Atlas Kỹ Thuật Hút Mỡ (Atlas of Liposuction)

42
Atlas of Liposuction
FIGURE 4-10
An incision in the lateral gluteal fold can facilitate the
approach for saddlebags and iliac crests liposuction as well
as the buttocks
surgeon to reach almost all the areas situated over the
posterior and lateral aspect of the thigh, the saddlebags,
the buttocks and the hips as well as the inner thighs. The
inconvenience consists of the fact that it is difficult to
suction properly the outer anterior aspect of the
saddlebags and a second incision in the outer thigh will
be necessary. This will allow the complete lateral hip and
thigh suction as well as the iliac crest if necessary and
the lower buttock. Through this incision, the author
conducts the cannula under the gluteal fold as medial as
possible helped in correcting the so-called “banana” which
is due to the hypertrophy and redundancy of the
infragluteal part of the upper posterior thigh. This
technique is useful for the complete circumferential suction
of the area (Figure 4-10).
Prepping and Draping
The patient is prepped from the waist down to the
midcalf area. It is important to visualize the knee and it
might also be necessary to move the leg upwards or
laterally to visualize the amount of fat to be removed.
During the surgery an elevation of the iliac crest will give
visualization in a tangential fashion of the whole outer
buttock and saddlebag area.
Surgical Technique
The usual back and forth motion of the cannula from
the incision point is used proceeding methodically in order
to avoid missing areas, thus obtaining an even result. The
crisscross technique is helpful to accomplish this goal and
to even-out the fat aspiration desired. It is especially useful
in cases of the infragluteal area where the thickest portion
of fat is often present and a large amount of suction is
necessary to obtain a new gluteal fold. 15–20 strokes are
made in each tunnel using a 4 mm or 3 mm cannula at
the beginning of the procedure. The continuation of the
procedure for finer point is done using a 3 mm cannula.
This technique has been done by the author using the
ultrasound or using the vibrating cannula, or using simple,
old-fashioned liposuction cannulas. During the surgery, the
zones are pinched with the left hand and the cannula is
introduced in the middle of the “sausage” to allow proper
suction until a desired thinning is obtained. The suction
proceeds carefully, observing the results during and after
the procedure using visual observation, palpation and
pinch (refer Table 3-2). These three techniques are the
only tools that the surgeon has, and although they are
relatively simple and unsophisticated, their continual use
should lead to satisfactory reduction.
Extent of the Liposuction
Liposuction is performed throughout the area marked for
defatting. It should only extend slightly past the periphery
of the area with the operator taking care not to extend
further beyond an area which has been properly marked.
Any changes in procedure during the operation can be a
mistake especially if the surgeon is inexperienced (Figures
4-11 to 4-13).
Refinements
They consist of feathering around the defatted areas and
are particularly important in the lower thigh and anterior
thigh areas since they might show irregularities if it is not
done properly. Feathering consists of introducing the
cannula with mild suction or without any suction and to
extend the undermining to 1–2 inches (Figures 4-14 to
4-17).
Gluteal Folds
A common problem encountered in saddlebag liposuction
is the need to create a gluteal fold especially when it does

43
Saddlebags
FIGURES 4-11A AND B
The aim of the surgeon is to obtain a gentle, smooth curve of
the lateral aspect of the hips and thighs (dotted line) instead
of the two fatty protrusions over the iliac crest roll and the
lateral thigh. A, B, and C are the imaginary points to join in
tracing the new contour of the thighs. Shading represents the
area to be liposuctioned. The markings are made accordingly
starting at A and ending at C
FIGURE 4-12
Final silhouette to be kept in mind (before liposuction) is
shown by the dotted line. The final result (dotted line)
represents the ideal normal silhouette as opposed to the
actual shape in solid line
FIGURES 4-13A AND B
The “Bermuda shorts” marked up for saddlebags and upper
thigh liposuction. Notice that this depiction of the Bermuda
shorts will mark the deformity called the banana deformity,
which has to be liposuctioned exhaustively to improve the
area
FIGURE 4-14
Two incisions, or three incisions can even be used for
saddlebag suction, however, one usually suffices

44
Atlas of Liposuction
FIGURE 4-15: THE BERMUDA
The liposuction area encompasses the whole surface of the
Bermuda shorts, however, it avoids suctioning the “Bermuda
triangle” marked by 2, which would flatten the buttocks too
much resulting in a pancake bottom. Avoid!!! liposuctioning
the two triangles: (1) The triangle over the femoral neck is
mostly devoid of excess fat. Liposuction in this area may
result in the same “violin” deformity. (2) represents the
Bermuda triangle to be avoided as described by Illouz
FIGURE 4-16
Feathering of the periphery of the suctioned areas
FIGURE 4-17
Often it is important to avoid penetrating the fascia layer as
may happen in trying to reach a distant area and tenting of the
skin with a long cannula. The opening situated too distally will,
in addition, aspirate some subcutaneous fat if the cannula is
pushed against the skin without discrimination

45
Saddlebags
not exist or if it is oriented downwards and laterally. In
order to correct the fold or to even suppress it, greater
suction in the area above and below of fat deposits is
performed and may require a secondary treatment to
obtain a proper reduction.
In summary, liposuction allows large amounts of fat
to be removed through very small incisions.
Technique Overview
Since the early years of liposuction, no notable advance-
ment or change in the technique used for treatment of
this area have occurred except for: (1) smaller cannulas
that take more time, however, prevent deep dents or
depressions; (2) superficial liposuction which improved the
skin contour and irregularities; (3) tumescent infiltration
which affords less bruising and bleeding and more
homogenous results; (4) ultrasound liposuction which for
some surgeons is very helpful in achieving the desired
results; (5) mechanically oscillating cannulas which make
the procedure faster, more efficient and less physically
challenging (Figures 4-18 to 4-24).
Complications in Saddlebag
Suction Lipectomy
This area of liposuction is the most prone to problems,
complications and dissatisfaction. It is difficult to remove
the fatty deposits with a smooth transition from the rest
FIGURE 4-18
Large saddlebags should be extensively defatted. Note that
the estimate will often turn out to be insufficient. Also, notice
the difference between the right and left buttocks here. The
right saddlebag has been suctioned along and between the
dotted lines
FIGURE 4-19
Wrong distribution of fat liposuction in the iliac crests and
saddlebags which results in insufficient removal
FIGURE 4-20
Conservative estimate of the removal as shown here does
not represent the reality of necessary suction
of the thigh. The feathering technique described by Fournier
is indicated. It consists of extending the undermining 4
inches further than the suctioned areas. A blunt cannula
without an opening has been devised for this technique
or a simple cannula without using much suction can be
used for reducing some of the surrounding fat.
The complications consist essentially of waves, irregu-
larities, bumps, depressions especially when the skin has
been well defatted and there is still some overhang because
the skin is adherent above and below the area of suction.
The undermining of the skin should extend beyond this
area of liposuction.

46
Atlas of Liposuction
FIGURE 4-21
A more adequate estimate shows the actual extent of suction
necessary for a harmonious result
FIGURE 4-22
Inadequate removal of a very large patient (5 feet 6 inches,
165 pounds). Approximately 3 liters were removed. The
design of suction should include the periphery of the
infragluteal area
FIGURE 4-23
Extremely large saddlebags and buttocks in obese patients
are often done in two stages for two reasons: (1) The inability
to assess exactly the amount of fat to reduce for an exact
result; (2) In view of excessive amount of fat removed, over
3000 cc. Autologous blood transfusion is helpful in recovering
the blood loss, in addition to the tumescent technique which
will reduce the amount of blood loss extensively. These
techniques have facilitated larger removals without any
difficulties
FIGURE 4-24
The entire extent of the saddlebag and posterior thigh suction
is depicted here. Feathering is indicated at the periphery of
the suctioned area

47
Saddlebags
Complications in saddlebag lipectomy
Dents
Uneven or unequal
Infection (rare, often sterile)
Rare, often sterile abscess
Ways of avoiding complications:
™ Suction from two different points (Crisscrossed)
™ The anterior part of the saddlebags should not be
suctioned from the gluteal crease
™ Careful to stay deep
™ Do not perforate the superficial fascia of the thigh
unless superficial liposuction is undertaken as a full
process of the surgery (Figures 4-25 to 4-37)
TABLE
4-1
FIGURE 4-25
The thin patient with minimal bulges. Even if they are thin,
many patients are still unhappy about unsightly bulges over
their body such as the iliac crests, saddlebags, inner thighs
and poor gluteal folds. In the thin patients with moderate
saddlebags the results can be quite gratifying especially in
cases of thin bodies with only slight excess which might not
be apparent to the untrained eye but may be very important to
a patient such as a dancer or a model. Improving the
saddlebags and the gluteal crease will be a very important
positive gesture in these cases where the beauty of the body
is marred by the defect which become only unquestionably
apparent when one compares the pre- and postoperative
pictures
FIGURE 4-26
Thin 28-year-old female six months postoperative from
saddlebags liposuction. Notice the overall improvement in
the shape of the upper thigh. The only problem is the double
fold or “banana” often seen when insufficient upper thigh fat
has been removed
A particular area of complication is the anterior part
of the suction of the thigh since it leaves a depression
which is difficult to improve. The author prefers an upper
trochanteric incision which allows smoother removal of
fat without causing depressions (Table 4-1).

48
Atlas of Liposuction
FIGURES 4-27A AND B
In thin patients only careful liposuction of the outer medial thigh will avoid the depressed areas shown here. This is the layer of
fat between the skin and the tensor fasciae latae (TFL) that will not absorb any difference thickness since the TFL is very rigid
FIGURE 4-28
Area of liposuction depicted posteriorly. General area mar-
kings. The circle encompasses the extent of the liposuction
FIGURES 4-29A AND B
An additional band of liposuction will help create a well-
rounded buttock and improve the infragluteal fold

49
Saddlebags
FIGURE 4-30
A 26-year-old woman with saddlebags. In patients with
moderate lipodystrophy one has to be more precise in the
suction especially in the area below the buttocks. Some of
these patients should be very carefully selected and warned
about the irregularities that will result from the surgery.
Although these irregularities seem to be more the result of
cellulite, it is nevertheless the duty of the surgeon to either
avoid or forewarn these patients. The new superficial
liposuction technique can be very helpful in these cases to
smooth out the skin surface
FIGURES 4-31A TO C
(A) Preoperative patient; (B) Early postoperative results
showing the ecchymosis and edema in the treated area; (C)
Six months postoperative after liposuction
FIGURES 4-32A AND B
(A) Preoperative 27-year-old woman with large saddlebags; (B) Six months postoperative

50
Atlas of Liposuction
FIGURES 4-33A AND B
(A) Preoperative 26-year-old woman with large saddlebags; (B) Six months postoperative saddlebag liposuction. Notice the
extension of the gluteal fold that is going to fall laterally. Notice the iliac crest excess more prominent postoperatively although it
has not been operated on
FIGURES 4-34A AND B
Liposuction performed in the prone position through a lateral incision in the bathing suit area.
The hip incision will prevent dents and depressions and allow a smooth defatting
FIGURES 35A AND B
(A) Preoperative 35-year-old woman with small saddlebags. The patient was very insistent in having a correction. (B) Ten years
postoperative

51
Saddlebags
FIGURES 4-36A AND B
(A) Preoperative woman body builder with moderate saddlebags, inner thighs, and iliac crests; (B) Postoperative
FIGURES 4-37A AND B
(A) Preoperative 33-year-old woman with moderate inner thighs and saddlebag lipodystrophy; (B) One year postoperative after
liposuction

5 Suction Lipectomy of
the Buttocks
General Principles
Buttock liposuction is most often associated with trochan-
teric suction. The large protuberant buttocks found in some
patients are often embarrassing to them. In the past no
specific treatment was available. Although the Pitanguy type
of surgery devised for treatment of the saddlebags and
buttock lipodystrophy existed, this treatment was
unsatisfactory since it left extensive scars in the gluteal fold.
This operation did not correct the actual deformity creating
a secondary deformity similar to the first one called a violin-
type deformity. Problems associated with this surgery
consisted of large, visible scars, secondary deformities and
A B S T R A C T
Buttock liposuction is most often associated with
trochanteric suction. The large protuberant buttocks
found in some patients are often embarrassing to them.
The actual deformity consists of an extensive
protuberance and thickness of the entire buttocks. In
case of hyperlordosis, the protrusion is anteroposterior
and exaggerated by the patient’s body attitude. The
deformity starts at the lumbar area and ends up at the
gluteal crease often making the crease deeper and more
exaggerated. In this chapter, the gluteal crease anatomy
is described and the procedure of buttock liposuction
is discussed with possible complications.
excessive morbidity following these extensive operations.
Liposuction has brought a new approach that improved the
prognosis. It allows a sizeable reduction of volume mass
without skin excisions and without scarring.
The actual deformity consists of an extensive
protuberance and thickness of the entire buttocks.
Different shapes can be seen. In case of hyperlordosis,
the protrusion is anteroposterior and exaggerated by the
patient’s body attitude. In some cases where only mild
obesity is present, the buttocks seem to have developed
more than the remaining part of the body. The deformity
starts at the lumbar area and ends up at the gluteal crease
often making the crease deeper and more exaggerated.
The gluteal fold can be transformed in its direction going
outwards and downwards instead of upwards, or even
sometimes not existing at all.
Suction lipectomy consists of removal of the bulk of
the fat in the buttocks. This surgery is used for cases, in
particular, called steatopygia. This type of deformity is a
combination of hyperlordosis and over development of
the fatty layers of the buttocks. It is treated in the same
fashion in the African-American or in the Caucasian.
Other causes of the deformity are age, postpartum obesity
and generalized glandular problems such as myxedema.
Indications
Patients who have large buttocks associated with large
trochanteric size and iliac lipodystrophy are good
Adrien E Aiache

53
Suction Lipectomy of the Buttocks
candidates. Often patients who have a narrow pelvis will
develop protuberant buttocks when they are gaining
weight. There are no specific contraindications in reducing
the size of the buttocks except for the usual medical
contraindications for any type of surgery.
Contraindications
Patients who have hyperlordosis with excess spinal
curvature develop a protuberance that appears more
excessive than it is in reality. One should not fall into the
trap of suctioning an area of the buttock which has no
real deformity that could end with deformed smaller
buttocks.
Age
Although present in younger people, the deformity is more
common in middle-aged females with short legs and a
wide pelvis or in people with a narrow pelvis and often
in African-American patients with hyperlordosis.
As the patients get older they develop more cellulite
and cottage cheese skin. Besides the general health
contraindications for this type of surgery, the esthetic
contraindications consist of extreme heaviness or
redundancy with sagginess of the buttocks.
Patients should be advised that short of a complete
excision lipectomy of the lower part of the buttock, they
will have a moderate improvement in their deformity.
Other contraindications are the extreme amount of
dimpling and cellulite present in the buttocks which will
not respond to deep suction but will respond to
superficial suction and cellulite release.
Markings
The patients are marked while standing. The incisions are
placed in the inner third of the gluteal fold at the level
of the hip and lateral to the sacroiliac joint allowing
proper crisscrossing in the suctioning process (Figures
5-1 to 5-6).
The “Bermuda triangle” is spared in order to allow
some roundness of the buttocks after suction. The uses
of the pinch test as well as the techniques of observation,
palpation and inspection are complemented by
photographic documentation in different positions.
The markings are made differently depending on the
area to be suctioned in the vicinity such as the iliac crests,
the saddlebags and the upper thighs. The gluteal fold is
carefully elected and marked.
FIGURE 5-1
Liposuction is performed from a lateral hip incision and a
gluteal fold incision. Making a crease. The liposuction is
performed in the new crease for 2 or 3 inches until proper
flattening and retraction is obtained. A deep crease is
obtained by turning the suction cannula over with its opening
up against the skin and by scraping the dermis of any
residual fat. (1) The crease should not be too long laterally;
(2) Defatting the area above and below the crease is done as
usual; (3) The area immediately adjacent to the crease is
defatted further emptying the subcutaneous fat; (4) The
suction cannula is turned outward in an area along the new
crease which is thinned out extensively in order to create an
adhesion of the skin to the muscle
FIGURE 5-2
Buttock liposuction aims at reducing the overall size and
protrusion of the buttock. It can be done through the lateral
thigh approach as well as the buttock fold. 2–3 cm of
thickness is to be spared

54
Atlas of Liposuction
FIGURE 5-3
Liposuction of the thighs in the area immediately below is
useful and although it will help in reducing the overall area, it
may also contribute to the loss of support of the buttocks and
a resulting sagging and flat buttock
FIGURE 5-4
Crisscrossing from two incisions is useful. Incisions can be in
the buttock fold and the lateral iliac area (left). In iliac crest
suction, the suction can be in the lateral iliac area and the
sacral area (right)
FIGURE 5-5
Buttock liposuction. The area shown indicates the extent of
suctioning for proper shaping of the buttock
FIGURE 5-6
Buttock liposuction avoids the central triangle in order to keep
some roundness to the buttock and prevent flattening. The
lateral hip triangle (B in Fig. 5-5) is often preserved since it is
already depressed. The liposuction process involves the
whole buttock, avoiding the area of the “Bermuda triangle”
situated in the inner part of the buttock and the outer triangle
at the end of the trochanter is avoided in the same manner

55
Suction Lipectomy of the Buttocks
Anesthesia
General anesthesia is most often complemented with a
solution of diluted epinephrine for bloodless surgery in
addition to the tumescent infiltration of the area. Local
anesthesia is sometimes possible depending on the extent
of the area to be reduced and the psychological attitude
of the patients as well as their individual pain tolerance.
The usual dilution of 0.1% xylocaine with epinephrine
1:1,000,000 can be used as a tumescent infiltration.
Prepping and Draping
After the patient has been anesthetized, draping is done
with the patient in the prone position with the arms
extended in a comfortable way. Draping consists of four
drapes applied around the buttock area.
Technique and Instruments
Four and three mm cannulas are used for the procedure.
The smaller cannulas are used for feathering and
superficial suction for proper control of the suction. The
suction is accomplished leaving a blanket of fat of
approximately 1–2 cm of thickness. This is checked by
using the pinch technique, observation and palpation.
Crisscrossing is performed as usual, and at the completion
of the procedure feathering is performed superiorly and
laterally to allow a better slope of the skin from the
suctioned area to the non-suctioned area (Figures 5-7
and 5-8).
Closure
5-0 nylon or 4-0 chromic sutures are used. Garments are
then applied over a thick bandage for drainage of the
area.
Discussion
Liposuction of the buttocks has proven to be an effective
new treatment for a deformity which was uncorrectable
in the past.
Morbidity is low and postoperative complications are
minimal. Also, the success rate obtained by this new
procedure is excellent.
The Gluteal Crease
An important aspect of the crease:
„
It should be a noticeable feature
„
It should have pleasant “smiling” configuration and
direction
„
It should be of a certain pleasing length ending smoothly
on the lateral thigh
„
It should be symmetrical in its position and orientation
(Figures 5-9 to 5-11).
Gluteal Crease Anatomy
The ileocutaneous ligament of Luschka holds the skin to
the ilium with a fan-like structure giving the crease its
shape on the buttock. From an esthetic point of view it
FIGURE 5-7
The creation of the fold is achieved by suction of the gutter
below the buttock and thinning of the skin in the exact
trajectory of the fold by turning over the cannula with the
opening up
FIGURE 5-8
In making a crease the fold is designed in the proper
direction. Defatting above and below it is then performed. The
cannula is thrust between the grasping fingers of the left hand
and the “sausage-shaped” fold is defatted thoroughly

56
Atlas of Liposuction
FIGURE 5-9
There is often no need to lengthen the gluteal fold, otherwise
it will go too far laterally
FIGURES 5-10A AND B
Consequences of buttock and saddlebag liposuction showing
prolongation of the buttock fold
FIGURE 5-11
The gluteal fold should not be too long laterally since it does
not improve the buttock from an esthetic point of view
is questionable if the presence of this is important. It is
less often seen in tall, thin women with long bodies and
lordosis.
It is fair to conclude that the existence of the gluteal
crease is synonymous with the beginning of ptosis of the
buttock as much as the inframammary fold is a sign of
ptosis of the breast. The gluteal crease, being a fixed
point, will show ptosis of the buttocks in cases of any
excess or looseness and has been compared by others to
the inframammary folds.
The “inverted” buttock fold was found undesirable by
some surgeons; however, with proper examination with an
understanding of the young pelvis it will be a commonly
accepted characteristic associated with small buttocks, flat
on the oblique view and a very short gluteal fold. To
achieve these goals in creating a young-looking buttock the
process is as follows (Figures 5-12 and 5-13):
1. The accentuation of the crease is marked by making
proper markings as a first step. The new crease is elected
and marked. It should be oriented slightly outwards and
upwards and be of proper length going up to the outer
third of the thigh.
2. A wide strip is suctioned above the level of the new
crease for approximately 1–2 inches depending on the
size of the buttocks.
FIGURE 5-12
Upper markings on the right buttock show the new location of
the gluteal fold in a patient who had uneven folds

57
Suction Lipectomy of the Buttocks
FIGURE 5-13
Liposuction in the area of the new fold is done thoroughly
above the old fold and slightly above the new fold
3. Below the elected crease, a large area is suctioned bearing
in mind the shape of the banana which develops below
the crease if the upper thigh is not entirely well defatted.
4. At the level of the crease after thorough defatting, the
cannula is turned over with the opening up against the
epidermis and the skin is scraped of its dermal fat, thus
permitting adhesions to form at the level of the new
crease (Figures 5-14 to 5-17).
FIGURE 5-14
After liposuction of the saddlebags and buttocks there may
be a difference in the height of the buttocks. Correction is
done by suctioning the area above the gluteal fold up to the
new fold location. Recently, a new tendency is emerging in
the Western young population which is mirrored by prevalent
magazine exposure showing flat buttocks without any gluteal
crease. During buttock liposuction, attempts have been made
to attain that goal to avoid the most lateral area of the upper
thigh and at its junction with the buttocks
FIGURE 5-15
Typical elastoplast dressing after buttock suction, however,
lately garments are preferred for the postoperative care
FIGURE 5-16
Markings for infragluteal suction and raising the gluteal
crease. The markings represent the level of the new crease
and the area of suction needed to obtain it
FIGURES 5-17A AND B
(A) Preoperative 26-year-old woman who underwent
saddlebag and buttock suction elsewhere ending up with
asymmetrical buttock fold; (B) Postoperative result after
raising the right gluteal crease

58
Atlas of Liposuction
FIGURES 5-18A AND B
(A) Preoperative 38-year-old woman with extensive lipodystrophy, peau d’orange, cellulite, flabby skin and poor skin tone.
Extremely large deposits may require repeated removals with the tumescent technique and at times an autologous blood
transfusion to be able to remove a larger amount of fat. Note the extent of markings; (B) Postoperative after one suction lipectomy
that yielded 2300 cc of fat and blood mixture. No blood was given. She returned for a second suction which was satisfactory
Buttock liposuction complications
Problems:
™ Uneven level
™ Double buttock
™ “Banana”
™ Irregular gluteal fold
™ Dents, depressions
™ Long gluteal fold
To avoid them:
Even work with careful suction and appreciation of the
suction by observation and pinch test
TABLE
5-1
Buttock Liposuction
Complications
Besides the general health complications consisting of
shock, bleeding, infection, hematomas, seromas and
esthetic difficulties no other specific complications except
for have been encountered. The author has seen some
large ecchymoses which have resolved spontaneously
(Figures 5-18A and B).
The main complications following the surgery are as
follows (Table 5-1):
„
Flat buttocks (especially if the Bermuda triangle has been
suctioned out and has not been avoided).
„
Asymmetry in shape of the buttock and the buttock folds
with folds not pleasantly made, either too curved or too
straight, which is a problem difficult to correct.
„
Double fold: The phenomenon of the double fold or
so-called “banana” is rather difficult to correct since any
removal of fat between the two folds will not always
result in correction of the lower fold. The correction of
the banana has been so far complete suction of the fat
that is present in its underlying surface. The best
treatment is usually that of prevention and the author
believes that if one leaves a central column of fat in the
posterior thigh for support of the buttock, the banana
phenomenon will not appear and flatness of the buttock
will also be prevented (Figures 5-19 to 5-28).

59
Suction Lipectomy of the Buttocks
FIGURES 5-19A AND B
Treatment of the banana secondary to gluteal fold
liposuction. An important structure to preserve consists of the
“pillars” situated under the buttocks preventing their slide and
their flattening. Treatment of the banana secondary to gluteal
fold liposuction will have to be performed in an effort to
achieve vertical tunnels of suction across the gluteal fold and
in view of the fact that too many incisions are prescribed by
Giorgio Fisher, the author is using a long 4 mm cannula or a
3 mm cannula introduced from the sacral dimples. The
bananas are then suctioned through perpendicular strokes
leaving some vertical elements to suspend the thigh and
avoid a collapse of the buttocks and a secondary banana
appearance
FIGURE 5-20
The extent of the liposuction made to allow support of the
buttocks preventing the flatness secondary to loss of the
thigh pillars. The tip of the triangle should be wide enough to
provide a good cushion
FIGURE 5-21
Proper liposuction from the hip to obtain the new buttock
shape
FIGURE 5-22
Buttocks showing the ideal new shape indicating the lack of
subgluteal groove

60
Atlas of Liposuction
FIGURES 5-23A AND B
(A) Preoperative 29-year-old woman; (B) Postoperative
following saddlebag and buttock liposuction
FIGURE 5-24
The treatment of the banana secondary to gluteal fold
liposuction can be added from a sacral incision to go across
the fold and reduce the banana size
FIGURE 5-25
A patient who underwent liposuction and who is still left with
bilateral small “bananas” and multiple areas of dimples due to
cellulite
FIGURE 5-26
Patient has had liposuction and is left with multiple dents,
irregularities with the banana protuberance and an uneven
removal of the saddlebags
FIGURE 5-27
Expected result to be obtained after the reduction of the
buttocks
FIGURE 5-28
Areas of suction in order to reduce the anteroposterior
protrusion of the buttocks

6 Suction Lipectomy of
the Thighs
General Principles
Thigh liposuction is often associated with trochanteric
suction. The large thighs can be protuberant, especially
anteriorly where they create a special type of deformity,
and posteriorly, especially located in the infragluteal area,
and often, of course, in the medial part of the thighs
which is going to be represented after that. The treatment
consists of liposuction although in some cases it has to
be associated with an excision of the inner thighs if the
skin is in excess. Anteriorly and laterally, no incision has
been found necessary. The operation can correct the actual
deformity and can improve the appearance and the
A B S T R A C T
The thighs are an important area of esthetic concern
for women. Liposuction of the thighs is indicated for the
deformities mentioned above which have overdeveloped
thighs and thighs that are overdeveloped in a limited
area such as the anterior portion, lateral portion or the
medial portion. Liposuction of the thighs is
contraindicated in older females presented with
redundant, irregular, cascading skin. The results for these
cases would be far from acceptable, although with
superficial liposuction a moderate improvement can be
obtained. The indications, technique and possible
complications are discussed.
thickness of the thigh, especially in cases of “thunder
thighs”, and liposuction has really improved the treatment
of these areas. The actual deformity consists of an
extensive development of the fat in the anterior, medial
and posterior aspect of the thigh, which can be treated
with liposuction (Figures 6-1A to C). The deformity starts
in the area immediately below the buttocks and anterior in
the groin and ends up just before the knee deformity. This
can be improved and often improvement of the knee
suction is necessary to continue to improve the appearance
of the thighs themselves (Figures 6-1 and 6-2).
Indications
People who have large thighs and often patients who have
narrow pelvises develop large legs and thighs, and they
want this area to be improved.
Contraindications
Only in cases where the thighs are extremely developed
and a problem could occur if patients have excess skin
and overlapping of the thighs, which is a rare problem.
Age
Any age is possible in these patients up to the age where
a patient can be done safely if their cardiovascular system
is stable.
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62
Atlas of Liposuction
FIGURES 6-1A TO C
(A) Preoperative 42-year-old woman with generalized overdevelopment of the thighs. Large thighs can be reduced by
performing circumferential suction in a single operation or in multiple stages if the extraction should exceed 3000 grams;
(B) Extensive bruising of the inner left thigh showing the extent of the liposuction for reducing the whole inner thigh; (C) Six
months postoperative after liposuction on the lateral, medial, anterior and posterior thighs in four consecutive procedures under
local anesthesia
FIGURE 6-2
Markings show the extent of liposuction needed to accomp-
lish reduction in posterior thigh volume
Markings
Patients are marked while standing and very often
segments can be performed since there is a large removal
of fat in these areas and no excess fat removal should
be performed for fear of losing blood and fluid to an
extent that is difficult to contain by the anesthesiologist
(Figures 6-3 to 6-8).
FIGURES 6-3A AND B
(A) Marking for anterior and lateral thigh liposuction; (B) Two
years postoperative
Anesthesia
General anesthesia is most often used and complemented
by a solution of diluted xylocaine with epinephrine for
bloodless surgery in a solution called either superwet or

63
Suction Lipectomy of the Thighs
FIGURE 6-4
Markings showing extent of liposuction need to accomplish
a significant reduction in medial, posterior and lateral thigh
volume
FIGURE 6-5
Anterior thighs: The reduction of the anterior thigh will
contribute to an overall reduction in thigh circumference
enhancing its appearance. Incisions are made in the groin
and above the patella
FIGURE 6-6
Superficial liposuction technique through an inguinal incision.
This allows anterior thigh liposuction and tightening of the
anterior thigh skin
FIGURE 6-7
Crisscrossing of the anterior thigh in order to obtain a smooth
even surface

64
Atlas of Liposuction
FIGURES 6-8A TO C
(A) Preoperative patient with excessively large anterior thighs; (B) Following reduction of anterior thigh; (C) After further
liposuction
tumescent anesthesia. The usual dilution of 0.1% xylocaine
with epinephrine 1:1,000,000 can be used as a tumescent
infiltration.
Prepping and Draping
After the patient has been anesthetized, draping is done
leaving the entire legs free, prepping the feet, and the
perianal and vaginal area for proper sterile technique.
Technique and Instruments
The 4 mm and 3 mm cannulas are used for the
procedure. The smaller cannulas are used for feathering
and for superficial suction for control of the suction. The
suction is accomplished leaving a blanket of fat
approximately 1–2 cm of thickness, especially in the
medial area where the skin is thinner and in the lateral
area where the fascia is ending up in the midthigh area.
Crisscrossing is always performed as usual and at
completion of the procedure feathering is performed to
complete the surgery. Closure is performed with 5-0 nylon
or 4-0 chromic sutures which are removed in
approximately 1 week’s time (Figures 6-9 to 6-11).
Discussion
Liposuction of the thigh has proven to be an effective
treatment of a deformity that was uncorrectable in the
past. Morbidity is low and postoperative complications are
minimal.
Complications
Possible complications are listed in Table 6-1.
TABLE
6-1
Possible complications
Anterior thighs:
™ Depressions
™ Insufficient removal
™ Bumps
Inner thighs:
™ Irregular skin
™ Adhesions and distortions
™ Excess skin flabbiness means irregular results
Lateral thighs:
™ Depressions
™ Insufficient removal
™ Bumps

65
Suction Lipectomy of the Thighs
FIGURE 6-10
Typical appearance of anterior thigh lipodystrophy with
anterior convexity
FIGURE 6-11
A 28-year-old woman with anterior fatty deposits
FIGURE 6-9
Combination of anterior thigh liposuction and saddlebag
liposuction done through different incisions

7 Liposuction of the
Inner Thighs
General Principles
Treatment of the inner thighs by liposuction can bring
considerable improvement to the esthetic appearance of the
female body (Figure 7-1). Before the advent of suction,
the only treatment consisted of large trochanteric excisions
leaving excessive scarring going from the inner anterior
A B S T R A C T
Treatment of the inner thighs by liposuction can bring
a considerable improvement to the esthetic appearance
of the female body. Before the advent of suction, the
only treatment consisted of large trochanteric excisions
leaving excessive scarring going from the inner anterior
aspect of the thigh until the inner posterior aspect.
Indications include patients who are simply obese with
the inner thigh excess as a part of their general obesity
which includes the outer thighs, the whole leg and thigh
as well as the whole body, patients having difficulties
with touching thighs due to narrow pelvis and due to
this configuration the slightest amount of obesity in the
inner thighs creates a nuisance, and patients with modest
fat excess consisting only of a soft and flabby texture
in the inner thighs which are touching. The patients
should be forewarned of the very real possibility of
creating dents and depressions.
FIGURE 7-1
Markings showing the inner thigh approach for suction of the
medial thigh
aspect of the thigh until the inner posterior aspect.
Liposuction has brought a great advance in this field.
Indications
Several types of patients are good candidates for this
procedure. Firstly, patients who are simply obese with the
inner thigh excess as a part of their general obesity which
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67
Liposuction of the Inner Thighs
includes the outer thighs and the whole leg and thigh as
well as the whole body. In some cases, the excess of inner
thigh development is such that it prevents patients from
walking properly so that they have to walk with the legs
abducted, a difficult and awkward task. The second types
of patients, for this liposuction, are built in such a way as
to have difficulties with touching thighs. These patients have
narrow pelvises and due to the configuration, the slightest
amount of obesity in the inner thighs creates a nuisance.
The third case is of a modest excess consisting only of
a soft and flabby texture in the inner thighs which are
touching. These patients will often require treatment only
from an esthetic point of view. This deformity is the most
common.
A special characteristic of inner thigh fat is the deep
softness making it easy to extract by liposuction. Also,
note that the skin of the inner upper thigh is often soft
and very flabby. These two factors mean that the operator
will have to be extremely cautious to prevent large
depressed areas.
Caveats
The patients should be forewarned of the very real
possibility of creating dents and depressions.
Markings
The patient will be marked in the standing position and
in the lying down position. In the standing position, the
patient will be standing with her knees touching so the
amount of fat excess and “thigh kissing” can be noted
properly, marking the upper part of the excess as well as
the lower aspect. This should be corroborated by
positioning the patient with the legs abducted, then
marking again the excess from the upper to the lower part
especially delineating the amount to be removed, bearing
in mind the fact that a smooth transition should be
obtained at the junction of the excess with normal areas.
The patient should be marked in the lying down
position with the legs abducted and lying on the side. This
will exactly indicate the lateral and medial aspect to be
extracted as well as the amount of hanging skin when the
patient has her legs outstretched while she is lying on one
side (Figures 7-2 to 7-7).
The topographic map can be drawn with the pinch
test, a helpful tool in determining the amount of fat to
be removed.
The fat thickness will be variable depending on the
case. This should be taken into consideration before
starting the procedure. The pinch test is used as described.
FIGURE 7-2
Posterior approach infragluteal incision, inner thighs: Parti-
cularly easy to extract is the fat from the medial thigh area.
One, however, has to persist using multiple strokes until the
result is visibly achieved. 4 mm and 2 mm cannulas are used
and the depth of suction must be controlled at all times. The
remaining fat later should be thinner than the posterior or
lateral thigh
FIGURE 7-3
Prone position used for inner thigh suction in conjunction with
saddlebag and knee liposuction from a medial inner thigh
incision
In addition, it is performed in the adjacent tissues in order
to estimate the difference with the areas of excess.
Incisions
The incisions can be located in the inner part of the groin
and a more convenient location is the lower third of the
thigh or in cases where lateral thigh suction is done, the
medial part of the infragluteal crease. These multiple
approaches allow the crisscross technique (Figures 7-8 to
7-12).

68
Atlas of Liposuction
FIGURE 7-4
Inner thigh liposuction through an inferior gluteal fold
FIGURE 7-5
Contrary to previous opinions, this area must be done
superficially with a small caliber cannula for best results
FIGURE 7-6
Proper measurement of the inner excess is done with the
patients lying on their side. The elevated leg allows judgment
of the skin flaccidly and redundancy
FIGURE 7-7
Surgery is often performed in the same position on the lower
thigh while the upper thigh is folded anteriorly for a proper
approach
Anesthesia
General anesthesia is preferred for most cases although
in some cases, local anesthesia could be useful. The local
anesthesia formula is the same as for the other cases.
Prepping and Draping
The patient is placed in the supine position if other
procedures are also to be done and the inner thigh suction
is performed from the lower third incision. In cases where
liposuction is utilized for the saddlebags, the prone position
will also be adequate. Cases under local anesthesia are
convenient since the patient can be moved around to the
prone, supine and lateral decubitus position with the legs
stretched up allowing suction of the whole inner aspect of
the thighs under direct vision. The 4 mm incision is made
and the cannula is introduced from all these areas
described. The suction is done in the usual fashion using
multiple strokes in each tunnel area and repeating the
maneuver until a full thinning out of the zone is done.
Another useful technique is to apply the palm to the skin
and suction under the palm. If an area cannot be
completely defatted, the skin is pinched and it is held as
a “sausage” to allow the cannula to penetrate between the
fingers. In cases under local anesthesia, multiple changes

69
Liposuction of the Inner Thighs
FIGURES 7-8A TO E: INNER THIGH LIPOSUCTION
(A) Preoperative markings. In some cases there is an absence of mid medial thigh fat although the upper and lower fat areas are
overdeveloped. Liposuction should not include the mid portion otherwise it could lead to a bowed-leg appearance. Two
incisions are made with the intent of sparing the midthird; (B) A few weeks previously she underwent an abdominal liposuction
with vertical scar revision; (C) One year postoperative after inner thigh and knee liposuction; (D) Areas that were treated with
liposuction; (E) After upper and lower thigh liposuction, the medial part of the inner thigh is avoided. It might eventually need
suction too since it may present an unsightly bulge

70
Atlas of Liposuction
FIGURE 7-9
Anterior inner thigh suction can be accomplished through a
groin incision on the patient supine
FIGURE 7-10
Anterior thigh liposuction can be combined with an inferior
thigh approach that is useful for knee liposuction as well
FIGURE 7-11
The patient is positioned in the lateral decubitus with the
upper leg stretched-out anteriorly to allow a proper approach
to the inner thigh of the opposite leg
FIGURE 7-12
Different positioning of the legs for inner thigh suction

71
Liposuction of the Inner Thighs
FIGURES 7-13A TO C
(A) Markings showing the area of liposuction and the feathering for inner thighs; (B) Six months postoperative; (C) One year
postoperative. These results improve in time if the patient does not gain weight
FIGURES 7-14A AND B
(A) Extensive area of liposuction will allow reduction of the
whole inner thigh from the groin to the knee. The outer line
indicates the area of feathering. Also notice the two anterior
incision points near the groin and on the anterior inner knee
above the patella; (B) One year postoperative after she also
underwent suction lipectomy of the knees
in the position of the patient will help in achieving a
comfortable result (Figures 7-13 and 7-14).
Refinements
Feathering the areas anterior, posterior and inferior to the
zone that is suctioned is performed with low suction and
without suction to allow a good junction with the non-
liposuctioned tissues. The multiple positions of the leg and
thigh will allow visualizations of the results and the
touchup necessary to obtain a smooth junction and
contour. The result is checked by observation, palpation
and use of the pinch test as for any case of liposuction.
Closure, Dressings and
Postoperative Care
Suturing using 4-0 plain catgut and Steri-strips is done and
the garments are applied for proper suspension and
coaptation of the skin. Postoperatively, antibiotics are
given prophylactically as well as pain medication. The
strips are changed two days after surgery and then after
1 week.
Discussion
Treatments for inner thigh excess are a great progress in
the treatment of unsightly fatty deposits. In the past, large
excisions of skin with fat excision were necessary. At this
point, only in cases of extreme redundancy and flabbiness
of the inner thigh skin can these surgeries be performed
again. The treatment with liposuction alone presents fewer
complications than other techniques and few problems are
encountered as well as few revisions which were necessary
at times.

8
Combination of
Techniques: Liposuction
with Trochanteric
Lipectomy
General Principles/Introduction
The shape of the buttocks, hips and thighs, and the
quality of the skin of these areas depends on ethnic
background, obesity and age as well as past pregnancies.
These factors often results in excessive development
of the hips, buttocks and thighs. The treatment in the
past consisted of large excisions of crescents of skin from
A B S T R A C T
The shape of the buttocks, hips and thighs, and the quality
of the skin of these areas depends on ethnic background,
obesity and age as well as past pregnancies. These factors
often result in excessive development of the hips, buttocks
and thighs. The treatment in the past consisted of large
excisions of crescents of skin from the lower part of the
buttock to the upper part of the thigh and from the
iliac crest to the inner buttock area. These large excisions
resulted in complete removal of the offending excesses,
however, the scars from these techniques were usually
extensive. The size of the buttocks and the saddlebags
can be markedly reduced with liposuction and the
deformities can be improved. Some cases require a
combination of procedures with liposuction and excisions.
Trochanteric lipectomy, liposuction and inner thigh
liposuction combined with dermatocrurolipectomy are
discussed in this chapter.
the lower part of the buttock to the upper part of the
thigh and from the iliac crest to the inner buttock area.
These large excisions resulted in complete removal of the
offending excesses, however, the scars from these
techniques were usually extensive (Figures 8-1 to 8-3). In
addition, the various complications were difficult to treat.
The problems were many—scar unevenness, hypertrophy,
irregularities of the thighs, widening of the scars with
irregular shapes of the buttocks and sometimes even
FIGURES 8-1A AND B
Markings for a combination of saddlebag suction and
excision. The solid thick line indicates the skin excision
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73
Combination of Techniques: Liposuction with Trochanteric Lipectomy
FIGURE 8-2
In combination lipectomy and suction, the liposuction is
performed in the areas to be improved then the crescent
excision is made
FIGURE 8-3
Saddlebags combination. (Left buttock) Total area of
defatting and feathering at the periphery; (Right buttock) Area
of excision of skin and fat down to the muscle. II, III: Area of
liposuction (A) Iliac crests; (B) Buttock suction; (C) Upper
posterior and lateral thigh
recreation of the original deformity (such as the hourglass
shape). Other complications included skin slough, sliding
of the flaps, seromas, hematomas and wound breakdown.
With the liposuction technique, the field has suddenly
opened for young women who are now able to achieve
their dream of obtaining a shapely silhouette without
extensive scarring. The size of the buttocks and the
FIGURES 8-4A AND B
(A) Preoperative 54-year-old woman admitted for combina-
tion procedures with saddlebag excision, buttock liposuction
and iliac crest liposuction; (B) Six months postoperative
results showing the extensive scars caused by the excision.
Even when liposuction is performed, the so-called “violin
deformity” can recur. One has to be careful in planning the
removal of fat in the vicinity of the lipectomy scars to avoid
this deformity
saddlebags can be markedly reduced and the deformities
improved.
However, many patients have too much skin sagging,
redundant skin, flabbiness or even skin folding. These
patients are usually older and have lost weight. In these
patients, the return to the large skin excision method is
necessary (Figures 8-4 and 8-5).
It is then for these cases that the combination of
older techniques with the new technique of liposuction
has been offered. It can be given to patients where one
has been unable to achieve good results without the
excisions or unable to achieve some reducing of the fat
areas without suction.
Trochanteric Lipectomy and
Liposuction
Indications
Good candidates for the combined techniques are those
who cannot be treated by liposuction alone and who
would benefit from trochanteric lipectomy. These are
usually patients who have a certain degree of localized
obesity around the hips, upper thighs, inner thighs and,
in addition, patients who do not have enough skin turgor
and tonus.
A second group is the patients who have lost weight,
who do not have excess fat but a large amount of
flabbiness.
Finally, the patients with a very large amount of fat
with excesses of the hips, buttocks and thighs might
benefit from the combined treatment if the surgeon

74
Atlas of Liposuction
FIGURES 8-5A AND B
(A) Preoperative 52-year-old woman; (B) One year postoperatively after saddlebag excision with liposuction and lift of the inner
thighs
knows that liposuction will end up with extremely flabby
tissues.
Caveats
Patients should be forewarned of the usual difficulties
associated with suction lipectomy and trochanteric
lipectomy such as irregularities, waving, over-removal or
under removal in addition to excessive scarring, seromas,
hematomas, infection and even widening of the scar.
Markings and Preoperative Medications
Markings are made on the erect patient. The markings
indicate the areas to be suctioned out at the periphery of
the ellipse for proper tightening of the tissues. The ellipse
marking indicates the exact amount of tissue to be excised
according to the surgeon’s estimate. The marking will be
extended laterally to delineate an additional triangular
excision starting at the groin and going down to the
superior third of the thigh if necessary. In addition,
markings indicate the areas of feathering at the periphery
of the excision and defatting.
Location of Incisions for Liposuction
The incisions are marked anywhere along the line of
ellipse excision in addition to the line in the anterior thigh,
if necessary. The second incision for crisscrossing
sometimes will consist of a sacral dimple area incision for
proper defatting of the lower buttock area before closure.
Anesthesia
General anesthesia is the only way to carry out this
process and treat these patients. Only minor revisions can
be performed with local anesthesia.
Prepping, Draping and
Surgical Technique
The patient is prepped and draped in the routine manner
in the prone position. First the suction lipectomy is
performed from any incision along the lines of the ellipse
excision. The suction is performed in the usual manner and
crisscrossing is done from other vantage points in order
to obtain a smooth removal above and below the zone of
excision. It is performed with a 4 mm cannula and a 3 mm
cannula for finessing. After the suction is done, excision
of a large crescent of skin is performed. The skin is incised
down to the gluteus muscle leaving no undermined skin
and leaving a certain amount of fat on each of the flaps
in order to reapproximate the flaps in a smooth even
fashion avoiding inversion or depression of the scar.
Closure
Once all areas have been excised, closure of the superficial
fascial system (SFS) is performed in layers using 2-0 vicryl
sutures followed by subcuticular closure of 3-0 or 4-0
vicryl. Often no skin closure is necessary and tape is
applied in the area. The closure usually does not leave any
dead space below it so that rarely a drain will be necessary.

75
Combination of Techniques: Liposuction with Trochanteric Lipectomy
Postoperative Care
The patient is discharged and sent in lateral decubitus
position or prone position to avoid pressure on the
wounds. They are allowed to ambulate as soon as
physically able.
Discussion
Combining liposuction with trochanteric lipectomy has
proven useful in cases that lie at the limit at each
respective technique. The problems associated with these
techniques are the usual ones associated with lipectomy.
The liposuction has given a new tool to the treatment of
these deformities without adding much to the morbidity.
Although the technique leaves extensive scarring, it has
found to be the only treatment available in certain difficult
deformities. Since the conventional surgery of trochanteric
lipectomy has been followed in the past by severe
problems, the acceptance of this new combination of
techniques is still low and the percentage of patients
operated with this method is still relatively small.
Inner Thigh Liposuction
Combined with
Dermatocrurolipectomy
The technique of dermatocrurolipectomy has been
improved since the work of surgeons on the subject has
helped in reducing the scars which were always a problem.
Better anchoring techniques of the skin are the main
reason for the improvements.
The shape and configuration of the inner thighs
depend on many factors including obesity, ethnic
characteristics and variation in the looseness of the skin.
This ends up in relaxation of the skin to a “nonreturn
stage”. One of the most important factors is age itself,
although inner thighs can be redundant and flabby early
in life (Figures 8-6 to 8-9).
Because the skin is soft, pliable, thin and hairless, it
seems to be an area of early redundancy and ptosis. The
treatment in the past consisted of large excisions of skin
excess with skin closure.
Many modifications have been made by authors, such
as Lockwood, who have attempted to prevent the early
recurrences and problems of inferior migration of the
scar. Although these scars are inevitable, they were in the
past too conspicuous to gain wide acceptance by the
female population. This conspicuousness of the scar was
FIGURE 8-6
Anatomy of the perineum showing Colles’ fascia and its
relation to the inner thigh muscles. (Source: Reproduced with
permission from Gray’s Anatomy, 30th edition. Philadelphia:
Lea & Febiger; 1985. p. 503)
FIGURE 8-7
The trochanteric and thigh lipectomy as per J Lewis
performed in the past
due to the tension effected by leg gravity in addition to
the fatty excess tugging the skin down giving a widened,
hypertrophied, discolored scar migrated below the line of
bathing suits in addition to a tight pull over the vulva
popping the vulva open. The combination of suction with
this new technique of suturing the flap has improved the
postoperative appearance. In addition, the secondary
effects of real tightening of the inner thighs in removing
the stigma of “old- age cellulite” with crumpled, cascading

76
Atlas of Liposuction
Indications
Candidates for the dermatocrurolipectomy technique are
older women with excess skin and redundancy in addition
to fat excess.
Caveats
Patients should be warned about the still present
possibility of scar migration and widening as well as the
potential for hematomas, seromas and even skin slough
with this new technique.
Markings and Preoperative Preparation
Made on the erect patient, the markings first indicate the
higher part of the excision. It should start from the
midinguinal point anteriorly, stay high in the sulcus and
away from the labia majora, and end up approximately in
the middle posterior subgluteal fold. The lower part of
the excision is placed where the skin excision will be done.
This is measured by pulling and pinching on the skin to
approximate the skin edges and elect a proper location
of the excision (Figures 8-10A and B).
The markings will indicate the area of suction to be
performed inferiorly, anteriorly and posteriorly joining in
the middle of the thigh. The lower part of the markings
should always be taken into consideration during the time
of surgery and left until the end of the procedure since
it is possible to excise too much skin or too little skin.
In very large excisions a small triangle can be made,
ending up in a vertical scar posteriorly, which will help
in approximating the lateral excesses of the skin. The
markings also indicate the area of suction which would
be performed either at the beginning or at the end of
the excision of the skin.
Anesthesia
General anesthesia is the most common. The patients are
usually placed in the prone position allowing the first part
of the surgery to be performed. They are then turned
over in the supine position to end up with the inner and
anterior part of the excision.
Surgery
„
The patient is under anesthesia in the prone position.
Suction lipectomy of the inner thigh is then performed
thoroughly through that inner posterior crease. This step
of the procedure is performed with the knowledge that
FIGURE 8-8
Dermatocrurolipectomy performed in addition to suction
lipectomy. On the left the excision of the skin ellipse is
performed from the anterior groin area along the ischial
tuberosity and posteriorly into the gluteal fold. On the right,
showing the scar resulting from this type of excision
FIGURES 8-9A AND B
Stages of the dermatocrurolipectomy: (A) Incision going from
the groin to the crural crease and the ischial area and, on the
left side of the patient, undermining and excision of the lower
skin flap with identification of Colles’ fascia; (B) Closure of the
skin and dermis with fixation to Colles’ fascia
skin has been helpful. The acceptance by older patients
unwilling to wear bathing suits in the past has been
gratifying.
A
B

77
Combination of Techniques: Liposuction with Trochanteric Lipectomy
the flap to be excised does not need suction and that
the suction itself should be extensive enough to correct
the deformity and to allow a relaxation of the inferior
flap that will be elevated. It extends as far as the excess
of fat has been estimated.
Excision of the posterior part of the ellipse is then
started and it encompasses the whole thickness of the inner
thigh skin down to the fascia of the pelvic diaphragm. No
undermining is done and the lower flap should easily reach
the upper flap at the level of Colles fascia.
After surgically cleaning up the area that has been
exposed and removing the excess fat tissue, further
dissection is done in order to identify Colles fascia; this
is accomplished by following the fascia of the adductor
and by feeling the inner ramus of the pelvis which is the
higher part of the anchorage of the skin.
According to Lockwood, this step is the most
important one in order to suture the deep dermis of the
lower flap to a stable area of the groin in order to
prevent scar descent. The sutures consist of 2-0 PDS and
the skin is closed with 3-0 nylon.
„
Once the surgery is done posteriorly, the patient is turned
over in the supine position, prepped and draped, and the
legs are abducted in a frog-leg position and held in
stirrups in the gynecological position. This position will
allow the completion of the excision of the triangle of
skin anteriorly and allow proper suturing to the sulcus
area.
„
As far as the skin flap itself is concerned, a modification
of Lockwood’s excision prevents the widening of the
pubic hair area. It consists of an angled excision of
anterior skin with vertical excision up to the groin itself
and horizontal incision at the groin laterally.
FIGURES 8-10A AND B
(A) Preoperative 52-year-old woman with lipodystrophy and flabbiness of the inner thighs; (B) Six months postoperative after
inner thigh dermatocrurolipectomy
Continuation of the ellipse of skin excision is
performed down to the fascia of the adductor muscle.
The identification of Colles fascia is further performed in
the supine position before being able to approximate the
lower flap to it.
„
Following the excision of skin, undermining is done for
1–2 inches to allow the inner thigh ellipse to be
positioned to the fascia of the muscular layers occupying
this area. The fat is aspirated over the fascial area for
proper identification of the deep fascia in its extension.
No major nerves or vessels are present in that area.
The superficial fascia and the dermis of the lower flap
are then elevated and sutured to Colles fascia and the
ischiopubic area in order to sustain the flap and hold it
permanently. This anchoring technique is done with a few
strong sutures of 2-0 PDS, then the skin is closed and
bandages applied. The bandages should be changed often
or done without altogether in view of the maceration
possible in these cases of deep sulcus surgery. The
patients are allowed to ambulate freely and frequent
showering is advised two days after surgery.
„
This technique of inner thigh dermatocrurolipectomy
can be sometimes combined with suspension techniques
for lateral thigh lifts and lateral dermatocrurolipectomies
as described originally by Pitanguy. This combination of
techniques is often very satisfactory for combined
procedure of the inner and posterior thigh.
Conclusion
New approaches in dermatocrurolipectomy have been
helpful in preventing recurrences and complications that
were seen with older techniques.

9
Liposuction of the
Knees
General Principles
Before the liposuction techniques, no specific improvement
could be obtained in the shape of the knees, the lower
thighs or even the area of the upper calves. A variety of
problems in and around the knees can now be successfully
treated.
First, the lower thighs often have areas of accumulated
fat which distorts their natural shape and causes a loss
of normal contour.
A B S T R A C T
The lower thighs often have areas of accumulated fat
which distorts their natural shape and causes a loss of
normal contour. In patients who have excess fat deposits,
the knees become indistinguishable from the thigh and
the S-shape is lost. In older women an accumulation of
fat will occur just medial to the medial condyle. The upper
area of the calf can also be too fat and again the patient
loses normal leg contour. Liposuction can be used to
correct the deformities of the knee areas. Bleeding,
irregularities (especially around the condyle) and sharp
demarcation of the defatted area can be seen. General
complications consist of the thromboembolic
phenomenon and especially deep venous thrombosis
when large zones develop ecchymosis, hematoma and
constriction around the knee.
In the normal subject the thigh is wider in its upper
part and becomes thinner towards the area above the
knee. A nice lazy-S curve can be observed in the inner
part of the thigh going into the knee and again the same
curve can be observed going into the calf. In patients who
have excess fat deposits, the knees become indistin-
guishable from the thigh and the S-shape is lost.
The knees themselves can also be too prominent. This
is a common problem in older women where an
accumulation of fat will occur just medial to the medial
condyle. This accumulation will give a very unesthetic
appearance to the knee and is often the subject of a
request for correction.
The upper area of the calf can also be too fat and
again the patient loses normal leg contour. This fat usually
accumulates just below the popliteal area and medially
obturating the pleasing curve of the gastrocnemius muscle
(Figures 9-1 to 9-3).
Treatment of the anterior knee, although less requested
(Figures 9-4 to 9-6), is becoming more common and is
available. The problem usually consists of an accumulation
of fat in the anterior part of the thigh above the patella
hiding the area of the patella giving an ugly appearance to
the legs and knees. There is often an excessive amount and
the knees themselves are deformed by these fatty deposits.
Contraindications
Elderly patients and patients with circulatory problems are
Adrien E Aiache

79
Liposuction of the Knees
FIGURE 9-1
Knee liposuction is performed with small caliber cannulas, 3
and 4 mm, through a posterior medial popliteal incision
FIGURE 9-2
Careful planning of the extent of liposuction is important to
avoid a sudden step at the junction of the inner thigh and the
upper knee. The feathering technique is of help in preventing
the step deformity. The use of small caliber cannulas will be
helpful in feathering the area to be liposuctioned
FIGURE 9-3
A wider area in the lower third of the thigh is shown where
liposuction should extend anteriorly and posteriorly for a
pleasant effect. The upper leg area should be defatted until a
gentle curve is obtained giving a good projection to the
condyle and the gastrocnemius
FIGURE 9-4
Anterior incisions for anterior knee liposuction

80
Atlas of Liposuction
prevalent. The skin is, however, conforming very well to
these areas.
Caveats
The area to avoid is situated just below the patella.
Although the knee can be well-suctioned, the suctioning
should be meticulous in order to obtain the desired shape.
Avoid going too high towards the thigh and also avoid
creating a sharp contrast with the remaining portion of
the thigh. The same problem can arise below if the
defatting has been too extensive and there is a sharp
transition with the calf. The condyle area should be
thoroughly suctioned and a good control of the suction
should be effective since the author has seen
complications from uneven and non-careful suction.
Complications
Bleeding, irregularities (especially around the condyle) and
sharp demarcation of the defatted area can be seen.
General complications consist of the thromboembolic
phenomenon and especially deep venous thrombosis when
large zones develop ecchymosis, hematoma and con-
striction around the knee.
Markings
The patient is usually marked in the standing position to
assess the esthetic appearance of the leg. The extent of
the markings will vary depending on the area to be
improved. It can reach the midthigh and extend more
posteriorly and anteriorly. The condyles are marked for
suction depending on their shape. The markings are
different according to each surgeon; however, the author
favors the three-lobed shape which consists of a large area
of suction in the lower thigh area, tapering and again
expanding to encompass the area just below the condyles
and above the medial belly of the gastrocnemius.
Location of Incisions
Through a posterior popliteal incision placed medially in
the lower thigh the desired liposuction can be
accomplished over a fan-shaped area going up as far as
the midthigh (Figures 9-7 to 9-9). A lateral incision might
be necessary if there is an excess of fat in the lateral
aspect of the knee and the lateral aspect of the thigh.
Lastly, an anterior medial patellar incision is done
above the patella allowing further suction of the anterior
lower thigh above the patella, the areas anterior and medial
FIGURE 9-5
Special type of marking for knees and anterior lower thigh
liposuction
FIGURE 9-6
Liposuctioning the knee. The liposuction starts from the
middle to lower thigh and continues around the condyle to the
upper third of the lower leg. A gentle curve should be
obtained with these areas liposuctioned out
dangerous to approach since vascular complications may
occur such as arterial thrombosis and especially deep vein
thrombosis.
Age
Age is not a crucial factor. Patients of almost any age can
benefit although, again, the complications can be more

81
Liposuction of the Knees
FIGURES 9-7A TO D: INCISION SITES FOR KNEE SUCTION
(A) Anterior approach from a fold in the suprapatellar area
and in the infrapatellar area; (B) Posterior approach through
an inner popliteal fold or an outer popliteal fold incision; (C)
Inner knee suction through an inner popliteal fold or an inner
infrapatellar incision; (D) An additional incision can be made
in the lateral popliteal fold allowing suction of the lateral leg
and calf
FIGURES 9-8A AND B: INCISION LOCATION FOR
ANTERIOR KNEE LIPOSUCTION
(A) A suprapatellar incision allows suction of the lower
anterior thigh. An infrapatellar incision allows suction
immediately on top of the patellar bursa; (B) Two superior
incisions can be used for the lower and inner thigh, an inferior
patellar incision for the medial leg
FIGURE 9-9
Knee liposuction may be performed on the patient in the
prone position through a medial popliteal incision
to the patella and inferiorly in a very sensitive area on
the tibia situated immediately medial to the patella. This
zone is especially important to defat if one wants to
obtain an esthetic result.
The upper calves should also be marked for suctioning
in two areas. The first is medial to the calf and defatted
just below the medial condyle. The area will extend only
two or three inches down since the normal curve of the
gastrocnemius should be conserved.
The second area is more posterior and the whole area
above the gastrocnemius can be defatted. In cases where
it is hypertrophic, the defatting can be done through the
same medial posterior popliteal incision. This area is
tailored to the amount of fat that is required to be
removed over the gastrocnemius muscle.
Medial Condyles
The medial condyle can be defatted through the same
incision. The procedure is most common in older women
where the condyle is covered with a thick layer of fat.
The suction can be accomplished as anterior as possible
near the patella and defat especially the top area to defat
which is situated medial to the patella.
The examination and assessment of fat removal is
done in the usual manner using the pinch test and clinical
observation. Topographic markings can be made although
they are often difficult to follow in the liposuction
procedure. The pinch test used properly will allow gradual
tailoring of the areas to prevent a sharp demarcation with
the nonliposuctioned area (Figures 9-10 and 9-11).

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Atlas of Liposuction
FIGURES 9-10A AND B
(A) Preoperative obese patient. The removal of fat will have to be limited over the condyle in order to prevent an excessive
difference with the remaining thigh; (B) Six months postoperative
FIGURES 9-11A AND B
(A) Preoperative 32-year-old woman with condyle lipodystrophy. The protrusion of the condyle giving an “older” appearance to
the leg. Note on young patients with beautiful legs, the beginning of distortion that is starting in the condylar area; (B) Three
months postoperative
Anesthesia
If this area is done singularly, local anesthesia can be used
safely. It again consists of a diluted solution of xylocaine
with epinephrine. If the suction is only a part of a larger
area of other zones, general anesthesia is preferable. The
patient is prone for the original part of the treatment,
then supine for the completion of the anterior and medial
portion of the knee.
Surgical Technique
The relevant areas are infiltrated with anesthesia before the
procedure and then using the popliteal fold medial
incision, suction is accomplished using a 4 mm cannula
followed by a 3 mm cannula used methodically starting
in the lower thigh making multiple fan-shaped strokes
going downward to the condyles and then below the
condyles in the upper calf area. Tedious working is
necessary to accomplish the desired results and obtain a
good S-shaped curve to the inner knees. If the anterior
and posterior areas of the knee are to be performed, the
patient is switched in the supine position, reprepped and
draped, and the incision medial to the patella in the fold
is used to complete the anterior and medial portion of
the knee. As mentioned, the area immediately above the
tibial tuberosity is important to defat to obtain a
harmonious shape. Despite the original general principle

83
Liposuction of the Knees
FIGURE 9-12
In order to obtain and appreciable result, knees should be
well-carved. A typical area demarcated by Illouz above the
condyle and a lesser area below. Defatting entails the whole
surface of the condyle and the groove above and below. A
proper marking entails a much more extensive area than the
one originally proposed by Illouz
FIGURE 9-13
Condylar liposuction is accomplished through an inner
popliteal incision on this patient in the lateral decubitus under
local anesthesia
that removal should be conservative, it has been our
experience that fat removal in the knee should be as
thorough as possible in order to obtain a noticeable result.
This zone should be left with a very thin mattress of fat.
Anteriorly, a small cannula can be used to refine the
defattening (Figures 9-12 and 9-13).
Refinements
Since this area is particularly difficult to shape properly,
extreme care must be taken to refine the procedure at its
borders and in the actual area of suction. In particular,
proper defatting is necessary around the condyles with
complete defatting both above and below the condyles to
obtain the S-shaped curve. Feathering is necessary in all
these areas especially in the middle part of the thigh and
especially anteriorly if it is done since there could be a
sharp demarcation between the thigh and the portion
immediately above the patella (Figures 9-14A and B).
FIGURES 9-14A AND B
(A) Anterior knee liposuction can be accomplished through
an anterior incision above the patella using a small cannula
(3 mm or 4 mm) and can even go higher on the thigh. The
zone of incision is at the lower part of the curve; (B) Six
months postoperative
Dressings
Closure of the wound is done with nonabsorbable sutures
and the proper garments are then applied immediately.
Postoperative Care
The patient will remain in the recovery room until
completely recovered, then discharged with antibiotics and
pain medication. The important part of the technique is
to prevent tightening around the knee which could block
the return of the saphenous vein.
Complications
In the presence of varicose veins some bleeding may be
encountered. One must approach this problem with care.
Other specific problems are excess redundancy of the skin

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Atlas of Liposuction
which is only seen above the knee. Thrombophlebitis or
infections can occur and should be prevented as much as
possible.
Discussion
The liposuction technique has been found useful in the
treatment of the knee and areas around it. It is a very
satisfactory procedure. It is a positive improvement and
is relatively simple to perform with few difficulties
(Figures 9-15 to 9-18).
Knees
Depending upon the area worked on, the shape of the
knees will be more or less satisfactory if proper
sculpturing is not achieved.
Complications of knee liposuction
Knees:
™ Insufficient removal
Unequal
Dents from irregular removal
Depressions
™ The condyle should be “cleaned” of fat
The upper junction with the thigh should be tapered
TABLE
9-1
An area of dissatisfaction is at the point of junction
of the thigh and the calf where either too little or too
much has been removed from both areas. The condyle,
difficult to correct well, presents cosmetic problems in
shape and volume. The complications of knee liposuction
are given in Table 9-1.
FIGURES 9-15A AND B
(A) Preoperative 25-year-old woman with lipodystrophy of the
knees; (B) Three months postoperative
FIGURES 9-16A AND B
(A) Preoperative 18-year-old woman with mild knee lipodystro-
phy limited to the condylar area; (B) Six months postoperative
FIGURE 9-17
A difficult area is the bulge below the patella. Although it
contains the infrapatellar bursa, this area can successfully be
improved by thinning the skin over it since it does, in fact,
contain some excess fat
FIGURES 9-18A AND B
(A) Preoperative 52-year-old woman with large knees and
inner thigh lipodystrophy; (B) Four months postoperative

10 Abdominal
Liposuction
General Principles
Liposuction of the abdomen is done for patients who
have abdominal lipodystrophy. These problems are present
in the young as well as in older patients and consist of
an excessive deposition of fat in the abdominal wall,
occupying the whole abdomen anterior part as well as the
flanks and the epigastrium.
Although in the past abdominal lipectomies were the
treatment of choice, at this time the surgery consists of
A B S T R A C T
In the past abdominal lipectomies were the treatment
of choice for excessively fat abdomen and panniculous.
In cases where skin excess is not a major problem and
in younger patients liposuction has brought an interesting
armamentarium of techniques for reducing the abdominal
wall. In cases with large fat deposits and skin excess,
the patient should be warned in advance that the
appearance of skin excess with fold formation may look
worse since the liposuction will remove the fat and leave
skin with poor turgor above it. Another warning is that,
postpartum stretch marks cannot be erased. Complications
consist of hematoma, bruising, pain, irregularities of the
skin if the crisscross technique has not been well-used,
seroma and hemorrhage (rare). The technique is discussed
with possible complications in this chapter.
limited incisions and complete defatting of the abdominal
wall. In cases, where skin excess was not a major problem
and in younger patients where there was no alternative,
liposuction has brought an interesting armamentarium of
techniques for reducing the abdominal wall.
The reserved local fat deposit in the abdomen is located
mainly in the lower abdomen where two different levels
exist. There is a deep reserved fat and a superficial fat
situated between the superficial fascia and the skin. In the
epigastrium, these two zones are not easy to distinguish and
the whole epigastrium, which is more dense and fibrous, has
mainly one layer of fat over the superficial fascia.
Indications
Indications are excellent in feminine gynoid morphic types
who present small pot-bellies. Liposuction is less
satisfactory when the LFD is larger and extends into the
upper abdomen. The liposuction of the abdomen is
usually reserved for patients with moderately protruding
abdomen and moderate fat deposits. These are patients
who would have been rejected for lipectomy in the past.
Other acceptable cases are postpartum women left with
an abdominal redundancy associated with little or no skin
excess. Even in the presence of stretch marks, the
procedure can be performed with reasonable success if
there is enough excess of fat. Although the stretch marks
cannot be removed, the appearance of the abdomen and
the surface of the skin will improve.
Adrien E Aiache

86
Atlas of Liposuction
Caveats
In cases with large fat deposits and skin excess, the patient
should be warned in advance that the appearance of skin
excess with fold formation may look worse since the
liposuction will remove the fat and, however, leave skin
with poor turgor above it. Another warning is to the
postpartum stretch marks patients since they cannot be
erased. In cases of skin excess with laxity and very little
fat deposits, improvement can only be moderate. One of
the additional effect of superficial liposuction is the
improvement of the skin laxity since it has been known
to help in skin retraction.
Markings
Markings are to be made in the standing and sitting
position. This will determine the exact amount of fat to
be removed and highlight the areas which are the fattest.
This will also delineate the junction with the thinner fat
panniculous ascertained with the pinch technique applied
all over the abdominal wall. The markings will also
delineate the periphery of the area and, in addition to the
incisions to be made, the feathering zones (Figures
10-1 to 10-9).
In some cases, the fattest areas are around the
umbilicus. Other cases might have some excess in the
FIGURES 10-1A AND B
(A) The “pinch technique” is necessary before, during and after suction to obtain a smooth surface; (B) The rolling pinch helps
evaluating the skin thickness
FIGURE 10-2
The cannula is then directed upwards with a light touch to the
fascia (the thickness of 1 cm of abdominal roll should be
obtained)
FIGURE 10-3
The actual folding of the pinch test shows the elevation of the
fat layer when the wound is open allowing an exact estimate
of the fat thickness available for suction

87
Abdominal Liposuction
FIGURE 10-4
The flat of the opposite hand controls the skin thickness
during the suction
FIGURE 10-5
Typical markings for abdominal liposuction. The stippled area
and the thumb line are indicating the zone of feathering
FIGURE 10-6
Abdomen basic liposuction technique. An incision is made in
the inferior or superior umbilicus. Suction reaches the
xiphoid, goes over the ribs, further out in the waist, down to
the pubis and then to the iliac crest
FIGURE 10-7
Another incision is located in the suprapubic area where it is
hidden by the pubic hair. It now reaches the epigastrium
easily with a 3 or 4 mm cannula

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Atlas of Liposuction
FIGURES 10-8A TO C
Markings made on the patient where the waist suction is unnecessary, however, note the height of the epigastric markings
which indicates the patient has excessive fat in this area
FIGURE 10-9
Markings made on a thin patient who has localized deposits
around the umbilicus and the epigastrium. Note, how the waist-
line is spared in order to prevent “coup de hache” deformity
suprapubic area. These should be marked carefully for
proper suction. The precostal area on both sides above
the ribs and covering the last three ribs also should be
taken into consideration since it has been found often to
be protruding after liposuction of the area below it has
been done.
The sitting position will be helpful in determining the
amount of skin laxity in the areas of the abdomen which
are the fattest.
Incisions
An infra- or supraumbilical incision can be performed.
The second common incision is in the suprapubic zone.
Other incisions can be placed in previous scars of
appendectomy, cholecystectomy, or median abdominal
scars. The scars can be revised at the same time. One
should be careful in suctioning around the scars since it
could enter hernias (Figures 10-10 to 10-15). The area
around the umbilicus is done from the suprapubic area
FIGURE 10-10
Liposuction performed from the umbilical incision allows for a
complete abdominal suction. The thickness of the skin can be
seen over the cannula

89
Abdominal Liposuction
FIGURE 10-11
The crisscross technique allows for a thorough and uniform
suction of an area
FIGURE 10-12
The incision for liposuction can be performed in a scar from:
(1) Cholecystectomy; (2) Median or paramedian laparotomy;
(3) Sympathectomy; (4) Appendectomy; (5) Cesarean
section, or (6) Gastrectomy. These scars can be revised
during the procedure if they are responsible for adhesions or
if they are thick or inverted
FIGURE 10-13
A submammary incision is useful for epigastrium suction and
is less dangerous in avoiding possible perforations of the
diaphragm (make sure that the patient is in complete
extended supine position)

90
Atlas of Liposuction
FIGURES 10-14A AND B
The umbilical incision allows for a circular suction of the upper and lower abdomen
FIGURE 10-15
By approaching the abdomen from the opposite side of the
table, lower abdominal suction is easier
and suction is done assiduously until the excess is well-
removed and a proper umbilical zone is obtained. The
second area of difficulties is below the xyphoid where
through the umbilical incision a very assiduous suction
should be performed. Since the periumbilical area can be
missed during regular suctioning, a cannula with an
opening situated 2 inches from the end is used.
Instruments
The 3 mm straight cannula is the most effective. The
Concord type is helpful in suctioning out the waist and
flank. The 4 mm cannula is useful for finishing up the
areas around the umbilicus, xyphoid and the flank. As the
surgeon improves and becomes more proficient in the
technique, he can use a smaller size cannula to achieve
an even surface. The author uses often the Robles cannula
for finessing of the zone and proper suctioning in the
superficial zones.
Technique
Once the incision has been made either above or below
the umbilicus, suction should follow the regular rule of
creating parallel tunnels in a spoke-like fashion defatting
each tunnel properly before moving to the next one. A
good technique is to mark different quadrants from the
umbilicus and achieve the liposuction in each of these
until it is properly done. A smaller cannula is used to
suction the remaining fat areas which are palpated,
visualized and grabbed in the palm of the hand. The
suction in some areas is done in three steps:
¼
A larger suction cannula is used on the whole area
described while the midline is omitted superiorly and
inferiorly.
¼
In the second stage the 3 mm cannula is used to suction-
out the midline up to the xyphoid and down to the pubis.
These areas being denser and more interspersed with
connective tissue respond better to smaller cannulas.
¼
The 3 mm is used to finesse the areas, which is the final
stage. A longer cannula without suction can be used for
the elevation of the tissues.
Positioning
The patient is in the supine position. The operator being
one-handed introduces the cannula from either side of the