Atlas Kỹ Thuật Hút Mỡ (Atlas of Liposuction)

23
Introduction
As patients come in for improvement of their abdomen,
they often do not realize that it is only a part of a circum-
ference of their body and that often, the waist, needs further
reduction in order to improve the overall results. Furthermore,
a complete circular thinning of the torso middle portion
is often a better technique at improving a torso which is
a circular structure. This concept called “body contouring”
A B S T R A C T
A complete circular thinning of the middle portion of
the torso is often a better technique at improving a torso
which is a circular structure. This concept called “body
contouring” allows patients to obtain drastic
improvements in their silhouettes. Patients who present
abdominal redundancy associated with poorly marked
waists and lack of a lumbar curvature are good
candidates. Young athletes and body builders who are
getting older can improve the mid trunk area. Obese
patients who want abdominal improvement can have this
technique although it will not altogether improve the
torso since the intra-abdominal organs are overdeveloped
in these patients. Contour liposuction has been very
gratifying in all types of cases but is less satisfactory in
cases of redundant, flabby, flaccid skin.
FIGURES 23-1A TO C
Circular suction improves the circumferential aspect of the
torso. (A) On the left, shows a slight reduction in circum-
ference if only anterior suction is done; (B) On the right,
shows the improved circumferential reduction with waist
suction and below; (C) shows the reduction of the circum-
ference when a circular circumferential liposuction is done
allows patients to obtain drastic improvements in their
silhouettes (Figures 23-1A to C).
The surgical techniques for such improvements were
developed originally by Gonzalez Ulloa. However, the scars
were extremely extensive and visible. These techniques are,
nevertheless, still necessary when the skin redundancy is
extreme and will not allow proper draping after the
suction.
Contour Liposuction
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Contour Liposuction
FIGURES 23-2A AND B
(A) Preoperative markings. This encompasses the lumbar area, the waist and the iliac crest as well as the lower part of the rib
cage as wells as of the upper and lower abdomen to the waist, and the anterior iliac crest; (B) Three years postoperative after
liposuction of the upper and lower abdomen to the waist, the anterior iliac crest waist, lumbar area, and the lower part of the rib
cage. Note the improved contour in spite of the fact that this patient gained a few pounds of weight. Saddlebags were also
operated on by liposuction

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Atlas of Liposuction
FIGURES 23-3A AND B
(A) Preoperative 28-year-old man, a body-builder showing some heaviness in his lumbar area and waist; (B) Postoperative after
liposuction. Note the two paralumbar scars
The contour liposuction is an interesting evolution of
the suction which was done in different areas of the torso
until it was realized that a complete circumferential
liposuction will be most helpful.
Indications
Patients who present abdominal redundancy associated
with poorly marked waists and lack of a lumbar curvature
will be good candidates. Young athletes and body builders
who are getting older will improve the mid trunk area in
that fashion. Obese patients, who want an abdominal
improvement, can have this technique although it will not
altogether improve the torso since the intra-abdominal
organs are overdeveloped in these patients. Examination
and palpation discover the area of fatty excess in the
anterior abdomen, the waist, and in the posterior lumbar
area including the lower rib zone and the iliac crests.
Markings and Incisions
After marking the elected areas for suction, the placement
of the incisions is made. Two incisions in the parasacral
area, one possibly above it in the midline to defatten the
posterior rib zone, an umbilical incision as well as a
suprapubic incision and a lateral incision at the edge of
the rectus are useful for complete contouring. The markings
are then made going from the rib cage down to the pubis,
over the iliac crest laterally, posteriorly at the level of the
ribs or above them, and inferiorly at the level of the iliac
crest and the lumbar area. At the periphery, a second
marking is made for refinements and feathering.
Anesthesia
General anesthesia is indicated in such an extensive area
of liposuction. It is supplemented by the tumescent

195
Contour Liposuction
FIGURES 23-4A TO D
(A) A 23-year-old man with slight contour lipodystrophy in spite of vigorous physical exercise; (B) Three months postoperative;
(C) Preoperative before second surgery; (D) Postoperative after secondary liposuction
technique. In addition, it is often a zone of potential
improvement with ultrasound since the lateral waist area
has been very difficult to correct with pure liposuction.
Technique
The patient is placed in the prone position. Through two
lateral lumbar incisions and possibly a central thoracic
incision using the tumescent anesthesia then the suction
cannula, suction is done thoroughly in these zones.
Crisscrossing is done using the two different incisions in
the opposite direction. Then the patient’s wounds are
closed with absorbable sutures, bandaged and the patient
is turned over in supine position. From that point, the
procedure is completed using a procedure similar to the
abdominal liposuction and the lateral waist liposuction.
Postoperative Care
After a period of two days of rest, bandages are removed
and the patient is placed in a girdle and is allowed proper
showering and toilet. Exercises are allowed a week after
surgery. Prophylactic antibiotics and pain medications are
given.

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FIGURES 23-5A AND B
(A) Preoperative, a 28-year-old male showing some
heaviness of the lumbar and waist areas; (B) Postoperative
after contour liposuctioning
Complications
Hematomas, infections or slough are rare. No general
complications such as embolus or pneumonia have been
noted. On the other hand, the usual cosmetic problems
can be seen as with any type of suction, they consist of
irregularities, bumps and lumps, and depressions.
Only by slow, thoughtful and painstaking surgical
technique will result gratifying and the rate of
complication lessened.
Conclusion
Contour liposuction has been found a useful tool in
improving the torso in patients where recently only
abdominal liposuction was used. The contour liposuction
has been very gratifying in all types of cases—men,
women, young adults, athletes, and are only less
satisfactory in cases of redundant, flabby, flaccid skin
(Figures 23-2 to 23-5).

24 Autologous Fat
Reconstruction
Treatment of Cutaneous
Surface Defects by Fat
Injections
Since the advent of liposuction, the interest in fat as a
tissue filler for contour defects has emerged. In the past,
only limited applications have been found for using the
properties of fat as a “filler”. Dermatocutaneous fat grafts,
fat flaps and isolated fat grafts have been used with
limited applications and successes.
A B S T R A C T
Dermatocutaneous fat grafts, fat flaps and isolated fat
grafts have been used with limited applications and
successes. Fat transfer has been used successfully to fill
defects and for esthetic purposes. The liposuction
technique allows a large amount of fat to be harvested
and to be reimplanted as a filler. There is discussion of
donor sites, amounts of fat to be injected, instruments
to be used and possible complications. When there is
fat resorption, fat injection is sometimes performed after
freezing excess fat and storing it or by using a new
donor area. The process of fat reinjection has given
acceptable results in cases where other treatment was
available.
The liposuction technique allows a large amount of
fat to be harvested and to be reimplanted as a filler for
areas where defects are present (Table 24-1).
TABLE
24-1
Body contour defects
™ Steroid injection sites
™ Liposuction depressions
™ Abdominal inverted scars
™ Young-age or old-age cellulite
™ Post-traumatic fat necrosis
™ Thin ankles
™ Depressed cheeks
™ Senile hands
Some attempts have been made to use autologous fat
for breast implantation but this technique has been
condemned by the American Society of Plastic Surgery
since the necrotic fat could become calcified and mimic
cancer on mammograms.
Originally the procedure was started by reinjecting fat
in cases where during a liposuction a defect was
inadvertently created. Then the immediate reinjection of
the aspirated fat was performed in the hope of preventing
a depression from becoming permanent and the
irregularities from being noticed. Furthermore, in cases
where the depression was noted after the initial stage of
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postoperative swelling and edema, correction by injection
of fat can be done either from frozen fat or from a new
area as a donor (Figure 24-1).
Indications for this technique have enlarged to zones
of contour defects either congenital or traumatic such as
cases of fat depression due to accidents where the fat
necrosis is a result of a deep contusion and destruction
of fat (Figures 24-1 to 24-4).
Other areas for fat implants are the deep furrows
present in aging faces: the frown lines, the nasolabial folds,
the peribuccal and even some deep lip furrows are
improved by injecting the fat.
Donor Sites
The location of fat harvesting is elected (Table 24-2). The
iliac crest area the flank, the knees, the lower buttocks and
the inner thighs are often used as well as the abdomen;
however, it is important not to create depressions or
defects during the harvesting as it can be found in the
abdomen.
FIGURES 24-1A AND B
(A) Preoperative slight dent and depression in the left upper
thigh secondary to an excessive liposuction in that zone;
(B) The area to be corrected is marked-out with ink. The fat
has been reinjected without undue tension. Often it is sur-
rounded by areas of fatty excess and the challenge is to
equalize the surface properly with a combination of lipo-
suction and autologous fat injection
FIGURE 24-2
Different means have been devised to collect the fat while the
liposuction process goes on. In this case, the fat is filtered
and separated from the blood and is going in a sterile catch
basin to be reinjected
FIGURES 24-3A TO C
Different injection guns are available allowing the fat to be injected with power since this has been aspirated with a larger
cannula. The fat is otherwise sometimes engulfed in connective tissue and exits the syringe only with a powerful force
especially when it has been taken with larger gauge cannula. (A) Chajchir reinjection system; (B) Levine autolipoplasty syringe
assist device developed for high pressure injection;. (C) Byron microinjector for pressure injections
TABLE
24-2
Fat injection donor sites
Knees
Often bruises, tender
Iliac crests
Less deforming, less painful, inconspicuous
Abdomen
Possible dents and depressions
Saddlebags
Often difficult to obtain the right amount
of fat without depressions or irregularities
since the fat is deep
Arms
Objectionable bruising
Waist
Ideal on thin people, especially on men
Chin
Sometime useful for immediate reinjection
when there is a large amount
Inner thighs
Excellent, soft fat

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Autologous Fat Reconstruction
FIGURE 24-4
A trap syringe devised to catch the fat that is aspirated and
separated from the blood and the connective tissue
An area surrounding a depression can be liposuctioned
and the fat can be used for injecting into the depressed
area itself.
Instruments
Cannulas (#4 and #3) are used in the routine liposuction
technique and a catch basin collects the fat. The fat is
taken in a sterile manner then is cleansed at the time of
its implantation either by passing it through a large grill
where the large, irregular, thick particles are discarded or
by washing it with saline solution. Areas of previous
suction are the least satisfactory for donor sites since the
fat lobules are connected to multiple strands of connective
and scar tissue and are difficult to reinject. It is often
better to find a new area to obtain smoother fat (Figures
24-2 to 24-5).
FIGURE 24-5
Different small size cannulas developed for manual syringe
aspiration of fat
FIGURE 24-6
A 14 gauge or 16 gauge needle is inserted in the medial knee
area or the left hip using a manual negative pressure. The fat
is then withdrawn using back-and-forth motion
FIGURE 24-7
An excellent donor site consists of the iliac crests which has
often an excess of fat and where the depression after
aspiration will not be conspicuous as it could be in the
abdomen
Technique
The donor sites are infiltrated with an anesthetic solution
using, in independent cases, a 10 cc syringe. Anesthesia
is given using a 25 or 27 gauge needle. The aspiration
technique is started by using the syringe connected to a
14 or 16 gauge needle. Once the needle is introduced
under the skin, negative pressure is created manually by
pulling back the piston and holding it, and a back and
forth motion is performed until the fat slowly accumulates
in the syringe. Two to three punctures are sometimes
necessary to obtain a good amount of fat from different
spots (Figures 24-6 and 24-7). The facial area to be
injected is anesthetized. The anesthesia can be similar to
dental anesthesia using a solution of xylocaine with
epinephrine and infiltrating the supraorbital nerve or the
infraorbital nerve and mental nerve from the oral
commissure. Then the local anesthesia itself is injected.

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The syringe containing the harvested fat is tilted,
separating it by gravity—the blood from the lighter fat.
The blood is expelled and the fat injected using multiple
parallel channels along the creases. If the blood is too
copious and mixed with the fat and does not seem to
separate spontaneously, the syringe is then introduced into
a centrifuge. Before centrifugation, the syringe should be
covered with a blind cap or with a smaller gauge needle
in order to prevent the fat from exiting the syringe under
pressure while the blood is allowed to separate out. Once
the fat is purified and it is visible that there is no other
tissue mixed with it, it can then be reinjected in the
different areas that have been elected (Figures 24-8 and
24-9).
This technique of fat harvesting is modified according
to each surgeon’s preference. It is logical to utilize the fat
that has been extracted by liposuction at the same
operative procedure; however, since the discovery of the
fat defect is often made at a later stage, the correction
by fat injection is sometimes performed by freezing the
fat and storing it or by using a new donor area. The
preoperative assessment of size of the defect, its relation-
ship to the surrounding tissues and the marking of the
deep creases to be created are all done and the deep
creases are marked with ink. These markings allow the
infiltration with anesthesia and the injection to be done
without distortion of the exact line to be repaired
(Figures 24-10 to 24-13).
FIGURES 24-8A AND B
The vertical positioning of the syringe allows the fat to float on
top and separate from the remaining blood which is then
ejected. The blood is liquid and heavier than the fat
FIGURE 24-9
The centrifuge is used for faster separation of the fat from the
blood. It can be used only for a few seconds makeing sure
that a smaller needle is connected to the syringe for proper
ejection of the blood without fat which is heavier and will not
go through the small needle gauge
FIGURE 24-10
Markings are made over each of the deep lines present in a
typical case of perioral wrinkling. Five to seven inferior buccal
lines are also commonly found and infiltrated. In the upper lip,
seven to nine vertical lines can be found
Fat Evaluation
(Figures 24-14 to 24-17)
Over-correction is achieved up to a point where it
becomes cosmetically unacceptable (Table 24-3). A 16
gauge or 14 gauge needle is used as a dissector to free
the dermis from its deeper attachments and to insert a
layer of fat in order to prevent the reattachment of the
dermis to the deeper tissues. This technique allows the
vertical wrinkles of the lip to be somewhat corrected. In

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Autologous Fat Reconstruction
FIGURE 24-11
Precise location and extent of each of the deep lines of the
face (frown, nasolabial, marionette and lip lines)
FIGURE 24-12
The nasolabial fold is often approached from its inferior fold
where 1–2 cc of fat are injected
FIGURE 24-13
Different lines below the mouth can
also be injected with fat. The bulk
injection in that area improves the
downward droop of the corner of the
mouth
FIGURES 24-14A AND B
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FIGURE 24-15
Favored by some surgeons, the site of injection can be
intraoral as the anesthesia injection which is done intraorally
toward the infraorbital nerve and the mental nerve bilaterally
FIGURE 24-16
Early appearance of a patient who received a fat injection two
days before. With proper make-up, the bruising can easily be
concealed
FIGURE 24-17
Fat is deposited along the lip in each deep crease after
subcision of the crease is done. Approximately 7 to 9 creases
are usually found in the upper lip and 5 to 7 in the lower lip.
Subcision consists of a subcuticular undermining with a large
bore needle
the nasolabial correction, the infiltration is started from
the lowest point of the crease and is continued upward
until it reaches the area below the nostril. It could also
be performed from the oral mucosa and the line of
injection will be perpendicular to the nasolabial line
allowing multiple strands of fat to cross the nasolabial line
and helping in the correction of the defect. In thin and
flat faces, a disk of fat is injected around the nostrils and
lateral to it, in order to restore the maxillary projection.
From the same lower injection point, a zone below the
lip commissure is infiltrated to correct the peribuccal deep
creases. These marionette lines are notorious for not
keeping the fat and some over-correction and area grafting
is necessary to obtain an improvement and to lift the
corners of the lips. A test of overfill consists of the
spontaneous regression of fat through each injection site.
No specific postoperative care is necessary. The patient
is advised to keep the area as immobile as possible and
apply some ice during the first 24 hours. No analgesics
or antibiotics are given.
It is felt that a period of two days is crucial in the
survival of the fat that has been injected. The first hours
are usually allowing the fat to survive by osmolality and
by osmosis; however, a new circulation is to develop to
assure the survival of the fat cells. This specific finding
is important in understanding the poor survival of fat
which is sometimes blamed as nonsurvival at all.
Results
Since 1986, the author has performed more than 2,000 fat
grafts. Of these cases, approximately 50% have received a
second injection approximately three months after, and
approximately 15% have received a third injection. Only 3–
5% of the patients have received more than four injections.
TABLE
24-3
Amount of fat injection
Dorsum of the nose
1–2 cc for irregularities, dents,
depressions
Acne scars
1/8 to 1/2 cc
Premaxillary
3 cc per area under each nostril
Chin
5–10 cc

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Autologous Fat Reconstruction
FIGURES 24-18A AND B
(A) Preoperative 54-year-old woman with facial redundancy
and perioral wrinkling with deep nasolabial fold and peri-
buccal folds; (B) Postoperative result 6 months after facelift
and autologous fat transplantation to the nasolabial area,
peribuccal zone and lip creases
FIGURES 24-19A AND B
(A) Preoperative 68-year-old woman who had an acceptable
result from face-lift but still presented multiple deep lines
(frontal, nasolabial, buccal, perioral); (B) Three months
postoperative result after injections in the frontal, nasolabial,
buccal and perioral wrinkles
FIGURES 24-20A AND B
(A) Preoperative 42-year-old woman with facial redundancy
and deep nasolabial lines; (B) Six months postoperative after
autologous fat transplantation and one year after complete
facial suction without incisions
FIGURES 24-21A AND B
(A) Preoperative 52-year-old woman with facial redundancy
and lipodystrophy; (B) Four months post-meloplasty and
nasolabial and peribuccal fat transplantation
the orbicularis vessels, thus creating large hematomas that
take quite a while to disappear.
Discussion
The process of fat reinjection has given acceptable results
in cases where other treatment was available. This
treatment is used in cases of severe wrinkling where the
only treatment consisted of collagen or dermologen
injections or surgical excision. The technique has multiple
advantages. It is simple and can be performed with
needles and syringes, thus not requiring any specific
equipment or set-up. It can be performed as a treatment
room procedure. It allows the correction of multiple areas
of the face and can be repeated until the results are
satisfactory. In addition, it has afforded a large improve-
ment in the face-lifting procedure which was wanting in
areas such as the frown lines, the nasolabial crease and
the peribuccal crease. The procedure is recommended
since it has brought a high degree of satisfaction.
Approximately 50% of the cases were corrected only once.
The natural course of the treatments is the following: After
an initial period of swelling and bruising, the treated area
returns to a natural stage with some swelling and eventually
will return to a normal appearance, which will prompt the
patient to request a secondary or tertiary injection. A large
number of the patient never had more than one or two
injections and have been satisfied with the results (Figures
24-18 to 24-21).
Complications
No severe complications were observed. A couple of areas
of redness and cellulitis have been noticed in the knee.
Approximately 5–10% of the patients will have a
hematoma in the donor site, more often in the knee than
the hip, and swelling, ecchymosis and distortion will last
2–6 weeks especially in the perioral area since the injection
of fat through a large bore needle can sometimes injure

25 Non-cosmetic
Liposuction
Introduction
The technique does not offer the same advantages as the
fat extraction can offer for lipodystrophy. However, it has
been used in some cases and seems to be helpful to a
degree. The technique, however, has not replaced other
surgical techniques available for the treatment of
lymphedema. Some improvements of the condition have
been noted and could be attributed to the scar formation
after suction preventing the deposits of fluid due to the
lymphatic insufficiency.
Fatty Tumors: Lipomas
Although mentioned in some publications, the actual
suction of lipomas has been quite frustrating. The tumor
consists of well-demarcated, firm fatty globules that do
not respond well to the liposuction. Theoretically, it is
A B S T R A C T
Liposuction has been used to correct deformities in a
number of entities. These include lymphedema, fatty
tumors (lipomas), flaps and tubed pedicles, nodular
multiple lipomatosis, scars and fat depressions that are
traumatic or iatrogenic, and in Dercum’s disease or
adiposis dolorosa (painful lipomatosis). The technique of
liposuction is described for each of these disorders.
possible to liposuction lipomas it is rather difficult to
accomplish and one often has to complement the
liposuction by actual removal of the tumor by dissection
with its capsule from the surrounding tissues.
Reconstructive Flaps and
Pedicles
Liposuction has been useful in defatting tube pedicles and
flaps created for reconstruction. An abdominal tube pedicle
and abdominal flap as well as flaps created for repair of
decubiti or limb injuries can often be bulky and really lend
themselves to sculpturing and tailoring by liposuction.
The technique is used after complete insertion and
survival of the flap; if it is accomplished too early, this
could jeopardize the vascularization of a newly created
flap or tube pedicle. It has been a useful adjuvant in
sculpturing the actual transfers and obtaining a better
cosmetic result to these flap transfers and recovered areas.
Nodular Multiple Lipomatosis
Cases of multiple lipomas are distressing to patients. In the
past, only a multiple excision treatment with multiple scars
resulting was the only solution available. These scars were
often too disturbing and too noticeable for those patients
who were less anxious to have surgery done. Liposuction has
proven helpful for treating such patients (Figure 25-1).
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Non-cosmetic Liposuction
Technique
Each of the lipomas is marked carefully with circular
markings with the help of the patient because it is often
easier to feel the tumors with the fingers than to visualize
them. An average of 20–30 lipomas can be marked with
a circle around each of them. The patient is then prepped
and draped in the routine fashion, and premedications
given. Each of these areas is infiltrated with a diluted
solution of xylocaine with epinephrine. Some time is
allowed to elapse so the swelling will be less disturbing
when checking the exact location of the tumor. Once the
tumor is felt by both pinch techniques, roll the tumor
between the index and thumb, it is then grasped with the
pinch of the left hand while the right hand uses a 14 G
needle connected to a syringe and aspiration is performed
into it.
This type of surgery is demonstrative of syringe
liposuction since it is easier to use for proper control of
each of the lipomatous tumor excisions. The 10 cc syringe
which has been kept with negative pressure and connected
to a 14 G needle is inserted approximately 3/4 of an inch
from the tumor itself. By careful multiple puncture of the
tumor area, fat is removed. Progressing, one at a time,
multiple extractions of these tumors can be performed.
Traumatic and Iatrogenic Scars
and Depressions
The treatment of depressed areas consists of a combi-
nation of liposuction and fat reinjection in order to re-
establish a normal contour. The entry for suction is
usually located in an area already scarred and deformed.
An incidental fact connected to this new field has been
the new understanding of some problems which have
been missed in the past such as body depressions and
bumpiness (Figures 25-2 and 25-3).
Closed trauma with concomitant fat destruction by
devascularization is still not understood by many
physicians who are confronted by such problems and do
not realize the significance of the lack of vascularization
in the fat necrosis.
Liposuction in Dercum’s
Disease
Dercum’s disease or adiposis dolorosa, which was
described in 1888,1,2 is a disease characterized by painful
adipose tissue in overweight middle-aged woman. The
cause of the disease to that date is unknown and the
diagnosis is only a clinical diagnosis.
FIGURES 25-1A AND B
A 27-year-old man with multiple congenital lipomas. Note the
numerous circles drawn around each of the lipomas that are
felt only with the pinch test. These were treated by 16 gauge
syringe liposuction under local anesthesia
FIGURES 25-2A AND B
(A) Preoperative 27-year-old woman with left inner thigh deformity secondary to a car accident and a severe contusion to the thigh
resulting in fat necrosis; (B) Six months postoperative result after liposuction around the defect and autologous fat injection

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Atlas of Liposuction
FIGURES 25-3A AND B
Post-traumatic severe contusion of the hip with fat necrosis
and a resulting depression. The donor area has been marked
in order to remove the protruding fat and reinjected it into the
neighboring depression
Liposuction is used in the whole area of the painful
fatty deposits. The suction has shown that it apparently
decreases the pain and although long-term results have not
been yet established, the effect of the suction seems to
be stable. Later work by Brorson et al.3 has shown that
the decrease of pain is apparently a constant effect of
liposuction.
References
1. Dercum FX. Three cases of a hitherto unclassified affection
resembling in its grosser aspects obesity, but associated with
special nervous symptoms-adiposis dolorosa. Am J Med Sci.
1892;104:521-35.
2. Dercum FX. A subcutaneous connective tissue dystrophy of the
arms and back associated with symptoms resembling
myxoedema. University Med Magazine. 1888-1889;1:140-50.
3. Brorson H, Aberg M, Fagher B. Liposuction in adiposis dolorosa
(morbus Dercum): an effective therapy. Ugeskr Laeger.
1992;154(27):1914-5.

26 Combination of
Liposuction and
Body Implants
Body Shaping with Implants
The possibilities afforded by implants have shown that
some patients can be improved in their contour by a
combination of augmentation and reduction by liposuction
allowing real “sculpture” of the body. Such cases are
breasts implants, pectoral implants, calf implants, buttock
implants, deltoid implants, forearms implants, malar and
chin implants as well as mandibular implants. All of these
cases can be associated with liposuction to improve their
contour in addition to augmentation by autologous fat
injection.
Pectoral Implants
The technique of pectoral implants is evolving slowly.
Although it is a difficult and delicate area it can give
A B S T R A C T
The technique of body implants is often confronted by
deformity of the body parts that is due to a lack of muscle
definition as well as an excess of fat in an unwanted
zone. Such is the case in buttocks with lower fat deposits,
and a fat and flat chest wall. There are discussions of
buttock, pectoral and calf implants with liposuction, and
chin, malar and mandibular angle implants with
liposuction. The problems with each are outlined.
excellent results to patients interested in improving the
shape of their chest wall. However, it is found that some
disfiguring factors may be present in addition to the defect
of pectoralis muscle underdevelopment. In particular, some
patients exhibit gynecomastia and chest fatty excesses
associated with their problem consisting of pectoralis
muscle underdevelopment.
In these cases the treatment consists of excision of
the breast glandular tissue responsible for the chest
deformity followed by liposuction of the surrounding
tissues around the gland, if present, and then followed by
submuscular implantation of pectoral implants designed to
improve the muscular appearance of their chest. In some
cases it could be associated with liposuction of the
pectoral area below the implants (Figures 26-1 and 26-2).
Associated Liposuction with Implants
In the technique of body implants, one is often
confronted by deformity of the body parts which is often
due to a lack of muscle definition as well as an excess
of fat in an unwanted zone. Such is the case in buttocks
with lower fat deposits, and a fat and flat chest wall.
The combination of implants and liposuction improves
appearance of the parts. In the chest, the liposuction can
involve the lower chest area and axilla.
In calf implants, a real sculpturing is necessary to
shape the legs. Suction is accomplished through the
incisions for calf implants and from below.
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Atlas of Liposuction
FIGURES 26-1A AND B
(A) Preoperative 27-year-old man with pectoral underdevelopment and fatty chest after gynecomastia surgery; (B)
Postoperative result after pectoral implants, and lower chest and axilla liposuction
Buttock Implantation
The technique of buttock implantation has helped in
shaping the buttock areas on patients who have an
underdevelopment associated with poor posture. In these
cases, the technique consists of using liposuction through
FIGURE 26-3
Buttock implants: Incisions and placement of implants
an infragluteal fold or a lateral buttock fold removing the
excess fatty tissues situated in lower portion of the
buttock. The buttock implantation consists of a solid soft
buttock implant positioned under the gluteus major muscle
through a central sacral cleft incision. In these cases, care
is taken not to compress area of the sciatic nerve
emerging just below pyriformis muscle situated under the
gluteus major muscle and at the level below gluteus
medius. In these cases, since the implantation cannot be
low enough for proper contour due to the anatomic
elements mentioned above, the addition of lower buttock
liposuction is helpful in determining a better shape to the
buttock (Figures 26-3 to 26-5).
During the buttock implantation, lower part is not
elevated due to the high submuscular position, thus
showing an excess of fat in the inferior gluteal zone.
Liposuction will correct this unhappy appearance.
Calf Implantation
In cases of deformities of the leg consisting of under-
development of the muscular elements in the calf
FIGURES 26-2A AND B
(A) Preoperative 29-year-old man with bilateral pectoral
underdevelopment and redundancy of the chest; (B)
Postoperative result after pectoral implants and inferior chest
liposuction

209
Combination of Liposuction and Body Implants
FIGURES 26-4A AND B
(A) Preoperative female with underdeveloped buttocks; (B) Postoperative result after liposuction and buttock implants
FIGURES 26-5A AND B
(A) Preoperative female with poorly developed buttocks; (B) Postoperative following liposuction and implants
associated with excess fatty deposits around lower thighs,
knees and upper leg, a combination of calf implants with
liposuction of knees, the lower thighs and the upper
calves is necessary. Some patients will necessitate an
inferior leg liposuction sculpturing the ankles and areas
below the gastrocnemius muscle, followed by subfascial
implantation of the calf implant. This combination of
techniques is used in conjunction during the same
operation (Figures 26-6 to 26-9).
Technique
The technique of knee liposuction or calf liposuction is
only secondary to the technique of implantation since the
implantation itself is a procedure necessitating more
rigorous asepsis, and the author favors the preliminary
implantation of the calf implants and a closure of layers
of the fascia and subcutaneous tissue followed then by
liposuction of knees and the calves. This combined
approach has given more security in the attempt at
reducing the potential problems of infection.
The calves are marked in the usual manner for
implantation, and the incision for the calf is used as in
the regular calf implantation shown in the following
chapter. Following this implantation the incisions for
liposuction are performed in the lateral and medial aspect
of the posterior popliteal incision for implantation and in

210
Atlas of Liposuction
FIGURE 26-6
Combination of calf implants and knee
liposuction. The approach is through the
popliteal fold posteriorly and anteriorly
from a medial incision above the patella
FIGURES 26-7A AND B
(A) Preoperative 27-year-old woman with calf underdevelopment and fatty lipodystrophy of the knees and lower thighs; (B)
Postoperative appearance after calf implantation, and upper leg and lower thigh liposuction
the medial and lateral aspect of the Achilles tendon, if
ankle suction is necessary. Once the suction has been
performed in these areas, the patient is turned into a
supine position and using a small incision in the medial
aspect of the knee above the patella completion of
liposuction of the knees is performed.
Chin Implants with Neck Liposuction
Patients seeking neck and chin liposuction often have chin
underdevelopment. Chin implants, which are useful in
correcting a poor appearance of the neck, will certainly
be helped by liposuction.
Suction of the neck is performed as a starting
procedure. It is done through one incision or two located
at each end of the incision necessary for implant
introduction.
The remaining part of the surgery is performed as
usual for chin implantation. It is also possible to use an
intraoral approach for the implant and perform the
suction through a submental crease incision (Figures
26-10 to 26-13).

211
Combination of Liposuction and Body Implants
FIGURES 26-8A AND B
(A) Preoperative female with small calves; (B) Postoperative following calf implants
FIGURE 26-9
Drawing of the incision for a chin implantation associated with
liposuction of the neck and chin
Bandages will help in compressing the implant and the
zone that has been liposuctioned. Often the liposuction
improves contour of the chin and neck in patients seeking
chin implants.
Malar Implants with Cheek
Liposuction
Patients eager to have a chiseled facial look are thus
desirous to show a malar and mandibular contour while
the cheeks are hollow. This specific look is often more
attractive in film or pictures than on live patients, and it
is requested by people in the movie or modeling
profession.
Bichat’s fat pads can be extracted at the time of
malar implants through the oral route. The combination
of these two procedures enhances the results of each of
them.

212
Atlas of Liposuction
FIGURES 26-10A AND B
(A) Preoperative 33-year-old woman with chin underdevelopment and neck lipodystrophy; (B) Postoperative after neck
liposuction and chin implant
FIGURES 26-11A TO C
Association of chin implant and malar implant combined with melolabial liposuction and liposuction of Bichat’s fat pad
FIGURES 26-12A AND B
(A) Preoperative female with facial atrophy from aging; (B) Postoperative following chin and malar implants and liposuction

213
Combination of Liposuction and Body Implants
FIGURES 26-13A AND B
(A) Preoperative male with flattened malar areas and retrusive chin; (B) Postoperative after liposuction and implants to the
malar area and chin
Mandibular Angle Implants and
Cheek Liposuction
In patients who desire a very dramatic chiseled look, it
is sometimes useful to associate the facial liposuction,
either the subcutaneous fat or Bichat’s fat pad, with
mandibular angle implants thus obtaining the desired cheek
shape and contour. As usual, the mandibular implant is
performed through the oral approach with an incision
over the anterior border of the mandible, and the implant
is then placed at the angle. Using a skin incision below
the lobule, liposuction of neck and cheek can be done
to improve the chiseled appearance.

27 Modalities Beyond
Simple Liposuction
Introduction
Fat removal has evolved since removal of fat with a sharp
curette reported in 19211 (although one case resulted in
blood vessel injury of an extremity that necessitated
amputation) to excision techniques, curettage and finally lipo-
suction. There have been multiple instruments devised to
make removal of fat through liposuction with small incisions
easier for the surgeon and less traumatic to the patient.
External Ultrasound
External ultrasound (EU) may be used on tumesced areas
immediately before liposuction to facilitate the procedure
A B S T R A C T
The evolution of fat removal has gone from simple
excision to curettes and then liposuction with an electrical
cutting cannula instrument that could be used with simple
liposuction or with cutting of the fat globules with a blade
or mainly simple liposuction. Further evolution led to
ultrasound-assisted liposuction, power-assisted
liposuction, and, at times, a return to cutting instruments.
The techniques that evolved were to reduce scar and
make liposuction easier to perform. Some of the ancillary
techniques are discussed.
or to speed healing on follow-up visits during the
postoperative period.
The application of ultrasonic energy to the adipose
tissue effectively liquefies the fat, releasing a combination
of triglycerides, normal interstitial fluid and the infused
tumescent solution. These components form an emulsion,
which can be removed using vacuum suction. Because of
the predilection of the ultrasonic waves for low-density
tissue such as fat, there is felt to be a selective targeting
of fat cells without affecting the intervening connective
tissue and neurovascular structures. The depth of
penetration is inversely proportional to the frequency used.
It is felt that ultrasonic energy affects the adipose tissue
via several mechanisms: thermally, micromechanically and
through the phenomenon of cavitation. Internal ultrasonic
liposuction primarily utilizes the principles of cavitation.
The exact mechanism by which EU affects fatty tissues
is not currently clear; however, it is felt to be a
micromechanical effect.2
Because of the problems associated with internal
ultrasound the author has worked to develop the concept
of EU.3 External ultrasonic energy may be used
preoperatively to produce a more favorable result without
the side effects and complications associated with internal
ultrasound. EU may also be applied postoperatively to
reduce swelling and shorten the recovery course.
Any surgeon utilizing ultrasonic energy for any
purpose should be knowledgeable about its usage and side
effects as well as possible complications. Also, any ancillary
Melvin A Shiffman

215
Modalities Beyond Simple Liposuction
personnel should be adequately trained and experienced
in the use of ultrasonic devices.
In 1989, Gasperoni presented subdermal superficial
liposuction.4,5 The technique consists of suctioning the
superficial subdermal fat through small gauge cannulas
(1.8–2.0 mm diameter) and then proceeding with the same
thin cannulas to aspirate the deeper fat as well. The
procedure is begun with a thin cannula and gradually
increased in gauge. The advantages of using this technique
include suction of the subdermal fat layer making it
possible to obtain effective skin retraction; the treatment
of all the layers of fat is made in an even fashion so that
good results are predictable. It is possible to treat patients
with slight adiposities as well as areas with small thickness
of fat layers such as the ankles, and the procedure is
similar for patients with large adiposities and those with
small ones.
When subdermal fat increases its volume, the vertical
septae of subdermal layer are stretched pulling the dermis
thus giving the skin so-called “cellulite” aspect. Other skin
dimples and hollows may be due to considerable
irregularities of a firm deep fat or may be iatrogenic. In
these cases and in regions where the fat is fibrous and
hard, EU is indicated to soften the fat crushing it with
the mechanical impact of its waves.6-9 EU may be applied
not only to the superficial fat but also to the deep one.
This layer should be treated whenever the deep fat is
fibrous and hard. When EU is used, care should be taken
to infiltrate immediately under the dermis to facilitate the
EU waves propagation in the superficial layer of fat.
When the deep fat must be effectively reached by the EU
waves, it must be infiltrated conspicuously to allow a
successful cavitation induced by the EU. A thin layer of
ultrasonic gel is spread on skin of the areas to be treated
with ultrasound. The ultrasound is then delivered through
a 3 MHz probe to treat the superficial fat and with a 1
MHz probe to treat the deeper layers. A 2 MHz probe
may be additionally used when we must be sure that all
layers are treated.
Low-level Laser-assisted
Liposuction
Laser is defines as ‘Light Amplification by Stimulated
Emission of Radiation’. Neira10-14 described use of the
low-level laser to assist in liposuction. The laser used for
liposuction is an external beam cold laser, electric diode
with 635 nm wavelength that irradiates adipose tissue at
1.2, 2.4 and 3.6 joules/cm2 at 2, 4 and 6 minutes exposure
in each area.
Low-level laser energy has an impact on the adipose
cell consisting of opening a transitory pore in the cell
membrane which permits the fat content to go from
inside to outside the cell. The cells interstice and capillaries
remain intact. Partial disruption of the adipose cell has
been observed. The irradiated cells were recultured and
showed that they recover the normal anatomy and were
alive.15
Nd:YAG (Neodymium:YAG)
The Nd:YAG laser is a solid laser formed by a granite
aluminum yttrium crystal (YAG)16 contaminated with an
unusual soil (Neodymium) that emits an infrared band in
1064 nm. Histological studies were performed 30 minutes
after laser lipolysis from a piece of tissue resected in a
dermolipectomy.17,18 It was possible to observe areas with
necrobiotic adipose tissue with accumulation of lipophagic
macrophages cells forming granulomatous lipophagic
nodules. Twenty-five days after laser lipolysis it was
possible to observe adipose tissue with breakage of the
cell walls surrounded by histiocytes with foamy cytoplasm.
There were also areas with scar fibrosis, and the nerve
threads were intact. The use of the laser causes a
destruction of the fat cell specifically protecting the nerves,
while in a tumescent liposuction the fat cell is evacuated
intact. The remaining tissue is immediately phagocytized
by the macrophages and the immune system, while fibrosis
covers and retracts the empty spaces.
Orthostatic Liposculpture
Orthostatic liposculpture was originated by Fischer19 in
order to perform liposuction in the same standing position
as the markings are made. A table was developed that
would bring the patient to a standing position for
liposuction and could be reversed, if the patient became
dizzy or faint.
Powered Liposuction
Development of Powered Liposuction
Technology
The concept of using mechanical instrumentation with
liposuction technology is as old as liposuction itself. Arpad
and Giorgio Fischer introduced the concept of liposuction
in combination with instruments they developed which
they called the cellusuctiotome.20 The Fischers’ early instru-
ments contained blades with moving internal components

216
Atlas of Liposuction
designed to cut fat when it was aspirated into the cannula.
Later, blunt cannulas were developed with side ports and
other designs that aspirated fat with little blood loss.
Gross et al (1995)21 used an existing cannula that had
an exposed internal blade driven by a motorized
handpiece, which was modified for use in fat removal. His
“liposhaving” procedure was an open technique in which
the fat harvesting unit was used for neck liposuction using
submental incisions. Fat cells could thoroughly be removed
from the platysma to allow for an even and complete fat
extraction. This was revived in 2000 by Schaefer22 using
an endoscope rather than direct vision.
Coleman (2000)23 developed an oscillating blade within
a cannula that facilitates removal of fat.
The oscillating cutting cannulas demonstrated decreased
work on the part of liposuction surgeon. This led to the
development of a number of reciprocating cannula
systems. The instruments contained a motor, driven either
electrically or by air, which moved the tip of liposuction
cannula forward and backward. These designs have been
found to decrease the work of performing liposuction on
the part of surgeon and increase the rate of fat removal.
Current Instruments
Flynn (2002)24 clinically assessed available instruments and
an independent engineering firm measured each
instrument. Laboratory measurements such as the degree
of torque, amount of heat produced, size and weight,
amount of torque force, and degree of vibration were
among the measurements taken by the independent
engineering firm. A concise practical description of each
instrument was featured. Stroke force was variable with
instruments having a range of 9.5–30 pounds. The noise
of the units varied between 60–87 decibels. Units
produced variable heat with surface temperature
measurements ranging from 77°F to 102°F. Build quality
and reliability varied from instrument to instrument. The
air-driven devices were clumsy and loud.
Coleman et al25 evaluated the efficacy of powered
liposuction. A variety of electrical and air-driven
instruments were used. All cannulas were 3 mm in outside
diameter. The amount of fat extracted was measured using
a mucous specimen trap, widely used by respiratory
therapists, in series between the cannula aspiration hose
and the aspirator. They documented that there was
increased efficiency in fat removal.
Ultrasound
Scuderi26 and Zocchi,10-14, 27-31 pioneered the application of
ultrasonic vibration to fat emulsification and removal. The
hope and objective of this effort was to create both
technology and associated techniques that consistently
produced a safer and more effective means of esthetic body
contouring when compared to liposuction. The benefits of
tissue selectivity were expected to produce a method of
lipoplasty that was more ‘fat specific’ than the existing and
well-known suction cannula. This technology and technique
were named UAL for ultrasound-assisted lipoplasty.
The first generation UAL device was produced by the
SMEI Company of Italy and utilized smooth, solid probes
at a frequency of 20 kHz. The solid probes had a stepped
design with diameters at the tip as small as 3.0 mm (small
probe) and diameters at the base as large as 6.0 mm (large
probe). The basic technique involved good surgical practice
and two fundamental rules: (1) The essential use of a wet
environment produced by infiltration of sufficient wetting
solution and (2) constantly moving the probe to prevent
thermal injury.30
Fodor (1998)32 published his experience on 100
patients using a contralateral study model. His conclusions
comparing SAL to UAL found no significant differences
between SAL and UAL and failed to prove the claimed
benefits attributed to UAL.
The UAL technique and instruments continued to
evolve. Originally application times were long, significant
complications were reported and safety was questioned33-38
As application times were reduced, the complication rate
declined. The concept of ‘loss of resistance’ became
widely known as a realistic surgical endpoint. Rapid probe
movement39 was introduced as another means to safely
control the energy presented by the second-generation
machines. Results ranged from safe and effective use of
UAL to high complication rates and questionable safety.
A number of surgeons continued to use the ultrasonic
instrumentation safely and effectively.26-29,40-43 Their
evolving technique allowed them to get effective results
without the complications noted at introduction of the
technology.
Vibration Amplification of Sound
Energy at Resonance (VASER)
VASER-assisted Lipoplasty (VAL) is a third generation
ultrasound-assisted liposuction. The VASER® system is
highly selective for fatty tissue resulting in decreased
overall damage to the vessels, nerves, structural tissues and
lymph tissue. VAL uses ultrasonic frequency vibrations to
emulsify the fatty component of tissue matrix but in a
fundamentally different manner than earlier versions of
ultrasonic instrumentation for lipoplasty. The VASER
system delivers significantly less power to the tissues while

217
Modalities Beyond Simple Liposuction
simultaneously increasing fragmentation/emulsion efficiency
compared to UAL devices and eliminates the simultaneous
aspiration feature of UAL devices.44,45
Water Jet-assisted Liposuction
Taufig (2000)46 devised a method of water jet-assisted
liposuction that allows a controlled and selective removal
of fat tissue within the epifascial/subcutaneous area via
usage of a cannula system. The technique uses energy of
the pressurized fluid using a specialized cannula in which
infusion tube and nozzle are integrated as well as a
suction unit. An infinitely variable force pump dispenses
the fluid in a controlled manner via a nozzle at the top
of cannula system. The cannula is attached to a common
and well-proven suction device for liposuction.
The water jet technique uses an isotonic sodium
chloride solution with an additive of adrenaline in the
ratio of 1 mL to 3 L of sodium chloride solution that
is suctioned off almost at the same time as the dissolved
fat particles.47 Therefore, no side effects are being caused
by the solution. This avoids a separate fragmentation step
as with the tumescent technique.
References
1. Grazer FM. Historical perspective. In: Grazer FM (Ed). Atlas
of Suction Assisted: Lipectomy in Body Contouring. New York:
Churchill Livingstone; 1992. pp. 1-4.
2. Zocchi ML. Basic physics for ultrasound-assisted lipoplasty. Clin
Plast Surg. 1999;26(2):209-20.
3. Cook WR Jr. Utilizing external ultrasonic energy to improve the
results of tumescent liposculpture. Dermatol Surg. 1997;23(12):
1207-11.
4. Gasperoni C, Salgarello M, Emiliozzi P, et al. Subdermal
liposuction. Abstract of the 10th Congress of the International
Society of Aesthetic Plastic Surgery, Zurich 11-14 September.
1989. p. 95.
5. Gasperoni C, Salgarello M, Emiliozzi P, et al. Subdermal
liposuction. Aesthetic Plast Surg. 1990;14(2):137-42.
6. Cook WR. Utilizing external ultrasonic energy to improve the
results of tumescent liposculpture. Dermatol Surg.
1997;23(121):1207-11.
7. Havoonjian HH, Luftman DB, Menaker GM, et al. External
ultrasonic tumescent liposuction. A preliminary study. Dermatol
Surg. 1997;23(12):1201-6.
8. Kinney BM. Body contouring with external ultrasound. Plast
Reconstr Surg. 1999;103(2):728-9.
9. Silberg BN. The technique of external ultrasound-assisted
lipoplasty. Plast Reconstr Surg. 1998;101(2):552.
10. Neira R, Solarte E, Isaza C, et al. In vitro effects of 635 nm low
intensity diode laser irradiation on the fat distribution of one
adipose cell “ICO 19 Florence, Italy (2002) SPIE (Int Soc
Optical Engineering) Proceeding. 2002;4829(2):961-2.
11. Neira R, Rebolledo AF, Solarte E, et al. Diffraction and
dispersion of coherent light in adipose tissue. Colombian
National Congress Physics and Optic. Rev Colombiana Fisica.
2002;33(1):191-5.
12. Neira R, Rebolledo AF, Solarte E, et al. Coherent light dispersion
in adipose tissue samples. Colombian National Congress Physics
and Optic. Rev Colombiana Fisica. 2002;34(1):210-3.
13. Neira R, Solarte E, Reyes M, et al. Laser irradiation effect in
adipocyte dilutions. Colombian National Congress Physics and
Optic. Rev Colombiana Fisica. 2001;33(2):325-8.
14. Neira R, Arroyave J, Ramirez H, et al. Fat liquefaction: effect
of low-level laser energy on adipose tissue. Plast Reconstr Surg.
2002;110(3):912-2.
15. Neira R, Arroyave J, Solarte E, et al. In vitro culture of adipose
cell after irradiating them with a low level laser device. Presented
at the Bolivian Plastic Surgery meeting. Lima, Peru, Oct. 6-9,
2001.
16. Goldman A, Schavelzon DE, Blugerman GS. Laserlipolysis:
Liposuction using Nd-YAG laser. Rev Soc Bras Cir Plast.
2002;17(1):17-26.
17. Schavelzon DE. Laserlipolysis for the Treatment of Localized
Adiposity. World Congress on Liposuction Surgery. Westminster,
Colorado, October 4-6, 2002.
18. Sandhofer M, Douwens KE, Sandhofer-Novak R, et al.
Laserlipolyse und liposkulptur. Äesth Chir. 2002;3:20-6.
19. Fischer G. Orthostatic liposculpture. In: Shiffman MA, Di
Giuseppe A. Liposuction: Principles and Practice. Berlin:
Springer; 2006. pp. 217-21.
20. Fischer G. History of my procedure, the harp string technique
and the sterile fat safety box. In: Fournier PF. Liposculpture:
The Syringe Technique. Paris: Arnette; 1991. pp. 9-21.
21. Gross CW, Becker DG, Lindsey WH, et al. The soft-tissue
shaving procedure for removal of adipose tissue. A new, less
traumatic approach than liposuction. Arch Otolaryngol Head
Neck Surg. 1995;121(10):1117-20.
22. Schaefer BT. Endoscopic liposhaving for neck recontouring.
Arch Facial Plast Surg. 2000;2(4):264-8.
23. Coleman WP 3rd. Powered liposuction. Dermatol Surg.
2000;26(4):315-8.
24. Flynn TC. Powered liposuction: an evaluation of currently
available instrumentation. Dermatol Surg. 2002;28(5):376-82.
25. Coleman WP 3rd, Katz B, Bruck M, et al. The efficacy of
powered liposuction. Dermatol Surg. 2001;27(8):735-8.
26. Scuderi N, Devita R, D’Andrea F, et al. Nuove prospettive nella
liposuzione la lipoemulsificazone. Giorn Chir Plast Ricostr
Estetica. 1987;2(1):33-9.
27. Zocchi ML. Metodo di trattamento del tessuto adiposo con
energia ultrasonica. Congresso dell Societa Italiana di Medicina
Estetica. Roma, Italy April 1988.
28. Zocchi ML. New prospectives in liposcultpuring: the ultrasonic
energy. Abs. 10th ISAPS Congress. Zurich, Switzerland,
September 1989.
29. Zocchi ML. Clinical aspects of ultrasonic liposculpture. Perspect
Plast Surg. 1993;7:153-74.
30. Zocchi ML. Ultrasonic assisted lipoplasty. Clin Plast Surg.
1996;23(4):575-98.
31. Zocchi ML. Basic physics for ultrasound-assisted lipoplasty. Clin
Plast Surg. 1999;26(2):209-20.

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32. Fodor PB, Watson J. Personal experience with ultrasound-
assisted lipoplasty: a pilot study comparing ultrasound-assisted
lipoplasty with traditional lipoplasty. Plast Reconstr Surg.
1998;101(4):1103-16.
33. Troilius C. Ultrasound-assisted lipoplasty: is it really safe? Aesthet
Plast Surg. 1999;23(5):307-11.
34. Lack EB. Safety of ultrasonic-assisted liposuction (UAL) using
a non-water-cooled ultrasonic cannula. A report of six cases of
disproportionate fat deposits treated with UAL. Dermatol Surg.
1998;24(8):871-4.
35. Baxter RA. Histologic effects of ultrasound-assisted lipoplasty.
Aesthet Surg J. 1999;19:109-14.
36. Perez JA. Treatment of dysesthesias secondary to ultrasonic
lipoplasty. Plast Reconstr Surg. 1999;103(5):1534.
37. Gerson RM. Avoiding end hits in ultrasound-assisted lipoplasty.
Aesthet Surg J. 1997;17:331-2.
38. Grolleau JL, Rouge D, Chavoin JP, et al. Severe cutaneous
necrosis after ultrasound lipolysis. Medicolegal aspects and
review. Ann Chir Plast Esthet. 1997;42(1):31-6.
39. Tebbetts JB. Rapid probe movement ultrasound-assisted
lipoplasty. Aesthet Surg J. 1999;19(1):17-23.
40. Maxwell GP. Use of hollow cannula technology in ultrasound-
assisted lipoplasty. Clin Plast Surg. 1999;26(2):255-60.
41. Kloehn RA. Liposuction with “Sonic Sculpture”: Six years’
experience with more than 600 patients. Aesthet Surg J.
1996;16(2): 123-8.
42. Rohrich RJ, Beran SJ, Kenkel JM, et al. Extending the role of
liposuction in body contouring with ultrasound-assisted liposuc-
tion. Plast Reconstr Surg. 1998;101(4):1090-102; discussion 1117-9.
43. Gilliand MD, Commons GW, Halperin B. Safety issues in
ultrasound-assisted large volume lipoplasty. Clin Plast Surg.
1999;26(2):317-35.
44. Cimino WW. Ultrasonic surgery: Power quantification and
efficiency optimization. Aesthetic Surg J. 2001;21(3):233-40.
45. Jewell ML, Fodor PB, de Souza Pinto EB, et al. Clinical
application of VASER-assisted lipoplasty: A Pilot clinical study.
Aesthetic Surg J. 2002;22(2):131-46.
46. Taufig AZ. Hydro-jet-liposuction: a new method for liposuction.
Presented at Vereinigung der Deutschen Plastischen Chirurgen
meeting, Cologne, Germany, September 2000.
47. Taufig AZ. Water-jet-assisted liposuction. In: Shiffman MA, Di
Giuseppe A (Eds). Liposuction: Principles and Practice. Berlin:
Springer; 2006;326-30.

28 Medicolegal Aspects
of Liposuction
Introduction
Liposuction has been considered to be a safe procedure.1-4
However, complications and deaths are occurring that are
unnecessary and giving liposuction a poor reputation.
California has legislated means to reduce patient
complications. Legal methods in controlling the problem
are detrimental to cosmetic surgery. It is up to the plastic
and cosmetic surgeons to reevaluate the procedure and
find means to prevent further deaths. There should be a
consensus of knowledgeable liposuction surgeons utilizing
the peer reviewed literature and outcome statistics.
Megaliposuction is one culprit that is being performed
without adequate safeguards to protect the patient.
Fournier5 has shown that megaliposuction can be
performed safely in a hospital setting with continuous
A B S T R A C T
Liposuction has been considered to be a safe procedure.
However, complications and deaths are occurring that are
unnecessary and giving liposuction a poor reputation.
Anesthesia, liposuction limits, megaliposuction and
medications are discussed. The legal aspects of medical
malpractice are described including medical negligence,
standard of care, informed consent, patient rapport,
handling complications and the angry patient. Legal cases
are presented with comments on what happened and why.
central venous and/or pulmonary artery pressure measure-
ments as an aid in fluid management. Anesthesiologists
generally are not prepared for the large subcutaneous fluid
infiltration and resultant fluid shifts outside a hospital
setting. There is no literature that has calculated the fluid
balance problems in megaliposuction.
Should subcutaneous fluids be cold, room temperature,
or warm? With large amounts of cold solutions,
hypothermia is apt to occur and the problem of cryo-
globulinemia or of disseminated intravascular coagulation
(DIC) may become a factor. Are the physiologic solutions
(saline) absorbed rapidly or in 8–12 hours as with
lidocaine? Is the use of larger amounts of lidocaine
(> 35 mg/kilo) necessary even with tumescent anesthesia?
Certainly the use of over 35 mg/kilo of lidocaine is
unnecessary in a patient having general anesthesia or
intravenous deep sedation.
As dedicated cosmetic surgeons, we should endeavor
to answer these questions and many more before we push
the envelope of extent of liposuction any further. It is
necessary to sit back right now and produce the statistics
and problems being encountered in order to evaluate
where liposuction is and where the dangers lie.
Anesthesia
Klein6-9 has given liposuction a safer means of performing
the procedure with less blood loss, and better results with
smoother appearance and increased fat removal.10 There
Melvin A Shiffman

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Atlas of Liposuction
is also a reduced incidence of pulmonary embolism (fat
or clot). The combination of lidocaine and epinephrine
in a normal saline solution allows the use of local
tumescent anesthetic to perform liposuction in situations
where general anesthesia or intravenous sedation may be
undesirable either by the patient or surgeon.
Lidocaine up to 55 mg/kilo has been shown to be
safe,11-15 but there are certain perioperative medications
(cytochrome P450 inhibitors) which can reduce lidocaine
metabolism and cause lidocaine toxicity.16 In those
situations where these medications have been taken
inadvertently or are essential for the patient, general
anesthesia or intravenous sedation can be utilized with
reduced amounts of or without lidocaine in the
subcutaneous infusion. Infusion solutions can be modified
from 500 mg lidocaine and 1 mg epinephrine in 1000 ml
normal saline to lidocaine 250 mg/L and epinephrine
0.5 mg/L with adequate hemostatic response and
reasonable comfort with intravenous sedation.
Liposuction Limits
With the advent of tumescent technique, the reduction of
blood loss has allowed an increase in amount of
liposuction aspirate. The limit imposed by the “dry” (with
local anesthesia only) or “wet” (limited amount of local
anesthesia, epinephrine and fluid into subcutaneous tissues)
techniques was 3,000 ml total aspirate. This was because
blood loss (30% of the aspirate) would result in 1,000 ml
of blood being aspirated with 3,000 ml aspirate plus blood
in the tissues.17 Blood replacement was recommended, if
3,000 ml aspirate was exceeded.
The tumescent technique of utilizing large amounts of
subcutaneous fluid with epinephrine and lidocaine has
decreased blood loss to almost 1% of the aspirate, thus
allowing aspirates of 4,000–6,000 ml of supernatant fat
without danger to the patient.18,19
Some physicians are attempting megaliposuction
(exceeding 8,000–10,000 ml supernatant fat), although
there is insufficient data to establish fluid requirements,
blood loss, and need for hospitalization.18 Only
experienced surgeons with adequate monitoring and
prolonged patient observation should be attempting this
type of procedure. Caution would tell us to do the
liposuction in two or three phases.
Other Dangers
Reports have shown that antiobesity medications may be
a danger to any patient undergoing general anesthesia.20
Sudden hypotension can occur with induction that
responds only to neosynephrine and not to ephedrine.
Perforation of the abdominal wall with infusion
cannula or a thicker liposuction cannula has been known
to occur. Bowel, vascular or bladder perforation may be
the result. The onset of peritonitis is heralded by
increasing abdominal pain and should be recognized by
the surgeon.
No matter how careful the surgeon is in performing
such a relatively low-risk procedure as liposuction, there
are always dangers of mishaps. The cosmetic surgeon
should be aware of the risks and complications, know
how to avoid them if possible, and certainly know how
to treat them.
Requirements for Medical
Negligence
The plaintiff’s attorney must establish all four aspects of
negligence in order to pursue a case of medical negligence.
Duty
When the physician establishes a relationship with a
patient, the physician has a duty of due care in the care
and treatment of that patient.
Breach of Duty
The physician may breach that duty by not using adequate
skill and knowledge in treating a patient. This breach may
be established by an expert witness testifying to the
opinion that the defendant failed to follow the Standard
of Care. The types of breaches may also include lack of
informed consent. A lay jury may establish the standard
if the facts are within the knowledge and experience of
lay persons. This can best be seen in the case where a
foreign body (sponge, instrument) is left in the surgical
wound.
Injury
An injury, physical or mental, to the plaintiff must be
shown by facts of the case usually through medical
records.
Cusation
Causation requires that the injury to be caused by the
breach of duty. In other words, the breach of the

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Medicolegal Aspects of Liposuction
standard of care may have been failure to place a breast
implant under the muscle on the right side but the injury
was capsule contracture on the left side.
Standard of Care
The standard of care is what a reasonably prudent
(careful) physician would do under the same or similar
circumstances. The court considers expert testimony to
establish the standard of care in most instances, except
if the circumstances are in purview of a lay person. Also,
the court may consider what a responsible minority of
physicians would do under the same or similar
circumstances. Medical literature may help to establish
standard of care.
The standard can also be what a reasonably prudent
physician in a responsible minority would do under the
same or similar circumstances.
Informed Consent
Definition
The patient has the absolute right to receive enough
information about his diagnosis, proposed treatment,
prognosis, and possible risks of proposed therapy
and alternatives to enable the patient to make a
knowledgeable decision. The patient is the one who makes
all the decisions in opposition to the old paternalistic
theory that gave the physician complete control over all
decisions. A physician would now have to prove that the
decision he made was because of the patient’s inability to
make the decision or because there was an extreme
emergency.
Other requirements of the “Informed Consent”
doctrine in law require that a complication which was not
explained to the patient did in fact occur and that the
patient would not have agreed to have the surgery, if
informed of that particular risk or complication.
Legal Definition
In terms of surgical procedures, the surgeon must have
explained to the patient the nature and purpose of any
proposed operation or treatment, any viable alternatives,
and the material risks and benefits of both. All questions
must be answered.
In order for the plaintiff to succeed in a complaint
for lack of informed consent, he must show:
„
that the risk or complication, which was not explained
to him, indeed did occur, and
„
that if he had been informed of that particular risk, he
would not have consented to the surgical procedure.
There are different means of proof at trial depending
upon the jurisdiction (state). The opinion as to what risks
is “material” to the patient in order to make his decision,
under the same or similar circumstances, can be that of:
1. A reasonably prudent physician: This allows a physician
to testify as to what is material.
2. A reasonably prudent patient: This allows the jury to
decide what a reasonably prudent patient would consider
material risks.
3. The plaintiff patient: This places the onus on the
plaintiff to decide what would be the material risks. The
cosmetic surgery patient may be unique because cosmetic
surgeries are elective procedures and not medically
required except, perhaps, for the patient’s mental well
being.
Patient Rapport
There is nothing as important as a good doctor-patient
relationship before performing cosmetic breast surgery.
This requires careful discussion with the patient
concerning the surgical procedure proposed, viable
alternatives, and the potential risks and complications of
each procedure by a caring empathetic staff person or the
doctor. The surgeon must, at the very least, give the
patient the opportunity to ask questions of him/her to
allow the patient to feel more comfortable with the person
doing the surgery. Be careful when the patient is first seen
by the surgeon on the day of surgery. This is not a good
idea, if ultimate litigation is to be avoided. If a patient
is coming in from a long distance or from another state,
a consultation can usually be performed at least the day
or night before surgery.
There should be strict control on all staff persons
involved in the patient’s care so that incorrect information
is not given to the patient and that the patient is not told
“do not worry”. This requires detailed training of each
of the office staff from receptionist to scrub technician
and registered nurse on what to say and not say to
patients and how to respond to patients problems.
No one should get angry with a patient or appear
rushed. The patient should be treated with respect and
dignity. Questions must be answered and phone calls
should be returned in a timely fashion.
Complications
If a complication occurs, the surgeon should be available
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long it will take for the complication to subside. Every
complication seen by the office personnel should be
reported to the surgeon and he decides what to do.
Any complication can lead to a lawsuit even though
it appears minor because the patient may think it to be
major. Remember that the cosmetic surgery patient, despite
all the warnings about possible complications, feels that
there will be no complications and that he/she will look
much better than they did before surgery.
The Angry Patient
If a patient shows anger, whatever the cause, the surgeon
should try to handle problem in an expeditious manner.
This means speaking with the patient to find out cause
of anger and figure out ways to satisfy him/her. Avoiding
this type of patient after surgery will frequently lead to
litigation. This means answering all phone calls in a timely
fashion, showing a truthful caring attitude, and seeing the
patient frequently enough to satisfy the patient’s needs.
Medical Record
Handwriting that cannot be deciphered should be avoided.
Not only is this irritating to the attorneys and expert
witnesses, but the State Medical Board may find this to
be inadequate records and thus unprofessional conduct
and loss of medical license may ensue. Handwritten notes
are a continuous problem especially when years later the
doctor who wrote the note cannot read it.
Typewritten notes are easy to read and usually contain
much more information than written notes. This author
dictates all of the medical record notes. The cost to get
a microcassette for dictation and hire someone to take off
the dictation will save the surgeon time with minimal cost
including maintaining the medical license.
Legal Aspects
The first thing an attorney thinks is that a bad result is
fault of the surgeon because of a negligent act. This may
include claims of poor training, lack of skill, lack of
knowledge or inattention during surgery. The attorney will
seek out an “expert witness” to show a breach in the
standard of care. The ‘standard of care’ is essentially a
legal term meaning what a reasonable prudent (careful)
physician would do under the same or similar
circumstances. The defendant surgeon’s attorney will try
to find an expert witness to show that there was no
breach in the standard of care. The surgeon should be
realistic because everyone makes mistakes and the expert
witness should not be biased and should give an honest
opinion as to whether or not the standard of care has
been breached.
Legal Cases
The following cases will illustrate some of the disasters
in liposuction with comments.
Sousaris v Anonymous, Case No.
78-193-0105-96, Hawaii (1997)
This 48-year-old plaintiff’s decedent had liposuction of the
abdomen, flanks, pelvis, chin and neck on January 5, 1996.
There was 2,500 ml of tumescent solution used and there
was 3,450 ml total aspirate using a 6 mm cannula. On
the 7th postoperative day, the incisions in the pubic area
began draining fecal material. She was admitted to the
hospital and had resection of a necrotic perforated
segment of small bowel protruding through and
incarcerated in a 1 cm opening in the abdominal wall, 5
cm lateral to the midline and inferior to the level of the
umbilicus. Multiple abdominal wall debridements were
carried out for necrotizing soft tissue infection. She
developed DIC and adult respiratory distress syndrome
and died on January 30, 1996. The plaintiff claimed that
the defendant negligently perforated the abdominal wall
and small bowel and pulled the small bowel loop through
the abdominal wall opening with the suction cannula. The
defendant claimed that an asymptomatic undiagnosed
Spigelian hernia was present and the bowel loop was
injured during the liposuction.
Comment
Although this case was lost at arbitration, there was no
way that the Spigelian hernia could have been recognized
preoperatively and, therefore, bowel perforation under
these circumstances was unforeseeable. The Spigelian
hernia is the only logical explanation of the events:
1. Seven days until intestinal content leakage occurred: It
is usually seen when there is interruption of the blood
supply of bowel loop with delayed perforation.
2. The 1 cm abdominal wall opening was in the precise
position for a Spigelian hernia.
3. The 6 mm cannula would not have made a 1 cm
abdominal wall perforation.
4. It is virtually impossible to pull a loop of bowel through
a 6 mm opening in the abdominal wall with the
liposuction cannula even with -760 mm of mercury
vacuum.

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Medicolegal Aspects of Liposuction
5. Protrusion of a loop of bowel in an incarcerated hernia
with scarring (as in this case) only occurs from
longstanding herniation.
The case is presently being appealed.
Medical Board of California v Matory,
Tustin District, CA
Medical Board of California v Hoo,
Tustin District, CA
The 46-year-old plaintiff’s decedent had surgery on March
17, 1997. The surgeon performed liposuction of the arms,
abdomen, flanks, thighs, calves and buttocks over a 6.5-
hour period. A total of 14,500 ml tumescent solution was
used consisting of Ringer’s lactate, with lidocaine and
epinephrine (concentrations not recorded). There was
10,900 ml of total aspirate. An endoscopic brow lift was
performed over 1 hour and this was followed by a face
lift for 3 hours. The anesthesiologist gave over 18,000 ml
of intravenous fluids over the 10.5 hours of surgery,
despite only an 860 ml of total urine output. At
completion of the procedure, the patient was cold,
edematous and nonresponsive. The paramedics were called
and cardiopulmonary resuscitation started. At the
emergency room the hemoglobin (Hgb) was 2.1 and
hematocrit value (HCT) 6.85. Attempts at resuscitation
were unsuccessful. Autopsy showed cerebral edema with
compression of the medulla oblongata into the foramen
magnum. Both surgeon and anesthesiologist had their
licenses revoked.
Comment
The events that transpired are a combination of breaches
in the standard of care by both surgeon and anesthe-
siologist. The surgeon should not have planned to do
megaliposuction (> 10,000 ml aspirate) outside a hospital
setting and without central venous or Swan-Ganz
monitoring. The liposuction could have been performed
in at least two to three sessions on an outpatient basis.
To perform other cosmetic procedures for five and a half
additional hours was unnecessary and risky. The surgeon
should have forewarned the anesthesiologist to limit
intravenous fluids since the 14,500 ml tumescent solution
would be reabsorbed into the vascular system over a
period of time. If 500 mg of lidocaine was in each liter
of solution (Klein’s formula), then there was 100 mg/K
administered which probably would have resulted in
lidocaine toxicity after 8–10 hours. The anesthesiologist
never notified the surgeon that the blood pressure was low
throughout the procedure and that there was a very low
urine output. He should have understood and kept track
of the fluid balance and not administered large amounts
of intravenous solution. Even at the end of the
procedure, when the patient was cold, edematous, and
nonresponsive, the anesthesiologist did not notify the
surgeon of all the problems except to say that the patient
should probably be admitted to the hospital because of
the prolonged procedure. There was failure to promptly
notify the paramedics about the blood pressure instability
and patient unresponsiveness, after the surgery was
completed. There was no effort to check the Hgb and
HCT after such a large liposuction procedure, and there
was no attempt to warm the patient following liposuction
part of the procedure.
Teillary v Pottle, New Hanover County
(NC), Superior Court. In: Medical
Malpractice Verdicts, Settlements and
Experts. 1996;12(8):47 and
1996;12(11):46.
The plaintiff, a former nurse, had liposuction of the
abdomen. She was seen postoperatively for abdominal
pain, hospitalized and then released. She went to an
emergency room shortly thereafter and was readmitted for
surgery. The small bowel had 32 perforations that had to
be repaired. There was a $490,000 settlement.
Comment
Persistent severe abdominal pain (not simply soreness)
after abdominal liposuction is from perforated vessel or
viscus, until proven otherwise. Bowel perforation during
abdominal liposuction is a known complication of the
procedure, especially if there are abdominal wall scars that
can misdirect the cannula. However, sixteen different
through-and-through intestinal perforations could only
occur if the nondominant hand was not palpating the
cannula tip (one of the principles of liposuction). Delayed
diagnosis of the perforations probably contributed to the
decision to settle.
Herron v Stewart, Forsyth County (NC),
Superior Court. In: Medical Malpractice
Verdicts, Settlements and Experts.
1995;11(10)47.
The 37-year-old plaintiff’s decedent had liposuction of the
face planned for December 1990. On induction of general
anesthesia, cardiovascular collapse occurred. The patient

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was revived after 40–50 minutes but suffered severe brain
damage. She lived in a vegetative state for 2 years and died
in January 1993. The plaintiff claimed that there was
failure to timely diagnose and respond quickly to the
cardiovascular collapse and that there was failure to follow
proper medical procedures. There was a confidential
settlement after the jury was deadlocked in June 1995.
Comment
Failure to timely diagnose and respond quickly to
cardiovascular collapse is inexcusable. Every office
performing surgery, even with local anesthesia, must be
prepared for any emergency event, especially cardiac arrest.
Brain damage or death is known sequelae of cardiac arrest
even in the best of circumstances, but especially in an
outpatient setting and not in a hospital.
Medical Board of California v Su, Sand
Diego District, CA
Mondeck v Su, California
The plaintiff’s decedent had lower abdominal liposuction
scheduled for June 21, 1994. Preoperatively, she was given
atarax 100 mg, prednisone 60 mg, valium 50 mg,
ciprofloxacin 750 mg and augmentin 500 mg. The
tumescent solution consisted of 500 cc Ringer’s lactate
with lincomycin 1,500 mg, keflin 1,000 mg, ciprofloxacin
100 mg, marcaine 240 mg, epinephrine 2.5 or 5 mg, and
lidocaine (amount unrecorded). Approximately 200 ml of
this solution was injected over 8 minutes despite a blood
pressure of 74/57 just prior to the infusion. One minute
later the patient complained of headache and then lost
consciousness. The defendant claimed that epinephrine
1 mg intramuscularly (IM) was given and oxygen started.
When the paramedics arrived 4 minutes later the patient
was pulseless and cyanotic, no cardiopulmonary
resuscitation was being given, there was no oral airway,
and no oxygen was being administered. The defendant
voluntarily surrendered her license to the Medical Board.
Comment
There is absolutely no need for multiple antibiotics for
prophylaxis. Adding antibiotics to the tumescent solution
increases the risk of drug reaction, and the absorption rate
and length of action is unknown. There is no indication
for the use of marcaine (bupivacaine) in tumescent
solution, especially if lidocaine is in the solution. Marcaine
bonds to the cardiac nerves and the possible effects
include heart block, decreased cardiac output, hypotension,
bradycardia, ventricular arrhythmias, ventricular tachycardia,
ventricular fibrillation and cardiac arrest. Epinephrine is
not absorbed when given IM in a patient in cardiac arrest.
It should have been given intravenously. There was failure
to timely perform essential lifesaving procedures such as
cardiopulmonary resuscitation, to maintain adequate airway
and to administer oxygen.
Medical Board of California v
Greenberg, Tustin District, CA
In California, 31 cases of postoperative infection following
liposuction were documented from one physician’s office.
Subcutaneous nodules appeared 1–6 weeks postoperatively
in these patients. The nodules showed inflammation and
then drained serous fluid and pus. Mycobacterium chelonae
was cultured from 10 patients and Mycobacterium fortuitum
from 1 patient. The heath department investigated the
physician’s office and noted that the liposuction tubing
and towel drapes were washed, not sterilized, and reused.
Comment
It was ultimately learned that the liposuction cannulas,
which were supposed to be heat sterilized, actually were not
being sterilized properly. The individual kept in the office
to sterilize and do the back office work was untrained
except being told how to do things by her predecessor. In
fact, the 20-minute heat sterilization cycle was being started
when the autoclave was turned on and not when the proper
temperature and pressure had been attained. It is the
physician’s responsibility to hire adequately trained personnel
or otherwise do adequate training in office.
Medical Board of California v O’Neill
The 36-year-old female patient was 5’6" in height and
weighed 249 pounds. On March 4, 1996, liposuction of
the abdomen, neck and inner thighs was performed under
intravenous sedation. Blisters on the lower abdomen were
noted on June 9, 1996 and bacitracin ointment applied.
On July 9, 1996, there was a huge red “bruise” on the
lower abdomen and pustules in the pubic area. The
patient’s temperature was 101.4°F. Treatment with duricef
was changed to augmentin. A diagnosis of cellulitis was
made on August 9, 1996 at which time debridement of
the abdominal wall and neck were carried out. The
accusation was that there was failure to diagnose and
adequately treat the infection.
Comment
On the 4th postoperative day, the diagnosis of cellulitis
should probably have been made and consideration given

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for intravenous antibiotics. For infectious disease, consul-
tation would have been appropriate. Cellulitis is a superficial
infection and would ordinarily not require debridement
unless there is underlying necrosis. Late treatment of
necrotizing fasciitis results in increased tissue loss.
Taylor v Graves, San Diego County
(CA) Superior Court, Case No. 694348
Medical Board of California v Graves
The 50-year old, 5’4", 220 pound plaintiff had liposuction
by the defendant. The hips, legs and abdomen were
liposuctioned on December 12, 1994 removing 11,000 ml
aspirate, and this was repeated at a second procedure
removing 4,000 ml aspirate. The defendant had a medically
untrained individual in his office who cleaned instruments
and acted as surgical assistant but was known to have
performed liposuction on other patients. The plaintiff
developed postoperative urinary incontinence which her
expert witness stated was caused by the liposuction
trauma. The plaintiff claimed that the liposuction resulted
in indentations and irregularities of the hips and abdomen
which were from negligent surgical technique by an
untrained healthcare employee of the defendant. The
plaintiff also alleged that there was lack of informed
consent and that liposuction should not have been
performed on a morbidly obese patient. There was a
confidential settlement and the Medical Board of
California revoked the defendant’s license.
Comment
The performance of liposuction is a medical procedure
that can only be performed by a licensed physician. To
allow anyone else to perform liposuction is considered as
aiding and abetting the unlicensed practice of medicine,
and the physician is subject to revocation of his/her state
license. Liposuction in a morbidly obese patient may have
poor cosmetic results, and this must be explained to the
patient and recorded in the medical record. Surgical
removal of redundant skin by some form of
abdominoplasty may be necessary postliposuction, and this
also must be discussed with the patient and recorded.
Medical Board of California v Chavis,
Los Angeles District, CA
The 43-year-old, 4 feet 11 inch, 197 pound female had
liposuction of the medial and lateral thighs, hips and
abdomen. Five liters of tumescent fluid was injected
(50 ml lidocaine, 1% epinephrine and 12.5 mEq sodium
bicarbonate in each 1,000 ml normal saline). Aspirate was
3,500 ml with estimated blood loss of 300 cc and
intravenous fluids of 3,000–4,000 ml. Versed 17.5 mg and
stadol 3.5 mg were used over the 1 hour 50 minutes of
surgery. Four hours postoperatively the patient wanted to
get out of bed to sit in a chair. While in the chair, in
the presence of her husband and the registered nurse, the
patient became unresponsive. No breath sounds were
noted, but the pulse was present. Mouth-to-mouth
resuscitation was started, and the husband performed
compressions when the pulse became no longer palpable.
The paramedics took patient to the hospital emergency
room (ER) where HCT was 8.1 and the Hgb 2.8. She
expired after unsuccessful resuscitation at the ER. She had
disseminated intravascular coagulopathy, hypothermia,
anemia and pulmonary edema diagnosed at autopsy. The
physician’s license was revoked.
Comment
Marked blood loss is unusual when the tumescent
technique is used, but it may occur. In this case, the
surgeon gave the patient Aleve orally just prior to surgery.
The physician should have known that NSAIDs can cause
bleeding problems. When this patient had pulmonary
arrest, there were not enough medical personnel in the
office to perform cardiopulmonary resuscitation. In
actuality, the husband had to do cardiac compression
during the arrest which is totally unacceptable in a
physician’s office. The patient had been given 5,000 ml
subcutaneous fluid and 3,000–4,000 ml intravenously over
a 2-hour period of time which may have contributed to
the pulmonary edema.
Anonymous vs Anonymous
In March, 1999, three female patients had liposuction for
minor lipodystrophies in a dermatologist’s nonaccredited
office in Florence, Italy. Tumescent anesthesia was utilized,
but there was no data on the contents of the solution.
The cannulas used were sterilized by autoclaving at
another clinic and transported to the office where the
surgeries were performed. Within a few hours
postoperatively, each patient developed high fever, nausea,
vomiting and feelings of anxiety. Hospitalization in an
intensive care unit was immediate. Blood tests showed
infection to all three patients with blood cultures positive
for Staphyloccocus aureus and Pseudomonas aeroginosa. Despite
intravenous antibiotics and resuscitative measures, one
patients developed renal failure followed by coma and
pneumonia. She died after 1 week. The two other patients
recovered following dialysis and 2 weeks in the hospital.

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Investigation by local authorities showed the cannula to
be free of contamination, but the saline solution used for
tumescent anesthesia was contaminated from being left
open for 1 week (not discarded). The physician was
suspended by the College of Surgeons for operating in
an office not authorized for surgical procedures. All three
cases are presently being litigated.
Comment
All surgeries should be performed under sterile conditions.
Liposuction is no exception. Caps and masks, with sterile
gowns and gloves, and sterilization of the skin will help
to prevent contamination. Proper sterilization of
instruments is essential, and excess intravenous and
tumescent fluids should be discarded, not reused. There
tends to be a cavalier attitude by many physicians
performing liposuction surgery that infections are so rare
that indiscriminate contamination of the field by unsterile
scrub suits and suction tubing will cause no harm. This,
however, is a danger to the patient and is below the
standard of care for a reasonably prudent (careful)
physician. The postoperative nausea and vomiting might
possibly be from lidocaine toxicity, but without the
patient’s weight and total lidocaine dosage, this cannot be
properly evaluated. It would be unusual for the peak
lidocaine level to occur a few hours after surgery. Total
surgery time would have to be taken into consideration,
since, with proper tumescent anesthesia of 2:1 or 3:1, the
lidocaine serum level should peak from 8 hours to 10
hours after “administration”.
Estate of Caswell v Daniel,
Commonwealth of Kentucky Fayette
Circuit Court (Eighth Division), Case
No. 99-CI-1947.
The 30-year-old plaintiff’s decedent had liposuction of the
abdomen and panniculectomy on July 2, 1998. Four liters
of tumescent solution was injected, and 4,475 cc aspirated.
There was no written consent for liposuction. Two hours
postoperatively, there was a significant drop in blood
pressure to 80/47. He was given increased intravenous
fluids. For the next 3½ hours, the blood pressure varied
from a high of 105/68 to a low of 66/40. This was
followed for the next 1 hour and 10 minutes by systolic
blood pressures in the 70s. The patient was then
transferred to the intensive care unit. Hematocrit ordered
at 19:45 hours was reported at 21:00 hours as 30.9. Repeat
hematocrit at 22:45 hours was 20.8. Packed cells were
ordered at 00:05 hours on July 3, 1998, and transfusions
begun at 00:15 hours. The patient had cardiac arrest at
00:30 hours and was pronounced dead at 01:35 hours.
Autopsy showed the cause of death to be from
exsanguination with 1,600 ml of blood in liposuction area
of the abdominal wall, 400 ml in the scrotal sac, and
extensive hemorrhage in the subcutaneous tissues
extending to the back.
There was a settlement for an undisclosed amount.
Comment
Hypotension following a major surgical procedure is
primarily caused by blood loss. Hematocrit should have
been ordered 2 hours postoperatively when the first
hypotensive episode occurred. The low blood pressure did
not respond adequately to crystalloids. When the
hematocrit was 30.9 at 21:00 hours, blood should have
been given. Packed cells are not indicated for hypotension
following blood loss unless albumin or Hespan is used
at the same time. Whole blood is the better means of
expanding the vascular volume. By the time the patient
had severe hypotension for over an hour, there was little
likelihood of survival because of irreversible shock from
extensive tissue damage. A timely diagnosis and treatment
of blood loss would have saved this patient’s life.
Estate of Marinelli v Geffner, New
Jersey Superior Court (1999). In:
Medical Malpractice Verdicts
Settlements. 1999;15(8):37.
The 23-year-old female plaintiff’s decedent had liposuction
by the defendant dermatologist in May 1994. One day
following the surgery, the patient died from a pulmonary
embolus. The plaintiff claimed that the defendant was
negligent in failing to tell the decedent not to take birth
control pills, and also applied the bandages in a manner,
which cut off the circulation and caused blood clots to
form. There was also a question raised about the use of
liposuction in a woman weighing only 115 lbs. There was
a $558,000 verdict.
Comment
It is essential that patients discontinue birth control pills
prior to cosmetic surgery over 1 hour. Estrogens are a
known cause of thromboembolism. Cutting off the
circulation with bandages would result in edema of the
extremity and possibly cause deep vein thrombosis.
Liposuction can be performed in a patient of any weight
and is dependent upon the abnormal location of the fat
deposits rather than patient weight.

227
Medicolegal Aspects of Liposuction
Donnell-Behringer v McCann, Los
Angeles County (CA) Superior Court,
Case No. VC26507. In: Medical
Malpractice Verdicts Settlements
Experts. 2000;16(8):50.
The 45-year-old plaintiff had surgery on her shoulder and
liposuction in the defendant’s outpatient surgery clinic. She
had follow-up visits with the defendant on the 1st and
2nd postoperative days. On the 3rd postoperative day, the
plaintiff was admitted to the hospital by another doctor
for infection of the liposuction site that required surgery.
The plaintiff alleged that the defendant negligently
performed liposuction, failed to utilize proper surgical
techniques and was negligent in postoperative care. The
defendant claimed that he was not negligent, that the
standard of care had been met, and that infection was
a risk of the procedure. There was a $902,000 verdict that
was reduced through MICRA (Medical Injury
Compensation Reform Act of 1975) to $660,000.
Comment
Infection is a known risk of any surgical procedure. The
fact that infection occurred and was not timely recognized
by the surgeon despite regular office visits was enough to
convince the Jury of a breach in the standard of care.
Since the patient had to be admitted to the hospital and
operated upon by another doctor, there is evidence that
the infection was diagnosable by another physician within
a day of having been seen by the defendant.
Trebold v Fowler, Dallas County (TX)
District Court, Case No. 00-6073-D. In:
Medical Malpractice Verdicts
Settlements Experts. 2002;18(8):55.
The 44-year-old plaintiff had liposuction of the abdomen
and thighs. Postoperatively discoloration and necrosis of
the skin of abdomen and thighs developed that required
debridement and packing. The result was disfiguring scars
of abdomen and thighs. The plaintiff alleged breach in
the standard of care. The defendant claimed that the
plaintiff failed to follow postoperative instructions. There
was a $291,000 verdict with the plaintiff 20% negligent.
Comment
Infection, necrosis and scarring are known complications
of liposuction. Despite a lack in breach of the standard
of care, the Jury found for the plaintiff possibly because
of severity of the necrosis and scarring and prolonged
recovery.
Medical Board of Texas v Ramirez, 1987
In 1987, a young 5 feet 1 inch, 117 pound female, had
liposuction of the abdomen. No preoperative or
postoperative antibiotics were administered. Two days
postoperatively, the patient developed an overwhelming
infection and sepsis. She was admitted to the hospital and
treated with intravenous antibiotics but she died.
Comment
Sterility is a sine qua non of any surgical procedure.
Instruments and wounds should be handled with strict
sterile precautions. The cavalier attitude of some surgeons
not to use masks, gowns, sterile drapes and a sterile
surgical suite to perform liposuction risks patient lives.
Liposuction causes extensive internal tissue damage and
the standard of care requires perioperative antibiotics.
References
1. Dillerud E. Suction lipoplasty: A report on complications,
desired results, and patient satisfaction based on 3511
procedures. Plast Reconstr Surg. 1991;88(2):239-46.
2. Hanke CW, Bernstein G, Bullock S. Safety of tumescent
liposuction in 15,336 patients: National survey results. Dermatol
Surg. 1995;21:459-62.
3. Illouz YG. Body contouring by lipolysis: A 5-year experience
with over 3000 cases. Plast Reconstr Surg. 1983;72(5):591-7.
4. Pitman GH, Teimourian B. Suction lipectomy: Complications
and results by survey. Plast Reconstr Surg. 1985;76(1):65-72.
5. Fournier PF, Eed M, Fikioris A, et al. La liposculpture dans l’obesite.
Rev Chirurg Esthet Langue Francaise. 1992;17(69):43-52.
6. Klein JA. The tumescent technique for liposuction surgery.
Presented at the Second World Congress of Liposuction Surgery
of the American Academy of Cosmetic Surgery, Philadelphia,
June 1986.
7. Klein JA. The tumescent technique for liposuction surgery. Am
J Cosm Surg. 1987;4(4):263-7.
8. Klein JA. Tumescent technique for regional anesthesia permits
lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg
Onc. 1990;16:248-63.
9. Klein JA. Tumescent technique chronicles: Local anesthesia,
liposuction and beyond. Dermatol Surg. 1995;21:449-57.
10. Lillis PJ. Liposuction surgery under local anesthesia: Limited
blood loss and minimal lidocaine absorption. J Dermatol Surg
Oncol. 1988;14:1145-8.
11. Burk RW, Guzman-Stein G, Vasconez LO. Lidocaine and
epinephrine levels in tumescent technique liposuction. Plast
Reconstr Surg. 1996;97(7):1378-84.
12. Coleman WP III. Controversies in liposuction. Cosmet
Dermatol. 1995;8:40-1.

228
Atlas of Liposuction
13. Lillis PJ. The tumescent technique for liposuction surgery.
Dermatol Clin. 1990;8(3):439-50.
14. Ostad A, Kayeyama N, Moy RL. Tumescent anesthesia with a
lidocaine dose of 55 mg/kg is safe for liposuction. Dermatol
Surg. 1996;22:921-7.
15. Samdal F, Amland PF, Bugge JF. Plasma lidocaine levels during
suction-assisted lipectomy using large doses of dilute lidocaine
with epinephrine. Plast Reconstr Surg. 1994;93:1217-23.
16. Klein JA, Kassardjian N. Lidocaine toxicity with tumescent
liposuction: A case report of probable drug interactions.
Dermatol Surg. 1997;23:1168-74.
17. Illouz Y-G. Refinements in lipoplasty technique. Clin Plast Surg.
1989;16(2):217-33.
18. American Academy of Cosmetic Surgery: 1997 Guidelines for
liposuction surgery. Amer J Cosm Surg. 1997:14(4):389-92.
19. Chrisman BB, Coleman WP. Determining safe limits for
untransfused outpatient liposuction: Personal experience and
review of the literature. Dermatol Surg Oncol. 1988;14(10):
1095-102.
20. Shiffman MA. Anesthesia risks in patients who have had
antiobesity medication. Am J Cosm Surg. 1998;15(1):3-5.

Index
A
Abdomen 23, 24, 192
basic liposuction technique 87f
liposuction of 85, 105, 107f
shape of 97
suction lipectomy of 107
Abdominal
esthetic surgery 104
etching 96
lipectomy 9, 97
liposuction 85
complications 96
umbilical incision 109f
suction lipectomy 103f
wall 92f
Adhesion of skin to muscle 53f
Advantages of crisscross technique 27
Angry patient 222
Ankles 24, 25
Anterior
approach to love handles suction
111f
incisions for anterior knee
liposuction 79f
inner knee above patella 71f
portion of knee 82
Arms 24
Arteries 8
Associated liposuction with implants
207
Autologous fat
injection 198f, 205f
reconstruction 197
Axilla liposuction 208f
B
Beer belly 91
Bichat’s fat pad, liposuction of 212f
Bilateral sympathectomy scars 107f
Bleeding 80, 96, 119
Blepharoplasty 189f
Blood 199f
replacement 220
vessel injury 1
Body
contouring 192
implants, combination of 207
shaping with implants 207
Body’s tubular shape 95f
Breach of duty 220
Breast liposuction 126
Breasts 24
Buttock
crease, upper part of 123f
implantation 208
implants 208f
liposuction 209f
liposuction 52, 58, 60f, 73f
shape of 72
suction 73f
suction lipectomy of 52
Byron microinjector for pressure
injections 198f
C
Calcified and mimic cancer on
mammograms 197
Calf
implantation 208, 211f
implants, combination of 210
Caliber cannula for best results
68f
Candidates for surgery 10
Cannula 19
introduced down to deep fascia 21
over muscular fascia 27
sizes 20
surgical tip 34f
Caveats 39, 101, 112
Cellulite 28, 39
release technique 32
respond poorly to liposuction 9
Central part of abdomen 93
Cheek, liposuction of 186f, 213
Chin 212f
implant 212f
with neck liposuction 210
liposuction of 186f, 211f
Circumferential aspect of torso 192
Classification of abdomen 104
Closure of skin 76
Colles’ fascia 76f, 77
Complete extended supine position
89f
Complications in saddlebag 45
lipectomy 47f
Condyles in upper calf area 82
Conjunction with abdominal
liposuction 112f
Connective tissue 199f
Constriction around knee 80
Contour liposuction 192, 196f
Correction of saddlebags 115
Coup de Hache deformity 93f
Creation of new waistline 112f
Crest liposuction 124
Crisscross suction of saddlebags
with markings 41
Crisscross technique
advantages of 27
for saddlebag suction 41f
Crisscrossing from hip 111f, 117
Criteria for proper cannula selection 19
Current instruments 216
Curvaceous lines 7
D
Dean
cannulas with glass bottles 18
suction machine with disposable
canisters 18f
Depressions 205
Development of powered liposuction
technology 215
Disseminated intravascular
coagulation 219
Droop corner of mouth 201f
E
Elevated cannula 29f
Epigastric bulging 106f
Epinephrine 4, 220
Esthetic considerations 11
Etching, abdominal 96
Extent of liposuction 27, 104
External ultrasound 214
assist with liposuction 36
machine 34f
Extremely extensive scar 38
F
Face 23, 24
liposuction of 22f
Page numbers followed by f refer to figure.

230
Atlas of Liposuction
Facial liposuction, complications of 189
Fat
cells 202
evaluation 200
from blood, separation of 200f
layer, pinch test elevation of 86f
layers 31
Fatty
chest after gynecomastia surgery
208f
lipodystrophy of knees 210
tumors, lipomas 204
Female
breast liposuction 131
with underdeveloped buttocks
209f
First prototype suction machine 2
Flabbiness of inner thighs 77f
Flaccid skin 196f
Flaccidity 106f
Flat buttocks 54f, 58
Flexion irregularities 119
Floating of umbilicus 105
Fluid 220
Fold in suprapatellar area 81
G
Gluteal crease anatomy 55
Gluteal folds 42
Grams aspirator 18
Groin above patella 63f
Gynecomastia 126
in body builder 127
H
Hematoma 73, 80, 96
Higher part anchorage of skin 77
Hip with necrosis resulting
depression 206
History of liposuction 1
Hockey-stick type of incision 188f
I
Iliac crest 22f, 23, 24, 73f, 115, 119
deformity 119
excess 38f
liposuction 73f, 115, 118f, 120f
complications of 118t
suction 116f
groin incision 118f
waist 193f
Implants to malar area, liposuction 213f
Incision
location for anterior knee
liposuction 81f
sites for knee suction 81f
Inferior
chest liposuction 208f
epigastric arteries 99f
Informed consent 221
Infragluteal incision, suction from
117f
Injection guns 198f
Injury 220
Inner infrapatellar incision 81f
Inner knee suction 81f
Inner thigh 25
liposuction combined 75
liposuction through inferior glutea
68
Intra-abdominal lipodystrophy 91
Introduction of cannula 21
K
Knee 24, 25, 84, 203
lipodystrophy 120f
liposuction from medial inner 67
liposuction of 22f, 78, 210
liposuction performed with small
caliber 79
suction lipectomy of 71f
L
Large iliac crests lipodystrophy
121f
Large saddlebags 45f
Larger gauge cannula 198f
Lateral
incision in bathing suit area 50f
thigh 73f
Left
buttock 73f
upper thigh 198f
Legal
aspects 222
cases 222
definition 221
Lengthen the gluteal fold 56f
Level of Colles fascia 77
Levine autolipoplasty syringe 198f
Lidocaine 4, 220
Limits, liposuction 220
Lip creases 203f
Lipectomy, abdominal 9, 97
Lipodystrophy 77f, 204
Liposuction 1, 73, 212f, 219
abdominal 85
combination of 207
fat injection 198f
in Dercum’s disease 205
limits 220
techniques 78, 197
with different systems 33
Liposuction of
abdomen 85, 105
and saddlebags 107f
arms 22f
Bichat’s fat pad 212f
cheek 186f
chin 186f, 211f
face 22f
iliac crest 120f
inner thighs 66, 69f
knees 22f, 78
love handles 109
lumbar bulge 123f
neck 186f, 187f, 211f
Liposuctioning knee 80f
Local anesthesia, limited amount of
220
Local tumescent anesthesia 4
Location of incision 119
Loses normal leg contour 78
Love handles 109f
liposuction of 109
Lower
abdomen to waist 193f
chest 208f
epigastric artery 105
thighs 210
Low-level laser-assisted liposuction 215
Lumbar
area 196f
and waist 194f
bulge
liposuction of 122, 123f
suction of 122
curvature 194
liposuction 125f
sacral bulge, suction of 124f
suction and curvature 125f
M
Malar
areas 213f
implants 212f
with cheek liposuction 211
Mandibular angle implants 213
Medco aspirator 19f
Medial
condyles 81
incision above patella 210f
portion of knee 82
Median laparotomy 89f
Medical record 222
Medicolegal aspects of liposuction 219
Mediterranean population 115
Mental nerve bilaterally 202f
Middle posterior subgluteal fold 76
Miniabdominoplasty technique 103
Missing waist 93

231
Index
Modalities beyond simple liposuction
214
Moderate lumbar and iliac crest
lipodystrophy 124f
Motor-driven cannula with cutting 2
Multiple congenital lipomas 205f
Mycobacterium
chelonae 224
fortuitum 224
N
Narrow pelvis broad chest 110f
Nasolabial
area 203f
crease 203
fold, upper part of 201f
peribuccal fat transplantation
203f
Nd:YAG 215
Neck 24, 187f
lipodystrophy 212f
liposuction of 186f, 187f, 189f, 211f
Neodymium:YAG 215
Nerve injuries 191
Nerves 8
Nodular multiple lipomatosis 204
Non-cosmetic liposuction 204
Nonreturn stage 75
Nordic-type body with long thorax 109f
O
Obesity 72
Oblique position 122
Old-age cellulite 30
Operating room protection against
vapor contaminate 35
Original medicalex suction machine 17f
Orthostatic liposculpture 215
P
Paramedian laparotomy 89f
Patella using small cannula 83
Patient rapport 221
Patient with excessively large
anterior thighs 64f
Pectoral implants 207, 208f
Peribuccal crease 203
Pinch
technique 86f
test elevation of fat layer 86f
Placement of implants 208f
Planatome 2f
Point junction of thigh 84
Poorly developed buttocks 209f
Posterior medial popliteal incision
79f
Powered liposuction 215
Preoperative
female with small calves 211f
markings 193
Prepping feet 64
Principles of liposuction 223
Proper inspection of case 119
Protrusion of buttocks 60f
Pseudodeformity of saddlebags 11
Q
Quality of skin 97
R
Reconstructive flaps and pedicles
204
Recreation of new umbilicus 105
Redundancy of chest 208f
Redundant skin 73
Refinements 71
Re-implantation of umbilicus 105
Requirements for medical negligence
220
Result of trochanteric lipectomy 12f
Retrusive chin 213f
Rib cage 104
Right buttock 73f
Robles cannula 112, 119
S
Sacral incision 111f, 117
Sacroiliac level allow lumbar suction
123
Saddlebag deformity 39
Saddlebags 23, 24, 38, 38f, 60f,
67, 120f
liposuction of 40f, 107f
Second prototype motor suction
machine 2f
Skin
closure of 76
excision 73
quality of 97
Sklarvac multipurpose suction unit 18f
Small
caliber cannulas 20f
chin incision 191f
needle gauge 200f
Sodium bicarbonate 4
Special equipment for ultrasonic
suction 33
Special type of marking for knees 80
Spinal herniation with form fruste of
spina bifida 122
Standard of care 221
Stretch marks 9
Subcutaneous tissues 220
Suction
from sacral incision 117f
lipectomy 45
complications in cases of 190f
to iliac crest 123f
Superficial
aponeurotic fascial system 31
fascial system 30, 31, 74
liposuction 31
Superior epigastric arteries 99f
Swan-neck cannula and guided
cannula 3
Syringe aspiration of fat 199f
T
Technique of abdominal lipectomy 97f
Tensor fasciae latae 39
Thigh kissing 67
Thighs 23, 24
suction lipectomy of 61
Thunder thighs 61
Tissue filler for contour defects 197
Traumatic scars 205
Treatment of
cutaneous surface defects by fat
197
lymphedema 204
Triamcinolone 4
Trochanteric lipectomy 12f, 73
Tubing for MEDCO 19f
Tumescent technique 3, 220
Types of abdomen 104
Typical application of elastic tape 22
U
Ultrasonic generator 33f
Ultrasonic-assisted lipectomy 36
Umbilicus 105
Upper abdomen to waist 193f
Upper epigastric artery 105
Upper part of
buttock crease 123f
nasolabial fold 201f
Upper posterior thigh 73f
V
Vibration amplification of sound
energy 216
Violin deformity 73f

232
Atlas of Liposuction
W
Waist
area 196f
liposuction, abdominal 110f
suction 192
Wall, abdominal 92f
Water jet-assisted liposuction
217
Woman with
abdominal lipodystrophy 113f
lipodystrophy of knees 84f
Wound breakdown 73
Wrinkled abdomen or stretch 101
X
Xyphoid 104
Y
Young-age cellulite 30