Atlas Phẫu Thuật Thẩm Mỹ (Tập 2) – Atlas of Cosmetic Surgery

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Conclusions
The world of fillers has indeed changed since the early 1980s
when collagen was introduced. Newer fillers offer physicians
and patients more long-lasting correction but this duration
comes with a price that includes the need for greater tech­
nical prowess and, in some instances, great risks of compli­
cations. When adopting a new filler into one’s practice, it is
important to have a thorough understanding of the risks and
benefits of this new filler. Understanding the history and tech­
niques associated with previous fillers may in some instances
help to provide insight into the potential for a new product.
The hyalurons, calcium hydroxyapatite, poly L lactic acid
products, silicones, and collagens offer the dermatologic sur­
geon new opportunities to treat their patients. Understand­
ing the techniques associated with their use will help to insure
safe and effective treatments for patients seeking soft tissue
­augmentation.
REFERENCES
  1. Duffy D. Silicone conundrum: a battle of anecdotes. Dermatol Surg
2002; 7:590–594.
  2. American Society for Aesthetic Plastic Surgery. ASAPS 2005 Data.
  3. Anon. Restylane Consensus conference. Plast Rec Surg 2006; 117:3.
  4. Matarasso S, Herwick R. Hypersensitivity reactions to nonanimal
stabilized hyaluronic acid. J Am Acad Dermatol 1955; 1:128–131.
  5. Beer K. A randomized, evaluator-blinded comparison of efficacy of
hyaluronic acid gel and avian-sourced hylan B plus gel for correction
of nasolabial folds. Dermatol Surg 2007; 33(8):928–936.
  6. Morretti M. Aesthetic Buyers Guide. Aliso Viejo, CA, 92656. 2005
  7. Medicis Aesthetics, Inc. Restylane injectable gel package insert.
Scottsdale, Ariz.
  8. Allergan Inc. Hylaform package insert. Irvine, CA.
  9. Juevederm package insert, Inamed Aesthetics, Santa Barbara, CA.
10. Glaich AS, Cohen JL, Goldberg LH. Injection necrosis of the glabella:
protocol for prevention and treatment after use of dermal fillers.
Dermatol Surg 2006; 32:276–281.
11. Gooderrman M, Solish N. Use of hyaluronic acid for soft tissue
augmentation of HIV-associated lipoatrophy. Dermatol. Surg 2005;
31:893.
12. Alam M, Goldberg L. Serious adverse vascular events associated with
perioperative interruption of antiplatelet and anticoagulant therapy.
Dermatol Surg 2002; 28:992–998.
13. Carruthers A, Carruthers J. A prospective, randomized, parallel group
study analyzing the effect of BTX-A (Botox) and nonanimal sourced
hyaluronic acid (NASHA, Restylane) in combination compared with
NASHA (Restylane) alone in severe glabellar rhytides in adult female
subjects: treatment of severe glabellar rhytides with a hyaluronic acid
derivative compared with the derivative and BTX-A. Dermatol Surg
2003: 29:802–809.
14. Narins R, et al. Fanning and slow injection for restylane/ perlane.
Presented at the AAD, Washington DC, 2007.
15. Klein A. In search of the perfect lip: 2005. Dermatol Surg 2005;
31:1599.
17. Schanz S, Schippert W, Ulmer A, et al. Arterial embolization caused
by injection of hyaluronic acid (Restylane). Br J Dermatol 2002;
146:928–929.
18. Lowe N, Grover R. Injectable hyaluronic acid implant for malar and
mental enhancement. Dermatol Surg 2006; 32:881–885.
19. Elson ML. The role of skin testing in the use of collagen injectable
materials. Dermatol Surg 1989; 15:301–303.
20. Kraus M, Klein A. Soft tissue augmentation. In: Kaminer M, Dover J,
Arndt K, Atlas of cosmetic surgery, 1st edn. Philadelphia: WB
Saunders: 2002.
21. Semchyshyn N, Sengelmann RD. Botulinum toxin A treatment of
perioral rhytides. Dermatol Surg 2003; 29(5):490–495.
22. Vleggar D, Bauer U. Facial enhancement and the European experience
with Sculptra. J Drugs Dermatol 2004; 3:542–547.
23. Sculptra package insert, Sanofi Aventis Pharmaceuticals, Bridgewater,
NJ.
24. Narins R, et-al. Sculptra US clinical trial. In Press.
25. Beer, K. Sculptra in the treatment of acne scars. J Dermatol Surg.
In press.
26. Burgess CM, Quiroga RM. Assessment of the safety and efficacy of poly
L lactic acid for the treatment of HIV associated facial lipoatrophy.
J Am Acad Dermatol 2005; 52:233–239.
27. Rapaport MJ, et al. Injectable silicone: cause of facial nodules, cellulitis,
ulcerations and migration. Aesth Plast Surg 1996; 20:267–276.
28. Duffy DM. Injectable liquid silicone: new perspectives. In: Klein AW,
ed. Tissue augmentation in clinical practice: procedures and techniques.
New York: Marcel Dekker; 1998:237–267.
29. Jones D, Carruthers A, Orentreich D, et al. Highly purified 1000
cst silicone oil for the treatment of human immunodeficiency virus
associated facial lipoatrophy: an open pilot trial. Dermatol Surg 2004;
30:1279–1286.
30. Narins R, Beer K. Liquid injectable silicone: a review of its history,
immunology, technical considerations, complications and potential. Plast
Reconstr Surg 2006; 118(supp):77s.
31. Orentreich D, Jones D. Liquid injectable silicone in procedures in
cosmetic dermatology: soft tissue augmentation. Philadelphia: Elsevier;
2005: 77–91.
32. Prather C, Jones D. Liquid injectable silicone for soft tissue
augmentation. Dermatol Ther 2006; 19(3):159–168.

History and Science
Background history
The first published reports of autologous fat transfer appeared
in the medical literature in the late 1800s. This was followed
by a brief interest in other fillers such as paraffin to restore fa­
cial contours secondary to trauma or disease. Fat transfer did
not again gain popularity until the 1980s with the populariza­
tion of tumescent liposuction. However, inconsistent results
and a peripatetic following continuously haunted the proce­
dure. It was not until the advent of structural fat grafting and
the numerous interpretations of that technique that fat came
into its own as the predictable, stable, long-lasting volumetric
expander that it is.1,2
Basic science
Most current recommendations for the procedure of struc­
tural fat transfer come from animal studies in the scientific
­literature. A recent study looking at transplantation of
­human fat into immunocompromised mice found that fresh
fat cell survival was better in the specimens with the least
manipulation and that no unique combination of prepara­
tion or harvesting techniques appeared to be more advanta­
geous at 3 months.3 However, some authors have found that
a variety of techniques used to collect, clean, and reinject fat
do not damage the fat cells, including the presence of lido­
caine.4–6 In addition, harvesting fat via manual suction in the
method outlined below has been shown to produce a high
yield of preadipocytes with an intact stromal cell fraction.7
Transplantation techniques that are currently performed
have a correlation to studies done looking at superior survival
of ‘pearls’ of fat in the animal model.8 Neovascularization
is necessary for transplanted fat survival, but stem cell dif­
ferentiation, and tissue fibrosis may also contribute to lasting
augmentation.9–11 Using fatty acid patterns unique to differ­
ent body sites, transplanted fat has shown survival of at least
12 months in one study.12 In one review article the authors
concluded that survival of aspirated fat cell grafts depended
mainly on the anatomic site, the mobility and vascularity of
the recipient tissue, or underlying causes and diseases, and
less on harvesting and reinjection methods.13 Fat processed
after liposuction and abdominoplasty procedures has been
shown to contain progenitor stromal cells. This in and of
itself may lend support for autologous fat as the ideal filler
for aging skin.14
PROCEDURES AND TECHNIQUES
Preoperative clinical consideration
Understanding the principles for rejuvenation through aug­
mentation requires careful study of the architecture of a
young face. In youth, the soft tissue of the face is abundant
Autologous Fat
Transplantation
Lisa Donofrio
C h a p t e r
20
p a r t 2
Key Points
n A youthful face is soft, round in contour and without
shadows.
n Autologous fat is an excellent way to restore
youthful convexities to the aging face.
n Fat should be extracted under tumescent anesthesia
with as little trauma to the fat cells as possible.
n Fat should be placed in the face in structural planes
with blunt cannulas.
n Fat should be placed pan-facially, addressing all
cosmetic units.
n Repeat transfers with either fresh or frozen fat may
be needed for optimal correction.
n Fat, when placed correctly, has an excellent track
record for safety and longevity.

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Cosmetic surgery procedures and techniques
and diffuse. Due to the continuity of neighboring cosmetic
units, there are few shadows and no ‘break points.’ The fore­
head arcs up and away from the underlying calvarium. This
arc starts at the hairline and ends in the superior sulcus of the
upper lid. In addition, the forehead and temple area is wide
and extends beyond the lateral eye brow visually. In fact, the
upper third of the face appears fuller than the lower third,
imparting a ‘flipped triangle’ with the apex occurring in the
mentum. The cheek and lower lid is a continuous plane in the
young face and also form an arc from the tarsus of the lower
lid to the jawline. This arc, like the forehead arc, is due to
an abundance of subcutaneous fat and serves to lift the skin
off and away from the bony framework of the midface. Pho­
tographs of young patients are extremely helpful when dis­
cussing rejuvenation of the periorbital area. Skin redundancy
in the upper lids is not a primary event, but rather a result
of fat loss with relative skin excess. Youthful eyes are full in
contour and have less lid show than their aging counterparts
(Fig. 20-1). Evaluation of the suborbital area requires that the
patient be classified into one of two suborbital aging patterns:
atrophic or hypertrophic. In atrophic suborbital aging there is
hollowing and loss of fullness throughout the entire suborbital
area, oftentimes with demarcation of the underlying bony
orbit (Fig. 20-2). However, in hypertrophic suborbital aging
there is apparent protrusion of the suborbital fat anterior to
that of the inferior cheek mass (Fig. 20-3). Atrophic subor­
bital aging is true loss of suborbital, subcutaneous fat, whereas
hypertrophic suborbital aging is actually cheek atrophy, with
persistence of the intraorbital fat, and most likely represents a
relative hypertrophic event.
At the level of the jawline in youth, there is a fullness that
sweeps from ear to ear in another smooth arc. Fat around the
mandible in youth leads to a roundness of the lower face that
gives a very clear distinction between the lower face and the
neck but displays no angularities (Fig. 20-4). Loss of soft tissue
and bony remodeling that occurs with aging results in involu­
tional changes that lead to flattening of the anterior projec­
tion of the forehead and midface and loss of the soft, defining
contours of the jawline (Fig. 20-5). Flattening of the face is
akin to deflation in a balloon. The skin envelope, an ­innocent
bystander in all of this, responds to positional changes by
‘sagging.’
A
B
Fig. 20-1  The same woman (A) age 16 and
(B) age 50. Notice the increase in lid show with
aging. (Photo property of Lisa Donofrio, MD)

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Autologous fat transplantation  •  Chapter 20
A
B
Fig. 20-2  A 48-year-old female with atrophic
suborbital aging. (A) Before and (B) 18
months after one session of fat transplanta­
tion with only frozen fat. (Photo property of
Lisa Donofrio, MD)
A
B
Fig. 20-3  A 55-year-old female with hyper­
trophic suborbital aging. (A) Before and
(B) after fat transplantation to the superior
cheek/tear trough. (Photo property of Lisa
Donofrio, MD)
Fig. 20-4  Young, full face. (Photo property of Lisa Donofrio, MD)
Fig. 20-5  Old face. Note loss of arcs of face and definition
of jawline. (Photo property of Lisa Donofrio, MD)

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Cosmetic surgery procedures and techniques
The donor site to be liposuctioned is prepared with a solution
of hibicleans and sterile water and the face is washed with
antibacterial soap. Patients are placed onto a sterile, draped
operating table covered with a sterile sheet. Sterile gloves and
masks are worn by the operator and his/her ­assistant. A sterile
gown is optional and at the discretion of the surgeon. Box 20-1
details the preoperative patient instructions.
Procedural techniques
Fat extraction
Fat should be taken from an area that benefits the patient aes­
thetically, has a low risk for contour irregularities, and has the
greatest potential for lipogenic activity.15,16 These areas often
occur on the outer thighs or posterior waists of women and
the flank area of men. The area to be suctioned is best demar­
cated with the patient upright. Using a surgical marker, the
area is outlined using a ‘bulls-eye’ to denote the central area of
greatest fat density. The patient is then laid down on a sterile
draped surgical table so that the area to be suctioned is easily
accessed. The superficial skin is anesthetized with 1% xylo­
caine with epinephrine and either a stab incision made with a
#11 blade or a hole made with a 1.5 mm punch. Tumescent
fluid can then be infiltrated via a multiholed infiltration spray
cannula until the tissues are turgid. The recommended recipe
for a modified Klein tumescent fluid particularly appropri­
ate for fat harvesting is shown in Box 20-2. The optimal time
for fat extraction after tumescing is 20 to 60 minutes. ­During
that time, vasoconstriction and anesthesia is optimal. The fat
should be harvested with manual suction only by ­attaching
a 10 mL syringe to an open tipped Luer lock cannula (Fig.
20-7). Negative pressure is generated by pulling back on the
plunger while moving the cannula in a back and forth mo­
tion. Fat collection occurs quite quickly in this manner and
with little to no blood in the aspirate (Fig. 20-8). The syringes
Drawing on the face
Keeping with the initial treatment plan determined in the
initial consultation, the blueprint indicating areas to be aug­
mented is transferred to the face with either a laundry marker
or gentian violet pen. The author finds the laundry marker
desirable due to its low cost and ease of removal with soap
and water. It is helpful to delineate bony landmarks that may
assist in fat placement, especially after distortion due to local
anesthesia infiltration. It is also helpful to pre-mark any base­
line asymmetry. Having the patient gaze up accentuates the
inferior rim or the orbit and tear trough deformity and facili­
tates marking these areas. Manually lifting the eyebrow until
no lid redundancy remains helps the surgeon to draw in a new
supratarsal crease by following the arc of the globe. The man­
dibular markings are drawn by palpating and denoting the
anterior border of the mandible and then drawing a second
line 1 cm below and posterior to the first. This marking should
span from mastoid to mastoid (Fig. 20-6). In addition, any
fullness in the jowl or submentum should be marked as such to
avoid filling this area. Other markings may include highlight
points or scars to be corrected.
Patient preparation
Preoperative photographs should be taken from multiple an­
gles in animation as well as repose. Baseline static and dynamic
asymmetries as well as lid ptosis or scars should be noted in the
chart and pointed out to the patient. Antibiotic prophylaxis is
recommended for 7 days starting the day before the proce­
dure with Keflex 500 mg b.i.d., erythromycin 500 mg b.i.d., or
ciprofloxacin 500 mg b.i.d. Premedication on the day of the
procedure may include 5–10 mg of oral diazepam if needed.
Fig. 20-6  Facial markings. Note jawline drawing occurs below
mandible. (Photo property of Lisa Donofrio, MD)
Box 20-1  Patient preoperative instructions
• Refrain from taking nonsteroidal antiinflammatory drugs,
ginko biloba, ginseng, ginger, omega-3 fatty acids (such as
fish or flaxseed oil) and vitamin E for 2 weeks before
the procedure.
• No alcohol for 2 days before the procedure.
• Get preoperative labs drawn (CBC, Chem panel, LFT,
PLT, and PT, PTT) at least 1 week before procedure.
• Have ice or bags of frozen peas on hand in freezer
at home.
• Wear loose dark clothing day of procedure.
• Bring girdle or biking shorts to office on day of procedure.
• Have someone drive you home from the office on day
of procedure.
• Start antibiotic the day before procedure and continue
for 6 days after procedure.

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Autologous fat transplantation  •  Chapter 20
Fat transplantation technique
Transplant principles
In preparation for transplantation fat should be transferred to
1 mL syringes (Fig. 20-9). This insures control over the place­
ment of small aliquots of fat and keeps the injection pressures
low during transplantation. All transplantation takes place via
blunt cannulas. The workhorse cannula is an 18 g, Luer lock
stainless steel instrument (Fig. 20-10), but smaller cannulas
approaching 20 g may also be utilized for fine fat placement
(Byron, Arizona USA). There are two techniques for fat place­
ment: threading and pearling. Threading occurs when fat is
placed in a retrograde movement, pulling a ‘thread’ or strand
of fat through the recipient tissues. Pearling occurs when fat is
placed via a depot technique, depositing ‘pearls’ of fat directly
into an area. With both of these methods, only very small
amounts of fat are positioned in the facial tissues, generally in
an aliquot of less than 0.1 mL. Fat should be deposited in all
tissue levels starting right above the bone (where available) and
into and around the mimetic muscles and subcutaneous deep
and superficial fat. It is not recommended for fat to be placed
should then be capped with a tight seal and either left to set­
tle with gravity or preferably centrifuged at 3400 RPM for 20
seconds to condense the fat. Centrifuged fat will separate out
into a tumescent fluid infranate, a fat cell middle layer, and a
triglyceride supranate. The infranate should be decanted and
the syringes recapped.
Facial anesthesia
Patient comfort is essential for a local anesthesia procedure.
Facial blocks using 1% lidocaine can be administered when
appropriate in the infraorbital, mental, supraorbital, and
­supratrochlear areas. The majority of the local anesthesia,
however, takes place via local infiltration of 0.5% lidociane
via a 30 g, 1 inch needle. Injections are done slowly and kept
in the deep fat to minimize trauma and bleeding of superfi­
cial vessels. In the perioral area an intraoral route of anesthe­
sia is preferable over the percutaneous route. It in this area
it is necessary to fill the superior and inferior labial vestibule
with a 1% lidocaine solution superficially to achieve adequate
lip anesthesia. Immediately before injection of anesthetic
­solutions, sodium bicarbonate should be added to the syringes
to decrease pain on injection.17
Box 20-2  Modified Klein solution for tumescent anesthesia
• 1 L Lactated ringers solution
• 1 mg epinephrine
• 50 mg lidocaine
• 12.5 meq sodium bicarbonate
Fig. 20-7  Coleman® extraction cannula (Byron, AZ, USA). (Photo
property of Lisa Donofrio, MD)
Fig. 20-8  Fat harvesting. (Photo property of Lisa Donofrio, MD)
Fig. 20-9  Transferring the fat to 1  mL syringe. (Photo property
of Lisa Donofrio, MD)

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Cosmetic surgery procedures and techniques
cannula, linear deposits of small amounts of fat are created by
inserting the cannula to the hub and depressing the plunger
on the withdrawal phase of the movement while pulling the
cannula cephalad. The entire forehead is covered this way,
fanning from each incision (Fig. 20-12). Total volumes will
approach 10 mL or more. The level of infiltration occurs in
the subdermis. Immediate ridging is common and should be
manually manipulated to smooth the contours.
Temple augmentation
Loss of fat from the temporal extension of the buccal fat pad
leads to a downward displacement of the lateral brow and col­
lapse and narrowing of the contours of the upper face. The
temple should be filled from an incision site in the ­superior
border of the temporal fossa near the temporal fusion line.
The cannula needs to dive deep in this area so fat can be
placed under or near to the temporalis muscle. A curved in­
filtration cannula such as the Amar #7 (Miller Medical) is a
good choice to facilitate even infiltration of fat (Fig. 20-13).
Injection volumes can approach 5 mL per side when using this
deep injection technique (Fig. 20-14).
intradermally due to the high risk of uneven fibrosis encoun­
tered with this method. The best technique for dispensing the
fat is for the operator to hold the 1 mL syringe in the domi­
nant hand while palpating the recipient tissues and guiding
the cannula tip under the skin with the nondominant hand.
The thenar eminence of the dominant hand is used to depress
the plunger on the syringe while moving the syringe through
the tissues (Fig. 20-11). The infiltration cannula may be left in
place, unscrewed from an empty syringe and reattached to a
full one for continued augmentation. Both the nondominant
hand and the hand infiltrating the fat are monitoring tissue
tension and gathering feedback on the state of fullness of the
recipient tissue. Every attempt to place fat in ‘virgin tunnels’
should be made. Tissues that feel loose or friable are indicative
of areas previously infiltrated and should be avoided. The box
below summarizes injection technique.
Forehead transplantation
The goal of forehead augmentation is to project the forehead
skin away from the calvarium and form a continuous arc
from the hairline to the upper lid crease. The direction of fat
­deposit should be vertical, preferably from the hairline down.
Multiple stab incisions should be made at the hairline with
either a #11 blade or a Nokor needle. Using a blunt ­infiltration
Fig. 20-11  Proper hand position for fat infiltration. (Photo property
of Lisa Donofrio, MD)
Fig. 20-12  Forehead infiltration. (Photo property of Lisa
Donofrio, MD)
Fig. 20-10  Blunt 18 g infiltration Donofrio® cannula (Byron, AZ,
USA). (Photo property of Lisa Donofrio, MD)
• Use only blunt 18–20  g cannulas to place the fat.
• Use only 1  mL syringes filled with fat.
• Place fat in all layers of subcutaneous tissue,
starting close to bone where available.
• Take advantage of multiple incision sites to layer
and cross-hatch placement.
• Try to inject in only ‘virgin tunnels.’
• Inject in pearls of 0.1  mL or less.
• Inject threads in a retrograde manner.
Pearls

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Autologous fat transplantation  •  Chapter 20
incisions sites are preferable. One is made at a point in the
cheek midway between the midpupilary line and the lateral
canthus and used to fill the lateral half of the suborbital area
(Fig. 20-16). The other is made lateral and inferior to the nasal
alae and used for deep filling at the level of the orbital rim and
to access the inner half of the suborbital area (Fig. 20-17). Fat
should be placed under the orbicularis oculi muscle, anterior to
the orbital septum. Fat is placed in linear threads throughout
the suborbital area, maintaining a perpendicular alignment
to the lid margin, or in pearls deep to the suorbicularis occuli
fat pad following the curve of the orbital ridge inferior to the
arcus marginalis Care should be taken to place small amounts
of fat less than 0.05 mL via only blunt cannulas. Fingers of the
nondominant hand must protect the globe at all times. Plac­
ing fat in a horizontal direction from a lateral incision point
carries a high risk of textural irregularities and should be re­
served for only the most seasoned of fat transplant surgeons.
The ­correction of hypertrophic suborbital aging requires fill­
ing of the cheek to re-establish the cheek to eye continuum
and will be saved for discussion below.
Brow augmentation
Brow filling can take place via one of the entry sites made at
the hairline or from the area superior or lateral to the eye­
brow. From a superior infiltration site fat should be placed in
pearls or droplets starting at the marking for the supratarsal
crease and pulling the ‘tail’ of the drop superiorly towards
the brow. From a lateral incision the cannula can be threaded
the length of the brow and fat deposited as the cannula is
withdrawn. Care should be taken to fan the fat and stay in the
deep subcutaneous tissue when coming from a lateral incision
to avoid producing a tube of fat. The brow can take a total of
1–2 mL of fat and must be tapered to blend seamlessly with
the ­neighboring temple and forehead (Fig. 20-15).
Suborbital augmentation
The plan for augmentation of the suborbital area is dependent
on whether the patient displays the atrophic or the ­hypertrophic
pattern of suborbital aging. In the case of atrophic aging, two
Fig. 20-13  Amar #7 cannula (Miller Medical, USA). (Photo
­property of Lisa Donofrio, MD)
Fig. 20-14  Temple infiltration. (Photo property of Lisa Donofrio, MD)
Fig. 20-15  Brow infiltration. (Photo property of Lisa Donofrio, MD)
Fig. 20-16  Lateral suborbital infiltration. (Photo property of Lisa
Donofrio, MD)

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Chapter 20
Cosmetic surgery procedures and techniques
Malar augmentation
Filling of the central and lateral cheeks with autologous fat is
one of the most predictable and easily mastered rejuvenation
procedures. Dramatic changes are achievable by simply re­
storing the arc in profile to the midface. Volume in the central
face restores the ‘apple’ of the cheek and serves to anteriorly
advance the skin of the midface, causing a lifting effect to the
nasolabial fold and lower face. When correcting hypertrophic
suborbital aging, the central malar fat needs to be advanced
to the plane of the suborbital protuberant fat or even beyond.
In doing so, the suborbital fat visually recedes (see Fig. 20-3).
Starting at an incision lateral to the base of the nasolabial fold,
fat is placed diffusely in the subcutaneous tissue starting deep
to the zygomaticus major. Fanning and weaving linear strands,
the cannula is advanced anteriorly through the muscle, then
brought up into the indigenous subcutaneous fat (Fig. 20-18).
Once the cannula reaches the superficial subcutaneous plane
the medial half of the tear trough can be filled. Then from
either an incision inferior and lateral to the zygomatic arch
or at the most lateral part of the zygomatic arch fat can be
deposited parallel to the arch and perpendicular to the previ­
ously placed fat (Fig. 20-19). The most lateral part of the tear
trough can also be address from this incision. Lastly, a concave
buccal hollow can be restored to its youthful convexity by
either one of the above incisions or one inferior to the buccal
fat pad. It is very common to place 7–15 mL in the areas of
the central, lateral and buccal cheek to re-establish anterior
projection and convexity of the midface.
Perioral augmentation
Chronologic aging leads to both fat and mucosal atrophy and
bony reabsorption in the perioral area. The resultant collapse,
shriveling, and lengthening of the upper lip is a hallmark
change of the senescent face. Fat replacement serves to push
the cutaneous portion of the lip forward, visually shortening
it. It also interrupts the skin–muscle interaction attenuating
­vertical perioral rhytides. Both the cutaneous and mucosal por­
tions of the upper and lower lip are best reached by ­incisions
lateral to the nasolabial and labiomental crease, respectively.
The direction of infiltration is parallel to the border of the lip
when treating the prementum and diagonal when infiltrating
the mucosa (Fig. 20-20). Infiltration amounts of 1–2 mL of fat
per side, upper and lower, for a total of 4–8 mL in the entire
cutaneous perioral area is normally required. The mucosal
portion of the lip can be augmented with 1–2 mL per side,
indending to evert the lip by starting in the deep mucosa and
working superficially with repeated passes.
Nasolabial and labiomental crease augmentation
As discussed above, treatment of the nasolabial fold is ­often
achieved by anteriorly projecting the central cheek, thus
‘­suspending’ the fold. In addition, volumizing the cutaneous
portion of the upper lip resets the medial portion of the fold.
However, if additional augmentation into the fold is desired,
any of the previously made incision sites lateral to the fold
can be used to place fat perpendicularly across the fold and
are preferable to fat placement directly along the long axis
of the fold (Fig. 20-21). The same concept holds true for the
Fig. 20-17  Medial suborbital infiltration. (Photo property of Lisa
Donofrio, MD)
Fig. 20-18  Central malar augmentation. (Photo property of Lisa
Donofrio, MD)
Fig. 20-19  Lateral malar augmentation. (Photo property of Lisa
Donofrio, MD)

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Autologous fat transplantation  •  Chapter 20
platysma muscle. When the desired volume is achieved, it is
recommended to then approach through one or more parallel
incision to smooth out the area. Augmentation and advance­
ment of the chin and pre-jowl sulcus may be accomplished
through one of these anterior incisions (Fig. 20-24). Injection
of 1–2 mL of fat in the chin is usually sufficient. Due to the
tough fibrous tissue in this area, however, even placement can
be an oftentimes arduous task.
It is oftentimes necessary to carry the mandibular augmen­
tation to include the lateral third of the face. This is called
‘backfilling.’ Standing at the head of the patient, assess the
need for lateral face filling by evaluating atrophy anterior to
the ear. Usually, this area of atrophy is evident as a sharp de­
marcation along the line of the parotid fascia. Filling this area
imparts a balance to the three-dimensionality of the face and
serves to lift and pull the midface and jowls laterally. With an
incision a few centimeters anterior to the tragus, fat is placed
into the deep subcutaneous tissues to the most inferior part of
the lateral jawline (Fig. 20-25). Five or more millileters of fat
Fig. 20-22  Labiomental crease augmentation. (Photo property
of Lisa Donofrio, MD)
Fig. 20-23  Lateral mandibular augmentation. (Photo property
of Lisa Donofrio, MD)
­labiomental crease. Augmentation of the lateral cheek, jaw­
line, and buccal area often will redistribute the skin redun­
dancy that forms this fold. To directly fill this fold, approach it
from either an incision lateral or medial to it, being careful to
bridge the fold with linear strands of fat obscuring the inser­
tion of the retaining ligament in this area (Fig. 20-22). When
performing direct filling of either the nasolabial or labiomen­
tal crease, it is prudent to use restraint and place only 1–2 mL
of fat per side. The placement of large amounts of fat can
lead to an undesirable ‘simian’ look and should be avoided.
Jawline and lateral facial augmentation
As discussed above, a young mandible displays ‘rounded an­
gularity.’ To achieve this, 8–20 mL of fat are placed along and
inferioposterior to the mandibular border, thus ‘­wrapping’
the mandible in fat. Incision sites are perpendicular to the arc
of the jawline and the cannula is advanced under the man­
dible, depositing fat when withdrawn (Fig. 20-23). The level
of placement is superficial, at the level of insertion of the
Fig. 20-21  Nasolabial fold and prementum augmentation. (Photo
property of Lisa Donofrio, MD)
Fig. 20-20  Deep mucosal lip augmentation. (Photo property
of Lisa Donofrio, MD)

318
Chapter 20
Cosmetic surgery procedures and techniques
A
B
C
Fig. 20-26  (A) A 32-year-old female (B) age 37 after traditional central facial filling (C) age 40 after balancing the lateral face with ‘backfilling.’
(Photo property of Lisa Donofrio, MD)
can be infiltrated in this area with very little tissue ­distortion.
This is an area that patients rarely ask to have filled, but ­almost
always notice with appreciation (Fig. 20-26).
Postoperative clinical considerations
Following the extraction and injection of autologous fat, the
patient should immediately apply ice to the face and is in­
structed to continue application of ice for 20 minutes out of
each hour until retiring and again sporadically throughout the
next 2 days. All incision sites on the face and body are left un­
sutured. The ‘donor’ site where the fat was taken from should
be dressed with an absorbent pad and some type of compres­
sion applied, through the use of either a ­compression garment
or tight biking shorts. These dressings should stay in place for
the rest of the day and may be changed if soaked through
with draining tumescent fluid. Most patients will prefer some
type of compression of the donor site for the next 3 days
due to ­ discomfort in the area. Intramuscular ­ triamcinolone
may be given (40 mg) to attenuate postoperative swelling. Pa­
tients should be instructed to finish the course of antibiotics
as ­ prescribed. Incision sites on the face heal quickly, but if
open or oozing, patients should avoid contamination of the
sites with tap water. Swimming or immersion bathing is not
­permitted until all incision sites have healed. Due to a combi­
nation of the distorting effects of local anesthesia and the im­
mediate edema incurred through a blunt injection technique,
most patients will appear markedly distorted in their facial
contours for the first few days ­following a fat transfer. Over
the course of 2 weeks, as the edema and bruising subside, the
benefits of ­volume replacement can be seen and appreciated.
Fig. 20-24  Central mandibular and mental augmentation. (Photo
property of Lisa Donofrio, MD)
Fig. 20-25  Backfilling. (Photo property of Lisa Donofrio, MD)

319
Autologous fat transplantation  •  Chapter 20
Complications
The most common complications seen with fat transfer are
eccymosis, edema, and contour irregularities. Occasionally,
injection site scars, divots or discoloration, hemosiderin hy­
perpigmentation, subcutaneous fat cysts, infections, or over­
correction or undercorrection of an area may be encountered
(Box 20-5). Rarely, discreet lumps can be seen, especially in
the periorbital area. Box 20-6 highlights methods for treat­
ing bumps in this area. Even more rare, but nonetheless cited
in the literature, are vascular occlusive events such as skin
­necrosis, blindness, and stroke following fat injections.20–26 It
is unclear what causes this rare yet horrific side effect, but fol­
lowing the ‘safety pearls’ detailed in Box 20-7 should theo­
retically minimize factors necessary for a small-vessel vascular
occlusion and insure a safer procedure.
­Unfortunately for most, this appearance is short lived and
additional augmentation may be necessary to achieve a long-
lasting, final result. Postoperative patient instructions are
­detailed in Box 20-3.
Repeat fat transfer procedures
If the patient desires more augmentation, this can be per­
formed in a month’s time into the same areas previously
treated or to new areas altogether. If again using fresh fat,
then a new donor site should be chosen and the procedure
repeated according to the guidelines above. Another option is
to freeze fat extracted from the initial procedure to use when
needed. Autologous fat freezes quite nicely in a commercial
freezer in the original syringes used for extraction. It may be
placed directly into a freezer that is monitored and alarmed
to maintain a constant temperature of around −30°centi­
grade. Be sure to decant off the tumescent fluid infranate,
leave any triglycerides that may be present in the syringe and
use a cap that forms a tight Leur lock seal. Double bag the
filled syringes with patient’s name, date of birth, date of pro­
cedure, and social security number on the syringes and bags.
When the patient returns for a ‘touch-up’ visit, the fat-filled
syringe after verification should be rapidly thawed by plac­
ing inside an ­examination glove and having the patient place
in contact with his or her skin. The axillae are a preferred
area for warming the fat. Before injection, the fat should
again be transferred into 1 mL syringes, stopping short of the
triglyceride supranate if present. Frozen fat is an economic
and easy alternative to fresh fat re-harvesting, but meets with
much criticism from its skeptics that note the unlikelihood of
viability after the above method of freezing and thawing of
fat. However, those clinicians and patients who have used fro­
zen fat can often attest to its longevity of augmentation, and
emerging literature supports its use and potential for viability
(see Fig. 20-2).18,19 Current research is underway to perfect
a freezing technique that hopefully will appeal to even the
most ardent of skeptics. Box 20-4 details recommendations
for freezing.
Box 20-3  Patient postoperative instructions
• Apply ice for 20 minutes out of every hour until bedtime.
• Apply ice for 2 full days after procedure.
• For bruises, alternate ice with warm compresses, starting
on third day after procedure.
• Keep incision sites clean.
• Cover any open incision sites when washing.
• No immersion swimming or bathing until all incision sites
have healed.
• No swim goggles for 3 weeks after fat transfer.
• Take antibiotic as prescribed until course completed.
• Call office for fever, drainage, or redness at incision sites.
• Extreme pain is not normal following fat transfer and may
signify an early infection. Call immediately!
Box 20-4  Recommendations for freezing fat
• Leave triglycerides in syringe before freezing to act
as cryoprotectant.
• Double bag and triple identify tubes with name, date
of procedure, and social security number.
• Transfer identity sticker from syringe into patient chart
­before procedure.
• Have nurse verbally verify fat information with patient
and sign off on chart.
• Alarm and back up freezers.
• Maintain constant temperature of −20–30°centigrade.
• Rapidly thaw before using to minimize ice crystal
formation.
Box 20-5  The most common side effects encountered
following fat transfer
• Ecchymosis
• Edema
• Minor contour irregularities
• Postinflammatory hyperpigmentation
• Fat absorption
Box 20-6  Options for the treatment of periorbital lumps
­secondary to fat transfer (in the order in which they should
be executed)
• Time (wait 2 months before treating any lumps to account
for prolonged edema)
• ‘Push through’ lump with injection cannula to feather
and disperse into surrounding tissue
• Dilute triamcinolone injection (2–4 mg/mL) into lump (may
be attempted before or after above)
• Fill around bump with more fat to blend in
• Attempted suction of bump (rarely works)
• Surgical removal

320
Chapter 20
Cosmetic surgery procedures and techniques
Autologous fat is a safe, wonderful, predicatable filler. In
most cases when care and thought has been given to its cor­
rect placement, it is also an extremely long-lasting filler. Many
authors using a multilevel, standardized, microinjection tech­
nique have photographically documented long-term follow-up
and persistence of augmentation with fat (Fig. 20-27).27,28
The dynamic nature of autologous fat, its function of storing
and releasing lipid, its ability to undifferentiate and rediffer­
entiate along stem cell lines, and its sensitivity to a variety of
hormonal stimuli makes it a very difficult study subject. How­
ever, it is these very qualities that magnify its allure and lead to
natural, truly rejuvenating results.
REFERENCES
  1. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg
1997; 24(2):347–367.
  2. Donofrio LM. Structural lipoaugmentation: a pan-facial technique.
Dermatol Surg 2000; 26(12):1129–1134.
  3. Smith P, Adams WP Jr, Lipschitz AH, et al. Autologous human fat
grafting: effect of harvesting and preparation techniques on adipocyte
graft survival. Plast Reconstr Surg 2006; 117(6):1836–1844.
  4. Shiffman MA, Mirrafati S. Fat transfer techniques: the effect of harvest
and transfer methods on adipocyte viability and review of the literature.
Dermatol Surg 2001; 27(9):819–826.
  5. Shoshani O, Berger J, Fodor L, et al. The effect of lidocaine and
adrenaline on the viability of injected adipose tissue – an experimental
study in nude mice. J Drugs Dermatol 2005; 4(3):311–316.
  6. Moore JH Jr, Kolaczynski JW, Morales et al. Viability of fat obtained
by syringe suction lipectomy: effects of local anesthesia with lidocaine.
Aesthetic Plast Surg 1995; 19(4):335–339.
  7. von Heimburg D, Hemmrich K, Haydarlioglu S, et al. Comparison
of viable cell yield from excised versus aspirated adipose tissue. Cells
Tissues Organs 2004; 178(2):87–92.
  8. Nguyen A, Pasyk KA, Bouvier TN, et al. Comparative study of survival
of autologous adipose tissue taken and transplanted by different
techniques. Plast Reconstr Surg 1990; 85(3):378–386.
  9. Yamaguchi M, Matsumoto F, Bujo H, et al. Revascularization
determines volume retention and gene expression by fat grafts in mice.
Exp Biol Med (Maywood) 2005; 230(10):742–748.
10. Coleman WP 3rd, Lawrence N, Sherman RN, et al. Autologous
collagen? Lipocytic dermal augmentation. A histopathologic study.
J Dermatol Surg Oncol 1993; 19(11):1032–1040.
11. Tholpady SS, Aojanepong C, Llull R, et al. The cellular plasticity of
human adipocytes. Ann Plast Surg 2005; 54(6):651–656.
12. Sadick NS, Hudgins LC. Fatty acid analysis of transplanted adipose
tissue. Arch Dermatol 2001; 137(6):723–727.
13. Sommer B, Sattler G. Current concepts of fat graft survival: histology
of aspirated adipose tissue and review of the literature. Dermatol Surg
2000; 26(12):1159–1166.
14. Stashower M, Smith K, Williams J, et al. Stromal progenitor cells
present within liposuction and reduction abdominoplasty fat for
autologous transfer to aged skin. Dermatol Surg 1999; 25(12):
945–949.
15. Hudson DA, Lambert EV, Bloch CE. Site selection for
autotransplantation: some observations. Aesthet Plast Surg 1990;
14(3):195–197.
16. Lilleth H, Boberg J. The lipoprotein-lipase activity of adipose tissue
from different sites in obese women and relationship to cell size.
Int J Obesity 1978; 2(1):47–52.
Box 20-7  Safety pearls for fat transfer
• Use epinephrine in anesthetic solution to impart
vasoconstriction.
• Inject retrograde.
• Use blunt cannulas.
• Inject with low injection pressures by using only 1 mL
­syringes.
• Know your anatomy.
A
B
Fig. 20-27  A 55-year-old female (A) before and (B) 20 months after full-face fat transfer series. (Photo property of Lisa Donofrio, MD)

321
Autologous fat transplantation  •  Chapter 20
17. Burns CA, Ferris G, Feng C, et al. Decreasing the pain of local
anesthesia: a prospective, double-blind comparison of buffered,
premixed 1% lidocaine with epinephrine versus 1% lidocaine freshly
mixed with epinephrine. J Am Acad Dermatol 2006; 54(1):128–131.
18. Ullmann Y, Shoshani O, Fodor L, et al. Long-term fat preservation.
J Drugs Dermatol 2004; 3(3):266–269.
19. Bertossi D, Kharouf S, d’Agostino A, et al. Facial localized cosmetic
filling by multiple injections of fat stored at −30 degrees C. Techniques,
clinical follow-up of 99 patients and histological examination of 10
patients Ann Chir Plast Esthet 2000; 45(5):548–555. discussion
555–556.
20. Dreizen NG, Framm L. Sudden unilateral visual loss after autologous fat
injection into the glabellar area. Am J Opthamol 1989; 107:85–87.
21. Teimourian B. Blindness following fat injections. Plast Reconstr Surg
1988; 82:361.
22. Feinendegen DL, Baumgartner RW, Schroth G, et al. Middle cerebral
artery occlusion and ocular fat embolism after autologous fat injection in
the face. J Neurol 1988; 245:53–54.
23. Danesh-Meyer HV, Savino PJ, Sergott RC. Case reports and a small
case series; ocular and cerebral ischemia following facial injection of
autologous fat. Arch Opthamol 2001; 119:777–778.
24. Egido JA, Arroyo R, Marcos A, et al. Middle cerebral artery embolism
and unilateral visual loss after autologous fat injection into the glabellar
area. Stroke 1993; 24:615–616.
25. Lee DH, Yang HN, Kim JC, et al. Sudden unilateral visual loss and
brain infarction after autologous fat injection into the nasolabial groove.
Br J Opthamol 1996; 80:1026–1027.
26. Feinendegen DL, Baumgartner RW, Vaudens P, et al. Autologous fat
injections for soft tissue augmentation in the face; a safe procedure?
Aesthet Plast Surg 1998; 22:163–167.
27. Coleman SR. Long term survival of fat transplants: controlled
demonstrations. Aesthet Plast Surg 1995; 19:421–425.
28. Donofrio LM. Pan-facial volume restoration with fat. Dermatol Surg
2005; 31(11 Pt 2):1496–1505.

HISTORY AND SCIENCE
Background and history
Adipose tissue is deposited in human subcutaneous tissue
as an energy reservoir, and serves to provide the body with
temperature and vibratory insulation. It is deposited and
­reabsorbed as part of normal homeostasis, and its sites of
deposition are in large part genetically predetermined. Two
general body shapes are known to exist: gynecoid and android
(Fig. 21-1). The gynecoid body type is the usual female shape,
with fat preferentially deposited peripherally in locations such
as the thighs and hips. The male android body type tends to
deposit fat centrally in the intra-abdominal region. There are
certainly exceptions to both, as well as substantial crossover in
fat distribution patterns between men and women. However,
an individual may be near his or her ideal body weight, yet
still have disproportionate, localized adipose deposition. It is
for such a patient that liposuction is ideal.
Liposuction is the aesthetic removal of undesirable localized
collections of subcutaneous adipose tissue.1 The concept of li­
posuction was first introduced in Rome in 1976 by Georgio and
Arpard Fischer,2 and suction equipment was further developed
by Yves-Gerard Illouz in France.3 Early liposuction techniques
were ‘dry,’ relying on general anesthesia for pain control. This
early technique was plagued with complications due to extreme
fluid shifts, excessive blood losses necessitating transfusions, and
an extended recovery time. The American dermatologist Jeffrey
Klein introduced the super wet, or ‘tumescent’ technique for
liposuction in 1987.4 This technique of infiltrating large vol­
umes of dilute lidocaine and epinephrine obviated the need
for general anesthesia, virtually eliminated the need for blood
transfusions, and decreased patient recovery time.4–6
Safety
The evolution of liposuction over the past decade has been
driven by the desire to increase safety and allow the procedure
to be performed in an outpatient setting. Klein’s work in devel­
oping the anesthesia system for liposuction has been invaluable
to the practicing liposuction surgeon. It is now possible to treat
larger surface areas of the body under purely local anesthesia
with liposuction. This has dramatically decreased the compli­
cation rate for liposuction, and improved aesthetic outcomes.
Surgeons are able to use extremely small cannulas, some less
than half the size of those used with the original dry technique.
The use of small cannulas, in a subcutaneous compartment
that has been expanded with fluid, gives the surgeon the ideal
platform on which to perform his or her work. The tumescent
technique allows the procedure to be performed by a wide ar­
ray of surgeons, and it has obtained an enviable safety record.
Data from the American Society of Dermatologic Surgery
(ASDS) tumescent liposuction survey published in 1995 dem­
onstrated the high safety profile for this procedure.7 Of the
15 336 patients treated, no deaths, blood transfusions or
­hospital admissions were reported. Recently reported adverse
Tumescent Liposuction
Carolyn I. Jacob and
Michael S. Kaminer
C h a p t e r
21
P a r t 2
Key Points
n The safety of pure tumescent anesthesia liposuction
is unquestionable when published guidelines are
adhered to.
n The smart hand technique and ­triangulation
in ­treated areas can improve efficacy and
­predictability.
n Postoperative compression is essential to ­prevent
postoperative irregular contours and seroma
­formation.

324
Chapter 21
Cosmetic surgery procedures and techniques
outcomes in the New England Journal of Medicine were reported
to be due to lidocaine toxicity, but careful inspection of the
data suggests that is likely to be an erroneous conclusion.8 In
2002, a national survey reported no deaths in 66 570 liposuc­
tion procedures performed by dermasurgeons between 1994
and 2000. The overall rate of serious adverse events (SAE) was
0.68 per 1000 cases. The SAE rates were higher for hospitals
and ambulatory surgery centers than for non-accredited ­office
settings.9 A second study, performed by the Accreditation
Association for Ambulatory Health Care Institute for Quality
Improvement examined 688 cases from 39 organizations, and
found a major complication rate of 0.14%, with one patient
requiring hospitalization.10 In 2005, Coldiron et al. examined
4 years of Florida data and found no adverse events with the
use of tumescent anesthesia alone in liposuction.11
Ultrasonic liposuction, both internal and external, has
­recently been developed and hailed by some to be superior to
the standard tumescent technique. However, experience has
shown that although ultrasound can be a useful adjunct to
tumescent liposuction, it has not replaced it as the treatment
of choice. The high cost of the ultrasound equipment, larger
incisions needed for internal ultrasound assisted liposuction
(UAL), and the steep learning curve have put UAL out of the
reach of many surgeons. For these reasons it will not be dis­
cussed further in this chapter. New machinery and techniques
are certain to evolve in time, but tumescent liposuction
­remains the standard for liposuction surgery
Basic science
Lidocaine toxicity is the most significant factor that limits the
amount of anesthesia used in tumescent liposuction. Tradi­
tional dosing of lidocaine with epinephrine for dermal or
local infusion is 7 mg/kg.12 Using the tumescent technique,
lidocaine doses of 35 mg/kg were shown to be safe and
­effective,13 and a second study has shown that dosages up to
55 mg/kg can be used with minimal risk of lidocaine toxicity.14
That same study also suggests that even higher doses of lido­
caine can be used, and some liposuction surgeons around the
country have safely used lidocaine in doses of 70–80 mg/kg
and higher. The very dilute nature of the lidocaine (0.05–
0.1%) in the tumescent solution, the slow rate of infiltration,
the relatively avascular subcutaneous fat compartment, the
vasoconstrictive effect of epinephrine, the high lipid solubil­
ity of lidocaine and its strong binding affinity to adipose tis­
sue, and the vascular compression due to tissue tumescence
all combine to delay systemic uptake of lidocaine.13,15–17 The
peak plasma concentration has been shown to be 8–12 hours
after infusion, and estimated by the following formula:14
Peak plasma lidocaine concentration ( g/ml)
= [dose(mg)/1000
µ
] 1.25
−
Lillis initially reported on the safe use of lidocaine doses of
60–90 mg/kg;5 however, this was based on plasma lidocaine
levels monitored over a 60-minute period. Ostad et al. have
shown in 60 patients that liposuction with a lidocaine dose of
55 mg/kg is safe, with no evidence of lidocaine toxicity over a
24-hour period.14 The peak plasma lidocaine concentrations
obtained from these patients was below 5 μg/ml, under the
threshold for when recognizable signs of lidocaine toxicity
develop.
Lidocaine is an amide anesthetic which blocks sodium
channels, thus inhibiting the propagation of the neural
impulse. It is rapidly and efficiently eliminated by hepatic
­metabolism via the cytochrome P450 enzyme CYP3A4.
Patients should be screened for concomitant use of medi­
cations which are known P450 CYP3A4 inhibitors, such as
erythromycin or ketoconazole.18 Lidocaine toxicity has been
reported in one patient taking sertraline hydrochloride (Zoloft)
and Flurazepam (Dalmane) who had liposuction performed
using 58 mg/kg tumescent lidocaine. At 10 hours, she had
clinical symptoms of nausea, vomiting, anxiety and impaired
short term memory with total blood plasma lidocaine concen­
tration of 6.3 μg/mL.18 Zoloft and other serotonin reuptake
inhibitors have been shown in vitro to inhibit the activity of
cytochrome P450 3A4 and 2D6.19 In general, some physicians
­recommend decreasing the lidocaine dose by 30–40% in
­patients concurrently taking medications which interfere with
the P450 complex18 (Appendix A). Whether this is actually
necessary in clinical practice has not been definitively deter­
mined.
The initial clinical manifestations of lidocaine toxicity are
perioral numbness or tingling (Table 21-1). As lidocaine levels
rise, the patient may develop slurred speech, tinnitus, become
somnolent or confused. At terminally high levels, the patient
may have cardiac collapse. Lidocaine suppresses the myocar­
dium at a cellular level, depressing diastolic depolarization
and automaticity in the ventricles.20
Fig. 21-1  Android (left) and gynecoid (right) body types. Pink
areas denote zones of adipose deposition.

325
Tumescent liposuction  •  Chapter 21
The advent of tumescent liposuction has eliminated the
need for intravenous fluid replacement during the proce­
dure, and substantial fluid shifts are not common with this
technique. Saline is used as the foundation for liposuction an­
esthesia, and when placed in the subcutaneous space is ab­
sorbed slowly into the microvasculature. This form of volume
replacement, known as hypodermoclysis, is the mechanism
for volume replacement during tumescent liposuction surgery.
Since the fluid is absorbed slowly over hours and not minutes
(as with intravenous fluids), it allows the patient to mobilize
and excrete fluids at a rate controlled by normal homeostatic
mechanisms. This allows for long-term hydration of the pa­
tient over the immediate postoperative period, yet virtually
eliminates the risk of fluid overload. However, the surgeon
must use caution when placing subcutaneous fluids during
liposuction. It is possible to use such high volumes of local
anesthesia (greater than 5–6 liters of fluid) that the patient is
at risk for volume overload, particularly patients with a history
of cardiac or renal disease.
Epinephrine has a threefold importance for tumescent
liposuction. It provides excellent hemostasis, slows the rate
of lidocaine absorption, and prolongs local analgesia. Unlike
lidocaine, there is no described limitation for epinephrine
dosing.21 For treatment of anaphylaxis, the recommended
therapeutic dose is 0.01 mg/kg body weight.22 When utilizing
the tumescent technique for liposuction, total epinephrine
doses as high as 10 mg have been used without adverse ef­
fects.21 Epinephrine toxicity is initially manifest by patient
anxiety, agitation, or palpitations. With increased levels, hy­
pertension, tachycardia, or arrhythmias may occur. A study
of 20 patients undergoing liposuction, monitored at 3, 12,
and 23 hours after tumescent fluid infiltration, demonstrated
the peak serum epinephrine levels to occur at 3 hours. Peak
levels were three to five times the upper limit of normal (nor­
mal resting values: 0–133 pg/mL; patients with pheochro­
mocytoma range 200–12 700 pg/mL).23 The majority had
returned to normal at 12 hours. The only reported side effect
was anxiety.21
Clinical studies
Liposuction is one of the most commonly performed aesthetic
surgical procedures.24 In the United States 33–40% of adult
women, and 20–24% of adult men are trying to loose weight.
Another 28% of each group is trying to maintain its weight.25
Whereas women cite appearance as more important than fit­
ness, the reverse is true for men.26 Women and men differ in
the areas most commonly treated (Box 21-1).
Discussion
Indications for liposuction published by the ASDS are cos­
metic body contouring, diseases involving the subcutaneous
tissue (lipomas, lipodystrophy, axillary hyperhidrosis), and re­
construction.1 Ideally, liposuction should be used in conjunc­
tion with an exercise program, and not as a substitution for
weight loss by diet control. Many patients pursue liposuction
for specific body locations which disturb them. For 87% of
female patients, their family history is a good predictor of
­localized adipose deposition which is resistant to diet and
­exercise.27 The physician should take the patient’s wishes into
consideration, as well as the overall proportions of the patient.
Not only is proportion important, but contour, flow, and sym­
metry of body lines are an essential part of liposuction plan­
ning. Patients with localized irregular contours or localized fat
deposits are superb candidates for liposuction and tend to do
quite well. The surgeon’s role is to identify those body areas
that can be contoured with liposuction to create an overall aes­
thetic and contour improvement. Due to these global consid­
erations, liposuction has been referred to as liposculpting. This is
one of the most challenging aspects of liposuction surgery.
For some patients, skin laxity, muscle flaccidity or location
of fat pads deeper than the subcutis (i.e. intra-abdominal) may
not make them good liposuction candidates. One judges skin
laxity by the ‘snap test’ (Fig. 21-2). To perform this test, the
surgeon pinches 1–3 cm of skin, retracts and releases. Ideally,
there should be instant recoil of the skin to its prior location.
Slow recoil or excess laxity may be an indicator that the
­patient will have redundant skin folds or surface irregularities
after liposuction. This needs to be explained to the patient,
and in some cases, a combination of procedures may enable
the patient to obtain results they are anticipating. For exam­
ple, abdominoplasty in addition to abdominal liposuction can
improve the final contour of the abdomen. However, risk and
Box 21-1  Most common areas of liposuction for men
and women27
Men
Women
Flanks/love handles
56%
Abdomen
55%
Abdomen
32%
Outer thighs
38%
Neck/jowls
11%
Hip/waist
10%
Breast
5%
Neck/jowls
3%
Table 21-1  Total plasma lidocaine levels and clinical signs and
­symptoms20
Total plasma lidocaine
level (μg/mL)
Clinical signs
and symptoms
<1.5
Idiosyncratic
1.5–4
Mild CNS
4–6
Mild CNS and cardiovascular
toxicity
6–8
Major CNS and cardiovascular
depression
>8
Seizures, hypotension,
­respiratory, and cardiac
­depression

326
Chapter 21
Cosmetic surgery procedures and techniques
morbidity are increased by the addition of abdominoplasty
to the surgical plan.28,29 For this reason, recognition of those
patients at risk for poor skin retraction is essential. Age is not
the sole predictor of skin retraction, and even adults over age
40 can achieve smooth postoperative contours.30 Locations
that are at particular risk for poor skin retraction (in the
­patient with poor skin tone) are the neck, upper arms, lower
abdomen, inner and outer thighs. We refer to patients with
less than optimal skin elasticity as having soft skin. This can
be recognized as the preoperative appearance of cellulite and
dimples on the outer thigh, ridges or folds on the abdomen,
hanging neck skin, or wrinkled inner thigh skin. Patients with
soft skin must be treated with caution, and they should be
counseled as to the expected outcome of surgery. Aggressive
suctioning in these patients can produce less than optimal re­
sults. However, even patients with good skin tone and elastic­
ity can experience poor skin retraction, most commonly on
the upper abdomen, distal anterior thighs, and the anterior
axillae. In these patients the addition of monopolar RF tissue
tightening (Thermage, Hayward, CA) at the time of surgery
can increase skin retraction by almost twofold (personal
­communication, R. Fitzpatrick, 2005).
Tumescent liposuction has evolved to be a very safe, repro­
ducible method for selective fat removal and body contouring.
A thorough understanding of the surgical concept, as well as
extensive training in the procedure, offer the surgeon a unique
opportunity to create aesthetically pleasing contours with fat
removal.
PROCEDURES AND TECHNIQUES
Preoperative clinical ­considerations
Through written information, informative video tapes, and
patient discussions, a physician strives to inform the patient
about the procedure of liposuction, including realistic goals,
expectations, and possible side effects and/or complica­
tions. Good surgical judgment must be used to determine
if the patient has realistic expectations and will participate
responsibly with pre- and postoperative care. As with other
cosmetic procedures, it is advisable to be wary of patients
who are over-anxious, demanding on staff, or the physician
thinks will only be satisfied if they obtain a perfect result. All
staff, from the front office receptionists to the nursing staff,
should be encouraged to inform the physician of any idio­
syncrasies which they may notice. Patients with suspected
eating disorders or body dysmorphism should be referred for
appropriate counseling.31
As with any procedure, liposuction requires the participa­
tion of both patient and physician. The initial patient inter­
view with careful history and physical examination should
prepare the patient and answer all of his/her questions. The
patient should be given information regarding what medica­
tions to avoid 2 weeks prior to the procedure (Appendix B),
and be given information regarding what to expect on the day
of the procedure. This helps to alleviate anxiety and minimize
confusion.
A thorough medical history is essential to evaluating undue
risk of bleeding, infection, emboli, thrombophlebitis, edema
and a history of past surgeries which may complicate the
technique.1 Not only should current medications and medica­
tion allergies be recorded, but also any history of hepatitis,
hepatotoxic chemotherapy, and use of birth control pills or
cytochrome P450 competitors. A complete skin examination
should be done, noting adipose distribution, quality of skin
tone and elasticity as previously mentioned (i.e. snap test). All
treatment sites should be evaluated for pre-existing hernias,
varicosities, scars, asymmetry, or other findings. Due to the
forces of gravity, evaluation should be done with the patient
standing. Some physicians also examine the patient sitting,
and in the supine position with the hip flexed.
Fig. 21-2  The ‘snap test’ to determine skin laxity. The top figure
represents the initial pinch of skin, and the surgeon observes recoil
as the skin is released (bottom figure).

327
Tumescent liposuction  •  Chapter 21
Laboratory studies are done to screen patients for general
health, bleeding disorders, and underlying disorders which
may affect the metabolism of medications used throughout the
procedure. Typical studies include liver function tests, hepatitis
profile, electrolytes, complete blood count, prothrombin time,
partial thromboplastin time, and pregnancy test for premeno­
pausal women. Other tests may include urinalysis, bleeding
time, or infectious disease studies such as for the human
­immunodeficiency virus.1
Pre- and postoperative care are truly part of the art of
­medicine, and vary with each physician. The results of the
1995 ASDS study of physicians performing liposuction showed
88% started antibiotics 1 day preoperatively, of which over
80% used a cephalosporin. Oral sedation was used by 53%
of physicians, including valium (diazepam) and ativan (lo­
razepam). Preoperative vitamins were recommended by 24%
of physicians participating in the study, most commonly vita­
mins C and K, as well as a multivitamin.27 To minimize local
bacterial flora, some physicians have the patient wash at home
with antibacterial soap (Hibiclens, Zeneca Pharmaceuticals,
Wilmington, DE) each of 3 days prior to the procedure.32
At present, there is no required certification to perform
­liposuction. It is solely dependent on the ethical standards of
physicians and medical communities to monitor the proce­
dure. One may read the literature, study instructional materi­
als, and attend practical or hands-on courses, but performing
the technique under the guidance of an experienced physi­
cian is invaluable. The nuances of the procedure, patient’s
emotional requirements, managing complications, and the
‘normal’ healing phases must be understood by the physician
prior to beginning a liposuction practice. Although the safety
record for tumescent liposuction is superb, it remains an in­
vasive surgical procedure. Physicians with good surgical skills
and fundamentals can master the basics of the procedure.
However, the art of tumescent anesthesia and cannula motion
for liposuction are not always intuitive and can be a challenge
to even the most skilled surgeon. For these reasons, preceptor
experience, such as a hands-on course or a surgical fellowship,
are essential to developing solid fundamental skills for liposuc­
tion surgery.
Procedural techniques
Prior to the procedure, laboratory examinations should be re­
viewed and confirmed, an informed operative consent signed
(Appendix C), and last-minute questions answered. The initi­
ation of preoperative antibiotics should be confirmed, as well
as the discontinuation of medications that can promote bleed­
ing (Appendix B). The patient’s weight should be obtained on
the day of surgery, and used both as a reference for postopera­
tive visits as well as to calculate maximum lidocaine dosage
for the procedure. If preoperative calculations are performed
by nursing staff or assistants, the surgeon should be certain
to verify calculations, including the conversion of pounds to
kilograms and the calculation of lidocaine dosage.
Although many doctors perform liposuction in office
­examination rooms, it is advisable to have a larger room
­(approximately 140 square feet or larger) in which to perform
liposuction. It should have good surgical lighting and an
­adjustable operating room table. Monitoring is not essential
for all cases, especially those without sedation and less than
1000 cc of aspirate. Oxygen saturation, blood pressure, and
pulse should be monitored intraoperatively for larger cases or
when sedation is used.
A set of preoperative photographs should be taken from
at least two angles of the area being treated. Whether these
are 35 mm, instant (Polaroid), or digital, they should be stored
for future reference. Some physicians have the photographs
available during the procedure for reference. Having the pho­
tographs available for comparison postoperatively is essential
when evaluating possible complications, or patient concerns.
For this reason it is important to be able to obtain reproducibly
good results with consistent distancing, focus and lighting.
Marking the areas to be treated is an interactive procedure
between the physician and patient. As mentioned above, the
patient has a desired outcome in mind, and the physician must
weigh this with the overall cosmetic appearance of the patient
as well as functional anatomy and treatment ‘danger zones.’
While the patient is alert, and utilizing standing, sitting, and/
or supine positions, the physician should clearly mark the
treatment areas. The physician needs to be able to clearly
mark areas to be aggressively treated, areas not to be treated,
and areas to be ‘feathered,’ or lightly treated. One may uti­
lize different colored marking pens, or one color with different
types of marks, as long as it is clear to the surgeon (Fig. 21-3).
We have found that a fine- to medium-point black Sharpie
(Sanford, Bellwood, IL) pen works well, does not come off
during the procedure, yet fades during the following few days.
Because the above relies on the patient being cognitively alert,
we wait to administer any preoperative sedation until after
everything has been confirmed with the patient.
The patient is prepped in a sterile manner with a surgical
scrub (betadine, Purdue Fredrick Co., Norwalk, CT or Hibi­
clens, Zeneca Pharmaceuticals, Wilmington, DE) to minimize
skin flora and risk of infection. Although cellulitis is rare, it
can be a devastating complication. Areas not to be treated
are covered with sterile drapes, exposing only the treatment
area(s). Some physicians consider liposuction a clean proce­
dure, and do not follow full sterile technique guidelines. The
authors prefer to use sterile technique. Many patients become
chilled during the procedure, so it is helpful to have a table
heating device in place under the patient (Gaymar hydrocol­
lator heating pad, George Tieman Co., New York, or the Bear
Hugger Warmer, Augustine Medical Inc., Minnesota), as well
as careful control of room temperature. Additional options for
keeping the patient warm during the procedure are stocking
caps to contain body heat and prevent loss through the scalp,
warm socks and the LipoSat infusion device (LaserPoint AG,
Nordkirchen, Germany) , which allows heating of the tumes­
cent solution to 37°C for patient comfort.

328
Chapter 21
Cosmetic surgery procedures and techniques
The equipment used for tumescent liposuction varies greatly
between practitioners depending on style, training, treatment
site, patient factors, and desired aggressiveness of liposuc­
tion. Common items are an infusion mechanism and can­
nula for infusion of the tumescent anesthetic solution, ­suction
­apparatus, and suction cannulas of specified ­diameters and tip
designs. Some cannulas are coated with zirconium nitride or
polytetrafluoroethylene to enhance slickness and reduce resist­
ance. Tip shapes vary and include blunt, bullet, spatula, and
‘V’ shapes. V-shaped cannulas such as the Toledo V or Byron
closed neck dissector are primarily used to gently break apart
fibrous bands. Standard cannula lengths range 10–35 cm. The
length of the cannula should be sufficient to effectively cover
the entire area to be treated. This is necessary to ensure proper
feathering of edges, and allow for complete triangulation of
the treated area (Box 21-2; Table 21-2; Fig. 21-4).
Cannulas may be purchased with or without handles.
Those without handles use either standard luer lock, or ­deluxe
luer-lock tip bases to fasten them to the handles. A recent
study evaluated the variety of cannula handles available, test­
ing them for ergonomic ease. Fatigue and potential repetitive
stress on the hand and arm of the surgeon can be reduced
by using appropriate cannula handles. The human hand has
the ability to grip in two natural anatomic planes, forming the
biplanar grip. The first plane allows a grip around a cylinder,
and the second allows a trapping effect around the cylinder
(known as the trapping plane). The most ergonomic was found
to be the biplane handle, whose construction allows a full
two-plane grip with a trap of the two planes allowing a more
­relaxed grip (Fig. 21-5).33
Fig. 21-3  Preoperative markings of the female hips and buttocks.
Note lines of flow and markings to guide the surgeon intraoperatively.
Box 21-2  Cannulas
Aggressive – large diameter, numerous holes, holes
placed toward tip of cannula
Keel Cobra
3–3.7mm
Capistrano
10–12 gauge
Mercedes
10–12 gauge
Pinto
10–12 gauge
Toledo
10–12 gauge
Intermediate – medium ­diameter, distal holes oriented
away from dermis
Accelerator/Triport
3 mm
3-Port Radial or Standard
3 mm
Pyramid
3 mm
Klein (dual port)
12 gauge
Capistrano
14 gauge
Keel Cobra
2.5 mm
Texas
2.5 mm
Dual Port Standard
2.5 mm
Fournier
2.5 mm
Sattler
2 mm
Least aggressive – small ­diameter, ­distal holes
­oriented away from dermis
Capistrano
16 gauge
Klein (dual port)
14–16 gauge
Spatula
2–3 mm
1-Hole Standard
2 mm
Table 21-2  Gauge–millimeter equivalents for liposuction cannulas
Gauge
Equivalent
8
4.2 mm
10
3.4 mm
12
2.8 mm
14
2.2 mm

329
Tumescent liposuction  •  Chapter 21
In addition, many powered cannulas have come into use to
facilitate the back and forth movement of the cannula (Fig. 21-6).
This reciprocating motion allows easier movement through
subcutaneous tissue when compared to manual techniques in
some surgeon’s hands. Katz et al. found reduced intraopera­
tive pain, procedure time, and surgeon fatigue when compar­
ing the powered cannulas versus standard cannulas.34 Other
surgeons find the vibration of the cannula to be a distraction
to the sensation felt by the smart hand, and find operative time
to be increased when using powered cannulas.
More recently, the role of laser assisted liposuction has
begun to evolve. A long-pulsed 1064 nm laser (SmartLipo,
Cynosure, Westford, MA) is the energy source, and is ­delivered
through fiberoptic tubing inserted into a 1 mm cannula. The
laser procedure can be performed either immediately before
or after traditional tumescent liposuction. The role of the laser
is being evaluated, but it is thought to aide in the break-up and
rupture of adipocytes, facilitating fat removal, and making it
easier for the surgeon to remove unwanted fat. In addition,
the laser energy is thought to heat collagen fibers, thereby cre­
ating a skin-tightening effect similar to some of the noninva­
sive tissue tightening technologies currently in use. However,
this tissue tightening occurs much deeper (in the fat) than with
many of the available noninvasive technology. There is some
thought that this technology may also help to improve the
­appearance of skin overlying areas that are treated with lipo­
suction, including potentially the improvement in cellulite.
Many aspirators are available for use (Box 21-3). Factors
influencing choice include types of compatible tubing, noise
made by the machine, reliability, and size. It is interesting to
note that suction pumps tend to work more efficiently at sea
level than at higher altitudes (personal observation, 1999), pre­
sumably due to differences in atmospheric pressure. Suction
cannulas vary in length, diameter, tip style, and orifice place­
ment. All of these components factor into the aggressiveness of
the suction cannula. More aggressive cannulas are wider in
­diameter, shorter, have an open or pointed tip rather than blunt
tip, and have more and larger orifices for aspiration. Nearly
all cannulas are designed to be used with the suction holes
directed away from the underside of the dermis (Fig. 21-7).
Fig. 21-4  Cannula varieties.
Fig. 21-5  Cannula handles. The one furthest right has the most
ergonomic biplanar hold.

330
Chapter 21
Cosmetic surgery procedures and techniques
The tumescent technique is a method of delivering large
volumes of dilute lidocaine with epinephrine in buffered
­saline via subcutaneous infiltration to achieve adequate local
anesthesia and assist with hemostasis (Fig. 21-8).4 Table 21-3
lists the standard preparations.
Epinephrine, without the addition of sodium ­bicarbonate,
will make the tumescent solution acidic, which may cause
burning with infusion. Also, lidocaine action may be more effi­
cient when it is in solution near its pK (pK of lidocaine = 7.7).5
Tumescent solution is also buffered because sodium bicarbonate
added to lidocaine in vitro augmented the bacteriocidal activity
of lidocaine.35 Lidocaine has been shown to be bacteriocidal
for organisms isolated from the skin.36 Concentrations greater
than 0.5% lidocaine provide a dose-dependent inhibition of
bacterial growth, Gram-negative greater than Gram-positive
organisms.37 In dilutions of 0.05%, lidocaine is bacteriostatic
for Staphylococcus aureus.38 In in vitro studies using suspensions
of bacteria (105 cfu/mL), all Gram-positive organisms, includ­
ing Staphylococcus aureus, had significantly lower colony counts in
0.05% lidocaine.39 When tumescent anesthesia is used, infec­
tion is a rare complication.40
The higher concentration of lidocaine (0.1%) is used for
more sensitive areas, such as the abdomen, lateral thighs,
knees, inner thighs, periumbilical area, neck, flanks, and
back14,41 Some physicians choose to only utilize the 0.05%
lidocaine formula for liposuction to decrease total lidocaine
dosage and enable them to treat larger surface areas. However,
0.05% lidocaine is not as efficient at producing anesthesia as
the 0.1% concentration. Therefore, an increase in sedation is
often required when using 0.05% lidocaine for local liposuc­
tion anesthesia. Another option is to use the 0.075% solution
which retains much of the anesthetic activity of the 0.1%
­solution but with 25% less lidocaine, allowing larger areas to
be treated in one session. The 1:1 000 000 concentration of
epinephrine is more commonly used, but some surgeons have
used concentrations as low as 1:2 000 000 epinephrine with
good results.
A
C
B
Fig. 21-6  Powered cannula varieties. (A) Byron ARC cannula (Byron Medical Tuscon, AZ). (B) MicroAire PAL (MicroAire Surgical Instruments,
Charlottesville, VA). (C) VibraSat (LaserPoint AG, Nordkirchen Germany).
Box 21-3  Commonly used infusion and aspiration pumps
Wells Johnson Single or Dual Infusion Pump (Wells Johnson,
Tuscon, AZ)
HK Infusion pump (HK Surgical, San Juan Capistrano, CA)
Hercules aspirator (Wells Johnson, Tuscon, AZ)
Reliance aspirator (Bernsco, Hauppauge, NY)
Byron Psi-Tec III (Byron Medical, Tuscon, AZ)
LipoSat (LaserPoint AG, Nordkirchen, Germany)
Titan (Miller Medical, Mesa, AZ)
Infusion cannula
Fig. 21-7  The sprinkler-tip tumescent anesthesia infusion cannula.

331
Tumescent liposuction  •  Chapter 21
A double-blind, randomized crossover study demonstrated
warming of local anesthetic solution for tumescent liposuction
significantly reduces pain on infusion as perceived by the pa­
tient.42 A randomized, double-blind, prospective trial of adult
volunteers serving as their own controls showed that warmed,
buffered lidocaine was significantly less painful to infuse than
plain lidocaine, buffered lidocaine, or warmed lidocaine.43
There are many ways to deliver the tumescent anesthesia.
Peristaltic mechanical pumps are able to deliver up to 5–6
­liters of fluid in 15–20 minutes. However, a rate of less than
100 cc/minute is commonly used (a setting of 2–3 on the Klein
Pump).6 Roller pumps, spring return syringes, and pressurized
infusion bags can also be used. Tumescent anesthesia fluid is
delivered by blunt-tipped, 6–12 inch, small diameter cannulas
(12–14-gauge) (see Fig. 21-7). These are less traumatic than
conventional sharp-tipped needles and preserve the neuro­
vascular structures.44 They also minimize risk for penetrating
deeper structures. In skilled hands, 18–20-gauge spinal nee­
dles can also be used for infusion. Appropriate incision sites
should be planned to account for the length of the liposuction
cannula to be used, to provide adequate access to all treatment
areas, and to facilitate draining of the tumescent fluid during
the postoperative period. The surgeon can maximize the use
of anatomic landmarks during this phase of the procedure,
such as hiding an incision adjacent to the umbilicus.
Using a fine-gauge needle with a small-caliber syringe, each
cannula incision site should be anesthetized. Some physicians
use buffered 1% lidocaine with epinephrine, but we prefer to
use the same solution as that which will be used to provide tu­
mescent anesthesia. An approximately 3–4 mm incision with
a #11 blade serves as a cannula insertion site.6 Insert the #11
blade only partially and at an angle to avoid trauma to deeper
tissues. A 1.5–2 mm punch biopsy tool is an alternative, which
may have the advantage of remaining patent longer than tra­
ditional incision sites to facilitate drainage. However, the au­
thors have not found this to be necessary. The blunt-tipped
small-diameter infusion cannula is inserted, attached to either
the peristaltic motorized pump, pressurized infusion bag, or
other delivery system. As discussed earlier, the infusion rate
may vary and is titrated to the comfort of the patient, most
commonly less than 100 cc/min.
The rate of infusion can be increased proportionate to the
amount of pre-medication given.41 Varying combinations of
sedatives and analgesics are given (Box 21-4); however, each
patient will respond to and metabolize medication at vary­
ing rates. Therefore, dosages and choice of medications used
should be titrated to each patient individually.
It is best to criss-cross paths of anesthetizing both hori­
zontally and vertically within the depth of the adipose tissue
to ensure complete anesthesia. Caution should be used so as
to not create excess friction on the incision sites, as this can
impair healing. The infusion cannula is moved slowly within
the subcutaneous space to thoroughly anesthetize each region.
Areas closer to the infusion incision are anesthetized first to
allow the cannula to move comfortably to distal regions. The
anesthetic fluid also serves to hydrodissect the tissue, creat­
ing a plane for the cannula to move in.6 Trying to change
directions, or angling the cannula while in mid-stoke should
be avoided. A change in cannula direction during its motion
can cause tenting or dimpling of the overlying skin. This can
be particularly problematic during the suctioning phase and
produce contour irregularities.
Fig. 21-8  Infusion of subcutaneous tumescent anesthesia.
The pink color represents anesthetic fluid hydrodissecting
and ­expanding the adipose compartment.
Table 21-3  Tumescent anesthetic solution
Strength
0.1%
0.075%
0.05%
2% lidocaine
50 cc
37.5 cc
25 cc
0.9% normal saline
1 L
1 L
1 L
Epinephrine 1:1000
1 mg
1 mg
1 mg
Sodium bicarbonate
8.45%
12.5 mL
12.5 mL
12.5 mL
Triamcinolone
10 mg/cc
1 cc
1 cc
1 cc
Box 21-4  Commonly used sedatives and analgesics41
Diazepam (5–15 mg p.o.)
Lorazepam (1–2 mg p.o.)
Triaxzolam (Halcion: 0.25 mg p.o.)
Hydroxyzine hydrochloride (Vistaril 25–50 mg i.v. or i.m.)
Midazolam hydrochloride (Versed: 2.5–5 mg i.v. or i.m.)
Promethazine hydrochloide (Phenergan: 25 mg i.v. or i.m.)
Meperidine hydrochloide (Demerol: 50–75 mg i.v. or i.m.)

332
Chapter 21
Cosmetic surgery procedures and techniques
The end point for infusion is reached when the tissue
­becomes firm to hard, and indurated (Fig. 21-9). For both
infusing tumescent anesthesia fluid and suctioning, one hand
moves the cannula, and the other serves as a ‘smart hand’ to
guide and feel the cannula position. This usually nondomi­
nant hand lies on the skin and palpates, constantly assess­
ing the movement of the cannula, depth in the tissue, and
degree of tissue induration. The end point for infusion can
also be assessed by blanching as a result of vasoconstriction.
The amount of tumescent anesthesia fluid infiltrated will
depend on the anatomic location (Table 21-4). The surgeon
must be cautioned that there is no absolute rule as to how
much anesthesia is required to fully treat an area. Factors
that can affect volumes of infiltration include body weight
and the amount of fat in a particular anatomic area, and
the amounts listed in Table 21-4 represent averages based on
the authors’ experience. Clearly, certain patients will require
more or less local anesthesia depending on individual
­anatomic variation.
Infusion patterns for men and women are different. Adipose
tissue in women tends to lie in the mid- to deep subcutaneous
space, and therefore anesthetic solution should be directed to
these locations. Men tend to have fibrous subdermal fat that
requires aggressive suctioning to remove adipose, as well as
mid-subcutaneous space adipose tissue (Fig. 21-10). For this
reason, it is essential to add tumescent anesthetic solution to
the subdermal fat in sensitive areas for men (breasts, abdo­
men, love handles), in addition to anesthetizing the mid- and
deeper subcutaneous compartments.
The ideal time delay between tumescent infusion and lipo­
suction varies from patient to patient, and from location to
location. Approximately 15 minutes is needed to establish
adequate vasoconstriction.41 A good indicator of the appro­
priate time delay is the visible blanching that occurs in the
tumesced sites.44 However, a minimum of 30–45 minutes is
required to establish the profound anesthesia that is essential
for performing adequate and careful suctioning. The areas an­
esthetized should extend beyond the border of the intended
liposuction sites to prevent tenderness at the periphery, and
allow for feathering.
The concept of liposculpture is evolving as physicians
treat not just one cosmetic unit, but adjacent cosmetic units
(Box 21-5), blending the treatment sites to result in a more
natural symmetry of proportions. Preoperative markings
help the surgeon to delineate areas to be treated, with an
improvement in the overall aesthetic appearance as the goal
of surgery. However, it is the intraoperative technique that ul­
timately determines the final result. The surgeon must pinch,
feel, inspect, move, and contour the subcutaneous tissue in a
manner that will produce an improved skin contour. As lipo­
suction surgeons, we rely on the skin’s remarkable ability to
contract and drape over the underlying soft tissue. It is im­
perative to keep the patient’s unique physical characteristics
and skin type in mind while suctioning. Skin that has poor
elasticity will not re-contour as well as skin with good tone,
and this is part of the art of liposuction/liposculpture. The
surgeon factors in all of these issues to determine just how
much fat to remove, and from which areas, to produce the
final result.
Fig. 21-9  Determining the end point for tumescent anesthesia
infiltration. Prior to infusion (top) the skin is soft, but when infusion
is complete (bottom) the skin is firm and resists downward pressure.
Table 21-4  Approximate volume of anesthesia used according
to body site
Site
Volume (liters)
Neck
0.4
Arms
1.0 per side
Upper abdomen
0.75
Lower abdomen
1.0
Hips
0.75 per side
Love handles
1.0 per side
Flanks
0.75 per side
Outer thighs
1.0 per side
Inner thighs
0.75 per side
Knees
0.5 per side
Calves & ankles
1.0 per side

333
Tumescent liposuction  •  Chapter 21
Body position during the procedure must be changed fre­
quently, including that of the physician as well as the patient.
The physician should use all sides of the operative table to ex­
amine and treat the patient, accessing areas from a minimum
of two directions, preferably three. We refer to this method
of suctioning as triangulation. Patient position should also be
changed during surgery if the physician needs to access the
fat. An advantage of tumescent liposuction surgery is that
the patient is awake and therefore able to follow commands.
The patient can be asked to change body position during the
procedure to make it easier for the surgeon to treat an area
of the body. The central premise is that the surgeon must be
certain to treat all marked areas in a manner that will yield
smooth contours. Asking the patient to change position on
the table is one part of the process.
The concept of triangulation is central to obtaining smooth
liposuction results (Fig. 21-11). The surgeon should think
of each unit area of fat as a compartment that needs to be
treated, and linking these areas will produce smooth contours.
Each unit area should be accessed and suctioned from three
directions (triangulated) in order to avoid producing ridges.
When an area is suctioned from one direction it is possible to
leave ridges, as small areas of fat between the cannula tunnels
remain. Suctioning from two directions helps to reduce this
risk, but the third vector dramatically reduces the appearance
and feel of residual fat and ridges.
The nondominant smart hand is one of the most important
elements of liposuction surgery. This hand is used to guide the
cannula, as well as assess cannula position and depth within
the fat, bring fat into the cannula path, stretch or stabilize skin,
and in general serve as the sensory input from the patient back
to the physician (Fig. 21-12). Visual clues are also extremely
helpful for liposuction contouring, but the smart hand is an
invaluable link between the surgeon and patient. A surgeon’s
mastery of the smart hand concept is likely to improve lipo­
suction results significantly.
With the use of tumescent anesthesia blood loss is minimal.
The physician should continuously be monitoring the aspirate
for quantity and quality of adipose (Fig. 21-13). If the amount
of blood increases in the aspirate at any time during the pro­
cedure, active suction of that area should be discontinued.
Klein has reported that approximately 12 cc of blood is lost
for each 1000 cc of fat that is aspirated using the tumescent
technique.45
Skin
Fascia
Muscle
Skin
Fascia
Fat
Fat
Fat
Fat
Muscle
Men
Women
Fig. 21-10  Relative location of fat in men and women (anterior
lower abdomen as example). Note relative size/proportion of fat
above and below superficial fascia in men and women.
Box 21-5  Liposuction cosmetic units
Neck, submental region, and jowls
Posterior upper arm
Posterior axillary line and upper back
Upper abdomen
Lower abdomen
Hip or love handles
Waistline and mid back
Outer thigh
Inner thigh extending to knee
Anterior thigh
Posterior thigh
Calve and ankle
Breast

334
Chapter 21
Cosmetic surgery procedures and techniques
Adequate tumescent anesthesia should make the procedure
nearly painless. The use of large cannulas initially takes ad­
vantage of the period of maximal anesthesia. Smaller cannu­
las cause less pain as they are advanced through the adipose
tissue and offer more options for fine-tuning and removing the
remaining adipose tissue (Fig. 21-14). Changing the angle, di­
rection, diameter of the cannula, altering the patient position,
or applying manual traction with the smart hand may allow
treatment of tender areas, avoiding the need to use further
anesthesia in an area.6
The structure and function of each body region necessi­
tates variations in the liposuction technique. Local anatomy,
the ­quality of adipose tissue (soft or fibrous), thickness of the
dermis, and skin elasticity all factor into the approach to a
­liposuction cosmetic unit. The following discussions focus on
the unique approach we take for different anatomic regions
(Box 21-6).
When adding laser assisted liposuction to the procedure,
the surgeon inserts the fiberoptic cannula and moves it in a to-
and-fro motion very similar to traditional liposuction. The la­
ser part of the procedure is performed under sterile technique
and the same general guidelines for technique and anesthesia
as tumescent liposuction. The goal of treatment is to feel that
the resistance the laser cannula meets diminishes with treat­
ment, which serves as an indicator that the fat to be treated
Fig. 21-11  Triangulation of liposuction cannulas.
Fig. 21-12  Use of the smart hand. The surgeon uses the non­
dominant hand (left in this photo) to palpate the skin and give tactile
feedback.
Fig. 21-13  Liposuction aspirate demonstrating nearly 1.5 liters
of fat without any significant bleeding.

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Tumescent liposuction  •  Chapter 21
has been adequately heated. The surgeon can also focus on
the subdermal region to theoretically heat that region and en­
hance skin contraction. In some areas (neck, jowls), surgeons
prefer to reduce the power settings on the machine to more
gently heat the fat and reduce risk of nerve injury. This is also
an area of investigation.
Liposuction of the neck and jowls
The neck and jowls are both a very difficult and very reward­
ing area to treat with liposuction. Traditional methods of
treatment for the aging neck
have primarily included face
and neck lifting procedures.
However, for selected patients,
­liposuction can be a definitive
treatment. The ideal patient
has good skin tone and elastic­
ity, moderate submental fat,
mild jowl formation, and a
high-set hyoid bone.
There are two basic physi­
cal findings of patients who are candidates for neck liposuc­
tion: aging and obesity. Patients with neck obesity often have
excess adipose tissue in other areas of the body, but many
are interested in treatment of the neck to define their facial
features for appearance ­enhancement. These patients often
do extremely well with liposuction, in part because many are
young (under age 45) with superb skin elasticity (Fig. 21-15).
Aging can be challenging to treat with neck liposuction, but is
perhaps the most common indication for therapy. These pa­
tients are often older (over age 40), have mild to moderate jowl
formation, fair to good skin tone and elasticity, and mild to
moderate submental fat. Rhytides will often improve follow­
ing careful and aggressive suctioning, and neck contours can
be greatly improved (Fig. 21-16).
Since liposuction is not a skin tightening procedure, patients
must be carefully evaluated. The patient is asked to clench the
teeth, which will tighten the platysma muscle and define fat
location. The surgeon pinches the submental skin between
thumb and forefinger to assess both quantity and location of
fat. Submental fat can be either pre- or post-platysmal. Pre-
platysmal fat can be suctioned through a small submental inci­
sion, but post- (or retro-) platysmal fat must be excised ­directly.
Asking the patient to place the tongue up against the hard
palate will also help the surgeon to identify fat location. The
surgeon should also release the skin as part of a snap test to
determine skin elasticity. If the skin feels loose and does not
recoil quickly, then liposuction alone is unlikely to provide
maximal benefit. For many patients, adjunctive tissue tighten­
ing can enhance results. For those patients seeking to avoid
a facelift, monopolar RF (Thermage, Hayward, CA) can be
useful when performed immediately before neck liposuction.
Skin tightening can be increased by almost twofold when lipo­
suction and RF are performed on the same day.
The clenched teeth test is also useful to evaluate platysma
location and banding. As patients age, some will develop
vertical subcutaneous bands that represent nondecussating
platysma muscle fibers. When identified preoperatively, the
surgeon can elect to repair the platysma muscle at the time of
liposuction through a submental incision. The surgeon should
also evaluate submandibular gland position. Many patients
Fig. 21-14  Orientation and placement of liposuction cannula
­tunnels. Smaller cannula diameters are often used to remove super­
ficial fat after deeper fat is suctioned with larger-diameter cannulas.
Box 21-6  Anatomic sites and liposuction aggressiveness46
Aggressive – 80–100% removed
Love handles
Back/flank
Male breast
Medial knee
Upper and lower abdomen
Moderate – 50–80% removed
Hips
Arms
Outer thighs
Buttock
Inner thighs
Calves/ankles
Neck
Jawline
Light – less than 50% removed
Mid inner thigh
Jowls
Anterior distal thigh and knee
Posterior knee

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Chapter 21
Cosmetic surgery procedures and techniques
have ptotic submandibular glands which appear as a subcu­
taneous fullness bilaterally along the inferior portion of the
mandibular ramus. This ptotic gland can appear to be jowls,
and it is important to identify this preoperatively. Patients
are told that submandibular gland position is unlikely to im­
prove with liposuction alone, and that may compromise final
results. Platysma repair as well as superficial musculoapo­
neurotic system (SMAS) plication can improve gland position
in some cases, but other surgical procedures are available to
­definitively correct submandibular gland ptosis. They will not
be discussed in this chapter.
The position of the hyoid bone is also an important determi­
nant of postoperative results. The hyoid bone is a central compo­
nent of neck architecture and musculature, and is an important
landmark when evaluating patients preoperatively. Patients
with a relatively low hyoid position will tend to have a less well-
defined cervicomental angle, whereas those with a high-set
­hyoid are able to obtain greater definition to the cervicomental
angle (Fig. 21-17).47 Although both groups are candidates for
neck liposuction, it is helpful to counsel patients preoperatively
as to the limits of liposuction if they have a low hyoid position.
The authors have found that platysma repair at the time of
A
B
Fig. 21-16  Female 51-year-old patient with
moderate adipose (A) before and (B) 6 months
after neck liposuction.
A
B
Fig. 21-15  Female 28-year-old
patient (A) before and (B) 6 months
after neck liposuction.

337
Tumescent liposuction  •  Chapter 21
liposuction can help to improve cervicomental angle formation in
patients with both low- and high-set hyoid position (Fig. 21-18).
For patients with poor skin tone and/or severe jowl and
rhytide formation, full or partial facelift procedures can be of
significant benefit.
Liposuction
The neck is marked with the patient in the sitting position
(Fig. 21-19). The anterior border of the sternocleidomastoid
muscle is defined and outlined, and markings continued in­
feriorly across the midline just above the sternal notch. The
submental crease is marked, as is the jawline. Care must be
taken to identify the jowl bilaterally as it will extend slightly
below the mandibular ramus. The superior extents of the jowl
should be marked as well. The extent of submental fat is then
identified and marked.
The neck is anesthetized through a 3–4 mm submental
incision using a short 6-inch sprinkler-tip infusion cannula.
Anesthesia is performed with 0.1% lidocaine tumescent so­
lution. Care must be taken to anesthetize beyond the skin
markings to provide a feather zone and margin for error
with cannula motion. The jowls and lateral neck are an­
esthetized with either the infusion cannula or a 20-gauge
spinal needle from a lateral jawline location. Caution must
be use when anesthetizing the jowl, since over-filling can
theoretically lead to intraoral airway occlusion. Anesthesia
is allowed to sit for a minimum of 30–45 minutes prior to
suctioning.
The patient is asked to hyperextend the neck to provide
optimal access. If the patient has difficulty with this maneu­
ver, the headrest of the bed should be dropped to facilitate
A
B
High
hyoid
bone
Low
hyoid
bone
Fig. 21-17  Hyoid bone position. Note the change/improvement in
cervicomental angle when the hyoid bone is relatively higher in position.
Fig. 21-18  Female 62-year-old patient
(A) before and (B) 6 months after neck
liposuction with platysma repair.

338
Chapter 21
Cosmetic surgery procedures and techniques
neck hyperextension. The submental region is suctioned first
with either a 12-gauge Klein or 3 mm Accelerator cannula
with the holes oriented away from the dermis. The submental
region should be machine suctioned thoroughly (Fig. 21-20).
However, it is recommended that a small amount of subder­
mal fat be left to prevent skeletonization of the neck. Caution
must be used when suctioning in the region of the marginal
mandibular branch of the facial nerve. It is most vulnerable
to injury below the ramus of the mandible when the neck
is ­hyperextended, as well as along the anterior third of the
jawline (Fig. 21-21). Suctioning in a superficial plane in these
regions is advised. Suctioning of the neck should not extend
beyond the medial border of the sternocleidomastoid muscle
to avoid injury to vascular structures.
The jowls and jawline are suctioned as a unit. Initial de­
bulking should be done through a lateral 3 mm incision placed
along the jawline. A 2 mm, 3-inch spatula-tipped cannula with
5 cc syringe suctioning is used (Fig. 21-22). Caution must be
used on the jowl and medial cheek, as over-aggressive suc­
tioning of the upper jowl can produce an unnatural dimple
appearance. The cannula should also be used to gently un­
dermine the medial jowl to reduce the appearance of labio­
mandibular tethering and rhytides. The inferior jowl, jawline,
and lateral neck are then aggressively suctioned with the 2 mm
spatula-tipped cannula on machine suction. Caution must be
used to stay in the superficial fat to avoid nerve injury. The
Fig. 21-19  Preoperative markings for neck liposuction.
Fig. 21-20  Machine suctioning of submental region. Note
surgeon’s left hand identifying and protecting the marginal
mandibular nerve.
Fig. 21-21  Danger zones (shaded pink boxes) for potential injury
to the marginal mandibular branch of the facial nerve (pink line).
Fig. 21-22  The 2 mm, 3 inch spatula-tipped cannula.

339
Tumescent liposuction  •  Chapter 21
cannula orifice can be oriented both towards and away from
the dermis. Particular attention should be paid to the medial
fibrous fat which is located just inferior to the ramus of the
mandible along the medial jowl. Failure to adequately suction
this area can produce an unnatural bulge.
After suctioning has been completed, submental fibrous
bands can be released. We have found that this may reduce
the appearance of puckering of the neck postoperatively, but
with the addition of monopolar RF preoperatively, this has
become less useful. Submental fibrous bands can be released
under direct vision if additional surgery is to be performed
(such as platysma repair), or can be eliminated with a closed
neck dissector (Byron, Tucson, AZ) (Fig. 21-23). This instru­
ment has a sharp V-shaped notch at its distal tip which is
gently advanced in the superficial fat to catch and cut fibrous
bands (Fig. 21-24).Caution should be used to avoid aggressive
treatment and increased bleeding. The closed neck dissector
should not be used to treat the lateral neck or jawline as this
may increase the risk of permanent marginal mandibular
nerve injury (Fig. 21-25). The marginal mandibular nerve
function should be assessed before, during and after the pro­
cedure by having the patient grimace to show the lower teeth,
pucker, or protrude the lower lip.
Fig. 21-23  The closed neck dissector. Note V-shaped notch at tip.
Fig. 21-24  Superficial dissection of fibrous bands of the neck with
the closed neck dissector.
Fig. 21-25  Lateral borders of area to be treated with closed neck
dissector. Superior edge of dissection is marked in black at approxi­
mately 45-degree angles from the submental incision, extending to
sternocleidomastoid bilaterally.

340
Chapter 21
Cosmetic surgery procedures and techniques
• Determine hyoid bone placement and presence
of submandibular ptosis.
• Add monopolar RF to enhance skin tightening.
• Ensure patients wear postoperative garments
appropriately.
Pearls
Fig. 21-26  Platysma plication. Note initial running suture (pink)
from superior to inferior, with continuation of the running suture in an
oversewn plication from inferior to superior. Suture is tied on itself at
superior end.
Fig. 21-27  Final appearance of platysma plication. Central two
layer plication produces majority of tightening. Bilteral oblique
­plication sutures augment platysma tightening as well as help to
suspend and elevate submandibular glands.
Platysma repair
Repair of the platysma muscle can be performed through a
submental incision when platysmal bands are present. Numer­
ous techniques can be utilized to eliminate platysmal bands,
but the authors have found this technique to be quick, reliable,
and reproducible.48,49 An approximately 3 cm elliptical incision
is made with a #15 blade encompassing the 3 mm stab wound
in the submental crease. The skin ellipse is excised, and the
submental region visualized. Hemostasis is obtained with elec­
trocautery. A headlamp is useful for this part of the procedure.
The medial borders of the platysmal bands are identified
with blunt dissection extending from the submental incision
inferior to the level of the thyroid cartilage. If subplatysmal
fat is present, it is removed under direct vision with electrosec­
tion or sharp dissection. The platysma is then plicated in the
midline using a running clear 4-0 nylon, PDS, or comparable
suture. The plication is performed in a superior to inferior
direction, with a buried superior knot. When plication reaches
the level of the thyroid cartilage, the repair is then turned in
a fold-over maneuver from inferior to superior (Fig. 21-26).
The surgeon should be certain to maintain constant tension
on the plication suture to ensure adequate platysmal tighten­
ing. The fold-over is performed by taking bites outside of the
initial plication seam (on either side of the seam) to imbri­
cate the platysma over the initial superior-to-inferior running
suture. The suture is continued superiorly to the initial bur­
ied knot and tied to the free strand of that knot. Additional
­plication sutures can be placed bilaterally in the region of the
submandibular glands to both tighten the platysma further as
well as elevate the ptotic submandibular gland (Fig. 21-27).
Hemostasis is obtained and confirmed, and the submental
wound closed with subcutaneous 5-0 vicryl (polygalactin 910,
Ethicon, Inc., Somerville, NJ) and 6-0 prolene (polypropylene,
Ethicon, Inc., Somerville, NJ) skin sutures.
Postoperative compression
A double-layer compression garment is placed postoperatively
to improve skin contraction and reduce postoperative bleed­
ing. Reston foam or French tape can also be applied under the
garments to further improve results. Adequate compression
along the jawline for a minimum of 7–10 days is essential to
obtaining adequate tissue adherence and contraction.
• Do not oversuction mid-cheek as this can lead to
hollowing.
• Beware of submental skin ridging.
• Over-aggressive suctioning of the submentum
can lead to bony prominence of hyoid cartilage.
Pitfalls

341
Tumescent liposuction  •  Chapter 21
Liposuction of the arms
Women with significant lipodystrophy of the proximal arm
often have to wear blouses 2–3
sizes larger than they might
otherwise need so that the
arms fit. For this reason, even
modest improvements result in
significant patient satisfaction
(Fig. 21-28). In our experi­
ence, it is a misconception that
liposuction of the upper arms
often results in postoperative
irregularities with poor skin
retraction.50–52 Liposuction of the arms is performed almost
exclusively on women, with the posterior and posterolateral
aspects of the arm involved more often than the anterior and
medial upper arms. On occasion, a localized fat deposit on
the ulnar side of the proximal forearm requires treatment as
well. Conservative but thorough fat extraction is obtainable
without undue trauma due to the soft quality of the fat in the
area. Avoiding trauma to the subdermis with correct cannula
choices, and minimal use of the smart hand will minimize
­irregularities.53 Skin of the upper arm has good potential for
significant skin contraction. Brachioplasty (arm lift) and the
resultant scar can produce such an unattractive and uncor­
rectable result that liposuction, and even a second liposuction
session, are often preferable alternatives. In some patients,
­radiofrequency skin tightening can be a useful adjunct to
­upper arm fat removal.
The patient is evaluated in a standing position with arms
extended horizontally with the thumb pointing up, or elbows
bent, to maximize the laxity of the posterior and postero­
lateral compartments. As with other sites, skin tone and tex­
ture must be evaluated. If skin tone is poor preoperatively,
the patient may still achieve significant skin contraction if
thorough fat removal is performed, but texture will often
not improve. For some patients, concurrent treatment of the
upper back and anterior/posterior axillary regions is per­
formed as well.
At least two incision sites are needed for infusion of 0.1%
tumescent anesthesia. For infiltration of the posterior and
­posterolateral arm, incision sites are just proximal to the ­
elbow and at the apex of the posterior axillary line. The soft,
loose tissue of the upper arms can often be infiltrated more
rapidly than other areas. The amount of total tumescent
anesthesia may vary greatly, with an expected range of 500–
1000 cc per arm.
Two to three incision sites across the mid-posterior up­
per arm are used for aspiration. For large-volume cases (over
400 cc removed), initial very cautious debulking may be done
with the 3 mm Accelerator cannula. In smaller-volume cases,
we find the 12-gauge Klein cannula is preferable. As previ­
ously mentioned, pinching, lifting, and downward pressure
from the smart hand is not necessary in this area, and may in­
crease the risk for subdermal fibrosis, adhesions, puckering and
indentations. The 3 mm Accelerator (Eliminator) or 12-gauge
Klein cannulas have a relatively nonaggressive tip and, with
their recessed openings placed away from the dermis, are ideal
for fat removal of the arms. Particular attention must be paid
to thoroughly treat the proximal upper arm and fat overlying
the medial epicondyle, as incomplete treatment of these areas
are the most common causes of patient dissatisfaction. An in­
cision site just distal to the fat overlying the medial epicondyle
provides access to that area as well as the more fibrous fat just
proximal to the elbow. This may be the only area of the up­
per arm which may need use of the smart hand to assist with
fat aspiration, due to the fibrous nature of this area. For final
assessment, the patient is instructed to hold her arms straight
up, occasionally exposing residual pockets of fat in the poste­
rolateral compartment.
In the rare case where the anterior upper arm needs treat­
ment, the 3 mm Accelerator (Eliminator) or 12-gauge Klein
A
B
Fig. 21-28  Female 34-year-old patient (A) before and (B) 6 months after arm liposuction.

342
Chapter 21
Cosmetic surgery procedures and techniques
cannula is preferred due to the thin dermis in this area.
Incision sites in the anterior axilla and just distal to the area of
fat to be removed are utilized. Postoperative pain of the arms
is minimal compared to other areas, and increases with poorly
fitting compression garments.
Liposuction of the trunk
It is useful to consider trunk anatomy and cosmetic contours
from two views: anterior and lateral. The lateral view will re­
veal contour irregularities of the upper and lower abdomen.
The anterior view will allow the surgeon to view the upper
waist and back, waist, and hips. Patients will often discuss ar­
eas of the trunk that bother them such as the lower abdomen,
but it is the responsibility of the surgeon to identify which
adjacent regions might benefit from suctioning. Also, the sur­
geon should consider whether any areas, if the patient were to
gain weight, might look unnatural juxtaposed with the treated
area. For these reasons, we have found that this anterior and
lateral classification is useful. Patients interested in lower ab­
dominal liposuction are evaluated for possible upper abdomi­
nal liposuction. Those patients interested in treatment of the
hips or waist are evaluated to determine whether treatment of
the entire lateral waistline unit is indicated.
The abdomen can thus be divided into cosmetic units, many
of which are interrelated. The upper and lower abdomen are
separate cosmetic units, but often treated together in one session
(Fig. 21-29). The hip is another cosmetic unit, and the waist/
mid-lower back (below the bra line) is a cosmetic unit as well.
• Choose young skin with good elasticity.
• Arms can be a good place for the inexperienced
liposuction surgeon to begin.
Pearls
A
B
Fig. 21-29  Female 39-year-old patient (A) before and (B) 6 months after upper and lower abdominal liposuction.
• Obvious skin laxity can lead to ridging.
• Seroma formation may occur if garments are not
properly worn.
Pitfalls

343
Tumescent liposuction  •  Chapter 21
A
B
C
D
Fig. 21-30  Female 43-year-old patient (A) before and (B) 6 months after upper and lower abdomen, hips, waist and back liposuction. Female
42-year-old patient (C) before and (D) 6 months after same procedure. Note retraction of pannus in both patients without the need for abdomi­
noplasty.
The hip and waist/mid-lower back are considered the lateral
area of the trunk, and these two cosmetic units are often treated
in one session. The upper back (above the bra line) is most often
treated in conjunction with the arms and posterior axilla, and
is not considered part of the abdomen/trunk cosmetic region.
The result is a total of four cosmetic units of the abdomen and
trunk. In some patients, treatment of all four cosmetic units in
one surgical session is indicated. This helps to maximally con­
tour the abdomen/trunk by removing adipose tissue in three
dimensions. In addition, postoperative healing and skin con­
traction along suction vectors provides maximal improvement
of the abdominal pannus and waistline (Fig. 21-30).

344
Chapter 21
Cosmetic surgery procedures and techniques
Upper and lower abdomen
Prior to suctioning, the patient must be evaluated for abdomi­
nal hernias and scars. Ventral
hernias including umbilical,
postsurgical, and Spigelian
(lateral rectus sheath) should
be ruled out through clinical
examination.
Preoperative
markings should reflect the
extent of suctioning, areas to
be suctioned, and localized
collections of adipose tissue
(Fig. 21-31). The lower abdo­
men, when suctioned alone, is often clearly demarcated and
easily outlined. When the lower and upper abdomen are to be
treated together, the extent of suctioning extends from under
the breasts to the suprapubic region.
Anesthesia is obtained through two incisions placed along the
suprapubic region, as well as from mid-abdominal sites along
the lateral aspect of the area to be treated. Anesthesia is placed
in the mid-subcutaneous space, and allowed to sit for a mini­
mum of 30 minutes prior to suctioning. Tumescent 0.075–0.1%
lidocaine anesthesia is used for the upper abdomen, especially
the areas over the costal margin. When possible, 0.1% lidocaine
should be used for the lower abdomen, but this area can be an­
esthetized with 0.075% lidocaine and suctioned effectively. The
cannula will often pass through and under older scars without
difficulty, but caution should be used with newer scars.
Suctioning is performed with the 3.7 mm swan-neck Keel
Cobra cannula for debulking larger patients. The 3 mm Accelerator
cannula can be used to debulk smaller patients. Triangulation of
areas is essential to produce smooth contours, as near 100% fat
removal is the goal of therapy. All too often surgeons leave too
much fat after suctioning, believing this will help ensure a smooth
result. However, patients are often disappointed if some fat is left.
It is the authors’ experience that removal of 90% or more of ab­
dominal region fat produces smooth results with excellent patient
satisfaction. The 12-gauge Klein cannula is used to feather treat­
ment sites and ensure maximal smooth fat removal.
It is essential to thoroughly suction the periumbilical region,
as well as the deep fat of the upper and lower abdomen. Many
patients will have well-defined adipose collections that lie on
the rectus sheath deep to Camper’s and Scarpa’s fascia, both
superior to the umbilicus and inferior/lateral to the umbilicus.
Suctioning of these areas is essential to producing a flat abdo­
men (Fig. 21-32). It is often necessary to lift the skin with the
smart hand and carefully advance the cannula into a deep
adipose plane to access this fat. Clearly, caution is needed to
prevent sub-rectus suctioning. We have found it helpful to use
short cannula strokes, and avoid any cannula motion lateral
to the rectus sheath when attempting this deep fat maneuver.
By avoiding cannula motion lateral to the rectus, it reduces
the chances of becoming sub-rectus with cannula position. It
is also imperative that cannula position be superficial when
crossing the costal margin to prevent injury in that location.
Fig. 21-31  Preoperative markings for abdominal liposuction. Note
use of flow lines and markings (large ‘X’ to denote areas of adipose
concentration) to aid surgeon intraoperatively.
• Whenever possible, include waist and flanks with
abdomen.
• Define extra- and intra-abdominal fat with patient
before starting procedure.
• Use smart hand to gently lift the lower layer of
adipose to provide thorough deep suctioning.
• Inform patient of possible early start of menses
after procedure.
• Warn patients of excessive fluid in mons or
testicular region on postoperative days 0–3.
Pearls
• Incomplete umbilical anesthesia will lead to
discomfort.
• Rarely, patients will develop skin mottling.
• Beware aggressiveness at midline of rectus sheath.
• Failure to remove enough fat can lead to patient
dissatisfaction.
Pitfalls

345
Tumescent liposuction  •  Chapter 21
Hips
The hips are either treated alone or in combination with the
­upper back and waistline. Some
women will also have the lateral
thighs treated in combination
with the hips to re-contour the
lateral silhouette (Fig. 21-33).
Correction of the double-bulge
of the hips and lateral thighs
can have a profound impact
on body shape. However, many
women will benefit from suc­
tioning of the hips alone. These
women typically have an athletic build, and have isolated hip
adipose deposits. Some will have mild outer thigh fullness, but
their athletic shape makes treatment of this area less necessary.
The hip is outlined bilaterally with the patient in the stand­
ing position. The inferior border of the area to be treated is
often easily recognized as a distinct junction between hip and
upper lateral thigh. This pseudo-groove should not be treated,
even when combining hip and lateral thigh liposuction, since
this can produce disfiguring depressions. The anterior and
posterior hip are also usually distinct, and the surgeon can
feel for the boundaries of the hip with the pinch technique.
Typically, the amount of fat one can pinch diminishes sub­
stantially as one moves away from the central area of hip
adipose tissue. The superior hip can have an indistinct border,
and it is for this reason that hip liposuction is often combined
with treatment of the waistline. When treating the hip alone,
it is important to feather suctioning up into the waistline.
Anesthesia is placed with 0.1 or 0.075% tumescent lido­
caine, and allowed to sit for 30 minutes. The right hip is anes­
thetized (and suctioned) with the patient lying on the left side,
and vice versa for the left hip. Initial debulking can be per­
formed with the 12-gauge Klein or 3 mm Accelerator cannu­
las. Final blending is done with the 12-gauge Klein cannula.
Triangulation is essential, and the goal of therapy is creation
of a smooth contour in harmony with the lateral thigh, but­
tock, and waistline. Sufficient fat is removed to achieve this
result, and can vary significantly. For most patients, 50–80%
fat removal from the hip is adequate. Occasionally, near 100%
fat removal is needed to obtain the desired contour.
Mid-lower back and waistline
Contouring of the waist can produce beautiful aesthetic results,
and a shapely waistline is one
of the things appreciated most
by patients after their lipo­
suction surgery. To adequately
contour the waistline, the sur­
geon must also treat the back
in the vicinity of the bra line.
For most patients, suctioning
of the hip at the same time is
Skin
Fascia
Muscle
A
B
Fig. 21-32  Removal of deep anterior lower abdomen fat. (A) Drawing illustrating location of fat on anterior lower abdomen both above and
below superficial fascia. (B) Smart hand maneuver to elevate skin and expose deep adipose compartment for suctioning.
• Suction hips along with outer thighs in women
with double-bulge ‘violin’ deformity.
Pearls

346
Chapter 21
Cosmetic surgery procedures and techniques
necessary to achieve optimal results. This allows the surgeon
to maximally contour the lateral abdomen, blending it into the
flank and ultimately the back. Volumetric reduction of fat in
three dimensions along the abdomen, flank, waistline, and back
is essential for creating substantial improvements in shape and
contour.
The patient is marked in the standing position, with vectors
of suctioning clearly marked (Fig. 21-34). It is important to
suction along intended vectors of skin retraction to promote
skin redraping postoperatively. The surgeon can pinch the
lower back fat to localize it, and this area is marked. Incisions
along the mid-waist, posterior mid-back, and under the lateral
breast are used for anesthesia and suctioning. Additional inci­
sions are placed as needed at the inferior zone of treatment
to promote triangulation and facilitate drainage. Anesthesia
is obtained with 0.075–0.1% lidocaine, and allowed to sit for
40–45 minutes. It is advisable to allow the tumescent solution
in this region to sit for slightly longer than other areas to pro­
vide maximal anesthesia. The waistline and mid-lower back
can be a particularly sensitive area to treat due to the very
fibrous nature of the fat. Some surgeons prefer to use external
ultrasound in this area (and other areas with fibrous fat) to
make fat removal easier, but the authors have found this to be
cumbersome and unnecessary.54,55
The goal of waistline and upper back suctioning is near
100% fat removal. Initial debulking is performed with either
the 3.7 mm Keel Cobra or 3 mm Accelerator cannula. The
surgeon must be certain to suction the very deep fat that lies
just superficial to the muscular fascia, similar to the technique
for the upper and lower abdomen deep fat. The smart hand
is sometimes used to lift the skin of the waistline to allow the
cannula to access the deeper fat. Final blending and contour­
ing can be done with a 12-gauge Klein cannula, but for many
patients the 3 mm Accelerator is adequate for this task. It must
be emphasized that triangulation and aggressive suctioning
are needed to fully contour the waistline. A few extra minutes
of attention to detail in this region can produce dramatic
­improvements in results.
Liposuction of the buttock
The buttock is a challenging area to suction, and is almost
exclusively done in women.
Many women are interested in
reducing the overall size of the
buttock, but often have diffi­
culty verbalizing exactly what
it is that bothers them. The
usual concern is size, but the
buttock has so many different
­contours, projecting in both
a lateral and posterior direc­
tion, that definition of treatment parameters can be difficult.
Therefore, it is buttock shape, symmetry and proportion that
• Be aggressive on waistline, especially in males
as the adipose tends to suspend from the thick
dermis.
• Evaluate hip size to determine if they need to be
suctioned along with the waist to prevent step-
off deformities.
Pearls
A
B
Fig. 21-33  Female 41-year-old patient
(A) before and (B) 6 months after hip
and outer thigh liposuction.

347
Tumescent liposuction  •  Chapter 21
should guide surgical judgment, and not absolute size. The
goal is to treat the buttock so that it fits in harmony with the
shape and silhouette of the patient. For these reasons, treat­
ment of the buttock is often combined with treatment of the
hips and lateral thighs, considering this to be an extended
­cosmetic liposuction unit. Preoperative markings are essential,
and serve as a roadmap and guide for the surgeon.
Caution must be used to avoid the inferomedial buttock
in the vicinity of the sciatic nerve, as well as the medial but­
tock near the gluteal cleft. In addition, suctioning and cannula
motion should never cross the inferior gluteal crease where
the buttock meets the upper posterior thigh. Suctioning of the
inferior buttock/upper thigh crease can disturb the fibrous
junction in that region and lead to an unnatural ptosis of the
buttock. Blending of the buttock with the lower back, hip, and
outer thigh can produce superb contours (Fig. 21-35). Over-
suctioning can produce a flattened buttock with irregular
­contours, which is not desirable.
After appropriate surgical markings have been made,
­anesthesia is achieved with 0.075–0.1% lidocaine tumescent
anesthesia bilaterally. The patient is often positioned in the
prone position for anesthesia, occasionally rocking gently
onto one hip to allow anesthesia of the contralateral ­buttock.
Incision sites should be placed in the lateral infragluteal
crease, the upper medial buttock and the upper lateral buttock
to ­promote triangulation. Anesthesia is placed predominantly
in the mid and deep fat of the buttock.
Anesthesia is allowed to sit for a minimum of 30 minutes
and suctioning begun. Caution must be used to remain in
the mid and deep fat of the buttock, avoiding superficial suc­
tioning. Treatment of the superficial fat can quickly lead to
contour irregularities in this very technique-sensitive region.
The main theme that should guide the surgeon is to retain the
contour and convexity of the buttock while decreasing size
and improving contours. Mid and deep fat liposuction are es­
sential tools for the physician. Initial gentle debulking can be
done with a 3 mm Accelerator cannula in most patients, while
larger patients can be treated with the more aggressive 3.0 or
3.7 mm Keel Cobra cannula. Following debulking, the mid fat
is contoured with a 12-gauge Klein cannula.
Final results will often depend on the ability of the surgeon
to blend the buttock with the hip, lower back, and lateral thigh.
The challenge of buttock liposuction is to judge the amount
of fat removal correctly, and to precisely contour the junc­
tion of the buttock with the hip and outer thigh. Actual per­
centages for fat removal are less important than the aesthetic
result, and this is judged through intraoperative surgical feel,
both visual and tactile (with the smart hand). In many cases,
measuring exactly how much fat has been removed from each
side can help the surgeon obtain symmetry.
Liposuction of the legs
Localized adipose deposits of the legs are particularly well
suited to liposuction surgery. Although some people (usually
women) have diffusely large legs with abundant adipose tis­
sue, many have well-shaped legs with discrete collections of
fat. It is for these women that liposuction is ideal. Thorough
Fig. 21-34  Preoperative markings for liposuction of the back and
waistline. Note use of markings to aide surgeon intraoperatively,
and suctioning vectors (three black lines on waistline) to contour
the waistline and produce retraction of the pannus and skin.
• Suction in the midplane only.
• Avoid over-suctioning with large cannulas.
• Measure milliliters of fat removal to ensure
symmetry.
Pearls
• Excessive removal can lead to a flat, unattractive
contour.
Pitfalls

348
Chapter 21
Cosmetic surgery procedures and techniques
contouring of these localized fat deposits can dramatically
change the shape and flow of leg lines. Clothing fits better,
and the patient usually feels much more comfortable with her
shape in general. As opposed to truncal obesity, many women
struggle with the shape of their thighs for years, even when
close to their ideal body weight. Genetics plays a significant
role in determining leg shape.
Women with generalized leg obesity can be improved
with liposuction surgery, but many have underlying bone and
muscle anatomy that will not support the appearance of a thin,
shapely leg. These women must be counseled preoperatively
that although liposuction can alter leg contours and perhaps
thin their legs, it is unlikely that they will convert from some­
one with an obese leg to one with a thin leg. Naturally, there
are exceptions to this rule, but we have found this to be true
in general. Also, there is a subset of women who have soft skin.
This term refers to women who have abundant cellulite in
the setting of a relatively obese leg. The limiting factor for
women with soft skin is that over-aggressive suctioning can
produce rapid and dramatic skin depressions. Caution and, if
anything, under-treatment are the rules for such patients.
It is useful to think of the leg as having discrete cosmetic lipo­
suction units. These include (1) ���������������������������������
the ������������������������������
outer thigh, (2) inner thigh
extending down to and including the knee, (3) anterior thigh,
(4) posterior thigh, and (5) the calves/ankles. With lidocaine
toxicity as the limiting factor, the surgeon must factor in anat­
omy, patient desires, and surgical reality in determining which
cosmetic units to treat. The outer thighs, inner thigh and knee
are commonly treated in one session together. Occasionally the
outer thigh is treated alone in the absence of other leg obesity,
but in many cases the outer thigh and hip are treated together.
Outer thighs
The goal of therapy is creating a flow of skin that allows the
outer leg to blend naturally
with the hip, buttock, and
trunk (Fig. 21-36). Suction­
ing of the outer thigh must be
approached with caution, as
taking too little fat will yield
a disappointed patient and
taking too much a disfigured
patient. The outer thigh is
a landmark area, one that is
used as a reference point by
those casually observing a woman’s shape to determine over­
all body type, thinness, and aesthetic contour. When the outer
thigh is large or unnatural in shape, it tends to stand out and
A
B
Fig. 21-35  Female 43-year-old patient (A) before and (B) 6 months after liposuction of the abdomen and buttocks.

349
Tumescent liposuction  •  Chapter 21
be noticeable to the eye. Therefore, improvement in outer
thigh contours can have a profound effect on body shape and
patient self-image (Fig. 21-37).
The patient is marked in the standing position (Fig. 21-38).
Anesthesia is obtained with 0.075 or 0.1% lidocaine and
allowed to sit for 30 minutes. Each leg is anesthetized and
treated with the patient lying on the contralateral thigh.
Three to four incisions are used, the most common in the
lateral aspect of the gluteal crease. The other incisions are
placed at 2, 8, and 10 o’clock around the typical oval drawn
to mark the outer thigh.
Initial debulking is performed with the 3 mm Accelerator
cannula in most individuals, but with the 12-gauge Klein in
thin women. The 12-gauge Klein is then used to suction more
superficially and to perform final blending and triangulation.
Although relatively superficial liposuction is performed, it is
advisable to leave a narrow zone of intact subdermal fat to
retain optimal contours.
Areas in which to be cautious include the upper lateral
thigh, distal lateral thigh, and Gasparotti’s point.56 The upper
lateral and distal lateral thigh are susceptible to over-suctioning
and ridging or dimpling, particularly around cannula insertion
A
B
A
B
Fig. 21-36  Female 40-year-old patient
(A) before and (B) 6 months after liposuction
of the outer thighs and hips.
Fig. 21-37  Female 35-year-old patient
(A) before and (B) 3 months after liposuction
of the outer thighs.

350
Chapter 21
Cosmetic surgery procedures and techniques
holes. It is important to move the cannula from one inser­
tion hole to the next with regularity to avoid over-suctioning
through one incision and creating a dimple under that incision.
Gasparotti’s point is just posterior to the greater ­trochanter,
and depressions in this location result from aggressive suc­
tioning of the deep fat (Fig. 21-39). Abduction and internal
rotation of the leg are useful to drop the greater trochanter
out of the surgical field, and thus protect against a Gasparotti
point depression (Fig. 21-40). Numerous devices are available,
including the triangular wedge pillow, that promote this leg
position and aid the surgeon (Wells Johnson, Tuscon, AZ).
The authors prefer to have an assistant abduct the leg.
The endpoint for outer thigh liposuction is subjective.
Contour and flow are the most important concerns, and the
smart hand pinch technique is invaluable. The surgeon pinches
other areas of the leg that appear to be well contoured, and
determines how many finger-widths (using the index finger) of
skin is contained in the pinch (Fig. 21-41). This becomes the set-
point of the leg, and is often 1 to 1.5 finger-widths. The goal of
outer thigh suctioning becomes bringing the outer thigh pinch
test to match that 1 to 1.5 finger-widths. But the surgeon must
use the pinch test in conjunction with visual and other tactile
clues to determine the optimal liposculpture ­endpoint.
Inner thighs and knees
For many women, the inner thigh region is a difficult place to lose
weight and improve contours.
Diet and exercise programs can
have some limited success, but
liposuction is a superb treat­
ment option for this anatomic
region (Fig. 21-42). When eval­
uating the inner thigh and knee,
the surgeon must determine
both the amount of fat removal
to be performed as well as the
extent of surface area to treat.
Specifically, a decision must be made to either treat the entire
inner thigh and knee region as one unit, or to treat the upper
inner thigh and/or knee as separate cosmetic units.
The difficulty with treating the inner thigh or knee as
distinct entities is that the risk of contour irregularities and
step-offs increases. Blending of the knee or inner thigh with
the mid thigh can be challenging, and the amount of fat that
Fig. 21-38  Preoperative markings for liposuction of the outer thigh.
Central circle with three ‘X’ marks is the area with the most adipose
tissue, and the outer circle denotes the feather zone.
• Abduct leg to prevent over-suctioning at
Gasparotti’s point.
• Triangulate and trust the smart hand pinch test.
Pearls
Greater
trochanter
Femur
Risk zone
for depression
Fig. 21-39  Gasparotti’s point. The area posterior to the greater
trochanter is a risk zone for liposuction-induced depressions and
soft tissue deformities.
• Soft skin and dimpling may not improve with
procedure.
• Beware suctioning under gluteal crease which
may lead to a ‘double banana’ roll.
Pitfalls

351
Tumescent liposuction  •  Chapter 21
A
B
Fig. 21-40  Indentation due to over-suctioning at Gasparotti’s point
A
B
Fig. 21-41  The pinch technique to evalu­
ate liposuction endpoints. (A) Diagram
illustrating use of the index finger as a
measuring device to determine amount
of remaining fat. (B) The pinch technique
showing very little remaining subcutaneous
fat on the lower abdomen (less than one
finger).

352
Chapter 21
Cosmetic surgery procedures and techniques
can be removed from these regions is limited if the surgeon
must prevent a line of demarcation at the junction with the
mid thigh. Suboptimal cosmetic results can be more frequent
when the mid thigh is not treated.
For these reasons, the authors have developed a preferred
method for treating the entire inner thigh and knee as one
cosmetic unit, extending from the inguinal crease down to the
superomedial calf. Very gentle suctioning of the mid thigh
region allows more thorough fat removal from the upper in­
ner thigh and knee, improves blending and feathering into the
mid thigh, and increases patient satisfaction by contouring
and debulking the entire medial upper leg.
The patient is marked in the standing position with the
knee fully extended, the leg advanced forward (a modified
lunge position), and externally rotated (Fig. 21-43). The fat
pads of the medial knee and upper inner thigh are identified
and delineated, as is the inguinal crease. Markings should in­
clude the proximal medial calf as treatment of this area helps
to define knee contours and improve the flow of skin lines.
The surgeon should be certain to mark and identify the pos­
terior knee and posterior upper thigh fat pockets, as failure to
treat these areas will lead to less than optimal postoperative
contours. Adequate contouring of these posterior adipose col­
lections is essential since these fibrous areas will dominate the
postoperative appearance if not removed. Also, reduction of
these compartments allows the remainder of the inner thigh
and knee skin to fall into position after suctioning rather than
being tented by these posterior fibrous adipose collections.
The anterior and posterior borders of the region to be treated
should also be marked, and are loosely used as feathering
guides into the anterior and posterior thigh. Careful feather­
ing is essential to maintain normal thigh contours and flow.
Anesthesia is obtained with 0.075–0.1% tumescent lido­
caine anesthesia through multiple incision sites. Incision
sites below the knee should be avoided since they often heal
less well than those above the knee. Thorough anesthesia of
the fibrous posterior knee and inner thigh regions is helpful
for improving patient comfort. Anesthesia should be placed
2–3 cm beyond the anterior and posterior markings to
allow for feathering. Anesthesia should sit for a minimum of
30 minutes prior to suctioning.
The knee is suctioned first, with the patient in the frog-leg
position and slightly rotated onto the side being treated. The
degree of convexity of the medial femoral condyle and the
tibial plateau may create a pseudolipodystrophy in an area
devoid of fat. Palpation upon physical examination will dif­
ferentiate the depth of the fat pad from the underlying bony
prominences. A 12-gauge Klein cannula is used to treat the
knee, with near complete fat removal as the goal. The sur­
geon should feather this treatment area into the proximal calf
and the mid thigh. It is useful to perform the feather maneu­
vers during the initial phases of suctioning, as this can allow
for more thorough and even fat removal from the knee and
upper inner thigh. Early feathering tends to improve the sur­
geon’s feel during the procedure, often eliminating the need to
‘chase’ a persistent ridge or depression. Treatment of the pos­
terior fibrous knee fat is performed with the 12-gauge Klein
cannula, but in some patients a more aggressive cannula such
as the 12- or 14-gauge Capistrano cannula is needed to debulk
this area.
The proximal inner thigh is initially gently debulked in
the deep fat with the Capistrano cannula. The 12-gauge
Capistrano is used for most patients, but thinner patients can
be debulked with the 14-gauge Capistrano cannula. Caution
A
B
Fig. 21-42  Female 28-year-old patient
(A) before and (B) 6 months after ­inner
thigh and knee liposuction. Note ­increased
space between thighs and knees. Patient
has also had outer thigh liposuction.

353
Tumescent liposuction  •  Chapter 21
is a must when using the Capistrano cannula in this region. Its
benefit is that it can quickly and thoroughly debulk the upper
inner thigh, including the very fibrous and resistant posterior
inner thigh fat. However, over-zealous or superficial use of this
cannula can produce persistent ridges and contour irregulari­
ties. The surgeon should limit the number of cannula strokes
performed from any single incision with the Capistrano can­
nula, so triangulation is essential with this instrument. The up­
per thigh is then fine-tuned with the 12-gauge Klein cannula,
with blending and feathering into the mid thigh. Fat removal
from the upper inner thigh should not be 100%, but more in
the 50–80% range. This is one area that flow and the surgeon’s
aesthetic sense are essential determinants of the end point of
treatment.
The mid thigh is the medial region located between the
upper inner thigh and the knee. It should be viewed as a con­
nector, essentially a bridge between the upper and lower in­
ner thigh region. For this reason, treatment of the mid thigh
helps the surgeon to blend and contour the inner leg. The
overall contour changes of the inner leg come from suction­
ing of the upper inner thigh and knee, but the mid thigh is
the glue that holds the cosmetic unit together. Suctioning of
the mid thigh should be performed gently in the mid fat with
a 12-gauge Klein cannula, taking only what comes very easily.
The endpoint of treatment is when the upper thigh and knee
blend smoothly with the mid thigh, as well as when the entire
inner thigh blends smoothly with the anterior and posterior
thigh. Caution should be exercised in the vicinity of Hunter’s
canal and the femoral artery, since aggressive suctioning in
this area can produce a very unnatural postoperative fullness
(lump) in the area. Final blending with the upper inner thigh,
posterior upper thigh, and knee is performed during the final
stages of mid thigh suctioning. The rule of thumb is that it is
better to remove too little rather than too much fat from the
mid thigh.
It is useful for the surgeon to think of the inner leg as an en­
tire cosmetic unit during the final stages of suctioning. Taking
a literal step back to view the flow and contours of this region
can help the surgeon see areas that require further treatment
and blending.
Postoperative compression of the upper inner thigh is espe­
cially important, and the surgeon should be certain to choose
garments that provide adequate support in this area. Some
garments have a cut-out in the groin area to facilitate toilet use,
but this opening can hinder compression of the upper thigh
and should be eliminated as soon as possible ­postoperatively.
Anterior and posterior thighs
The authors infrequently treat the anterior and posterior thighs.
The anterior thigh is occasion­
ally treated as an extension of
the knee, and in most cases in­
volves gentle suctioning of the
distal anterior thigh from two
incisions placed in the medial
and lateral suprapatellar re­
gions. The so-called banana roll
of the upper posterior thigh
is occasionally suctioned very
Fig. 21-43  Preoperative markings for inner thigh and knee lipo­
suction. Note the three zones to be treated: upper inner thigh, mid
thigh, and knee extending to superior calf.
• Avoid over-suctioning of mid thigh above
Hunter’s canal.
• Treat upper inner thigh and knee as one
cosmetic unit when possible.
• Feather early to avoid having to chase a ridge.
Pearls
• Avoid over-suctioning of inner mid thigh as this
may create irregular contours.
• Beware soft skin issue with possible accentua­
tion of inner thigh skin sagging.
Pitfalls

354
Chapter 21
Cosmetic surgery procedures and techniques
gently. Over-treatment of this
area can produce a very un­
natural ridging. Gentle mid to
superficial suctioning of the
fat can improve contours and
encourage skin tightening with
a good safety margin. The 12-
gauge Klein cannula is used
for both regions.
Calves and ankles
Lipodystrophy of the calves and ankles is often not dependent
on body weight, and is usu­
ally present from early ado­
lescence. Fatty deposits of the
calves and ankles often make
patients look much heavier
than they really are, but for­
tunately liposuction can help
in this area. With the use of
tumescent anesthesia, smaller
cannulas, and good postop­
erative compression, excessive
bruising, persistent swelling and irregularities frequently can
be minimized.57 The challenge of calf and ankle ­liposuction
is treating a small convex surface so that at the end of the
procedure the patient has an even smaller, natural appearing,
shapely convex lower leg. Patients with a history of deep
­venous thrombosis, hypercoagulable state, angina, past myo­
cardial infarction, or large varicose veins are not candidates
for liposuction of the calves and ankles.
The patient is marked in the standing position. It is often
useful to have the patient stand on a stool or low bench. The
anterior leg in the pretibial area is rarely treated due to the
almost universal absence of fat in this region. Tumescent
­anesthesia is obtained with 0.1% lidocaine and allowed to
sit for 30–45 minutes.
Suctioning is performed with small cannulas, usually a
12-gauge Klein or 3 mm spatula cannula. Incisions are kept to
a minimum (usually 4–8 per leg) since lower leg incisions often
do not heal as well as those placed in other areas. Areas to ­focus
on include the lateral and medial upper calf, as contouring
of this area will often substantially improve leg shape. Further
debulking of the posterior calf can reduce circumference and
provide additional contour improvements. Moderate liposuc­
tion around the ankle region can refine distal lower extremity
contours.
The goal of calf and ankle liposuction is gentle but thor­
ough fat removal. The surgeon must use caution so as to avoid
injury to the underside of the dermis, which can produce un­
natural ridging and become quite noticeable in this region.
Therefore it is advisable to treat the calf and ankle as one
cosmetic unit, leaving a small amount of subdermal fat while
enhancing contours through targeted suctioning of the areas
discussed above.
Postoperative compression garments and leg elevation are
essential following calf and ankle liposuction. Patients are
encouraged to ambulate and perform leg exercises to pre­
vent deep venous thrombosis (DVT). Despite the best efforts
of both patient and surgeon, postoperative lower leg edema
is to be expected and often will persist for many months.
Evaluation for DVT should be performed regularly during the
first 2 postoperative weeks, and necessary studies performed
when indicated. Postsurgical swelling resolves slowly and
­patient counseling can be invaluable during this time period.
Female breasts
Excessive breast tissue can be a physically impairing issue for
some women. Large, pendulous breasts can cause back pain,
shoulder pain (from tight bra straps), and can lead to poor
posture. For women with excessive breast size, or downward
placed nipples (nipple ptosis), mastopexy (cold steel breast re­
duction) is appropriate. Some women, however, have only 1–2
cup sizes over what they desire, and for them liposuction of
the breast may be appropriate. It can also be used for patients
who have asymmetrical breasts. Liposuction provides a quick,
virtually scarless alternative to the traditional breast reduction
procedure.
The most appropriate female candidates are those with
good skin tone, an anteriorly oriented nipple complex and
lack of nipple ptosis, and relatively fatty breast tissue with
the absence of a prominent glandular component. Younger
women tend to have more glandular tissue than older women
and are therefore less favorable candidates. The amount
of fat that can be removed via liposuction is less than that
achieved by excision; therefore, patients who expect consid­
erable reduction may not be good candidates. On average,
• Use small cannulas.
• Warn patients of prolonged leg edema.
Pearls
• Avoid over-suctioning on anterior thighs as this
may create irregular contours.
Pitfalls
• The three-dimensional nature of calf liposuction
can make smooth final results an elusive goal.
Pitfalls

355
Tumescent liposuction  •  Chapter 21
breast size can be reduced by 1–2 cup sizes with liposuc­
tion. Although liposuction of the breast can give a certain
amount of lift to the breast, it is not predictable and should
not be exaggerated when discussing results with the patient.
However, for some women, the amount of correction of
both nipple and breast ptosis can be significant. Ptosis of
the breast is measured as the shortest distance between the
inframammary crease and the lowest point of the breast
profile, and from the inframammary crease to the nipple
(Fig. 21-44). There is a relative contraindication for patients
who have a family history of breast cancer, and all women
should have pre- and 6-month postoperative mammograms
performed.58
After photographs have been taken, the patient’s breast size
may be measured via the water displacement method. A 4-liter
beaker is filled to the brim and the breast is immersed in the
beaker. The water that is displaced is caught in an underlying
bowl or pan and that water volume is measured. This should
be repeated twice on each breast to obtain precise measure­
ments (Fig. 21-45). Alternatively, a digital hand-held scale
can be used to measure breast weight. Preoperative markings
should be made with the patient in the upright position. It is
important to draw the contours to include the inframammary
crease as a landmark, and to include the anterolateral triangle
of tissue near the axillae if this area is to be treated in the
cosmetic unit (Fig. 21-46)��.�
The breast is anesthetized with 0.1% tumescent anesthesia
through small incisions placed inferolaterally, inferomedially,
and in the anterior axillary line. These same incisions are
used for the aspiration and heal imperceptibly. Twenty-gauge
needles can be used to deliver the anesthesia, or the standard
short sprinkler-tip infusion cannula can be used. It is impor­
tant to thoroughly anesthetize all levels of the breast tissue
(superficial, mid, and deep). Typically, the volume of anesthe­
sia required will be from 120–150% of the volume of the
breast measured by the water displacement test. On average
this requires 750–1250 cc per breast. After anesthesia is com­
plete, the aspiration begins in the mid layer of the breast. It
is important to use the smart hand to steady the breast tissue,
Fig. 21-44  Ptosis of the breasts is measured before breast reduc­
tion by liposuction (Courtesy of Habbema and Hanke).
Fig. 21-45  The volume of the breast is measured preoperatively
using water displacement (Courtesy of Habbema and Hanke).
Fig. 21-46  Preoperative markings indicate areas to be removed
during liposuction. The fat accumulation extends into the posterior
axillary line (Courtesy of Habbema and Hanke).

356
Chapter 21
Cosmetic surgery procedures and techniques
and allow for even planes of suctioning. After the mid layer
is suctioned in all four quadrants, it is important to address
both the superficial (cautiously) and deep levels. The central
and superficial tissue often has a glandular component and
therefore it may be difficult to remove sufficient fat from these
areas. Using a 12- or 14-gauge Capistrano cannula can help
to remove the glandular tissue. A stab incision on the upper
outer perimeter of the areola can be used to access the adipose
which is intertwined with the glandular tissue under the nip­
ple. Approximately 25–50% of the volume of breast weight
(based on the preop volume) should be removed. The better
the skin quality and breast position preoperatively, the more
aggressive the surgeon can be intraoperatively. After suction­
ing is complete, it is important to measure the amount of fat
removed from one breast to be consistent with volume reduc­
tion in the other breast.
Postoperatively, absorbent padding and a chest binding
garment are worn for 24 hours. The garment is then worn for
23 hours a day for 1 week. Thereafter, a supportive sports bra
can be worn 23 hours a day for 3 months. The average patient
will achieve a 1–2 cup size reduction.
Liposuction for men
The male breast and love handles are areas commonly treated
with liposuction. In some male patients, the upper and lower
abdomen will benefit from suctioning as well. The guid­
ing principle in men is that fat is much more fibrous than in
women, and therefore often requires more aggressive suc­
tioning to remove. In addition, male fat tends to hang off the
underside of the dermis in a more superficial location than
female fat. Men also have mid and deep adipose tissue, but
this superficial fat is often quite difficult to access without
substantial subdermal tissue trauma.
The advantage of treating men is that their skin/dermis
is often quite thick and resilient, responding quite well to
­aggressive treatment. The one exception is neck skin, which
does not retract and redrape as well as in the female. The
surgeon is often able to suction with the goal of near 100% fat
removal in men without producing unnatural ridges or sur­
face irregularities. Naturally, extreme care must be exercised
to produce optimal skin contour and flow, but male skin and
fat can, for the most part, be treated more aggressively than
in females.
Male breast
The male breast responds well to liposuction. A careful history,
screening for breast cancer in
the patient and close relatives
is essential. Some, but not
all, physicians also advocate
mammograms preoperatively.
Screening for fibrous subareo­
lar glandular tissue is also help­
ful, as patients with extensive
glandular tissue will often ben­
efit from sharp excision under
direct visualization. Marking is performed with the patient in
the standing position. Asking the patient to contract/flex the
A
B
Fig. 21-47  Female 48-year-old (A) before and (B) 6 months after liposuction of the breasts, demonstrating elevation of the breasts and
­reduction in ptosis (Courtesy of Habbema and Hanke).

357
Tumescent liposuction  •  Chapter 21
pectoral muscles often helps to delineate the extent of the area
to be treated. The superomedial breast area often requires
minimal suctioning, with most fat removed from the lateral, in­
fra- and subareolar breast regions. Some men will also benefit
from suctioning axillary and upper back adipose connections
to the breast area.
Anesthesia is obtained with 0.1% tumescent lidocaine an­
esthesia and allowed to sit for 30–45 minutes. Incisions should
be placed in concealed areas, such as the inframammary
crease and axillary folds. Initial suctioning is performed with
the 3 mm Accelerator cannula from multiple incision sites and
with careful triangulation. Thorough suctioning under the ar­
eola is important for enhanced contours, and more aggressive
or sharper cannulas are sometimes required (e.g. Pinto can­
nula). In our experience, injury to the nipple complex is rare
with liposuction alone. Final contouring is performed with
the 12-gauge Klein cannula. If glandular tissue persists under
the nipple after healing is complete, it can be removed under
direct visualization during a follow-up procedure, utilizing a
1–2-inch curvilinear infra-areolar incision. However, the need
for surgical excision of residual glandular tissue following li­
posuction is uncommon. Direct excision of glandular tissue at
the time of liposuction surgery is avoided since it can induce
necrosis of the nipple complex due to aggressive suctioning
and subdermal trauma to that area.
The optimal amount of breast fat to be removed is some­
times difficult to determine. In younger patients, more aggres­
sive treatment is often beneficial as the skin will redrape well.
Older patients tend to have less skin elasticity, and in these
patients thorough, smooth fat removal is indicated to produce
optimal skin retraction. Some patients will benefit from selec­
tive suctioning and liposculpting to enhance the definition of
chest contours and further define underlying pectoral mus­
cles. The male breast can also have a pseudocapsule, creating
a diffuse mound of tissue that tends to move as the cannula
­approaches it. Stabilization of this mound with the smart
hand is essential.
Postoperative compression is important, and obtained with
either a standard male breast liposuction garment or conven­
tional 9–12-inch abdominal binders.
Love handles and abdomen
Fat removal from the abdomen and love handles should be
thorough for men. Most male patients desire and benefit from
near 100% fat removal in these
areas. However, adipose tissue
in these areas is quite fibrous,
and aggressive suctioning is
indicated. Careful treatment
of the superficial fat compart­
ment is often essential in these
regions, as failure to remove
this tissue can lead to persist­
ent fullness.
The areas to be treated
are marked in the stand­
ing position. The love han­
dles can be treated alone, or
combined with treatment of
the upper and lower abdo­
men. Evaluation for hernias
is essential preoperatively (see
section on liposuction of the
female abdomen). Many men
have intra-abdominal fat that
causes a protuberant abdomen. It is essential to identify this
during the initial consultation and educate patients about the
location of their adipose tissue. Fat that is deep to the rectus
muscle cannot be treated with liposuction. Patients who have
fat superficial and deep to the rectus will often be disappointed
with their results if they are not counseled preoperatively as
to the limitations of treatment. The ideal patient has little to
no intra-abdominal fat and well-defined adipose collections
superficial to the rectus and oblique muscles (Fig. 21-48).
Anesthesia is obtained with 0.075–0.1% tumescent lidocaine
anesthesia. Allowing the anesthetic to sit for an additional 15–
20 minutes (45–50 total) is helpful in these very sensitive areas.
Multiple incision sites are used, hiding them in the suprapubic,
periumbilical, and hair-bearing regions when possible. Initial
suctioning can be performed with the 3.0 or 3.7 mm Keel
Cobra cannula in larger individuals, as well as 10–12-gauge
Capistrano cannulas. Caution must be used to prevent ridging
when using these aggressive instruments despite the fact that
men tend to have resilient skin. Further suctioning is performed
with the 3 mm Accelerator cannula, and superficial fat removed
with either the Accelerator or 12-gauge Klein cannula.
The abdomen is treated with the patient in the flat supine
­position. Caution should be used when crossing the costal mar­
gins. Each love handle is best treated with the patient lying on his
contralateral side. Very aggressive suctioning of the deep fat in
the love handles is essential for contouring. Many men have firm,
fibrous fat in the posterior love handle/lower back region, and
this can be a challenge to maximally debulk. Use of aggressive
cannulas such as the 10–12-gauge Capistrano can be useful.
Postoperative compression is obtained with 9- or 12-inch
elastic abdominal binders. Male patients are encouraged to
• Stabilize breast tissue to ensure suctioning
through pseudocapsulated adipose.
Pearls
• Over-suctioning can lead to nipple retraction and
scarring.
Pitfalls