91
Abdominal Liposuction
abdomen for easier control. The pinch test should be
performed all along the procedure in order to obtain a
uniform thickness of approximately 1 cm. The suction
starts in the lower level and ends up in a more superficial
one. In areas of junction with nonsuctioned areas, care
should be taken to avoid depressions.
Anesthesia
Because the abdominal wall is extensive and local
anesthesia is often very painful, general anesthesia is most
often necessary. The operation is then started with the
tumescent infiltration from the zones of incision and then
suction is performed. In a limited number of cases, in thin
patients, a small extent of liposuction is necessary and
local anesthesia can be used.
Prepping and Draping
It is routine for the abdominal wall and draping is done
from the nipples down to the midthigh. At the end of
the procedure the patient is set in the setting up position
to assess the appearance of the skin after suction.
Closure
Closure is done with absorbable sutures, Steri-strips
applied and the patient is set in a garment (Figure
10-16).
Postoperative Care
The patients return home after they are awake and they
are started on prophylactic antibiotics and pain medication.
The patient is then changed at 2 days for evaluation of
the areas and seen a week later. Exercises and massages
are advised 8 days after surgery.
Intra-abdominal Lipodystrophy
Intra-abdominal excess due to omental excess and
mesenteric fat combined with weak and flabby abdominal
muscles is a problem in cases if one is to achieve a
satisfactory result in abdominal suction. The epigastrium
gives poor results because it is enmeshed in connective
tissue and fibro-fatty tissue as opposed to the lower
abdominal wall which has a layer of soft fatty tissue. The
excess of volume in abdominal organs and the omental
fat gives the so-called beer belly which is difficult to
improve in view of the fact that this large abdomen will
not improve considerably due this inside fat.
The treatment which consists of liposuction is not
giving the same optimal results as normal anatomical cases
and the patient will be disappointed. It has been thought
that possibly some reduction in the omental fat could
improve the so-called beer belly, however, no surgery has
been performed to that effect at this point (Figures
10-17 to 10-22).
FIGURE 10-16
Elastoplast is applied across the abdominal wall horizontally.
This technique of dressing is now abandoned in favor of
immediate garment application
FIGURE 10-17
Actual markings showing extension to the waist and
feathering in the lower rib cage area
92
Atlas of Liposuction
FIGURES 10-18A AND B
The sitting position is often more demonstrative of excess fat
in the abdominal wall
FIGURE 10-19
The liposuction process when performed through an
umbilical incision directed at removing the heavy fat layer
often present above and below the rib cage
FIGURE 10-20
Abdominal liposuction is difficult in the infracostal area.
Extremely cautious and persistent suction should be
performed. Any lack of precision and evenness will result in
an irregular abdomen especially in older patients. Younger
patients who have a taut skin will show fewer irregularities
FIGURE 10-21
Markings of a different shape: Thickness of the waist area is
preserved while most of the excess fat of the abdomen and
iliac crests is removed
Discussion
This liposuction of the abdomen is a satisfactory
technique for reducing the protrusion of the abdominal
wall (Figures 10-23 to 10-33).
Complications
Complications consist of hematoma, bruising and pain
with irregularities of the skin if the crisscross technique
has not been well-used. Irregularities consist of dents
instead of excess fatty lobules. They could be present
since the entry into the level of fat situated between the
skin and the superficial aponeurosis is unforgiving.
Hemorrhages are extremely rare, however, seromas can be
seen and they are treated by either draining or routine
tapping.
In more extensive cases, liposuction of the abdomen
will be complemented by skin excision.
93
Abdominal Liposuction
FIGURE 10-22
The anterior waist should be dealt with carefully. Excess
removal of fat may result in a deep groove or may show
insufficient removal. In patients with some waist skin
relaxation due to age, a conservative suction is advised
(“coup de hache” deformity)
FIGURE 10-23
Wrong design showing only suction in the central part of the
abdomen and missing the waist
FIGURE 10-24
Although the waist is marked for liposuction, the part above it
is left untouched, thus resulting in a straight, shapeless body.
Instead, suction should be more extensive
FIGURE 10-25
Wrong design in abdominal liposuction. This design does not
takes into consideration the excess of the supracostal area,
the waist, or the flanks. This design could actually rarely be
applied to an actual patient although it was shown in many
previous textbooks
94
Atlas of Liposuction
FIGURE 10-26
A cannula with an opening distant from the tip was developed
by Illouz in an attempt to allow suction around the umbilicus,
an area in which the to-and-through motion is otherwise quite
difficult
FIGURE 10-27
Unless a careful and thorough suction is performed, the
immediate area near the umbilicus will be missed
FIGURE 10-28
Localized touch-up areas can be performed under local
anesthesia from an umbilical incision using smaller cannulas
(size 3)
FIGURE 10-29
The inferior pubic incision allows a good defatting around the
umbilicus and this approach is excellent for an abdomen with
little obesity and touch-up
95
Abdominal Liposuction
FIGURES 10-30A AND B
(A) Preoperative; (B) Postoperative
FIGURE 10-31
Obese patients are not easy to sculpture properly. The
suction process leaves approximately 2 cm of fat, however, to
obtain this level requires an inordinate amount of suctioning.
The resulting skin cover will be excessive and will not drape
well leaving redundant skin. This phenomenon can be
explained by the fact that extreme obesity requires an
extreme network of vascular tissue, neural tissue and
connective tissue. These tissues are not suctioned, leaving a
certain bulk even after a large amount of fat has been
suctioned
FIGURE 10-32
Due to the body’s tubular shape it is often necessary to go
further around the waist, thus allowing the flattening effect to
show in a contour suction
96
Atlas of Liposuction
Abdominal Etching
Males are interested in looking more muscular and often
are dissatisfied with the appearance of their abdomen
since the fatty layer is hiding the muscular look.
Attempting to show detailed muscular shapes, a technique
abdominal etching has been developed. The technique
consists of a combination of superficial and deep
liposuction of the abdomen. The deep suction is
performed all over the abdominal wall following this step
using minimal incision in the umbilicus and the lateral
waist area as well as in the pubis, and using 2 or 3 mm
cannulas through 2 mm incisions. This technique consists
of doing a superficial suction at the level of the muscular
insertion of the rectus muscle, ending up in showing
bulging areas over the muscular element of the rectus.
The rectus muscle has three main transverse
intersections or inscriptions which are varied in their
position and length. Often there are three intertendinous
insertions at the same level side-to-side or offset at
different levels. The transverse intertendinous insertions
extend perpendicular to the linea alba. This line can be
oblique or could have a stair-shaped configuration and
these tendinous insertions are often asymmetric and
irregular since their levels are different from side-to-side
and can look uneven. The lowest insertion is at the level
of the umbilicus with these insertions being narrower than
the upper ones. The technique of etching uses a lateral
incision as well as a midline and superficial liposuction
FIGURES 10-33A AND B
(A) Preoperative; (B) Postoperative
using fine cannulas or a cellulite dissector type of cannula,
removing the fat to the thinnest level possible in order
to show the indentation of the intertendinous insertions.
This is done after the regular abdominal liposuction has
been done and it is a complementing technique depending
on the results obtained with the conventional abdominal
liposuction. These markings are made in the standing
position, carefully indicating the muscular masses.
Abdominal Liposuction Complications
Irregularities, waves, insufficient removal over the pubis,
around the umbilicus and the subcostal area and flanks
can present postoperative problems. In the presence of
a cholecystectomy or appendectomy scar, the suction
cannula could inadvertently penetrate the abdominal wall.
Bleeding or hematomas are relatively rare. Seromas are
more common especially if the cannula cuts a large
amount of connective fibers to the abdomen. Other
problems consist of an excess abdominal apron in poor
indications where the surgery should have been an open
lipectomy with suction.
Abdominal liposuction can be an extremely dangerous
technique of it is not performed by an operator who is
conscientious and consistent in his suction of this area.
In particular, one should be careful of possible umbilical
hernias that could be perforated with suction. The most
common problem is the “washing-board” look secondary
to extensive suction and thinning of the skin.
11 Combination of
Abdominal Liposuction
and Abdominal
Lipectomy
Introduction
The shape of the abdomen and quality of the skin usually
varies with ethnic background, number of pregnancies,
age, as well as the weight ranges the patient has been
through. Often these conditions will result in problems of
abdominal redundancy in addition to the fat redundancy,
a problem which is not solvable by either liposuction
alone or abdominal lipectomy alone.
Before liposuction, the only treatment available was an
abdominal lipectomy that consists of excising the
panniculus of skin and fat. This is done with wide
undermining of the flaps and advancement of the skin
with reimplantation of the umbilicus at a higher level on
the skin. Because the scars were often objectionable,
liposuction has helped in solving these problems. Other
A B S T R A C T
The shape of the abdomen and quality of the skin usually
varies with ethnic background, number of pregnancies,
age, as well as the weight ranges the patient has been
through. Often these conditions will result in problems
of abdominal redundancy in addition to the fat
redundancy, a problem which is not solvable by either
liposuction alone or abdominal lipectomy alone. In this
chapter, liposuction of the abdomen and abdominal
lipectomy alongwith possible complications are discussed.
complications that could occur, included skin slough,
seromas, and hematomas which are difficult to treat. Often
with abdominal lipectomy alone, the patient is left with
a large bulge in the epigastric area and two unsightly
bulges in the lateral area over the iliac crest. Liposuction,
when performed in conjunction with the abdominal
lipectomy, is a great improvement (Figures 11-1 to 11-12).
Although liposuction alone will improve the protuberant
round abdomen, it is limited to cases where the skin is
not redundant, presents a good surface and a good turgor.
FIGURE 11-1
Multiple shapes of incisions that can be performed in the
technique of abdominal lipectomy
Adrien E Aiache
98
Atlas of Liposuction
FIGURES 11-2A TO C
Example of the amount of skin that can be and that should be excised for proper healing in an abdominal lipectomy. It
encompasses the skin situated between the umbilicus above and the suprapubic area below which can be varied depending on
the demands of the case
FIGURE 11-3
Example of scar obtained after abdominal lipectomy
when the extent of the space between the pubis and the
umbilicus is extensive preventing a lower scar placement
due to lack of tissue from the zone above the umbilicus
which is irrigated from above
FIGURES 11-4A AND B
(A) Abdominal liposuction is performed from the umbilicus, the suprapubic area and/or lateral inguinal region. The grid area is
especially difficult to defatten and should be done with a fine cannula (#3). The lower line shows the incision for lipectomy; (B)
Stage 1: After liposuction of the upper flap portion through the umbilicus, an abdominal lipectomy is performed. Before incising
the lower flap, liposuction is performed from either of the incisions. A periumbilical and/or a suprapubic incision are useful. It is,
however, unnecessary to liposuction the skin flap that is excised during the procedure
99
Combination of Abdominal Liposuction and Abdominal Lipectomy
FIGURE 11-5
Stage 2: After liposuction of the lateral abdominal wall,
including the flanks, the lower incision is made and the skin
flap is raised from the abdominal muscles. The lower
abdominal incision is made and the abdominal flap is lifted up
to the area of skin excision using sharp and blunt dissection.
If the decision for upper skin excision has not been made,
surgery starts at the lower edge of the abdominal ellipse. It is
often dangerous to make an early commitment for the
excision since one could have too short an upper flap
FIGURE 11-6
Stage 3: An estimate of the skin excess is made by bringing
the flap down. The stippled area shows the excision to be
performed and this is done in one or two segments to make it
easier for excision. Note the need to reposition the umbilical
stalk to create a neoumbilicus if the original one is excised
FIGURES 11-7A AND B
(A) Inferior and superior epigastric arteries; (B) The segment
of skin supposed to be irrigated by the inferior epigastric
artery does not receive blood below the level of the umbilicus,
thus the lower part of the flap is jeopardized especially if the
lateral undermining of skin has severed the perforators which
lie laterally at the level of the rib edge. Any amount of skin flap
tension in these cases might end up in necrosis of the central
lower portion of the flap marked in gray
FIGURE 11-8
After abdominal liposuction, opening the abdominal wall and
elevating it shows the vascular and nervous strands left intact
attaching the skin to the muscle below. This view negates the
“tunnel” concepts
100
Atlas of Liposuction
FIGURE 11-10
Floating umbilicus is transplanted at a lower level of the
abdominal wall
FIGURE 11-11
Liposuctioning of the flanks, pubis, and iliac crest is best
done at this stage. One should again avoid the perforators
FIGURE 11-9
Stage 4: Open sky liposuctioning of the flap and umbilicus
reimplantation. After the excess skin has been excised
suction of the upper flap is again performed. Undermining of
the upper flap is done up to the xyphoid and the ribs. At this
stage the muscle repair is performed imbricating the rectus
muscle fascia with either absorbable or nonabsorbable large
sutures
101
Combination of Abdominal Liposuction and Abdominal Lipectomy
The quality of skin is the most important factor especially
after pregnancies as after 40 years of age the skin will
not contract properly. Another problem consists of the
discrepancy in the thickness of the abdominal skin above
the scar and the inguinal skin below. A pure abdominal
lipectomy ends up in a shapeless abdomen with a round
protuberance with no specific indentation and no bulges
in the area of the rectus muscle. Thus, liposuction will
enhance the results of lipectomy and the opposite can be
helped as well. Another advantage is the usefulness of the
liposuction in reducing unsightly bulges that cannot be
removed by lipectomy alone.
Indications
Patients who have a slight amount of obesity localized
around the umbilicus and epigastrium and who have
good skin tone with no excess are candidates for
liposuction alone.
Patients who have some excess of abdominal fat and
previous vertical or horizontal scars lend themselves to
an abdominal lipectomy in combination with liposuction
and scar revision with some type of skin excision.
Patients who have very little fat excess and a much
wrinkled abdomen or stretch marks are mainly candidates
for lipectomy bearing in mind that the suction will only
improve some of the contour without removing the
scaring of the stretch marks.
If the patient still has, in these cases, a little too much
skin redundancy, then a limited lipectomy will be more
useful in addition to liposuction. The limited lipectomy
consists of an inferior pubic scar very acceptable to
patients.
Patients who have a very large amount of fat and only a
certain degree of skin redundancy may benefit from
suction alone followed only secondarily if necessary by an
abdominal lipectomy if the skin has not retracted well
enough.
Patients who have excess skin and fat in the abdomen
with abdominal aprons are good candidates for a
combination of the suction and abdominal lipectomy.
These scars will often be shorter than those with
lipectomy alone. The skin excess dictates the proper
excision for closure without dog-ears.
Caveats
Patients should be warned of the problems mentioned such
as skin slough, irregularities, waving and scar hypertrophy,
and they should be told that a large scar will result from
the lipectomy even if it is performed in conjunction with
liposuction. It is incumbent upon the surgeon to explain
fully to the patient the advantages of suction especially
in the avoidance of scarring. The surgeon on his part should
look for possible umbilical hernia, diastasis recti, and incisional
hernias to avoid complications.
FIGURE 11-12
Stage 5: Neoumbilicus formation. Reimplantation
of the umbilicus is done and the skin flap is
sutured in position. The umbilicus can be shaped
in many different shapes depending on the
incision performed, such as a U-shape, Mercedes
sign-shape, V-shape, or even a cross shape or
circulation hole with defatting of the fatty layers
around the puncture hole
102
Atlas of Liposuction
FIGURES 11-13A AND B
After abdominal liposuction lifting the abdominal wall and elevating it will show the vascular and nervous trend left intact,
attaching the skin to the muscle below. This negates the notion of tunneling which amounts to visual concept which is not the
right concept when one sees that type of tissue left after liposuction. The lateral border contains the perforators that should be
saved
Markings and Preoperative Preparation
Markings are made on the erect patient (Figures 11-13A
and B). Using inspection, palpation, and pinch test, the
fat excess is determined in the epigastrium, the
midabdominal area, the flank, the lower abdominal area,
the suprapubic area, and the thinner zone above the iliac
ridges. Markings are made accordingly. These areas will
include the epigastrium and the flank as well as the
periumbilical area. Although there is some excess fat in
the lower abdomen, one should be careful and often one
will have to defat the suprapubic zone including the mons
pubis in order to prevent a sudden drop at the junction
with the pubis (Figures 11-14 and 11-15).
A circumferential area to be liposuctioned out is
marked and the fatter zones are marked with crosses. The
waist is marked and it is shown in its proper location.
The epigastrium also is marked with crisscrosses.
Strenuous crisscrossing of the epigastrium will be
necessary for good defatting since that zone is densely
occupied by septa and is tougher for liposuction.
Incisions
An incision is made in the infraumbilical area or in the
supraumbilical area. This will allow the suction to be
performed either all around the abdomen or only in the
upper abdomen when a combination of procedures is
used. This makes it generally easier to perform the
liposuction without missing any zones especially the
whole epigastric area which is then becoming the
hypogastric zone after its transportation advancement
below (Figures 11-1 to 11-3).
A suprapubic incision will allow for straight suction of
the whole abdominal wall. One will have to concentrate
especially on the upper abdominal portions before the
lipectomy itself. This incision is useful when one wants
to defat the entire periumbilical area.
Any scar can be used for liposuction if scars are present
and either the scar will be completely revised or it could
remain untouched. Only a small portion of the scar will
then be utilized for the introduction of the cannula. If
the scar happens to be vertical, the suction lipectomy is
performed from one of these areas which is then excised
with an ellipse around it. If the scar is eccentric, such
as a cholecystectomy or appendectomy scar, it might be
difficult to use it for lipectomy; however, it can be used
for liposuction before completion of the lipectomy.
Anesthesia
In view of the extent of surgery, general anesthesia is
preferable. The usual xylocaine with epinephrine solution
is infiltrated in a tumescent fashion.
Prepping, Draping and Surgical
Technique
The patient is prepped and draped in the routine manner.
The first step of the technique consists of liposuction.
It is performed from the elected incision using a 4 mm
103
Combination of Abdominal Liposuction and Abdominal Lipectomy
FIGURE 11-14
Abdominal suction lipectomy through the umbilicus and the area of a previous scar, can involve scar revision with a
conservative scar excision and repair, in a so-called miniabdominoplasty technique
FIGURE 11-15
Different incisions can be made for
the combination of abdominoplasty
with liposuction depending on the
actual defect of the patient and the
actual scars
104
Atlas of Liposuction
and 3 mm cannula. If there is scarring, a 3 mm cannula
may be more useful. In cases where the operator knows
the lower segment of the abdominal wall will be excised
for abdominal lipectomy, there is no need to suction that
zone. Depending on the possibility of advancement of the
upper skin flap, the lower incision might be raised
especially in the pubic area in order to perform the
closure without excessive tension.
Extent of the Liposuction
It is performed in the whole upper abdominal area
extending approximately 2 inches beyond the area marked
for undermining and for closure of the lipectomy. This
will help in draping the skin without tension. In addition,
the feathering of the suctioned areas allows a good
transition with the unoperated zone (Figures 11-4 to
11-12).
Refinement
Refinement consists of feathering and fine cannulas are
used to improve some of the recalcitrant areas after
lipectomy is performed. Important areas to feather are the
zone over the ribs, the waist and the mons pubis. If the
mons pubis is fat, it should be suctioned leading to a
more esthetically acceptable appearance with a good
transition to the thickness of the skin flap. The lipectomy
is done in a routine manner excising the ellipse of skin
and suture ligating the vessels encountered in the excision.
The upper flap is then completely undermined up to the
rib cage and the xyphoid and advanced into position. An
attempt should be made to drape the skin properly to
avoid plication laterally. The umbilicus location is
determined under the skin and a new opening is made
on the elected site. The zone around the new opening is
defatted by sharp dissection to allow a deep umbilicus.
Repair of the rectus is performed before this stage.
Closure
Once the zone is reapproximated the closing is performed
in layers for the lower abdominal scar using either chromic
or vicryl sutures in the deep layers and subcuticular suture
for the skin.
Postoperative Care
The surgery being more extensive and more painful than
liposuction alone, there are more complications as well as
postoperative rehabilitation. Patients are allowed to extend
their trunk gradually since they are asked to flex the trunk
over the thighs for approximately 30 degrees for a period
of 10 days. This facilitates viability of the flap free of
excess tension. Drains are removed according to the
amount of drainage. If a large drainage is found, the
drains are left approximately 4–7 days, however, if it
seems relatively dry, they are removed the second
postoperative day.
Abdominal Esthetic Surgery
Planning the Operation
The appearance of the abdominal wall presents many
variations which depend on the degree of obesity, skin
laxity, and the status of the abdominal muscles. In order
to obtain and appealing abdomen, it is important to bring
some variations in the surgical repair. The liposuction has
allowed many variations and has allowed to sculpt the
abdomen properly.
Examination
Examination estimate of removal and technique are
performed while the patient is standing and sitting. This
allows the judgment of the excess of skin either at the
epigastrium or above the pubis. Palpation gives an exact
idea of the fat deposit and the necessity of the suction
as well as the state of the rectus abdominis muscle, the
degree of diastasis and possible umbilical hernias or
Spiegelian hernias.
Classification of the Types of Abdomen
Many classifications have been presented (de Souza Pinto
et al,1 Wilkinson,2 Greminger,3 and Matarasso4). However,
it is difficult to classify and assign numbers to the many
varied states of the abdominal wall. It is only by judging
the elements present and the variations present that the
surgeon will decide the treatment to be used.
The consensus of opinion is that there is more than
one useful technique available for so many different
problems in the abdominal wall structure. The treatment
will be the following:
Liposuction only
Rectus muscle plication either through an inferior flap
incision or through an umbilical incision (Souza Pinto1
or Faria-Correa5)
Lower skin excision with any extent of skin undermining
Skin excision with undermining up to the umbilicus and
the xyphoid and ribs
105
Combination of Abdominal Liposuction and Abdominal Lipectomy
Mini-abdominoplasty: Partial undermining up to the
umbilicus and lower excision (Figures 11-10 to 11-15).
–
Recreation of a new umbilicus
–
Excision and re-implantation of the umbilicus.
–
Floating of the umbilicus.
The Umbilicus
The umbilicus is left untouched in cases of lower
abdominoplasty or mini-abdominoplasty. In some cases it
is possible to detach it from its deeper attachments
through the rectus fascia and to float it down with the
surrounding skin at a lower level (providing that it remains
esthetically within normal range).
In some cases, where a large amount of skin is
excised, a new umbilicus can be created by excising the
skin at the new umbilical region, defatting it and attaching
it to the fascia where the previous umbilicus was present.
This technique of making a completely new umbilicus out
of skin flap is often more satisfactory than keeping the
umbilicus itself since this one can result in a circums-
cribed, contracted, less natural-looking scar (Figures
11-11 to 11-13).
Complications
The rare complications seen in liposuction of the
abdomen have not been reduplicated in the cases of
combinations of suction with lipectomy. The risks are now
more real and are similar to the risks and complications
secondary to abdominal lipectomy such as wound
dehiscence, skin slough, deep vein thrombophlebitis,
pulmonary embolus and so on. The actual concept is to
stage in two procedures. It is felt that liposuction
combined with abdominal lipectomy has relatively high
percentage of complications as compared to liposuction
alone (Figures 11-16 to 11-24).
FIGURES 11-16A AND B
(A) Preoperative 59-year-old woman with abdominal lipodystrophy and cholecystectomy scar; (B) Six months postoperative
liposuction and abdominoplasty; notice that the cholecystectomy scar was completely excised
FIGURES 11-17A AND B
(A) Preoperative 58-year-old woman with abdominal lipodystrophy and loose abdominal skin. Liposuction-alone will not suffice.
The result can be disappointing—excess skin, sagginess, irregular areas and deep infolding of the previously visible fold;
(B) Two months postoperative after combination of liposuction and lipectomy. The scar ends up high in cases where the
umbilicus is distant from the pubis. This excessive distance will be difficult to gap with the remaining abdominal flap which
should come up to the zone of junction between the upper epigastric artery and the lower epigastric artery
106
Atlas of Liposuction
FIGURES 11-18A AND B
Patients with good skin tone and moderate skin flabbiness can have satisfactory results in spite of older age. However, for
patients with excess obesity and skin flabbiness and excess, the results of isolated suction lipectomy will be poor cosmetically
although somewhat improved in reducing the size of the abdomen. In some cases, the treatment of skin excess should be more
radical; otherwise defects will appear. The area undermine hardens and is thick and rigid. Thus, if only part of the abdomen is
undermined, the lower portion will appear swollen, rigid, and excessive for quite some time. It appears better to undermine the
whole lower abdomen instead of only a portion. (A) Preoperative; (B) Three months postoperative with some irregularities and
bumps
FIGURES 11-19A AND B
(A) Preoperative 45-year-old woman with mild abdominal lipodystrophy and moderate skin excess, epigastric bulging, and
flaccidity; (B) Six months postoperative following combination liposuction and lipectomy. A long distance between the umbilicus
prevents a low abdominal scar. Although the scar remains high in these cases, the shape of the abdominal wall is well-
preserved as opposed to cases of low incisions. A profile showing the epigastric bulge postoperatively. Due to the dense fibrous
tissue present in this area, this bulge is sometimes difficult to improve. In cases of expressionless abdomen, liposuction of the
lateral part of the flap is indicated
107
Combination of Abdominal Liposuction and Abdominal Lipectomy
FIGURES 11-20A AND B
Suction lipectomy of the abdomen precedes the waist skin excision,
depending on the existing scar or the extent of the skin excess. The
extent of the waist scar will differ
FIGURES 11-21A AND B
(A) Preoperative 52-year-old female with abdominal lipodystrophy and well-healed, bilateral sympathectomy scars; (B)
Postoperative following excision of the sympathectomy scars and liposuction of the abdomen and saddlebags
FIGURES 11-22A AND B
(A) Preoperative 56-year-old female with abdominal lipodystrophy and moderate loose skin below the umbilicus; (B)
Postoperative after suction lipectomy and minimal skin excision at the excess skin area. No planning of this scar was made. It is
only the result of excess skin excision
108
Atlas of Liposuction
FIGURE 11-23
Treatment of abdominal lipodystrophy with vertical scar:
Liposuction is performed first from the upper and lower parts
of the scar. Then a scar revision is made down the length of
the scar. It is important not to defat the edges of the scar for
1–2 inches in order to prevent depression of the scar
References
1. de Souza Pinto EB, de Almeida AE, Knudsen AF, et al. A new
methodology in abdominal aesthetic surgery. Aesthetic Plast
Surg. 1987;11:213-22.
2. Wilkinson TS. Limited abdominoplasty techniques applied to
complete abdominal repair. Aesthetic Plast Surg. 1994;18:49-55
3. Greminger RF: The mini-abdominoplasty. Plast Reconstr Surg.
1987;79:356-65.
4. Matarasso A, Wallach SG, Rankin M, et al. Secondary abdominal
contour surgery: a review of early and late reoperative surgery.
Plast Reconstr Surg. 2005;115:627-32.
5. Faria-Correa MA. Endoscopic abdominoplasty, mastopexy, and
breast reduction. Clin Plast Surg. 1995;22:723-45.
FIGURES 11-24A AND B
(A) Preoperative 40-year-old female with moderate lipodystrophy and a straight midline scar; (B) One year postoperative after
excision of scar and liposuction
12 Liposuction of the
“Love Handles”
General Principles
Indications
Patients with love handles are divided into two types:
(1) Males who have fat deposits over the lateral waist
although the remaining part of their body is relatively fit.
These males have excess fat deposits in the flanks but
otherwise a normal body habitus. Although often seen in
men, this condition is also found in females in association
A B S T R A C T
Love handles are a common problem in older patients,
especially middle-aged adults, who have put on some
weight. Males may have fat deposits over the lateral waist
although the remaining part of their body is relatively
fit. These males have excess fat deposits in the flanks
but otherwise a normal body habitus. This condition is
also found in females in association with other fat
deposits. The habitus in the female consists of a large
torso on a thin, narrow pelvis and straight leg which
becomes a problem when these women get fatter and
older, and the fat layers will essentially occupy this area
in a uniform fashion giving the same type of deformity
as the so-called love handles, seen in men. Liposuction
of the “love handles” is discussed in this chapter.
with other fat deposits. (2) The habitus in the female
consists of a large torso on a thin, narrow pelvis and
straight leg which becomes a problem when these women
get fatter and older. These women look lovely when
young. If their thin elongated narrow bodies then put
some fat on in middle age, the fat layers will essentially
occupy this area in a uniform fashion giving the same type
of deformity as the so-called love handles as seen in men
(Figures 12-1 to 12-3).
FIGURES 12-1A AND B
Incisions for love handles and for waist on a Nordic-type body
with long thorax, narrow hips and straight legs. The absence
of a waist depression can be corrected with liposuction
through the abdominal liposuction umbilical incision and
direct approach through the flank
Adrien E Aiache
110
Atlas of Liposuction
FIGURE 12-2
A 52-year-old woman with narrow pelvis and an absent waist
who has previously undergone abdominal liposuction
FIGURE 12-3
The absence of a waist on a patient with a narrow pelvis and
a broad chest. A typical problem presented in this case is
such a poorly defined waist in the female
Age
Love handles are a common problem in older patients,
especially middle-aged adults who have put on some
weight. This problem is associated with shortening of the
spinal column secondary to flattening of the intervertebral
disks and collapsing of the spine with aging ending up
in telescoping of the skin giving the excess on the sides
and anteriorly.
The problem is essentially the same in males and
females and the correction of the deformity consists of
an abdominal and waist liposuction (Figures 12-4 to
12-9).
FIGURE 12-4
In the creation of a waist, the liposuction process starts from
the umbilical incision and progresses further towards the
waist
FIGURE 12-5
A direct approach in creating a waist is through the lateral
incision
111
Liposuction of the “Love Handles”
FIGURE 12-6
A waist can be created by the abdominal liposuction.
Markings are made in the standing position and often are
useful in the sitting position which gives an accentuation of
the deformity
FIGURE 12-7
Anterior approach to love handles suction using a superior
crease of a stretch mark for the incision
FIGURE 12-8
The posterior approach for love handles suction on the
paraspinal area that is as useful
FIGURE 12-9
Crisscrossing from a hip and sacral incision
112
Atlas of Liposuction
Caveats
Patients should be warned about the possibility of
irregularities, dents and the fact that the skin might not
drape properly especially in the anterior abdominal portion
although the love handles themselves usually drape well.
In addition, the patient should be warned about the
possibilities of irregular correction, especially in the waist,
which is very difficult to suction evenly due to the special
texture of the fat in that area. In cases where there is
an excess of skin it will then be necessary to use a
combination of techniques with liposuction and skin
excision such as the flank plasty or the hip lift as
advocated by Lockwood.1
Preoperative Preparation
Patients selected for liposuction of the flanks and
abdomen should have only a moderate deformity. This
technique is not satisfactory in the correction of obesity
and will only exhibit the poor results of a difficult
extensive surgery. The preparation is the usual for
liposuction.
Anesthesia
Anesthesia is most often general. Only in a very limited
number of cases local anesthesia can be performed in that
area which is very tender.
Local anesthesia can be used in cases of very minimal
deformity, or if the patient wants only the creation of a
new waistline. This request is common in women who
want to have an improvement in their silhouette.
Markings
Markings are made with the patient in the upright
position. They may be isolated to the area of hypertrophy.
They depend on the appearance of the deformity in the
tangential position showing the protuberance in straight
anteroposterior position or in an oblique view. The pinch
test is also usually useful. Two parallel lines are made
reaching posteriorly and anteriorly ending up at the lateral
limits of the rectus muscle or if it is done in conjunction
with abdominal liposuction, it is included in the drawing
(Figures 12-7 to 12-9).
Prepping and Draping
The patient is usually placed in the supine position for
prepping and draping. The prepping is the usual and
draping is from the nipple down to the pubis.
Incisions
Two types of incisions are made, either from the abdo-
minal liposuction the incision is infra- or supraumbilical,
or a pubic incision. A second incision will be necessary
especially to obtain a good waist line and the incision will
be lateral to the rectus muscle belly at the level of the
umbilicus. If the flank is to be completed in the supine
position, the incision will be in the parasacral area.
Instruments
4 and 3 mm cannulas are useful. The completion of the
procedure is usually done with a Robles cannula which
helps in finessing the zone and defatting the tissue to its
maximum.
Technique
The sawing motion of the cannula is used starting in the
upper part of the bulge and ending gradually lower near
the iliac crest. The motion should be continued until an
appreciable difference is found in the waist by examination
and the pinch test. It is very important in women who
need it the most. In cases associated with abdominal
liposuction, a complementary liposuction of the anterior
part of the flank is done after abdominal suction using
the 4 mm cannula introduced through the umbilical scar.
This allows crisscrossing in the anterior aspect of the
deformity and at this point the patient can be placed in
prone position where completion of the waist is done
from the parasacral incisions. Depending on the extent of
the liposuction, the patient is either sent home or to a
nursing home or to the hospital (Figures 12-10A and B).
Refinements
Refinements consist of the feathering technique performed
above the markings over the areas of the ribs and inferior
in the zone of the iliac crest laterally and medially as well
as possible to obtain a harmonious waist. Not only should
one be careful in removing enough of the fatty deposits
in that area, but the mesh undermining is useful in
obtaining a better cosmetic result.
Complications
The usual complications of lumps and depressions are
seen, as well as irregularities and sometimes hematomas.
The most common complication is of a cosmetic nature
showing an uneven result and lack of symmetry.
113
Liposuction of the “Love Handles”
FIGURES 12-10A AND B
(A) Preoperative 27-year-old woman with abdominal lipodystrophy and poor waist definition; (B) Six months postoperative
FIGURES 12-11A AND B
(A) Preoperative 47-year-old woman with abdominal lipodystrophy and poor waist definition; (B) Four months postoperative.
Notice the improvement in the epigastrium
FIGURES 12-12A1 TO A3
114
Atlas of Liposuction
FIGURES 12-12B1 TO B3
FIGURES 12-12A AND B
A 39-year-old male, preoperative abdominal and love handle suction. In the male the deformity is the result of excess fat
deposits associated with a certain degree of collapse of the spine and consequent telescoping of the soft tissue with broadening
of the thorax due to the respiratory muscles
Discussion
This technique is useful in removal of love handles.
This area was never done before the era of liposuction.
Male patients are the most enthusiastic in the correction
of this problem since it is their first flaw when they reach
middle age. In addition, it is a valuable tool in giving a
waistline to women who have a Nordic type of body
habitus.
Conclusion
This valuable approach is likely to develop as growing
number of patients seek to correct their particular
problem (Figures 12-11 and 12-12).
Reference
1. Lockwood T. Lower body lift with superficial fascial system
suspension. Plast Reconstr Surg. 1993;92:1112-22.
13 Iliac Crest Liposuction
Introduction
The iliac crest area presents a common problem in
women. It consists of deposits of fat just below the waist
posteriorly and over the area of the iliac crest. This
condition is often associated with a certain degree of
obesity although in some cases it may exist without it; it
is showing as an objectionable protrusion of fat on a
patient who has an otherwise normal body configuration.
A B S T R A C T
The iliac crest area presents a common problem in
women. It consists of deposits of fat just below the waist
posteriorly and over the area of the iliac crest. This
condition is often associated with a certain degree of
obesity although in some cases it may exist without it;
it presents as an objectionable protrusion of fat on a
patient who has an otherwise normal body configuration.
These patients are often the same ones who come for
correction of saddlebags. The combination of the two
problems constitutes the so-called “violin-type deformity”
that is so common in the Mediterranean population.
Liposuction will correct the deformity. Bleeding and
flexion irregularities, dents, seroma, hematoma, and
lymphorrhea may occur, however the most common
problem is irregularities if the surgeon has been too
aggressive in the area.
This area contains fat relatively easy to aspirate and it gives
satisfactory results.
Indications
These patients are often the same ones who come for
correction of saddlebags. The combination of the two
problems constitutes the so-called “violin-type deformity”
that is so common in the Mediterranean population. The
area of the iliac crests is to be differentiated from the
flank, a problem which is more common in the males and
which presents deposits at a higher level in the waist area.
The iliac crest bulge is situated more posteriorly and below
the waist. Patients who come in usually have a problem
of excess deposits elsewhere too. Yet in some cases, it
could be isolated and especially unsightly. In the past there
was no treatment for this type of deformity until
liposuction was discovered.
Markings and Preoperative
Preparation
The patient is marked in the standing position. The most
anterior and posterior zones are marked along with the
upper and lower limits. The extent of the tissue to be
extracted is evaluated with the patient in the standing
position and while lying down. Palpation and the pinch
test will be helpful. In addition, the topographic map is
Adrien E Aiache
116
Atlas of Liposuction
FIGURE 13-1
The iliac crest deformity gives the so-called violin-type of
deformity when it is associated with the saddlebag excess
FIGURE 13-2
The iliac crest bulges were chiefly responsible for the
ungraceful shape of the hips ion middle-aged women as it is
shown in these drawings
FIGURE 13-3
The iliac crest suction can be performed through a hip
incision used for saddlebag suction
FIGURE 13-4
An excellent approach for iliac crest suction is afforded by the
hip incision used in saddlebag suction
117
Iliac Crest Liposuction
FIGURE 13-5
The preferred approach from the parasacral area allows a
comfortable suction of the iliac crests. Both lateral incisions
can be joined by suctioning the left iliac crest from the right
incision and vice versa. This helps to correct the “twist”
FIGURE 13-6
These two contiguous fat deposits can be suctioned through
the same incision. The actual extent of the procedure is more
extensive than the schema suggests
FIGURE 13-7
Crisscrossing can enhance the results of iliac crest suction
from a sacral and infragluteal incision
FIGURE 13-8
Crisscrossing from a hip and sacral incision
118
Atlas of Liposuction
FIGURE 13-9
An anterior approach for iliac crest suction using a groin
incision
FIGURE 13-10
An anterior approach for iliac crest suction using a superior
crease or a stretch mark for the incision. One can also use
the lateral part of an abdominal lipectomy incision
FIGURE 13-11
The outer buttock incision is useful for the hips and saddle-
bags and is very well hidden. A 4 mm cannula is used.
Finessing is done with a 3 mm cannula. Note the avoidance
of the trochanteric areas in the liposuction
FIGURES 13-12A AND B
Markings for iliac crest liposuction. The outer circle shows the
area of feathering
119
Iliac Crest Liposuction
used to record the thickest areas by crossing it repeatedly.
During surgery, the pinch test determines the thickness of
the zone and this helps in the control of the results
(Figures 13-1 to 13-13).
Location of Incision
It is located either in a dimple situated in the lateral aspect
of the iliac crest and if it is associated with saddlebag
liposuction it is situated in the hip thus helping in
suctioning both areas. In addition, these incisions are used
for crisscrossing.
Position
The position is prone although sometimes the lateral
decubitus position can be helpful. In cases of violin
deformity, the surgery can be done with the patient in the
prone position and the elevation of the hip allows the
proper inspection of the case.
Anesthesia
It can be general if surgery is associated with other areas
such as the saddlebags, buttocks or the thighs, however,
in some selected cases, local anesthesia can be useful. It
consists usually of the tumescent formula.
Prepping and Draping
The patient is prepped and draped in the prone position.
This position limits somewhat the most anterior aspect of
the area to be suctioned. Therefore, the patient will have
to be rotated during the surgery in order to complete the
work.
Refinements
Feathering by suction of the tissues surrounding the area
helps in preventing depressions. In addition, one has to
be careful not to remove an inordinate amount of fat
since it could result in unsightly dimples, depressions and
bumps. The refinements are done with a 3 mm cannula
and a Robles cannula.
Postoperative Treatment
The wounds are closed with absorbable sutures and Steri-
strips. The patient is then dressed in a garment for
approximately 3 weeks. The postoperative care is the same
as any suction case.
Discussion
No surgical technique was available in the past to correct
this iliac crest deformity; however, since the advent of
liposuction the treatment with small incisions can be
extremely helpful in correcting the problem (Figures
13-14 to 13-17).
Complications
Bleeding and flexion irregularities, dents, seroma, hema-
toma, and lymphorrhea have been mentioned, however,
the most common is of irregularities if the surgeon has
been too aggressive in the area (Table 13-1).
FIGURE 13-13
Posterior approach. Iliac crest suction from a paraspinal
incision.
Complications of iliac crest liposuction
Insufficient removal
Anterior dents near the anterior iliac crest
Extensive suction (more than you think) is necessary,
however, be careful when you reach the anterior iliac
crest
Too extensive liposuction with:
–
Dents
–
Depressions
–
Irregularities
To avoid difficulties:
–
Judicious suctioning
–
Careful pinch test and careful observation of
possible dents, depressions and step deformities
TABLE
13-1
120
Atlas of Liposuction
FIGURES 13-14A AND B
(A) Preoperative 34-year-old woman with iliac crest lipodystrophy associated with saddlebags and knees lipodystrophy; (B) Six
months postoperative after liposuction of iliac crest, saddlebags, and knees. Note that iliac crest is visible
FIGURES 13-15A AND B
(A) Preoperative patient with iliac crest lipodystrophy;
(B) Postoperative
121
Iliac Crest Liposuction
FIGURES 13-16A TO C
(A) Preoperative 46-year-old woman with large iliac crests lipodystrophy. These are most visible from the back and the removal
should extend to the periphery; (B) The extent of the markings showing the different zones where the suction process is to be
extended in order to obtain symmetrical results is greater in view of the severity of her problem; (C) Four months postoperative.
Notice the better cosmetic result on the right iliac crest
FIGURES 13-17A TO C
(A) Preoperative 35-year-old woman with iliac crest lipodystrophy; (B) In some cases the iliac crest excess will only shown in the
posterior view. When very large they can be perceived from the anterior view; (C) Six months postoperative after iliac
liposuction
14 Lumbar Bulge
Liposuction
Introduction
The exquisite beauty of the lumbar curve is seen in the
female when her body is in an oblique position. The
concave shape of the back just above the roundness of
the gluteal redundancy has been considered particularly
attractive in this decade. On male patients too, the curve
is important to obtain as can best be demonstrated on
athletes who have a good body definition and would like
to improve on the waist and the lumbar shape exhibiting
A B S T R A C T
Liposuction is indicated on patients who have this excess
bulge over the sacrum and around it. This excess is
associated with skin redundancy in patients making this
zone particularly unattractive. If superficial suction is used,
there still could be redundant skin after the liposuction.
One should be aware of the possibility of a spinal
herniation with a form fruste of spina bifida which could
be dangerous if entered. Possible complications include
hemorrhage, nerve damage, infection, irregularities of
the area with bumps and depressions and, although very
uncommon, meningitis secondary to a traumatic
perforation of the herniated dural sac. Liposuction of the
lumbar area is useful. This should allow the patient to
wear clothes and get an esthetic improvement.
a pure muscular definition without the somewhat
deforming bulges due to fat. The central sacral bulge (or
twist) is also the subject of concern and in this particular
case, the subject of this chapter.
Indications
Liposuction is indicated on patients who have this excess
bulge over the sacrum and around it. This excess is
associated with skin redundancy in patients making this
zone particularly unattractive.
Caveats
Although one has to be more optimistic if superficial
suction is used, the skin could still be redundant after the
suction. In addition, one should be aware of the
possibility of a spinal herniation with a form fruste of
spina bifida which could be dangerous if entered. If it
is suspicious, X-ray of the spine is indicated to rule out
spina bifida with a meningocele within it.
Anesthesia
Suction of the lumbar bulge is generally difficult to
perform under local anesthesia because it is tender and
the strong avulsion force exerted by the suction is not
easily controlled by local injections of anesthetic. General
anesthesia is thus favored.
Adrien E Aiache
123
Lumbar Bulge Liposuction
Markings
Markings are made in the standing position and the areas
to be liposuctioned are carefully delineated. Secondary
markings encompassing an area around it show the proper
feathering.
Incisions and Technique
Incisions measure approximately 4 mm and are positioned
approximately 5–6 cm lateral to the midline and 5–6 cm
above the sacrum. These incisions allow proper suction
of the whole zone which has been infiltrated with the
tumescent anesthesia. Two incisions are useful for
crisscrossing. In some cases, only one central incision can
be used in the upper portion of the gluteal crease.
Throughout suction, constant observation with palpation
and pinch test will be used to assess the area. 4 mm and
3 mm cannulas are usually used and the finessing is done
with the 3 mm cannula. The liposuction process is
sometimes completed by release of the attached septa
(Figures 14-1 to 14-4).
Complications
Although possible, complications such as hemorrhage,
nerve damage or infection have not been experienced by
the author. The main and frequent complication consists
of irregularities of the area with bumps and depressions.
In addition, although very uncommon, a possible
complication consists of meningitis secondary to a
traumatic perforation of the herniated dural sac.
FIGURE 14-1
Two lateral incisions at the sacroiliac level allow lumbar
suction and crisscrossing
FIGURE 14-2
Liposuction of the lumbar bulge can be performed through a
double parasacral incision but often is better done through a
central incision placed in the upper part of the buttock crease
FIGURES 14-3A AND B
A double parasacral incision allows extension of the suction to the iliac crest
124
Atlas of Liposuction
FIGURE 14-4
Crisscrossing across the midline allows complete suction of
the lumbar sacral bulge
Contraindications
Cases of extreme obesity will not improve markedly. In
addition, the possible meningocele would be a
contraindication.
Conclusion
Liposuction of the lumbar area is useful. This should
FIGURE 14-5
Lumbar lipodystrophy and the sacral bulge on this 27-year-
old woman who is scheduled for saddlebag liposuction
FIGURE 14-6
Large lumbar lipodystrophy on a patient who has undergone
saddlebag and thigh liposuction
FIGURE 14-7
A 35-year-old woman with moderate lumbar and iliac crest
lipodystrophy. Note that the lumbar bulges are not readily
apparent in the posteroanterior position as might be in the
oblique position
allow the patient to wear clothes and get an esthetic
improvement (Figures 14-5 to 14-8).
The presacral fat pads or lumbar bulge is present in
many women who are not usually aware of it until the
iliac crest liposuction has been done and this is usually
the time when they notice their bulge. One should be
aware of this fact and it is better to suction the
whole area when one is doing the iliac crest liposuction
thereby avoiding the postoperative complaints related to
that area.
125
Lumbar Bulge Liposuction
FIGURES 14-8A TO C
(A) Preoperative. Note the thickness of the central lumbar area and the sacral bulge. This area becomes more visible after iliac
crest liposuction; (B) Postoperative shortly after lumbar liposuction; (C) Two years postoperative result showing the
improvements of the lumbar suction and the curvature
15 Breast Liposuction
Gynecomastia
Treatment of the gynecomastia consisted of an infra-
areolar incision or a complete transmammary incision
allowing the approach to the desired fat and excess breast
tissue. The results were often esthetically unacceptable with
distortion, delayed healing, irregularities of the fatty
deposits and problems in healing of the nipple as well
as hemorrhage and infection. Favorable postoperative
esthetic results were very difficult to obtain. Smoothing
the chest wall was also very difficult and patients often
had to endure dished-out chest walls with waves,
irregularities and other problems at the junction of the
operated area with the surrounding tissue. Liposuction has
been useful in reducing the fat excesses involved in the
A B S T R A C T
Previous treatment of the gynecomastia consisted of an
infra-areolar incision or a complete transmammary
incision allowing the approach to the desired fat and
excess breast tissue. The results were often esthetically
unacceptable with distortion, delayed healing,
irregularities of the fatty deposits and problems in healing
of the nipple as well as hemorrhage and infection.
Treatment of gynecomastia, gynecomastia in the body
builder, and female breast liposuction are discussed with
possible complications.
gynecomastia, however, it has not been sufficient by itself
since the excision of the glandular portion in the
gynecomastia can only be done by sharp excision. It is
wrong, then, to think that gynecomastia can be treated
by liposuction alone (Figures 15-1A and B).
FIGURES 15-1A AND B
Gynecomastia incision performed in the infra-areolar skin
junction allows the liposuction process to be applied to the
whole mammary mound. Note the extent of the undermining
occupying the anterior chest. This is performed only after the
mammary gland (in the stippled circle) has been excised
totally
Markings
The patient is marked in the standing position marking
the infra-areolar incision and the area of fat to be
removed. When the patient is in a standing position,
Adrien E Aiache
127
Breast Liposuction
proper evaluation of the padding of fat present on the
chest wall is possible. Note that some patients will present
excessive gynecomastia with an excess of skin giving an
appearance similar to a female breast (Figure 15-2),
however, other cases with minimal fat will consist of an
increase in the glandular mound under the nipple and
around it. An exact marking of the area will help in
determining the results to be obtained. The pinch test is
very helpful and very telltale since it is always possible to
pinch the soft tissue on top of the gland and by a wider
pinch to get the glandular tissue under the fat. This pinch
test is done with a variation from the regular pinch test
since it will tell the volume of the gland which is
surrounded by fat.
Surgical Technique
Anesthesia is usually general; however, local anesthesia can
be given when the amount to remove is relatively small.
Tugging from the suction is always uncomfortable and the
patient will be held with difficulty during the surgery.
Once the local anesthesia has become effective, an incision
is made in the areola and sharp dissection is necessary
dissecting the skin away from the glandular portion of the
gynecomastia. This is done in the routine surgical fashion
of doing a mastectomy by freeing the gland from the
fibrofatty tissue around it. Once the skin has been
completely undermined over the gland, the gland is then
grasped and with strong retraction laterally the gland is
then dissected away from the pectoralis fascia using mainly
sharp and blunt dissection. Laterally, the gland ends up
in the mid-axillary line area where bleeding can be
encountered if the dissection of the gland enters the
tissues below it and it does not stay in the right plane.
At the end of the excisional part of surgery, liposuction
is performed around the zone to obtain a smooth
transition with the nonoperated area and at this point a
4 or 3 mm cannula can be used safely.
Closure is accomplished by reapproximation of the
skin to the pectoralis muscle by a basting stitch going as
distal as possible to prevent hematomas from filling the
undermined area. There is a large dead space which readily
fills with blood and fluid. Closure is done over a drain
for comfort. Postoperative care consists of prophylactic
antibiotics, pain medication, constraining the chest wall
with elastic bandages and approximately a 3-week period
of rest to prevent the pectoralis muscle from tearing away
from the skin.
Conclusion
Liposuction of the gynecomastia cases is useful as an
adjuvant after the surgical removal of the glandular
portion of the gynecomastia.
Gynecomastia in the
Body Builder
Surgical Treatment
The surgical treatment of gynecomastia has evolved from
the technique of subcutaneous mastectomy to the new
method of liposuction associated with gland excision
(Figures 15-3 and 15-4).
This approach is indicated for adolescent and middle-
aged men who have a combination of gland and fat
hypertrophy.
In the body builder, and especially those taking
anabolic steroids for muscle mass increase, the surgical
treatment has different characteristics.
Gynecomastia in the body builder is the direct result
of the prolonged and repeated intake of anabolic steroids
such as methandrostenolone (Dianabol), stanozolol
(Winstrol) and nandrolone decanoate (Decad-Durabolin).
Other anabolic steroids taken in tablets are oxandrolone
(Anavar) and oxymetholone (Androl-50). More medications
are developed in using these derivatives.
The intake of anabolic steroids and the deleterious
effects of these medications have been thoroughly
researched. Their use is banned in most athletic compe-
titions.
The patients complain of breast enlargement they
perceive during their training program. The enlargement
is not noticed at first by the patient who fails to
FIGURE 15-2
Large bilateral gynecomastia on a 46-year-old male.
Treatment consists of skin excision in addition to gland
excision, especially on the left breast with additional
liposuction around it
128
Atlas of Liposuction
FIGURES 15-3A AND B
(A) Preoperative fatty gynecomastia in a 36-year-old man who has general obesity; (B) Postoperative following breast excision.
Note the unsatisfactory result obtained without liposuction in this case
FIGURE 15-4
Through circumareolar incision, the skin of the nipple is
raised and the terminal portion ends of the galactiferous
ducts are cut leaving a thickness of 6–8 mm
distinguish it from the increase in muscle size (pectoralis
major and minor). The gradual enlargement of these
muscles seems to mask the concomitant enlargement of
the breast tissue. However, as the shape of the muscle
improves, the athlete discovers that his breast shape has
become distorted and has a shape not connected to the
muscle growth. In repose, the nipple droops looking down
and sits at the top of a soft mound present over the
lower edge of the pectoralis major muscle. During
contraction of the muscle, the shape of the muscle is
distorted and does not appear sharply defined since it is
overshadowed by the softness and the pyramidal shape of
the breast tissue on top.
No suspicious masses are found on examination of
these patients and the condition is found bilaterally in all
cases. A thin layer of fat is palpated although in some
of these patients not strictly involved in body building,
a thicker layer of fat may be present. Laboratory tests
should include a fibrinogen count which can be low in
some patients thereby increasing the chances of operative
and postoperative bleeding.
As a routine, patients are told to abstain from taking
these steroids for at least 2 months preoperatively.
Treatment
The treatment consists of the removal of the whole
mammary gland present below the nipple and over the
pectoralis major.
Anatomy
The anatomy shows that the mammary gland has the
exact extension in its development as in the female.
The base of the gland reaches up to 2 inches from the
clavicle, goes to the mid-axillary line and approximately
1 inch from the midline of the sternum in addition to
approximately 2 inches below the nipple. This gland is
present in all cases and when it enlarges, it enlarges more
conspicuously immediately under the nipple-areolar
complex, however, it is present in all cases all over the
chest wall and its enlargement can be extreme, making it
sometimes difficult to extirpate in one fragment from the
small incision. This gland has a very firm consistency
which does not respond to treatment such as ultrasound
or even the sharp curette which only will curette some
of the surface of the gland leaving the major part behind
(Figure 15-4).
129
Breast Liposuction
This anatomical fact explains why the concept of
treating gynecomastia with either plain fat suction with
curette or ultrasound is not acceptable and does not
reflect reality.
Anesthesia
Anesthesia is general or it can be local in some cases
where the patient is able to accept the pain associated
with a very large surface extirpation of the gland.
Incision
The favored incision consists of a semicircular infra-areolar
incision at the junction of the areola skin and breast skin.
Rarely, an axillary incision or a horizontal nipple incision
is used. In cases where the nipple is ptotic, the surgery
will then consist of an elevation of the nipple on a
crescent type of excision with a good vascular base for
the ellipse of the nipple since it could end up in nipple
necrosis if the circulation is not adequate. In other cases
where the enlargement is dramatic, the only type of
incision is similar to the incision used in mastopexies and
consists of an inverted T scar with some circumareolar
excision, however, assuring that there is enough circulation
to the nipple-areolar complex.
Technique
The incision is made through the subcutaneous tissue,
then undermining is performed over the mammary gland
with Metzenbaum scissors using a technique similar to the
subcutaneous mastectomy technique used by general
surgeons. The extent of undermining is predetermined by
the skin markings. It goes approximately 2 inches below
the clavicle, 1 inch from the midsternal line, in the
midaxillary line, and 2 inches below the areola in the
inframammary area. Care must be taken to leave a layer
of fat below the skin in order to preserve the skin flap
circulation and chest contour.
At the level of the nipple, the lactiferous ducts are
sectioned leaving 6–8 mm of thickness to the nipple. This
nipple-areola left behind is the only mammary gland that
should be left behind after the mastectomy. The mammary
gland is then grasped with a tenaculum and retracted
laterally while the assistant retracts medially. At this point,
the dissection of the mammary gland is performed with
sharp and blunt dissection freeing it from the pectoralis
fascia situated below it. A combination of sharp and blunt
dissection from the pectoralis fascia is used until the gland
is freed from medial to lateral. Laterally, the junction with
the axillary and midaxillary line tissues is performed
freeing the gland and leaving the pectoralis muscle, the
external oblique and the serratus behind as well. The
whole specimen is removed in one unit. In very big
builders, the gland is situated on very large muscles with
a very generous circulation and hemorrhage is relatively
common. Hemostasis should be extremely careful.
Sometimes, the whole specimen measures 8–10 cm in
diameter and up to 2–3 cm in thickness. This large
amount of breast tissue is very different from the amount
found in middle-aged or adolescent male gynecomastia
excision where there is a large component of fat
associated with a smaller gland.
The breast pocket is closed with a few rows of sutures
coapting the skin to the pectoralis fascia in order to avoid
large dead space and to limit the size of eventual
hematomas. Compressive bandages are used for 2–4 days.
Quite different from the new tendency towards
liposuction, this surgical technique is similar to the one
performed for female subcutaneous mastectomy and it is
involves removal of the whole mammary gland. Drains are
left at the corner of the wound for approximately 48
hours and up to 4–5 days if necessary (Figures 15-5 to
15-7).
FIGURE 15-5
The mammary gland occupies most of the chest wall and
increases uniformly in the body builder. The size of the gland
is 12 x 16 x 2 cm
Pathology
Pathologic slides taken from different areas of the gland
show essentially a composite of breast parenchyma
interspersed by typical breast ducts which are more
common than the breast parenchyma. The fat is situated
above and below the gland, however, it is not found in
the gland itself.
130
Atlas of Liposuction
FIGURES 15-6A AND B
(A) Preoperative 26-year-old man with gynecomastia; (B) Eight months postoperative
FIGURES 15-7A AND B
(A) Preoperative 26-year-old male with gynecomastia of long-term duration; (B) Postoperative at 8 months. Note the left breast
is still somewhat swollen and distorted due to a hematoma. This was treated by repeated aspiration with a large gauge needle
Complications
Breast hemorrhages necessitate reopening and hemostasis.
Hematomas necessitate only needle aspirations. No
infections, skin slough or chest wall distortion has been
observed. Although liposuction is recommended by some,
in the body builder it is not necessary, or if there is some
fat, only the circumference of the excised area has to be
suctioned.
Conclusion
1. Gynecomastia in the body builder is secondary to
anabolic steroid intake.
2. There is an increased risk of hemorrhage in these
patients who have very large vessels in conjunction with
very large muscles, and specific techniques obliterating
dead space associated with extremely careful hemostasis
is necessary.
3. No fat removal has been found necessary nor advised
in these patients.
4. The conclusion drawn by this work seems to suggest that
extremely large mammary glands are present, in an
undeveloped form, in all male patients and it only
develops to visible extent in body builders on steroids.
This indicates the necessity of performing large extensive
glandular resections in cases where it might not be
suspected.
Cases of breast carcinoma, although present in
1–100 breast cancers has not yet been found by the
author.
131
Breast Liposuction
Female Breast Liposuction
Incisions
Medial inframammary
Lateral inframammary
Periareolar
Axillary
Instruments
4 mm cannula
3 mm cannula
Anesthesia
General
Local for small reduction
Although many techniques of mammoplasty have been
developed, none has solved satisfactorily the problem of
excesses in the medial and lateral part of the breast and
the excessive protrusion of the tail of Spence in the axilla.
Even in using the inferior pedicle technique, the
mammoplasty alone is often insufficient and additional
procedures such as suction are necessary to improve the
total picture. All the different mammoplasty techniques are
short of being satisfactory in removing the fat unless
liposuction is performed.
Isolated liposuction for breast reduction has been
developed since quite sometimes. The author himself has
been the first to describe the liposuction on the tail of
Spence, the medial and lateral fat deposits, because the
total breast liposuction was not satisfactory in a large
percentage of cases. The isolated breast reduction by
suction is limited to cases that will improve without skin
reduction on patients who are not eager to have the scars
of breast reduction. The suction breast reduction is
remarkably simple in some cases and is usually a satis-
factory procedure when performed on the right patients.
Indications
Specific indications are limited to patients who have a
nipple-areolar complex that is esthetically well located since
the technique will certainly not elevate the complex. In
addition, indications are on people who have mainly fatty
overdevelopment. The fat tissue can be easily aspirated as
opposed to breast tissue.
Secondary indications are patients who have already
had a reduction mammoplasty and are eager to reduce
further their breast size, however, will probably be happier
if no additional scar incision or excision can be given.
These cases will respond well to a pure liposuction
reduction through already existing scars.
Markings
Markings are either made in old scars from reduction or
if they are new, they should be made as a small mark
either in the axilla in the medial or lateral submammary
fold, and sometimes in the infra-areolar skin junction. The
breast tissue for liposuction does not have to be marked
since it is visible, and the only markings to check are the
circumference of the breast and the possible excesses
medially and laterally (Figure 15-8).
FIGURE 15-8
From the outer inferior incision liposuction can be performed
on the whole chest wall
Instruments
4 mm and 3 mm cannulas are easier to use. In addition,
the Becker cannula can be utilized to try to remove some
breast tissue, however, in the author’s opinion it is not
an adequate technique for breast tissue reduction.
Anesthesia
Anesthesia is mainly general, however, in limited zones,
local anesthesia can be used on patients who are able to
withstand some pain.
Technique
The usual technique of to-and-fro liposuction is used in
these cases. The breast is carefully divided in different
132
Atlas of Liposuction
portions to be able to suction without missing any spots.
If the introduction of the cannula is difficult, only the
areas that can be done easily are performed and this is
the limiting factor in pure suction of the breast. Usually
older females with more fat and less breast tissue are
amenable to this type of procedure, especially very large
fatty breasts. If the surgeon decides to go ahead with the
planned mammoplasty reduction by any technique, it is
then possible after the suction period to continue with the
breast surgery and at the completion of the reduction by
surgery, additional liposuction is performed in these areas
an “open sky” technique for complete fatty removal
(Figures 15-8 to 15-17).
Refinements
Refinements are done especially in the lateral and medial
wall areas and this is done using a smaller cannula.
FIGURES 15-9A AND B
The incision can be drawn at the outermost portion of the inframammary
incision; it can be done either at the start of the procedure or at the finish. The
multiple spokes are liposuctioned-out in a fan shape, fanning laterally
FIGURE 15-10
Postoperative patient after reduction mammoplasty who still
exhibits a fatty fullness of the lateral chest wall
FIGURE 15-11
Postoperative reduction mammoplasty marked for secondary
reduction of the lateral roll (same patient)
133
Breast Liposuction
FIGURE 15-12
Secondary liposuction performed for the lateral roll in a case
where reduction mammoplasty was done previously
FIGURE 15-13
The medial fatty excesses are suctioned through a medial
approach through the inframammary scar
FIGURE 15-14
Breast symmastia. The extent of liposuction can improve the
problem only to a limited degree since the skin fold will
sometimes not drape well on the new chest contour
134
Atlas of Liposuction
FIGURES 15-15A AND B
The “tail of Spence” liposuction is performed through the axilla in any number of directions
FIGURE 15-16
Size reduction at the time of reduction mammoplasty will
avoid additional surgery and often shorten the inframammary
scars
FIGURE 15-17
The whole breast mound is liposuctioned resulting in an
overall reduction in size
Dressings
The areas of suction are cleansed and a compressive
bandage is applied with a compressive bra. Prophylactic
antibiotics and pain medication are routinely given.
Sequelae
Chest bruising can be extensive and can last for a few
weeks. Numbness of the areas of suction disappears in
few weeks. Complications of tape burns are due to the
Elastoplast or tape and bleeding is usually uncommon.
Nipple and inferior wound dehiscence and necrosis is
uncommon.
Discussion
This liposuction technique is found useful in either
complementing the techniques of reduction mammoplasty
or as a solo procedure for reduction of a fatty breast. In
cases where an unsatisfactory appearance has been
obtained by surgery, the liposuction can often sculpture
the breast mound as desired.
16 Breast Reduction
Combined with
Liposuction
Liposuction
Although many techniques of mammoplasty have been
developed, none has solved satisfactorily the problem of
excesses in the medial and lateral part of the breast as
well as the overall reduction of breast tissue when a large
amount of fat is present. The excessive protrusion of the
tail of Spence in the axilla is also a difficult area.
Even in using the inferior pedicle technique, mammo-
plasty alone is nevertheless insufficient and an additional
procedure such as suction is necessary. The improvement
is done in the breast tissue itself during the reduction or
before it, and at the end of the reduction, the suction is
A B S T R A C T
Although many techniques of mammoplasty have been
developed, none has solved satisfactorily the problem
of excesses in the medial and lateral part of the breast
as well as the overall reduction of breast tissue when
a large amount of fat is present. The excessive protrusion
of the tail of Spence in the axilla is also a difficult area.
Although some skin retraction can occur with liposuction,
the patient should be warned about the inability to
remove the dog ears by liposuction in addition to the
occurrence of irregular depressions in the lateral wall
of the breast. Liposuction of the breasts is a satisfactory
adjuvant in the breast reduction technique.
used medially, inferiorly, laterally and superiorly to improve
the borders of the breast tissue. Another advantage of using
suction is that symmetry can be obtained; this is often
difficult with surgical techniques alone.
Indications
Obese patients who present large breasts are prime
candidates for liposuction since they exhibit fat excesses
in and around the breasts themselves.
Patients who have a mild degree of symmastia are also
candidates for medial liposuction through the inner
portion of the inframammary fold.
The tail of Spence is also an indication for liposuction
providing that no breast tissue per se is present since it
is impossible for the suction process to extract breast
tissue.
Note that the lateral thoracic roll is the most common
deformity in obese patients and the one most satisfactorily
treated by liposuction (Figures 16-1 to 16-3).
Finally, the size of the entire breast can be reduced
by liposuction alone if the breast mound consists mainly
of fat and has little breast tissue; this is most often seen
in older women.
Caveats
Although some skin retraction can occur, the patient
should be warned about the inability to remove the dog
ears by the technique of liposuction in addition to the
Adrien E Aiache
136
Atlas of Liposuction
FIGURES 16-1A AND B
(A) Preoperative 54-year-old woman with breast hypertrophy and ptosis. Note the lateral fat bulge
near the axilla; (B) One year postoperative
FIGURES 16-2A AND B: BREAST SUCTION LIPECTOMY
(A) Preoperative patient. In large patients, the liposuction process is used medially, laterally, and
superiorly through different incisions; (B) Postoperative. To avoid the square appearance of the
breasts, suction lipectomy of the medial and lateral ends of the breast will be useful in reduction
mammoplasty
occurrence of irregular depressions in the lateral wall of
the breast.
Although the achievement of symmetry is of
importance, patients should be warned of the possibility
of ending up with asymmetrical sizes.
One important factor is the fact that suction alone
cannot elevate the nipple and if the nipple has not been
properly elevated to a new level, suction will not help in
achieving the desired results.
Markings
Breast excisions are marked according to the elected
technique for mammoplasty in the standing or sitting-up
position. The inferior submammary scar is marked and can
often be shorter when liposuction is used as an adjuvant.
The marking of the fatty excesses is made either
medially, superiorly or laterally to facilitate the surgery. The
pinch test is useful especially laterally to compare the real
excess of fat with the normal thoracic thickness of the
remaining portion of the chest. Extreme attention is given
to the markings and the actual positioning and shaping
of the breasts in order to assess the exact area of suction
to be performed in addition to the surgical procedure.
Anesthesia
In cases of moderate breast hypertrophy and fat excess,
local anesthesia is adequate.
137
Breast Reduction Combined with Liposuction
FIGURES 16-3A AND B
(A) Preoperative 54-year-old woman with breast hypertrophy of a fatty nature and large
thoracic rolls; (B) Eight months postoperative shows improvement in the thoracic roll
Although the surgical reduction seems to respond well
to local anesthesia, the suction procedure is often less
tolerable because the strong aspiration of fat tugs on the
thoracic muscle fibers. General anesthesia is used in larger
breasts and it is complemented by the diluted solution of
xylocaine and epinephrine.
Technique
Liposuction is often started before the reduction
procedure making the surgery easier and the surgical
excision less extensive. Otherwise, “open sky” suction is
performed in order to “clean” the wound edges and the
irregular areas of excess fat present in the remaining breast
segments after the reduction. This technique is not very
traumatic and spares most of the larger vessels.
After closure of the breast edges, sometimes the
suction can be used again to improve areas that need it,
especially the most common such as the lateral chest wall,
the medial protrusion, and the tail of Spence. A 4 mm
or 3 mm cannula is often the preferred instrument. The
result of liposuction is constantly checked during the
procedure by the pinch test and the roll test.
Refinements
Liposuction is performed in the lateral chest and the
medial chest area. Feathering is accomplished in all these
zones surrounding the liposuction to obtain a smooth
transition with the untouched areas.
Dressings
The areas of suction can be taped, however, a bra is the
best garment and it is held by a circumferential Elastoplast.
Sequelae and Complications
The chest bruising can be extensive and can last a few
weeks. Numbness of the areas suctioned usually disappears
within a few weeks. Complications have been tape burn
due to the Elastoplast, bleeding, and rarely infection.
Nipple and inferior mound dehiscence and necrosis is
uncommon although it can be found in any cases of
reduction mammoplasty and especially when it is
associated with fat liposuction.
Discussion
The liposuction technique is extremely useful in
complementing the techniques of reduction mammoplasty.
In cases where an unsatisfactory appearance is obtained,
the suction can often sculpture the breast mound as
desired. With this technique in mind, the surgeon can
shorten the inframammary scars and rely on the suction
process for release of tension of the wounds by reducing
the actual volume of the breast mass.
Conclusion
Liposuction of the breasts is a satisfactory adjuvant in the
breast reduction technique.
17 Back and Scapula
(Upper Back and
Thoracic Rolls)
Upper Back and Thoracic Rolls
A concept of understanding the thoracic roll is devised
as a condition that has a combination of skin rolls with
fat excess. It is thought that these thoracic posterior rolls
consist of an accordionization of the posterior thoracic
skin due to skin relaxation with aging and fat excess. The
rolls usually number three and are interspersed by valleys,
representing adhesions of the skin to five or six points
at the level of the deep fascia. Some improvements are
feasible by suction alone. A technique of sharp dissection
of the adhesions of the valleys is necessary to obtain
A B S T R A C T
The thoracic roll is a condition that has a combination
of skin rolls with fat excess. It is thought that these
thoracic posterior rolls consist of an accordionization of
the posterior thoracic skin due to skin relaxation with
aging and fat excess. The rolls usually number three and
are interspersed by valleys, representing adhesions of the
skin to five or six points at the level of the deep fascia.
The usual patient is a middle-aged woman with a slight
weight problem or a more severe one, especially in the
torso. The techniques of liposuction of the areas of the
thoracic roll, flankplasty, hip lift, and Dowager’s hump
are discussed with possible complications.
proper improvement and release of these adhesions. This
liposuction of the back and subscapular area is relatively
new in the liposuction techniques. Without it, there would
not be any available treatment for improvement of an
unsightly back and lateral thoracic area. This area is often
asked about by women who are concerned about their
appearance in low-cut dresses, bathing suits or even
leotards.
Indications
The usual patient is a middle-aged woman with a slight
weight problem or a more severe one, especially in the
torso. In addition, with this accumulation of fat there is
often skin excess. The back is then occupied by a couple
of large “waves” or fatty rolls. This area is especially of
concern to older women.
Markings
The areas are marked on the standing patient. Areas of
adhesion to the deep fascia are especially marked for their
identification during surgery and their release. The area to
be suctioned is also marked in all of its surface as well
as feathering going toward the central area and inferiorly.
Palpation is used with the pinch test to determine the area
of most excesses and the areas to be spared. If the
scapular area is too thick, some defatting will be necessary
especially at its lower border.
Adrien E Aiache
139
Back and Scapula
FIGURE 17-1
The back and subscapular liposuction encompasses the mid
back area between the scapulae and the waist
FIGURES 17-2A AND B
Typical thoracic rolls occupying the area on an older patient
FIGURES 17-3A TO C
A 44-year-old woman with back liposuction. Markings are made according to her wishes as to the removal of the unwanted
bulges. By a combination of inspection and palpation with the pinch test, the extent of the suction is indicated with ink
The markings then will mark in the area below the
scapula and this amounts to a large elliptical area
occupying the whole posterior area of the thorax (Figures
17-1 to 17-3).
Incisions
Crisscrossing is very important and two incisions will be
useful to accomplish this goal. A posterior border of the
axillary crease will help to liposuction downwards in the
back. A second incision either inferiorly near the thoracic
spine or in the midline can be used for proper
crisscrossing (Figures 17-4 and 17-5).
Instruments and Techniques
Instruments are the usual 4 mm and 3 mm cannulas and
especially a Robles cannula will be useful to free all the
deeper attachments of the deep fascia to the muscular
septa. This release is necessary to allow the skin to redrape
properly. Crisscrossing is performed from two zones. The
skin is grasped as a sausage and the cannula is introduced
between the fingers to extract the remaining fat.
Continuous testing and palpation is done as well as close
observation. A counter-incision should be made in some
areas for proper crisscrossing even if it is found to be
relatively difficult. The patient’s positioning has to be in
an exact prone position with even some flexion of the
back to prevent the untoward direction of the cannula to
go between the ribs or below the ribs and through the
diaphragm. This should be done with care to prevent
these potential complications.
140
Atlas of Liposuction
FIGURE 17-4
Back liposuction through an inferior approach using a 4 mm
cannula. Note the opposite hand position and function during
the suction
FIGURE 17-5
An alternative incision used after a large nevus of the back
has been excised
Caveats
In view of this fact, patients should be warned in advance
that there is a possibility of overhanging of skin when
the complete release is unsuccessful. The patients should
be warned about possible dents, waves and bumpiness,
however, the main problem is the remaining waves present
even after suction.
Refinements
Refinements with finer cannulas are done at the periphery
of the zone and either without suction or with light
suction. Closure is done as usual with absorbable sutures
and garments are applied for a few weeks. Postoperatively
the patient is discharged with garments, pain medication
and antibiotics, and they are allowed to start massages and
exercises the week postoperatively.
Complications
The usual surgical complications as well as the compli-
cations related to blood loss can be seen. The main type
of complication is of a cosmetic nature, as mentioned
above.
Discussion
The advent of liposuction has afforded patients a new treat-
ment for back deformities which were impossible to correct
in the past. The treatment provides good results and relatively
low rates of problems (Figures 17-6A and B).
Flankplasty
After Regnault and Daniels,1 original description of a
combination of abdominoplasty and flankplasty, Baroudi2
FIGURES 17-6A AND B
(A) Preoperative patient showing bilateral appearance of the fatty excesses which are noted just above the waist. Note the
unsightly bulge situated below the scapula and above the waist; (B) Postoperative after back liposuction