procedure.
Despite these and other difficulties faced in repeat liposuction
procedures, revision body contouring can be very gratifying and
successful for patients and their surgeons when the appropriate
expectations, approach, care, and techniques are applied. An ideal
body contouring procedure should be comprehensive in nature,
with applicability in most or all situations. The SAFELipo tech-
nique was developed specifically for repeat liposuction cases, in
which fat redistribution and equalization are paramount. The first
step of SAFELipo liquefies the fat into a malleable slurry. In a pri-
mary case, this makes fat extraction more precise and drastically
less traumatic. In revision cases, this liquefied fat is better utilized
to correct tissue-thickness disparities. And since the technique
is nonthermal, the tissue bed is an ideal recipient for local or
injected fat grafts when inadequate native fat exists.
Another advantage with SAFELipo is that avoiding the zones
of adherence and areas devoid of excess fat is unnecessary.
Typically, contour deformities are caused by avulsing (aspi-
rating) too much fat or the wrong layers of fat from an area, a
problem compounded by areas that have minimal amounts of
fat or areas that are more fibrous. Because there is no aspiration
when performing fat separation and fat equalization, areas
that are typically prone to contour deformities using standard
liposuction techniques can be traversed without fear of overly
suctioning or damaging them using SAFELipo. During the fat
separation and equalization stages, the zones can be navigated,
so the only time to be wary of these zones is when performing
fat aspiration. SAFELipo allows a much more comprehensive
treatment of entire anatomical areas given its ability to pass into
any thin areas and zones of adherence without creating suction
avulsion injuries.
93.4 The Evidence: Comparing
Liposuction Options
There are many proponents of energy-assisted liposuction,
and great results can be achieved. However, there are few
data supporting the advantages purported by these device
Fig. 93.11 (a–i) Thermal buttock and thigh liposuction referrals.
a
h
f
b
c
d
e
g
i

1466
XII Body Contouring
manufacturers. There has been one blinded, multicenter,
randomized, controlled trial comparing third-generation
ultrasound-assisted liposuction (UAL) with suction-assisted
liposuction (SAL), but this study was sponsored by the manu-
facturer of VASER. The authors concluded that UAL was superior
to SAL because of the slightly improved skin retraction (17% vs.
11%) and blood loss (11.2 vs. 14.0 mL blood/100 mL lipoaspirate),
but they ignored the higher incidence of dull pain, sharp pain,
numbness, burning sensation, and swelling in the UAL cohort.
The conclusion also disregarded their data indicating that
blinded patients were slightly more satisfied with traditional
liposuction. A separate side-to-side clinical trial failed to
demonstrate the improved skin retraction, bruising, or final
clinical result with UAL but did demonstrate increased swelling
associated with UAL.
Kenkel and colleagues investigated UAL in a porcine model, and
they demonstrated that the UAL lipoaspirate had a lower hemo-
globin concentration than SAL. The most interesting observation
was based on their perfusion studies performed on the pigs
after liposuction. Traditional liposuction showed more contrast
extravasation compared with UAL, and the authors concluded
that this indicated less vascular disruption associated with UAL.
However, diminished extravasation does not prove preservation
of vascularity—thrombosed vessels will neither extravasate nor
perfuse.
Without high-quality clinical outcome data, we should try
to understand the science behind UAL to help us make our
own deductions about its impact on our patients. The tissue
disruption from traditional SAL is mechanical, whereas UAL
adds cavitation and thermal interactions. Cavitation is based on
Bernoulli’s law³as the velocity of fluid increases, its pressure
decreases. Cavitation was first described in the context of the
damage to a ship’s propeller—the high-speed jet stream of water
causes a violent collapse of bubbles and structural damage to
the ship. Similarly, high-speed ultrasound waves in nonelastic
water-rich media create a cavitation effect. Cavitation vaporizes
liquid using reduced pressures rather than heat. Theoretically,
vessels are more elastic and less susceptible to direct cavitation
injury than water-rich cells, such as adipose cells. However, the
collateral tissue damage from the violent nature of cavitation
bubbles in UAL is not well understood. As demonstrated by the
need to use plastic insulating access site ports with UAL, collat-
eral damage occurs, and the tissue injury is not selective for only
adipose tissue. Additionally, there exists a thermal component to
UAL. Although the impact of thermal injury in UAL is time- and
technique-dependent, the technology is far from nonthermal, as
evidenced by iatrogenic UAL burn injuries. The collateral tissue
injury associated with UAL is well recognized; many surgeons
switch to a noncontinuous mode when using UAL superficially so
as to reduce dermal damage.
It is worth noting in this discussion of liposuction technologies
and processes that SAFELipo does not impart a thermal load on the
tissues, and there is no possibility of a burn or its accompanying
inflammatory response, one contributing reason why SAFELipo
demonstrated a 0% contour deformity rate in one recent study.
Contending with expensive devices that produce uncontrolled
and unpredictable thermal damage in delicate tissues is not some-
thing we are willing to accept, especially when there is a much
better alternative.
93.5 Subcutaneous Anatomy
The anatomy of subcutaneous fat is traditionally divided into a
superficial and deep compartment, separated by Scarpa’s fascia
or the superficial fascial equivalent. The superficial adipose
layer has dense, compact fat within tightly organized fibrous
septa, whereas the deeper fatty layer is more loosely arranged
and more areolar. Clinically, since liposuction is blind, it is more
useful to manage the fat from the perspective of depth relative
to the skin rather than with respect to Scarpa’s fascia. Although
somewhat arbitrary and simplified, we divide the subcutane-
ous fat into three layers: superficial, intermediate, and deep
(Fig. 93.12).
The deep and intermediate layers are safer and easier to treat,
while the superficial adipose layer requires more precision.
Irregularities in the deep layer can sometimes be disguised by
superficial fat, but inconsistencies in the superficial layer of fat
will predictably create deformities. Since the superficial fatty layer
is more fibrous and closer to the skin surface, laminar extraction
is more difficult, and irregularities are less forgiving. This is not
to say that the superficial compartment must be avoided and
cannot be safely manipulated. :ith SAFELipo, more fibrous and
superficial areas can be safely accessed if the surgeon increases
the separation and equalization phases.
Zones of adherence represent areas with thicker and stronger
fibrous connections between the skin and the underlying deep
fascia. Some authors recommend avoidance of liposuction of
these areas, because they are predisposed to postoperative irreg-
ularities. However, if identified preoperatively, the stiff fibrous
connections can be relaxed with separation and equalization. The
tissue will become more pliable, allowing the skin to redrape nat-
urally, and the whole area can be treated safely and successfully.
Often misunderstood and a source of dissatisfaction, cellulite
has two etiologies—both of which are the result of a mechanical
disharmony. In the superficial fat compartment, fat is tightly
packed within fibrous compartments. Septa run from the skin to
the superficial fascia with limited ability to expand and contract.
The primary type of cellulite, as described by Illouz, is caused by
compartmental fatty hypertrophy with the septa tethering the
skin to the fascia, creating compartment bulges. Treatment of
this type of cellulite is aimed at either reducing the fat within the
compartment or obliterating the septal anchor points. Lockwood
describes the second type of cellulite as a result of skin and fascial
laxity: ´:ith age and sun damage, the entire skin-superficial
fat-SFS >superficial fascial system@ relaxes and stretches, resulting
in ptotic soft tissues, pseudo-fat deposit deformity, and cellulite.”
This second type of cellulite is most common with massive-
weight-loss patients and older age and is surgically corrected by
tightening the skin and fascial system.
93.6 Markings
Most plastic surgeons are very familiar with the traditional spot
approaches that have been widely taught and adopted to treat
contour deformities. The technique proposes to treat hills with
liposuction and valleys with fat grafting and to leave alone areas
that are neither hills nor valleys. These spot approaches typically
require extensive preoperative markings and long procedure

93 Evaluation and Treatment of Iatrogenic Deformities, Including Contour Deformities
1467
times through multiple access incisions. In stark contrast, equal-
izing an entire area with the SAFELipo process is technically much
simpler to perform, with the added benefit of making formal fat
grafting unnecessary in many cases. Rather than aspirating down
the hills and filling in the craters, SAFELipo rakes across the entire
area to allow the hill excess to be swept across and fill in the cra-
ters, although it is important to understand that this process does
not equate to undermining. The vast majority of the stromal and
all of the vascular attachments should remain intact. If formal fat
grafting is still needed, the SAFELipo process provides a receptive
environment for the fat grafts and EVL, unlike the inhospitable
and frequently hostile recipient bed seen after thermal methods
of liposuction.
93.7 Technical Steps
Trunk liposuction (both primary and secondary cases) using the
SAFELipo process is typically performed in three positions: the
supine and both the left and the right lateral decubitus positions.
Although evidence is currently lacking, turning the patient
multiple times, including into the lateral decubitus position,
may reduce the risk of deep vein thrombosis and pulmonary
embolism, because venous pressure is decreased on the elevated
side, decreasing pooling and improving pelvic venous drainage.
Adequate padding of all pressure points is important, along with
careful sterile prepping and draping. A single whole-body prep is
preferable, with the sterile field extending from the neck down
to the end of the bed so that the patient can be moved into differ-
ent positions during the procedure without the need for further
prepping. Prone positioning is also used in select cases and can
be easily incorporated using the same initial full-body prep.
Performing liposuction from the usual three positions (supine,
right lateral, and left lateral decubitus) can help prevent contour
deformities, including “shark bites” in the midbuttocks and other
stigmata of liposuction that are seen frequently. Some surgeons
perform the procedure with the patient in a somewhat supine
position, but with the legs pulled up and across the body, which
will create an unnatural appearance of the trunk, hips, buttock,
and lateral thigh because of the twisting of the spine and the
bulging prominence of the femoral trochanteric area. Performing
contouring in this nonanatomical position of the buttock and
lower extremities can lead to overcorrection or undercorrection,
which frequently appears as contour deformities of the midbut-
tock, gluteal crease, and lateral thigh areas. In the lateral decubitus
position, the normal, standing position is most closely resembled,
allowing contouring to match the same position in which patients
evaluate themselves at home in front of a mirror. Additionally,
the lateral decubitus position makes epigastric liposuction easier
and safer, whereas in the supine position the epigastric fat can
be difficult to safely navigate against the hyperextended rib cage.
In the lateral position, the patient’s upper abdominal skin can
be freely pulled away from the underlying ribs, which are now
less protuberant because of the more flexed abdominal position.
There is also an element of added safety in performing the upper
abdominal work with the patient in the lateral decubitus posi-
tion, because the ribs are not constantly presenting themselves
with the potential to penetrate beneath them. Treating the target
areas from multiple positions and multiple access sites increases
cross-hatching and reduces irregularities (Fig. 93.13).
In any liposuction procedure, adequate infusion of the wetting
solution is crucial to minimizing blood loss, providing additional
anesthesia, and increasing working space through volume expan-
sion. In primary cases, a typical superwet infusion is used, with
an infusion-to-aspiration ratio of 1:1 or 1.5:1. In a revisionary
liposuction procedure, in which volume expansion of the target
zone is even more vital to being able to adequately traverse the
tissue planes, a tumescent approach with a ratio of 2:1 or even
3:1 is frequently needed. In the past, a Klein needle was used for
this important aspect of the procedure, encompassing an infusion
phase and then roughly 20 minutes of waiting to allow maximum
vasoconstriction of the tissues before performing step 1 of the
SAFELipo process, separation.
In collaboration with the senior author and in the course of
applying SAFELipo concepts to his liposuction and fat grafting
procedures, Dr. Daniel Del Vecchio first proposed the utility of per-
forming simultaneous separation and tumescence (SST). The time
needed for maximum vasoconstriction to take effect is drastically
reduced by simultaneously infiltrating the wetting solution while
performing step 1, separation. With a classic Klein needle and
slow manual movement of the needle, the wetting solution will
disperse into the areas of least resistance, and large depots of wet-
ting solution are created, typically at the fat–fascia interface, deep
to the targeted subcutaneous tissues and their associated capillary
networks. However, for maximal efficacy of the epinephrine, the
solution should be evenly dispersed throughout the entire subcu-
taneous space to maximize the surface area and contact between
the solution and targeted small blood vessels. SST separates the
tissues and creates a latticework of low-resistance tissue planes
for wetting solution dispersion and vasoconstriction. For SST, we
use an angled, exploded-tip 3-mm cage cannula, which is con-
nected to the power-assisted device and the tumescent solution
pump. Volume of flow and speed of vasoconstriction have both
been shown to be far superior to older .lein needle infiltration.
After SST, additional separation of targeted fat is usually desired.
Step 1, separation (including SST), accounts for approximately 40%
of the total procedural time. Fat separation is typically performed
using power-assisted liposuction (PAL) to maximize the oscilla-
tions and efficacy of the wings on the exploded-tip cannulas and
to minimize effort during liposuction (Fig. 93.14). Although PAL
makes SAFELipo less strenuous, more accurate, and much more
efficient, SAFELipo can be accomplished manually without power.
The angled cannulas or dissectors have a blunt tip and “wings”
or ba̧es that when passed through tissue create relative high-
and low-pressure zones. These moving zones of tissue pressure
Fig. 93.12 Subcutaneous fat layers.

1468
XII Body Contouring
gradients adjacent to the cannula wings allow fixed fat globules to
dislodge and detach from their surrounding attachments, essen-
tially separating these droplets of fat from each other and from
their supporting networks of blood vessels and stromal tissues.
This process of mechanical emulsification, or separation, changes
the normally solid fat architecture into a more liquid environment
in the targeted areas, in effect creating a treatment zone of low-re-
sistance emulsified fat, leaving higher-resistance untreated areas
above (skin) and below (musculofascial structures). The creation
of this resistance differential in these treatment planes is crucial
to being able to safely and easily navigate through the area during
the second step, aspiration.
In a repeat or revisionary liposuction case, the widening of
differential tissue resistance is even more important, because
the natural differential in resistance between the fat layer and
its overlying skin and underlying musculofascial structures has
disappeared as a result of scar tissue from previous liposuction.
Advocates of thermal liposuction (laser, ultrasound, radiofre-
quency) argue that these repeat cases are ideal for energy-based
liposuction technologies. However, from our experience, these
are the worst cases for thermal liposuction. Thermal liposuction
devices indiscriminately lower cannula resistance and blunt the
surgeon’s tactile feedback to stay in the correct tissue plane. In
a typical repeat liposuction case, there is already a fibrotic bed
and a more solid architecture of scar tissue, fat, and supporting
structures; this typically manifests to the surgeon as an inability
to pass an infiltration or liposuction cannula through the tissues.
Treatment times are longer, and a higher thermal load is imparted
to the tissue bed, increasing inflammation and subsequent scar-
ring—and in some cases, causing outright burns. Even with the
use of traditional liposuction in revision cases, end hits to the skin
or damage to deeper structures are much more common and can
result in unfavorable results.
Using SAFELipo, the separation step allows the surgeon to regain
the lost differential in resistance between these planes, allowing
for easy navigability through the target zones, whether the goal is
to remove more fat, redistribute what remains, or add more fat to
the area using EVL. For example, if additional fat is to be removed,
it is easy to remain within the targeted zone of separated, excess
fat, because its resistance has been made noticeably lower than
the overlying skin and underlying bed, similar to the feel of a typi-
cal primary liposuction procedure. The supporting structures and
blood vessels are spared, because they remain solid and distinct
from the targeted, emulsified fat that is preferentially aspirated.
There is no need for any thermal energy or suctioning during
step 1 (separation), so tissue and blood vessels surrounding the fat
are left intact. Separating the fat has been compared with shaking
an apple off the tree, a relatively gentle procedure. This step rede-
fines the proper subcutaneous plane to prevent misadventures
and avulsion injury to vessels or destruction of the stromal net-
work. As previously mentioned, PAL facilitates a more expedient
procedure, maximizing the amount of fat separation that can be
accomplished with each pass. The desired end point at this stage
is loss of resistance of all targeted fat, showing the operator that
the target zone is adequately mechanically emulsified.
After separation of the targeted fat from its attachments is
achieved, a more conventional cannula (e.g., a 3- or 4-mm angled
long-port double Mercedes Wall cannula) with smaller, less
aggressive, and more numerous ports is used to aspirate the now
´emulsified,µ low-resistance fat (Fig. 93.15). Because the fat has
already been separated, this aspiration process is fast and almost
entirely bloodless and can be accomplished with smaller, less
Fig. 93.13 Access sites (blue dashes).

93 Evaluation and Treatment of Iatrogenic Deformities, Including Contour Deformities
1469
aggressive cannulas that cause minimal trauma. Step 2, aspiration,
usually constitutes approximately 40% of the total treatment time
but can be much less, or even nonexistent in many revisionary
cases.
Similar to how water is sucked with a straw out of a glass of
water containing ice cubes, this mechanically emulsified/liquefied
fat is suctioned preferentially out of the subcutaneous layer,
leaving behind an intact supporting network. In contrast, standard
liposuction uses tremendous negative pressure to forcibly avulse
fat and supporting structures in their natural, solid, high-resis-
tance state. Because the targeted solid fat and the supporting
blood vessels in standard liposuction scenarios have similar tissue
resistance, they are both aspirated at nearly equivalent rates, which
is demonstrated universally in these scenarios as bloody aspirate.
The third step of SAFELipo is fat equalization. Much as in step
1, fat equalization is performed without any suction and with
the same exploded-tip cannula or dissector. Step 3 typically
constitutes approximately 20% of the total procedural time.
:hen first using the SAFELipo process, many practitioners find
that they spend less time in step 1 but far more time in step 3,
trying to equalize the remaining bed. As experience is gained and
the importance of step 1 is fully realized, the 40/40/20 time split
is more common. In repeat liposuction procedures, more time
is typically spent trying to equalize remaining hills and valleys,
through aggressive molding and contour equalization of the
remaining fat bed with the opposite hand in conjunction with
moving the exploded-tip instrument back and forth through the
uneven tissue bed. Additionally, EVL is almost universally used to
correct volume disparities in these challenging cases.
The fat equalization step effectively separates some of the
remaining fat, eliminates thicker and thinner areas of fat, and
leaves this newly separated fat as a smooth layer of “local” fat
grafts that prevent adherence of the dermis down to the deeper
fascia or other musculoskeletal structures. This blanket of “local”
fat grafts is left in place to buffer against scarring, skin adhesions,
and their resultant contour deformities. This smooth and even
layer of local fat grafts provides the smoothness and natural
appearance typically seen in SAFELipo procedures, even when the
remaining layer of fat is left very thin, which is in sharp contrast to
other forms of liposuction that typically create unsightly contour
deformities as the fat layer is made progressively thinner.
For primary and revisionary cases, the end point of the fat
equalization step is a smooth rolling pinch test. Using both hands,
and without using any instrumentation, the skin is gently pinched
and rolled between the fingers and thumbs, rolling across the
entire area in multiple different directions to assess the smooth-
ness of the skin and underlying fat layer. In areas of persistent
unevenness, the exploded-tip dissector can be inserted and
pushed back and forth through the uneven area while pinching
up the area with the opposite hand, applying gentle pressure to
the uneven area. In repeat cases where the area is still not smooth,
fat shifting and manual molding are performed, if needed, along
with formal fat grafting (EVL) if the area is still volume deficient.
Finally, the release of any remaining skin adhesions is performed
in a conservative and precise fashion.
Fat grafting using EVL is a logical extension of SAFELipo and
offers many advantages over traditional Coleman fat grafting
techniques. In expansion vibration lipofilling, a 4- to 5-mm
exploded-tip Wall CAGE cannula attached to a power-assisted
liposuction unit and fat reservoir is used rather than the typical 1-
to 2-mm cannula attached to a Luer lock syringe. A peristaltic roller
pump using matched tubing specifically for fat grafting propels
the fat from the collection canister, through the larger-bore tubing
and out the tip of the vibrating exploded-tip cannula. There are
no constriction points throughout the entire circuit, minimizing
shear and injury to the fat. Fat grafting using an in-line, vibrating,
exploded-tip 4-mm cannula allows recipient-site expansion as
the tip oscillates in the recipient area, creating differential pres-
sure zones. EVL and SAFELipo increase recipient site compliance,
improving the graft-to-capacity ratio, so the grafted fat is more
likely to be maintained and less likely to be dispersed into unde-
sired areas. EVL’s larger-diameter system and the multiple large
holes of the exploded-tip cannula reduce shear stress and force
on the fat cells. Additionally, larger-bore cannulas with their blunt
tips make inadvertent iatrogenic vascular injury or visceral cavity
penetration less likely. The cannula apparatus is markedly stiffer
and allows greater precision, eliminating the flexibility misguid-
ance that plagues Luer lock syringe techniques. The improved con-
trol and safety in fat grafting using EVL have made this technique
indispensable in body contouring. Another unique advantage of
using the SAFELipo process in conjunction with EVL is that even
at the end of the contouring, with a significantly dehydrated, thin,
and supple tissue bed, additional fat equalization can be utilized
to further improve the contour. This ability to further equalize and
improve the results toward the end of the procedure is in stark
contrast to any of the energy devices, which mandate usage in a
wet and hydrated field³typically seen only at the beginning of the
procedure. The ability to continue to hone and smooth the area
using nonthermal fat equalization as one approaches the final
result cannot be overstated in these complicated cases.
Several additional strategies are useful in helping prevent
contour deformities during liposuction. First, suction should be
cut off before inserting and removing cannulas to prevent the
Fig. 93.14 Basket-tip cannula.
Fig. 93.15 Double Mercedes tip cannula.

1470
XII Body Contouring
creation of a depression at a cannula entry site. Also, angled
cannulas are used exclusively and offer many unique advantages
to straight or radius-bent cannulas. A 20°-angled cannula can be
rotated and redirected without needing to retract the cannula
back to near the entry point (Fig. 93.16). This prevents digging
holes and also allows more complete coverage of an area, with
constant rotating of the angled cannula creating a “windshield
wiperµ effect and maximal coverage. Angled cannulas can also
be advanced with the tip pointing superficially, allowing the bent
portion of the cannula to rest against the deepest part of the bed,
and for the cannula entry angle to be greater. These factors allow
for a more easily controlled depth of treatment and less friction at
the skin entry point. Areas closest to the incision should always
be treated last, and the fat should be carefully equalized at the
access sites at the conclusion of the case. All access sites except the
sites used for formal fat grafting are left open to drain, minimizing
fluid accumulation, bruising, and persistent swelling. Finally, it is
generally prudent not to suction the midbuttock area and gluteal
fold area, as well as to frequently perform EVL fat grafting on them
to prevent further depression or collapse.
93.8 Postoperative Care
Secondary procedures are not only more difficult to perform
but also typically have a more complex postoperative healing
process. Intense and frequent management of these patients is
required, because they are prone to prolonged swelling and usu-
ally require precise and prolonged foam compression in order
to maintain a smooth and even contour over the long term. In a
similar way to how we counsel secondary rhinoplasty patients
regarding the procedure’s well-known complexities, we counsel
all secondary liposuction patients that it will take at least 1 year,
and usually 2 years or longer, for all swelling to resolve and for
the skin to soften and resume more normal pliability and elastic-
ity. Additionally, secondary liposuction patients are more prone
to paresthesias and dysesthesias, which can be helped by early
postoperative recognition and management with desensitiza-
tion therapy and lymphatic massage treatments starting 2 days
postoperatively. In addition to these postoperative modalities,
nerve pain can also be effectively prevented in most patients
with the use of pregabalin or gabapentin started preoperatively
and continued for at least 3 months postoperatively. Whole-body
“shaker” treatments, suction-assisted lymphatic drainage treat-
ments, and external ultrasound treatments have all been used
and can also speed recovery.
Repeat and revisionary patients frequently benefit from
prolonged compression management to assist in the resolution
of swelling and discomfort, as well as the prevention of contour
deformities. Either ô-inch or 1-inch Reston (3M Corporation)
foam that has been custom cut is used for uniform compression
of smooth, treated areas (Fig. 93.17, Fig. 93.18). The 1-inch Reston
foam with cutouts is also used for differential foam compression
for large depressions in which formal fat grafting was performed.
Single or multiple retraction sutures are also used in conjunction
with surrounding foam compression for some complicated and
particularly depressed deformities and are usually maintained for
4 to 5 days after surgery.
Providing some simple instructions on how to use the foam will
prevent mishaps and irritations from the foam. The adhesive side
of the foam, including all edges, is lined with gauze to prevent
blisters. The foam should be unstuck the morning after surgery and
again each day postoperatively. Simply unsticking the foam and
reapplying it immediately prevents traction blisters from forming
and keeps patients more comfortable. The same foam can be used
Fig. 93.16 Angled cannula.
Fig. 93.17 Foam compression with cutout.
Fig. 93.18 Garment with foam compression.

93 Evaluation and Treatment of Iatrogenic Deformities, Including Contour Deformities
1471
for 2 to 4 weeks around the clock, and then for 2 weeks during
the day (without wearing the foam at night) in most revisionary
cases. Baby powder should be used under the foam for greater
comfort, or an Under Armour compression shirt can be worn
under the foam if sensitivity develops. The foam can be washed
and dried and used for several weeks; it will become softer and
more comfortable as time goes on. One should use caution when
using foam after surgery, because it is stiff and sticky and has the
ability to cut into the patient’s skin, causing severe blisters or
ulcerations. Initial phase 1 (4 weeks postoperative) compression
garments are worn over the foam and should not be overly tight or
binding, which can lead to constriction bands in the garment that
can transmit to the skin and cause a contour deformity. Phase 2
compression garments are usually worn in place of foam and after
most settling has occurred after the initial 4 weeks after surgery,
and these garments can be worn significantly tighter.
In addition to using foam and the accompanying compression
garments, patients should be instructed to avoid skin creases and
flexion in susceptible areas (mostly the abdomen) and to avoid
wearing tight, constricting clothes for at least 4 months.
93.9 Results
SAFELipo processes including EVL for secondary liposuction
are an advancement over traditional, thermal, and other forms
of liposuction in several ways. The SAFELipo process approach
is more than just a reductive procedure. Fat is reduced, redis-
tributed, or augmented to the desired thickness and equalized
throughout entire anatomical units. Unlike all other forms of
liposuction, there is a much greater margin for error at the limits
of fat removal with SAFELipo. This process approach allows for
thorough—even aggressive—liposuction without increasing the
risk of contour deformities.
The avoidance of internal thermal devices improves the envi-
ronment for healing generally, and for fat grafting specifically,
because it prevents the depletion of adipocytes, and resident
adipose-derived stem cells resulting from direct cellular lysis,
chronic inflammation, and fibrosis (Fig. 93.19, Fig. 93.20).
93.10 Complications
Iatrogenic liposuction contour deformities are much more
difficult to correct than many other aesthetic procedures we
typically perform. With a revision rhinoplasty or a complicated
revision breast augmentation, the aesthetic outcome can fre-
quently match or even exceed that of the primary procedure.
However, after one or more corrective liposuction procedures,
patients will frequently still have some degree of residual defor-
mity, particularly when the original liposuction procedure used
thermal methods.
Liposuction is now being offered ´totally awakeµ and by
nonplastic surgeons, but the potential complications and risks
should not be minimized. Complications can vary from seromas
and iatrogenic contour deformities to intra-abdominal injury
and death. The trend to treat liposuction as a commodity or
something that is dependent on the newest device, rather than as
a procedure that requires precision, skill, experience, and proper
training, generates complacency, unnecessary risk, and poor
outcomes. The increase in iatrogenic deformities from liposuction
gave birth to the SAFELipo concepts. Awareness and consistency
of cannula throw angles will prevent asymmetric fatty removal.
Fig. 93.19 (a–f) Iatrogenic deformity of buttock and thigh from
ultrasound-assisted liposuction. Treated with SAFELipo and fat
grafting.

1472
XII Body Contouring
Using multiple patient positions during liposuction helps ensure
comprehensive treatment, while cross-hatching for fat extraction
and equalization will prevent iatrogenic divots. Thorough equal-
ization will correct tissue thickness disparities and leave local fat
grafts to generate a smooth, natural shape. The occasional seroma
will occur, but with prompt aspiration and compression, seromas
will not become a serious issue. Vascular injury and bruising can
be a problem with traditional avulsive liposuction techniques, but
with SST and SAFELipo, this risk is minimized. Examining patients
preoperatively for hernias; using larger-bore, stiff cannulas; and
suctioning the upper abdomen from the lateral position help
minimize the abdominal wall perforation risk. To reduce the
incidence of deep vein thrombosis, SCDs are used, and patients
are ambulated postoperatively on the day of surgery, and for sur-
geries over 4 hours, patients are discharged with their sequential
compression machines for continued use for an additional week.
Although not proven, we postulate that repositioning the patient
multiple times intraoperatively improves venous flow and reduces
the deep vein thrombosis risk.
93.11 Concluding Thoughts
Repeat liposuction cases are more complicated than the initial
cases and have a higher risk for suboptimal outcomes. Thermal
liposuction causes greater cell damage, inflammation, scarring,
fibrosis, and contour deformities, and it further complicates
the performance of repeat liposuction. SAFELipo is more than a
reductive procedure but rather includes fat shifting, fat equal-
izing, skin redistribution, and fat grafting as needed. The sepa-
ration step allows the surgeon to regain the lost differential in
resistance between tissue planes, allowing for easy navigability
and treatment throughout the target zones, whether the goal is
to remove more fat, break up fibrous scar, redistribute what fat
remains, or add more fat to the area using EVL. SAFELipo offers
a greater margin of error at the limits of fat removal without
increasing the risk of contour deformities, effectively breaking
the dose–response curve seen in other forms of liposuction.
Clinical Caveats
• Do not overpromise results with revision liposuction. I typi-
cally tell patients that I am aiming for a 50 to 75% improve-
ment in their deformities. In some patients 95% improvement
is possible, but this is not always feasible.
• Widely separate and equalize the tissue beyond the treat-
ment area to prevent step-offs and allow a greater area for
skin redistribution.
• Treatment areas should be approached from multiple access
sites (and ideally also from multiple patient positions) to
ensure uniform and thorough treatment.
• Close follow-up to monitor compression and garment wear is
critical to ensure proper fit and compliance.
Suggested Reading
[1] Del Vecchio D. Gluteal augmentation with circumferential liposuction: simul-
taneous separation tumescence (SST) and expansion vibration lipofilling (EVL).
51st Annual Baker Gordon Symposium on Cosmetic Surgery, February 2017,
Miami, Florida
[2] Del Vecchio D, :all S -r. Expansion vibration lipofilling: a new technique in
large-volume fat transplantation. Plast Reconstr Surg 2018;141(5):639e–649e
[3] Del Vecchio DA, Del Vecchio SJ. The graft-to-capacity ratio: volumetric planning
in large-volume fat transplantation. Plast Reconstr Surg 2014;133(3):561–569
[4] Farkas JP, Stephan PJ, Kenkel JM. Liposuction: basic technique and safety consid-
erations. In: The Art of Aesthetic Surgery, 2nd ed. St. Louis, MO: Quality Medical
Publishing; 2011
[5] Hoyos A, Perez ME, Guarin DE, Montenegro A. A report of 736 high-definition
lipoabdominoplasties performed in conjunction with circumferential VASER
liposuction. Plast Reconstr Surg 2018;142(3):662–675
Fig. 93.20 (a–d) Iatrogenic deformity of abdomen. Treated with SAFELipo and fat shifting.