Phẫu Thuật Da Liễu: Khía Cạnh Ngoại Khoa (Surgery of the Skin)

433
26
Botulinum Toxins
Doris M Hexsel MD and Camile L Hexsel MD
Summary box
 Botulinum toxin (BT) is a neurotoxin produced by Clostridium
botulinum, a Gram-positive anaerobic bacterium. It blocks
acetylcholine release after binding to the presynaptic
cholinergic receptors, thus preventing muscular contraction of
the affected muscles.
 BTs are commercially available typically in a lyophilized form,
and require reconstitution with 0.9% saline, preferably in low
volumes, prior to use.
 BT type A is a simple, safe, and highly effective drug widely
used for both cosmetic and therapeutic indications that has
revolutionized the treatment of the aging face.
 The main indications of BT in aesthetic medicine include the
treatment of facial dynamic wrinkles, platysmal bands, facial
asymmetry, and focal forms of hyperhidrosis.
 BT can be combined safely with a series of other invasive
and minimally invasive procedures, such as fillers and lasers,
optimizing the cosmetic results.
 The muscular effects of BT usually appear from 24 to 72 hours
after injection, reach a maximum level at around 2 weeks, and
last approximately from 4 to 6 months.
 BT is contraindicated when there is hypersensitivity to any
component of the formulations, neuromuscular diseases,
concomitant usage of some medications, pregnancy, and
breastfeeding.
 Complications are rare and usually technique dependent.
 INTRODUCTION
Botulinum toxin (BT) type A is a simple, safe, highly effec-
tive, and widely used therapeutic modality, which has revo-
lutionized the cosmetic treatment of the aging face in the last
decades. Acting through the transitory and reversible paraly-
sis of target muscles, BT is able to reduce wrinkles, change
the shape and position of important structures in the face
such as the eyebrows, and even delay or avoid the need for
invasive surgical interventions, for example treatment of gin-
gival smile. BT can be combined safely with a series of other
invasive and minimally invasive procedures such as fillers and
lasers, to optimize the cosmetic results. Moreover, BT is an
effective treatment for a significant number of diseases,
including forms of hyperhidrosis.
Neurotoxins
Neurotoxins are substances of endogenous or exogenous
origin that act in the nerve cells by interacting with mem-
brane proteins. Neurotoxicity is a phenomenon that occurs
when exposure to a natural or artificial toxic substance alters
the normal function by damaging the nervous system.1
The bacteria from the genus Clostridium are anaerobic
Gram-positive spore-forming bacilli, which secrete neurotox-
ins that may cause fatal consequences in humans, such as
botulism (Clostridium botulinum) and tetanus (Clostridium
tetani).1 Botulinum toxin is recognized as being the most
lethal toxin to man, followed by the tetanus toxin and the
diphtheria toxin, which is produced by Corynebacterium
diphtheriae that causes diphtheria.1
The botulinum and tetanus toxins have a similar chemical
structure and bind to the same receptor. However, they
affect different proteins in the synapse, and therefore have
different clinical effects. BT binds to the cholinergic recep-
tors blocking acetylcholine (ACh) release, preventing muscu-
lar contraction of the affected muscles.
Botulinum toxins
Botulism was first described in the mid-1800s, due to the
ingestion of contaminated sausage. Its etiologic agent,
Clostridium botulinum, was identified almost a century later
and, in 1949, the action mechanism of BT was discovered.
These discoveries led to the development of an injectable
medication, initially used as a therapeutic agent in research
in primates and later in humans.
Different species of Clostridium are responsible for the
production of 7 serotypes denominated A, B, C, D, E, F, and
G.2 The different serotypes have similar structure and func-
tion but differ in important aspects, such as their efficacy in
muscle paralysis, duration of effects, specific affinity to the
target, and location of the toxin complex in the chain of
amino acids.3 The manufacturing process, the species of bac-
teria used in the fermentation, the purification methods, and
the addition of inactive ingredients to the formulation are
factors that influence the characteristics, potency, and anti-
genicity of each product.4
Commercially available preparations
of botulinum toxins
Only BT-A and BT-B are available for commercial use and
are authorized for cosmetic and/or therapeutic uses in

434
Part 3  Aesthetic Surgical Procedures
chain within the cytosol, the turnover of the soluble N-ethyl-
maleimide-sensitive factor (NSF) attachment receptor
(SNARE), target proteins (SNAP-25/VAMP/Sintaxina), and
secondary biochemical events related to SNARE production
and/or peptide release.12
BT also inhibits sweat production by blocking ACh release
in the autonomous cholinergic fibers from sympathetic fibers
of the sweat glands.
Muscular repercussions in
the aging process
The facial aging process is a result of extrinsic and intrinsic
factors altering the skin surface and the facial contour due
to volumetric loss and remodeling. Facial wrinkles can be
classified as dynamic, static, or mixed. Dynamic wrinkles
are those caused or aggravated by muscular contraction.
Static wrinkles are apparent even if the facial muscles are
relaxed.
Aging causes alterations to the upper third of the face that
reflect the damage caused by ultraviolet rays, gravity, and,
to a significant extent, the activity of the muscles involved
in facial expression. Initially, the dynamic wrinkles on the
forehead appear perpendicular to the direction of the muscle
fibers, and become static over time. Wrinkles and ptosis
of the structures of the frontal region, mainly the eyelids
and eyebrows, are striking characteristics of aging. The glabel-
lar folds express negative feelings, such as anger, sadness,
tension, concern, disapproval, and/or tiredness.13,14 At first
they are dynamic wrinkles; as they worsen, they become
static with more evident cutaneous laxity and skin
redundancies.13
Within the mid-face, aging changes are due to remodeling
of the osseous and cartilaginous structures, loss of elasticity
and of subcutaneous tissue, resulting in loss of contouring
and the need of volume replacement, as well as muscle
relaxation.13
In the lower face, muscular hyperactivity and volumetric
losses of the mandibular region and adipose tissue contribute
to aging. Aging in this region is characterized by the horizon-
tal lip stretching, downward oral commissures, increase in the
distance between the columella and the vermilion border and
loss of lip thickness, perioral wrinkles, marionette lines, and
dimpled or peau d’orange chin.13
The main manifestations of neck aging are vertical bands of
the platysma muscle as well as horizontal wrinkles, deposits
of subcutaneous fat, and skin alterations related to photodam-
age. The bands are determined mainly by muscular hyperki-
netic activity and are treatable by BT-A. All clinical effects
of muscular hyperactivity, including asymmetries, can be
treated efficiently with BT.
In each individual, multiple factors influence aging in
various ways. For this reason, each patient requires a safe and
effective individual therapeutic plan that meets doctors’ and
patients’ expectations with safety, harmony, balance, and
naturalness of the appearance.
Short-, mid-, and long-term effects of
botulinum toxin injections
The muscular effects of BT usually appear from 24 to 72
hours after injection, reach a maximum level at around 2
weeks,14 and last approximately from 4 to 6 months,15,16 when
a new neuromuscular junction is formed allowing the return
humans, respectively. While serotype E has been used to a
limited extent, its role as a therapeutic agent requires further
clinical research.5
The most widely known type A BTs available internation-
ally are Botox/Vistabel (Allergan, Inc, Irvine, USA), Dysport/
Azzalure (Ipsen Ltd, Maidenhead, UK), Xeomin (Merz Phar-
maceuticals, Frankfurt, Germany) and Prosigne (Lanzhou
Institute of Biological Products, Lanzhou, China). Besides
these, PurTox (Mentor Corporation, Santa Barbara, USA) is
currently undergoing phase III clinical trials in the USA. Of
these, the most used commercial preparations of BT-A are
Botox/Vistabel and Dysport/Azzalure which will be referred
in this chapter to as Botox and Dysport/Azzalure, respec-
tively. Dysport is commercialized as Dysport 300U per vial
in the USA by Medicis and in Europe by Galderma as Azza-
lure 125U. The BTs-A and BTs-B (Neuroblock/Myobloc,
Elan Pharmaceuticals, San Francisco, USA) are compared in
Table 26.1.
BT-B was approved for the treatment of cervical dystonia.
While there are few published studies for cosmetic use of
BT-B, two important clinical findings are its use in patients
who are resistant to BT-A,6 and BT-B may have a slightly
faster action and extensive diffusion.7 The duration of BT-B
seems to be shorter than that of BT-A. In the treatment of
facial wrinkles, it lasts around 6–8 weeks with doses of 1000U
and 10–12 weeks with doses of 2000U.8 Moreover, BT-B has
also been shown to be safe and effective in the treatment of
hyperhidrosis (HH).9
Topically applied toxins may be available in the future. A
new topical BT-A (CosmeTox, DPM Therapeutics Corpora-
tion, Ancaster, Canada) and a proprietary, non-covalently
bound, transport peptide backbone (Revance Therapeutics,
Inc, Mountain View, USA) for topical application of BT
showed improvement in wrinkles in the upper third of
the face10 and as well as improvement in frontal HH,11
respectively.
Pharmacology and mechanism of action
Botulinum neurotoxins are formed by a simple polypeptide
chain with molecular weight of 150 kDa or 900 kDa, subdi-
vided into two chains, a heavy and a light chain, connected
by disulfide bonds. The heavy chain is specific for cholinergic
action and promotes the light chain translocation through the
endosomal membrane.5 In terms of their therapeutic effects,
BT-A and BT-B have the same mechanism of action, differing
in the cleavage of different cytoplasmic proteins, synapto-
somal-associated protein of 25 kDa (SNAP-25), and vesicle-
associated membrane protein (VAMP), respectively.8
The BT binds selectively and irreversibly to cholinergic
nerve terminals, mediated by its heavy chain.5 Next, the toxin
is internalized via endocytosis, mediated by the membrane
receptor. Once internalized, the light chain of the toxin mol-
ecule is released into the cytoplasm of the nerve terminal.
Once inside the cytoplasm, the BT light chain blocks the
release of ACh through the enzymatic cleavage of the specific
protein, either the SNAP-25 (BT-A) or the VAMP (BT-B).8
Through the blockage of ACh release, the nervous impulse
that causes the depolarization of the muscle membrane is also
blocked, preventing muscular contraction.
The different biochemical cellular events that serve as
the basis for the duration of effect of BT remain unknown.
However, contributing factors may be the lifetime of the light

435
Chapter 26  Botulinum Toxins
Table 26.1  Comparison of main commercial preparations of BTs
BOTOX
VISTABEL
DYSPORT
(THERAPEUTIC
USE)
DYSPORT
(COSMETIC USE)
AZZALURE
PROSIGNE
XEOMIN
NEUROBLOC/
MYOBLOC
Approvals
In over 75
countries
In 16
countries,
including
USA, Canada,
Italy, France
In over 70 countries,
including USA
In over 20 countries,
including USA and
outside Europe
Europe
China, North Korea,
Morocco, Philippines,
Indonesia, Brazil,
Peru, Ecuador, Chile,
Paraguay, Uruguay,
Venezuela, Thailand
and other countries
Germany,
Mexico and
Argentina
Launch in Brazil
is expected for
2010
Europe and USA
Active substance
BT-A complex
(925 kDa)
BT-A complex
(925 kDa)
BT-A complex
BT-A complex
BT-A complex
BT-A complex
BT-A neurotoxin
(150 kDa)
BT-B complex
(600 kDa)
Suggested
equivalences for
cosmetic uses
N/A
N/A
Between 1 : 2U and
1 : 2.5U
Between 1 : 2U and
1 : 2.5U
Approx. 1 : 2U or
1 : 2.5U
1 : 1
1 : 1
1 : 1000
Indications
Many, including
blepharospasm
and cervical
dystonia/
hyperhidrosis
Glabellar lines
Many, including
blepharospasm,
cervical dystonia,
cerebral palsy, post-
stroke spasticity and
focal dystonia
Glabellar lines
(USA), hyperkinetic
facial lines and
hyperhydrosis in
several countries
Glabellar lines
Blepharospasm,
strabismus, hemifacial
spasm and other
dystonias
Blepharospasm,
cervical dystonia
Cervical dystonia only
Mode of action –
target protein
SNAP-25
SNAP-25
SNAP-25
SNAP-25
SNAP-25
SNAP-25
SNAP-25
VAMP
Pharmaceutical
form
Lyophilized
powder for
solution for
injection
Lyophilized
powder for
solution for
injection
Lyophilized powder
for solution for
injection
Lyophilized powder
for solution for
injection
Lyophilized powder
for solution for
injection
Lyophilized powder for
solution for injection
Lyophilized
powder for
solution for
injection
Reconstituted solution
Number of units/vial
100
50
500
300 (USA) and 500 in
other countries
125 (Europe)
100
100
2500/5000/10 000
Reconstitution
0.9% NaCl
solution
0.9% NaCl
solution
0.9% NaCl solution
0.9% NaCl solution
0.9% NaCl solution
0.9% NaCl solution
0.9% NaCl
solution
Prepared solution,
dilutable
Storage
2–8°C
2–8°C
2–8°C
2–8°C
2–8°C
2–8°C
25°C
2–8°C, do not freeze
Shelf life (unopened)
36 months
36 months
24 months
24 months
24 months
36 months
36 months
24 months
Shelf life
reconstituted
Up to 24 h,
depending on
country
Up to 24 h,
depending on
country
4–8 h
4–8 h
4 h
4 h
Up to 24 h,
depending on
country
N/A
Auxiliary substances
Albumin 0.5 mg/
vial, NaCl 0.9 mg
Albumin
0.5 mg, NaCl
0.9 mg
Albumin 0.125 mg,
lactose 2.5 mg
Albumin 0.125 mg/
vial, lactose 2.5 mg
Albumin 0.125 mg,
lactose 2.5 mg
Gelatin 5 mg, dextran
25 mg, sucrose 25 mg
Albumin 1 mg,
sucrose 4.7 mg
Albumin, NaCl,
succinate, octanolate,
tryptophan
pH-Wert
5–7
5–7
5–7
5–7
5–7
5–7
5–7
5, 6
Toxin protein load
in dose-equivalence
range
5 ng/100U
2.5 ng/50U
5 ng/500U
5 ng/300U
5 ng/125U
4–5 ng/100U
0.6 ng/100 U
100 ng/10 000U
Specific activity
20 MU/ng
20 MU/ng
100 MU/ng
100 MU/ng
100 MU/ng
20–25 MU/ng
166 MU/ng
100 MU/ng

436
Part 3  Aesthetic Surgical Procedures
and after their reconstitutions. Freezing must be avoided
after dilution for all toxins.
 PRETREATMENT PREPARATION
Contraindications and precautions
BT is contraindicated in the following cases:
• Known hypersensitivity to any component of the
products.
• Neuromuscular diseases such as myasthenia gravis,
Eaton-Lambert syndrome, Bell’s paralysis, and
peripheral neuropathy.
• Pregnancy and lactation (BT is pregnancy category C).
• Concomitant usage of medications such as quinine,
calcium channel blockers, penicillamine,
aminoglycosides, and non-steroidal anti-inflammatory
drugs.
Other relative contraindications include: use in patients
with blood coagulation disorders or concomitant use with
medications that alter blood coagulation; previous infec-
tions or traumas in the treatment area; injection phobia;
patients with unrealistic expectations; and questionable
reasons for treatment or psychiatric disorders such as psy­
chosis, mania, severe depression, or body dysmorphic disor-
der (BDD).
Patient preparation, education,
and recommendations
Although botulinum toxin is a procedure that can be per-
formed quickly, it is important to spend time with the
patient, especially before the first treatment, ensuring expec-
tations are realistic, and educating the patient. Ensuring trust
and safety is of great importance, especially in treatments
with BT-A, whose procedures must be repeated every 4–6
months in order to maintain the results.
An empathic and respectful attitude towards patients will
make them feel comfortable in revealing their wishes, expec-
tations, fears, and concepts regarding the procedure. Although
the effects of BT are reversible, the treatment of patients
with unrealistic expectations should be avoided. Special
attention should be given to identify patients with BDD,
whose prevalence in dermatology medical offices is from 5 to
15%.28 These patients have a history of undergoing multiple
aesthetic procedures, mention their dissatisfaction with pre-
vious results, have high expectations, and usually request
combined procedures.15
Concerning the cosmetic results, the patient must be aware
that BT improves dynamic wrinkles, and offers better results
in the upper face. The possibility that some wrinkles may
remain must also be discussed with the patient. Wrinkles may
persist after treatment either because they are static and deep
and will not fully respond to BT, because of the need to
combine BT with other procedures, or because the purpose
of treatment may be to keep some wrinkles to obtain a more
natural, harmonious, and attractive expression. The patient
must also be informed that the effects of BT are not imme-
diately apparent and that their duration is limited, and that
repetition of treatment at intervals of 4–6 months is neces-
sary to maintain the results.
The patient must be aware of potential side effects. Anti-
coagulants may worsen ecchymosis, thus the risk : benefit
of muscular function. The anhydrotic effects tend to last
longer and most focal forms of HH require new injections
after 6–9 months.15
Repeated treatments with BT-A have been proven to be
safe and effective.17,18 Repeated treatments produce cumula-
tive changes to the innervation pattern and cumulative histo-
logical changes affecting some muscles more than others.18
After 2–4 years of treatment for cervical dystonia, atrophic
fibers were found in biopsies of the vastus lateralis muscle as
well as alterations to the static ocular alignment, caused by
periorbicular injections of low doses of BT-A that affect the
extraocular muscles.19
Studies on animals have demonstrated that some degree of
nerve regeneration always occurs and chronic denervation and
muscular atrophy do not persist after repeated BT-A injec-
tions. After repeated facial treatments with BT-A, a discrete
muscular clinical atrophy is frequently observed in the treated
muscles, which may be desired for some muscles but is pref-
erably avoided in others. By selecting the correct dose and
respecting the recommended intervals between injections,
muscular tonus recovery is allowed in the intervals between
injections.
Immunogenicity
The immunological properties of BT can stimulate the pro-
duction of neutralizing circulating IgG antibodies, causing
future treatments to be potentially less effective.20 Neuro-
logical patients using BT-A are more prone to develop anti-
bodies, which suggests a possible relationship of antibody
formation with high-dose injections and/or frequent inter-
vals.14 One case published in the literature reported BT-A
efficacy loss induced by antibodies in a young female patient.21
In order to reduce the possibility of antigenicity,22 the con-
centration of proteins in BT-A formulations has been reduced
significantly.
In order to avoid antibody formation, use the lowest effec-
tive dose and avoid repeating injections at less than 12-week
intervals.23 The use of BT-A for cosmetic purposes should not
prevent future therapeutic interventions.23
Storage and reconstitution
In order to obtain the most effective and long-lasting results,
certain precautions regarding the storage and reconstitution
of BT-A must be taken. The commercially used products
come in a lyophilized state. It is therefore recommended that
reconstitution be done immediately prior to use with 0.9%
sterile saline solution, with or without preservatives. Pre-
servatives do not interfere with the results. Preservative may
allow less painful injections, a longer storage period after
reconstitution, and reduced risk of bacterial contamination.24
Dilutions from 1 to 10 mL are currently used for cosmetic
purposes. The decision regarding the dilution is based on the
physician’s choice and experience. BT-B comes prediluted
and ready for use.
During reconstitution, avoidance of bubble formation is
recommended. The manufacturers of the commercially avail-
able BT-A recommend their use in the first hours after recon-
stitution. However, studies conducted with Botox and
Dysport (Azzalure) have shown that these medications are
effective and safe over longer periods, from 2 to 6 weeks.25–27
The BT-A must be stored in a refrigerator, except Xeomin,
which may be stored in temperatures up to 25°C, prior to

437
Chapter 26  Botulinum Toxins
aimed to establish the optimal dose for the glabella. Such
studies demonstrated comparable results and optimal effects
in treating glabellar wrinkles using doses of 20U of Botox30
and 50U of Azzalure,31,32 respectively. There is clinical evi-
dence that 1U of Botox is equivalent to 2–2.5U of Azzalure
and has similar results concerning efficacy, intensity, and
duration of the paralysis or anhydrosis and safety30–32
(Table 26.3).
The upper face
Wrinkles on the upper third of the face represent the classi-
cal indications for BT usage, especially for the glabella. Please
refer to the DVD-ROM for illustration of the techniques
described below. The usual doses are described in Table 26.3.
Glabellar frown lines
Glabellar lines, also called ‘frown lines,’ are mainly due to the
depressive action of the procerus and corrugator muscles.
BT-A injections in the glabella produce muscular weakness of
the muscles causing eyebrow repositioning, treating the phys-
iological ptosis of the eyelids and eyebrows, which can retard
the need for blepharoplasty and provide a younger and more
attractive appearance (Fig. 26.1). Moreover, the treatment
with BT in this region can modify eyebrow shape and correct
asymmetries. Caution is necessary when treating some pro-
fessionals, such as actors, who depend on these muscles.
The BT-A is injected slowly into one or two points in each
corrugator muscle, keeping the needle tip at a distance of
approximately 1 cm above the orbital rim. The needle must
be placed perpendicularly and pushed slowly upwards towards
the hairline. Two-fingered palpation of these muscles is rec-
ommended (Fig. 26.2), since this minimizes the occurrence
of side effects, especially eyelid ptosis.
The BT-A can be applied into one or two points of the
procerus muscle to treat the horizontal lines at the root of
the nose. A single injection made along the midline at a point
below the line joining the brows and above the crossing point
of the ‘X’ formed by joining the medial eyebrow to the con-
tralateral inner canthus is usually sufficient. In patients with
a long procerus muscle, the dose can be injected at two
points.
Several studies demonstrate the efficacy and safety of BT
use in the glabella.30–32,34 The usual recommended dose for
the treatment of the glabella is 20U of Botox30 and 50U of
Azzalure.31–33 Three central injection sites are essential for
the treatment of glabellar wrinkles, and there are two
ratio of discontinuation of such drugs 7–10 days before the
injections should be discussed.
Once questions are clarified, written informed consent
should be obtained. It is advisable to include authorization to
take and use pictures for education and publication. After
obtaining baseline photographs, the patient should return in
15–30 days for photographic review and documentation.
Postoperative care should be discussed, with emphasis on
minimizing the risk of adverse events and/or complications
after treatment with BT. Patients are instructed not to lie
down, manipulate the treated area, or practice physical activ-
ity up to 4 hours after the injections. Although some authors
recommend that patients contract the treated muscles repeat-
edly in the first hours after the injections, there are no con-
trolled studies indicating that this measure is helpful to
improve results.
 TECHNICAL ASPECTS
Injection techniques and
cosmetic considerations
Botulinum toxin injections are usually performed on an out-
patient basis with the patient seated in a chair with a raised
head support. Make-up must be removed and antisepsis is
carried out using 70% isopropyl alcohol or iodine. Topical
anesthetics, cold air, or ice compresses can be used before
the injection to minimize pain.
The injection sites are selected and marked with a skin-
marking pen. The injections must be symmetrical not only in
relation to the areas but also to the doses applied, except in
cases of asymmetries. The injections must be superficial. If
any hematomas appear, cold compress or soft manual com-
pression is applied directly to the spot where the vessel was
punctured.
The reconstitution of the products in low volumes is pref-
erable,29 since it results in a larger concentration of the
product and injections of smaller volumes, allowing a more
precise technique, decreasing the risk of complications, and
increasing the duration of some effects. Table 26.2 shows the
regular dilutions of 1 and 2 mL for Botox and the equivalent
doses for Azzalure, recommended by the present authors.
The dose of BT-A is measured in units (U) of biological
activity in animal models. The units in different products are
not equivalent but equivalent ratios between products can be
established. An equivalence of 1 : 2.5U between Botox and
Azzalure can be inferred by comparing controlled studies that
Table 26.2  Regular dilutions of 1, 2, and 2.5 mL for Botox and the recommended equivalent doses for Dysport/Azzalure
TO ACHIEVE THE
EQUIVALENCE BETWEEN
BOTOX AND DYSPORT/
AZZALURE OF
IF THE VIAL OF
100U (BOTOX)
IS USUALLY
DILUTED IN
THE VIAL OF 500U
OF DYSPORT
SHOULD BE
DILUTED IN
THE VIAL OF 300U
OF DYSPORT
SHOULD BE
DILUTED IN
THE VIAL OF 125U
OF AZZALURE
SHOULD BE
DILUTED IN
1 : 2U
1 mL
2.5 mL
1.5 mL
0.625 mL
1 : 2U
2 mL
5 mL
3 mL
1.25 mL
1 : 2U
2.5 mL
6.25 mL
3.75 mL
1.562 mL
1 : 2.5U
1 mL
2 mL
1.2 mL
0.5 mL
1 : 2.5U
2 mL
4 mL
2.4 mL
1 mL
1 : 2.5U
2.5 mL
5 mL
3 mL
1.25 mL

438
Part 3  Aesthetic Surgical Procedures
Periorbicular wrinkles
Also known as crow’s feet wrinkles, these are radial lines
mainly caused by the hyperactivity of the orbital portion
of the orbicularis oculi muscle, although intrinsic and extrin-
sic factors may also be involved. The injections of BT-A
provoke a transitory chemical denervation of the muscular
fibers of the orbicularis oculi muscle, resulting in muscular
additional injection sites which were originally described for
the glabellar area, targeting the frontalis muscle, but subse-
quently these two sites were found not to significantly
improve efficacy.34 However, in hyperkinetic patients with
strong corrugator muscles, three injection points might not
be enough.
Deep glabellar wrinkles may require combined procedures
with subcision and/or fillers, as discussed below.
Table 26.3  Suggested doses for Botox/Vistabel and Dysport/Azzalure in different cosmetic treatments. Doses are expressed in
total number of units (U) per treatment divided in both sides, when applicable
USUAL
TOTAL DOSE
OF BOTOX/
VISTABEL
RANGE OF
TOTAL DOSE
OF BOTOX/
VISTABEL
USUAL TOTAL
DOSE OF
DYSPORT/
AZZALURE
RANGE OF
TOTAL DOSE
OF DYSPORT/
AZZALURE
SUGGESTED TOTAL
NUMBER OF POINTS
TO BE INJECTED
(BILATERALLY)
Facial indications
Glabella
20U
15–40U
50U
30–70U
3–5
Periorbicular or
crow’s feet wrinkles
24U
10–30U
50U
30–60U
6–12
Forehead
15U
10–30U
40U
20–60U
5–10
Bunny lines
4U
4–8U
10U
10–20U
2
Repeated nasal flare
6U
4–10U
10U
10–20U
2
Nasal tip droop
2U
2–3U
5U
5–10U
1
Gingival smile
4U
4–10U
10U
5–15U
2
Perioral wrinkles
6U
4–10U
10U
4–18U
2–6
Marionette lines
3U
3–6U
5U
10–20U
2
Dimpled or ‘cellulitic’
chin
6U
5–10U
10U
10–20U
2
Neck
40U
40–60U
75U
50–100U
2–12
Chest
30U
30–100U
75U
75–120U
6–12
Hyperidrosis
Hands
100U
100–440U
200
200–500U
30–50
Axillae
100U
100–200U
200
200–500U
10–25
Forehead
50U
50–86U
100
100–200U
10–30
Feet
100U
100–400U
200
200–1000U
20–40
A
B
Figure 26.1  (A) Frowning of glabellar muscles before treatment. (B) After BT-A treatment, trying to frown the glabellar muscles.
Patient was injected with Botox.

439
Chapter 26  Botulinum Toxins
increase the ocular aperture, which may be desired by some
Asian patients.36 Caution should be taken to avoid increasing
of skin laxity and eye bulging.
Forehead lines
By raising the eyebrows, the frontalis muscle is responsible
for facial expressions of fear and surprise. Its contraction
results in the horizontal forehead lines.
Normally, five to 10 points are used for injection of the
forehead, depending on whether it is decided to treat the
forehead completely or partially. The distribution sites must
be established according to the physical exam of each patient.
The points are generally distributed horizontally or in a ‘V.’
Since the frontalis muscle is responsible mostly for the facial
expressions, the treatment of the entire frontal region causes
significant loss of these expressions (Fig. 26.4), which must
be discussed with the patient. Asymmetries demand special
techniques. It is important that all injections are made from
1 to 2 cm above the orbital rim, in order to avoid eyebrow
ptosis, which causes a tired appearance.
The mid and lower face
Low doses should be used in the mid and lower face in order
to produce the desired effect, which is usually only partial
relaxation of the muscles instead of paralysis. This is desired
to avoid side effects to muscles that are directly or indirectly
connected to the mouth and are very responsive to BT-A.
Bunny lines
Low BT-A doses are used in the transversal areas of the nasal
bone37 in order to treat nasal wrinkles. The injection must be
applied in the high lateral nasal wall, below the angular vein,
avoiding injections near the nasofacial groove in order to
prevent relaxation of the levator labii superioris muscle which
may lead to ptosis of the upper lip.37
The treatment may be less effective in patients who recruit
these muscles excessively or have had prior rhinoplasty.37
weakening and consequent improvement of these wrinkles
(Fig. 26.3).
The first point is marked at the center of the maximum
contraction area, usually located at the lateral canthus, at a
minimum distance of 1 cm from the lateral orbital margin.
Two or three additional points may be injected, 1–1.5  cm
above and below the first marked, in a line that follows the
orbital curvature.
The doses for treating periorbicular wrinkles vary but, gen-
erally, 5–15U of Botox is recommended on each side.35 Doses
are usually distributed in two to three points, and sometimes
four or five points, on each side, according to the patients’
needs. Injections result in some overlapping of the field of
effects, smoothing the skin surface (see Fig. 26.3).
To treat the muscular hypertrophy and the thin wrinkles
in the lower eyelid, intradermal injections of 2U of Botox or
5U of Azzalure can be injected in the midpupillary line, 3 mm
from the lower ciliary border. Moreover, this process can
Figure 26.2  Injection technique for BT-A applications at the
glabellar muscles.
A
B
Figure 26.3  (A) Periorbital wrinkles when
smiling, before treatment. (B) After BT-A
treatment. Patient was injected with
Dysport.

440
Part 3  Aesthetic Surgical Procedures
caused by the contraction of the levator labii superioris
muscle. Although simply an anatomic variant, it may cause
aesthetic concern to the patient.38
Injections of BT-A on each side of the levator labii superi-
oris alaeque nasi muscle applied in each nasofacial groove
will prevent the excessive exposure of the gums while
smiling, while preserving the remaining mouth movements
(Fig. 26.5).37,38
Perioral wrinkles
The vertical lines, also called ‘smokers’ lines,’ result from the
combined action of the orbicularis oris muscle with photo-
damage, intrinsic aging, and hereditary factors.39 Injections of
BT-A can be made at the vermilion border or up to 5 mm
from the border (Fig. 26.6).39 Injections at the corners of the
mouth must be avoided, because they may lead to undesir-
Repeated nasal flare
Some people dilate or rhythmically contract the nostrils on
certain occasions, which may cause embarrassment. Injec-
tions of BT-A are indicated on each side in the lower nasal
fibers above the lateral nasal ala.37
Nasal tip droop
The depressor septi nasi is a small muscle located in the exter-
nal inferior base of the nasal septum, which contributes to the
nasal tip lowering, aggravating the ptosis that usually occurs
with aging. Injections are done at the base of the columella.37
Gingival smile
Gingival smile is characterized by exposure of more than
2 mm of the upper gum when the individual smiles, mainly
A
B
Figure 26.4  (A) Facial expression and
wrinkles resulting from frontalis muscle
contraction before treatment. (B) After
BT-A treatment, showing less expression
and wrinkles, as well as difficulty in
raising the brows. Patient was injected
with Dysport.
A
B
Figure 26.5  (A) Gingival smile, before treatment. (B) After BT-A treatment of the levator labii superioris alaeque nasi muscle. Patient
was injected with 4U of Botox in each side.

441
Chapter 26  Botulinum Toxins
Dimpled or ‘cellulitic’ chin (peau d’orange)
The mentalis muscle originates in the jaw, covers the chin,
and inserts into the skin below the lower lip. The dimpled
aspect of the chin results mainly from the action of the jaw
muscles associated with loss of collagen and subcutaneous
fat.37 The BT injections are divided in two points, each one
injected bilaterally at the most distal point of the mentalis
muscle at the prominence of the chin (Fig. 26.7).40
Face lift
Some of the platysma muscle fibers are located in the malar
region and cause lowering of this region. High patient satisfac-
tion and a low incidence of adverse effects were reported in
able relaxation in the depressor anguli oris muscle, the zygo-
maticus major muscle, and the risorius muscle.
Caution is advised when selecting doses for treatment of
perioral wrinkles with BT-A for actors, musicians, and singers
as well as the equivalence between different commercial
preparations.
Marionette lines
The corners of the mouth are permanently turned down by
the action of the depressor anguli oris muscle. Doses of BT-A
are applied directly above the mandibular angle, along its rim,
and 1 cm lateral to the oral commissure, bilaterally,37 in an
imaginary line that follows the direction of the nasolabial
furrow.
A
B
Figure 26.6  (A) Perioral wrinkles mainly related to the action of orbicularis oris muscles, before treatment. (B) After BT-A treatment.
Patient was injected with 1U of Botox in each side of the upper lip (orbicularis oris muscle) and 2U of Botox in each side of the chin
(mentalis muscle).
A
B
Figure 26.7  (A) Dimpled chin, before treatment. (B) After BT-A treatment of mentalis muscle. Patient was injected with 5U of Dysport
in each mentalis muscle.

442
Part 3  Aesthetic Surgical Procedures
ness either of the levator labii superioris or the orbicularis oris
muscle, or asymmetric contractions of the depressor labii
inferioris muscle that can be weaker or stronger than the
contralateral muscle. The correction of this asymmetry with
BT-A requires individual evaluation. Doses and injections
must be managed according to the muscles and problems
involved. The treatment is carried out unilaterally or with
different doses.
The neck and chest
Neck wrinkles are more frequently related to photoaging and
skin laxity than platysmal bands, but BT-A can be used in
cases of visible contractions of this muscle. It can also be
indicated in cases of asymmetry and in selected cases
where early use in young patients may prevent age-related
cutaneous and muscular neck wrinkles. Horizontal neck wrin-
kles can also be treated with intradermal low doses of BT-A
injections.37
Wrinkles of the anterior mid-chest are, in general, caused
by the position adopted during sleep, but in some patients
they result from the action of the medial fibers of the pecto-
ralis major muscle and the tail portion of the platysma muscle.
The involvement of the pectoralis major muscle can be inves-
tigated by palpation while having the patient cross their arms.
The recommended doses can be given in a ‘V’-shape over the
wrinkles of this area, divided into three to six points on each
side (Fig. 26.9).33,44
Unusual cosmetic indications
Masseteric hypertrophy
Hypertrophy of the masseter muscle can start during child-
hood and causes a gradual and painless increase of the
inferior–posterior portion of the mandible, leading to an
increased growth of the jaw and a square face.45 The etiology
is unknown, but it can be aggravated by the grinding of the
teeth. In the treatment of masseteric hypertrophy, the doses
are divided into three points of each muscle treated. The high
doses are chosen to induce muscular atrophy, which usually
appears after 3–6 months.
the treatment of 130 patients with doses of up to 20U of
Botox.41 The doses are fractioned into 1–2U of Botox or
2–5U of Azzalure divided in two to four points along the
lateral mandibular border.
Facial asymmetries and facial palsy
BT-A is indicated for patients presenting with facial asym-
metries and facial palsy, to mitigate the contraction force on
the hyperactive side, thus obtaining improvement of these
clinical conditions. Facial paralysis results from trauma or
pathology. Studies carried out in patients with facial asym-
metry caused by facial paralysis report the efficacy of BT-A
injections.42,43 Common aspects of facial paralysis, such as
dystonias and facial spasms, can also be treated with BT-A
injections. BT-A can decrease the contralateral muscular
hyperkinesia, with few and limited adverse events, improving
the appearance and function of patients with facial paralysis43
and bringing significant psychological improvement.
The great variation that exists in the anatomy and function
of the facial muscles in conditions involving facial asymmetry
and paralysis does not allow common rules for the use of
BT-A. The injections must be planned and managed according
to the needs of each case, usually following the cosmetic
principles and doses for the hyperkinetic muscles. It is recom-
mended to start with small but effective doses and, in sub-
sequent treatments, to increase the dose and points of
injection, allowing patients some time to adapt to new mus-
cular movements. It is also important to avoid, whenever
possible, fractionated and repeated injections in order to
prevent the production of antibodies. Facial asymmetries may
occur in several regions of the face, as they can be caused by
different activity from several muscles that compose the
facial expression and, sometimes, to volumetric differences
between the two sides of the face. The asymmetric contrac-
tions may also lead to volumetric facial asymmetry, which
can be treated adjunctively with fillers (see below and
Fig. 26.8).
Asymmetric smile is a relatively common complaint that
may be present since birth or as a consequence of trauma or
surgery in the perioral area. It is caused by a segmental weak-
A
B
Figure 26.8  (A) Asymmetric smile due to
congenital asymmetry. (B) After treatment of
BT-A. Patient was injected with 5U of Botox
at the left depressor labii inferioris muscle.

443
Chapter 26  Botulinum Toxins
main indication of this combination is wrinkles on areas
where there is noticeable loss in tissue volume, causing wrin-
kles of mixed etiology. The BT-A can be administered
approximately 1 week prior to the injections of fillers or in
the same treatment session. Furthermore, combined use
appears to extend the life of the fillers.47
Hyaluronic acid (HA) and collagen are the main fillers
used in association with BT-A.47 A randomized prospective
study48 designed to verify the results obtained with the com-
bination of BT-A and HA in patients with severe wrinkles in
the glabellar region concluded that combined procedures pro-
duced enhanced outcomes and offered extended duration of
effects.
The use of fillers in combination with BT-A makes it pos-
sible to deal with facial rejuvenation in a more complete,
three-dimensional approach, promoting more satisfactory and
longer-lasting aesthetic results.
Lasers and light sources
Lasers and light sources can be used in association with BT-A
in order to improve cosmetic results as well as prolong the
Leg contour
Hypertrophy of the gastrocnemius muscle, responsible for
the contour of the legs, can also be treated with BT-A. Mus-
cular atrophy caused by the toxin is desirable.46 The doses
are estimated according to the size or muscular thickness
during contraction.
Adjunctive treatments
Markedly sophisticated results can be obtained by combining
BT-A with different cosmetic procedures during the same or
different treatment sessions, giving patients better and longer-
lasting cosmetic results.
Fillers
Adequate understanding of the clinical effects of BT-A and
fillers leads to precise and safe indications of combinations of
these techniques. Treatments that combine the use of fillers
and BT-A are capable of correcting the wrinkles by restoring
volume loss and relaxing hyperactive muscles in situations
where each treatment alone would give partial results. The
A
B
C
D
Figure 26.9  (A) Décolleté wrinkles are aggravated by crossing arms. (B) Palpation of the borders of the pectoralis major muscle can
denounce their involvement in these wrinkles. (C) Treatment of chest wrinkles are marked with points in a ‘V’-shape in the pectoralis
major muscle. (D) Patient receiving injections of BT-A. She was treated with 30U of Xeomin.

444
Part 3  Aesthetic Surgical Procedures
lished, treatment will depend on the location and extension
of the problem.
Gravimetry and the Minor’s test are helpful and useful
tests in the diagnosis and management of the disease. Gravim-
etry is often used in clinical research and evaluates the
quantity of sweat produced per minute in an area of the
body surface, whereas Minor’s test is more often used in
clinical practice and indicates the location of hyperfunctional
glands.54
Treatments for the different forms of HH include topical
and systemic medications, devices such as iontophoresis, psy-
chotherapy, and minimally invasive procedures such as BT
and surgical removal of sweat glands, including curettage and
liposuction, and even invasive surgery such as sympathec-
tomy.54 Scars and compensatory HH are notable complica-
tions of such surgical treatments, respectively. The latter
occurs in a significant number of patients submitted for sym-
pathectomy.
BT-A has been used widely for treatment of HH. BT-A
injections act at the nervous synapse, inhibiting ACh release
and causing hypo- or anhydrosis in the treated areas for 6–8
months or longer, with minimum sequelae and without any
risk of causing compensatory HH. The treatment of HH with
BT-A is considered safe and effective, with a high degree of
satisfaction among treated patients. It is approved by the US
Food and Drug Administration (FDA) and other regulatory
agencies from several countries. BT-B is also useful in the
treatment of HH. Table 26.3 lists the usual doses of BT-A
for the treatment of the main forms of HH.
Injection of BT-A in the treatment of HH is considered a
fast, effective, and safe procedure, in which complications or
adverse effects are rare. When they do occur, they include
pain, erythema, edema, and hematomas, but secondary
reversible muscular paralysis may also occur.
 PITFALLS AND THEIR MANAGEMENT
effects of BT-A, generating greater patient satisfaction. Lasers
and light sources have been used before or after BT-A injec-
tions, in different treatment sessions. Recently, it was dem-
onstrated that non-ablative rejuvenation laser and intense
pulsed light (IPL) can also be used immediately following the
application of BT-A, without interfering in the results from
BT-A.49
Different surgical modalities
BT-A can be used in association with several surgical modal-
ities. In such cases the aim is not only to further benefit facial
rejuvenation but also to offer synergic results. Among those
surgical procedures that can be used in association with BT-A
are blepharoplasty, eyebrow lifting, subcision, and surgical
rehabilitation of facial nerve paralysis.50,51 The postoperative
use of BT-A in areas of great cutaneous or muscular tension
facilitates wound closure, consequently improving cosmetic
and functional results in many cases.
There is controversy regarding which is the most suitable
time to use BT-A when it is used in combination with surgi-
cal treatments. When used prior to surgery, the main advan-
tage is stabilization of the tissues in the area of the wound by
reducing tension. BT-A can be efficiently incorporated within
the surgical plan before, during, or after surgery, as long as
the surgeon has full knowledge of the facial anatomy and
muscular interactions.
Treatment of hyperhidrosis
The eccrine sweat glands are present all over the body, except
in areas of modified skin such as the outer ear duct, vermilion
border of the lips, nail beds, clitoris, labia minora, glands,
and inner prepuce.52 The main function of the eccrine
sweat glands is sweat production, which is controlled by the
sympathetic nervous system, having ACh as the chemical
mediator.
Sweating helps to control body temperature and may vary
according to individual characteristics such as sex, age, and
race, and is stimulated by endogenous and exogenous factors.
HH is a condition in which the sweat production exceeds
the need required for thermoregulation. This clinical condi-
tion may cause embarrassment and significantly affects the
quality of life of those who suffer from it. The incidence of
HH can vary from 1% to 2.8% according to published
studies.53 HH can be generalized or localized. It can also be
primary, due to stimulation from the cortex or hypothalamus,
or secondary, due to diseases or other systemic factors, among
them neoplastic, metabolic, and neurological diseases, the use
of drugs and certain medicines, and psychological alterations.
The cause should always be investigated and treated when-
ever possible.54
Primary HH is a disorder characterized by excessive sweat-
ing in restricted areas. Among these, the most common are
palmar, plantar, and axillary HH, but other areas may be also
affected, such as the forehead, neck, abdomen, back, and
inguinal region.17
Primary HH generally begins in the first decades of life.
The diagnosis is based on the following criteria: non-occur-
rence during sleep; frequency of at least one incidence per
week; affects daily activities; and family history. Complete
clinical history may include triggering factors, duration of the
flare, and family history. Once the diagnosis has been estab-
Pitfalls and their management
 Use only approved toxins.
 Reconstitute the products in low volumes of saline, as it allows
precise injections with less risk of side effects.
 Listen to your patients to identify their expectations. Let
patients know what can be achieved with BT injections.
Observe their muscles and know how they use them, to
choose the proper techniques and doses.
 Always take pictures before and after the procedures.
 Use effective doses to avoid short duration of effect. Adjust
doses according to the patients’ needs.
 Know facial anatomy and select carefully the injection
points.
 When injecting the frontalis muscles, avoid overtreatment.
Consider treating the upper part of the frontalis in the majority
of patients, to avoid brow ptosis and masking expression.
 When injecting the glabellar area, inject 0.5–1 cm above the
orbital rim and avoid local massage to the area to prevent
eyelid ptosis.
 When injecting crow’s feet wrinkles, respect the distance of
1 cm from the lateral bony orbital rim to avoid complications
such as diplopia. In addition, avoid injections below an
imaginary line from the zygomatic arch to the malar eminence,
to prevent effect of the toxin in the zygomatic muscles. Be
careful in treating the lower eyelid.

445
Chapter 26  Botulinum Toxins
• Brow ptosis, or worsening of physiological ptosis of the
brows, may occur following treatment of forehead
wrinkles, when high doses of BT-A are used, or when
the forehead musculature is completely paralyzed,
leading also to a significant reduction in facial
expression, known as ‘masked face.’
• Excessive elevation of the eyebrow tails or excessive
arching of the brows are sometimes unwanted effects
for both men and women. It may occur when treating
forehead or glabellar areas. Alterations in the original
arching of the eyebrows and/or modifying the
cosmetically accepted typically male or female pattern
of the eyebrows may be a cause of patient
dissatisfaction.
• Asymmetry may occur following treatment with BT-A,
when used asymmetrically. This is treatable with
BT-A.
• In the mid and lower face, high doses of BT-A may
cause unwanted paralysis of the muscles related to the
perioral area, causing difficulty in articulating words and
incompetence of mouth functions. Furthermore,
injections into inappropriate points may compromise the
zygomatic major and levator labii superioris muscle,
causing ptosis of the upper lip and the corners of the
mouth, difficulties in mouth movements, and
asymmetry.
• In the neck, the most common complications are
dysphagia and difficulty in flexing the neck, which in
general result from injections of high doses.
• Use of BT in the anterior chest may result in reduced
muscular strength during the abduction and medial
rotation of the upper limbs. In cases where very high
doses are used, difficulty in breathing deeply may occur.
 SUMMARY
Used in the last 20 years in medical and cosmetic dermatol-
ogy, BT has been demonstrated to be a safe, predictable, and
very effective treatment for a number of cosmetic indications
and clinical conditions, such as hyperhidrosis.
Since patients usually repeat BT treatments every 4–6 or
more months and since the effects are dose and technique
dependent, when choosing the appropriate doses, techniques,
and frequency of injections for each individual patient, one
should keep in mind not only the short-term effects but also
the long-term effects, to reach the individual therapeutic or
cosmetic objectives.
This minimally invasive treatment can also be combined
with others, improving results as well as physician and patient
satisfaction.
 REFERENCES
1. Ryan KJ. Clostridium, Peptostreptococcus, Bacteroides, and other anaer-
obes. In: Ryan KJ, Ray CG, eds. Sherris medical microbiology. New York:
McGraw-Hill 2004; 317–322.
2. Eleopra R, Tugnoli V, Quatrale R. Different types of botulinum toxin in
humans. Mov Disord 2004;19(Suppl 8):53–59.
3. Aoki KR. A comparison of the safety margins of botulinum neurotoxin
serotypes A, B and F in mice. Toxicon 2001;39:1815–1820.
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BT injections are considered safe as long as they are per-
formed by an experienced or properly trained professional.
Most of the complications that arise with the use of BT-A
are technique related and the side effects and complications
of the use of BT-A in cosmetic treatments are rare and vary
among patients. Side effects are most commonly due to the
injections, and tend to disappear within a few hours, days, or
weeks. As reported by the FDA,55 the adverse effects related
to the cosmetic use of BT-A were mostly considered non-
serious, while in the case of the therapeutic uses, some side
effects are considered serious. In 995 cases of the cosmetic
use of BT, the most frequent reported side effects were
absence of effect (63%), reaction at the injection site (19%),
and ptosis (11%). In 124 of the cases, more than one side
effect was reported.55
The side effects resulting from the injection sites include
pain, erythema, edema, hematoma, ecchymosis, headache,
and short-term hyperesthesia. Discomfort during treatment
can be reduced by the use of topical anesthetics or cooling
the skin prior to the injections and by the use of small needles.
Applying ice immediately following the injections can also
reduce pain, edema, and erythema associated with intramus-
cular injections.
Complications may arise as a result of the direct action of
BT and/or may be technique related, as follow:56–58
• Transitory upper eyelid ptosis is the most feared
complication, and may appear following treatment for
glabellar wrinkles. It may occur due to the diffusion of
BT into the orbital septum, as a result of the direct
injection or manipulation of the injected areas, with a
consequent displacement of the product and paralysis of
the upper eyelid elevator muscle. It may also occur as a
result of the injection of large amounts, injections very
close to the orbital rim, or massages or intense
manipulation of the treated area following the
application.
• The injection of BT-A in the lower eyelids may cause
subsequent ectropion, entropion, and damage to the
ciliary ganglion caused by Adie’s pupil as well as more
evident skin laxity and bulging of the eyes.
• Diplopia or double vision may occur when injections are
close to the ocular globe or when there is diffusion of
the toxin into the orbit, with consequent paralysis of
the lateral rectus muscle.
• The appearance or aggravation of nasal wrinkles is seen
in a large number of patients that receive BT into the
glabella and/or the periorbital area, as the nasalis muscle
is more often recruited when the lateral part of the
orbicularis occuli muscle is relaxed. This is known as
the ‘Botox sign,’ also called ‘bunny lines,’ mainly
occurring when the patient smiles or attempts to frown.
 Select two or three sites in the perioral area and use the
lowest effective dose to avoid complications caused by mouth
incompetence.
 Touch ups can be done after 15–30 days to optimize the
results, to treat residual unwanted lines, and to correct
minor side effects such as asymmetries and excessive brow
elevation, if needed. Avoid frequent or repeated touch ups.
 Give patients post-treatment instructions.

446
Part 3  Aesthetic Surgical Procedures
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double-blind, placebo-controlled study of efficacy and safety of 3 doses
of botulinum toxin A in the treatment of glabellar lines. J Am Acad
Dermatol 2004;51:223–233.
32. Monheit G, Carruthers A, Brandt F, et al. A randomized, double-blind,
placebo-controlled study of botulinum toxin type A for the treatment of
glabellar lines: determination of optimal dose. Dermatol Surg 2007;
33(Suppl 1):51–59.
33. International meeting of Board of Botulinum Toxin, Azzalure, 2009.
34. Carruthers A, Carruthers J, Flynn TC, et al. Dose-finding, safety, and
tolerability study of botulinum toxin type B for the treatment of hyper-
functional glabellar lines. Dermatol Surg 2007; 33(Suppl 1):60–68.
35. Blitzer A, Binder WJ, Aviv JE. The management of hyperfunctional facial
lines with botulinum toxin. A collaborative study of 210 injection sites
in 162 patients. Arch Otolaryngol Head Neck Surg 1997;123:389–392.
36. Flynn TC, Carruthers J, Carruthers A. Botulinum-A toxin treatment of
the lower eyelid improves infraorbital rhytides and widens the eye.
Dermatol Surg 2001;27:703–708.
37. Carruthers J, Carruthers A. Aesthetic botulinum A toxin in the mid and
lower face and neck. Dermatol Surg 2003;29:468–476.
38. Coscarelli JM. Gingival smile: a new technique as an aesthetic solution.
In: Hexsel D, Almeida AT, eds. Cosmetic use of botulinum toxin. São
Paulo: AGE 2002; 198–203.
39. Mazzuco R. Perioral wrinkles. In: Hexsel D, Almeida AT, eds. Cosmetic
use of botulinum toxin. São Paulo: AGE 2002; 158–263.
40. Kogos L. Mental wrinkles. In: Hexsel D, Almeida AT, eds. Cosmetic use
of botulinum toxin. São Paulo: AGE 2002; 167–170.
41. Levy PM. The ‘Nefertiti lift.’ J Cosmet Lasers Ther 2007;9:249–
252.
42. Clark RP, Berris CE. Botulinum toxin: a treatment for facial asymmetry
caused by facial nerve paralysis. Plast Reconstr Surg 2005;115:
573–574.
43. De Maio M, Bento RF. Botulinum toxin in facial palsy: an effective treat-
ment for contralateral hyperkinesis. Plast Reconstr Surg 2007;120:
917–927.
44. Isaac C, Gimenez R, Ruiz RO. Breast wrinkles (décolleté folds). In:
Hexsel D, Almeida AT, eds. Cosmetic use of botulinum toxin. São Paulo:
AGE 2002; 178–181.
45. Park MY, Ahn KY, Jung DS. Botulinum toxin type A treatment for
contouring of the lower face. Dermatol Surg 2003;29:477–483.
46. Lemperle G, Exner K. The resection of gastrocnemius muscles in aes-
thetically disturbing calf hypertrophy. Plast Reconstr Surg 1998;102:
2230–2236.
47. Coleman KR, Carruthers J. Combination therapy with BOTOX and
fillers: the new rejuvenation paradigm. Dermatol Ther 2006;19:
177–188.
48. Carruthers J, Carruthers A. 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(8):802–809.
49. Semchyshyn NL, Kilmer SL. Does laser inactivate botulinum toxin?
Dermatol Surg 2005;31:399–404.
50. Hexsel D. Combining procedures with botulinum toxin in dermatology
and dermatological surgery. In: Hexsel D, Almeida AT, eds. Cosmetic
use of botulinum toxin. São Paulo: AGE 2002; 211–215.
51. Finn JC. Botulinum toxin type A: fine-tuning treatment of facial nerve
injury. J Drugs Dermatol 2004;3:133–137.
52. Montagna W, Yun JS. The skin of primates. The skin of the ring tailed
lemur. Am J Phys Anthropol 1962;20:95–118.
53. Strutton DR, Kowalski JW, Glaser DA, et al. US prevalence of hyper-
hidrosis and impact on individuals with axillary hyperhidrosis: results
from a national survey. J Am Acad Dermatol 2004;51:241–248.
54. Haider A, Solish N. Focal hyperhidrosis: diagnosis and management.
CMAJ 2005;172:69–75.
55. Coté TR, Mohan AK, Polder JA, et al. Botulinum toxin type A injections:
adverse events reported to the US Food and Drug Administration in
therapeutic and cosmetic cases. J Am Acad Dermatol 2005;53:407–
415.
56. Klein AW. Contraindications and complications with the use of botuli-
num toxin. Clin Dermatol 2004;22:66–75.
57. Pena MA, Alam M, Yoo SS. Complications with the use of botulinum
toxin type A for cosmetic applications and hyperhidrosis. Semin Cutan
Med Surg 2007;26:29–33.
58. Klein AW. Complications and adverse reactions with the use of botuli-
num toxin. Semin Cutan Med Surg 2001;20:109–120.
6. Baumann L, Slezinger A, Vujevich J, et al. A double-blinded, randomized,
placebo-controlled pilot study of the safety and efficacy of Myobloc
(botulinum toxin type B)-purified neurotoxin complex for the treatment
of crow’s feet: a double-blinded, placebo-controlled trial. Dermatol Surg
2003;29:508–515.
7. Flynn TC, Clark RE. Botulinum toxin type B (MYOBLOC) versus botu-
linum toxin type A (BOTOX) frontalis study: rate of onset and radius of
diffusion. Dermatol Surg 2003;29:519–522.
8. Yamauchi PS, Lowe NJ. Botulinum toxin types A and B: comparison of
efficacy, duration, and dose-ranging studies for the treatment of facial
rhytides and hyperhidrosis. Clin Dermatol 2004;22:34–39.
9. Baumann L, Slezinger A, Halem M, et al. Pilot study of the safety and
efficacy of Myobloc (botulinum toxin type B) for treatment of axillary
hyperhidrosis. Int J Dermatol 2005;44:418–424.
10. Chajchir I, Modi P, Chajchir A. Novel topical BoNTA (CosmeTox, toxin
type A) cream used to treat hyperfunctional wrinkles of the face, mouth,
and neck. Aesthetic Plast Surg 2008;32:715–722.
11. Glogau RG. Topically applied botulinum toxin type A for the treatment
of primary axillary hyperhidrosis: results of a randomized, blinded, vehi-
cle-controlled study. Dermatol Surg 2007;33(Suppl 1):76–80.
12. Sposito MM. Toxina botulínica tipo A – propriedades farmacológicas e
uso clínico. Acta Fisiatr 2004;(Suppl 1):1–44
13. Carruthers JD, Glogau RG, Blitzer A; Facial Aesthetics Consensus Group
Faculty. Advances in facial rejuvenation: botulinum toxin type A,
hyaluronic acid dermal fillers, and combination therapies – consensus
recommendations. Plast Reconstr Surg 2008;121(Suppl 5):5–30, quiz
31–36.
14. Salti G, Ghersetich I. Advanced botulinum toxin techniques against
wrinkles in the upper face. Clin Dermatol 2008;26:182–191.
15. Malick F, Howard J, Koo J. Understanding the psychology of the cos-
metic patients. Dermatol Ther 2008;21:47–53.
16. Rzany B, Ascher B, Fratila A, et al. Efficacy and safety of 3- and 5-injec-
tion patterns (30 and 50 U) of botulinum toxin A (Dysport®) for the
treatment of wrinkles in the glabella and the central forehead region.
Arch Dermatol 2006;142:320–326.
17. Kreyden OP. Botulinum toxin in the management of focal hyperhidrosis.
In: Benedetto AV, ed. Botulinum toxin in clinical dermatology. Abingdon:
Taylor & Francis 2006; 261–293.
18. Rzany B, Dill-Müller D, Grablowitz D, et al. Repeated botulinum toxin
A injections for the treatment of lines in the upper face: a retrospective
study of 4103 treatments in 945 patients. Dermatol Surg 2007;33(Suppl
1):18–25.
19. Moore P, Naumann M. General and clinical aspects of treatment with
botulinum toxin. In: Moore P, Naumann M, eds. Handbook of botulinum
toxin treatment. Bodmin: MPG Books 2003; 28–75.
20. Huang W, Foster JA, Rogachefsky AS. Pharmacology of botulinum toxin.
J Am Acad Dermatol 2000;43:249–259.
21. Lee SK. Antibody-induced failure of botulinum toxin type A therapy in
a patient with masseteric hypertrophy. Dermatol Surg 2007;33(Suppl
1):105–110.
22. Carruthers A, Carruthers J. Botulinum toxin products overview. Skin
Therapy Lett 2008;13:1–4.
23. Borodic G. Botulinum toxin, immunologic considerations with long-term
repeated use, with emphasis on cosmetic applications. Facial Plast Surg
Clin North Am 2007;15:11–16.
24. Hexsel D, Mazzuco R, Dal’Forno T, et al. Botulinum toxin for facial
wrinkles: history and future. Expert Rev Dermatol 2007;2:417–426.
25. Hexsel DM, Almeida AT, Rutowitsch M, et al. Multicenter, double-blind
study of the efficacy of injections with botulinum toxin type A reconsti-
tuted up to six consecutive weeks before application. Dermatol Surg
2003;29:523–529.
26. Hexsel D, Castro IA, Zechmeister D, et al. Multicenter, double-blind
study of the efficacy of injections with botulinum toxin A reconstituted
up to six consecutive weeks before application. Dermatol Surg 2004;
30:823.
27. Hexsel D, Rutowitsch M, Castro LC, et al. Blind multicenter study of
the efficacy and safety of injections of a commercial preparation of botu-
linum toxin type A reconstituted up to 15 days before injection. Derma-
tol Surg 2009;35:933–939.
28. Wilson JB, Arpey CJ. Body dysmorphic disorder: suggestions for detec-
tion and treatment in a surgical dermatology practice. Dermatol Surg
2004;30:1391–1399.
29. Carruthers A, Carruthers J. Botulinum toxin type A. J Am Acad Derma-
tol 2005;53:284–290.
30. Carruthers JA, Lowe NJ, Menter MA, et al. A multicenter, double-blind,
randomized, placebo-controlled study of the efficacy and safety of botu-
linum toxin type A in the treatment of glabellar lines. J Am Acad Der-
matol 2002;46:840–849.

447
27
Liposuction
Naomi Lawrence MD, Shari A Nemeth MD MS, and Janie M Leonhardt MD
Summary box
 Tumescent anesthesia using lidocaine and epinephrine allows
the removal of large volumes of fat with minimal blood loss
and low postoperative morbidity.
 A preconsultation questionnaire standardizes the medical
history and focuses the consultation on issues that are crucial
to the success of the liposuction.
 Most bleeding disorders and any medications that prolong
bleeding time are a contraindication to liposuction.
 Liposuction is not a treatment for obesity, but can create a
more aesthetic figure at an individual’s current weight.
 Continuous blood pressure monitoring, cardiac monitoring
with pulse oximetry, and the availability of supplemental
oxygen should be in place for procedures removing more
than 100 mL of aspirate.
 Following liposuction, around 12% of patients undergo
a touch-up procedure. If a patient gains weight, the
liposuctioned area will resist weight gain, which may cause fat
to accumulate in a new, less accessible area.
 INTRODUCTION
Liposuction with local anesthesia had its inception in 1987
with the publication of the seminal paper by Jeffery Klein on
tumescent anesthesia.1 Before this, adipose deposits had been
removed by en bloc resection in combination with skin exci-
sion or were scraped out through small incisions.2 Two Italian
cosmetic surgeons, Arpad and Georgio Fischer, introduced
the suction technique for removal of fat.3 The Fischers also
introduced the use of a blunt cannula and criss-cross tun-
neling. Fournier, a French general surgeon, promoted syringe
rather than machine liposuction and is considered one of the
main pioneers in the field.4 Illouz, a gynecologist, is credited
with popularizing liposuction by using the Fischers’ technique
with the Karman cannula – a widely available, reasonably
priced, soft, flexible cannula that was developed for abortion
procedures.5 Illouz is also responsible for the original ‘wet
technique’ in which a hypotonic saline solution with hyaluron­
idase was injected into the fat. ‘Wet technique’ liposuction
was popularized in Europe; however, prior to Klein’s intro-
duction of tumescent anesthesia the predominant form of
liposuction practiced in the United States was the dry tech-
nique. Patients were put under general anesthesia and minimal
local anesthesia was used, so significant blood loss was a
common complication with the dry method.
The introduction of tumescent anesthesia by Klein revolu-
tionized liposuction among dermatologic surgeons and cos-
metic surgeons at large. Liposuction with local anesthesia
allows the removal of large volumes of fat with minimal blood
loss, low postoperative morbidity, excellent cosmesis, and a
remarkable safety profile.
 PREOPERATIVE PREPARATION
Consultation
The consultation starts on the phone when the receptionist
books the appointment. It is important that whoever answers
the phone is knowledgeable about the procedure so they can
obtain some initial information to determine if the person
calling is a candidate for liposuction. If their health or physi-
cal characteristics or their expectations clearly make them a
poor candidate, it is best to find out before they come in for
a consultation. If the receptionist is too busy to spend time
with a potential liposuction candidate, the call may be trans-
ferred to the cosmetic consultant. The time spent on the
phone is rewarded with the patient being prepared for the
office consultations. It is not unusual for patients to tell us
that they booked their consultation with our office because we
gave them more information than other offices they called.
A thorough consultation takes 30–60 minutes. We use a
preconsultation questionnaire to standardize the intake of
medical history and focus the consultation on the issues that
are crucial to a successful liposuction (Fig. 27.1).
Medical history
Liposuction is an elective cosmetic procedure best done on
healthy patients. Patients should be carefully screened for any
medical conditions that would put them at increased risk of
surgical complications. Most physicians feel that cosmetic
procedures should be limited to patients who fall into the
American Society of Anesthesiologists’ Physical Status Clas-
sification System classes I or II (rarely class III) (Table
27.1).6,7 It is important to have a low threshold to request
medical clearance as patients sometimes downplay the sever-
ity of their medical conditions because they desire the pro-
cedure. We routinely request medical clearance for all

448
Part 3  Aesthetic Surgical Procedures
Patient name:
Date:
1. Do you have any medical allergies?
Yes No
Yes No
Yes No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Yes
No
Yes
No
Yes
No
Describe reaction
2. Are you on any medication or hormones?
3. Do you take any over-the-counter medications on a regular basis?
(Aspirin, antihistamines, etc.)
4. Do you have any of the following medical problems?
Heart disease
High blood pressure
Diabetes
Bleeding problems
Pulmonary embolus
Hepatitis
Thrombophlebitis (vein
inflammation)
Asthma
Lung disease
Liver disease
Kidney disease
Immune suppression
Yes
No
Artificial joints or heart
valves
– 1 –
Liposuction questionnaire
Figure 27.1  Liposuction questionnaire. (Developed by Naomi Lawrence.)

449
Chapter 27  Liposuction
If you have answered yes to any of the above, please describe your condition, or any
medical disorder you may have that is not listed:
Who is your primary care physician?
5. What is your height?
What is your weight?
6. Which of the following best describes your weight pattern? Please circle below.
a. I have maintained the same weight for many years. It rarely varies.
b. I usually stay within 5 to 10 pounds of my stated weight.
c. My weight tends to fluctuate 20 pounds or more.
d. I have recently lost pounds to achieve my present weight.
e. Other:
7. Which of the following best describes your exercise habits?
a. I do not exercise on a regular basis.
b. I do a 30 minute workout 2 to 3 times a week.
c. I do a 30 minute or greater workout 4 or more times a week.
d. My occupation involves daily exercise (i.e. aerobics instructor); or I am
involved in intense training (triathlete, marathon runner).
8. Place a check by all areas that you are interested in having evaluated for possible
liposuction. Circle the area that bothers you most.
Face
Neck
Arms
Back
Waist
Flanks
Abdomen
Hips
Buttock
Outer thigh
Inner thigh
Knees
Calves and ankles
– 2 –
Other:
Liposuction questionnaire (continued)
Figure 27.1, cont’d

450
Part 3  Aesthetic Surgical Procedures
– 3 –
9. Check those statements that best reflect your expectations of liposuction.
I am overweight and am looking to liposuction as an alternative to diet
and exercise.
I expect to lose weight through liposuction.
I expect immediate results after liposuction.
I am mostly interested in getting rid of cellulite.
I am near my ideal weight (or overweight) and would like to reduce a
localized area to make my figure more proportional.
I exercise regularly but have a couple of areas that seem resistant to diet
and exercise.
Liposuction questionnaire (continued)
Figure 27.1, cont’d

451
Chapter 27  Liposuction
patient’s surgeon. It is important to document the age of any
scars, as older scars are soft and pliable and can be suctioned
through, but newer scars should be suctioned around. Any
history of keloids or hypertrophic scars should be discussed
thoroughly with the patient as multiple incisions are neces-
sary for cannula insertion.
Medications
The medication history must be complete. The patient should
be queried about hormone replacement, herbal supplements,
and over-the-counter medications as well as prescription
drugs. High-dose estrogen can put a woman in a higher risk
category for thromboembolism, particularly if she is a smoker,
or is within the first year of therapy with high-dose estrogen.10
Butterwick concluded that the current standard of care is to
allow patients to remain on low-dose oral contraceptives as
the risk of thrombosis from these agents is extremely low.11
Any medications that prolong bleeding time are contrain-
dicated in liposuction. These include prescription medica-
tions such as warfarin or clopidogrel bisulfate, and
over-the-counter medications such as aspirin and non-steroi-
dal anti-inflammatory drugs (NSAIDs). The antiplatelet
effects of aspirin are irreversible and last 10–14 days and
7–10 days for NSAIDs. Patients should be instructed to
check all over-the-counter medications with the physician’s
office at least 2 weeks prior to surgery as many have ‘hidden’
aspirin or NSAID ingredients. Patients are given a full list of
herbal supplements that can affect coagulation, and they
are instructed to refrain from taking them for 2 weeks before
surgery (Table 27.2).12,13 If the patient takes one of these
medications, the liposuction is postponed.
Lidocaine is metabolized by the liver enzyme cytochrome
P450 (CYP450). There are a number of drugs which induce
this enzyme system or act as competitive inhibitors (Table
27.3). Competitive inhibition slows the metabolism of lido-
caine, causing an increase in blood levels, thereby potentiating
its toxicity. When a patient is taking one of these medica-
tions, the physician can either request that they discontinue
the medication, or decrease the maximum dose of lidocaine
used; however, there are no clear guidelines documenting
how this should be done. In our practice, we typically decrease
the maximum dose of lidocaine to 35 mg/kg in patients on
these medications. Alternatively, we will perform the lipo-
suction in two or more sessions. It is also important to note
the half-life of any medications that interact with lidocaine.
For example, the antidepressant fluoxetine (Prozac, Eli Lilly,
Indianapolis, IN) has metabolites that last approximately 2
months after administration has ceased. Lidocaine can safely
be given at 55 mg/kg in a patient on no such medications.14,18
Medication allergies
It is important to elicit any history of medication allergies as
well as usage of medications that could potentially interact
with the drugs administered during the procedure. The two
major drugs in the tumescent fluid are lidocaine and epine-
phrine. Allergy to lidocaine is extremely rare and is a con-
traindication to the procedure. Most patients who claim an
allergy to lidocaine are actually allergic to methylparaben, the
preservative in the anesthetic.15 If the patient claims to be
allergic to lidocaine, we refer to an allergist for provocative
testing. If the allergy is only to the preservative, we use
preservative-free lidocaine. People who are allergic to ester
patients over 60 years old or for those with a history of car-
diovascular disease, hypertension, or diabetes.
Lidocaine is metabolized by the liver, so patients with
impaired liver function from hepatitis C, hepatitis B, alco-
holic liver disease, previous treatment with chemotherapy
or antiretroviral therapy, or other liver disease may be at
increased risk for lidocaine toxicity.6,7
Immunosuppressed patients, whether due to medications
or disease, are at increased risk of infection. In these patients,
one must consider the risk:benefit ratio of the procedure and
confer with the specialist monitoring their care.
Patients are also screened for increased risk of thromboem-
bolism as evidenced by a prior history of thrombophlebitis,
deep venous thrombosis, pulmonary embolism, protein C or
protein S deficiency, high-dose estrogen therapy, tobacco use,
or other coagulopathy.8,9 Likewise, bleeding diatheses should
also be inquired about due to the increased risk of postop-
erative hematoma. Most bleeding disorders are a contraindi-
cation to liposuction. We highlight five questions by putting
them on a separate page of the questionnaire to identify
patients with potential bleeding abnormalities (Fig. 27.2). It
is essential to obtain a thorough medical history as standard
laboratory studies will not uncover all bleeding disorders
(such as von Willebrand’s disease).
Preoperative screening studies are performed on all patients
including a complete blood count with platelet count, chem-
istry profile with liver function tests, and prothrombin/partial
thromboplastin time. In addition, the surgeon may wish to
order screening studies for HIV and hepatitis B and C based
on local standards of care.9 On the day of the procedure, we
also perform a urine pregnancy test on all premenopausal
women.
Surgical history
The patient’s history of abdominal surgeries is important if
they are being evaluated for abdominal liposuction. Special
attention should be paid to any surgery complicated by dehis-
cence, hernia, infection, or subsequent adhesions that might
leave an incomplete rectus abdominus muscle layer over the
peritoneum. Careful examination of surgical scars should be
performed to evaluate for the presence of underlying hernias
and fibrous adhesions. If the history or exam is suspicious for
hernias, adhesions or scars, one should obtain medical records,
reports, or radiologic studies, or discuss the matter with the
Table 27.1  American Society of Anesthesiologists’ Physical
Status Classification

452
Part 3  Aesthetic Surgical Procedures
1. Do you have abnormal or heavy periods?
2. Do you have recurrent nose bleeds?
3. Have you had persistent bleeding after tooth extraction?
4. Do you have a history of anemia (low blood count)?
5. Do you have a history of easy bruising?
6. Do you have any family members with abnormal bleeding?
Liposuction questionnaire
Figure 27.2  Liposuction questionnaire. (Developed by Naomi Lawrence.)

453
Chapter 27  Liposuction
Table 27.2  Herbs that may cause bleeding or thrombosis
HERBAL COMPOUND
EFFECT
CONSTITUENT(S)
Anticoagulants
Alfalfa
Anticoagulant, coagulant
Coumarin, vitamin K
Angelica
Anticoagulant, antiplatelet
Coumarin
Anise (excessive doses)
Anticoagulant
Coumarin
Arnica
Anticoagulant
Coumarin
Asafoetida
Anticoagulant
Coumarin
Aspen
Antiplatelet
–
Bilberry
Antiplatelet
–
Black cohosh
Antiplatelet
Salicylate
Blackcurrent
Antiplatelet
Linolenic acid
Bladderwrack
Antiplatelet
–
Bogbean
Bleeding risk
Unknown
Boldo
Anticoagulant
Coumarin
Borage seed oil
Anticoagulant
Enzyme
Bromelain
Anticoagulant
Enzyme
Capsicum
Antiplatelet
Capsaicinoid
Cayenne fruit
Antiplatelet
–
Celery
Antiplatelet
Apigenin (coumarin)
Clove
Antiplatelet
Eugenol
Danshen
Anticoagulant
Protocatechualdehyde
3,4-dihydroxyphenyl-lactic acid
Da huang
Antiplatelet
–
Devil’s claw
Antiplatelet
Coumarin
Dong Quai
Anticoagulant, antiplatelet
Coumarin
Evening primrose seed oil
Antiplatelet
–
Fenugreek
Anticoagulant
Coumarin
Feverfew
Antiplatelet (crude extract)
–
Fish oil (omega-3)
Antiplatelet, prostacyclin synthesis, vasodilatation, reduced platelets
and adhesiveness, prolonged bleeding time
–
Fucus
Anticoagulant, increased risk of bleeding
–
Garlic (excessive doses)
Inhibition of platelet aggregation, increased risk of bleeding
–
German chamomile
Antiplatelet
Coumarin
Ginger
Anticoagulant, increased risk of bleeding
–
Ginkgo
Inhibition of platelet aggregation, decrease in blood viscosity
–
Ginseng
Anticoagulant, antiplatelet
–
Horse chestnut
Anticoagulant
Aesculin (coumarin)
Horseradish
Anticoagulant
Coumarin
Kava kava root
Antiplatelet
–
Licorice
Antiplatelet
Coumarin
Meadowsweet
Anticoagulant
Salicylate
Northern prickly ash
Anticoagulant
Coumarin
Onion
Antiplatelet
Unknown
Papain
Bleeding risk
Unknown
Papaya
Antiplatelet
–
Passionflower
Anticoagulant
Coumarin
Pau D’Arco
Anticoagulant
Lapachol
Poplar
Antiplatelet
Salicin
Quassia
Anticoagulant
Coumarin
Red clover
Anticoagulant
Coumarin
Roman chamomile
Anticoagulant
Coumarin
Safflower
Anticoagulant
Safflower yellow
(Continued)

454
Part 3  Aesthetic Surgical Procedures
Diet and exercise
Our preoperative questionnaire focuses on two other key
areas: diet and exercise history. There are several areas of
concern when evaluating a patient’s dieting and weight
history. Weight cycling – repeated weight loss and weight
gain – is a common pattern for many people who struggle
with their weight.20 When looking at predictors of weight
loss maintenance, those who diet frequently show signifi-
cantly more weight regain than those who diet less fre-
quently.21 Although patients who combine diet and exercise
lose more weight than those who either diet or exercise,
those who lose weight through exercise maintain their weight
loss best.22
If the potential liposuction candidate has recently lost sig-
nificant weight and liposuction is done at this point in their
weight cycle, subsequent weight regain can have a negative
impact on the result. The type of diet that the liposuction
candidate has been on is also important information. Diets
with a behavioral modification component have a higher
degree of success.23 Diets that are very low in calories and fat
have a low rate of success in maintenance as they can cause
the metabolism to slow down to conserve energy, and the
body enters a starvation mode.24 When the dieter returns to
eating normally, regain of weight can be very quick.
Although conventional wisdom has been that the best can-
didates for liposuction are those patients at or near their ideal
weight, patients with body mass indices (BMIs) in the obese
range (Table 27.4) frequently undergo this procedure. These
patients can be good candidates if they are truly looking for
reshaping and not weight loss. It is well documented that
obesity is a risk factor for cardiovascular disease and Type II
anesthetics should also have preservative-free lidocaine,
because the ester metabolite, p-aminobenzoic acid (PABA),
is the allergen which cross-reacts with the metabolite of
methylparaben.15 Epinephrine, which is added to the fluid as
a vasoconstrictor to decrease bleeding, is an endogenous cat-
echolamine to which allergy is not possible. Some patients
are more sensitive to its effects, particularly when it is admin-
istered in a highly vascular area such as the oral mucosa during
dental work. These patients may describe episodes of palpita-
tions in the past. However, even in this group it is rare for a
patient to experience such symptoms following tumescent
anesthesia because adipose is relatively less vascular than the
oral mucosa. When seen, tachycardia due to the epinephrine
in the tumescent infusion is probably due to a hypersensitive
conduction system in the patient.8 This is extremely rare for
us now that we have decreased the epinephrine dose to
0.65 mg per liter bag of tumescent fluid. Some surgeons will
also give clonidine 0.1 mg to every patient with a blood pres-
sure of 100/70 mmHg or greater.8
In many practices patients are given a preoperative dose of
antibiotics that cover Staphylococcus aureus. In the authors’
practice, patients are given 1 g of intravenous Ancef (Watson
Laboratories, Inc, Corona, CA) immediately prior to begin-
ning infusion of tumescent anesthesia. If they are allergic to
penicillin or cephalosporins, they are given oral clindamycin
to start the night before the procedure. Although reactivation
of varicella zoster virus following liposuction has been
reported, we do not advocate pretreatment with antivirals.19
Allergy to latex is also important to note so the surgeon and
assistants are sure to wear latex-free gloves and use latex-free
dressings. Most medical tubing is now latex free and does not
pose a problem.
HERBAL COMPOUND
EFFECT
CONSTITUENT(S)
Southern prickly ash
Anticoagulant
Coumarin
Sweet clover
Anticoagulant
Dicumarol
Sweet vernal grass
Anticoagulant
Coumarin
Tamarind
Increased bioavailability of aspirin and ibuprofen
Tonka bean
Anticoagulant
Coumarin
Turmeric
Antiplatelet
Curcumin
Vitamin E
Inhibition of platelet aggregation and adhesion, interference with
vitamin K-dependent clotting factor (large doses)
Wild carrot
Anticoagulant
Coumarin
Wild lettuce
Anticoagulant
Coumarin
Willow bark
Antiplatelet
Salicylate
Procoagulants
Agrimony
Coagulant
Vitamin K
Alfalfa
Anticoagulant, coagulant
Coumarin, vitamin K
European mistletoe
Coagulant
Coumarin
Goldenseal
Coagulant
Berberine
Green tea
Coagulant
Vitamin K
Plantain
Coagulant
Vitamin K
Stinging nettle
Coagulant
Vitamin K
Yarrow
Coagulant
Achilleine
Adapted from Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35–55 mg/kg for liposuction. J Dermatol Surg Oncol 1990;16:248–26314 and
Eggleston ST, Lush LW. Understanding allergic reactions to local anesthetics. Ann Pharmacother 1996;30:851–857.15
Table 27.2  Herbs that may cause bleeding or thrombosis—cont’d

455
Chapter 27  Liposuction
large-volume liposuction.25–29 Others have reported no
improvement in these parameters.30 Although, follow up in
all of these studies did not exceed 6 months, in the early
postoperative period liposuction does not appear to be detri-
mental to the patient’s metabolic health, and they may even
experience some health benefits.
The exercise history is important as it affects basal meta-
bolic rate, maintenance of weight loss, and overall health of
the patient. Additionally, muscle tone impacts on body
contour in a number of areas where liposuction is commonly
performed. A good physical exam enables the physician to
identify which areas could be improved by increasing muscle
tone. For example, a woman’s dissatisfaction with her upper
arm contour can be the result of excess adipose, skin laxity,
and poor muscle tone. Some women have good muscle tone
in the upper arms, but are looking for individual muscle
definition, as is common in men. Because even the thinnest
women have a higher body fat percentage than men, this look
is usually only attainable if women bring their body fat per-
diabetes mellitus. It has been hypothesized that removal of
subcutaneous fat with liposuction may decrease a patient’s
risk of these conditions by decreasing their overall adiposity.
Several groups have demonstrated short-term improvements
in insulin resistance, inflammatory markers associated with
cardiovascular risk, and glucose levels in patients undergoing
Table 27.3  Medications that interact with lidocaine*
PRECIPITANT DRUG GROUP
EXAMPLES AND COMMENTS
These drugs ↑ lidocaine serum levels (and potential toxicity) – CYP3A4 inhibition†
Antiarrhythmic agents
Amiodarone (an inhibitor), disopyramide, quinidine (competing substrates)
Antibacterial – macrolides/related
Clarithromycin, erythromycin
Antibacterial – other categories
Quinupristin/dalfopristin
Antidepressants – other
Nefazodone
Antidepressants – selective serotonin reuptake inhibitors
Fluoxetine (weak CYP3A4 inhibition), fluvoxamine (also CYP1A2 inhibitor)
Antifungal agents – azoles/triazoles
Ketoconazole > itraconazole > fluconazole
Calcium channel blockers
Diltiazem and verapamil (strong CYP3A4 inhibition), nicardipine (weaker)
Foods and nutrients
Grapefruit, grapefruit juice
HIV drugs – protease inhibitors
Ritonavir, indinavir > saquinavir, nelfinavir, others
Hormone antagonists
Danazol
Sedatives – benzodiazepines
Alprazolam, midazolam, triazolam (all competing substrates only)
These drugs ↓ levels of lidocaine due to CYP3A4 and 1A2 induction (loss of efficacy)
Antibacterial – rifamycins
Rifabutin (CYP3A4); rifampin (CYP3A4 and IA2), rifapentine (CYP3A4)
Anticonvulsants
Carbamazepine, phenobarbital, phenytoin (phenytoin induces CYP3A4 only)
HIV drugs
Nevirapine (CYP3A4 inducer only)
These drugs ↑ lidocaine serum levels (and potential toxicity) – CYP1A2 inhibition
Antiarrhythmic agents
Mexiletine
Antibacterial – fluoroquinolones
Ciprofloxacin, enoxacin, norfloxacin, etc.
H2 antihistamines
Cimetidine
HIV drugs – protease inhibitors
Atazanavir
Leukotriene inhibitors
Zileuton
Miscellaneous drugs
Tacrine
Other interactions of importance involving lidocaine (and related amides)
Antiarrhythmic agents†
Procainamide, tocainide; possibly additive cardiodepressant activity
β-Blockers†
Propranolol, sotalol; ↑ lidocaine levels, risk of arrhythmias
Neuromuscular blockers
Succinylcholine; prolongation of neuromuscular blockade
*Lidocaine (and related amides) are predominantly CYP3A4 substrates, but are also CYP1A2 substrates to a lesser degree.
†Conceptually relatively high-risk drug interactions, although at conservative doses well below the maximum dose listed in this chapter, the risk is fairly low; with higher doses,
be very cautious in patients concomitantly receiving these drugs.
From Huether MJ, Brodland DG, Local anesthetics. In: Wolverton SE, ed. Comprehensive dermatologic drug therapy, 2nd edn. Philadelphia: Saunders Elsevier 2007; 834.16
Adapted from Hansten PD, Horn JR, eds. The top 100 drug interactions: a guide to patient management. Freeland, WA: H & H Publications; 2006.17
Table 27.4  Body mass index
BMI
WEIGHT STATUS
Below 18.5
Underweight
18.5–24.9
Normal
25.0–29.9
Overweight
30.0 and above
Obese
Calculate BMI by dividing weight in pounds (lbs) by height in inches (in) squared
and multiplying by a conversion factor of 703.

456
Part 3  Aesthetic Surgical Procedures
is prudent not to perform liposuction even if the patient is a
good candidate physiologically. Even if they experience an
excellent result from liposuction, they will likely shift their
focus on imperfection to another body site. It is important
when these patients are identified to refer them to a psy-
chiatrist for treatment.35
 TECHNICAL ASPECTS
Physical examination
A thorough physical examination of the liposuction candidate
is important during the initial consultation to evaluate suita-
bility for the procedure. The patient should change into a
gown and stand for the examination. The physician should
discretely examine the fatty prominences, first concentrating
on areas that the patient wishes to have treated, and then
assessing general body proportions.
Areas of fatty prominence should be gently pinched
between the thumb and forefinger to assess the subcutaneous
fat. Having the patient contract the underlying musculature
aids in a complete evaluation. For each area there are certain
maneuvers which help to isolate subcutaneous fatty tissue
and allow assessment of the degree to which the area is acces-
sible to the liposuction cannula. Flexion of the gluteus muscle
is a particularly important maneuver in the buttock region
where muscular laxity and protrusion can contribute to the
overall prominence of the buttock region, including ‘saddle
bags’ (the area of the lateral thigh below the trochanteric
fossa).37 If the outer thigh protuberance decreases with con-
traction of the gluteal muscles, the weight of the buttocks
makes a significant contribution to the outer thigh deformity.9
Inherent skin features of the liposuction candidate should
also be noted. The presence of striae distensae, cellulite, and
actinic damage should be noted in the chart and brought to
the attention of the patient. Striae and cellulite will not
improve with the procedure. Evaluation of skin tone and
elasticity includes pulling the skin away from the patient’s
body and observing elastic recoil. Poor skin tone and elastic-
ity and the presence of actinic damage can limit the overall
improvement in contour due to a reduction in total retraction
and remodeling that can occur.6 For example, in the neck
subplatysmal fat, platysmal banding and excessive skin laxity
can lead to a less than optimal result, but many patients will
choose a less invasive procedure such as liposuction over a
face- or neck-lift procedure because they prefer less morbid-
ity. However, in the experience of many liposuction surgeons,
even patients with poor skin elasticity often achieve worth-
while results. Patients should also be made aware that post-
centage to an extremely low level. This can also give them a
cachectic appearance in the face, upper chest, and neck.
The buttocks and abdomen are other areas where improved
muscle tone positively impacts overall contour, because
muscle tone and extramuscular fat are the primary predictors
of buttock contour. In contrast, abdominal fullness may
also involve intra-abdominal fat, rectus abdominus diastasis
(usually in multiparous women), and ventral hernias.
Expectations
An entire section of our patient questionnaire is devoted to
exploring patient perceptions of liposuction and their goals in
regard to their body and this particular procedure (see Fig.
27.1). During the consultation, we explore the patient’s goals
to ensure that they are congruent with what liposuction can
accomplish.
An elegant study done by Ozgur et al.31 in 1998 looked at
three groups: patients seeking aesthetic surgery (AG), patients
seeking reconstructive surgery (RG), and a control group
(CG) of non-surgery seekers from the normal population.
Each group consisted of 100 people, and all 300 were asked
to complete a sociodemographic questionnaire, the life-satis-
faction index (LSI), a self-esteem inventory (SEI), and a
body-image inventory (BII). The LSI and BII were not sig-
nificantly different between the three groups. The SEI was
significantly better in the AG than the RG.31 This confirms
what we see in practice – that patients seeking cosmetic pro-
cedures generally do not have low satisfaction with their life
or distorted body images.32 Another survey of patients who
had undergone liposuction during a 5-year period revealed
that the majority of patients (80%) were satisfied with their
results.33 Based on this survey, patients who coupled body
contouring with eating a healthy diet and exercising regularly
had higher long-term satisfaction than patients who did not.34
Ten years ago the ideal candidate was described as a person
at their ideal body weight but with disproportionate adiposity
causing a contour deformity. Most liposuction surgeons now
have a broader definition of ‘ideal’ because we have seen
overweight patients (not morbidly obese) with disproportion-
ate adipose distribution who benefit from liposuction. Lipo-
suction is not a weight-loss procedure or substitute for
bariatric surgery. Good candidates are not seeking to lose
weight, but to create a more aesthetic figure at their current
weight. Often, this group of patients is so inspired by the
results of liposuction that they go on to lose weight through
diet and exercise.
During the consultation it is very important to set patient
expectations of the results of liposuction. In all body areas,
this result is limited by the pre-existing bony structure, skin
quality and texture, the tone and build of muscle, and adipose
in the area that is not amenable to liposuction. It is important
that they understand the components that will not be cor-
rected by liposuction alone. Patients are usually very accept-
ing of the imperfections remaining after liposuction if they
are counseled about them in advance of the procedure.
Body dysmorphic disorder (BDD) has become an increas-
ingly recognized condition among dermatology and cosmetic
surgery patients, affecting up to 7–15% of patients in these
practices.35 A diagnosis of BDD is based on the following
three criteria from the American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental Disorders, 4th
edn (DSM-IV) (Table 27.5).36 If a surgeon suspects BDD, it
Table 27.5  DSM-IV diagnostic criteria for body
dysmorphic disorder
1
Preoccupation with an imagined defect in appearance. If a
slight physical anomaly is present, the person’s concern is
markedly excessive
2
The preoccupation causes clinically significant distress or
impairment in social, occupational, or other important areas
of functioning
3
The preoccupation is not better accounted for by another
mental disorder (e.g. dissatisfaction with body shape and
size in anorexia nervosa)

457
Chapter 27  Liposuction
variety of machines available for purchase, and those with a
closed collection system, overflow trap, and disposable air
filter with efficient and uninterrupted suction are ideal.38
Liposuction cannulae may be composed of stainless steel,
aluminum, deldrin, or brass.39 The shape, diameter, hole
placement, and size determine the ease of fat removal, as well
as the relative injury to the tissue. Cannulae with several
holes and large-diameter tapered end (usually 3-mm) holes
placed distally on the tip are more aggressive and allow for
easier fat removal, along with increased potential for bleeding
and trauma to the tissue (e.g. Capistrano, Pinto, Cobra,
Becker, and Eliminator cannulae (Wells Johnson Company,
Tucson, AZ)) (Fig. 27.3A). Cannulae that have smaller diam-
eters (less than 3 mm), blunted ends, fewer holes, and holes
that are placed more proximally and away from the tip are
less aggressive and gentler to tissue (e.g. Klein, Fournier,
Standard cannulae (Wells Johnson Company)) (Fig. 27.3B).
Most liposuction surgeons choose cannulae with various
sizes and match both the type of tip and diameter to the
procedure at hand. In fibrous areas, it is best to start with a
cannula that has an aggressive tip and small diameter. As the
case progresses and fibrous adhesions are diminished, a less
aggressive cannula with a larger diameter can be used. Finally,
in areas where the fat is soft, such as the inner thigh, less
aggressive, smaller cannulae should be used to avoid oversuc-
tion. According to the American Society for Dermatologic
Surgery liposuction guidelines, a cannula for liposuction
should be no larger than 4.5 mm in diameter; however, most
liposuction cannulae are 2–3 mm in size or less.9
Procedure
As with any procedure, review the surgical plan with the
patient and obtain informed consent before beginning.
Patients are given lorazepam 1–2 mg (Ativan, Mylan Pharma-
ceuticals, Inc, Morgantown, WV) – which does not compete
for the enzyme CYP450 – to take the night before and the
morning of surgery. Therefore, all verification of the patient’s
understanding and consent must take place at the preopera-
tive visit. Some surgeons administer oral clonidine 0.1 mg the
day of the procedure if the patient’s resting blood pressure is
greater than 100/70 mmHg to prevent epinephrine-induced
tachycardia. On the day of the procedure, a negative urine
pregnancy test should be confirmed in all premenopausal
women. An intravenous line is placed in an easily accessible
site such as the patient’s dorsal hand. An antibiotic that covers
S. aureus such as cefazolin is administered before infusing the
tumescent anesthesia. A formal surgical scrub should take
place for those in contact with the patient during the proce-
dure. The patient should be prepped with Betadine (Becton,
Dickinson & Co, Franklin Lakes, NJ) or Hibiclens sponges
(Regent Medical, Norcross, GA) with extension of the field
well beyond the area to be suctioned to ensure proper disin-
fection. The patient is then helped into sterile undergarments
for the procedure. Markings, including insertion sites and
areas to be treated, should be placed with a sterile pen. The
patient is then assisted onto the sterile draped table, with care
taken not to contaminate the field. With the physician and
staff gowned and gloved, the procedure may begin.
Tumescent anesthesia
Tumescent solution should be prepared on the day of the
procedure by licensed medical personnel only. The preferred
operative skin redundancy may occur in the lower abdomen
due to a loss of elasticity and that surgical correction may be
necessary following liposuction.
Evaluation of body proportions, shape, and symmetry is
important for two reasons. Bony and muscular asymmetry
(especially scoliosis) can contribute to a poor end result and
must be brought to the attention of the patient during the
consultation. In addition, suction of a localized area, for
example the hips or waist of a patient with ‘saddle bag’ thigh
deformities, can accentuate the unsuctioned deformity.
Therefore, it is important to discuss these issues and together
plan a procedure that will leave a proportional and symmetric
appearance. This may mean extending the procedure to
regions that the patient had not planned on treating initially.
High-quality photographs should be obtained at the initial
consultation. These serve to aid in education of the patient
for procedure planning, as well as to document the
patient’s preoperative appearance. Postoperative photographs
should also be obtained to document the final result of
the procedure.
Surgical suite and set-up
An optimal surgical suite and equipment can enhance surgical
outcomes by providing a safe and comfortable environment
for the patient, the staff, and the physician. The surgical suite
should be large enough to accommodate an electric or pneu-
matic table with vertical mobility, suction machinery, and
liposuction equipment (intravenous pole, infusion pump, and
Mayo stand) with easy access by the physician and staff to
all sides of the patient.38 In addition to the equipment, items
to enhance the comfort of the patient should be available: a
well-padded surgical table, sterile towels for draping the
patient during the procedure, and a warm-water warming
blanket placed underneath the sterile waterproof cover on
the table.39 Sterility should be maintained through the use of
sterile instrument trays, gowns, gloves, masks, surgical caps,
towels, and waterproof disposable fabric for the table.
According to the guidelines of care for liposuction set forth
by the task force on liposuction of the American Academy of
Dermatology, all liposuction surgeons and designated operat-
ing room staff should have training in the management of
acute cardiac emergencies. Baseline vital signs, including
blood pressure and heart rate, should be taken preoperatively
and postoperatively. For procedures removing more than
100 mL of aspirate, the capability for continuous blood pres-
sure monitoring, cardiac monitoring with pulse oximetry, and
supplemental oxygen should be available. A plan for medical
emergencies should also be established.9
A sterile field is established on a Mayo stand at the patient’s
head. On the stand are the infusion and suction cannulae,
sterile tubing, syringes with 1% lidocaine with or without
epinephrine, a #11 blade, gauze, and towel clamps to secure
tubing and drapes in place.
Various mechanical pumps are available for delivering
tumescent solution. Those with variable speed settings are
preferable. The apparatus is prepared by connecting the bag
of tumescent solution to intravenous tubing, which is threaded
through the power pump and connected directly to the infil-
tration cannula or needle.
The mechanical aspiration pump is an electrically powered
machine designed to create negative pressure and collect the
fatty tissue aspirated during the procedure. There are a

458
Part 3  Aesthetic Surgical Procedures
being treated. Epinephrine is added to the solution at a con-
centration of 1 : 1 000 000 (1 mg of 1 : 1000 epinephrine to
1 liter of saline). Lower doses are effective, and in our office,
0.65 mg of 1 : 1000 epinephrine is added to a 1-liter bag of
saline with excellent vasoconstriction and theoretically less
risk of tachycardia. Finally, NaHCO3 is added in the amount
of 10 mEq in 1 liter of solution. The preferred concentration
of NaHCO3 is 8.4%, which contains 1  mEq/mL. Before
adding lidocaine, NaHCO3, and epinephrine, the saline may
be warmed to enhance the comfort of the patient during the
infusion process.41 Heating can be accomplished with a reli-
able microwave, taking great care that the infusion fluid does
not reach a potentially injurious temperature (usually 1
minute is appropriate for a liter bag, but this varies according
to machinery and altitude).
Tumescent anesthesia is administered once the patient is
relaxed and comfortable on the operating table. Insertion
sites should be marked and then anesthetized with buffered
1% lidocaine with epinephrine, usually at a dilution of
1 : 100 000. Incisions are created with a #11 blade through
the dermis to allow for entry of the blunt-tipped infusion
cannula into the subcutaneous tissue. The infusion tubing
should be cleared of air prior to inserting the infusion cannula.
vehicle is 0.9% sodium chloride (saline) in 1-liter or 500-mL
bags. The anesthetic is lidocaine, available in 1% or 2% solu-
tion. It is prudent for an office performing liposuction to
always prepare bags from either 1% or 2% lidocaine to main-
tain uniformity of preparation and minimize error. Epine-
phrine and sodium bicarbonate (NaHCO3) are added to the
solution to aid in vasoconstriction and acidic buffering,
respectively. A conservative dosage guideline for a maximum
lidocaine dose in tumescent anesthesia is 35–45  mg/kg.14
Doses as high as 55  mg/kg have been shown to be safe.18
Lower doses of lidocaine (35  mg/kg) are given when the
patient is taking a medication that interferes with CYP450,
specifically the CYP3A4 isoenzyme, responsible for clearance
of lidocaine. In particularly petite people, lidocaine concen-
trations in the range of 0.05% to 0.75% are typically used as
total dose is limited by the patient’s weight. Higher concen-
trations of lidocaine (0.1%) are generally used for more sen-
sitive areas such as the periumbilical area, inner thighs, waist,
and chest. Elsewhere, a concentration of 0.05% is usually
sufficient to provide adequate anesthesia for the procedure.
The total amount of tumescent fluid required for an antic-
ipated procedure can be estimated using general guidelines
(Table 27.6) aided by experience and dictated by the area
A
B
Spatula
Standard single port
Least aggressive
Dual port spatula
2 port spatula
Eliminator
Texas
Fournier
Moderately aggressive
Triport
Keel cobra
Mercedes
Pinto
Toledo
Most aggressive
Blunt
Bullet
Spatula
Basic tip configurations and tip styles
Figure 27.3  (A) Basic tip configurations and (B) tip styles. (Adapted with permission from Bernstein G. Instruments for liposuction.
In: Coleman WP, Lillis P, eds. Dermatologic clinics, volume 17. Philadelphia: WB Saunders 1999; 743.40)

459
Chapter 27  Liposuction
The cannula should be directed so that the apertures for
suction are facing away from the dermis. Deep and superficial
tunneling should be performed as the physician’s free hand
or ‘smart hand’ monitors the placement of the cannula tip so
as to avoid extending beyond the anesthetized regions.
Initially, the area being suctioned is tense from infusion of
the anesthesia. As suctioning progresses, the area becomes
more flaccid and it helps to use several techniques to stabilize
the tissue so that the surgeon is sure to suction in a consistent
plane. One helpful maneuver is to have an assistant flatten
the region by gently placing countertraction on the skin while
the surgeon continues to suction guided by their free hand.
It is also helpful for the assistant to gently grasp the flaccid
skin adjacent to the suction area of focus and roll in such a
way as to flatten the region being suctioned for the surgeon.
The end point of suctioning is determined by a number of
factors. When a tunnel is empty, the aspirate may be notably
devoid of suctionable fat and become increasingly bloody
with continued suctioning. When this occurs, the cannula
should be repositioned and suction should be stopped in this
area. Pockets of fat should be sought out and removed by
placing the cannula (with the suction apparatus off) into
tunnels and gently pulling back and up against the dermis.
Pockets of fat may become more pronounced with this
maneuver, and further suctioning of these well-defined areas
helps to create a more even result.
The procedure should be planned so that the total volume
of fat removed does not exceed 4500 mL in a single operative
session according to formal guidelines.9 This is usually the
equivalent of 6000–8000 mL of total aspirate, assuming 50–
60% of aspirate is fat. If a patient possesses areas of treatment
where the estimated fat aspirate is greater than 4500  mL,
treatments should be planned over multiple visits.
 OPTIMIZING OUTCOMES
Abdomen
The shape of the abdomen is affected by a number of factors,
including fatty deposition (underneath or overlying the rectus
abdominus), muscle laxity, antecedent abdominal surgery,
and inherent cutaneous features such as scars, striae, and
elasticity. Again, the initial physical examination and consul-
tation should serve to identify the overall shape of the person,
the presence of hernias, scars, a history of previous liposuc-
tion or laparoscopy (which can make subsequent liposuction
more difficult due to fibrous adhesions), and to set realistic
expectations for the procedure and its outcome. Liposuction
achieves excellent results when performed in a young, nul-
liparous woman with toned musculature where skin elasticity
is optimal, and fatty deposition localizes to the lower
abdomen. While most patients presenting for liposuction of
the abdomen do not fall into this category, worthwhile results
may still be achieved, sparing the patient from a procedure
such as an abdominoplasty which has a much longer recovery
period and higher risk profile.
The overall shape of the person should be examined in the
preoperative physical examination. There is a spectrum of
body types, each requiring different areas of focus, ranging
from liposuction of the lower abdomen alone to that of
the upper hips, abdomen, waist, and back. Narins divides
abdominal liposuction patients into five groups based on fat
distribution.45
The infusion cannula is then inserted and the infusion pump
turned on at a rate appropriate for the site being infused. The
infusion rate should be less than 100  mL per minute to
minimize patient discomfort. If using the Klein infiltration
system (Wells Johnson Company), a setting of 2–3 on the
pump is generally tolerated in minimally sedated patients.42
Gentle advancement of the cannula should be preceded by
infusion of the tumescent solution. In smaller areas, such as
the neck, cheeks, and the arms, a lower rate is required to
prevent overinfusion and compression of vital structures.
Anesthesia should be performed in a fanned approach from
each entry site, with care taken not to stretch the entry sites.
It is always preferable to make additional entry sites rather
than to cause large wounds in an attempt to reach the outer-
most portions of the surgical field. If the patient experiences
significant pain with the infusion process, slowing the rate
of the infusion can help to make the pain more bearable.42
The end point of infusion is best appreciated by palpating the
edges of the field, which become firm and indurated when
adequately infused. Within minutes, the area infused will
begin to blanch due to epinephrine-induced vasoconstriction.
Peak serum lidocaine levels are reached between 5 and 17
hours postinfusion.14,43 One group looked at tumescent
anesthesia above the clavicles and demonstrated that peak
serum lidocaine levels are reached sooner in this region than
with infusion of equivalent tumescent anesthesia in the
thighs.44
Once anesthesia is complete, and after allowing 15–20
minutes for the full epinephrine vasoconstriction effect,
suction may begin. Suction should be performed through the
infusion sites. More aggressive, thinner cannulae may be used
first to break up fibrous septae and create tunnels subse-
quently making removal of fat with larger (usually 3 mm),
less aggressive cannulae easier. Suction movement should be
in a linear and vertical manner with little horizontal move-
ment of the cannula in the creation of subcutaneous tunnels.
Table 27.6  Tumescent infiltration: estimated time
and volume
ANATOMIC
AREA
SMALL PATIENT
(min/mL)
LARGE PATIENT
(min/mL)
Outer thighs
15/600
25/1400
Inferolateral
buttocks
4/200
6/400
Inner thighs
15/800
25/1600
Inner knees
5/200
10/400
Hips
15/600
25/1200
Waist
10/300
20/600
Flanks/postaxilla
15/400
25/800
Buttocks
15/400
20/900
Abdomen
30/1400
60/2800
Arms
20/500
30/1000
Male breasts
15/400
30/1000
Male flanks
15/600
25/1000
Time and volume according to patient tolerance. For bilateral symmetric areas, use
double the indicated time per side. Physician may prefer to manually infiltrate chin,
cheeks, jowls, and breasts, which require special techniques.
With permission from Klein JA, ed. Tumescent technique: tumescent anesthesia
and microcannular liposuction. St Louis: Mosby 2000; 228.8

460
Part 3  Aesthetic Surgical Procedures
and detailed). Incision sites are typically made, with two or
three in the suprapubic region, one at the umbilicus, and two
on the lateral portions of the abdominal fat depositions. The
upper abdomen and periumbilical regions tend to be more
tender, and it is helpful to use 0.1% lidocaine to infuse these
areas. The patients should be lying on their back on the sur-
gical table for the procedure. As the patient is awake through-
out, it is helpful to bring the legs into a slightly flexed position
at times during the procedure to make grasping the abdomi-
nal skin easier. Towards the end of the procedure, it is helpful
to examine the patient for fatty pockets while lying in both
lateral decubitus positions, as pockets of fat that appear flat-
tened in a supine position become more apparent as they fall
away from the rectus muscle. The goal of abdominal liposuc-
tion should be to reduce the deeper fatty layers while main-
taining a superficial, even layer of fat attached to the skin.
Oversuction may lead to dimpling of the skin, uneven fatty
depositions, and even dermal necrosis (Figs 27.5 and 27.6)
Hips, outer thighs, and buttocks
Evaluation of a patient for liposuction in these regions requires
a three-dimensional approach. If isolated treatment occurs to
only one of these areas, a disproportionate appearance of
enlargement may occur in the unsuctioned areas. For the
hips, outer thighs, and buttocks it is important to take note
of underlying musculature, cellulite, and inelastic skin. None
of these imperfections can be improved with liposuction. It
is important to discuss with the patient what their ideal shape
would be, as cultural and personal preferences vary.
The first group is the lower abdomen patients. They are
typically those with a thin body habitus and a localized fatty
deposition of the lower abdomen. They tend to respond very
well to liposuction with excellent patient satisfaction. The
second group, those requiring liposuction of both the upper
and lower abdomen, must be carefully evaluated; this group
may also be relatively thin, so suction of the lower abdomen
alone may leave a prominent and possibly overhanging upper
abdomen. It is therefore imperative to do both areas to avoid
an unsightly disproportionate appearance. The third category
includes people who require liposuction of the upper and
lower abdomen, and the hips, waist, and back. They tend to
be older postmenopausal women, or those on hormone
replacement therapy with a history of weight gain.45
Men may also require a similar procedure as fat deposits of
the abdominal area are usually accompanied by fat excess of
the chest, flanks, and back (Fig. 27.4). It is important to note
that men with protuberant abdomens are not always good
candidates for abdominal liposuction because much of the fat
deposition may be behind the rectus abdominus and is there-
fore unsuctionable.
The fourth category of patients demonstrates atrophic,
stretched skin resulting from pregnancy, advancing age, and
‘yo-yo’ weight gain and loss.45 While more extensive liposuc-
tion is needed, it often provides satisfactory improvement. As
such, it is prudent to wait 3–4 months after the initial liposuc-
tion procedure to re-evaluate the patient for possible future
abdominoplasty. The fifth group needs abdominoplasty.
The patient should be marked while standing to accentuate
the larger areas of fatty deposition (which should be outlined
A
B
Figure 27.4  Flanks (A) before liposuction and (B) after liposuction.

461
Chapter 27  Liposuction
A
B
Figure 27.5  Abdomen (A) before liposuction and (B) 1 year after liposuction.
Positioning is key in preventing oversuctioning and result-
ant lipotrop. For the hips, the patient should be in the lateral
decubitus position. For liposuction of the outer thighs, the
patient should also be in the lateral decubitus position. A
surgical pillow is placed between the legs to rotate the femur
anteromedially with the toes pointed inward, mimicking a
standing position.37 Again, the importance of positioning is to
prevent oversuctioning, which is a potential problem in these
areas because the fat tends to be less fibrous. Additionally,
anatomic landmarks such as the trochanteric process create
A
B
Figure 27.6  Abdomen and waist (A) before liposuction and (B) 3.5 months after liposuction.

462
Part 3  Aesthetic Surgical Procedures
thigh liposuction is needed, this is usually recommended as
a serial procedure, as significant lymphostasis may result if
the entire circumference of the thigh is treated at once.8
Liposuction of the knee can create a more attractive,
defined appearance, and is often performed along with lipo-
suction of the medial thigh. A supine or lateral decubitus
position is preferred with treatment of the inferior extended
leg, as a flexed knee can move the medial knee fat pads pos-
teriorly and obscure them. Avoid aggressive suctioning in this
area because injury may occur to lymphatic vessels, creating
a seroma, sensory nerve injury, or damage dermal vasculature
leaving a persistent reticulated hyperpigmentation.8
Arms
Liposuction of the arms is typically done in women who
present with laxity of the proximal arm musculature and a
pendulous fatty prominence. This is best appreciated when
the arms are abducted at 90° from the body. Gentle liposuc-
tion of the medial and posterior (extensor) arm with avoid-
ance of the anterior flexural surface can create a
proportionate, attractive improvement. Oversuctioning must
be avoided. As skin redundancy is usually a significant con-
tributing factor to the arm’s overall appearance, the patient
should be prepared for only decreased convexity of the arms
rather than complete recontouring. Excessive tumescent
infusion should be avoided, as there is a small risk of develop-
ing a ‘compartment syndrome’ where a functional tourniquet
develops distal to the infused region, due to fluid compression
of neural, vascular, and lymphatic structures.8 At least two
positions should be used to gain access to the regions of the
arms that are to be treated. First, position the entire arm
laying flat, palm down, over the hips with the body in a lateral
decubitus position to maximally expose the posterior portion
of the arm. The other position is for the patient to be supine
or in a lateral decubitus position with the hand brought
behind the head, the forearm flexed, and the elbow pointing
away from the face, to expose the posterior portion of the
arm.8 Liposuction of the axilla should be avoided as a number
of important neurovascular structures, including the brachial
plexus, traverse this area. It is often helpful to combine lipo-
suction of the arms with suctioning of the anterior axillary
fat pad, which can become prominent with age. For this, the
patient should be lying supine with the forearm flexed at a
a pseudobulge of the lateral thigh in certain positions, which
can misguide the unprepared or inexperienced surgeon. The
end result of suctioning should be a region that is flat – never
concave. Subcutaneous fat tunnels may not be emptied, in
contrast to the abdomen where empty tunnels are helpful in
determining suction end points. Suctioning should be equal
on both sides and care should be taken to monitor amounts
of fat removed relative to proportions of each side.
Liposuction of the buttock must be done carefully, with
special consideration made to the inferolateral gluteal crease,
where a ‘banana roll’ composed of a defined infragluteal fat
pocket may worsen or lead to a ptotic buttock with oversuc-
tioning. It is advised by some authors to avoid suction of the
‘banana roll’ altogether or to suction superficially to avoid
trauma to the infragluteal ligaments (Luschka’s ligament).37
As always, the physical examination must focus on bony and
muscular prominences and asymmetry. Realistic expectations
should be set, as liposuction will not improve bony asym-
metry, the presence of large or asymmetrical muscle masses,
or skin laxity. Conservative buttock suction is recommended
with removal of no more than 30–50% of fat from the middle
and deep fat layers. Superficial suctioning of the buttocks
should be avoided as it may result in undesirable dimpling
(Fig. 27.7).
The medial thigh and knee
The medial thigh and knee are often considered together
because most women have fat that extends from one region
into the other. Excess fatty deposition here is rarely found in
men. Once again, a potential pitfall in this area is oversuction-
ing. The fat in these regions is much less fibrous than in other
regions and suctioning can quickly lead to overcorrection
defects. Positioning is important when treating the inner
thighs. The patient should be placed in the lateral decubitus
position with the resting, superior thigh flexed into a ‘high
step’ position. It is helpful to place a brick-shaped surgical
pillow underneath this thigh to assist in patient comfort, and
to place the legs in a more anatomic position optimal for
liposuction of the inferior extended leg.8 Careful observation
must be made in the marking phase of the procedure as the
fatty deposits of the medial thigh often encompass the ante-
rior, medial, and posterior thigh, and therefore must be
approached in a three-dimensional manner. If circumferential
A
B
Figure 27.7  Outer thigh (A) before liposuction and (B) after liposuction.

463
Chapter 27  Liposuction
entry points are placed just behind the earlobes, in a neck
crease. Suctioning should begin in the plane of fat just above
the platysma muscle, with subsequent suction more superfi-
cial with small (1.5–2-mm suction cannulae).47 It is crucial to
perforating the platysma with the cannula. This is a concern
particularly in older people who often present with platysmal
atrophy.48 Take care to avoid trauma to the marginal man-
dibular branch of the facial nerve as it drops below the angle
of the mandible in the hyperextended neck and crosses over
the mandible at the anterior border of the massetter muscle.
When the patient’s head is extended, the nerve may be
located as far as two fingerbreadths from the posterior man-
dibular border and become more superficial and more sus-
ceptible to injury.49 It is prudent to use the suction cannula
to elevate the subcutaneous fat away from underlying struc-
tures during suctioning to avoid injury in these areas. Avoid
oversuctioning of the cheeks and jowl–cheek margin, as unde-
sirable dimpling or hollowing may occur.49 Suctioning lateral
to the anterior border of the sternocleidomastoid should be
avoided as there are numerous vital structures traversing in
this area.
The most common postoperative deformities following
liposuction in this region are submental depressions or nodules
and platysmal band deformities requiring surgical correction.
These deformities tend to occur in patients with mild preop-
erative bands, redundant cervical skin, and submental obesity
(Fig. 27.8).50
Male chest
Before undertaking breast liposuction in men, a thorough
history and physical examination is essential. Possible etiolo-
gies for male breast enlargement include fatty deposition,
glandular deposition, medications (estrogens, spironolactone,
digitalis, diazepam, phenytoin, and clomiphene), alcoholism,
hypogonadism, and testicular and adrenocorticosteroid-
secreting tumors.51 Pay special attention to palpation of the
gynecomastia and regional lymph nodes and examine the
testes for testicular tumors.51 Although rare, breast malig-
nancy does occur in men, and an asymmetric, irregular, firm,
or fixed mass warrants a mammogram or biopsy.52
The male breast is one of the more vascular regions on
which liposuction may be performed. Bleeding is minimized
by the tumescent technique and by taking great care not to
traumatize the underlying pectoralis muscle during either
infiltration or suction. The male breast is also one of the most
fibrous regions on which liposuction is performed, varying
greatly in the content of glandular and fatty tissue. This
creates a challenge for the liposuction surgeon during the
procedure and an inherent unpredictability in the results as
fatty tissue is easily contoured by liposuction, while glandular
tissue is not.53 Patients should expect about a 50% improve-
ment in their gynecomastia.8 Persistent glandular tissue may
require excision to obtain optimal results and the possibility
of this must be conveyed to the patient before undergoing
the procedure.8,53,54
Tumescent anesthesia can be done with an infiltration
cannula, or a 25-gauge needle. Incision sites are placed along
the periphery of the breast and in the inframammary crease
to allow for complete infiltration and suction in a criss-cross
pattern. Following infiltration of tumescent solution, it is
helpful to wait 20 minutes before suctioning to allow for
complete fluid dispersion and improved vasoconstriction.53
90° angle and the arm abducted and lying flat on the bed.
Even suctioning of this area is important to avoid unnatural
creases and folds.8
Neck and jowls
Liposuction of the neck and jowls is both safe and successful
in rejuvenation of these regions, giving redefinition of the
cervicomental angle and jawline. Patient selection is para-
mount because concomitant or adjuvant procedures such as
platysma plication, superficial musculoaponeurotic system
(SMAS) plication, carbon dioxide laser resurfacing, chin
implants, and a full face lift are sometimes necessary to
achieve optimal results. An aged appearance in this region is
due to a multitude of factors including ptosis of fatty tissue
and decreased elastic tissue resulting in a loss of the neck sling
function. This allows the anterior margins of the platysma to
slide forward and the submental and submandibular fat to
bulge.46 Fullness in the region can be due to redundant skin,
muscle, or a low or anteriorly positioned hyoid bone (making
for an obtuse cervicomental angle). Patients with low-set or
anteriorly placed hyoid bones are much less likely to benefit
from neck liposuction alone. During the physical examina-
tion, one should note hyoid positioning (which should ideally
be at the level of the C3–C4 vertebrae), the jowls, and the
submental fat. The ideal candidate has full jowls with retained
skin elasticity, a high-set hyoid bone, and a palpable submen-
tal fat pad.47 As in other areas evaluated for liposuction,
having the patient flex underlying musculature can aid in
determining how much of the skin laxity is due to overlying
subcutaneous fat versus fat located underneath the muscula-
ture. Asking the patient to show their lower teeth can accen-
tuate platysmal bands and help identify patients who would
benefit from platysmal plication. It is important to identify
the position of the submandibular salivary glands as ptotic
glands can mimic jowls and cannot be treated by liposuction.47
As with all procedures, expectations for results and recov-
ery must be set well in advance. With liposuction of the neck,
patients should be warned that the area may retain a firm,
indurated, uneven appearance for up to 8 months following
the procedure, particularly after large lipectomies with more
dramatic preoperative skin laxity.48 Male skin often takes
longer to retract than female skin, and the less elasticity
retained, the less optimal the result.47 For marking the neck
of the liposuction patient, the following boundaries should be
noted: the mandibular border, the jowls, submental fat pad,
anterior borders of the sternocleidomastoid, platysmal bands,
and the thyroid cartilage.47 Marking should always be per-
formed with the patient seated in an upright position looking
straight ahead. The optimal position for the patient during
this procedure is with the head gently extended posteriorly,
and the chin raised with a supportive small pillow for neck
support. Tumescent fluid can be infused with a 25-gauge
1.5-inch needle into the submental area, jowl, neck, and
lateral cheeks. Care must be taken not to overinfuse the
buccal region as intraoral airway occlusion can occur.46 Fol-
lowing infiltration, it is preferable to wait for 20 minutes as
this results in adequate vasoconstriction, anesthesia, and dif-
fusion of tumescent fluid (detumescence), which allows for
easier handling of tissues during the procedure.8
Liposuction entry sites are typically placed in the submen-
tal crease at the midpupillary line, just below or lateral to the
jowls. If extensive lateral neck fat is present, two additional

464
Part 3  Aesthetic Surgical Procedures
A measurement of preoperative breast mass, either through
scale or volume displacement, can be helpful when performed
preoperatively, but requires multiple measurements and
standardized conditions. This gives the surgeon some indica-
tion as to how much fat to remove if they consider a percent-
age reduction. The authors avoid promising patients that they
will fit into a specific cup size following liposuction as women
wear and fill their bra cups differently.
A personal or family history of breast cancer is currently
considered a relative contraindication to breast liposuction. A
screening mammogram should be performed preoperatively
and repeated 6 months after liposuction. Although new cysts
and calcifications have been reported on postoperative mam-
mograms, these are distinguishable from the more ominous
radiologic findings associated with breast carcinoma.58 There
have been no reports to date of a patient undergoing breast
liposuction who had undetected breast cancer and subse-
quently developed metastases.58
Premenopausal candidates may express concern about the
effect of liposuction on their ability to breastfeed postopera-
tively. Although there is a paucity of data, there appears to
be little effect on breastfeeding ability following traditional
reduction surgery.59 Patients should be made aware that there
are no such data on the effect of liposuction-based reductions
on breastfeeding.
The patient should be positioned supine with the ipsilateral
arm behind the head or posteriorly displaced to bring the
breast flat against the chest wall. The breast is thoroughly
tumesced with anesthesia (0.1–0.125% lidocaine is prefera-
ble). Two incisions are recommended in the lateral axillary
line and one in the mid-inframammary crease. The suctioning
is concentrated in the deep to mid-plane of the lateral and
inferior quadrants. Less is taken from the upper quadrants as
this flattens naturally with age. The surgeon suctions the
predetermined amount, based on the desired reduction. At
this point most liposuction experts advocate removing small
amounts (about one-third of the measured breast volume) at
Suction is typically begun with microcannulae, allowing for
easier passage through the fibrous tissue. Klein recommends
beginning with a 16-gauge Capistrano cannula (HK Surgical,
Oceanside, CA) for initially tunneling with progression to
usage of the larger 14-gauge microcannula.8 Even the subare-
olar breast tissue may be gently suctioned with the use of a
short (5-cm or 7.5-cm) 16-gauge Capistrano cannula.8
As with other liposuction procedures, open drainage of
insertion sites is recommended with proper compression.
This serves to minimize postoperative ecchymosis and
hematomas.
Female breast
Patients seek treatment for large breasts for several reasons
including neck, shoulder, and back pain, intertrigo, postural
issues, and difficulty purchasing clothing. Traditional reduc-
tion mammoplasty is a major surgical procedure which requires
general anesthesia. It also has a significant risk for infection,
seroma, hematoma, scarring, skin loss, and fat necrosis.55 The
procedure requires an inverted T-shaped incision from the
areola to the inframammary crease, leaving a large, unattrac-
tive scar. Liposuction has been used adjunctively to remove
adipose from the anterior axillary fold and chest wall.56
Most physicians consider women with moderate breast
enlargement good candidates for breast liposuction if their
main complaints are related to breast size.57 Women whose
main complaint is extreme nipple ptosis or excess skin from
gigantomastia will not have an adequate response to liposuc-
tion alone. They are best treated with traditional reduction
mammoplasty with skin excision. Women over the age of 40
with adipose excess elsewhere on their bodies tend to be good
candidates. Young women with large breasts may be good
candidates, but often their excess breast tissue is glandular
tissue not adipose. Liposuction more efficiently removes fat
than glandular tissue, so excess glandular tissue may require
excision.
A
B
Figure 27.8  Neck (A) before liposuction and (B) after liposuction.

465
Chapter 27  Liposuction
suction with blunt-tipped cannulae.67 Most patients will
experience some postoperative bruising in the area suctioned.
It has been reported that up to 26% of patients fail to expe-
rience an improvement in their hyperhidrosis with LC.66 In
these patients, it is safe to perform the procedure a second
time, which often provides the desired results.66 Lack of
improvement may be the result of inadequate resection of
eccrine glands or a compensatory increase in function of the
remaining glands.66 In these patients, the increase in fibrosis
due to the first procedure may make the dissection of the
dermis more difficult for the surgeon. In non-responders,
repeat gravimetry and starch–iodine testing should be per-
formed prior to undergoing a second procedure as the phe-
nomenon of pseudohyperhidrosis, patient-reported excess
sweating without objective evidence, has been reported.66
Complication and response rates are similar between the first
and second surgeries.66 Wollina et al.67 looked at 163 patients
with focal axillary hyperhidrosis and compared minor skin
resection with subcutaneous curettage to suction curettage.
Although subcutaneous curettage was more effective, there
was significantly less downtime and scarring in the suction
curettage group, favoring it as the surgical treatment of choice
for focal axillary hyperhidrosis.68
Axillary bromhidrosis or osmidrosis is the unpleasant odor
that results when skin bacteria decompose apocrine sweat.
Traditional treatments for this are antiperspirants, deodor-
ants, perfumes, and antibacterial soaps. Surgical treatments
are similar to those described for hyperhidrosis.69 LC is
carried out in the same manner as described above; however,
some authors advocate using the Fatemi cannula which has a
total of 10 suction holes in a 3–4–3 configuration with ele-
vated sharpened scraping edges.69,70 The 4-hole side should
be turned to face the subdermis as the apocrine glands are in
the subcutaneous tissue. Additional curettage should be done
around the incision sites because the tissue around them
cannot be removed adequately with liposuction alone.69,70
Other uses for liposuction
Tumescent liposuction has been described by several authors
as an alternative to surgical excision of large, diffuse lipomas.71
When removing lipomas with liposuction, the patient benefits
from a smaller incision; however, it is important to recognize
that the fibrous capsule that typically surrounds lipomas
requires removal with a hemostat through one of the liposuc-
tion cannula entry points to minimize the risk of recurrence.
Complications associated with removal of lipomas with lipo-
suction include residual lesion, bruising, hematomas, and skin
dimpling.71
Other uses for liposuction that have been described include
debulking of plexiform neurofibromas and correction of
lymphedema in patients who failed to respond to conserva-
tive therapy.72,73
 POSTOPERATIVE CARE
Immediate postoperative period
Immediately after the liposuction, decisions must be made
whether to suture insertion points and whether to use a drain.
As a rule of thumb, dependent insertion sites ought to be left
open to drain, and a vacuum suction drain should be utilized
for large abdominal cases (at least 2000 mL fat removed) or
where copious bleeding is noted intraoperatively. Thereafter,
one session, and a serial approach if further reduction is
desired.
Although there is a risk of scarring with any procedure, the
incidence of hypertrophic and keloidal scarring in patients
undergoing breast liposuction is very low.60 Furthermore, the
concern that liposuction will result in worsened nipple ptosis
in these patients has been firmly refuted.59,60 To the contrary,
nipple ptosis has been shown to improve slightly following
liposuction although not to the extent one sees with tradi-
tional reduction mammoplasty.59,60 In addition, patients may
experience improved symmetry and shape.59
Axillary hyperhidrosis and
bromhidrosis/osmidrosis
There has been renewed interest in the treatment of axillary
hyperhidrosis, due to excessive eccrine sweat, and bromhi­
drosis, due to the interaction of apocrine sweat and bacteria.
Mild cases of excessive axillary sweating may be treated with
topical aluminum compounds, oral anticholinergic medica-
tions, or iontophoresis. In patients who do not respond to
these treatments, treatment with botulinum toxin A is an
option although its effects are temporary and repeated treat-
ments can be costly. For patients looking for a permanent
solution, surgery may be a viable alternative; however, surgi-
cal excision of the axillary skin or open adenectomy may lead
to extensive scarring. Endoscopic transthoracic sympathec-
tomy (ETS) is typically reserved for cases of hyperhidrosis
involving more than one body site, due to the frequent side
effect of compensatory hyperhidrosis.61 ETS is not consid-
ered first-line treatment for focal axillary hyperhidrosis as it
is more effective for primary palmar hyperhidrosis.61
Liposuction of the axilla for treatment of hyperhidrosis was
initially described using a blunt cannula; however, the stand-
ard liposuction cannula is inadequate for curettage of sweat
glands in the deep dermis. The method of liposuction-
curettage (LC)62 uses an aggressive rasping cannula and has
been shown to be more effective than traditional liposuction.63
Preoperatively, some surgeons recommend that gravimetry
studies be done to determine axillary sweat rates in mg/min.
Patients with higher sweat rates respond better to LC versus
those with normal to slightly elevated sweat rates.64
The patient is brought to the operating suite, and the
hyperhidrotic areas are identified with the Minor starch–
iodine test and the areas are marked. The arms are abducted
90–110° and the axillae are infused with tumescent anesthe-
sia.63,65 Two small incisions are made at the superior and
inferior axillary borders outside the marked area and a cannula
with a rostriform tip is inserted. The cannula is rotated such
that the holes face upwards towards the dermis. It should be
noted that this is the opposite of cannula positioning for
traditional liposuction. Criss-cross tunnels are created so that
the undersurface of the dermis is removed rather than the
adipose tissue because eccrine glands are located in the deep
dermis and upper subcutaneous tissue. Complete dissection
of the dermis and subcutaneous tissue is performed with the
primary end point being elevation of the axillary skin from
subcutaneous tissue and slight lividity of the skin.66
Postoperatively, patients wear a figure-of-eight compres-
sion dressing for 10 days. It should be noted that patients
undergoing LC with rasping cannulae have a higher rate of
side effects such as hematoma and erosion, due to the more
aggressive nature of the procedure versus conventional lipo-

466
Part 3  Aesthetic Surgical Procedures
certain fibrous septae that can be released by changing the
direction of suction. A decrease in cannula diameter can also
eliminate the problem. The areas can be reinfiltrated with
tumescent fluid, although the surgeon must be cognizant of
the total lidocaine dose the patient has received. If the area
is small, the surgeon can directly inject 5–6 mL of 1% lido-
caine with epinephrine into it. Finally, a small amount of
intravenous pain medication (25 mg of fentanyl (Durogesic;
Jansen Pharmaceutic, Titusville, NJ)) can get the surgeon
past the problem area.
Occasional ventricular ectopy can be present in some
patients and is often undiagnosed before the procedure as the
patients are not symptomatic. If known to be present, the
patient should be referred to a cardiologist for control of
the ectopy prior to surgery. Although this is a rare occur-
rence, it can necessitate canceling the procedure.
Vasovagal reaction is always possible with any procedure
and is managed with supportive care (Trendelenburg posi-
tion, cool packs, oxygen). Klein recommends 0.3 mg atropine
given intravenously.8
Tachycardia secondary to epinephrine in the infusion can
virtually be eliminated by two measures: first, by decreasing
the epinephrine from 1  mg to 0.65  mg in each bag of
local anesthetic; and second, by giving 0.1 mg clonidine to
all patients with blood pressure over 100/70 mmHg preop-
eratively. In our practice we have adopted the former
measure.
Infection is a rare complication of tumescent liposuction.74
We pretreat our patients with cefazolin or clindamycin as
noted earlier. Postoperative infections should be treated with
the appropriate oral or intravenous antibiotics based on bacte-
rial culture results, severity of the infection, and the presence
of systemic symptoms.
The cannula entrance sites should heal in 7–10 days with
appropriate technique. During the surgery it is important
not to stretch or excessively traumatize the entrance sites. It
is always better to make a new or larger entrance site if nec-
essary to reach a remote area or accommodate a larger
cannula. The most common cause for poor healing is through
non-compliance with wearing Band-Aids over the sites after
drainage stops. The written postoperative instructions must
be very clear on this point, as leaving the sites unoccluded
delays healing and results in less than optimal scarring.
Patients should be warned that entrance sites, like any healing
wound, can develop hyperpigmentation at 2–3 months.
Treatment with hydroquinone 4% or mequinol 2% (with or
without tretinoin) will successfully reverse this over several
weeks.
For the experienced liposuction surgeon, less than optimal
fat reduction of the target area occurs in a few circumstances.
Sometimes the surgeon incorrectly assesses the amount of fat
in the subcutaneous layer. This is probably more likely to
happen with the abdomen than any other area. Less than
complete suctioning of an area can also occur because the
patient is not tolerant of the procedure and the usual meas-
ures failed to make them comfortable, or an unusually bloody
aspirate causes premature termination of suctioning.
Lawrence & Butterwick studied the number of touch-up
procedures done in a large liposuction practice. They found
that over a 2-year period, 12.3% of 954 liposuction proce-
dures had a touch-up procedure.75 Men and women had an
equal number of touch-up procedures. The most common
areas for touch up were the neck and abdomen. These were
patients are brought to a standing position gradually to
prevent orthostatic hypotension. Excess fluid is expressed by
compressing the areas with a towel. This is ideally performed
in a shower if one is readily available in the surgical suite. A
seat should be available because the patient may experience
a vasovagal reaction. The patient is then cleaned off with
sterile sponges or a cloth. Absorbent pads (such as sanitary
napkins or HK pads) are placed over the incision sites and
held in place with tape or a tubular elastic retainer (Surgilast;
Glenwood, Inc, Tenafly, NJ).
The patient is assisted into the girdle and the appropriate
binder is placed over the girdle for the abdomen and neck
areas. Klein advocates a technique of bimodal compression
– that is heavy compression in the first 24 hours to facilitate
drainage and then mild compression for another 2–4 days.8
According to Klein, the traditional approach of prolonged
(2–4 weeks) heavy compression can result in post-traumatic
edema. Klein postulates that excessive compression can
impair subcutaneous lymphatic drainage, impeding lymphatic
uptake of large osmotically active molecules.8
The incision sites should be treated with moist occlusion
as soon as the drainage has ceased. A spot Band-Aid (Johnson
& Johnson Medical, Arlington, TX) is preferable to a strip
Band-Aid as the adhesive that completely surrounds the
central non-stick pad provides a more complete seal.
 PITFALLS AND THEIR MANAGEMENT
Pitfalls and their management
Intraoperative
 Discomfort: ‘hot spots’ with inadequate anesthesia – reinfiltrate
with local anesthesia; consider administration of intravenous
pain medicine.
 Bigeminy: ventricular ectopy; epinephrine hypersensitivity.
 Vasovagal: Trendelenburg position and comforting the patient
(consider atropine).
 Tachycardia: if blood pressure greater than 100/70 mmHg,
consider clonidine.
Immediate postoperative
 Infection: start IV antibiotics. Culture nasal passages of all
personnel who assist with the procedure. Consider using
phophylactic antibiotics in the future.
 Poor healing of insertion sites: scar revision may be needed in
the future; monitor for proper technique.
 Decreased skin sensation and dysesthesias: improves with
time.
 Irregularity in target area: counsel the patient to expect that a
‘touch up’ may be necessary.
 Seroma – compression: leave dependent insertion sites open;
consider short-term drains.
Long term
 Less than optimal reduction of target area: consider ‘touch up’
after 1 year.
 Weight gain: exercise and diet control.
During the course of the procedure, the patient may com-
plain that one or two areas are hypersensitive even if they are
well infiltrated. The surgeon can try one of several measures
to overcome this. First, try approaching the area from another
entry site. Sometimes the discomfort is due to a pull on

467
Chapter 27  Liposuction
 SUMMARY
Liposuction with local (tumescent) anesthesia is a procedure
that was originated and developed by dermatologic surgeons.
It is a procedure with excellent longevity of results and high
patient satisfaction. Studies by Bernstein, Hanke, Coleman,
and Housman of dermatologic liposuction have repeatedly
shown that it is an extremely safe and effective procedure.79–82
Tumescent liposuction should be considered as an option
in appropriate patients desiring a more sculptured physical
appearance.
 REFERENCES
1. Klein JA. The tumescent technique for liposuction surgery. Am J Cosmet
Surg 1987;4:263–267.
2. Schrudde J. Lipexheresis liposuction for body contouring. In Grazer F,
ed. Clinics in plastic surgery, volume 11. Philadelphia: WB Saunders
1984; 445–456.
3. Fischer A, Fischer G. First surgical treatment for molding body’s cellulite
with three 5-mm incisions. Bull Int Acad Cosmet Surg 1976;3:35.
4. Fournier P. Body sculpturing through syringe liposuction and autologous
fat re-injection. Corona del Mar: Samuel Rolf International; 1987.
5. Illouz Y. Body contouring by lipolysis: a 5-year experience with over 3000
cases. Plast Reconstr Surg 1983;72:591–597.
6. Butterwick J. Liposuction. Consultation and preoperative considerations.
In: Narins RS, ed. Safe liposuction and fat transfer. New York: Marcel
Dekker 2003; 41–67.
7. Kelley L. Lipotoxic at low lidocaine levels. World Congress on Liposuc-
tion, Detroit, Michigan, 2000.
8. Klein JA. Tumescent technique: tumescent anesthesia and microcannular
liposuction. St Louis: Mosby; 2000.
9. Coldiron B, Coleman WP, Cox SE, et al. ASDS guidelines of care for
tumescent liposuction. Dermatol Surg 2006;32:709–716.
10. Canonico M, Plu-Bureau G, Lowe GD, et al. Hormone replacement
therapy and risk of venous thromboembolism in postmenopausal women:
systematic review and meta-analysis. BMJ 2008;336:1227–1231.
11. Butterwick KJ. Should dermatologic surgeons discontinue hormonal
therapy before tumescent liposuction? Dermatol Surg 2002;28:1184–
1187.
12. Dineheart SM, Henry L. Dietary supplements: altered coagulation and
effects on bruising. Dermatol Surg 2005;31:819–826.
13. Shiffman MA, Warning about herbals in plastic and cosmetic surgery.
Plast Reconstr Surg 2001;108:2180–2181.
14. Klein JA. Tumescent technique for regional anesthesia permits lidocaine
doses of 35–55  mg/kg for liposuction. J Dermatol Surg Oncol
1990;16:248–263.
15. Eggleston ST, Lush LW. Understanding allergic reactions to local anes-
thetics. Ann Pharmacother 1996;30:851–857.
16. Huether MJ, Brodland DG. Local anesthetics. In: Wolverton SE, ed.
Comprehensive dermatologic drug therapy, 2nd edn. Philadelphia: Saun-
ders Elsevier 2007; 834.
17. Hansten PD, Horn JR, eds. The top 100 drug interactions: a guide to
patient management. Freeland, WA: H & H Publications; 2006.
18. Ostad A, Kageyama N, Moy RL. Tumescent anesthesia with a lidocaine
dose of 55  mg/kg is safe for liposuction. Dermatol Surg 1996;22:
921–927.
19. Andrews TR, Perdikis G, Shack RB. Herpes zoster as a rare complication
of liposuction. Plast Reconstr Surg 2004;113:1838–1840.
20. Brownell KD, Rodin J. Medical, metabolic, and psychological effects of
weight cycling. Arch Intern Med 1994;154:1325–1330.
21. Pasman WJ, Saris WH, Westerterp-Plantenga MS. Predictors of weight
maintenance. Obes Res 1999;7:43–50.
22. Skender ML, Goodrick GK, Del Junco DJ, et al. Comparison of two-year
weight loss trends in behavioral treatments of obesity; diet, exercise, and
combination interventions. J Am Diet Assoc 1996;96:342–346.
23. Wing RR, Greeno CG. Behavioral and psychosocial aspects of obesity
and its treatment. Baillière’s Clin Endocrinol Metab 1994;8:689–703.
24. McCargar LJ. Can diet and exercise really change metabolism? Medscap
Women Health 1996;1:5.
25. Robles-Cervantes JA, Yanez-Diaz S, Cardenas-Camarena L. Modification
of insulin, glucose and cholesterol levels in nonobese women undergoing
liposuction – is liposuction metabolically safe? Ann Plast Surg 2004;52:
64–67.
also the most commonly treated sites. Most touch ups were
done on the back, chest, and ankles. The weight pattern after
liposuction may play a role as 47% of these patients had
increased weight.
It is important when approaching the issue of touch up to
set reasonable expectations with the patient. Some patients
are looking for a level of perfection – a completely seamless
contour – that is simply not achievable for most. If a touch-up
procedure is anticipated, we prefer that they wait a year
before proceeding as subcutaneous fibrosis will continually
remodel and an area that may appear to be uneven at first
may smooth out. It is important that the surgeon appreciates
the abnormality that the patient wants corrected. It is a
mistake to resuction an area because the patient demands
it. If there is no correctable problem, there is no end
point for the procedure. The patient that complains of per-
ceived deformities that are not clinically evident is rarely
pleased with touch-up procedures. It is best to deal with
this patient directly and not get caught up in a cycle of
procedures.
It is very common for a patient to notice another area of
adiposity once their target area is corrected. The best way to
prepare them for this is to discuss it preoperatively. We try to
make note and point out during the initial physical examination
any areas that might appear disproportionate once the target
area is reduced. This has to be done carefully as it is important
for the patient not to feel pressured to add additional areas.
Once patients are made aware of this phenomenon, they are
much more reasonable when they notice disproportionate
adjacent areas postoperatively. If the remaining areas bother
them enough, they schedule additional liposuction.
Long-term outcome
Early in the screening for liposuction procedures, we spend
a considerable amount of time learning about patients’ past
weight patterns, diet, and exercise history. We discourage any
candidates that have a chronic weight cycling pattern, or have
recently lost more than 9 kg, but have not maintained that
loss for at least 6 months. Patients who use medications to
lose or maintain weight are also discouraged until they are
able to maintain their weight at least 6–12 months off med-
ication. The biggest pitfall in the long-term result for liposuc-
tion is subsequent weight gain. If a patient gains weight after
liposuction, the area liposuctioned will resist weight gain.
This may cause fat to accumulate in a new area (including
one not amenable to liposuction – that is, deep to muscle),
or to distribute unevenly.
In the first scenario, the enlargement of a new area is some-
times a welcomed event. Yun et al.76 retrospectively reviewed
73 liposuction cases and 34% of these patients reported sub-
jective breast enlargement. This result has been recognized
by several other investigators and this is typically a phenom-
enon in patients who subsequently gain weight after the pro-
cedure.77,78 In a patient with a small abdomen that was
fine-tuned with liposuction, even a small weight gain can
increase abdominal girth by increasing fat deep to the rectus,
and negate the results of the liposuction. The neck and the
abdomen have fatty areas deep to muscle that can enlarge
with weight regain.
In the second scenario, patients are often happier with
evenly distributed weight gain than they were with a dispro-
portionate adiposity.

468
Part 3  Aesthetic Surgical Procedures
55. Short K, Ringler SL, Bengston BP, et al. Reduction mammoplasty. A safe
and effective outpatient procedure. Aesthetic Plast Surg 1996;20:
513.
56. Matarasso A, Courtiss EH. Suction mammoplasty; the use of suction
lipectomy to reduce large breasts. Plast Reconstr Surg 1991;87:
709–717.
57. Moskovitz MJ, Muskin E, Baxt SA. Outcome study in liposuction breast
reduction. Plast Reconstr Surg 2004;114:55–60.
58. Mellul SD, Dryden RM, Remigio DJ, et al. Breast reduction performed
by liposuction. Dermatol Surg 2006;32:1124–1133.
59. Harris L, Morris SF, Freiberg A. Is breast feeding possible after reduction
mammaplasty? Plast Reconstr Surg 1992;89:836–839.
60. Moskovitz MJ, Baxt SA, Jain AK, et al. Liposuction breast reduction: a
prospective trial in African American women. Plast Reconstr Surg
2007;119:718–726.
61. Dumont P, Denoyer A, Robin P. Long-term results of thoracoscopic
sympathectomy for hyperhidrosis. Ann Thorac Surg 2004;78:1801–
1807.
62. Bechara FG, Sand M, Sand D, et al. Surgical treatment of axillary hyper-
hidrosis: a study comparing liposuction cannulas with a suction curettage
cannula. Ann Plast Surg 2006;56:654–657.
63. Darabaneanu S, Darabaneanu HA, Niederberger U, et al. Long-term
efficacy of subcutaneous sweat gland suction currettage for axillary hyper-
hidrosis: a prospective gravimetrically controlled study. Dermatol Surg
2008;34:1170–1177.
64. Lee MR, Ryman WJ. Liposuction for axillary hyperhidrosis. Australas J
Dermatol 2005;46:76–79.
65. Bechara FG, Sand M, Tomi NS, et al. Repeat liposuction-currettage
treatment of axillary hyperhidrosis is safe and effective. Br J Dermatol
2007;157:739–743.
66. Bechara, FG, Sand M, Hoffmann K, et al. Aggressive shaving after com-
bined liposuction and curettage for axillary hyperhidrosis leads to more
complications without further benefit. Dermatol Surg 2008;34:952–
953.
67. Wollina U, Kostler E, Schonlebe J, et al. Tumescent suction curettage
versus minimal skin resection with subcutaneous curettage of sweat
glands in axillary hyperhidrosis. Dermatol Surg 2008;34:709–716.
68. Perng CK, Yeh FL, Ma H, et al. Is the treatment of axillary osmidrosis
with liposuction better than open surgery? Plast Reconstr Surg
2004;114:93–97.
69. Seo SH, Jang BS, Oh CK, et al. Tumescent superficial liposuction with
curettage for treatment of axillary bromohidrosis. J Eur Acad Dermatol
Venereol 2008;22:30–35.
70. Lee D, Cho SH, Kim YC, et al. Tumescent liposuction with dermal
curettage for treatment of axillary osmidrosis and hyperhidrosis. Derma-
tol Surg 2006;32:505–511.
71. Choi CW, Kim BJ, Moon SE, et al. Treatment of lipomas assisted with
tumescent liposuction. J Eur Acad Dermatol Venereol 2007;21:243–
246.
72. Babovic S, Bite U, Karnes P, et al. Liposuction: a less invasive surgical
method of debulking plexiform neurofibromas. Dermatol Surg 2003;29:
785–787.
73. Warren AG, Brorson H, Borud LJ, et al. Lymphedema: a comprehensive
review. Ann Plast Surg 2007;59:464–472.
74. Katz BE, Bruck MC, Felsenfeld L, et al. Power liposuction: a report on
complications. Dermatol Surg 2003;29:925–927.
75. Lawrence L, Butterwick KJ. Immediate and long-term postoperative care
and touch-ups. In: Narins RS, ed. Safe liposuction and fat transfer. New
York: Marcel Dekker 2003; 329–341.
76. Yun PL, Bruck M, Felsenfeld L, et al. Breast enlargement observed after
power liposuction. A retrospective review. Dermatol Surg 2003;129:
165–167.
77. Finzi E. Breast enlargement induced by liposuction. Dermatol Surg
2003;29:928–930.
78. Frew KE, Rossi A, Bruck MC, et al. Breast enlargement after liposuction:
comparison of incidence between power liposuction versus traditional
liposuction. Dermatol Surg 2005;31:292–296.
79. Bernstein G, Hanke CW. Safety of liposuction. A review of 9478 cases
performed by dermatologists. J Dermatol Surg Oncol 1988;14:1112–
1114.
80. Hanke CW, Bullock S, Bernstein G. Current status of tumescent liposuc-
tion in the United States. Dermatol Surg 1996;22:595–598.
81. Coleman WP III, Hanke CW, Lillis P, et al. Does the location of the
surgery or the specialty of the physician affect malpractice claims in
liposuction? Dermatol Surg 1999;25:343–347.
82. Housman TS, Lawrence N, Mellen BG, et al. The safety of liposuction:
results of a national survey. Dermatol Surg 2002;39:971–978.
26. Giugliano G, Nicoletti G, Grella E, et al. Effect of liposuction on insulin
resistance and vascular inflammatory markers in obese women. Br J Plast
Surg 2004;57:190–194.
27. D’Andrea F, Grella R, Rizzo MR, et al. Changing the metabolic profile
by large-volume liposuction: a clinical study conducted with 123 obese
women. Aesthetic Plast Surg 2005;29:472–478.
28. Busetto L, Bassetto F, Zocchi M, et al. The effects of the surgical removal
of subcutaneous adipose tissue on energy expenditure and adipocytokine
concentrations in obese women. Nutr Metab Cardiovasc Dis 2008;18:
112–120.
29. Esposito K, Giugliano G, Scuderi N, et al. Role of adipokines in the
obesity–inflammation relationship: the effect of fat removal. Plast Recon-
str Surg 2006;118:1048–1057.
30. Klein S, Fontana L, Young VL, et al. Absence of an effect of liposuction
on insulin action and risk factors for coronary heart disease. N Engl J Med
2004;350:2549–2557.
31. Ozgur F, Tuncali D, Guker Gursu K. Life satisfaction, self-esteem, and
body image: a psychosocial evaluation of aesthetic and reconstructive
surgery candidates. Aesthetic Plast Surg 1998;22:412–419.
32. Hanke W, Cox SE, Kuznets N, et al. Tumescent liposuction report per-
formance measurement initiative: national survey results. Dermatol Surg
2004;30:967–978.
33. Broughton G, Horton B, Lipschitz A, et al. Lifestyle outcomes, satisfac-
tion, and attitudes of patients after liposuction: a Dallas experience. Plast
Reconstr Surg 2006;117:1738–1749.
34. Rohrich RJ, Broughton G, Horton B, et al. The key to long-term success
in liposuction: a guide for plastic surgeons and patients. Plast Reconstr
Surg 2004;114:1945–1952.
35. Glaser DA, Kaminer MS. Body dysmorphic disorder and the liposuction
patient. Dermatol Surg 2005;31:559–561.
36. American Psychiatric Association. Diagnostic and statistical manual of
mental disorders, 4th edn. Washington, DC: American Psychiatric Asso-
ciation; 1994.
37. Cox SE. Violin hips, outer thighs, and buttocks. In: Narins RS, ed. Safe
liposuction and fat transfer. New York: Marcel Dekker 2003; 121–148.
38. Monheit GD. The surgical suite for the liposuction surgeon. In: Narins
RS, ed. Safe liposuction and fat transfer. New York: Marcel Dekker 2003;
19–28.
39. Bernstein G. Instrumentation for liposuction. Dermatol Clin 1999;
14:735–749.
40. Bernstein G. Instruments for liposuction. In: Coleman WP, Lillis P, eds.
Dermatologic clinics, volume 17. Philadelphia: WB Saunders 1999;
743.
41. Yang CH, Hsu HC, Shen SC, et al. Warm and neutral tumescent anes-
thetic solutions are essential factors for a less painful injection. Dermatol
Surg 2006;32:1119–1123.
42. Narins RS, Coleman WP. Minimizing pain for liposuction anesthesia.
Dermatol Surg 1997;23:1137–1140.
43. Nordstrom H, Stange K. Plasma lidocaine levels and risks after liposuc-
tion with tumescent anaesthesia. Acta Anaesthesiol Scand 2005;49:
1487–1490.
44. Rubin JP, Xie Z, Davidson C, et al. Rapid absorption of tumescent lido-
caine above the clavicles: a prospective clinical study. Plast Reconstr Surg
2005;115:1744–1751.
45. Narins RS. Abdomen, hourglass abdomen, flanks, and modified abdomi-
noplasy. In Narins RS, ed. Safe liposuction and fat transfer. New York:
Marcel Dekker 2003; 95–119.
46. Kamer FM, Binder WJ. Avoiding depressions in submental lipectomy.
The Laryngoscope 1980;90:1396–1400.
47. Jacob CI, Kaminer MS. Surgical approaches to the aging neck. In Narins
RS, ed. Safe liposuction and fat transfer. New York: Marcel Dekker 2003;
197–214.
48. Goddio AS. Suction lipectomy. The gold triangle at the neck. Aesthetic
Plast Surg 1992;16:27–32.
49. Adamson PA, Cormier R, Tropper G, et al. Cervicofacial liposuction.
Results and controversies. J Otolaryngol 1990;19:267–273.
50. Kamer FM, Minoli JJ. Postoperative platysmal band deformity. A pitfall
of submental liposuction. Arch Otolaryngol Head Neck Surg 1993;
119:193–196.
51. Narula HS, Carlson HE. Gynecomastia. Endocrinol Metab Clin North
Am 2007 Jun;36:497–519.
52. Bermant M. Gynecomastia-dynamic technique. In Narins RS, ed. Safe
liposuction and fat transfer. New York: Marcel Dekker 2003; 215–234.
53. Fruhstorfer BH, Malata CM. A systematic approach to the surgical treat-
ment of gynaecomastia. Br J Plast Surg 2003;56:237–246.
54. Wiesman IM, Lehman JA, Parker MG, et al. Gynecomastia: an outcome
analysis. Ann Plast Surg 2004;53:97–101.

469
28
Autologous Fat Transfer: Evolving
Concepts and Techniques
Kimberly J Butterwick MD
Summary box
 There is increasing demand for fat transfer as a means of
facial volume restoration in cosmetic rejuvenation, where it
not only is a corrective technique for soft tissue defects and
rhytides but also it corrects the atrophy due to the aging
process.
 Because of improved understanding of the process of
neovascularization and fat as a living graft, the emphasis has
shifted from overcorrection to transfer of small volumes of fat.
 Autologous fat is usually harvested by gentle syringe
aspiration and concentrated by centrifugation prior to
reinjection into subcutaneous fat or muscle.
 Fat autograft muscle injection follows the patient’s anatomic
landmarks by placing fat within or adjacent to facial muscles.
 Potential complications of all fat transfer techniques include
nodule formation due to overcorrection, fat necrosis, infection,
and vascular occlusion, most of which can be avoided by
careful, sterile technique.
 Data on long-term outcomes are scarce and largely based on
two-dimensional photography. Further research on outcomes
and factors affecting survival of adipocytes is needed and
will necessitate finding an improved means of objective
measurement.
 INTRODUCTION
Fat augmentation is a popular and effective method for
restoring volume to facial and body defects utilizing a variety
of techniques. In many regards, fat fulfills the criteria as the
ideal filling substance. It is readily available in most patients,
inexpensive, non-allergenic, has no potential for infectious
disease transmission, and has high patient acceptance. How
well fat fulfills other key criteria of an ideal filler, such as
predictability and persistence of correction over time, is con-
troversial. This chapter will examine the evolving concepts in
fat transplantation and the debates regarding the optimal
techniques for achieving long-term results.
Historical vignette
The history of fat transfer dates back to 1893 in an oft-quoted
report by Neuber involving transfer of 1-cm pieces of fat from
the arm to facial depressions caused by tuberculosis.1 Lexer
utilized fat for facial hemiatrophy and malar augmentation in
1910.2 Bruning was the first to report injecting fat through a
needle in 1919.3 In the 1950s, Peer noted a 40–50% retention
of transplanted fat at 1 year.4 In the late 1970s and early
1980s, increasing interest in fat transplantation techniques
was stimulated by advancements in liposuction by Illouz.5 Fat
could now be extracted by suction rather than the older exci-
sion method. Fat grafting was still an open or semi-open
procedure until Fournier’s discovery in 1985 that fat could
be extracted with a syringe and needle.6 The popularity of fat
transfer subsequently grew and provoked further inquiry into
optimal techniques for harvesting, processing, and injection
of fat for achieving adipocyte survival and longevity of results.
The literature of the 1980s abounds with anecdotal and
empirical reports regarding fat cell viability but few, if any,
controlled studies. Some reported dissatisfaction with tran-
sient results.7
The 1990s brought a second, even more explosive surge of
interest in liposuction, with an 8-fold rise in the number of
procedures performed in the United States from 1990 to
1999.8 This growth was due in large part to Klein’s introduc-
tion of the tumescent technique, allowing liposuction to be
performed less invasively under local anesthesia with minimal
postoperative downtime and unparalleled patient safety.9 The
increase in liposuction procedures fueled an increased inter-
est in using fat for correction of soft tissue defects and
furrows. The 1990s also gave rise to an aging ‘baby boomer’
population with an increased demand for non-surgical reju-
venating procedures, including fat augmentation.10
New trends
Concepts and techniques regarding fat transfer changed
during this period. One of the most significant changes in
technique has been a shift from overcorrecting to transferring
small volumes of fat.11 This reflects a transition in the concept
of fat as a temporary reabsorbed filler to fat as a living graft.
In the 1980s and early 1990s, it was not uncommon for large
volumes of fat to be placed with deforming overcorrection of
50% or more.12–14 It was reasoned that all the fat was absorbed
and that overcorrection would result in more fibrosis. The
rate of resorption of these volumes was often variable, unpre-
dictable, and asymmetric.
The theory of fat survival postulates that following transfer
to the recipient site, the transplanted fat becomes ischemic.
Some cells die and others survive as intact adipocytes or

470
Part 3  Aesthetic Surgical Procedures
soft tissue.22–27 These concepts of aging diverge from the tra-
ditional view, that facial aging is a result of gravity-induced
ptosis. Restoring volume to the aged face is now becoming an
integral part of facial rejuvenation in addition to – or in some
cases instead of – more conventional methods. In order to
restore full facial volume, larger quantities in the range of
20–100  mL or more are required. Such quantities are not
currently feasible with synthetic fillers primarily due to
expense of numerous syringes and the temporary nature of
most synthetic fillers. Autologous fat is the natural choice for
volume correction of this degree. The challenge is the same,
whether filling a furrow with fat or replacing full facial volume.
How do we achieve optimal longevity of transferred fat?
Controversies in performing the procedure
Autologous fat transfer is a multistep procedure. A review of
the literature reveals that the proper method of performing
every step of the procedure has been the subject of debate.
At issue is the survival of the adipocyte and what factors have
a positive or negative impact on survival (Box 28.1).
Each of these factors has been examined to some degree
but definitive answers are lacking. Although the literature
is replete with anecdotal reports, there are few objective
studies. The difficulty in establishing consensus is a reflection
of the difficulty in measuring outcome. There is no practical
method to objectively document results. Transferred fat
cannot be labeled or distinguished from recipient site fat cells
with a distinct histologic marker. Successive imaging with
magnetic resonance or ultrasonography is expensive and
exposes the patient to unnecessary radiation. Measuring
outcome is further complicated by variable rates of aging over
time and changes in weight over time. We must therefore
rely on photographic results until a better means of assessing
outcome is available.
 PREOPERATIVE PREPARATION
A preoperative history and physical examination are per-
formed to screen for serious medical conditions, concomitant
preadipocytes until a blood supply is established from the
periphery. In the late 1980s, Coleman championed the sur-
vival theory of fat grafting and developed a method he called
Lipostructure™.15 He advocated placing small parcels of fat
with repetitive passes into multiple tissue planes, reasoning
that a blood supply was more easily established. Gentle atrau-
matic handling of the fat cells was required for survival of the
cells. Others reported improved longevity with smaller injec-
tion volumes and less traumatic harvesting and processing.16
In 1993, Carpaneda & Ribeiro17 validated these empiric find-
ings when they compared viability of fat cylinders of different
diameters. They found that smaller injected volumes, less
than 3 mm in diameter, had optimal viability. At 2 months,
viable fat cells were noted only in the peripheral zone of
larger grafts having diameters of 3.5 mm or more.17 The core
of larger grafts had undergone necrosis due to lack of vascu-
larization. In a recent review of the literature, small-volume
transfer was the common denominator in studies reporting
good longevity of fat.18
During the 1990s and into the 21st century we have also
seen an expansion in the indications for fat transfer. In the
1980s, fat was typically injected directly under rhytides or
soft tissue defects. A relatively new concept in rejuvenation
of the aging face is replacement of volume loss; not simply
injecting fat under specific rhytides and furrows, but rather
full-face volume restoration.
It has been increasingly recognized among aesthetic sur-
geons that rhytidectomy alone does not necessarily rejuvenate
a patient’s appearance. Berman thoughtfully challenges the
traditional concepts of rejuvenation, stating that the taut skin
achieved through rhytidectomy may not equate with a youth-
ful appearance.19 He and others recognize the need to correct
the atrophy of hard and soft tissues that occurs with age to
achieve a truly rejuvenated appearance (Fig. 28.1).19–22 It has
also been pointed out that rhytidectomy may cause soft
tissues to thin out even more, resulting in accelerated aging
and a skeletonized appearance.20
In addition to atrophic changes in soft tissues, remodeling
of the craniofacial skeleton is now recognized to occur
throughout life and impart further changes to the overlying
A
B
Figure 28.1  30-year facial volume loss.

471
Chapter 28  Autologous Fat Transfer: Evolving Concepts and Techniques
of saline for tumescent anesthesia, the viability increased to
85%. This study of preadipocytes and other studies of adi-
pocytes33 may help to explain why lidocaine has been used
for decades with apparent success for donor site anesthesia.
Differing dilutions of tumescent anesthesia have been recom-
mended with or without epinephrine. Amar21 recommends
infiltrating Klein’s solution much like a ring block around the
core of fat to be harvested in order to minimize contact with
lidocaine. A few authors recommend the use of Ringer’s
lactate rather than normal saline, reasoning that glucose-
containing solution may enhance fat cell viability.11
Harvesting technique
Utilizing an enzymatic assay of fat cell damage, Lalikos et al.34
showed that harvesting by suction versus direct excision of
fat did not increase apparent damage to the fat cell. Other
studies have also indicated that fat cells harvested by syringe,
machine aspiration, or direct excision all appear to have
similar viability. Suction aspiration at low-level negative pres-
sure did not appear to rupture cells in two studies, although
partial breakage was seen at negative pressures of 700 mmHg
and higher.
Syringe aspiration with low negative pressures is most often
recommended (Fig. 28.2). Those advocating the gentlest han-
dling suggest 10-mL syringes to minimize vacuum pressures
with the plunger held back no more than 2–3 mL.11,12,15 Other
experienced surgeons report harvesting with larger 20–60-mL
syringes without harming the fat cells, as documented with
cell culture for up to 2 months.35 Although various cannulae
and needles have been recommended, Shiffman & Mirrafati36
compared harvesting and reinjection with 2.5–3.0-mm can-
nulae or an 18-gauge needle. None of these caused disruption
of fat cells histologically.
Processing the fat
Once the fat is harvested, the next issue is whether or not it
requires further processing before injection. All would agree
on the first step, which is to stand the syringes upright for a
period of 15–60 minutes to allow separation into supranatant
and infranatant fractions (Fig. 28.3). The infranatant fluid is
then drained off the bottom and the oil fraction on top is
infections, bleeding diatheses, medications, and allergies.
Medications containing aspirin and non-steroidal anti-
inflammatory agents are discontinued 2 weeks before surgery.
Vitamin E and certain herbal formulations should be discon-
tinued before surgery. Prophylactic oral antibiotic therapy
may be started the night before the procedure: cephalexin
500 mg orally twice daily for 7 days, or minocycline 100 mg
orally once or twice daily for penicillin-allergic patients. To
minimize potential bruising, mephyton may be prescribed.
The choice for the donor site is discussed with patients in
advance. Benefits and risks are reviewed, as well as the post-
operative sequelae. It is important to inform patients of
expected downtime in advance.
 TECHNICAL ASPECTS
Harvesting
Donor site
The optimal donor site has not been unequivocally estab-
lished. Many choose the outer thigh as the ideal site due to
its non-fibrous nature and relative avascularity. The rationale
is that the least vascularized tissue will best survive the initial
hypoxic period after transfer. Hudson et al.28 found that adi-
pocytes from the buttock and outer thigh areas are the largest
and have the greatest lipogenic activity. Ullman et  al.29
injected fat from various sites into nude mice and found the
outer thigh fat to have the lowest resorption rate. In any given
patient, availability of fat is certainly a factor. Indeed, many
patients desiring improvement of a gaunt facial appearance
have very little body fat and one must obtain fat wherever
possible. Areas that are diet resistant such as the knee are
often recommended in that, theoretically at least, the trans-
planted cells will be stable whether the patient gains or loses
weight over time.
Use of lidocaine
Some studies indicate that lidocaine has a negative effect on
fat cell viability. This has been shown both with lidocaine 1%
and diluted lidocaine 0.1%.30,31 The effect could be removed
by rinsing with saline. In contrast to these earlier studies,
Keck et al.32 examined the effect of various local anesthetic
solutions on the viability of preadipocytes in vitro and found
the opposite to be true. After incubation for 30 minutes,
simulating the time of clinical exposure, cell viability was
found to be highest with lidocaine 1% at over 80% viability
versus articaine 1% at 55%, ropivacaine at 51%, and prilocaine
at 26%.32 Of interest, when the articaine was diluted in 1 liter
Figure 28.2  Gentle harvesting with a 10-mL syringe held back
with 1–2 mL pressure.
Box 28.1  Controversial factors in fat
cell survival
 Choice of harvesting site.
 Degree of negative pressure during harvesting.
 Diameter and type of harvesting cannula.
 Exposure of fat cells to air, blood, or lidocaine.
 Centrifugation of the fat.
 Rinsing the fat.
 Vascularity and mobility of the recipient site.
 Diameter and type of injecting cannula or needle.
 Freezing fat for later use.

472
Part 3  Aesthetic Surgical Procedures
glycogen, or growth factors but definite benefit has yet to be
demonstrated.
Injection techniques
The most common placement for transplanted fat is within
the subcutaneous fat.16,45,46 The suggested degree of overcor-
rection has decreased from originally 50% to 30% to now with
minimal or no overcorrection.4,11,44,45 Smaller volumes of fat
are thought to improve graft survival as previously mentioned.
Small volumes also reduce downtime for patients because
postoperative edema, as a general rule, is directly propor-
tional to the amount transferred.47,48 Retrograde injection
with gentle pressure is performed to minimize injecting a
large bolus of fat and to reduce the rare risk of intravascular
injection. The cannula is inserted and advanced to the most
distal site. Fat is then injected as the cannula is withdrawn
and small parcels of fat are placed. The recommended syringe
size for transfer varies from 10  mL36,48 to 3  mL11,45 to
1 mL.15,40,49 The author prefers the 1-mL syringe as less pres-
often decanted off. In Griffin’s survey of experienced cos-
metic surgeons, 62% wash the fat with saline or Ringer’s
lactate to remove lidocaine or blood.37 Lidocaine has been
shown to affect fat cell growth in culture and blood is thought
to stimulate phagocytosis of fat cells.38 In Sommer & Sattler’s
review, all authors agreed that blood in transplanted fat accel-
erates degradation of transplanted fat.18
Rather than rinse, many surgeons prefer to centrifuge the
fat. A survey of 508 plastic surgeons revealed that 47% cen-
trifuge, 29% rinse fat, and 12% transfer directly without
any processing.39 Centrifugation has been shown to separate
fat cells from blood products, proteases, free lipids, and
lipases which may degrade freshly grafted adipocytes.40
Various speeds and time intervals for centrifugation have
been recommended. Histologically, fat cells centrifuged for
10–60 seconds at 3600 rpm show no evidence of cell damage
although cells centrifuged for 15 minutes have been shown
to have distorted morphology.36,41 Whether or not centrifuga-
tion removes lidocaine has not been demonstrated. Centrifu-
gation does concentrate fat cells, resulting in a larger number
of cells per mL of volume transferred (Fig. 28.4). When
10 mL of fat is centrifuged at 3600 rpm for 1–3 minutes,
there is approximately 30–40% of the volume separated at
the bottom as a bloody fluid (Fig. 28.5). In one of the few
controlled studies, a double-blind comparison of fat transfer
to the dorsum of the hands with centrifuged versus non-
centrifuged fat, improved longevity and aesthetic results were
observed with the centrifuged fat at the 3-month and 5-month
follow-up visits in 100% of patients (Fig. 28.6).42 The author
now routinely utilizes centrifuged fat in essentially all cases.
Fulton et al.11 use centrifuged fat for facial correction, but
prefer non-centrifuged fat for larger-volume transfers into
breasts, biceps, or buttocks – areas in which lumpiness has
been noted with centrifuged fat. One must use sterilized
canisters or sleeves within the centrifuge, as Pseudomonas and
other pathogens have been cultured from the centrifuge.43
Another method of fat processing has been examined by
Moscatello et  al.44 involving the addition of collagenase in
order to dissociate the fat graft into smaller cellular packets.
In-vitro ceiling culture showed a greater than 80% viability
compared to 17% without the rather lengthy processing pro-
cedure. Others have looked at the addition of human albumin,
Figure 28.3  Syringes held upright for 10 minutes separate into
supranatant and infranatant fractions.
Figure 28.4  Centrifuged fat on left appears more concentrated
and cohesive on injection than non-centrifuged fat.
Figure 28.5  Before and after centrifugation at 3600 rpm for 3
minutes. Note 30–40% volume loss.

473
Chapter 28  Autologous Fat Transfer: Evolving Concepts and Techniques
Indications for fat augmentation
The most common indications for fat augmentation of the
face include the nasolabial fold and the marionette fold.
Other indications for fat transfer of the face include augmen-
tation of the cheeks, malar area, and chin. In the past decade,
cosmetic surgeons have begun to restore soft tissue volume,
not simply under the rhytide or defect, but for full-face
volume correction. Newer approaches for restructuring the
face include Lipostructure™,15 panfacial rebalancing,37 and fat
autograft muscle injection (FAMI).21
Body areas which are sometimes augmented with fat are
the buttocks, biceps, calf, and breast. Fat augmentation of
the breast is a controversial area given that calcifications
may develop postoperatively.54–56 Although these calcifica-
tions have been shown to differ radiographically from those
caused by breast cancer, the areas could require biopsy,
causing undue morbidity for the patient.55 Rejuvenation of
the dorsum of the hands is another indication for fat augmen-
tation. Generally, 10  mL or less is placed in each hand,
although Coleman recommends 20–30 mL per hand.57 Other
common indications for fat augmentation are defects from
sure is required to empty it and the size of the fat particles
is smaller (Fig. 28.7). When transferring to smaller syringes,
a female-to-female adapter is available and allows transfer
without exposure to air. Prolonged air exposure has been
demonstrated to negatively impact fat cell viability.50 A
10-mL syringe rack is useful for placing and securing the
upright syringes (Fig. 28.8).
Both blunt-tipped cannulae and 14–25-gauge needles have
been advocated for transfer.51 Some studies have suggested
the minimum diameter size of the injection instrument be no
smaller than 18-gauge to prevent damage to the fat cell.52,53
In Shiffman & Mirrafati’s study, injection with smaller-
diameter 20-gauge and 22-gauge needles caused damage to
adipocytes as evidenced by histologic changes in cellular and
nuclear morphology.36 Blunt-tipped cannulae reduce the risk
of bleeding and the rare risk of intravascular injection.
However, it is argued they pass through tissue with more
friction and trauma, which may cause increased bleeding and
inflammation in the recipient site.
A
B
Figure 28.6  (A) Before and (B) 12 months after long-term survival of the fat in the dorsum of the hands. Note improved result on
patient’s left hand with centrifuged versus non-centrifuged fat.
Figure 28.7  Fat particles are smaller when injected through a
1-mL syringe versus a 10-mL syringe with similar injection
pressures.
Figure 28.8  Syringe rack for securing upright 1-mL and 10-mL
syringes.

474
Part 3  Aesthetic Surgical Procedures
addresses areas of fat hypertrophy that are found in the aging
face.22 Microliposuction of the jowls and other areas is typi-
cally performed during the fat transfer procedure for aes-
thetic rebalancing (Fig. 28.9).
Fat autograft muscle injection
Most cosmetic surgeons agree that an abundantly vascularized
recipient site for transplanted fat will result in optimal sur-
vival of the fat, an opinion confirmed by several histologic
studies.12,17,37,58 French anatomist and plastic surgeon, Roger
Amar, has incorporated this principle into a technique, in
which fat is injected into or immediately adjacent to the
muscles of facial expression, and which he coined FAMI.
The concept of FAMI was inspired by a study in 1996 by
Guerrerosantos et  al., in which they demonstrated 5-year
survival of fat in rat muscle.59 Muscle thickness continued to
increase for 6 months following fat grafting. The FAMI tech-
nique involves full-face volume correction following the land-
marks of the patient’s own anatomy, namely the origin and
insertion of various muscle groups. Volumes placed range
from approximately 20 mL to 70 mL, utilizing a set of blunt-
tipped cannulae which are curved and angled to conform to
the skeletal contours of the face (Fig. 28.10). There is less
apparent trauma than methods by Coleman and others using
over 30 repetitive passes per syringe: with FAMI a 1-mL
syringe is emptied in one to three passes The fat is placed
along vectors which parallel blood supply, minimizing trauma
to the vessels. Patients are able to return to work in 3–7 days
depending on volumes placed. Amar has reported longevity
of 3–5 years with this method.60
FAMI can be performed as a full-face volume correction
or for localized volume loss such as the lips, tear-trough
deformity, chin, or perioral regions; however, a filler such as
hyaluronic acid should be favored to be used for the lips.
FAMI is ideal after rhytidectomy in patients with thin, overly
taut skin. It is also indicated in conjunction with liposuction
of the neck for replacing volume of the chin, mandibular
border, pre-jowl notching, and lower perioral regions61 (Fig.
28.11). Patients are asked to bring a photograph of them-
selves taken 10–20 years before the consultation in order to
appreciate the volumes that have been lost. In restoring the
disease or trauma, for example acne scars, linear morphea,
lupus profundus or erythematosus, and cellulite.
Lipostructure™
Sidney Coleman was one of the first to champion the place-
ment of small ‘parcels’ of fat in order to facilitate neovascu-
larization. He was also one of the first to advocate full-face
three-dimensional enhancement of youthful contours, which
he termed Lipostructure™. His method involves an intricate
layering of minute quantities of fat within multiple tissue
planes, not only in the subcutaneous plane but also adjacent
to bone, fascia, and muscle. Each droplet of fat is placed
‘within 1.5 mm of living vascularized tissue.’ Typically, 30 or
40 passes are required to empty a 1-mL syringe with a blunt-
tipped 17-gauge or 18-gauge cannula. Quantities injected for
a full face often exceed 100 mL. Because the fat is viewed
as a living graft, it is handled gently with atraumatic harvest-
ing, no rinsing, and brief centrifugation for 30 seconds.
Coleman15 reports long-term results with his method in the
order of years. ‘Before and after’ photographs suggest that
Lipostructure™ may replace the need for rhytidectomy. The
single most significant drawback to this method is the marked
edema seen for weeks or months postoperatively. The benefit
of dramatic panfacial correction must be weighed against the
extended recovery period for the patient.
Facial rebalancing
In order to circumvent prolonged edema for the patient,
Donofrio modified Coleman’s procedure with a method of
‘fat rebalancing,’ also involving the entire face but with
repeated smaller procedures (6–12) over a 1–2-year period.40
Fresh fat is utilized the first time, but in most patients, frozen
fat is injected on subsequent visits. The entire face is treated
with smaller total quantities (approximately 20–30  mL),
which reduces the downtime for patients to 1–10 days,
depending on the extent of the procedure. Fat is processed
atraumatically and injected with blunt-tipped cannulae with
the intricate, repetitive pass, layered method recommended
by Coleman. Fat is placed exclusively in the subcutaneous
space. Donofrio focuses not only on replacing fat but also
A
B
Figure 28.9  (A) Before and (B) after
facial rebalancing. (Courtesy of L
Donofrio.)

475
Chapter 28  Autologous Fat Transfer: Evolving Concepts and Techniques
or intravenous sedation depending on individual patient
requirements. Amar’s technique, which evolved over the past
7 years, now has a second step after muscle injection consist-
ing of supraperiosteal injections of highly centrifuged fat
which he believes consists of more stem cells. These injec-
tions would theorectically compensate for bone loss if these
cells could be shown to differentiate into bone in vivo.
The postoperative course of FAMI is unremarkable. There
is essentially no pain and little bruising, which appears on the
second or third day. Edema is the most significant symptom
and patients need to be warned in advance or they will be
concerned that too much fat has been placed (Fig. 28.15).
The recovery period will depend on the quantities placed.
With a full-face correction of 70 mL, the patient may require
7–10 days of downtime. In a preliminary report, the author
utilized 20–30 mL on average for partial-face corrections with
good results65 (Fig. 28.16). This lower total volume replace-
ment reduces the downtime to 3–5 days. Complications of
this technique have not been reported except for the usual
postoperative sequelae of bruising, edema, and temporary
palpable lumpiness, which is not generally visible. Potential
complications are discussed below.
Figure 28.10  FAMI injection cannulae are curved and angled to
conform to musculoskeletal contours.
A
B
Figure 28.11  (A) Before and (B) after lower face FAMI with 9.7 mL injected and concomitant liposuction of the neck. Note improved
chin height and mandibular border.
muscle sling of the face, the overlying skin drapes in the
smooth, uninterrupted contours of youth.
Amar’s harvesting and processing techniques include utiliz-
ing the medial knee as his preferred donor site, and process-
ing of the fat with centrifugation at 3600 rpm for 3 minutes.
Injection into the muscles is based on knowledge of the
origin, insertion, and plane of each muscle to be injected as
well as familiarity with the bony landmarks of the skull62–64
(Table 28.1 and Fig. 28.12). Specific injection cannulae have
been developed for various muscle groups, allowing for
smooth passage of the cannula. The cannula is directed to the
origin or insertion of the muscle and the fat is injected in a
retrograde fashion with low injection pressure (Figs 28.13
and 28.14). There are three ways the surgeon determines that
he/she is injecting in the muscle. For certain muscles, the
bundle can be palpated as the enveloping fascia is filled.
Other muscles are very thin, not palpable, and the surgeon
must rely on bony anatomic landmarks to guide the injection
as close as possible to the muscle. With some muscle groups,
a loss of resistance is the clue that the cannula has penetrated
the fascia and is within the muscle. Anesthesia for this pro-
cedure is achieved with nerve blocks, supplemented with oral
Table 28.1  Facial muscles commonly injected in FAMI
MUSCLE
PLANE
Frontalis
Superficial
Procerus
Superficial
Corrugator
Deep
Orbicularis oculi
Superficial
Zygomaticus minor
Superficial
Levator labii superioris alaeque nasi
Mid
Levator labii superioris
Mid
Levator anguli oris
Deep
Zygomaticus major
Mid
Depressor labii inferioris
Mid
Depressor anguli oris
Mid
Mentalis
Deep
Buccinator
Deep
Risorius
Mid
Platysma
Mid
Orbicularis oris
Mid

476
Part 3  Aesthetic Surgical Procedures
A
Corrugator supercilii
(frontalis and orbicularis
oculi cut away)
= Superficial
Key
Muscle layers
= Mid
= Deep
Frontalis
Orbicularis oculi
Palpebral part
Orbital part
Buccinator
Risorius
Orbicularis oris
Procerus
Levator labii superioris
alaeque nasi
Levator labii superioris
Zygomaticus minor
Levator anguli oris
Zygomaticus major
Mentalis
Depressor labii inferioris
Depressor anguli oris
Platysma
Facial muscles commonly injected in FAMI: lateral view
Figure 28.12  Muscles of facial expression. (A) Side view. (B) Front view.
 OPTIMIZING OUTCOMES
The optimal results will be determined by proper placement
and by survival of the fat cells.
Longevity
The literature contains few objective studies regarding the
longevity of transplanted fat. Horl et  al.66 demonstrated a
49% volume loss at 3 months, 55% loss at 6 months, and
negligible loss between 9 and 12 months utilizing magnetic
resonance imaging of fat transplants. Ultrasound imaging has
been utilized to demonstrate long-term correction up to 1
year in patients with defects due to disease processes.67,68
Another prospective study analyzed longevity via computed
tomography scanning with three-dimensional volume analysis
in HIV patients treated with the Coleman method.69 Not
only did fat endure at 1 year, but for unknown reasons, there
was a tendency for the volume to increase from the 2nd to
12th month. Saddick & Hudgins70 used a marker of fatty acid

477
Chapter 28  Autologous Fat Transfer: Evolving Concepts and Techniques
B
Frontalis
Orbicularis oculi
Palpebral
part
Orbital
part
Buccinator
Risorius
Orbicularis oris
Procerus
Levator labii superioris
alaeque nasi
Corrugator supercilii
(frontalis and orbicularis
oculi cut away)
Levator labii superioris
Zygomaticus minor
Levator anguli oris
Zygomaticus major
Mentalis
Depressor labii inferioris
Depressor anguli oris
Platysma
= Superficial
Key
Muscle layers
= Mid
= Deep
Facial muscles commonly injected in FAMI: anterior view
Figure 28.12, cont’d
Figure 28.13  Injection of the zygomaticus minor with cannula
#4.
Figure 28.14  Injection of the depressor anguli oris with cannula
#5.

478
Part 3  Aesthetic Surgical Procedures
composition that was specific to the donor site. They were
able to demonstrate a 1-year persistence of that marker in
the recipient site in one of six patients. In the other five, the
donor site marker was undetectable. They speculated that
perhaps recipient site factors caused conversion of the donor
site marker to the fatty acid composition of the recipient site.
Animal studies have shown long-term survival of autologous
fat. Nguyen et al.71 found persistence of transplanted fat in
rats at 9 months when fat was injected into the muscle. Fat
injected into the subcutaneous plane was completely
absorbed. Guerrerosantos reported 5-year survival of fat
when injected into rat muscle.59
Studies based on photographic results and physician assess-
ment have reported long-term results varying from ‘disap-
pointing’ to many years.7,11,45,46,48,72–75 Some have noted the
longest survival when the recipient site is relatively immobile,
such as the fixed scars of linear morphea,13 the forehead,16
the infraorbital area,11 or the backs of the hands76,77 (see Fig.
28.6). In a study of scleroderma-induced facial scars, these
results were corroborated: the forehead had the greatest
retention with 51–75% of correction remaining at 1 year,
while scars of the chin and nose showed poor retention of
correction with less than 25%.78 The most mobile area of the
face – the lips – has been least responsive to long-term cor-
A
B
Figure 28.15  Postoperative edema on day 3 after FAMI of lower face with 30.3 mL injected.
A
B
C
Figure 28.16  (A) Before; (B) 5 weeks after; and (C) 8 months after partial-face FAMI with 24.7 mL.
rection.11,53 Eremia & Newman found that longevity was
related to recipient site.53 Good to excellent results were seen
at 5–8 months for the nasolabial and melolabial folds and poor
results were observed in the lip and glabella. Perez notes more
permanent results in younger patients.74 Based on the limited
objective data, animal studies, and empirical results from
experienced cosmetic surgeons, one can conclude that long-
term fat survival is achievable. Further studies are ongoing to
define the factors resulting in optimal survival.
Touch-up procedures
Many recommend touch-up procedures for optimal results.
There are several reasons that touch-up procedures are per-
formed. With the use of small volumes for fat transfer, one
treatment session may not be adequate to achieve optimal
volume restoration. In addition, the patient may not have
enough downtime to undergo placement of more than 30 mL,
yet have a deficit of 100 mL or more. There is also variable
longevity of transplanted fat from months to years due to
incompletely understood factors. Ongoing aging and/or
weight loss of patients further contribute to the need to
replace additional fat after the initial session (Fig. 28.17).
Lastly, patients are often reluctant to have too much volume

479
Chapter 28  Autologous Fat Transfer: Evolving Concepts and Techniques
Data have been presented in this chapter to help the new
surgeon weigh the merits of the various methods. The author
has experience in many different techniques and has found
the FAMI technique a logical, learnable procedure with pre-
dictable results.
A typical protocol in the author’s practice is to have one
larger session of FAMI with 30–40  mL of fresh fat and
expecting a downtime of 5–7 days. This is followed by one
to three touch-up sessions, at intervals of 4–6 months, of less
than 10 mL of frozen fat. These smaller sessions heal over a
weekend (Box 28.2). Variations from this protocol include
injection sessions monthly or every other month for 1–2 years
with frozen fat for gradual sequential augmentation.40 Others
repeat the entire initial session every few years as needed
with fresh fat.15 Fournier advocates periodic injections every
few years to keep pace with the aging process.75 He also
regularly uses frozen fat as needed for touch-up procedures.
 PITFALLS AND THEIR MANAGEMENT
The complication rate is low with all fat augmentation
techniques.
placed, particularly in the lips, but when they see the initial
results, they realize they would like an even fuller look.
Use of frozen fat
Frozen fat is commonly utilized in clinical practice for aug-
mentations and touch-up procedures with apparently pleas-
ing results.40,48,75 However, it is argued that freezing fat affects
its viability. It is certainly efficacious to use frozen fat for
touch-up procedures rather than reharvest in a sterile fashion.
Few studies have addressed this question. Histologic studies
have shown frozen and thawed adipocytes that are identical
to those of normal tissue.79 Takasu & Takasu79 reported long-
term retention of fat that had been frozen for up to 7 years.
Shoshani et al.80 compared frozen fat versus fresh fat injected
into nude mice. Assessments by clinical observation, weight
and volume measurement, and histologic parameters demon-
strated successful take at 15 weeks in both groups with no
statistically significant difference in volume at 15 weeks. In
a side-by-side comparison study of fresh versus frozen fat
injected to the dorsum of the hands, it was found that frozen
fat lasted as long or longer at 3-month and 5-month inter-
vals.81 Indeed, aesthetically, the hand with the frozen fat was
preferred at the 3-month and 5-month follow up (Fig. 28.18).
The frozen fat was preferred initially as well in a majority of
patients because there was less postoperative edema of the
hand. Another study compared the viability of adipocytes
frozen with four different methods: snap frozen in liquid
nitrogen without media; frozen at −20°C without media;
incubated at 37°C with 10% bovine serum; or incubated
without media.82 The fat simply frozen at −20°C showed only
a slight drop in mitochondrial activity at 8 days, and all other
methods had a >60% drop in mitochondrial activity. However,
other studies reject the use of frozen fat. Lawrence found
no viable adipocytes in frozen aspirates measured by cell
culture.83 Research regarding the viability of frozen fat is
ongoing and clearly needed. In some countries, the legal
requirement is that fat is stored in a freezer for later use and
must fulfill the requirements for organ transplantation. These
regulations limit the use of frozen fat in transplantation.
Protocol for FAMI technique
With so many techniques and opinions, it may be confusing
for the novice in fat augmentation to know how to begin.
A
B
Figure 28.17  Dramatic facial volume
changes due to weight loss of only 10–15
pounds (4.54–6.81 kg) such as this will
significantly affect longevity of fat
augmentation.
Figure 28.18  Fresh fat (patient’s left) versus frozen fat (patient’s
right) in dorsum of hands. Equal or better results seen with
frozen fat at 5 months.

480
Part 3  Aesthetic Surgical Procedures
Overcorrection is probably the most common complication,
particularly in the infraorbital area. Visible, superficial nodules
may develop with overcorrection of this area, or from inject-
ing too large a bolus of fat too superficially (Fig. 28.19).
Caution is advised in this area if it is to be injected at all.
Experienced surgeons recommend that very minute quanti-
ties are injected in the periorbital area with each pass of a
1-mL syringe.49,84 Overcorrection may be difficult to treat.
Low-dose steroid injection, repeated massage, and excision
have been suggested treatments.49,84
Other complications are sometimes seen after fat augmen-
tation. Fat hypertrophy may follow weight gain after fat
augmentation, and may require surgical revision.85 The sym-
metry with the FAMI technique appears to mitigate this
problem (Fig. 28.20). Fat necrosis may occur on occasion,
resulting in extrusion of fat. Infection is another potential
complication. Patients need to be screened adequately for
concomitant, recurrent, or chronic infections, particularly of
adjacent facial areas such as sinus, dental, or ocular regions.86
These infections need to be adequately treated before under-
going the procedure. The use of prophylactic antibiotics is
Figure 28.19  Overcorrection in infraorbital region with
numerous small visible nodules.
A
B
Figure 28.20  (A) Before and (B) 2 years
after full-face FAMI in a 39-year-old man.
The patient’s face is symmetric despite a
10 lb (4.5 kg) weight gain. (Courtesy of R
Amar.)
Box 28.2  Author’s protocol for FAMI
 Sterile prep and drape.
 Donor site anesthesia with Klein’s tumescent formula.
 Nerve blocks of the face.
 Gentle harvesting with 10-mL syringes.
 Syringes held upright and infranatant fluid discarded.
 Full 10-mL syringe centrifuged at 3600 rpm for 3 minutes.
 Oil and infranatant fractions discarded.
 Transfer to 1-mL syringes.
 Inject cephalad to caudad each muscle group, bilaterally.
 Postoperative checks at 24 hours and 1 week.
 Evaluate for touch-up session at 4–6 and 8–10 months
postoperatively.
 Touch up injections with <10 mL of frozen fat p.r.n.
Pitfalls and their management
 Avoid overcorrection due to injection of a large bolus of fat; as
the infraorbital area is most prone to overcorrection, this area
is best done by the experienced surgeon using only minute
quantities with low injection pressure.
 Screen patients preoperatively for infection, especially in facial
areas, and treat prior to surgery. Use antibiotic prophylaxis
in all patients and use sterile technique in all steps of the
procedure.
 Avoid intravascular penetration by using blunt-tipped
cannulae, retrograde injection after withdrawal to assure one
is not intravascular, and minimal injection pressure with 1-mL
syringes.

481
Chapter 28  Autologous Fat Transfer: Evolving Concepts and Techniques
addition, adipocyte stem cells are known to release angiogenic
growth factors, which may facilitate neovascularization. The
isolation of these cells has been expensive and time consum-
ing and only a few studies have examined their use.97,98 In one
clinical study, adipose-derived stem cells were injected into
three patients with defects from Perry Rhomberg disease or
lupus profundus.99 Duration and clinical improvement were
rated higher than three control patients receiving traditional
fat transfer although statistical improvement was not demon-
strated. The isolating process took 90 additional minutes in
this study and involved centrifugation and digestion with col-
lagenase. Such processes may be applied in the clinical setting
more commonly if a clear benefit in outcome or duration
from the addition of progenitor stem cells can be demon-
strated.
Fratila100 suggested that lymph drainage 1 day after surgery
may reduce postoperative edema. Lymph drainage is a very
gently performed superficial massage, which will not affect
the viability of the transplanted fat cells, but reduces
postoperative edema. The reduction in edema lowers the
surrounding pressure on the transplanted fat, which will
maximize the result of the fat transplantation.100
 SUMMARY
Fat augmentation has been practiced for decades with good
reason. It is safe, relatively inexpensive, and readily available.
Now that cosmetic surgeons are recognizing that facial aging
is not simply due to gravity but rather to atrophy of tissues,
the use of fat for volume restoration is becoming even more
popular. Newer techniques of Lipostructure™, facial fat
rebalancing, and FAMI, are targeted to achieve true full-face
three-dimensional rejuvenation.
We are lacking an effective, practical means of objectively
measuring outcome. Without this, we will not be able to
answer basic questions of optimal harvesting site, processing
technique, and most effective injection technique. Histologic
and animal studies suggest there is greater potential for revas-
cularization with small volumes of fat thereby enhancing
survival. Limited data suggest centrifugation contributes to
long-term results. Gentle handling and cannula size of
18-gauge or larger seem to be important to survival. Scientific
research is emerging to address these issues. Further research
will also elucidate the role of preadipocytes or stem cells in
adipose tissue.
These are exciting times to be performing fat augmenta-
tion. It is a dynamic, expanding field offering the cosmetic
surgeon a creative outlet and the patient gratifying results.
 REFERENCES
1. Neuber F. Fat transplantation. Chir Kongr Verhandl Dsch Gesellch Chir
1893;20:66.
2. Lexer E. Correccion de los pechos dedulos (Mastoptose) por medio de
la implantacion de grasa. San Sebastian Guipuzcoa Media 1921;63:13.
(Translated in Hinderer UT, del Rio JL. Erich Lexer’s mammoplasty.
Aesthetic Plast Surg 1992;16:101–107.)
3. Bruning P. Cited by Newman J, Ftaiha Z. The biographical history of
fat transplant surgery. Am J Cosmet Surg 1987;4:85.
4. Peer LA. Loss of weight and volume in human fat grafts. Plast Reconstr
Surg 1950;5:217–230.
5. Illouz YG. The fat cell ‘graft’: a new technique to fill depressions. Plast
Reconstr Surg 1986;78:122–123.
6. Fournier PF. Facial recontouring with fat grafting. Dermatol Clin
1990;8:523–537.
generally recommended in all patients. Fat augmentation
should be carried out as a sterile procedure. The centrifuge
has been the source of infection with Pseudomonas.43 Sterile
centrifuge sleeves should be utilized, as well as sterile instru-
ments (Fig. 28.21). There have also been reports of infection
with Staphylococcus, Streptococcus, and Mycobacterium.43,45,49,86
The most serious potential complication of fat augmenta-
tion is vascular occlusion caused by inadvertent intravascular
injection. Blindness has been reported following fat injections
of the glabellar lines87,88 and also from injection of the nasola-
bial fold.89 Middle cerebral artery occlusion and ocular fat
embolism have also been reported following fat injection of
the face.90,91 Occlusion or emboli are rare complications.
Reports have indicated sharp instrumentation and 10-mL
syringes with high injection pressures were utilized.91 Use of
blunt-tipped cannulae will minimize the risk of vascular pen-
etration as well as initial withdrawal of the plunger to assure
one is not intravascular. Retrograde fill, 1-mL syringes, and
low injection pressures further reduce the risk of intravascu-
lar injection. When evidence of vascular compromise is seen
on the skin with dramatic blanching, Wexler advises placing
the patient in Trendelenburg, applying nitroglycerin paste,
and massaging the area until the flush returns to the skin.92
A potential complication of intramuscular injection is dys-
function of facial muscles. Although not reported by Amar,
weakness of facial muscles of mastication has been observed
when fat is injected intramuscularly.93 The masseter muscle
is not injected in the FAMI procedure. In addition, the curved
and angled cannulae of FAMI most likely minimize injury to
the muscle.
 FRONTIERS
The future of fat transplantation may lie not in the adipocyte
itself but in the injection of preadipocytes or stem cells.
These cells are fibroblast-like fat cell precursors that are
present in adipose tissue. They can be grown and differenti-
ated into mature fat cells in culture.94–96 Initial research indi-
cates that stromal cells from adipose tissue are smaller and
more resilient. Indeed, they have been found to survive
ischemia better than mature adipocytes and have the poten-
tial to differentiate into fat cells after transplantation. In
Figure 28.21  Removable centrifuge sleeves should be sterilized
for each case.