The Unfavorable Result in Plastic Surgery_ Avoidance and Treatment (2018, Thieme)

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isting disharmony between the upper and lower lips but
also obviating it. In the same way that it is a useful ad­
junct to an upper lip lift, it can successfully treat relative
underprotrusions or overprotrusions and inversions of
the lips as they relate to each other from a lateral view­
point. For example, if the lower lip is protruding beyond
the upper lip in a prognathous manner, it is prudent
to consider V-Y–plasties of the upper before any filler
or fat augmentation (fat transfer mucosal advancement
[FATMA] procedure7) to not only correct this dishar­
mony but also prevent exacerbation of the prognathic
lower lip with volume alone.
Fortunately, most patients do not complain about
the nuances of how the upper and lower lip synergisti­
cally harmonize with each other. Though these patients
are not dissatisfied per se, they certainly are unsatisfied
with their results but may not have the sophisticated
aesthetic sense to effectively express their complaints.
By understanding not only the direct and indirect ben­
efits of reshaping an individual lip, but also its poten­
tial untoward ramifications on the opposing lip and the
whole perioral region in general, the plastic surgeon can
better offer a comprehensive surgical plan to not just
treat the lips as individual units but as synergistic ele­
ments influencing the mien of not just the mouth, but
the face in general.
Asymmetry
Postoperative asymmetry is more often than not a
translation of preoperative asymmetry. Up to 90% of
patients seeking perioral reshaping are unaware of
these minor asymmetries, but if they are not preop­
eratively pointed out to the patient by the surgeon
they will most likely be discovered postoperatively by
the patient and later presented to the surgeon as evi­
dence of wrongdoing. The surgeon’s explanations will
then be perceived as excuses. Thus clear and standard­
ized photographs are invaluable, because their two-
dimensional nature can more objectively convey to the
patient preexisting asymmetries. These should include
a basal view to document any columellar deviation,
photographs of the lips in repose and slightly parted to
reveal the dental backdrop, and shots of the mouth in
various stages of expression.
By having a patient preoperatively acknowledge
both preexisting lip asymmetries and the limitations of
any lip reshaping procedure to absolutely correct them,
postoperative problems of asymmetry are relatively easy
to manage.
Patient Dissatisfaction
With no other operation, except perhaps for male rhi­
noplasty and endoscopic subperiosteal midface lift,
does patient selection play such a critical role in a re­
spective successful outcome. Regardless of an excellent
physical result by most objective measures, if it falls
short of the patient’s purely subjective threshold for
success, the operation has essentially failed. Unfortu­
nately, the patient’s emotional response to a perceived
failure of perioral surgery can disproportionately over­
shadow any actual flaw that may exist.
Although physical scars from perioral surgery are
no different from those from a facelift, they are dif­
ferent in one critical aspect: the psychological impact
on the patient. Over the years, I have observed myriad
patients obsess over ostensibly trivial imperfections in
scars, changes in the nares, and negligible asymme­
tries, which normally go unnoticed by most others.
The reason for this stems from the deep-rooted psy­
chosexual nature of the lips themselves—they not only
reflect the beauty of youth but also impart a subtext
of fertile sexuality, as does a secondary sexual charac­
teristic. Lips exhibiting age-related changes, scar im­
perfections, asymmetries, disharmony, or simple hy­
poplasia may expose counterproductive behavior in
a patient stemming from subconscious insecurity of
sexual influence and authenticity. Consequently, the
stakes are high with lip reshaping surgery. Patients can
experience unprecedented elation eclipsing that from
any other surgery or can be “devastated” by the most
minor of problems. Therefore patient selection is para­
mount to a successful result.
Conclusion
Lip reshaping procedures demand intimate compre­
hension, strategic planning, and precise execution to
deliver symmetrical and beautiful results with minimal
complications. Patients must be counseled in detail re­
garding the healing process and outcome possibilities.
Photographs of various types of scars, residual asym­
metries and imperfections, and other possible results
are a helpful adjunct during the preoperative consulta­
tion. If a patient will not tolerate any of these possibili­
ties, it is wise to avoid operating on their lips, because
their unrealistic expectations of what the surgery can
and cannot do may sabotage an otherwise excellent
aesthetic result.

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Chapter 27 Perioral Aesthetic Surgery
5. Ching S, Flowers RS. Perioral rejuvenation using the valen­
tine anguloplasty. In: Paper presented in American society
for aesthetic plastic surgery annual meeting. New Orleans,
LA; 2005
6. Zide BM. The mentalis muscle: an essential compo­
nent of chin and lower lip position. Plast Reconstr Surg
2000;105(3):1213–1215
7. Haworth RD. Customizing perioral enhancement to obtain
ideal lip aesthetics: combining both lip voluming and re­
shaping procedures by means of an algorithmic approach.
Plast Reconstr Surg 2004;113(7):2182–2193
References
1. Capon A, Iarmarcovai G, Gonnelli D, Degardin N, Magalon
G, Mordon S. Scar prevention using Laser-Assisted Skin
Healing (LASH) in plastic surgery. Aesthetic Plast Surg
2010;34(4):438–446
2. Choe JH, Park YL, Kim BJ, et al. Prevention of thyroidectomy
scar using a new 1,550-nm fractional ­erbium-glass laser.
Dermatol Surg 2009;35(8):1199–1205
3. Tierney E, Mahmoud BH, Srivastava D, Ozog D, Kouba DJ.
Treatment of surgical scars with nonablative fractional la­
ser versus pulsed dye laser: a randomized controlled trial.
Dermatol Surg 2009;35(8):1172–1180
4. Austin HW, Weston GW. Rejuvenation of the aging mouth.
Clin Plast Surg 1992;19(2):511–524

418
CHAPTER
28

Hair Restoration
Alfonso Barrera
Hair transplantation was popularized in the late 1950s by
Orentreich,1 whose work spurred many important con­
cepts for aesthetic surgeons. For example, Orentreich pre­
sented the donor “dominance concept” that the genesis of
hair is at the root of each individual hair follicle and that
roots transplanted from a donor area (occipital and tempo­
ral areas) to areas of baldness will continue to grow hair as
long as it would have in the donor area. This is the key to
hair transplantation: the hair in the donor area is resistant
to the effects of dehydrotestosterone (DHT), which is why
it continued to grow, whereas the hair in the areas of bald­
ness (the top of the head and crown) is not.
Of course, getting the hair to grow is not enough; it must
grow and look natural. With that in mind, it is fairly easy to
determine whether a patient is a good candidate for hair
transplantation. As for any other elective procedure, the sur­
geon must make sure the patient has a low risk for surgical
complications. If the surgeon has any doubts about the pa­
tient’s health, clearance should be obtained from the pa­
tient’s primary care physician. If the patient is taking anti­
coagulants, the surgeon must determine whether it is safe
for the patient to discontinue them. Hypertension, diabetes,
and other conditions that affect surgical safety and healing
must be under control.
Current Hair Transplantation
Techniques
My technique is based on 30 years of private practice; it is
the most common procedure performed in my practice.2–11
Many of my patients have experienced unfavorable results
elsewhere and are seeking revision.
When planning hair transplantation, surgeons must
think and plan for the long term; even on young patients,
a mature hairline should be designed. The level of the hair­
line is an important component of facial aesthetics. It frames
the face and defines the proportions of the face. Ideally it is
about a third of the vertical length of the face.
There is no magic measurement from the eyebrows to
the hairline; the ideal distance varies depending on the cra­
niofacial proportions. The surgeon must artistically design
it for each patient individually to mimic a natural mature
hairline.
The surgeon marks the planned hairline preoperatively,
ensuring the patient understands that a hairline that is ap­
propriate for a 16 year old will not look natural at age 40 or
50 years and older. The hairline should also be slightly ir­
regular, with no rows or lines—in essence, a no-line hairline.
Single-hair grafts should be used at the hairline.
I prefer the strip technique for donor site harvesting.
Referred to as follicular unit transplantation (FUT), this
technique involves harvesting a narrow horizontal ellipse
of scalp from the donor area (occipital and temporal areas),
incising parallel to the hair follicles and closing primarily
without tension. This allows the donor site to heal very well
with minimally detectable scarring. This technique is de­
scribed in detail later in this chapter.
An alternative technique for harvesting the donor hair
is follicular unit extraction (FUE), in which a 0.8- to 1-mm
round punch blade is used to extract the follicles one by one,
manually or by robotics. A large area of donor scalp needs to
be shaved. This makes it extremely difficult to harvest a high
percentage of intact hair follicles, because it is difficult to go
exactly parallel to each hair root along its length and extract
them all intact when only the surface is visible. Incomplete
and transected grafts do not grow hair well.
Although there is a learning curve in both techniques, I
prefer (FUT) because of the broad visibility with background
lighting and magnification of each hair root from top to

419
Chapter 28 Hair Restoration
midline, up to 1.5 cm gradually tapering to 1 cm over the
temporal areas (Fig. 28.1).
The donor strip is sliced into 1- to 2-mm slivers (ellipse).
The grafts must be handled as atraumatically as possible.
The grafts are grasped with jeweler’s forceps by the fatty
tissue under the hair bulbs or by the tissue around them,
not by the hair bulb or dermal hair papilla itself (Fig. 28.2).
The grafts should initially be placed at about 5 mm from
each other, beginning at the front hairline and proceeding
posteriorly. As fibrinogen turns into fibrin (15 to 20 min­
utes later), the grafts become more secure in place. A sec­
ond pass is then made anteriorly between the previously
inserted grafts, setting the grafts about 2.5 mm apart. Pack­
ing them densely too soon often causes them to “pop out”;
reinserting them can be frustrating and time consuming.
Again as the fibrinogen turns into fibrin more passes are
made, placing more grafts between those already placed
until there is approximately 1 to 1.5 mm between grafts11
(Figs. 28.3 and 28.4).
Dressing consists of a nonadherent dressing, gauze, and
a 3-inch elastic bandage (Fig. 28.5), which are removed on
the second postoperative day. The donor site sutures (3–0
Prolene) are removed on the 10th postoperative day.
The hair begins to grow at 3 to 4 months and appears
aesthetically pleasing at around 6 months; the final result
bottom and the ability to keep the graft at least 95% intact,
hence increasing the viability and growth. Most patients
have limited donor hair, so it is essential not to waste any.
I place the patient supine and use intravenous seda­
tion with midazolam and fentanyl and occipital and supra­
orbital nerve blocks with 0.5% bupivacaine with epineph­
rine 1:200,000. For a small child, general anesthesia may be
better.
Once the area is well anesthetized, tumescence infiltra­
tion is used along the donor ellipse to limit bleeding and
assist in the graft dissection. I use the following solution:
•• 120 mL of normal saline
•• 20 mL of 2% plain lidocaine
•• 1 mL of epinephrine 1:1,000
•• 40 mg of triamcinolone
The same solution is used to infiltrate both the donor and
the recipient area. By adding triamcinolone, patients have
significantly less postoperative pain and edema.
The occipital-temporal area generally has the thickest,
most permanent hair. The donor site ellipse varies in dimen­
sions depending on the number of grafts planned and the
density of the donor site. If 2,000 or more grafts are planned,
generally the ellipse measures 20 to 30 cm by 1 cm at the
Fig. 28.1 (a) Making the ellipse no more than 1 cm wide ensures closure without tension and a safer and more predictable degree of mini­
mal scarring. (b,c) Harvesting with a no. 10 Bard Parker blade under ×3.5 loupe magnification, making the incision parallel to the hair shafts.
The plane of dissection is just deep to the hair follicles and superficial enough to avoid injury to significant vessels and sensory nerves. A
small amount of subcutaneous fatty tissue is often left over the galea or fascia. (d) A tension-free closure, such as with 3–0 simple running
Prolene, is important, because it allows for optimal donor site healing. Closing without undermining is preferred but not essential. (e) Donor
strip (ellipse) on the sterile silicone board, with background lighting to further increase visibility of the hair roots.
a
b
c
d
e

SECTION IV AESTHETIC SURGERY
420
Fig. 28.2 (a) Surgical assistants dissecting follicular unit grafts under ×10 magnification. (b) Slivers of scalp 1 to 2 mm thick, incised paral­
lel to the hair follicles, maintaining them intact from beginning to end. The harvested donor tissue must be kept chilled in normal saline
solution. (c) Follicular unit dissection from out of the slivers. Accuracy is imperative for graft survival and ultimate growth. (d) Magnified
view of one-, two-, and three-hair follicular unit grafts. Notice the integrity of each graft.
a
b
c
d
Fig. 28.3 (a) “Stick and place” technique on the scalp. (From Barrera A, Uebel C, eds. Hair Transplantation: The Art of Follicular Unit Micro­
grafting and Minigrafting. 2nd ed. New York: Thieme Medical Publishers; 2014.)
Surgeon
Assistant
Epidermis
Dermis
Subcutaneous
Galea
Periosteum
Bone
a
Continued

421
Chapter 28 Hair Restoration
assuming they have sufficient donor hair, the procedure can
be repeated several times. I prefer to wait a year between
sessions to assess the results and allow the scalp to recover
completely. A year later, or any time thereafter, the area can
be regrafted, filling in between the previous grafts to further
increase the hair density.
is evident at around 12 months (Fig. 28.6). This hair trans­
plantation procedure is always successful. By handling the
grafts gently and atraumatically, at least 90% of the grafts
should grow good, healthy hair.
However, the number of hair grafts done will affect the
result. For patients who want as much density as possible,
Fig. 28.3, cont’d (b) Placement of grafts. (From Barrera A, Uebel C, eds. Hair Transplantation: The Art of Follicular Unit Micrografting and
Minigrafting. 2nd ed. New York: Thieme Medical Publishers; 2014.)
Place grafts at 5 mm distance
Fibrin holds
existing graft
in place
Insert new
graft between
existing grafts
Fibrinogen
turns to fibrin
Wait 20–30
minutes
Repeat
after 20–30
minute wait
2.5 mm
Downward
pressure
Neighboring
grafts pop out
5 mm
2.5 mm
1–2 mm distance
between grafts
b

SECTION IV AESTHETIC SURGERY
422
Fig. 28.5 Dressing consists of a nonadherent dressing,
gauze, and a 3-inch elastic bandage.
Fig. 28.4 (a) A surgical assistant and the surgeon insert all the grafts using the “stick and place” technique. (b) A no. 22.5 blade is used
for the scalp. (c) The surgeon selects each site and the blade inclination that will allow the hair to grow at the most optimal angle (inclina­
tion), mimicking any residual thinning hair (if available). Using single-hair follicular units at the front hairline (approximately 1 cm) is key;
posterior to that point, one-, two-, three-, or four-haired follicular units may be used. (d) The graft is brought into position to slide it along
the blade shaft, into the recipient slit. (e) The graft is inserted using the blade as a shoehorn. (f) The graft is held in place with the tip of the
blade as the jeweler’s forceps are retracted to prevent it from pulling out.
c
d
e
f
a
b

423
Chapter 28 Hair Restoration
Fig. 28.6 A 63-year-old patient before (left) and after (right) having 8,109 follicular unit grafts inserted in three sessions. (These images
provided courtesy of A. Barrera.)
Continued

SECTION IV AESTHETIC SURGERY
424
A Hairline That Is Too Low or Too
Straight
A mature man’s hairline is typically not less than 8.0 to 8.5
cm from the midglabellar area, is symmetrical, and exhibits
bilateral temporal recession. The most common problems
associated with hairline design are blunted temporal angles
or hairlines placed too low on the forehead. Correction usu­
ally involves surgical excision, redesign, and elevation or re­
orientation of the hairline.
In most cases, the hairline can be redesigned in a single
surgical session, and hair grafts can be concomitantly incor­
porated into the surgical plan as part of a comprehensive
approach to correction.
Invariably, a pluggy hairline appearance also coexists,
and a simple linear excision of the hairline serves as an ex­
cellent method to directly eliminate the offending large plug
appearance. This excision should not be too wide. The fron­
tal scalp is typically more difficult to advance than assumed
during the preoperative assessment, and a tight closure at
the anterior hairline will lead to a wide scar. As stated previ­
ously with regard to plug correction, a second and possible
third session of plug reduction and grafting is often neces­
sary to obtain the optimal result (Fig. 28.7).
Avoiding Unfavorable Results
in Hair Restoration
This section details the unfavorable results that can occur
from hair transplantation, how to prevent them, and how
to correct them (Video 28.1).12–19 Most unfavorable results
are caused by poor planning and execution of the proce­
dure.
Fig. 28.6, cont’d A 63-year-old patient before (left) and after (right) having 8,109 follicular unit grafts inserted in three sessions. (These
images provided courtesy of A. Barrera.)
Summary Box
Common Complications Associated with
Hair Restoration
•• Blunted temporal angles
•• Hairline too low on forehead
•• Unnatural hairline
•• “Pluggy” hairline appearance
•• Scarring from scalp flaps
•• Scarring from alopecia of the donor site
•• Poor hair growth after restoration

425
Chapter 28 Hair Restoration
Fig. 28.7 (a,d,g) This patient had a previous hair transplantation that resulted in an anterior hairline that was too low with grafts that were
too large, resulting in an unnatural appearance and a pluggy look. (b) Immediately after excision the area and cephalic advancement of the
hairline. (c,f,j) One year postoperatively. (e,i) Immediately postoperatively. (h) Marking of the area to be excised. (These images provided
courtesy of A. Barrera.)
a
b
c
d
e
f
g
h
i
j

SECTION IV AESTHETIC SURGERY
426
The hair recycled from the removed plugs and addi­
tional hair concomitantly harvested from the occipital re­
gion can be densely transplanted anterior, posterior, and
most importantly adjacent to the plug reduction sites. In
most cases, the plug reduction sites are not sutured closed.
The final appearance of the healed scar after plug reduc­
tion is essentially indistinguishable whether the site was
sutured or left to heal by secondary intention; however, de­
pending on the size of the punch removal, suture closure
may be appropriate.
Although each patient’s distribution of plugs is unique,
the final surgical plan is always to create a zone of natural-
appearing hair at the leading edges, anteriorly and poste­
riorly, and to take advantage of the centrally located plugs
of higher hair density. In some instances, the patient may
prefer to soften all plugs previously grafted or have them
removed completely. Although a single session will provide
significant improvement, two and sometimes three sessions
of plug reduction may be necessary to adequately convert
the unnatural hair transplant into a natural result. In gen­
eral, a second session is performed 6 to 8 months after the
first procedure. Occasionally a fast-track approach can be
used, with additional plug reduction and grafting performed
within the first 2 months after the initial corrective proce­
dure (Figs. 28.8–28.10).
Oversized Grafts: Clumpy or Pluggy
Appearance
The essential problem with an unnatural-looking hair graft
is the size of the graft; if it is too large, it results in a pluggy
appearance. Thus the most direct approach to this problem
is to reduce the size of the graft. Grafting alone anterior
to the pluggy hairline will not improve the appearance be­
cause it fails to address the basic dense plug problem.
Correction involves using a punch that is approximately
0.5 to 0.75 mm smaller than the estimated size of the un­
sightly plug. As an example, if 4-mm plugs are being re­
duced, a 3.25- to 3.5-mm punch would typically be chosen
for plug reduction and subsequent recycling. This removes
a substantial amount of the plug hairs and leaves behind a
few hairs that will look soft and natural.
The actual technique of plug removal is very straight­
forward. The hair in the plugs to be reduced are trimmed to
approximately 3 mm, and the punch removal is performed
eccentrically to leave a crescent or sliver of the remaining
original plug, approximately three to four hairs. The punch
excision should be deep enough to include 1 to 2 mm of sub­
papillary fat. These removed plugs are then recycled into fol­
licular unit grafts. The yield of salvaged follicular unit grafts
is approximately 50 to 70%.
Fig. 28.8 Plug reduction and recycling. (a–d) A 2.5-mm punch is used to remove most of the hairs from the previous hair plugs, recycling
the hair from the plugs as new grafts. (e,f) Additional hair grafts can be used to further camouflage the deformity. (These images provided
courtesy of A. Barrera.)
a
b
c
d
e
f

427
Chapter 28 Hair Restoration
Fig. 28.9 Before (left) and after (right) plug reduction and recycling. (These images provided courtesy of A. Barrera.)
Fig. 28.10 Plug removal. This patient did not
have good donor hair and preferred to just elimi­
nate as best as possible the unnatural plugged
look. This required the use of 5–0 nylon sutures.
(These images provided courtesy of A. Barrera.)

SECTION IV AESTHETIC SURGERY
428
which can be especially large if necrosis occurs (Fig. 28.12).
This alopecia can be prevented by harvesting long and
narrow donor strips as opposed to short and wide strips. The
length should be 15 to 30 cm depending on the number of
grafts. The width should be 1 cm, because at this width the
donor site can typically be closed without any undermin­
ing. Occasionally, with sufficient laxity (elasticity), a wider
strip may be acceptable, but using 1 cm as a guide is the
safest option.
In secondary or tertiary hair transplantation, when scar­
ring is present and there is less elasticity in the donor area,
Scarring from Scalp Flaps
Scarring is uncommon from modern techniques and is
mostly seen after temporo-parietal-occipital (TPO) flaps
are used (Fig. 28.11).
Scarring Alopecia of the Donor Site
Scarring alopecia is primarily caused by excessively tight
closures in the donor site areas (occipital and temporal
areas). This results in varying degrees of widened scars,
Fig. 28.11 (a) Example of an unsightly scar from a temporo-parieto-occipital flap. (b–d) The scarring was corrected by two sessions of fol­
licular unit grafts into and in front of the scar. (These images provided courtesy of A. Barrera.)
a
b
c
d
e
Fig. 28.12 Scarring alopecia of the donor site caused by
excessive tension at the time of donor site closure.

429
Chapter 28 Hair Restoration
The most common cause of poor hair growth is inaccu­
rate graft dissection—that is, the follicular unit grafts need
to be carefully dissected and need to be intact from top to
bottom. Additionally, they need to be handled gently and
atraumatically and kept wet in chilled normal saline. Grafts
should be transplanted as soon as possible; ideally all grafts
should be used within 4 to 5 hours.
Excessively dense graft packing (more than 50 per
square centimeter in one session) decreases the ultimate
percentage of follicular unit graft hair growth. Grafts should
have 1 to 1.5 mm of space between them initially; after a
year more density can safely be added between previous
grafts.
Conclusion
When the surgeon is faced with correcting unfavorable
results in hair transplantation, creativity, long-range surgi­
cal planning, and a variety of techniques can be used. The
techniques chosen for an individual patient depend on the
presenting problem. Fortunately, most patients with un­
sightly hair transplants can expect cosmetically significant
improvements if correction is planned and carried out ap­
propriately.
strips may need to be narrower than 1 cm. In addition, the
undermining may be too tight to close the donor area. The
best solution is to perform extensive undermining in the
caudal direction, extending well beyond the mastoid, to the
midneck level, to mobilize a skin flap cephalically and allow
for a tension-free closure (as when doing a facelift).
A donor area with alopecia can be reconstructed by hair
grafting excised with extensive undermining and closed. It
must be closed without tension. The scalp is very inelastic,
so minimal advancement is accomplished by undermining
the cephalic edge. Extensive caudal undermining is neces­
sary, all the way down to below the mastoid area down into
the neck. Advancing and recruiting skin from the upper neck
is necessary for successful restoration (Fig. 28.13).
Poor Hair Growth After Hair
Transplantation
Naturally the type and quality of hair varies by patient; the
texture, color, hair shaft diameter, and curl (genetically de­
termined) all affect the perception of thickness. Similarly,
the number of grafts performed and the percentage of graft
survival are important.
Fig. 28.13 Correction of scarring alopecia from a previous hair transplantation in which excessive tension at the closure resulted in necro­
sis, leading to the alopecia. Extensive undermining was needed. (a) Marking the area to be excised. (b) The tips of the surgeon’s fingers
demonstrate the extent of the subcutaneous undermining needed to advance the edge of scalp and close without tension. (c) Closure with
simple running 3–0 Prolene without tension. This same technique can be used at the time of the donor site closure when there is too much
(unplanned) tension to prevent ischemia and necrosis and resultant scarring alopecia.
a
b
c

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11. Barrera A, Uebel C, eds. Hair Transplantation: The Art of
Follicular Unit Micrografting and Minigrafting. 2nd ed.
New York, NY: Thieme Medical Publishers Inc; 2014
12. Vogel JE. Correction of cosmetic problems secondary to
hair transplantation. In: Unger W, Shapiro R, Unger R, Un­
ger, eds. Hair Transplantation, 5th ed. London: Informa
Healthcare; 2010:291–296
13. Vogel JE. Hair restoration complications: an approach to
the unnatural-appearing hair transplant. Facial Plast Surg
2008;24(4):453–461
14. Vogel JE. Correcting problems in hair restoration surgery:
an update. Facial Plast Surg Clin North Am 2004;12(2):
263–278
15. Vogel JE. Correction of the cornrow hair transplant and
other common problems in surgical hair restoration. Plast
Reconstr Surg 2000;105(4):1528–1536, discussion 1537–
1541
16. Brandy DA. Corrective hair restoration techniques for the
aesthetic problems of temperoparietal flaps. Dermatol
Surg 2003;29(3):230–234, discussion 234
17. Bernstein RM, Rassman WR, Rashid N, Shiell RC. The art
of repair in surgical hair restoration—part II: the tactics of
repair. Dermatol Surg 2002;28(10):873–893
18. Epstein JS. Revision surgical hair restoration: repair of un­
desirable results. Plast Reconstr Surg 1999;104(1):222–
232, discussion 233–236
19. Lucas MWG. Partial retransplantation. A new approach in
hair transplantation. J Dermatol Surg Oncol 1994;20(8):
511–514
References
1. Orentreich N. Autografts in alopecias and other selected
dermatological conditions. Ann N Y Acad Sci 1959;83:
463–479
2. Barrera A. Micrograft and minigraft megasession hair
transplantation results after a single session. Plast Reconstr
Surg 1997;100(6):1524–1530
3. Barrera A. Refinements in Hair Transplantation: Micro and
Minigraft Megasession. Perspect Plast Surg 1998;11(1):
53–70
4. Barrera A, ed. Hair Transplantation: The Art of Micro­
grafting and Minigrafting. 1st ed. St Louis, MO: Quality
Medical Publishing; 2002
5. Barrera A. Hair grafting tips and techniques. Perspect
Plast Surg 2001;15(2):147–158
6. Barrera A. Advances in hair restorstion. Aesth Surg J 2003;
23(4):259–264
7. Barrera A. Clinical decision-making in hair transplanta­
tion. In: Nahai F, ed. The Art of Aesthetic Surgery: Prin­
ciples and Techniques. Vol 2. 2nd ed. St Louis, MO: Quality
Medical Publishing; 2005:1691–1724
8. Barrera A. Applied anatomy in hair transplantation. In:
Nahai F, ed. The Art of Aesthetic Surgery: Principles and
Techniques. Vol 2. 2nd ed. St Louis, MO: Quality Medical
Publishing; 2005:1679–1689
9. Barrera A. Clinical decision making in hair transplanta­
tion. In: Nahai F, ed. The Art of Aesthetic Surgery: Prin­
ciples and Techniques. Vol 1. 2nd ed. St Louis, MO: Quality
Medical Publishing; 2011:604–633
10. Vogel JE, Jimenez F, Cole J, et al. Hair restoration surgery:
the state of the art. Aesthet Surg J 2013;33(1):128–151
Discussion by James E. Vogel
For plastic surgeons who routinely perform a variety of
cosmetic and reconstructive procedures, hair restora­
tion surgery (HRS) should be one of the most favorable.
As with all surgical procedures, the patient ultimately
needs to obtain the result they expect. Given the mod­
ern advances in HRS, the result discussed with the pa­
tient during the consultation should be very reproduc­
ible and predictable. Thus as in all cosmetic procedures,
it is essential to select patients carefully and establish
a realistic hair restoration plan that can be achieved
in the short term and maintained over the life of the
patient. The chapter described the techniques for re­
pairing poorly performed or outdated transplants and
the modern techniques for performing HRS to avoid an
unfavorable outcome. A few general comments are ger­
mane.
The first step in avoiding an unfavorable result
in HRS does not take place in the operating room but
rather in the office: having a frank and realistic discus­
sion with the patient during the consultation. It is es­
sential for all patients with hair loss, and particularly
young patients in their early 20s, to fully understand
that progressive hair loss is inevitable and guaranteed
unless treated medically. Even with treatment, under
ideal circumstances hair loss is just slowed down. Young
patients need to understand that hair loss and HRS is
at the most basic level a matter of supply and demand.
Put another way, over the patient’s life there is a guar­
anteed progressive increase in baldness (demand), but
during this same time there is a severe limit (supply) on
the amount of donor hair available for hair transplanta­
tion. This seemingly obvious and simplistic correlation
is not only difficult for some patients to accept; even
some surgeons ignore it. It is not uncommon to see a
patient 20 years after a transplant who had a great result
initially but, because of progressive hair loss over the
years, has an isolated patch of hair grafts in the midst of
baldness that looks very unnatural and unfavorable. In
these cases the result would have been much improved
if the initial surgical planning had considered the nature

431
Chapter 28 Hair Restoration
of progressive baldness and the initial grafts placed with
the consequences of this anticipated hair loss in mind
(Fig. 28D.1).
Thus managing expectations with regard to the re­
alities of progressive hair loss cannot be overemphasized
to avoid an unfavorable result in HRS. The scope of this
review limits a detailed discussion on the medical treat­
ment of hair loss, a topic that has been reviewed else­
where.1,2 Finasteride is the most potent and only FDA-
approved oral medication to stop or significantly reduce
the rate of ongoing hair loss. The potential side effects,
especially the sexual consequences of this medication,
are a significant deterrent for many patients. Promising
treatments for reducing the ongoing nature of hair loss
over time include plasma-rich platelets, genetic manipu­
lation, and other regenerative medical treatments.
Another important aspect of the patient consulta­
tion is the understanding that the quality of the trans­
plant result will only be as robust as the quality of the
donor hair itself. A discussion and analysis of the donor
hair texture, diameter, follicular density, wave, and color
contrast with regard to that of the scalp, as well as the
quantity of usable hair, are all features to be considered.
In addition, the presence of a permanent scar from do­
nor strip harvest versus the newer, minimally invasive
follicular unit extraction (FUE) technique that leaves a
much more discrete scarring footprint needs to be dis­
cussed. The artistry of the hairline design needs to be in
keeping with the patient’s facial proportions the degree
of temporal recession to maintain a balanced frame of
hair for the face.
These brief comments illustrate the deceptively
simplistic nature of HRS. Although most patients are
very Internet savvy, online forums and advertisements
for hair restoration can produce much misinformation
and hype. Given the favorable economics of HRS and
the lack of any one surgical board claiming HRS in its
domain, myriad physicians with varying backgrounds
have adopted this specialty into their practice or as their
main professional focus. Fundamentally most unfavor­
able results from HRS come from offices where training
and attention to sound principles and fundamentals are
minimized. Preoperative consultations are often com­
pleted by personnel who are at best marginally trained
and at worst primarily driven by commission. An unfa­
vorable surgical result is often predictable because more
is promised than can be delivered.
Conclusion
When patients present with problems caused by HRS,
they commonly lament that their entire lifestyle re­
volves around the concealment of an unnatural hair­
line or otherwise strange hair appearance. Patients
who bear this burden of surgical misadventure typi­
cally wear hats or even hair pieces. They often resort
to using camouflage spray or powders to conceal scars,
pluggy-appearing grafts, or open areas of scalp. These
unfortunate patients also carry the emotional burden
of anger and distrust toward hair restoration surgeons.
When meeting with a patient who has had an un­
favorable result from HRS, the first goal is to establish
a relationship of trust and understanding. It is essential
to start where all consultation should begin—by estab­
lishing realistic goals and expectations. The techniques
for repair based on the problems of HRS have been well
described.3–7 Fortunately many of these patients’ unfa­
vorable surgical results can be corrected to the degree
that their lives no longer are focused on embarrassment
and concealment of their hair.
Fig. 28D.1 This 43-year-old patient underwent hair transplants in the temporal and crown areas 21 years prior. At that time, these
were the only areas of baldness that needed treatment. Progressive hair loss over time and poor surgical planning have resulted
in the loss of all nongrafted hair and a unfavorable and strange scalp hair appearance because of the persistent hair transplants.

SECTION IV AESTHETIC SURGERY
432
References
1. Unger W, Shapiro R. Chapter title. In: Shapiro R, Unger
R, Unger M, Unger W, eds. Hair Transplantation. 5th ed.
London: Informa Healthcare; 2010
2. Vogel JE, Jimenez F, Cole J, et al. Hair restoration surgery:
the state of the art. Aesthet Surg J 2013;33(1):128–151
3. Vogel JE. Correction of cosmetic problems secondary to
hair transplantation. In: Shapiro R, Unger R, Unger M,
Unger W, eds. Hair Transplantation, 5th ed. London: In­
forma Healthcare; 2011; 291–296
4. Vogel JE. Hair restoration complications: an approach
to the unnatural-appearing hair transplant. Facial Plast
Surg 2008;24(4):453–461
5. Epstein JS. Revision surgical hair restoration: repair of
undesirable results. Plast Reconstr Surg 1999;104(1):
222–232, discussion 233–236
6. Bernstein RM, Rassman WR, Rashid N, Shiell RC. The art
of repair in surgical hair restoration—part II: the tactics
of repair. Dermatol Surg 2002;28(10):873–893
7. Brandy DA. Corrective hair restoration techniques for
the aesthetic problems of temperoparietal flaps. Der­
matol Surg 2003;29(3):230–234, discussion 234

433
CHAPTER
29

Liposuction for Body Contouring
Simeon Wall Jr.
Liposuction as a means of body contouring continues to
grow in popularity and technologic sophistication. Sur­
geons performing liposuction have a better understanding
of fat anatomy and fluid management, along with better
instrumentation and technique to provide a more pre­
dictable, smoother result, with less disruption to vascular
supply. Despite more than 35 years of progress, including
the ability to maintain patient safety in larger-volume li­
posuction procedures, no techniques or technologies to
date have been able to break the “dose-response curve”
seen in liposuction in which the dose is the increasing
amount of fat removed from an area and the response is
the tendency toward skin irregularities or contour defor­
mities1-6 (Fig. 29.1).
Most well-trained and experienced surgeons are able
to work well within the boundaries that this dose-response
curve dictates; however, sometimes the cosmetic results
achieved fall short of patient or surgeon expectations, re­
quiring secondary or even multiple procedures, none of
which are capable of matching or exceeding the result that
could have been achieved in an optimal primary procedure.
Many technologies have been advocated that purport
to eliminate the uneven, irregular, wavy, or otherwise un­
smooth appearance of the treated area seen as “too much
fat was removed,” even though this amount of fat and skin-
pinch thickness was the desired amount by the patient and
surgeon. Most of these proposed technologies use thermal
energy, namely ultrasonic, laser, or radiofrequency.7 The
Fig. 29.1 Traditional dose-response curve in liposuction. (Reproduced from Aly
A, Nahas F. The Art of Body Contouring: A Comprehensive Approach. New York:
Thieme; 2017.)
Skin surface irregularity
Fat removal
TRADITIONAL “DOSE-RESPONSE” CURVE IN LIPOSUCTION
Contour deformity
Standard liposuction

SECTION IV AESTHETIC SURGERY
434
and are more extensive in nature than a “revision” proce­
dure. Another distinction between revision and secondary
liposuction is temporal. Secondary procedures are usually
not done sooner than a year after the initial procedure,
even if performed by the same surgeon.
Reasons for a Repeat Procedure
Repeat procedures are done for a variety of reasons, includ­
ing unsatisfactory results or the need for further improve­
ment. Many times, a liposuction patient simply seeks fur­
ther reduction to an area that was already treated, either
because of weight gain or because they were dissatisfied
with the amount or distribution of the liposuction. A typi­
cal scenario is a patient who underwent “spot” liposuction,
usually of the upper or lower abdomen only.9 Because the
entire abdominal or truncal unit was not contoured com­
prehensively, the patient is dissatisfied with the remaining
area(s) of adiposity and therefore presents for a more com­
prehensive procedure secondarily (Figs. 29.2 and 29.3).
most recent addition has been water jet–assisted liposuc­
tion.8 Not only have these technologies so far failed to re­
duce complications from liposuction, they have added an
unintended, second dose-response curve of creating contour
deformities based on the thermal load imparted to the tis­
sues. Among other factors, such as the power, energy type,
and how it is applied, the treatment time itself becomes the
main contributor to creating contour deformities.
Revision Liposuction Versus Secondary
Liposuction
Revision liposuction and secondary liposuction procedures
differ in a few important ways. Revision liposuction refers
to a repeat operation usually done by the same surgeon to
improve on the first result or to fix something left undone
or not optimally done during the first procedure. Secondary
liposuction procedures are often, but not always, done by a
different surgeon than the one who did the first procedure
b
a
Fig. 29.2 Prior liposuction of the circumferential trunk. (Reproduced from Aly A, Nahas
F. The Art of Body Contouring: A Comprehensive Approach. New York: Thieme; 2017.)
b
a
Fig. 29.3 Prior liposuction with abdominal etching. (Reproduced from Aly A, Nahas F. The
Art of Body Contouring: A Comprehensive Approach. New York: Thieme; 2017.)

435
Chapter 29 Liposuction for Body Contouring
Difficulties Inherent in Repeat (Revision
or Secondary) Liposuction
The feasibility of liposuction itself is based on the prem­
ise that there is a relatively low-resistance, “harvestable”
subcutaneous adipose tissue layer between the higher-re­
sistance planes of the overlying superficial fat and dermis
above, and the underlying musculoskeletal structures be­
low. This differential in resistance between these planes is
what allows a cannula to easily pass through and stay in the
target fat layer. Put simply, liposuction works because fat is
less dense and easier to traverse, disrupt, and remove than
the tissues that surround it.
Once a liposuction procedure has been performed, this
treatable tissue layer is scarred, adherent, or even obliter­
ated, making navigation and fat extraction more difficult and
potentially more dangerous even for experienced hands. For
example, in a primary liposuction procedure, when signif­
icant resistance is encountered at the cannula tip, this 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 left from an earlier procedure.
This loss of differential resistance seen in repeat liposuc­
tion procedures is the main reason these procedures so com­
monly result in problems, such as skin “end hits,” because of
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 perforation or
damage to other deeper structures.
Many competent and experienced body contouring sur­
geons avoid performing repeat liposuction procedures al­
together, perhaps wisely. Plastic surgeons typically strive
for beautiful results that “do no harm” to the patient, but
when considering repeat liposuction, they are faced with
two nearly universal truths that distinguish these proce­
dures from most other revision plastic surgery procedures:
1. The result will never be as good as the result that could
have been obtained from an optimally performed pri­
mary liposuction procedure.
2. The risk of significant or serious injury is significantly
higher and outside the usual scope of a primary lipo­
suction procedure.
Despite these and other difficulties faced in repeat lipo­
suction procedures, revision and secondary body contour­
ing with liposuction can be very gratifying and successful
for patients and their surgeons given the appropriate ap­
proach, care, techniques, and expectations.
Repeat procedures are also associated with complica­
tions different from those commonly seen after primary li­
posuction procedures. Repeat liposuction can be compared
to operating in concrete (Box 29.1). In these procedures, the
The most common presentation is a patient who is dis­
satisfied and seeks a secondary procedure because of one or
many contour deformities that resulted from an initial lipo­
suction procedure. These contour deformities can be rep­
resented by overall skin waviness, hills and valleys, strange
contours, or outright divots and depressions. In association
with these contour deformities, many patients also have skin
damage in the form of hemosiderin deposition, pigmentary
changes, and scarring from thermal or avulsive liposuction
methods. Internal scarring is represented by an unnatural
static and/or dynamic appearance of the area, with tether­
ing, tightness, and worsening appearance with positional
changes or skin tension. External scarring is usually only
seen with thermal methods of liposuction where there were
entry site burns, or even internal burns so severe that the
overlying skin was burned and scarred.
Avoiding Unfavorable
Results and Complications in
Liposuction for Body Contouring
Summary Box
Complications and Unfavorable Results Asso-
ciated with Liposuction for Body Contouring
Complications
•• Edema
•• Ecchymosis
•• Seroma
•• Hematoma
•• Undercorrection
•• Overcorrection
•• Skin laxity
•• Fat embolism
•• Deep venous thrombosis
•• Hyperpigmentation
•• Irregular scar
•• Skin necrosis
Unfavorable Results
•• Skin waviness
•• Hills and valleys
•• Strange contours
•• Divots and depressions
•• Skin damage (e.g., hemosiderin deposition,
pigmentary changes, scarring)
•• Internal scarring resulting in skin tension
•• External scarring (i.e., thermal injuries such as
entry site burns)

SECTION IV AESTHETIC SURGERY
436
connective network, and dermis. In repeat cases, in which
fibrotic areas have been created from previous procedures,
the longer treatment times required lead to more thermal
damage, and the process starts all over, ending in yet more
contour deformities, when the explicit goal was fewer (Box
29.2).
For these reasons I have abandoned internal thermal
technologies and use only fat-preserving techniques and
technologies for both primary and repeat liposuction cases.
In addition, fat grafting and fat equalization is an integral
part of all of my contouring cases, necessitating a healthy
recipient bed and healthy fat for maximum survival and re­
generative potential.
Underextraction
Many patients request repeat procedures for further fat re­
duction either because of underextraction during the ini­
tial procedure or because of reaccumulation of adiposity
from weight gain. In these patients, it is easy to think that
simply removing additional fat from the target areas is all
that is required, sometimes referred to as spot liposuction.
In practice, however, even a straightforward repeat lipo­
suction patient can be deceptively difficult to retreat with
liposuction given the scar tissue and fibrosis encountered
in nearly all of these cases. At best, these patients exhibit
a denser, more fibrous area to reliposuction, making it
more difficult to evenly extract more fat. More commonly,
these patients have fibrotic deep fat compartments mostly
devoid of suctionable fat, with only a relatively superficial
zone of fat to be navigated, having a variable amount of fi­
brosis and tethering to the overlying dermis and underlying
fascia. For this reason, no repeat liposuction patient should
be approached as a simple case.
SAFELipo
An ideal body contouring procedure will seek to be com­
prehensive in nature, with applicability in most or all
differential in resistance between the intended plane and
the unintended planes is narrowed, and sometimes elimi­
nated. As outlined previously, this difficulty in navigating
through scarred, adherent subcutaneous tissues increases
the risk of damage to skin and to deeper structures, poten­
tially creating a life-threatening complication. In addition,
these procedures also take more time, another factor that
increases overall risk. Obviously, in such an environment, fat
extraction is more challenging, and smoothness and unifor­
mity are more difficult to achieve.
Cannula “misadventures,” injury to skin and body struc­
ture, vascular disruption and major bleeding, nerve damage,
musculoskeletal injury, and internal organ perforation have
all been reported. Although these injuries are possible with
any liposuction procedure, they are more likely to occur in
repeat liposuction, where there is a high-resistance, scarred,
and confluent tissue bed that requires more cannula passes
and greater force to adequately perform the procedure.
In traditional liposuction, the dose-response curve refers
to the propensity toward contour deformities with greater
amounts of fat removal1 (see Fig. 29.1). This has been an
issue in liposuction since its advent. Thermal methods of
liposuction (laser, ultrasonic, radiofrequency, and others)
were developed as an attempt to thwart this phenomenon
but have failed in this regard and instead initiate a damage–
response slope that can ultimately lead to contour deformi­
ties related to thermal injury.
Thermal Injuries
The thermal injury imparted to the tissues varies with
the type and power of the device and how much energy is
used, setting up a second “dose-response” curve of simply
using the device (the treatment time) that contributes to
the creation of a contour deformity by way of the thermal
load imparted to the treated areas. In addition, the thermal
injury caused by these devices is not restricted to targeted
fat, but may affect nontargeted fat as well as the supporting
stromal network of tissues: blood vessels, nerves, stromal
Box 29.1
•• Like operating in concrete—narrower differential
in resistance between subcutaneous plane and
unintended planes
•• Takes much more time than primary
liposuction—more difficult to thoroughly extract
fat
•• High risk of damaging skin or deeper structures
•• More bleeding
•• Greater tendency for contour deformities—more
difficult to achieve smoothness and uniformity
•• Contour deformities already present
•• Common need to fat graft
Difficulties Inherent with
Revision Liposuction
Box 29.2
Laser/ultrasound-assisted lipectomy/
radiofrequency
↓
Fibrotic area from previous liposuction
↓
Requires longer treatment times
↓
More thermal damage
↓
More fibrosis and scar formation
↓
More contour deformities
Progression of Deformities
with Repeat Liposuction

437
Chapter 29 Liposuction for Body Contouring
igated, and the only time to be wary of these zones is when
performing fat aspiration. Thus SAFELipo allows for much
more comprehensive treatment without creating problems.
Indications and Contraindications
Good candidates for repeat liposuction, in general, have
a body mass index of 30 or below, good diet and exercise
habits, and reasonable expectations regarding outcomes.
For patients who request a secondary liposuction proce­
dure to address reaccumulation of fat, these factors be­
come even more important. Patients who were not adher­
ent to postoperative care after their first procedure or who
quickly gained weight after a previous body contouring
procedure might be considered suboptimal candidates for
a repeat procedure.
Because a patient requesting a repeat procedure has al­
ready had a negative experience, carefully explaining what
to expect from a repeat procedure is important. Obviously,
if the surgeon is not able to completely fix the areas that
are not aesthetically pleasing, this should be explained to
the patient before he or she undergoes a second or third
procedure. In addition, it is important to ensure the patient
understands the limitations inherent in repeat procedures
and the likelihood that the result will not be as optimal as
might have been obtained with a better-performed first pro­
cedure. This is particularly true if the initial procedure in­
volved the use of thermal liposuction because of the exces­
sive amounts of scarring and fibrosis seen in these cases.
In some cases, when patients have undergone one or more
procedures using internal laser-assisted liposuction, no sig­
nificant improvement can be gained; these patients should
be advised not to undergo another procedure. If the patient’s
expectations are not likely to be met by any available tech­
niques, or if the amount of surgery required becomes exces­
sive to gain only a modest improvement, these situations are
good indicators that any operative plan will fail to ultimately
please the patient.
Similar to revision rhinoplasty, I wait at least 1 year be­
fore performing a secondary procedure. That time is needed
to ensure all swelling has resolved and that the tissues are as
pliable, soft, and elastic as they can be. In addition, given the
typical need to add, redistribute, and subtract from an area,
a stable, unchanging tissue bed is required before planning
reoperation. Most patients with moderate to severe contour
deformities need 18 months to 2 years for the area to “settle”
before attempting a significant repeat liposuction operation;
the longer the time interval between the original surgery
and the repeat operation, the higher the chances for long-
term improvement and success.
Patient Evaluation
Some patients are left with so little subcutaneous fat after
their initial procedure (and previous repeat procedures)
that it is impossible to perform another procedure. Even
with the SAFELipo process, there needs to be some amount
of residual fat to create a smooth and natural-appearing
situations. For most patients, this requires not just the re­
moval of fat tissue, but also fat grafting and fat redistribu­
tion. The SAFELipo technique (Separation, Aspiration, Fat
Equalization) was developed specifically for repeat liposuc­
tion cases, in which fat grafting is often required, and the
previously mentioned issues (scarring, existing contour
irregularities, etc.) often exist (Box 29.3). It is a multistep
approach of comprehensive fat management that not only
reduces fat through liposuction, but can augment and re­
distribute fat. There are other techniques used in repeat
procedures, but this chapter focuses on SAFELipo and its
application in repeat procedures, the technique used by this
author exclusively for both primary and secondary liposuc­
tion on all parts of the body and face. There will inevitably
be a significant amount of overlap in how these techniques
are used in primary versus secondary procedures, but this
chapter specifically addresses how SAFELipo is used in re­
peat procedures.
SAFELipo is different from other forms of advanced li­
posuction techniques in a few important ways that become
apparent as the individual steps are explored. Of note, SAFE­
Lipo incorporates a process approach to fat contouring, with
specific, repeatable delineated steps that standardize and
simplify surgeries. A similar process approach has been ap­
plied to other cosmetic surgical procedures (e.g., breast aug­
mentation) and has been shown beneficial. Furthermore, in
contrast to thermal and avulsive forms of liposuction (stan­
dard suction-assisted liposuction), SAFELipo greatly reduces
the risk of disrupting blood vessels and support structures,
while at the same time maximizing the potential for an aes­
thetically pleasing outcome.
Another differentiator with SAFELipo is that avoiding the
zones of adherence is unnecessary, because a contour defor­
mity is not created using fat separation and fat equalization.
Rather, during the fat separation stage, the zones can be nav­
Box 29.3
1. Separate fat from its attachments without dam­
aging the supporting structures by nonthermal
mechanical emulsification and liquification of
the fat.
2. Aspirate the separated fat preferentially
without causing suction avulsion injury to the
supporting structures, a bloodless process.
3. Equalize the fat in the remaining bed, leaving a
smooth layer of local fat grafts to prevent scar
and contour deformities.
Additional step for repeat SAFELipo:
4. Perform fat shifting, fat grafting, and release
processes to improve the residual defects and
volume deficiencies.
SAFELipo Process

SECTION IV AESTHETIC SURGERY
438
until discharge from recovery to prevent hypothermia.
Hypothermia, or a core temperature drop to below 36°C
at any time during surgery, has been shown to increase
bleeding, postoperative nausea and vomiting, and wound
infection. Anecdotally, I have also seen more difficulty
in postoperative pain management in patients who be­
came hypothermic during surgery. Forced air units, heat-
retaining stockinettes, circulating hot water mattresses,
intravenous fluid warmers, warm infiltration fluids, warm
prep solution, and a warm (74°F) room during the prep
are used for significant primary or repeat body contouring
procedures.
contour. Cases that rely on pure fat grafting to create a
smooth appearance are very difficult to execute and should
be approached with extreme caution, if at all.
Preoperative Planning and Preparation
As with primary liposuction, intermittent or sequential
compression devices on the lower extremities are applied
before induction of anesthesia and used throughout the
surgery and for several days postoperatively, or until the
patient is ambulating normally. Passive and active patient
warming maneuvers are used from an hour before surgery
b
a
d
c
Fig. 29.4 Preventing contour deformities: markings to avoid the midbuttocks. (Reproduced from Aly A, Nahas F. The Art of Body Contour­
ing: A Comprehensive Approach. New York: Thieme; 2017.)

439
Chapter 29 Liposuction for Body Contouring
reduced, redistributed, or augmented—usually represented
by concentric black rings for reduction and cross-hatched
markings in red for areas of redistribution or augmen­
tation. It is also useful to make orientation marks on the
treated areas to aid in symmetry while treating in various
body positions (Fig. 29.4).
Patient Positioning
The positioning for repeat liposuction does not inherently
differ from that of primary liposuction. That said, I avoid
the prone position whenever possible. Adequate padding
of all pressure points including at any positional changes
is important, as is careful sterile prepping and draping. I
prefer to do a single whole body prep with the sterile field
extending from the neck down to the end of the bed so the
patient can be moved into different positions during the
procedure with no further prepping needed (Fig. 29.5).
Revision liposuction using the SAFELipo process is typi­
cally performed in three positions—supine and both the left
and right lateral decubitus positions. Although evidence is
currently lacking, turning the patient multiple times in­
cluding into the lateral decubitus positions may reduce the
risk of deep venous thrombosis and pulmonary embolism,
because venous pressure is decreased on the elevated side,
decreasing pooling and improving pelvic venous drainage.
Performing liposuction from these three positions can
help prevent contour deformities, including “shark bites” in
the midbuttocks and other common stigmata of liposuction
Surgical Technique
The application of a process approach to liposuction,
whether primary or repeat, simplifies the technique on
many levels and allows for a much more complete treat­
ment of the targeted areas, whether they require removal,
redistribution, or addition of fat. As opposed to other meth­
ods of liposuction, any or all excess fat can be removed
smoothly from the targeted areas without fear of causing
skin injury or contour deformity.
Anesthesia
Repeat liposuction procedures are typically performed with
general anesthesia. Except for minor touch-up procedures,
repeat liposuction procedures do not lend themselves to
being performed with local, tumescent, or conscious se­
dation anesthesia for the same reasons these methods are
avoided for significant primary liposuction procedures.
In addition, the dense scar tissue and unnavigable tissue
planes that are commonly encountered limit the surgeon’s
ability to easily, completely, and painlessly pass infiltration,
separation, or liposuction instruments.
Markings
Repeat liposuction procedures usually require distinct top­
ographic markings to clearly delineate the hills and valleys.
It is wise to have a relatively detailed map of the areas to be
b
a
d
c
Fig. 29.5 Single whole body prep. (Reproduced from Aly A, Nahas F. The Art of Body Contouring: A Comprehensive Approach. New York:
Thieme; 2017.)

SECTION IV AESTHETIC SURGERY
440
The normal standing position is most closely mimicked
in the lateral decubitus position, allowing the contour to
match the same position in which the patient evaluates
herself or himself at home in front of a mirror. In addi­
tion, the lateral decubitus position allows for thorough
(Fig. 29.6). Some surgeons perform the procedure with the
patient mostly in the supine position. Contouring in this
nonanatomic position of the lower extremities can lead to
overcorrection or undercorrection, commonly seen as con­
tour deformities of the midbuttock areas.
Fig. 29.6 Shark-bite contouring deformities at the midbuttock. (Reproduced from Aly A, Nahas F. The Art of Body Contouring: A Compre­
hensive Approach. New York: Thieme; 2017.)

441
Chapter 29 Liposuction for Body Contouring
through tissue, create low pressure zones that allow fixed
fat globules to dislodge and detach from their surround­
ing attachments, essentially separating these droplets of
fat from each other and from their supporting networks of
blood vessels and stromal tissues. This mechanical emul­
sification, or separation process, changes the normally
solid fat architecture into a more liquid environment in the
targeted areas, in effect creating a treatment zone of low-
resistance emulsified fat and higher-resistance untreated
areas above (skin) and below (musculoskeletal structures)
the target zone. The creation of this differential resistance
in these treatment planes is crucial to being able to safely
and easily navigate through the area during the second step
of aspiration (Video 29.1).
In a repeat liposuction case, the creation or widening of
differential resistance is even more important, given that the
natural differential in resistance between the fat layer and
its overlying skin or underlying musculoskeletal structures
has disappeared because of scar tissue from previous lipo­
suction. In a typical repeat case, there is already a fibrotic
bed and a more solid architecture of scar tissue, fat, and sup­
porting structures, which typically manifests to the surgeon
as an inability to pass an infiltration or liposuction cannula
through the tissues or to stay within the target zone. In this
scenario, end hits to the skin or damage to deeper structures
are much more common and in the past were almost un­
avoidable. The fat separation step allows the surgeon to re­
gain the lost differential in resistance between these planes,
which allows for easy navigability through the target zones,
whether the goal is to remove more fat, redistribute what re­
mains, or add more fat to the area. For example, if additional
fat is to be removed, it is now easy to remain within the tar­
geted 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 typical primary lipo­
suction procedure. The supporting structures and blood ves­
sels are spared because they remain solid and distinct from
the targeted, emulsified fat that is preferentially aspirated.
Of note, no thermal energy or suctioning is used dur­
ing the fat separation step, so tissue and blood vessels sur­
rounding the fat are left intact. The desired end point at this
stage is loss of resistance of all targeted fat, demonstrating
to the operator that the target zone is adequately mechani­
cally emulsified.
Step 2: Fat Aspiration
After separation of the targeted fat from its attachments
is achieved, a more conventional cannula (e.g., a 2-, 3-,
4-, or 7-mm PAL long-port double Mercedes cannula, or a
4-mm, 12-track Del Vecchio cannula [Beacon Aesthetics])
with smaller, less-aggressive, and numerous ports is used
to aspirate the now emulsified, low-resistance fat. Because
the fat has already been separated, this aspiration process is
fast and almost entirely bloodless and can be accomplished
treatment of the upper abdominal area, whereas the su­
pine position many times does not. The patient’s upper
abdominal skin is able to be freely pulled away from the
underlying ribs, which are now not as protuberant given
the more flexed abdominal position. There is also an ele­
ment of added safety in performing the upper abdominal
work from the lateral decubitus position because the ribs
are not in the way with the potential to penetrate the lungs
underneath (Fig. 29.7).
As stated earlier there are three steps used in primary
liposuction cases (see Box 29.3). In secondary cases, a fourth
step is often added that can include fat shifting, fat grafting,
and release processes to address any residual defects or vol­
ume deficiencies10-21 (see Box 29.3).
In any liposuction procedure, adequate infusion of wet­
ting solution is crucial to minimizing blood loss, providing
additional anesthesia, and increasing working space by vol­
ume expansion. In primary cases, a typical superwet infu­
sion is used, with a ratio of 1:1 or 1.5:1 infusion to aspira­
tion. In a repeat procedure, where 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 commonly needed.
Step 1: Fat Separation
The first step, fat separation, is accomplished classically
with an angled variation of a Becker basket cannula but is
more efficiently performed with an angled exploded-tip
fat separator; this step accounts for about 40% of the to­
tal procedural time. Fat separation is typically performed
using power-assisted liposuction (PAL) to maximize the
movement and effect of the wings on the exploded-tip can­
nulas and to minimize effort during liposuction. Although
PAL does make SAFELipo less strenuous and somewhat
more efficient, all aspects of SAFELipo can be accomplished
manually without power. The angled cannulas or dissectors
have a blunt tip and “wings” or baffles that, when passed
Fig. 29.7 The sides of the body are treated in the lateral decubitus
position.

SECTION IV AESTHETIC SURGERY
442
in which case the more baffled separators can be used to
ease equalization of the area.
Step 3 typically accounts for approximately 20% of the
total procedural time. When first using the SAFELipo pro­
cess, 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 val­
leys, with aggressive molding and contour equalization of
the remaining fat bed done by the opposite hand in con­
junction with moving the exploded-tip instrument back
and forth through the uneven tissue bed. This fat equaliza­
tion step effectively separates some of the remaining fat,
eliminating thicker and thinner areas of fat, leaving 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 SAFE­
Lipo procedures. As in primary liposuction procedures, the
utility of the SAFELipo process in repeat procedures allows
for much more versatility and applicability when faced
with smaller, less-aggressive cannulas that cause minimal
trauma to surrounding fat left behind, which is needed to
provide a smooth, natural contour (Video 29.2).
Step 2 usually encompasses about 40% of the total treat­
ment time, although the amount of time needed is highly
variable in repeat liposuction cases because the amounts of
fat to be aspirated can vary widely. If not much fat needs to
be aspirated, step two may be used only in predetermined
fat donor areas to harvest fat for later grafting in volume-
deficient areas.
Similar to how water is sucked with a straw preferen­
tially out of a glass of water and ice cubes, this mechanically
emulsified, liquefied fat is suctioned preferentially out of
the subcutaneous layer, leaving behind an intact support­
ing network. In contrast, standard liposuction uses tremen­
dous negative pressure to forcibly avulse fat and supporting
structures in their natural, solid, high-resistance state. Be­
cause the targeted fat and the supporting blood vessels have
similar tissue resistance, they are both aspirated at nearly
equivalent rates.
Step 3: Fat Equalization
Similar to step 1, step 3 is performed without any suction
and with the same exploded-tip cannula or dissector, un­
less unusual resistance or unseparatable fat is encountered,
b
a
Fig. 29.8 Fat shifting without (a) and with (b) formal fat grafting.

443
Chapter 29 Liposuction for Body Contouring
proposes to treat “hills” with liposuction and “valleys” with
fat grafting (and to leave alone areas that are neither hills
nor valleys) (Fig. 29.10). These spot approaches typically
require extensive preoperative marking and long proce­
dure times. In stark contrast, equalizing an entire area with
the SAFELipo process is technically much simpler to per­
form, with the added benefit of making formal fat grafting
unnecessary in many cases. If formal fat grafting is still
needed, the preceding SAFELipo process provides a recep­
tive environment for the fat grafts, unlike the inhospitable
and commonly hostile recipient bed seen after thermal
methods of liposuction.
Several additional techniques are useful in helping to
prevent contour deformities during liposuction. First, suc­
tion should be pinched off before inserting and removing
cannulas, to prevent creation of a depression at a cannula
entry site. Also, angled cannulas are used exclusively, be­
cause they can be rotated and redirected without needing
to retract the cannula back to near the entry point. This pre­
vents digging holes and also allows for more complete cover­
age of an area, with constant rotating of the angled cannula,
creating a “windshield wiper” effect and maximal coverage.
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, minimiz­
ing fluid accumulation, bruising, and persistent swelling.
Finally, it is generally prudent to avoid suctioning the mid­
buttock area and gluteal fold area (and to fat graft them to
prevent further depression or collapse) (Fig. 29.11).
with uneven, complex, fat-deficient, or severely fibrotic
patients (Video 29.3).
The fat equalization step combines aspects of the fat
separation, fat shifting, and local fat grafting to produce a
smooth, even, and compliant remaining layer of fat for an
aesthetically pleasing result (Fig. 29.8). In the past, one of
the biggest challenges of liposuction was how to remove all
of the unwanted fat in an area without creating a dented,
lumpy, or wavy surface in the treated area. This comprehen­
sive process has answered that challenge to allow dramatic
yet smooth and natural results.
For primary and repeat cases, the end point of the fat
equalization step is a smooth rolling pinch test. Using both
hands, and without any instrumentation, the skin is gently
pinched and rolled between the fingers and thumbs, “roll­
ing” across the entire area in multiple different directions to
assess the smoothness of the skin and underlying fat layer
(Fig. 29.9). 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 revision cases if the area is still not smooth, fat shift­
ing and aggressive manual molding is done, if needed, along
with formal fat grafting if the area is still volume deficient at
that point. Finally, release of any remaining skin adhesions is
performed in a conservative and precise fashion at this time,
completing the procedure.
Most plastic surgeons are very familiar with the tra­
ditional “spot” approaches that have been widely taught
and adopted in treating contour deformities. The technique
Fig. 29.9 Smooth rolling pinch test.
Liposuction?
Fat graft?
Liposuction?
Fat graft?
Fig. 29.10 The spot approach to fat distribution. (Reproduced from
Aly A, Nahas F. The Art of Body Contouring: A Comprehensive Ap­
proach. New York: Thieme; 2017.)

SECTION IV AESTHETIC SURGERY
444
Fig. 29.11 Angled versus straight cannulas. (a–e) Straight cannulas provide the most den­
sity at the point of entry. (f–i) Angled cannulas reach more points. (j–m) Angled cannulas
provide the highest density from any point of rotation. It is much easier to work very far
away from the point of entry. (Reproduced from Aly A, Nahas F. The Art of Body Contour­
ing: A Comprehensive Approach. New York: Thieme; 2017.)
b
a
c
d
f
e
h
g
i
j
l
k
m

445
Chapter 29 Liposuction for Body Contouring
step of the SAFELipo process, when residual defects are ad­
dressed. With Cellfina, traction sutures and large, imprecise
cutting cannulas or wires are no longer needed (Fig. 29.14).
Revision Liposuction—Step 4: Fat Grafting
and Fat Shifting
The fourth step of a systematic approach is done as needed
for a revision liposuction procedure. It involves fat shifting
and molding of areas, formal fat grafting, release of adhe­
sions, and differential and uniform foam compression (see
Postoperative Care)10-21 (Figs. 29.12 and 29.13, Video 29.4).
Ancillary Procedures
The Cellfina cellulite device (Merz) is useful in repeat lipo­
suction procedures for releasing tethered areas, or dimples,
in a precise and standardized fashion. Releasing these
tethered spots at a controlled depth causes less bleeding,
less disruption of the supporting stromal network, and
ultimately less disruption of the fat that may have been
grafted into these areas. Before the procedure, the spots
to be treated with Cellfina are photographed and marked,
although the actual device is used only during the final
Fig. 29.12 Fat shifting and grafting after a prior suction-assisted lipectomy of the hips, lateral thighs, and buttocks.
Fig. 29.13 (a) This patient previously underwent steroid injections and was left with a noticeable shark bite on the upper buttocks. (b) Re­
sult after SAFELipo and fat shifting and grafting.
b
a
Fig. 29.14 A Cellfina cellulite device.

SECTION IV AESTHETIC SURGERY
446
Repeat patients often benefit from prolonged compres­
sion management to assist in resolution of swelling and dis­
comfort and prevention of contour deformities. Either 0.5- or
1-inch Reston foam (3M) is used for uniform compression
of smooth, treated areas. The 1-inch foam with cutouts is
used for differential foam compression for large depressions
where formal fat grafting was performed (Fig. 29.15).
Several techniques will prevent mishaps and irritation
from the foam: All foam is lined on all edges with gauze to
prevent blisters. The foam should be unstuck the morning
after surgery and at 2 to 3 days postoperatively. Simply un­
sticking the foam and reapplying it immediately prevents
traction blisters from forming and keeps patients more com­
fortable. The same foam can be used for 2 weeks around-
the-clock, then 2 weeks during the day (wearing nothing
at night).
Baby powder should be used under the foam for greater
comfort; an athletic compression shirt can be worn under
the foam if sensitivity develops. The surgeon must use cau­
tion in applying new foam after surgery, because it is stiff
and sticky, able to cut into the patient’s skin and cause se­
vere blisters or ulcerations (Box 29.4). Compression gar­
ments 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 con­
tour deformity.
Revision liposuction commonly needs to be combined
with other body contouring procedures, including abdomi­
noplasty, to maximize results. These procedures can also be
combined with unrelated procedures such as breast enhance­
ment procedures. Fat harvesting from repeat liposuction ar­
eas for transfer to other body areas is also feasible, although
the quality of fat grafts is at times of less quality and can be
bloodier. In general, there are few differences in terms of
which ancillary procedures are appropriate to combine with
a repeat liposuction compared with a primary liposuction.
Postoperative Care
Not only are secondary procedures more difficult to per­
form, but the postoperative healing process is also typically
more complex. More involved care is required for these
patients, because they are prone to prolonged swelling
and development of unevenness and contour deformities.
I counsel all secondary liposuction patients that it will take
at least 1 year and usually up to 2 years or longer for all
swelling to resolve and for the skin to soften and resume
more normal pliability and elasticity. In addition, these
patients are more prone to paresthesias and dysesthesias,
which can be helped by early postoperative recognition and
management with pregabalin, desensitization therapy, and
massage treatments starting after 2 weeks postoperative.
Uniform foam
compression
Differential compression
with cutouts
b
a
Fig. 29.15 (a) Differential foam compression for large depressions or with fat grafting. A 1-inch foam lined with gauze is used for 5 to 7 days,
then changed to uniform compression. (b) Uniform compression. Foam cutouts are used beneath the compression garment.

447
Chapter 29 Liposuction for Body Contouring
Beyond foam and the accompanying compression gar­
ment patients should be instructed to avoid skin creases and
flexion in any area (mostly the abdomen) and should not
wear tight, constricting clothes for at least 4 months.
Results and Outcomes
The SAFELipo process approach is more than just a re­
ductive procedure. Fat is reduced, redistributed, or
augmented to the desired thickness and equalized
throughout entire anatomic units. The technique allows
for thorough—even aggressive—liposuction without in­
creasing the risk of contour deformities (Figs. 29.16 and
29.17, Video 29.4).
Box 29.4
•• Line all edges with gauze to prevent blisters.
•• Unstick foam at 2 to 3 days postoperatively.
•• Continue with the same foam for 2 weeks
around-the-clock, then 2 weeks during the day
(wear nothing at night).
•• Baby powder can be used under the foam, or an
athletic compression shirt can be worn under
the foam if sensitivity develops.
•• The foam can be washed and dried.
Tips to Using Foam After
Surgery
Fig. 29.16 This 40-year-old multipara patient (left), 67 inches tall and 167 lbs., had a prior suction-assisted lipectomy of the circumferential
trunk, thighs, buttocks, and gluteal folds. In addition, she underwent a ultrasound-assisted lipectomy of the circumferential thighs, but­
tocks, and gluteal folds. Results (right) are after revision liposuction with SAFELipo, which included the circumferential trunk and thighs and
fat shifting and fat grafting of the midbuttocks and gluteal folds. (Reproduced from Aly A, Nahas F. The Art of Body Contouring: A Compre­
hensive Approach. New York: Thieme; 2017.)
Continued

SECTION IV AESTHETIC SURGERY
448
Fig. 29.16, cont’d

449
Chapter 29 Liposuction for Body Contouring
Relaxed buttocks
Flexed buttocks
Fig. 29.16, cont’d

SECTION IV AESTHETIC SURGERY
450
thermal methods. The levels of fibrosis and scarring seen
from thermal liposuction generally reduce the possibility
that all residual deformity can be successfully addressed.
SAFELipo is more than a reductive procedure, but rather
includes shifting and adding of fat as needed, equalization of
fat, and skin release. It allows for a dramatic and thorough li­
posuction without the increasing risk of contour deformities.
It is more than a reductive or additive procedure because it
removes, redistributes, blends, and adds fat as needed. It
releases and equalizes skin. It also treats deeply and super­
ficially without disrupting vascular and stromal networks.
Conclusion
Revision and secondary liposuction procedures are associ­
ated with outcomes that are less ideal than those seen even
with other revision cosmetic procedures. With liposuction,
patients undergoing an extensive secondary procedure
will almost always have some degree of residual deformity
from existing contour irregularities, skin imperfections, or
scarring that compromise the overall result. In addition,
some residual areas of deformity will not be amenable
to repair, particularly when the previous procedure used
Fig. 29.17 This patient (left) underwent prior suction-assisted lipectomy twice and ultrasound-assisted lipectomy once. Results (right) are
seen 1 year after SAFELipo of the superficial abdomen, SurgiWire (Coapt Systems) release of the scar, and a 60-cc fat graft.

451
Chapter 29 Liposuction for Body Contouring
13. Gir P, Brown SA, Oni G, Kashefi N, Mojallal A, Rohrich RJ.
Fat grafting: evidence-based review on autologous fat
harvesting, processing, reinjection, and storage. Plast Re­
constr Surg 2012;130(1):249–258
14. Gale KL, Rakha EA, Ball G, Tan VK, McCulley SJ, Macmillan
RD. A case-controlled study of the oncologic safety of fat
grafting. Plast Reconstr Surg 2015;135(5):1263–1275
15. Lee JH, Kirkham JC, McCormack MC, Nicholls AM, Ran­
dolph MA, Austen WG Jr. The effect of pressure and
shear on autologous fat grafting. Plast Reconstr Surg
2013;131(5):1125–1136
16. Coleman SR, Saboeiro AP. Fat grafting to the breast
revisited: safety and efficacy. Plast Reconstr Surg
2007;119(3):775–785, discussion 786–787
17. Kling RE, Mehrara BJ, Pusic AL, et al. Trends in autolo­
gous fat grafting to the breast: a national survey of the
American Society of Plastic Surgeons. Plast Reconstr Surg
2013;132(1):35–46
18. Cleveland EC, Albano NJ, Hazen A. Roll, spin, wash, or fil­
ter? Processing of lipoaspirate for autologous fat grafting:
an updated evidence-based review of the literature. Plast
Reconstr Surg 2015;136(4):706–713
19. Auclair E, Blondeel P, Del Vecchio DA. Composite breast
augmentation: soft-tissue planning using implants and
fat. Plast Reconstr Surg 2013;132(3):558–568
20. Rubin JP, Coon D, Zuley M, et al. Mammographic changes
after fat transfer to the breast compared with changes af­
ter breast reduction: a blinded study. Plast Reconstr Surg
2012;129(5):1029–1038
21. Del Vecchio DA, Del Vecchio SJ. The graft-to-capacity ra­
tio: volumetric planning in large-volume fat transplanta­
tion. Plast Reconstr Surg 2014;133(3):561–569
References
1. Illouz YG. Body contouring by lipolysis: a 5-year experience
with over 3000 cases. Plast Reconstr Surg 1983;72(5):591–
597
2. Coleman SR. Structural Fat Grafting. Quality Medical Pub­
lishing: St Louis, MO; 2004
3. Gasperoni C, Salgarello M, Emiliozzi P, Gargani G. Subder­
mal liposuction. Aesthetic Plast Surg 1990;14(2):137–142
4. Gupta SC, Khiabani KT, Stephenson LL, Zamboni WA. Ef­
fect of liposuction on skin perfusion. Plast Reconstr Surg
2002;110(7):1748–1751
5. Wells JH, Hurvitz KA. An evidence-based approach to li­
posuction. Plast Reconstr Surg 2011;127(2):949–954
6. Shiffman MA. Prevention and treatment of liposuction
complications. In: Shiffman MA, Di Giuseppe A, eds. Lipo­
suction—Principles and Practice. New York, NY: Springer;
2006:333–41
7. Kennedy J, Verne S, Griffith R, Falto-Aizpurua L, Nouri K.
Non-invasive subcutaneous fat reduction: a review. J Eur
Acad Dermatol Venereol 2015;29(9):1679–1688
8. Taufig AZ. Water-jet-assisted liposuction. In: Shiffman
MA, Di Giuseppe A, eds. Liposuction—Principles and Prac­
tice. New York, NY: Springer; 2006;326–30
9. Chang KN. Correction of contour deformities after lipo­
suction. In: Nahai F, ed. The Art of Aesthetic Surgery, Prin­
ciples and Techniques. 2nd ed. St Louis: Quality Medical
Publishing; 2010
10. Saylan Z. Liposhifting instead of lipofilling: treat­
ment of postlipoplasty irregularities. Aesthet Surg J
2001;21(2):137–141
11. Salinas HM, Broelsch GF, Fernandes JR, et al. Comparative
analysis of processing methods in fat grafting. Plast Re­
constr Surg 2014;134(4):675–683
12. Khoobehi, Sadeghi A. Single staged mastopexy with autolo­
gous fat grafting. Plast Reconstr Surg 2009;124(4S):8–9
Discussion by Onelio Garcia Jr.
Liposuction is currently the number one aesthetic sur­
gical procedure reported by the American Society for
Aesthetic Plastic Surgery (ASAPS) More than 400,000
cases were reported by ASAPS members in 2016.1 That
liposuction has maintained such a high ranking among
aesthetic surgery procedures over the past decade is
a testament to the high patient satisfaction rate as­
sociated with the procedure. Also contributing to its
popularity is a relatively low complication rate when
performed by properly trained plastic surgeons with
significant experience in body contouring.
Most plastic surgeons performing liposuction in the
United States prefer the traditional suction-assisted lipo­
suction (SAL) technique. I prefer to use third-generation
ultrasound-assisted liposuction (UAL) for body contour­
ing. The use of ultrasound in body contouring surgery is
not a new phenomenon. It was first applied to this field
by Scuderi et al2 in the late 1980s and later introduced
to the United States by Zocchi3 in 1993.
A UAL task force was formed in 1997 in a collabora­
tive effort that included national plastic surgery socie-
ties working with members of the U.S. Food and Drug

SECTION IV AESTHETIC SURGERY
452
Administration and the ultrasound device manufactur­
ers.4 More than 2,000 surgeons were trained by the task
force, but despite these efforts there were serious com­
plications reported with the use of these devices.
Most of the complications were related to the ther­
mal effects of ultrasound on the adipose layer and the
surrounding tissues. There were reports of serious skin
burns not just at the access incisions but also large sur­
face areas of skin overlying the treatment sites. Seromas
were common, as were postoperative contour deformi­
ties from scar adhesions secondary to internal thermal
injury from the devices.
By the late 1990s many prudent surgeons had aban­
doned UAL in body contouring because of the significant
number of serious complications reported. The ultra­
sound devices available for body contouring at the turn
of the century left a lot to be desired. The energy deliv­
ered to the tissues by the ultrasound probes in use at
the time was extremely high and was associated with
a significant thermal response at the tip of the probe
that often resulted in thermal injury to the tissues. The
UAL aspirate associated with these devices consisted of
a significant amount of free lipids, adipose cellular de­
bris, and disrupted adipocytes. Needless to say this was
not a viable aspirate.
The VASER System
In 2001 a third-generation ultrasound device was in­
troduced. The VASER system, or Vibration Amplifica­
tion of Sound Energy at Resonance, was designed and
manufactured by Sound Surgical Technologies. This
device design significantly diminished the amount of
ultrasound energy delivered to the tissues that was the
cause of many of the complications reported with the
earlier devices.5 Soon after its debut, a multicentric,
pilot clinical study was reported by Jewell et al6 using
VASER-assisted liposuction in 77 patients with good
outcomes and no complications. A decrease in com­
plications using VAL compared with early UAL devices
was reported by de Souza Pinto and colleagues,7 and I8
found significantly less blood in VAL aspirate compared
with traditional SAL aspirate in 57 consecutive patients
undergoing contouring of the posterior trunk.
Despite all the literature in support of VAL and re­
ports of its safety and efficacy, it is still a poorly under­
stood device. Many surgeons still use the device at ul­
trasound energy settings much higher and ultrasound
times much longer than what is actually required to ob­
tain adequate fat fragmentation. These prolonged ultra­
sound times are probably a consequence of early manu­
facturer’s recommendations that proposed applying the
ultrasound energy for 1 minute per 100 mL of wetting
solution used. These recommendations are associated
with much higher levels of ultrasound energy delivered
to the tissues than is necessary to achieve appropriate
fat fragmentation. Applying the VASER ultrasound en­
ergy for 45 to 60 seconds for every 100 mL of expected
aspirate volume is a safe and effective way to achieve
fat fragmentation and emulsification while keeping the
thermal effects on the tissues to a minimum. The 45 sec­
onds per 100 mL of aspirate interval applies to soft areas
like the inner thighs and lower abdomen, whereas tight,
fibrous areas such as the posterior trunk or gynecomas­
tia may require 60 seconds per 100 mL of expected as­
pirate time interval.
My technique for VAL in body contouring is similar
to what is described in the SAFELipo technique except
that the fragmentation phase is performed by means of
a VASER ultrasound probe instead of an exploded-tip fat
separator. The fat fragmentation phase in VAL is equiva­
lent to the fat separation phase in SAFELipo. VASER ul­
trasound applied for recommended time intervals at
recommended energy settings causes fragmentation of
the fat tissue matrix, creating smaller clumps of viable
adipocytes. Acoustic streaming is caused by fluid forces
that swirl around the vibrating ultrasonic probe tip. This
intense swirling causes the fat cells that have been sep­
arated from the matrix to mix with the infusion fluid
to create an emulsion. Electron microscopy studies of
VASER aspirate have shown that it contains viable adipo­
cytes within the emulsion and without cell wall altera­
tions9 (Fig. 29D.1). The aspiration and fat equalization
phases of the procedure are almost identical between
VAL and SAFELipo.
Fig. 29D.1 Electron microscope view of separated fat cells. Vi­
able adipocytes have no cell wall alterations. (Reproduced from
Garcia O. Ultrasonic liposuction. In: Rubin JP, Jewell ML, Richter
DF, et al, eds. Body Contouring and Liposuction. New York: El­
sevier Saunders; 2013:543–558.)

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Chapter 29 Liposuction for Body Contouring
Preoperative Considerations
It is generally agreed that circumferential contouring,
regardless of technique, yields a more harmonious aes­
thetic result than spot liposuction (Fig. 29D.2). Most of
my VASER body contouring is performed under general
anesthesia and, with few exceptions, involves circum­
ferential contouring. Wetting solution is infiltrated into
the tissues at approximately a 3:1 ratio of solution to
expected aspirate volume. The use of lidocaine in wet­
ting solutions carries the risk of lidocaine toxicity in
higher volume cases in which more wetting solution
is used. There is little proven benefit of its use when
general anesthesia is used in these cases. Because I
commonly use large volumes of wetting solution, my
formula consists of 1 mL of epinephrine 1:1000 in 1 li­
ter of Ringer’s lactate.10 For local anesthesia I add 30
mL of 1% lidocaine to each liter of my wetting solution.
Although some authors claim to routinely use doses ex­
ceeding 50 mg/kg while maintaining a safety margin,
my recommendation is that the total dose should not
exceed 35 mg/kg. Most of the major liposuction con­
touring cases that involve large surface areas require
general anesthesia, and local cases do not require high
volumes of wetting solution, so there really is no good
reason to push the limits on lidocaine toxicity.
My preoperative markings are performed in the
standing position, and for circumferential cases I prefer
lateral decubitus over supine. This type of positioning
allows for better lineal access of the ultrasound probes
into the treatment areas, avoids torque on the probes,
and prevents end hits.
Surgical Technique
My aspiration phase is performed with 3.7-mm and
3.0-mm VentX atraumatic cannulas (Valeant Pharma­
ceuticals). Depending on the case, the aspiration phase
removes approximately 70% to 90% of the emulsion.
The remaining emulsion is then used for fat equaliza­
tion. This is easily performed by manipulating this
mobile adipocyte-containing solution into the desired
areas, leaving behind a layer of viable fat to smooth
out the contours. My protocol for secondary and revi­
sion liposuctions is similar, except that tumescent in­
fusion is used in greater quantities, sometimes a 4:1
ratio, and the ultrasound energy levels vary depend­
ing on the case. In many revision cases the aspiration
b
a
c
d
f
e
Fig. 29D.2 Circumferential body contouring of the trunk using VASER-assisted liposuction. (a–c) Preoperatively. (d–f) At 3 months
postoperatively.

SECTION IV AESTHETIC SURGERY
454
phase is minimal, if any, and most of the separated fat
is used as an emulsion in the fat equalization phase to
even out deformities (Fig. 29D.3). Advantages of the
VASER in these cases is that it allows fat fragmentation
in a relatively tight, scarred environment with mini­
mal trauma, minimal blood loss, and much less effort
than by manually forcing a cannula through scar tissue
(Video 29D.1).
Conclusion
In general, my technique for VASER-assisted liposuc­
tion in body contouring is very similar to the SAFELipo
technique. The main differences are in the fragmenta­
tion and separation phase, in which Dr. Wall performs
manual separation by means of an exploded-tip can­
nula and I prefer the use of a VASER ultrasound probe
to induce fat fragmentation. The end result of the frag­
mentation and separation is similar, because at the ap­
propriate settings the VASER delivers a relatively low
level of ultrasound energy to the tissues (less than 50%
of what previous devices delivered), and this subse­
quently translates to a minimal thermal load on the tis­
sues.11 The blood loss in the aspirate is significantly less
using VASER as opposed to manual separation, particu­
larly in tight, fibrous areas.12 VASER aspirate harvested
at recommended settings contains viable adipocytes
that are suitable for grafting.13
b
a
Fig. 29D.3 (a) Midabdominal contour deformity after laser-assisted liposuction. (b) Revision VASER-assisted liposuction 1 year
after the initial surgery. The correction was done entirely by means of fat equalization.
b
a
c
d
Fig. 29D.4 Left, this 39-year-old athletic man was seeking detailed liposculpture of the trunk. Right, six months after undergoing
circumferential VASER-assisted liposuction.

455
Chapter 29 Liposuction for Body Contouring
For all the aforementioned reasons I choose to per­
form body contouring using VASER-assisted liposuction.
I firmly believe that the use of the third-generation ul­
trasound devices coupled with the use of small-diame­
ter, atraumatic cannulas for aspiration has significantly
improved the level of precision, particularly in cases in
which the anatomic details are paramount in achieving
the desired results (Fig. 29D.4). Although the device has
the potential for thermal complications, they occur al­
most universally as the result of improper use, applying
too much ultrasound energy. Proper use of protectors
for access incisions and adhering to the recommended
energy levels and treatment time intervals is associated
with infrequent and minor complications.
The VASER ultrasound probe or the manual use of
an exploded-tip cannula only assist in the fat fragmen­
tation and separation and emulsification phase. It is the
artistry and attention to detail by the surgeon during
the aspiration and fat equalization phases that will ulti­
mately be responsible for the aesthetic outcome of the
contouring procedure. There are three basic but inte­
gral phases of liposuction (discussed in the chapter),
and the SAFELipo technique is a model of how the three
phases interact. Of particular importance is an emphasis
on leaving behind an amount of residual fatty emulsion
for the equalization phase, which is paramount in avoid­
ing or correcting contour deformities.
References
1. The American Society for Aesthetic Plastic Surgery.
Cosmetic Surgery National Data Bank, Procedural Sta­
tistics; 2016
2. Scuderi N, Devita R, D’Andrea F, et al. Nuove prospet­
tive nella liposuzione la lipoemulsificazone. Giorn
Chir Plast Riconstr ed Estetica 1987;2(1):33–39
3. Zocchi ML. Clinical aspects of ultrasonic liposculp­
ture. Perspect Plast Surg 1993;7:153–174
4. Fredricks S. Analysis and introduction of a technol­
ogy: ultrasound-assisted lipoplasty task force. Clin
Plast Surg 1999;26(2):187–204, vii
5. Cimino WW. History of ultrasound-assisted lipo­
plasty. In: Shiffman MA, DiGiuseppe A, eds. Body
Contouring: Art, Science and Clinical Practice. Berlin:
Springer-Verlag; 2010:399–403
6. Jewell ML, Fodor PB, de Souza Pinto EB, Al Shammari
MA. Clinical application of VASER-assisted lipoplasty: a
pilot clinical study. Aesthet Surg J 2002;22(2):131–146
7. de Souza Pinto EB, Abdala PC, Maciel CM, dos Santos
Fde P, de Souza RP. Liposuction and VASER. Clin Plast
Surg 2006;33(1):107–115, vii
8. Garcia O Jr, Nathan N. Comparative analysis of blood
loss in suction-assisted lipoplasty and third-genera­
tion internal ultrasound-assisted lipoplasty. Aesthet
Surg J 2008;28(4):430–435
9. Garcia O. Ultrasonic liposuction. In: Rubin JP, Jew­
ell ML, Richter DF, Uebel CO, eds. Body Contouring
and Liposuction. Philadelphia: Elsevier Saunders;
2013:543–558
10. Garcia O Jr. Aesthetic body contouring of the poste­
rior trunk and buttocks using third generation pulsed
solid probe internal ultrasound–assisted lipoplasty.
In: Shiffman MA, DiGiuseppe A, eds. Body Contour­
ing: Art, Science and Clinical Practice. Berlin: Spring­
er-Verlag; 2010:493–504
11. Cimino WW. Ultrasonic surgery: power quantifi­
cation and efficiency optimization. Aesthet Surg J
2001;21(3):233–241
12. Garcia O. Comparison of blood loss in suction-assist­
ed lipoplasty and third-generation ultrasound-assist­
ed lipoplasty. In: Shiffman MA, DiGiuseppe A, eds.
Body Contouring: Art, Science, and Clinical Practice.
Berlin: Springer-Verlag; 2010:565–573
13. Panetta NJ, Gupta DM, Kwan MD, Wan DC, Commons
GW, Longaker MT. Tissue harvest by means of suc­
tion-assisted or third-generation ultrasound-assisted
lipoaspiration has no effect on osteogenic potential of
human adipose-derived stromal cells. Plast Reconstr
Surg 2009;124(1):65–73

456
CHAPTER
30

Abdominoplasty
Joseph P. Hunstad and Daniel J. Krochmal
The primary aims of abdominoplasty are restoration of a
more ideal abdominal wall contour and removal of excess
abdominal skin and soft tissue. Laudable goals of this pro­
cedure are to obtain an abdomen that is thin, tight, and flat.
If a surgeon accomplishes these objectives, while achiev­
ing a relatively inconspicuous scar, an aesthetically pleas­
ing umbilicus, and a complication-free recovery, a patient
is usually quite satisfied with the overall result. If any of
these goals are not obtained, the result may be unfavorable.
The “unfavorable” aesthetic results in abdominoplasty
are usually correctable with revision procedures. With re­
gard to actual complications, the more common ones are
typically minor in nature and management is straightfor­
ward. The possible severe complications, including fatal pul­
monary embolus, necrosis of the abdominal wall skin and
soft tissues, and life-threatening infection, are rare.1 This
chapter presents prevention concepts for the more common
complications and the unusual challenging complications,
along with their management. Also discussed are some tips
and tricks that have resulted in enhanced outcomes in our
hands.
Avoiding Unfavorable
Results and Complications in
Abdominoplasty
The ideal patient for an abdominoplasty is an otherwise
healthy, nonsmoking patient with a normal body mass in­
dex, a lax abdominal wall with rectus diastasis, and excess
abdominal skin. Patients that are at higher risk for compli­
cations or a suboptimal result include those who are mor­
bidly obese (visceral fat precludes a tight plication), have
lung disease including severe chronic obstructive pulmo­
nary disease (muscle plication will limit lung excursion),
are currently smoking, or have a strong personal or family
history of blood clots.
Summary Box
Possible Complications Associated
with Abdominoplasty
•• Seroma
•• Hematoma
•• Infection
•• Poor scar location or quality
•• Asymmetry or incomplete correction
•• Unaesthetic umbilicus
•• Deep vein thrombosis or pulmonary embolism
Primary Goals
Removal of Excess Soft Tissue
Although a patient may have abdominal wall laxity, it
is typically the extra abdominal skin and fat that lead to
patient desire for abdominoplasty. To this end, it is impor­
tant to deliver a result that the patient will find satisfying.
Although rectus plication will contribute to the “tight and
flat” criteria, it is the removal of excess skin and fat that will
cause the abdomen to be “thin” and eliminate redundant
rolls and folds that are very bothersome to the patient.
Preoperative assessment of the location of excess ab­
dominal skin is critical. Typically, the extra skin is located
in the mid and lower abdominal regions, in which case a

457
Chapter 30 Abdominoplasty
have concerns regarding loose skin postoperatively, extra
skin may be excised secondarily (the vertical resection of
the fleur-de-lis can also be performed staged, but this is
not optimal).
The abdominal wall has a superficial and deeper (sub-
 scarpal) fat layer. We have previously reported that the sub-
scarpal fat appears to be “parasitic” to the overlying skin and
fascial tissues in that blood supply progresses from lateral
to medial and superficial to deep after perforator division.
Therefore not only is trimming of the subscarpal fat help­
ful to reduce abdominal flap thickness, it removes fat with
poor blood supply that is the most common site for fat ne­
crosis postoperatively. Subscarpal fat resection is typically
performed sharply at the level of the superficial fascia, tak­
ing care to preserve the integrity of the fascia to facilitate an
excellent abdominal closure2 (Fig. 30.5).
traditional abdominoplasty is indicated (Fig. 30.1). In some
patients, particularly those who have undergone massive
weight loss, there will be horizontal skin laxity in addi­
tion to a vertical component; in these cases, a fleur-de-lis
abdominoplasty with a vertically oriented scar should be
considered (Fig. 30.2). Although unusual, skin laxity can be
located primarily in the upper abdomen. When asked by
their surgeon to demonstrate what their desired abdomen
would look like, these patients lift their upper abdominal
wall toward the chest to give them the desired appearance
(Fig. 30.3). In these cases, a reverse abdominoplasty is ap­
propriate.
Following rectus plication, the patient is placed in the
semi-Fowler (beach chair) position. The skin on the ab­
dominal flap is demarcated precisely to create a closure
that will be of the appropriate tension (Fig. 30.4) If patients
a
b
Fig. 30.2 Fleur-de-lis abdominoplasty. (a) This 37-year-old woman was undergoing a circumferential abdominoplasty with a fleur-de-lis
component to remove the horizontal skin laxity. She also underwent an augmentation mastopexy, with gel implants placed submuscularly.
(b) Result 6 months postoperatively.
Fig. 30.1 Standard abdominoplasty. This
48-year-old woman was undergoing cir­
cumferential trunk liposuction with but­
tock fat grafting and abdominoplasty. The
majority of skin laxity and striae are in the
infraumbilical zone and would be resected
as part of the standard abdominoplasty.

SECTION IV AESTHETIC SURGERY
458
a
b
Fig. 30.3 Reverse abdominoplasty markings. (a) This 50-year-old woman desired an improved abdominal contour. The skin laxity was
primarily central and in the epigastric regions. (b) When the patient lifts the skin envelope upward, excellent contour of the abdomen is
achieved. Thus the patient literally tells the surgeon the direction of skin excision. Patients will typically do this in the preoperative consul­
tation standing in front of a mirror when a surgeon asks about the desired result.
a
b
Fig. 30.4 (a) Demarcating the abdominal flap. A Lockwood abdominal demarcator (or equivalent) is used to precisely mark the line of exci­
sion. Care must be taken to set the skin at the appropriate tension before resection. (b) Measuring the abdominal flap. After demarcation,
the flaps to be excised are measured bilaterally to ensure equal amounts of skin are being resected to maximize symmetry.
Fig. 30.5 Subscarpal fat resection. The subscarpal fat is parasitic at
this point, because it now relies on vessels that are more superficial.
Therefore this fat may be trimmed sharply without worrying about
vascular compromise to the remainder of the skin flap. The integrity
of Scarpa’s fascial layer must be preserved, because it is important
for closure.

459
Chapter 30 Abdominoplasty
volume is decreased, but the diastasis remains. Exercise is
not effective in reducing the diastasis; the treatment is sur­
gical plication.
The amount of diastasis is typically easily assessed at
the time of initial consultation by abdominal palpation dur­
ing abdominal wall loading maneuvers. Evaluation for true
hernias should also be conducted at this time. The most
common locations are in the periumbilical and midline re­
gions, but they may be found in scar tissue from previous
abdominal operations (Fig. 30.7). Patients who still main­
tain a significant amount of intra-abdominal fat should be
encouraged to lose weight beforehand, because this will al­
If excess adiposity exists postoperatively, thorough ab­
dominal liposuction may be performed to significantly thin
the flap without concern for vascular compromise (Fig.
30.6). To prevent postoperative excess adiposity, we rou­
tinely perform thorough tumescent liposuction of the en­
tire abdominal flap, flanks, and hip rolls before flap elevation
during the initial abdominoplasty.3 Although still somewhat
controversial, thorough circumferential body liposuction in
combination with abdominoplasty has been repeatedly
demonstrated to be highly successful with a minimal risk
of vascular compromise when proper thorough tumescent
infiltration has been performed. The addition of liposuction
enhances the final outcome, delivering an overall circum­
ferential body thinning that is perceived by patients very
positively (Video 30.1).
The abdomen is not a structure in isolation, but is only
one side of a cylindrical trunk. This is why we routinely per­
form circumferential liposuction. If there is excess skin pos­
teriorly, this may be resected. If the excess skin is inferior,
a circumferential abdominoplasty should be performed. If
the excess skin is on the upper back, a bra-line back lift or
other upper back excisional technique may be performed.
The result will be a significant circumferential improvement
with a reduced anteroposterior dimension and a more pleas­
ing profile.
Correction of the Rectus Diastasis
Rectus diastasis may be congenital or acquired. In ac­
quired cases, increased intra-abdominal volume stretches
the muscles apart. Two of the more common reasons for
increased abdominal volume are pregnancy and weight
gain with a significant intra-abdominal distribution. After
childbirth or weight loss, the contributing intra-abdominal
a
b
Fig. 30.6 (a) This 50-year-old woman had a prior abdominoplasty, with residual adiposity of the abdomen, flanks, back, and hip rolls. She
underwent SmartLipo MPX followed by suction-assisted lipectomy of these areas. (b) Result 4 months postoperatively. Despite the previous
abdominoplasty, the patient was able to be aggressively liposuctioned without compromised bloodflow to the skin (even when including
laser energy with the SmartLipo MPX). Although aggressive liposuction can be used at the time of initial flap elevation during abdomino­
plasty procedures, laser energy should not be included at that stage.
Fig. 30.7 Abdominal wall hernia. This woman was undergoing an ab­
dominoplasty when a true abdominal wall hernia was discovered at
the right extent of her prior cesarean section scar. One must be espe­
cially cautious of these occult hernias when performing liposuction.

SECTION IV AESTHETIC SURGERY
460
Unfavorable results can often occur if there is residual
epigastric fullness, the waistline remains straight, or abdom­
inal wall laxity returns after the procedure. Residual epigas­
tric fullness, especially on abdominal loading maneuvers,
can occur if the plication is not complete from the xiphoid to
the symphysis. Failure to recognize that the plication should
be performed in a bone-to-bone fashion commonly leads to
an unfavorable return of epigastric fullness that will result
in patient dissatisfaction. Every effort should be made to en­
sure the abdominal flap is elevated to the level of the xiphoid
and the plication started at the most superior aspect of the
dissection. A waistline that remains convex postoperatively
is often disappointing for both the patient and physician.
For women, the waistline should be concave, and flow­
ing in a sinusoidal fashion from the chest to the waist to the
hips. To create this shape, a wide plication should be per­
formed to create a tight, flat abdominal wall. In individuals
with significant abdominal laxity, this plication can actually
bring together the medial borders of the external oblique
muscle and fascia. Such a wide plication will invert the rec­
tus muscles; however, because most women do not desire a
chiseled “six-pack abs” look, a flat abdomen and a concave
waistline will be viewed quite favorably.
For men the waistline should be essentially straight.
The medial edges of the rectus muscles should be reapproxi­
mated, with a wider plication performed if it will result in a
decreased anterior-posterior distance (any tighter of a plica­
tion will cause a decrease in the lateral distance, which will
feminize the waistline).
The return of abdominal wall laxity after abdomino­
plasty is suboptimal.5 Repeat plication is indicated, and of­
ten the scar plane of the rectus fascia holds sutures well
and allows for a strong plication during secondary pro­
cedures. If the fascia is of poor quality and cannot ade­
quately support the plication suture, the abdominal wall
may be reinforced with mesh—an acellular dermal ma­
low for a tighter operative muscle plication and therefore a
more ideal contour. Operating on a patient with significant
intra-abdominal visceral fat will yield disappointing results
for both the patient and surgeon.
A stable preoperative weight is important. A patient’s
weight should be stable for at least 3 months before the
operation. Lifestyle changes contributing to weight gain
preoperatively will lead to weight gain postoperatively if
continued, and the result will be suboptimal. For patients
who have undergone bariatric surgery, nutritional analysis
preoperatively is important to ensure satisfactory healing.4
Postoperatively, the patient’s weight should remain stable to
maintain the favorable result accomplished surgically. Typi­
cally, if patients lose weight after surgery, the operative re­
sult is even more dramatic.
Several maneuvers are helpful to prepare the patient for
the tight muscle plication. We suggest that patients wear an
abdominal binder tightly, day and night, for 2 weeks, which
simulates the muscle plication and allows the body to adjust
physiologically before surgery. We also request the patients
begin a clear liquid diet 2 to 3 days before the procedure to
decompress the bowel, which will reduce intra-abdominal
volume.
At the time of the procedure, the abdominal skin and
subcutaneous tissue is typically separated from the abdomi­
nal wall fascia inferiorly up to the rib margin and xiphoid
process superiorly. We recommend a strong and complete
muscle plication be performed between the xiphoid and pu­
bic symphysis. We typically overcorrect the diastasis and
perform a tight muscle plication to create an elegant waist­
line laterally and a flat abdominal contour (Fig. 30.8). Suture
selection and technique vary; we prefer a 0 looped Ethilon
in a running fashion from the xiphoid to the pubis without
interruption at the level of the umbilical stalk. This tech­
nique is time-efficient and creates a strong fascial plication.
We have never had this suture fail.
a
b
Fig. 30.8 (a) Markings for the rectus plication. The medial borders of the rectus abdominis muscles are marked with methylene blue, and
the outer markings represent the desired extent of the plication suture. There are myriad methods of plication; we prefer a looped 0 Ethilon
suture run from xiphoid to pubis without interruption. (b) After the rectus plication. A wide rectus abdominis plication (WRAP) has been
performed. The extent of the plication is adjusted (in this case, brought in) based on the tension of the closure to prevent “cheese-wiring”
of the fascia.

461
Chapter 30 Abdominoplasty
are marked, and the incision is placed inside those marks.
The ideal incision placement is usually low and easily hid­
den in even the lowest cut garments. The patient should
strongly lift up on the abdominal flap, and the incision
should be marked at the level of the pubic bone (Fig. 30.10).
If the patient does not strongly lift the abdomen superiorly
while it is marked, the incision will migrate cephalad as a
result of the pull of the abdominal flap during healing and
ultimately leave it in a higher and more visible position. The
ideal abdominal incision is placed low enough that it usually
removes the upper third of the hair-bearing mons. Correc­
tion of a high-riding scar involves a scar revision to lower
the final scar (Fig. 30.11).
A common tactic for patients with a long infraumbilical
skin segment is to cheat the low transverse incision higher
to ensure that the umbilical hole is fully resected and no
vertical T is created. This can be a mistake. If the final scar
trix, permanent mesh, or resorbable mesh that promotes
tissue ingrowth. We prefer to use GalaFLEX (Galatea Sur­
gical) or Phasix (Bard), which is a monofilament poly-4-
hydroxybutyrate mesh (Fig. 30.9). A mesh for reinforcement
should be available in the surgical center in case it is needed.
Secondary Goals
Scar Placement and Quality
Abdominoplasty cannot be performed without a scar. Even
if a great abdominal contour is achieved, an unsightly scar
will be bothersome to the patient. An unsightly scar can
result from suboptimal placement or scar quality.
If the patient desires to hide the scar within a particular
article of clothing, the patient should bring that article of
clothing the day of surgery; the boundaries of the clothing
Fig. 30.9 Rectus fascial plication reinforcement. During plication in
this 54-year-old woman’s abdominoplasty, her fascia was found to
be weak. The abdominal wall was reinforced with a prosthetic mesh
to prevent a return of abdominal wall laxity.
Fig. 30.10 Strong cephalad pull during marking by the same pa­
tient as in Fig. 30.1. The strong pull upward mimics the pull of the
abdominal flap after the abdominoplasty. Marking with the patient
pulling strongly upward helps prevent superior migration of the
scar postoperatively into an unfavorably high position.

SECTION IV AESTHETIC SURGERY
462
vised with local anesthesia at a time that is most convenient
for the patient.
Umbilicus
A focal point of the abdomen is the umbilicus. To this end,
an umbilicus that is not ideal may also serve as a point of
concern. There are four tenants to creating an aesthetic
umbilicus. Smaller is perceived to be preferable to bigger.
A vertically oriented ellipse is viewed more favorably than
a circle. An “innie” is better than an “outie.” Midline um­
bilical placement should be achieved during the procedure,
because secondary correction of this is very difficult.
An innie umbilicus is facilitated by a wide rectus pli­
cation, which will shorten the umbilical stalk by pulling it
inward as the rectus muscles are plicated. Because of this,
sutures to deepen or “tack down” the umbilicus are not
necessary. Midline placement is achieved by dropping a
plumb-line string from the xiphoid to the pubic symphysis
after skin flap demarcation and temporary stapled closure,
then using a Lockwood demarcator to mark the umbilical
location on the abdominal flap. If the preoperative umbili­
cus is lateral to the midline, asymmetric rectus plication is
performed to place the umbilicus in the midline. Once the
proper position of the umbilicus is identified on the abdomi­
nal flap, a vertically oriented ellipse is resected of skin and
subcutaneous tissue and the umbilicus is delivered through
the abdominal wall. The ellipse should be kept small, be­
cause the umbilicus usually enlarges with time. It is far eas­
is low and easily hidden in clothing, patients will tolerate a
small vertical T segment. They should be informed of this
possibility preoperatively, however. If the small vertical seg­
ment continues to be bothersome (unusual), it may be ex­
cised secondarily when the infraumbilical skin has healed
and relaxed.
Scar quality, an important element of the final result for
the patient, is deemed excellent if it is thin and flat and the
color is a close match to the surrounding skin. A thin, flat
scar is facilitated by decreased tension on the skin closure.
A strong, complete Scarpa’s fascia–layer closure will offload
the tension on the skin. The skin edges should be approxi­
mated precisely, with a slight skin edge eversion, to allow
for optimal primary healing. Skin edges that do not align
precisely will heal secondarily and can reduce scar quality.
The incision should be supported in the early postoperative
period to help create the best scar possible. Skin glue or tape
may be used for this purpose; we use sterile paper tape cut
every 5 cm to allow for postoperative swelling, followed by
conversion to continuous strips of paper tape after approxi­
mately 5 days. Tapes are changed weekly. After 3 to 4 weeks,
the tape may be discontinued and scar cream initiated.
Thick, hypertrophic scars may respond to intradermal
injection of a steroid (we use a 1:1 triamcinolone and 5-flu­
orouracil combination). Scars that retain redness for pro­
longed periods from hypervascularity may be treated with
pulsed-dye laser. Widened scars, or any scars that remain
problematic despite nonoperative approaches, may be re­
a
b
Fig. 30.11 (a) This 47-year-old woman had a high scar after an abdominoplasty. She was displeased with the high position of the scar. She
desired a lower umbilicus instead of the presence of a vertical scar in the lower midline. She also wanted excess tissue removed posteriorly,
along with the creation of a more full buttocks. (b) Result 6 months after revision abdominoplasty to lower the scar, an umbilical float pro­
cedure to lower the umbilicus, and a purse-string gluteoplasty. The scar has been significantly lowered, and her hip and thigh shape has
improved with the circumferential abdominoplasty with purse-string gluteoplasty.

463
Chapter 30 Abdominoplasty
Minimizing soft tissue trauma by meticulous surgi­
cal technique and avoidance of excessive electrocautery,
along with precise hemostasis, will decrease trauma to
the surgical surfaces and therefore decrease the release of
reactive fluid. Drain placement after abdominoplasty has
been the standard of care for many years. When concur­
rent circumferential body tumescent liposuction is per­
formed, the drainage output can be very significant in the
early postoperative phase. Dead space may be obliterated
with a combination of internal space-obliterating (or pro­
gressive tension) sutures and external compression such
as an abdominal binder, which will facilitate adhesion of
the abdominal flap to the underlying abdominal wall, or
at a minimum compartmentalize any fluid collections for
quicker absorption6,7 (Fig. 30.13). The introduction of Tis­
suGlu Surgical Adhesive (Cohera Medical), placed as dis­
crete drops, holds great promise and was recently ap­
proved by the U.S. Food and Drug Administration8 (Fig.
30.14).
Regardless of these techniques, a seroma can still occur.9
When a seroma is detected, percutaneous drainage should
be initiated and performed several times weekly until the
seroma is no longer detectable (Fig. 30.15). External com­
ier to secondarily revise an umbilicus to make the aperture
larger, and quite difficult to undergo umbilicoplasty to re­
duce the size (Fig. 30.12).
Managing Unfavorable
Results and Complications in
Abdominoplasty
Seroma and Pseudobursa
Any time a dead space is created, there is propensity for
fluid to accumulate in this region. A fluid collection that is
clinically detectable postoperatively, requires repeated per­
cutaneous aspiration, and/or affects the aesthetic result is
considered a seroma. Elevation of the abdominal flap creates
a large area of dead space. The addition of liposuction in­
creases the surgical surface area even more, causes trauma
to the flap itself, and necessitates the use of tumescent fluid,
which may remain after the procedure. As a result, seromas
can occur after abdominoplasty with concurrent liposuc­
tion. However, there are maneuvers to reduce its occurrence.
a
b
c
d
e
Fig. 30.12 (a) This 40-year-old woman who had a previous abdominoplasty presented with a high scar and a superiorly placed umbilicus.
A revision abdominoplasty to lower the scar, repeat the muscle plication to tighten the abdominal wall and shorten the umbilical stalk, and
an umbilicoplasty were planned. (b) After the rectus plication was performed, the previous umbilical aperture was cinched using 2–0 Ti-
Cron in a purse-string fashion. (c) Rewidening of the umbilical aperture 17 months postoperatively. The patient was displeased with this
appearance and desired a revision. (d) Preoperative markings. A repeat purse-string cinching technique was planned. The umbilicus was
incised, and undermining was performed to the extent of the outer circle to mobilize the tissue centrally. (e) After the abdominal wall was
undermined, a 2–0 Ti-Cron suture was placed in a purse-string fashion to cinch the aperture. Unfortunately, the patient was lost to follow-
up before postoperative pictures were obtained.

SECTION IV AESTHETIC SURGERY
464
If fluid accumulation is recalcitrant, a thick capsule may
form around the seroma pocket and form a pseudobursa
(Fig. 30.16). Often what is noticed is a localized, visible full­
ness on the abdominal wall, typically in the mid- to lower
pression is critical during this time to reduce fluid reaccu­
mulation. Although various sclerosing agents have been de­
scribed (e.g., ethyl alcohol, doxycycline, bleomycin, talc), we
have not found these agents to be very useful.
Fig. 30.13 Space-obliterating sutures in a 44-year-old woman un­
dergoing a circumferential abdominoplasty. Quilting sutures were
placed to coapt the skin envelope and rectus fascia and obviate the
need for a drain.
Fig. 30.14 Cohera’s TissuGlu Surgical Adhesive was used on this
43-year-old woman undergoing an abdominoplasty as part of the
initial U.S. Food and Drug Administration trials. The unit dispenses
three drops of product at a time directly onto the rectus fascia,
spaced out a certain distance. The abdominal flap is then placed
onto the rectus fascia in the desired location and held in place until
the glue cures. The product was recently approved for the approxi­
mation of tissue in abdominoplasty.
Fig. 30.15 A seroma with percutaneous drainage. This 57-year-old
woman underwent a liposuction and abdominoplasty and developed
a seroma postoperatively, evidenced by a ballotable fluid collection
in the lower quadrants. To treat a seroma, the skin is prepped with
antiseptic, local anesthesia is infiltrated into the appropriate location
(typically the area that is maximally ballotable), and needle aspira­
tion is performed using an 18-gauge needle and a large syringe. Ex­
ternal compression should be applied after the procedure to keep
the pocket decompressed. Typically, multiple sessions of needle as­
piration are needed for resolution.
a
b
Fig. 30.16 Pseudobursa. (a) This 49-year-old man had a large dermal fat graft procedure, with his abdomen as the donor site. Because of
the need for increased thickness of the graft, the pattern was designed more centrally on the abdomen, and the resultant scar placed higher
than our traditional abdominoplasty. He developed a seroma postoperatively. Despite frequent repeated needle aspiration procedures, he
developed a chronic seroma with a clinically obvious periumbilical fullness consistent with a pseudobursa. He presented for resection of
the pseudobursa and bilateral resection of “dog ears.” (b) The capsules of the two pseudobursae were dissected free from the surrounding
normal tissue and marked with methylene blue for easier photographic identification. If possible, a pseudobursa should be resected in its
entirety (including the entire capsule), with drain placement or aggressive placement of space-obliterating sutures to prevent recurrence.