Phẫu Thuật Tạo Hình Đường Nét Cơ Thể Và Hút Mỡ (Body Contouring and Liposuction)

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© 2013 Elsevier Inc
Part 6  Thigh, buttock and lower extremity contouring
Chapter 41 
Key Points
●
The patient should be aware of the risk of infection.
●
Highlights marking points.
●
General anesthesia.
●
Supine and prone position.
●
Harvesting and preparation of fat.
●
Fat injection and post operative cases.
Buttock contouring with liposuction
and fat injection
Constantino G. Mendieta
INTRODUCTION
In the old days liposuction was about debulking, removing
as much fat, and leaving the flap as thin as possible (two
dimensional). This in many cases would create a flat, unat­
tractive and unesthetic look. Today, liposuction has a com­
pletely different philosophy that involves fat redistribution
as well as selective anatomic suctioning to create hills and
valleys at the muscular borders. The shadowing created will
highlight the anatomic zones, creating a sculpted three-
dimensional result. The harvested fat is used to enhance,
contour and reshape zones.
New applications for fat grafting are beginning to revo­
lutionize the way we perform our procedures, not only in
body contouring but in the full range of esthetic and recon­
structive operations. It is quickly becoming the gold stan­
dard for large volume muscle enhancement of the buttock,
calves, pectoral muscle, rectus abdominis muscle, biceps,
deltoids, and other anatomic areas. When it is used for
gluteal contouring, it provides the ideal three dimensional
approach needed, not only for volume expansion, but for
reshaping as well.
Nearly all the procedures are performed under general
anesthetic in my office based American Association
for Accreditation of Ambulatory Surgery Facilities, Inc.
(AAAASF) approved surgical center (Only ASA I and II
patients). The surgical team is very small, consisting of my
assistant, my circulator, and me. My assistant helps posi­
tion, turn the patient, and prepare the fat.
PREOPERATIVE PREPARATION
Routine preoperative medical evaluation and lab tests
appropriate for age are performed. The patient is instructed
to stop all medications and products that affect platelets at
least 4 weeks prior to treatment. Bowel preps are not rou­
tinely given. As a special note, patients who have rheuma­
toid arthritis and are taking immunosuppressive medications
such as remicade may be more susceptible to infections and
even mycobacterial infections, so these medications should
be stopped at least 2 weeks before the procedure and dis­
continued for 1–2 months after. The patient is made aware
of this increased risk of infection. A clearance from their
rheumatologist is obtained.
Markings of Esthetic Units
The abdomen is defined by three major muscle groups that
can be appreciated on the surface anatomy; the rectus abdo­
minus, the external oblique and the transversalis muscle
(Fig. 41.1). The union between these muscles is called the
raphe and it is these raphes that need to be accentuated
during contouring in order to highlight and define the
underlying anatomy.
The highlight points of interest are the midline raphe
(linea alba), the raphe between the lateral rectus and the
external oblique, and the raphe between the lower lateral
rectus and the transversalis muscle. In the past I would
mark the areas to be debulked but today I mark these high­
lighted zones.
When it comes to the posterior zones, there are 10
esthetic units found to the posterior region, with 6 that truly
define the buttock frame/ shape (zones 1–5 and zone 8)1
(see Fig. 41.2A). The midlateral buttock (Zone 8) becomes
of particular interest since it is the only zone out of the six
that may require fat transfers to smooth the contour. This
zone has no muscle, therefore fat transfers are into the less
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PART | 6  Thigh, buttock and lower extremity contouring
parasacral areas); this represents the height of the gluteal
muscle I am trying to achieve. With these points marked it
is easy to identify and mark the second landmark – the “V”
zone, also known as zone 1. This is the space identified by
the most superior point of the intergluteal fold and both
posterior iliac spine dimples; the connection of these points
creates an equilateral triangle. When this zone is suctioned
it adds tremendous contour to the esthetic of the buttock.
Third, I identify any depression in the midlateral buttock
(zone 8) (see Fig. 41.2C). Sometimes these depressions
extend all the way to the anterior leg; therefore, care is
taken to mark the lateral extent of the deficiency, and finally
any dimples or irregularities are marked. Zone 3 is evalu­
ated and I try to mentally quantify how much fat I want to
FIG. 41.1  (A & B) The abdomen is defined by three major muscle groups that can be appreciated on the surface anatomy; the rectus abdomi­
nus, the external oblique and the transversalis muscle.
A
B
vascularized subcutaneous tissues requiring more care and
precision with the fat grafting technique.
Total three-dimensional body contouring will focus on
the abdomen, the waist, and the buttock. The patient is
marked in the preoperative holding room the day of surgery
in the standing position. The highlight points are identified
in the abdomen and the areas to have liposuction in the
posterior area are identified; these always include zones 1,
2, 4, and the areas over the internal/external oblique
muscles. The patient is always reminded that in Florida we
have a 4 liter supernatant fat limit and therefore all areas
being marked may not be suctioned.
Three landmarks areas are identified in the buttock; the
first is the posterior superior Iliac spine (dimples in the

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Chapter | 41  Buttock contouring with liposuction and fat injection
FIG. 41.2  Esthetic units/zones.
1
4
10
2
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Sacrum V-zone
Flank
Upper buttock
Lower back
Outer leg
Gluteus
Diamond zone: inner gluteal/ leg junction
Mid-lateral buttock point C
Inferior gluteal/posterior leg junction
Upper back
3
8
5
6
7
9
Esthetic units/zones
A
1
4
2
3
3
5
5
2
Esthetic units/zones
B
8
8
C

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PART | 6  Thigh, buttock and lower extremity contouring
Infiltration
The tumescent fluid is infiltrated through the access
incisions, whose exact locations are determined on the
operating room table. Usually I will have two in the lower
abdomen, two near the superior iliac crest, one in the
superior umbilicus, one or two in the posterior flank, and
one in a very consistent spot, which is the posterior supe­
rior intergluteal crease. This allows me to contour the
sacrum. On average 4–5 liters of tumescent fluid are used
per case.
Suctioning Details
The technique involves a visualization exercise whereby
the surgeon visualizes the deep and superficial layers
in the mind. Suctioning will then proceed in a layered
and anatomic sequence, but throughout the process the
remove using the very sophisticated categories of very
little, none, or a lot. Photos are taken of the markings since
these become extremely helpful because often these marks
are erased during surgery.
Medications
Preoperative medicines include Solu-Medrol 125 mg IV
(precaution for fat embolism), Cleocin 600 mg IV. If the
patient is high-risk for postoperative nausea then Zofran
8 mg ODT (sublingual is given prior to surgery). Decadron
10 mg IV is given towards the end of the case for postop­
erative swelling and to help prevent nausea and vomiting.
If they have a history of reflux Reglan 10 mg IV and Zantac
50 mg IV are added, especially since they will be in the
prone position. We try to give 1 liter of IV fluids prior to
the case beginning.
PREPARATION IN OR
The patient is prepped circumferentially while in the stand­
ing position using room temperature Hibiclens solution
(Fig. 41.3). A sterile sheet is placed on the OR table on top
of a water-based warming pad (HTP-1500 Heat Therapy
Pump and Pad, Adroit Medical System). The best setting is
41.6 °C (107 °F).
FIG 41.3 APPEARS ONLINE ONLY
A draw sheet is also placed to help turn the patient
during the procedure. All pressure points are padded; pneu­
matic stockings are connected. A Foley catheter is inserted
for fluid status monitoring.
It is during this time that the fat collection canister is
prepared since the fat needs to be collected during the suction
process. There are a number of collection systems for obtain­
ing fat cells (Fig. 41.4), all of which have pros and cons.
FIG 41.4 APPEARS ONLINE ONLY
My current fat collection system consists of a glass
bottle (Wells Johnson) or a plastic bottle collector (J-Cell).
These are very large Lukens trap devices that collect the
aspirate by connecting one suction tube from the patient to
the bottle and another tube that goes from the bottle to the
suction machine (Fig. 41.5). Once this is all in place the
procedure can begin.
Surgical Techniqu: Tumescent Mixture
The fluid consists of 1 liter of lactated Ringer’s solution
(prewarmed) mixed with 1 ampule of 1 : 1000 epinephrine.
The amount of lidocaine used will vary depending on the
type of anesthesia being used; if the procedure is under GA,
then 20 ml of 1% lidocaine with epinephrine 1 : 100 000 is
used; if it is performed under IV sedation, 50 ml of 1%
lidocaine with epinephrine 1 : 100 000 is used.
FIG. 41.5  Lukens trap device.

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Chapter | 41  Buttock contouring with liposuction and fat injection
Fig. 41.4  Collection systems for obtaining fat cells.
A
B
FIG. 41.3  Preparation of the patient in the operating room.

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PART | 6  Thigh, buttock and lower extremity contouring
It is crucial to separate the deep from the superficial
layer during this procedure since the entire deep layer needs
to be cleared out. The superficial layer is mainly to establish
the contour definition. How thin the superficial layer will
become will depend on patient goals and fat characteristics.
In some cases it is very easy to palpate and differentiate
between these layers (the flap can then be picked up between
the fingers like a rolling pinch test and the layers are appre­
ciated through palpation), but in others the layers are so
compactly associated that they are difficult to distinguish
from each other. In these situations, both layers are freed
and broken up with Vaser or with pre- and post-tunneling
(suction OFF).

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Chapter | 41  Buttock contouring with liposuction and fat injection
FIG. 41.6  Separation of the superficial layer.
Superficial fat
Deep fat
Scarpa’s fascia
The degree of superficial liposuction is much less in
these moderate to severe dermolipographing cases and it is
therefore a conservative approach. In these cases I will
leave about 2–3 cm of fat under the dermis since it is not
possible to get closer to the surface.
In cases of mild to no dermolipographing, technology
is not needed since the skin molds extremely nicely and
irregularities are extremely rare (Fig. 41.7A, B). I leave
about 1 cm of fat under the dermis.
FIG 41.7B APPEARS ONLINE ONLY
Positioning
Supine Position
This position addresses the abdomen, zones overlying the
external oblique, some of the flank, and lateral chest wall.
In the supine position the suction focuses on defining
the abdomen (midline raphe, lateral boarder of the rectus
muscle, rectus muscle six pack, external oblique, serratus
anterior) as well as trying to define the lateral chest wall.
The one technical contouring point while in the supine
position is to avoid suctioning below the iliac crest (Fig.
41.8) because this may lead to over-suctioning of the upper
buttock, creating a step off that does not flow smoothly. The
area below the iliac crest and zone 3 are best suctioned
under direct visualization in the lateral decubitus position.
Lateral Decubitus Position
The most important zones to contour in gluteal esthetics are
the lower back, sacrum and the posterior flank triangle (the
triangle zone is defined inferiorly by the superior iliac crest,
FIG. 41.7  Mild to no dermolipographing.
A
physician is visualizing the position of the cannula in the
respective layer (Fig. 41.6).
Suctioning begins in the deep layer at the highlight
points (abdominal raphes) and gradually moves more
superficial (remember to visualize through the entire
process). The initial deep layer suctioning is performed for
two reasons. The first reason is to assess the quality of the
fat; is it hard, soft, fibrous, compact or is it soft, easy to
extract and loosely associated (not compact)? The second
reason is to assess the relationship the fat has to the dermis,
a term I coined “dermolipographing” (DLG). This means
the imprint the cannula, leaves on the skin surface; in some
patients the cannula track marks are easily imprinted,
leaving skin surface irregularities; in others, the cannula
can be brought up to the subdermal layer and no marks are
left (as if the cannula was never there). Because the fat to
dermis ratio is extremely variable, and depending on the
particular patient’s dermolipographing sensitivity, the har­
vesting technique can be varied.
For those individuals who have a medium to strong
dermolipographing propensity, I will not be able to suction
so superficially. To avoid track marks, I try to mechanically
break up the strong fatty dermal association by using one
of the following disruptive approaches, separately or in
combination:
● Vaser ultrasound machine at a power of 80% pulsed
with a 3-ring probe to soften the fat, starting at approxi­
mately 1–2 cm depth and below.
● Power-assisted specialized Mendieta cannula (5 mm)
with the suction turned off (as recommended by Dr.
Simeon Wall, Jr) for pre- and post-tunneling.
These methods are used until the cannula passes freely
through the tissue and there is hardly any resistance (this
can take about 20–30 minutes). Once the presuctioning
process is completed, liposuction is continued with the
method preferred but using a thinner 4 mm, or on rare occa­
sions a 3 mm cannula. I continue with the power-assisted
cannula system power x.

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Chapter | 41  Buttock contouring with liposuction and fat injection
The Vaser, power-assisted machine and specialized
cannula are invaluable when I run into very fibrous or dense
fat or fat that has a strong dermolipographing property. It
also works well for that fluffy fat that is difficult to extract
(typical of the massive weight loss patient). I use the Vaser
in 70% of my cases and the power-assisted machine in
every case. In my experience, the use of the power-assisted
and ultrasound-assisted technologies results in the destruc­
tion of about 10% more of the fat cells when compared to
the standard machine suction, yet my grafting survival rates
have not changed (70–80%).
results. It may have required more harvesting, but in the
long run survival results were the same. Interestingly
enough, when I compared the body jet technology to the
ultrasound and power-assisted technology I was able to
obtain 20% more fat with the body jet system, and it con­
tained very little fluid. The body jet is not used in every
case since these cases do take longer to perform, but in
cases of limited fat it has its advantages.
Liposuction will be performed in the supine, lateral
decubitus and prone positions. Each position has a specific
purpose and technical goal that has become more apparent
to me as I have learned to contour the body and buttock
area.
Fig. 41.7  Mild to no dermolipographing.
B
This tells me that if I have the same amount of super­
natant fat in the syringes (after the separation process),
irrespective of technology used, it does not affect the final

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PART | 6  Thigh, buttock and lower extremity contouring
approached from the lateral decubitus and prone positions
(see 41.9A, B, C).
FIG 41.9A APPEARS ONLINE ONLY
The Upper Buttock/Zone 3
These two zones are still a great challenge because if
you suction too much it creates an unflattering step off, and
if you under-suction it makes the buttock appear too square.
The goal is to contour this zone to allow the buttock to
smoothly transition all the way up to the iliac crest. I have
learned to use the preoperative photos to determine how
much suction will be done, since often the results may look
superiorly by the 12th rib, medially by the lumbar muscle,
and laterally by the internal oblique (see Fig. 41.2B).
The lateral decubitus position is used to suction
the posterior triangle, the upper lateral buttock, zone 3, the
posterior lateral chest wall zone, and the back. In the past
I tried addressing the waistline from the supine and prone
positions, but the contour was never really gratifying.
While it looked acceptable on the operating table, the
results at 3–6 months left something to be desired. It was
not until I learned how to really suction the posterior
triangle in the lateral decubitus position that I started to
see tremendous changes. This position is the best for
contouring the waistline. The posterior triangle is best
FIG. 41.8  Avoid suctioning below
the iliac crest.
Iliac crest
A
Posterior superior iliac spine
Erector spinae
External oblique
12th rib
Posterior triangular space
B

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Chapter | 41  Buttock contouring with liposuction and fat injection
Fig. 41.9  Lateral decubitus position. The lateral decubitus position is used to suction the posterior triangle, the upper lateral buttock, zone
3, the posterior lateral chest wall zone and back.
Posterior flank triangle
A

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Chapter | 41  Buttock contouring with liposuction and fat injection
Fig. 41.9  Lateral decubitus position. The lateral decubitus position is used to suction the posterior triangle, the upper lateral buttock, zone 3,
the posterior lateral chest wall zone and back.
B
C
acceptable on the operating table but only 3 months later
more needed to be removed, or it was over-suctioned. This
is not a very forgiving zone and the technique has a steep
learning curve (see Fig. 41.10A, B).
FIG 41.10A APPEARS ONLINE ONLY
Prone Position
This position will help contour the V zone, remaining fat
in the posterior flank triangle, and remaining fat in the
upper buttock/zone 3, lower sacrum/lower back and, if
present, the lower inner gluteal fold excess.
Once the patient is in the prone position, the V zone is
defined through an access incision placed at the superior
intergluteal crease (see Fig. 41.11A). Contouring this zone
requires a cross-suction approach; therefore a second
incision is placed somewhere in the flank, usually at the
superior posterior iliac crest (not iliac spine) (see Fig.
41.11B). This is a zone that will require much more removal
than usual.
In the prone position the posterior flank triangle is
further defined since it is much easier to finalize the contour
in this position (Fig. 41.12). The lateral upper buttock
sometimes has excess fat that could not be appreciated

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Chapter | 41  Buttock contouring with liposuction and fat injection
Fig. 41.10  The upper buttock. The goal is to contour this zone to allow the buttock to smoothly transition all the way up to the iliac crest.
A

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PART | 6  Thigh, buttock and lower extremity contouring
FIG. 41.10  The upper buttock. The goal is to contour this zone to allow the buttock to smoothly transition all the way up to the iliac crest.
B
from the lateral decubitus position. If this excess is visible,
I take it down.
FIG 41.12 APPEARS ONLINE ONLY
On occasions the lower inner gluteal fold has excess fat
and this is suctioned as well.
While volume will add gluteal projection, it is this
aggressive contouring that will create the esthetic buttock
frame. Remember that adding volume alone does nothing
but create another big buttock. To create gluteal contour it
will require more aggressive suctioning than you are used
to, in particular the V zone (sacrum), and the posterior flank
triangle (see Fig. 41.13).
Straining
Currently there is no consensus as to the best harvesting
and fat preparation method. But when it comes to retention
rates, others have shared similar fat survival rates as mine
(70–80%), even though they use completely different har­
vesting and injection techniques. If survivability is the rela­
tive constant, then when it comes to body or buttock fat
transfers, it seems logical that we should focus on effi­
ciency, time management, cost management, and effective­
ness. I use a regular strainer (purchased at the local store);
this is an easy and inexpensive system for straining the fat
(Fig. 41.14A, B, C). I have used this system for a number
of years.
The drawback with most of these systems is that it
retains about 20% of fluid, giving falsely elevated absorp­
tion rates.
FIG 41.14C APPEARS ONLINE ONLY
Straining passively takes too long and often the dense
fat will clog the fine mesh holes, slowing the process down
further. To help things along, the assistant picks up the
strainer and repeatedly shakes it back and forth much like
a chef sautés or you might strain spaghetti. If this technique
is not working well and the fluid refuses to strain, a tongue
blade is used to swirl the aspirate and let the fluid flow
through. Care is taken not to scrape the tongue blade force­
fully on the bottom or sides of the mesh to avoid fat cell
destruction. The swirling is gentle and at mid strainer level,
the idea being to avoid squeezing the fat cells. Once all the
fluid is sieved, the supernatant fat is placed in a 1 liter metal
collecting bowl and covered with a sterile towel. The entire
process is repeated until all currently available aspirates
have been strained. Once the bowl is full, 10 ml of antibi­
otic solution (Cleocin 600 mg mixed with 20 ml of saline
solution) is added and the fat swirled again. If I am still
harvesting, my assistant will proceed with syringe loading.
Remember, we are working simultaneously; therefore,
there is no down time between harvesting and preparing fat.
This entire process moves smoothly and quickly.
Some reference values: the amount of tumescent
fluid injected is usually 4 liters, the amount of intraopera­
tive IV fluid is usually 4–5 liters, and it usually takes 5–6
liters of aspirate (fluid and fat) to obtain 2 liters of super­
natant fat.
Syringe Loading Depending on Fat Density
The injection cannula used should have a blunt tip (a sharp
one will cut, create hematomas and lead to a possibly
greater chance of fat embolism).

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Chapter | 41  Buttock contouring with liposuction and fat injection
Fig. 41.12  Posterior flank triangle is further defined in the prone position rather than the lateral decubitus position.
Posterior flank triangle
The drawback to my system is that it exposes the cells
to air. I do not believe that the air affects the cells because
they are in a moist environment, covered, or in syringes and
not desiccating. However, the process does create several
potential contamination points. The other drawback to the
open strainer is that I lose about 10 to 15% of good cells;
these are the small fat cells that fall through the strainer.
Many of the other available systems for fat processing have
the opposite problem, maintaining too much fluid (10–20%)
in the fat to be transferred (falsely elevating the absorption
rates). They also tend to clog easily or are cumbersome to
use. Moving towards a closed system is better and there are
many companies available that provide canisters.
Only the supernatant fat is transferred (no oil); the har­
vested aspirate needs to be separated into its components
(the supernatant fat – pure intact fat cells) from the sur­
rounding aspirate fluid (tumescent, blood, and lipids)). The
well-known methods of centrifuging and decanting work
well for facial fat grafting procedures, but the face requires
small volumes that can easily be handled with these
methods. The buttock, on the other hand, deals with large
aspirate volumes (4–6 liters), and while large centrifuge
machines exist they are very bulky, require additional per­
sonnel, and add a tremendous amount of time to the proce­
dure. Decanting is not efficient with such volumes. The
most efficient method for me has been straining.
Fig. 41.14  Buttocks fat grafting images. (C) The fluid is allowed to
drain completely.
C

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Chapter | 41  Buttock contouring with liposuction and fat injection
FIG. 41.11  Prone position. Contouring this zone requires a cross-suction approach, therefore a second incision is placed somewhere in the
flank, usually at the superior posterior iliac crest (not iliac spine).
Sacrum
A
Iliac crest
Posterior superior iliac spine
B
FIG. 41.13  To create gluteal contour it will
require more aggressive suctioning than
you are used to, in particular the V zone
(sacrum), and the posterior flank triangle.
Sacrum

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PART | 6  Thigh, buttock and lower extremity contouring
FIG. 41.14  Buttocks fat grafting images. (A) The fat is poured into a stainless steel strainer. (B) The supernatant fat is strained. (From Hunstad JP,
Repta R. Reverse Abdominoplasty. In: Atlas of Abdominoplasty. Saunders, Philadelphia, 2009.)
A
B
60cc wide bore syringe
4mm cannula
Fibrous fat
FIG. 41.16  In the case of extremely fibrous fat not passing through the small syringe Luer-lock opening the fat is transferred using a large
bore 60 cm3 tummy syringe connected to a large bore 4 mm harvesting tummy cannula.
My transfers are done using a 10 ml syringe connected
to a 3 mm × 20 cm cannula (for subcutaneous injections)
and a 60 ml Luer-lock syringe using a 4 mm × 15 cm Luer-
lock Byron cannula (for intramuscular injections) (see Fig.
41.15).
FIG 41.15 APPEARS ONLINE ONLY
On rare occasions the fat is extremely fibrous and will
not pass through the small syringe Luer-lock opening. In
these cases, the fat is transferred using a large-bore ml
tummy syringe connected to a large-bore 4 mm harvesting
tummy cannula (Fig. 41.16).
It is important to assess the quality of the fat as it is being
strained. On occasion it is difficult to tell if the fat density
will be an issue. In these cases, the Luer-locks are loaded,
and if an issue develops, the Luer-lock syringe is emptied
into the tummy syringe, and for that syringe only, the tummy
system used. Rarely, the entire aspirate is fibrous, in which
case all the injections are done with the tummy system. I
always have these syringes and cannulas readily available
since I never know when I might need them.
Loading
The 60 ml Luer-lock syringes are loaded in the following
manner: the syringe plunger is temporarily removed while
the fat is poured using a small 50 ml metal cup (Fig. 41.17).
All four 60 ml syringes are loaded while the 10 ml syringes
are loaded quickly and easily using the transfer tool con­
nected to the 60 ml syringe (see Fig. 41.18A,B).
FIG 41.17, 41.18B APPEARS ONLINE ONLY
I have found this tool much easier than using a three-
way stopcock, since the three-way may cause more cell
trauma. Remember, at this time I am still harvesting, so my
assistant is on hold until the next batch of fat comes through.
He/she will repeat the emptying and straining process, col­
lecting the fat in the 1 liter bowl and adding antibiotic
solution to each new batch until the harvesting is complete.
If the bowl becomes full, we have a spare bowl waiting.
The strained fluid is periodically poured into a large plastic
nonsterile 3–4 liter bowl and the fluid discarded.
FAT INJECTIONS
The fat injections will serve two purposes; to help shape/
contour the gluteus and to add volume to the buttock.
Imagine a block of clay: you first need to remove the edges
to start to create form and shape and then you work on the
details. Liposculpture is working on the frame of the
buttock, laying out a well-defined and contoured frame, but
the gluteus itself also has to be shaped.

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Chapter | 41  Buttock contouring with liposuction and fat injection
Fig. 41.15  Syringe loading depending on fat density.
60cc syringe
10cc syringe
Fig. 41.17  Loading the 60 cm3Luer-lock syringes.
Fig. 41.18  All four 60 cm3 syringes are loaded while the 10 cm3
syringes are loaded quickly and easily using the transfer tool con­
nected to the 60 cm3 syringe.
Transfer tool
3 way stop cock
B

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Chapter | 41  Buttock contouring with liposuction and fat injection
FIG 41.20B APPEARS ONLINE ONLY
The lateral access incision is used for the lower gluteus,
zone 8, the superior medial muscle and central medial
zones. The midlateral buttock or zone 3 is added first since
this will render shape to the outer buttock. These subcutane­
ous injections are done using the 10 cm3 syringe attached
to the 2.4 mm cannula, placing the fat through repetitive
passes in a stacking manner. To obtain better survival this
area is also reinforced by cross fanning injections coming
from a different position (the infragluteal access point).
This perpendicular fat deposition or cross-hatching will add
volume with support (Fig. 41.21A,B).
FIG 41.21B APPEARS ONLINE ONLY
The lateral port’s (Fig. 41.22A,B) best asset is in build­
ing up the superior medial muscle, which is what helps
define gluteal esthetics by adding volume and helping
accentuating the V zone.
FIG 41.22A APPEARS ONLINE ONLY
POSTOPERATIVE CARE
Drains
The sacrum tends to produce a bloody aspirate and is
extremely prone to seromas. In hopes of improving these
rates, I started draining. I found that using open drains was
better than closed suction drains since the drains could be
discontinued sooner and there were fewer post drain
removal seromas (seromas that develop after the drain has
been pulled).
I use a total of four drains. The most important drain
of all is placed in the sacrum through the open access supe­
rior intergluteal fold incision. When the patient returns to
the supine position, the anterior drains are placed: two in
the most dependent anterior abdominal access incisions
(Jackson Pratt drains) and one in the open superior umbili­
cal access incision along the midline (linea alba track).
These drains are kept for 5–7 days and the patient is
FIG. 41.18  All four 60 cm3 syringes are loaded while the 10 cm3 syringes are loaded quickly and easily using the transfer tool connected to
the 60 cm3 syringe.
A
This is an area of central flatness; this area is filled first
through more superficial Injections. Once contoured,
overall volume is added deep in the muscle.
The fat transfer is always done by a repetitive back and
forth motion, layering the fat at multiple levels with mul­
tiple passes. The syringe is in constant motion while the fat
is slowly injected in a linear threading type fashion (no
stagnant globular injections). The less vascularized subcu­
taneous tissue has a lower fat survival rate; to counteract
this, we need greater care and precision with the fat
injections.
Fat Transfer in Supine and Lateral
Decubitus Positions
While nearly all of the fat injections are done in the prone
position, there are some fat transfers that need to be
done in the supine and lateral decubitus positions (Fig.
41.19A,B). The midlateral buttock depressions (Zone 8)
(see Fig. 41.2) sometimes swing all the way around to
the anterior lateral leg. This depression is filled while
the patient is in the supine position using the 10 cm3
syringes; the fat is layered using multiple repeated passes,
placing the fat in the mid deep level and moving superfi­
cial until the defect is filled.
FIG 41.19A APPEARS ONLINE ONLY
On occasions some abdominal irregularities are acci­
dently created during the fat harvest and these are filled
using the 10 cm3 syringes. The lateral leg is also injected
while in the lateral decubitus position.
Prone Position Injections
Two access points are used to help create a cross fanning
pattern injection. The inferior gluteal crease is used as an
access point to build up part of the medial inferior gluteal
muscle, part of the Zone 8 depressions, part of the upper
gluteal muscle, but mainly the central gluteal muscle
(Fig. 41.20A,B).

457.e1
Chapter | 41  Buttock contouring with liposuction and fat injection
Often the gluteus has zones of obvious deficiency and
these are best addressed with superficial injections since
volume for volume the more superficial the injection the
more projection seen. In other words, 10 cm3 placed in the
superficial tissues (above muscle fascia) translates to greater
projection than 10 cm3 placed deep in the muscle. There­
fore, when I am augmenting the buttock, I always asses how
much fat is available. If I think my fat is limited, I will
purposely place more toward the superficial muscle and
subcutaneous tissues. I will focus more on shape than
volume. In these cases nearly all the fat transfer is done
with 10 cm3 syringes since the fat is being placed more
superficial (65–70 % muscle, 30–35% subcutaneous). Once
shape is obtained, volume is added deeper in the muscle
with 60 cm3 syringes. However, if there is plenty of fat, the
fat is first placed deep in the muscle for volume, followed
by the superficial injections for contour (80–85 % muscle,
15–20% subcutaneous).
A lower volume syringe (10 cm3) is a better choice since
it requires less manual plunger pressure to expel the fat
from the syringe, making it easier to deliver steady consis­
tent pressure throughout the back and forth syringe motion.
In other words, the larger 60 cm3syringes require more
manual pressure to push the fat through the syringe Luer-
lock opening; sometimes the syringe plunger locks due to
a dense fat particle blocking the exit point and more pres­
sure is applied on the plunger to expel the culprit. As this
fat cell/tissue is pushed through, as greater pressure on the
plunger is being maintained, the remaining fat cells are
accidently pushed through under greater pressure than
usual, creating a greater influx of volume (moving glob
injection). This fluctuant uneven pressure grade causes
unequal amounts in each linear pass. The muscle, due to its
great vascularity and rich medium, can deal with these
uneven distributions, and it does not seem to affect fat
survival, but the subcutaneous tissues are not as forgiving.
The goal in the subcutaneous tissues is to deliver thinner
equal volume fat threads with tighter layering using a cross
fanning approach. In the muscle the linear threads can be
thicker and don’t need to be as tightly layered, so 60 cm3
are adequate.
Fig. 41.19  Fat transfer in supine and lateral decubitus positions.
Mid lateral
buttock depression
A

457.e2
PART | 6  Thigh, buttock and lower extremity contouring
Fig. 41.20  Prone position injections. Two access points are used to help create a cross fanning pattern injection.
B
Fig. 41.21  This perpendicular fat deposition or cross hatching will add volume with support.
B

457.e3
Chapter | 41  Buttock contouring with liposuction and fat injection
A
Fig. 41.22  The lateral port.

457.e4
PART | 6  Thigh, buttock and lower extremity contouring
Garments and Pressure Pads
Most patients ooze a tremendous amount. The garment used
is a regular liposuction garment. Extra pressure is applied
to these sensitive areas (posterior flank triangle and sacrum)
by placing two rolled towels in the posterior triangle and
two in the sacrum, using the liposuction garment to keep
them in place. If more pressure is needed, then towels are
placed on top of the garment and secured in place with a
wrap-around abdominal binder. This has helped in decreas­
ing postoperative oozing and blood loss.

458
PART | 6  Thigh, buttock and lower extremity contouring
FIG. 41.20  Prone position injections. Two access points are used to help create a cross fanning pattern injection.
A
FIG. 41.19  Fat transfer in supine and lateral decubitus positions.
Mid lateral
buttock depression
B
maintained on PO antibiotics (Keflex 750 mg PO bid)
while drains are in place. The drains have worked extremely
well and while post drain removal seromas occur they are
much less frequent (especially in the sacral area).
Recovery Room
The patient is kept in the supine position until they are
awake and able to control their airway; at this point they
are placed prone. The recovery room focuses on body tem­
perature and fluid status. If the patient oozes more than
normal and only the garment was placed intraoperatively,
then additional pressure is placed by the use of an abdomi­
nal binder along with strategically placed towels. Because
there is ongoing fluid shift, it is imperative that fluid status
be aggressively monitored in the early recovery phase. The
surgeon should have a low threshold for monitoring hemo­
globin levels.

459
Chapter | 41  Buttock contouring with liposuction and fat injection
FIG. 41.21  This perpendicular fat deposition or cross hatching will add volume with support.
A
B
FIG. 41.22  The lateral port.

460
PART | 6  Thigh, buttock and lower extremity contouring
Fig. 41.3, 41.4, Fig. 41.7B, Fig. 41.9A, Fig. 41.10A, Fig. 41.12, Fig.
41.14C, Fig. 41.15, Fig. 41.17, Fig. 41.18B, Fig. 41.19A, Fig. 41.20B,
Fig 41.21B, Fig. 41.22A can be found online
Bonus images for this chapter can be found online at

Sitting/Sleeping
Pressure will destroy the transferred fat, so the patient’s
main requirement is to keep pressure off the buttock for at
least 6 weeks. Therefore, absolutely no sitting is permitted
for 10 days (except for using the bathroom) but after this
they can sit with modifications; a pillow is placed at the
posterior hamstrings (not touching the buttock), this keeps
the buttock in the air and avoids pressure. With this tech­
nique they can return to work, drive, and go to movies at
10 days but traditional sitting is not allowed for 6 weeks.
Similarly, transport home and for postoperative follow up
should be in the prone or lateral decubitus position or when­
ever they stand for the first 3 days.
Postoperative Instructions
The patient is to wear a liposuction garment for 4–6 weeks;
often Endermologie is suggested for the areas of
liposuction, starting in the second postoperative week.
Patients are told not to go clothes shopping for 3 months,
but in reality the final results are not seen until 6 months.
FURTHER READING
Centeno RF, Young VL. Clinical anatomy in aesthetic gluteal body con­
touring surgery. Clin Plast Surg 2006;33(3):347–58.
Roberts 3rd TL, Weinfeld AB, Bruner TW, et al. “Universal” and ethnic
ideals of beautiful buttocks are best obtained by autologous micro
fat grafting and liposuction. Clin Plast Surg 2006;33(3):371–94.
Mendieta CG. Intramuscular gluteal augmentation technique. Clin Plast
Surg 2006;33(3):423–34.

461
© 2013 Elsevier Inc
Part 6  Thigh, buttock and lower extremity contouring
Chapter 42 
Key Points
●
Lower extremity liposuction is described.
●
Liposuction and lipofilling are described.
●
Buttocks and leg reshaping are described.
●
Removal and addition of fat for better contour is
discussed.
Liposuction of the lower extremities
and leg reshaping with fat
Catherine Bergeret-Galley
INTRODUCTION
Lower extremity fat reduction and reshaping of the legs and
buttocks is a common request from French women patients.
There are specific techniques required to achieve excellent
results on the lower extremities (Figs 42.1 and 42.2).
Since the original description of the lipoaspiration tech­
nique by Illouz in 1977,1–3 many authors have applied
the principles of vacuum liposuction with a smooth blunt
cannula and introduced some modifications to achieve
better shape and contours, better skin retraction, and more
fat removal.
When it comes to leg reshaping, the preoperative con­
sultation is fundamental, permitting a good selection of
patients based on the local and general conditions found at
the interview and clinical examination. It is important to
keep in mind the condition of the legs, especially the impor­
tance of skin quality, color, texture, elasticity and the quality
of the vessels (essentially the veins), which should be
respected as much as possible to avoid complications and
lead to a good result (Figs 42.3 and 42.4).
I believe that liposuction technique must be adapted
to the quantity of fat you need to remove, the quality of
the skin, and the expectations of your patient. It is really
important not to dissociate the buttocks from the legs,
because when we talk about corporal harmony, women
look at the upper part of their bodies, essentially breast,
shoulders and arms, then the abdomen, and are finally
interested in having a nicer shape and size of their but­
tocks and legs.
PREOPERATIVE PREPARATION
It requires a systematic approach to meet the expectations
of the patient, in terms of skin quality and improvement of
size and shape. Almost 100% of patients seeking lower
extremity liposuction are women.
During the consultation, systematic questioning is
important to pinpoint serious contraindications and define
predictable results with the patient.
Ongoing medication is noted. All medication is dis­
cussed with the patient and usually all vitamins and medica­
tions interfering with coagulation are kept to a minimum
and removed for 14 days pre- and postoperatively. This is
to avoid extensive bruises or hematoma, which could be
painful postoperatively and favor deep venous thrombosis
(DVT).
The medical history is important, such as cardiac
arrhythmia, DVT, pulmonary embolism, and serious blood
coagulation abnormalities.
During patient examination body weight, body mass
index (BMI), and distribution of the fat, deep and superfi­
cial, are all noted, as are pre-existing varicose veins, which
need to be documented by Doppler ultrasonic examination.
The patient’s skin quality is also evaluated and discussed.
Photos are taken without underwear and shown to the
patient, who might not have noticed a tendency to slight
hypertrophy, a real hemicorporal hypertrophy, or simply an
asymmetry in shape and contour. Skin irregularities, as well
as difficult regions to treat, are marked on the patient and
new photos are taken, kept in the file and discussed with
the patient, especially areas which will not be improved by
liposuction or areas where the skin likely will not retract
once the fat is removed. This is to avoid misunderstanding
and will help the patient realize that her final result is
satisfactory.
If it is planned to transfer some fat to reshape the
buttocks, the calves or the breast, special consent for
lipofilling will be signed, as well for inner leg and
buttock lifting.

462
PART | 6  Thigh, buttock and lower extremity contouring
FIG. 42.1  Patient 1 year postoperative after circumferential liposuction of the upper legs. (A, B) Front view; (C, D) back view.
A
B
C
D

463
Chapter | 42  Liposuction of the lower extremities and leg reshaping with fat
A
B
C
D
FIG. 42.2  Circumferential liposuction of upper legs and buttocks. Patient 1 year postoperative. (A, B) Side view; (C, D) front view; (E, F) back
view.
Continued

464
PART | 6  Thigh, buttock and lower extremity contouring
E
F
Many women are candidates for leg reshaping, and
for buttocks and breast fat grafting at the same time;4,5
therefore it is important to properly inform the patient in
order to benefit from both techniques. At that final point of
the consultation the photos are helpful and in certain cases
will be signed and approved by the patient. The patient is
also asked to select photos of her ideal legs and buttocks in
magazines and bring them. This helps me to understand the
patient’s expectations, which sometimes can be unrealistic
and a reason to decline the surgery.
It has been my experience that an obese patient with bad
quality of skin, venous malformations, and cardiac arrhyth­
mia will not be a suitable candidate for the procedure.
For other patients, who do not have an accumulation
of major risk factors, the decision is always taken
individually.
For this surgery, it is always important to balance the
esthetic, functional, and psychological benefit given with
the risk of complications. As a natural consequence, sur­
geons not familiar with the technique should be more cau­
tious when evaluating the indications and adapt the estimated
volume of fat removed as well as the number of treated areas
to their experience, not to exceed 10% of the corporal
surface. With experience, total leg reshaping becomes easier
and patients are satisfied. Lower extremity liposuction and
reshaping is not a procedure for inexperienced surgeons.
Proficiency in being able to produce safe, satisfactory out­
comes along with patient selection is essential.
Three days before surgery pubic hairs should be clipped
and specific garments such as a corset and stockings are
fitted.
The patient showers with Betadine the night before and
on the morning of the day of surgery.
Sedative Before Surgery
Antibiotic prophylaxis is given 1 hour before surgery to
provide maximum serum concentration during surgery. If
surgery is longer than 3 hours, another dose is given. Nor­
mally, we use a cephalosporin-type antibiotic.
Surgical Technique
My patients are always under general anesthesia. Intubation
has my preference over epidural with light sedation.
We always start in the prone position unless we plan
lipofilling to the buttocks or calves. If so, we will start in
the supine position to avoid needless changes of position.
FIG. 42.2  Continued

465
Chapter | 42  Liposuction of the lower extremities and leg reshaping with fat
A
B
FIG. 42.3  Limitation of results due to skin quality. 1 year postoperative. (A, B) Side view; (C, D) front view.
To perform good liposuction of the lower extremities
you need to know about liposuction techniques.6
Nowadays, liposuction cannot be performed without
good infiltration. Good infiltration means enough infiltra­
tion but not excessive; infiltration will be adapted to the
approximate amount of fat to be removed and to the quality
of the fat; if the fat is fibrous I will infiltrate more. A simple
rule is: infiltration equal to the evaluation of fat to be
removed (1 : 1). However, of course, it is subject to some
variation. We need to adapt to the venous circulation
and the eventual existence of varicose veins, in order to
avoid vessel damage. That is why the quantity of epi­
nephrine (adrenaline) will be slightly variable in the solu­
tion. Infiltration is between 3 and 6 liters for full leg
reshaping, depending on the areas treated and the size of
the patient.
Isotonic serum infiltration is preferred because we no
longer consider leg and buttocks reshaping without
thinking of potential fat reinjections to improve the shape
and give more volume where it is needed; especially for
the buttocks but also for the lower parts of the legs like
the calves, or to treat a small iatrogenic irregularity.
Hypo-osmolar infiltration is not discussed here because I
believe that an isotonic infiltration for fat transfer is
essential.
The infiltration is done with a long multiperforated
Klein cannula attached to a pump for constant delivery. The
solution is isotonic: saline water 0.9%, with 1 to 1.5 mg
epinephrine (adrenaline) (1 : 1 000 000 000–1 : 666 000) per
liter and Xylocaine (not to exceed, if possible, a dose of
35 mg/kg of bodyweight).
The dose of Xylocaine is adapted to the postoperative
pain estimation and needs to be increased if the fat is fibrous
(especially on young women) or diminished if large volumes
of infiltration are needed, to limit its potential toxicity.
Xylocaine decreases postoperative pain and allows the
patient to stand up as soon as awake immediately after
surgery. This is the ideal prevention of DVT. I also add
10 mg of Naropeine (ropivacaine hydrochloride) for longer
analgesic action.
Continued

466
PART | 6  Thigh, buttock and lower extremity contouring
C
D
FIG. 42.3  Continued
The epinephrine (adrenaline) is really important; it
diminishes the blood loss and avoids extensive bruises or
hematomas by constricting blood vessels.
The incision needs to be hidden as much as possible,
but as the leg is round and the cannulas are straight, mul­
tiple incisions are needed to achieve a good result.
We start infiltration first in the prone position and as
soon as the infiltration is finished, we can start aspirating
the fat on the side where we initially started the infiltration.
When the liposuction is finished in the prone position, we
turn the patient and we continue in the supine position for
the interior and anterior parts of the legs.
One assistant is systematically devoted to process the
fat as soon as it is harvested. We collect the fat directly in
sterile drain bottles, which allow us to keep the fat sterile
and manipulate it. The fat is then transferred to large plastic
bags especially made for decantation (Cytori Therapeutics
Inc., USA); other systems are also available. The bag has
a natural decantation function that drains all fluids and then
leaves the fat concentrated. A moderate quantity of Ringer’s
lactate or isotonic saline is added, which allows residual
blood, triglyceride oil and damaged cell membranes to be
eliminated through the filter. The fat is then transferred into
10 ml syringes, ready for reinjection. In terms of stem cell
concentration, I would prefer light centrifugation but it
doubles the operating time and, in my experience, does not
add to my technique and outcomes.
ALTERNATIVE TREATMENT
uring the last year we have started using the system BODY-
JET (Human Med AG Germany). This system is built on
the principle that the liposuction canula is also containing
a smaller canula for high pressurized saline (mixed with
adrenaline and xylocain), where the jet stream is breaking
off lobules of fat, subsequently absorbed by the suction.
The infiltration is done simultaneously with the suction.
The fat is collected in a sterile bucket, rinsed and concen­
trated, as the assistant is simply transferring the fat directly
into 10 ml syringes, for grafting.

467
Chapter | 42  Liposuction of the lower extremities and leg reshaping with fat
Besides the shorter operating time, the patients seems
to have less bruising and less pain. This is probably due to
less trauma during the procedure.
OPTIMIZING OUTCOMES
What is important in leg liposuction is to adapt to the
quality of the skin, and in terms of its quality, it is better to
preserve some fat under the skin than remove too much. If
too much is removed, skin irregularities are left. Of course
we want to have the maximum result in terms of leg recon­
touring; most patients will not accept skin contour irregu­
larities as a result of the liposuction so we need to aspirate
only as much as the skin can tolerate.7 More than 30% of
skin retraction is possible in younger women, who are the
best candidates for this surgery. If there is any doubt about
the quality of the skin, some fat can be left behind, and a
second procedure carried out 6 months to 1 year after the
first surgery, to achieve a better result. Exceptions to this
are when a simultaneous skin excision is planned, such
FIG. 42.4  Patient no. 4, 1 year after circumferential liposculpture of legs and buttocks, lipectomy of abdomen and inner leg lifting – back
view (A, B).
A
B
as thigh or buttock lifting. This will limit the potential
irregularities by skin tightening, reinforced by deep fascia
sutures and anchoring to ligaments to avoid migration of
scars.
Vibration-assisted liposuction (VAL) can be useful in
fibrous fat and is not incompatible with fat transfer. It is my
opinion that techniques of liposuction assisted by laser or
ultrasound damage the fat cells (preadipocytes and adipo­
cytes) and should be avoided for the lower parts of the legs
where the risks of burn and necrosis are maximum.
Liposuction technique is critical. I use the fan or trian­
gular technique, a regular, systematic tunnelization of the
fat, which is multilayered but avoids excessive crisscross­
ing. This also avoids creating caverns in which blood and
seromas can accumulate. A too aggressive technique will
also destroy too many fasciocutaneous septa and prevent
good skin retraction.
We start deep on the muscle fascia and then proceed in
the middle part of the fat deposit, and finally more superfi­
cial, but never ultra superficial. I leave 1 cm of the fat

468
PART | 6  Thigh, buttock and lower extremity contouring
Specific complications are:
● Local skin irregularities.
● Residual skin excess due to excessive fat removal and
poor skin elasticity.
● Asymmetry.
● Blistering and skin necrosis due to too superficial suc­
tioning, damaging the subdermal plexus: should be
treated like a burn.14
● Local infection is possible but unusual if rigorous steril­
ity is observed. A dreadful complication, fortunately
exceptional, is necrotizing fasciitis. A patient who
develops fever, erythema and unusual pain a few days
after surgery should be closely observed until the symp­
toms disappear. Bacteria from the perineum, in combi­
nation with cutaneous streptococci, and staphylococci,
are usually responsible. Patients with a gynecological
infection should not be operated until cured and preop­
erative preparation should include rectal evacuation
before the last shower.
The major complication is DVT, so a rigorous anti­
thrombosis program is recommended. Before surgery a
thorough documentation is necessary to exclude or treat
predisposing factors. During surgery avoid hypothermia,
using body temperature intravenous fluids. After surgery, I
recommend the use of anticoagulants, pneumatic compres­
sion boots for the first night if the patient stays overnight,
and an elastic corset and double stockings. The best preven­
tion is early mobilization and ambulation after surgery.
RESULTS
Postoperative ecchymosis and edema will take a long time
to disappear: a few weeks to several months. Edema around
the ankles can last 6 months. It is important that the patient
is well informed about the postoperative period, the side
effects, and potential complications. Corset and double
stockings are worn for 3 weeks, night and day, and 3 weeks
more daily. If this is not respected a severe, painful swelling
of the lower legs and ankles is common. However, the
postoperative restrictions are usually well accepted by a
well-informed patient who already sees the improvements
of the contour after a few days.
The final result will be obtained only after 1 year for
total legs, and 6 months for upper leg reshaping. The
patient’s own behavior is important. By observing a healthy
diet, regular exercise and swimming after 3 to 4 weeks,
recovery is easier and results are definitely better. The coop­
eration of the patient is fundamental.
CONCLUSION
Total lower extremity liposuction is a challenging proce­
dure, that takes a long time to perform, but will produce
attached to the skin and 4 to 5 mm on the ankles. Less
than that is too superficial and gives no benefit to the
skin.
It is not considered that ultra superficial liposuction,
even with very small and thin cannulas, can improve cel­
lulite and other superficial fat accumulation. Such liposuc­
tion just favors skin irregularities.8
Blunt cannulas are used and the Illouz-style cannula
with 5 holes is preferred. The holes can be round or square
but they need to be large and non-cutting. We use long and
short cannulas with a diameter of 5 to 2 mm. The rule is,
the more peripheral on the leg I go, the smaller cannula I
use, and around the ankles always 2 mm. I have a special
cannula with an angulation for the ankles.
I believe that it is necessary to perform liposuction in a
nontraumatic fashion. If there is too much bleeding it is a
good approach to remove the cannula and have the assistant
press on the area; reinfiltrate with saline and epinephrine
(adrenaline) and move to another area, to return later. Being
careful and following these guidelines should reduce the
blood loss.
When we aspirate the calves, we really need to avoid
going intramuscular; this can happen: care is needed to
stay in the subcutaneous fat. We also need to be careful with
the inner leg region and knee so as not to damage the
saphenous vein.
Combined Techniques: Pros and Cons
While performing leg reshaping, you can easily plan fat
reinjections.9,10–12 For inner leg or buttocks lifting, I rec­
ommend being more cautious: if I know that the skin will
not retract or have a doubt about the quality of the skin, I
will first plan an extensive leg liposuction, and fat transfer
if necessary, knowing my limits, and discuss with the
patient preoperatively a two-stage surgery.13 It is sug­
gested to the patient that the inner leg or buttocks lifting
can be done in another session with a complementary
liposuction. Doing this gives the skin the maximal chance
to retract, and leaves good fascias to anchor the sutures
for a later lifting.
Total circular leg liposuction represents a large surface
of the body and postoperative pain will be proportional,
even with good infiltration. It is better, if possible, not to
combine it with an inner leg lifting at the same time.
The attached video shows the technique of leg reshap­
ing, fat harvesting and fat transfer for the body.
COMPLICATIONS
General complications are the same for all surgeries and
will not be discussed here.
VIDEO
3.1

469
Chapter | 42  Liposuction of the lower extremities and leg reshaping with fat
8. Kim YH, Cha SM, Naidu S, et al. Analysis of postoperative compli­
cations for superficial liposuction: a review of 2398 cases. Plast
Reconstr Surg 2011;127(2):863–71.
9. Coleman SR. Long-term survival of fat transplants: controlled dem­
onstrations. Aesth Plast Surg 1995;19:421.
10. Coleman 3rd WP. Autologous fat transplantation. Dermatol Clin
1999;17:891.
11. Chajchir A. Fat injection: long-term follow-up. Aesth Plast Surg
1996;20:291.
12. Cardenas-Camarena L, Lacouture AM, Tobar-Losada A. Combined
gluteoplasty: liposuction and lipoinjection. Plast Reconstr Surg
1999;104(5):1524–31; discussion 1532–3.
13. Cardenas-Camarena L, Silva-Gavarette JF, Arenas-Quintana R.
International Confederation For Plastic Reconstructive and Aesthetic
Surgery (IPRAS), Zapopan, Jalisco, Mexico. Gluteal contour
improvement: different surgical alternatives. Aesth Plast Surg
2011;35(6):1117-25.
14. Carendas-Camarena L, Arenas-Quintana R, Robles-Cervantes JA.
Buttocks fat grafting: 14 years of evolution and experience. Plast
Reconstr Surg 2011;128(2):545–55.
very happy patients, who enjoy both functional and esthetic
benefits from the procedure.
The philosophy of leg reshaping is really important. In
Europe, liposuction of the lower extremities and leg reshap­
ing is in increasing demand.
REFERENCES
1. Illouz YG. Illouz’s technique of body contouring by lipolysis. Clin
Plast Surg 1984;11(3):409–17.
2. Illouz YG. Body contouring by lipolysis: a 5-year experience with
over 3000 cases. Plast Reconstr Surg 1983;72(5):591.
3. Illouz YG. Refinements in the lipoplasty technique. Clin Plast Surg
1989;16(2):217–33.
4. Bircoll M, Novak BH. Autologous fat transplantation employing
liposuction techniques. Ann Plast Surg 1987;18(4):327–9.
5. Bircoll M. Cosmetic breast augmentation utilizing autologous
fat and liposuction techniques, Plast Reconstr Surg 1987;79(2):
267–71.
6. Troilius C. Ten year evolution of liposuction. Aesth Plast Surg
1996;20(3):201–6.
7. Weniger FG, Calvert JW, Newton ED. Liposuction of the legs and
ankles: a review of the literature. Plast Reconstr Surg 2004;79113(6):
1771–185.

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© 2013 Elsevier Inc
Chapter 43 
Key Points
●
Calf and thigh implants in the femoral region are
described.
●
Leg perimeter augmentation is described.
●
The indications are for patients with thin legs,
sequelae to poliomyelitis, and for burn and accident
sequelae.
●
Montellano implants were conceived by the author.
●
There is a real augmentation of 2.5 to 3.0 of the leg
perimeter.
Calf and thigh implants
Luiz Montellano
INTRODUCTION
Plastic surgery has allowed us to improve numerous body
contouring problems along the years. Amongst those, new
techniques have emerged in the treatment of deformities of
the lower extremities secondary to poliomyelitis, burns,
trauma and the so-called thin legs, in order to increase the
perimeter of the legs and obtain a certain harmony. Implant
use in calf and thigh surgery has gained great interest as it
has shown great results. Silicone gel implants mimicking
the legs’ musculature have been designed by the author,
allowing anatomical and natural postoperative results (Fig.
43.1). Retractors were also created in order to facilitate the
insertion of these implants.
BACKGROUND
In 1979 Carlsen1 showed the use of hard silicone implants
for calf augmentation, but also emphasized the fact that
they were not the best implants for this surgery, as there
were many complications. In the same year, Glicenstein3
published an article where he used cigar-shaped silicone gel
implants for calf augmentation, through a skin incision in
the middle third of the leg. Then in 1985, Montellano5
presented his first cases of calf augmentation using ana­
tomical silicone gel implants at the 22nd National Brazilian
Meeting of Plastic Surgery.
ANATOMY
The calf is composed of three major muscles:
1. The soleus, which contains important vascular struc­
tures, namely the posterior tibial artery, vein and nerve,
and inferiorly the external saphenous vein and nerve.
2. The gastrocnemius, which is approximately 18 cm long,
with its inferior part located at ±5 cm from the internal
malleolus.
3. The lateral gastrocnemius, approximately 12 cm long,
with its inferior part located at ±10 cm from the external
malleolus.
These three muscles converge inferiorly at the heel,
where they form the Achilles tendon, also known as triceps
surae (Fig. 43.2).
The implants are placed under the aponeurosis of the
medial gastrocnemius muscle, always preserving a thin
muscular layer.
The thigh is composed of two muscular groups starting
beneath the gluteal sulcus. The superficial group is formed
by the biceps femoris, semitendinosus, semimembranous
and adductor magnus. The deeper muscular group is com­
posed of the adductor minimus, adductor brevis, adductor
longus, vastus medialis and internal rectus muscles. An
important structure, the sciatic nerve exits the pyramidal
muscle through its inferior-medial part and travels between
the two muscular groups mentioned above, reaching the
popliteal fossa where it divides into two branches: the
common fibular and tibial nerves.
The implant is placed in the medial-posterior region of
the thigh, under the following muscles: internal rectus,
adductor magnum, semimembranous and vastus medialis
muscles (Fig. 43.3).
MATERIALS AND METHODS
Implants used in the lower extremities are silicone gel
implants presenting a superior base triangular shape, similar
to the format of the inferior limb muscles.
Part 6  Thigh, buttock and lower extremity contouring

471
Chapter | 43  Calf and thigh implants
Implants used for calf augmentation vary in size and
measure approximately 14, 18 or 22 cm long, 4 to 6 cm
wide and 2 to 3 cm in height. Those used for thigh augmen­
tation have a similar triangular shape, but are slightly larger
and present an additional guide at their distal extremity,
which facilitates their insertion up to the bottom of the
previously created pocket. Dissectors used for these proce­
dures, also designed by the author, have a wide and blunt
tip. Their sizes vary from 25 to 30 cm in length. Also,
retractors such as “L” wide and Finochietto2 types are used
for these procedures (Fig. 43.4).
SURGICAL TECHNIQUE
Calf Implants
Demarcation of the incision lines and the undermining
regions is done preoperatively with each patient in the
standing, sitting and supine positions, in order to ensure the
correct placement of the implants. The lateral borders of the
gastrocnemius muscle are delimited; a distance of 10 cm
above the internal malleolus and superficially a 3 cm
zig-zag incision above the popliteal fossa are also marked
(Fig. 43.5). The surgery is performed with the patient in the
supine position under epidural or general anesthesia, and in
some cases under local anesthesia with mild sedation of the
patient, in the presence of an anesthesiologist.
After infiltration of the demarcated areas, a 3 cm long
incision is performed in the popliteal fossa. Dissection is
pursued in the subcutaneous tissue and the aponeurosis of
the gastrocnemius medialis muscle,10 then undermining
is done up to 2 cm below the initial incision. The skin inci­
sion and the one on the aponeurosis are the same length
(Fig. 43.6). Subsequently, undermining is continued at the
FIG. 43.1  Retractors were also created in order at facilitate the
insertion of these implants.
FIG. 43.2  These three muscles converge inferiorly at the heel, where
they form the Achilles tendon, also known as triceps surae.
FIG. 43.3  The implant is placed in the medial-posterior region of
the thigh, under the following muscles: internal rectus, adductor
magnum, semimembranous and vastus medialis muscles.
FIG. 43.4  Retractor sizes vary from 25 to 30 cm in length. Also,
retractors such as “L” wide and Finochietto2 types are used for these
procedures.

472
PART | 6  Thigh, buttock and lower extremity contouring
In the immediate postoperative period, the patient stays
in the supine position with slight elevation of the legs,
avoiding direct contact of the calves with the bed. The
patient is discharged 24 hours postoperatively, with main­
tenance of the elastic stockings for a period of 30 days
(Fig. 43.9).
Thigh Implants
Demarcation is done preoperatively with the patient in the
standing and supine positions, in the posterointernal region
of the thigh, up to 5 cm above the knee. The access is
through the gluteal fold, with the implant placed between
the rectus internal, adductor magnum, vastus medialis and
a small portion of the semimembranous muscles (Fig.
43.10). Hemostasis is performed superficially in the
FIG. 43.5  (A) The lateral borders of the gastrocnemius muscle are delimited, also a distance of 10 cm above the internal malleolus and
(B) superficially a 3 cm zig-zag incision above the popliteal fossa are marked.
A
B
subaponeurotic or supramuscular layer, in order to facilitate
introduction of the tip of the dissector in the posterior
region of the leg toward the lateral and distal borders of the
previously marked areas. It is mandatory to preserve a thin
muscular layer in the undermined region, in order to avoid
any damage to the aponeurosis. Caution must also be taken
to avoid any damage to the neurovascular structures in the
popliteal region. With the use of blunt instruments, dissec­
tion is less traumatic, with insignificant bleeding. The
implants are then inserted by sliding them into the pockets
created through a fixed guide at their distal end, facilitating
their placement into the lower part of the pockets (Fig.
43.7). The surgical wound is then closed in three layers:
aponeurosis, subcutaneous tissue and dermis. Layers of
Micropore® are placed on the wound and medium com­
pression elastic stockings are used (Fig. 43.8).

473
Chapter | 43  Calf and thigh implants
FIG. 43.7  The implants are then inserted by sliding them into the pockets created through a fixed guide at their distal end, facilitating their
placement into the lower part of the pockets.
A
B
C
D
FIG. 43.6  (A) Dissection is pursued in the subcutaneous tissue and the aponeurosis of the gastrocnemius medialis muscle,10 (B) then under­
mining is done up to 2 cm below the initial incision.
2 cm
A
B

474
PART | 6  Thigh, buttock and lower extremity contouring
superior subcutaneous layers as there is minimal bleeding,
as in calf implant procedures, with closure of the wound in
two layers, using subcutaneous and intradermal sutures,
and elastic compression.10
DISCUSSION
In this study, we analyzed a total of 380 patients who have
undergone these procedures since 1980. The objective of
these procedures was to treat deformities of the lower
extremities secondary to poliomyelitis, trauma and burns.
Many of these cases required prior expansion with the use
of tissue expanders. Interestingly, the great majority of
cases that we performed were esthetic in nature, namely for
the treatment of thin legs and varus knees.
In cases of asymmetry of the thighs or calves, implants
of different sizes were used and in some patients only one
implant was placed. In approximately 50% of the patients,
85 cm3 calf implants were used; in 40%, 140 cm3 and in
10% of cases 180 cm3 implants were placed. The same size
implants were used for thigh augmentation, 180 cm3
implants for 70% of the patients and 140 cm3 for 30% of
the cases. Nowadays, specific implants are used for thigh
FIG. 43.8  Layers of Micropore® are placed on the wound and
medium compression elastic stockings are used.
augmentation that are slightly larger in width and height
than calf implants, achieving a more natural look and a
better fit for this region.
The results obtained were graded as “good” in approxi­
mately 98% of patients. The complication rate was low,
with 2% of cases presenting hypertrophic scars (which sub­
sequently improved with the use of the zig-zag skin inci­
sion) and some degree of asymmetry. We also had a few
cases of compartment syndrome due to excessive localized
swelling which gradually improved after regression of the
edema.
Approximately 70% of patients complained of localized
postoperative pain in the first 3 days, 30% complained of
pain up to the 7th postoperative day and 10% up to the 15th
postoperative day. In general, patients were advised to
return to their routine daily activities 21 days postopera­
tively, with no restriction after 45 days.
POSTOPERATIVE CARE
● In-patient for 24 hours. Ambulation is allowed after 48
hours.
● Must use a compressive bandage in the incisions for 3
weeks.
● Must use soft compression tights and high heels (5 cm)
for 30 days.
● Antibiotics for 7 days.
● Anti-inflammatory and pain relief drugs for 10 days.
COMPLICATIONS AND
THEIR MANAGEMENT
● Immediate: dehiscence of the scar, necrosis in the line
incision, seroma.
● Late: asymmetry, infection, overcorrection, implant
removal.
CONCLUSION
Overall, the use of silicone gel implants for calf and thigh
augmentation has been shown to be an effective procedure,
with satisfactory long term results for both patients and
surgeons. With these procedures, we obtained a 2 to 3 cm
increase in the perimeter of the calves and a 3 to 4 cm
increase in the perimeter of the thighs (Fig. 43.11).
There were no areas of contracture in these regions,4 but
rather the formation of a pseudoepithelial capsule around
the implant. Also, no contour distortion was seen, probably
due to the active movements of the muscles which are in
close proximity to the implants. This is one of the reasons
why the use of smooth silicone gel implants is preferred
to textured or polyurethane-covered implants in these
regions. In the postoperative period, radiographic and
magnetic resonance imaging are done in order to verify

475
Chapter | 43  Calf and thigh implants
FIG. 43.9  (A) Pre- and (B) postoperative views.
A
B

476
PART | 6  Thigh, buttock and lower extremity contouring
FIG. 43.10  (A) The access is through the gluteal fold, with the implant placed between the rectus internal, adductor magnum, vastus medialis
and a small portion of the semimembranous muscles (B–E).
A
B
C
D
E

477
Chapter | 43  Calf and thigh implants
FIG. 43.11  Pre- (A) and postoperative (B) views.
A
B
FIG. 43.12  Pre- (A) and postoperative (B) views.
A
B

478
PART | 6  Thigh, buttock and lower extremity contouring
5. Montellano L. Plástica da panturrilha. Anais XXII Cong Bras Cir
Plást, Gramado: APLUB; 1985. p. 637.
FURTHER READING
Montellano L. Aesthetic calf surgery. Annals of the International Sym­
posium “Recent advances in Plastic Surgery”. São Paulo. 1989.
p. 343.
Montellano L. Calf Augmentation. Annals of Plastic Surgery, Vol 27,
Number 5, Boston: Little Brown and Company; 1991.
Montellano L. Aesthetic calf surgery. Annals of the International Sympo­
sium “RAPS-92”. São Paulo, 1992. p. 167.
Montellano L. Anestesia loco-regional em cirurgia estética. São Paulo:
Hipócrates; 1993. p. 407.
Montellano L. Atualização em cirurgia plástica estética. São Paulo: Robe
Editorial; 1994. p. 563.
Montellano L. Atualização em cirurgia plástica. Fundamentos a Cirurgia
Estética. Rio de Janeiro. Medsi Editorial, 2003. p. 771.
Testutl, Jacob O. Anatomia topográfica. Salvat Editores, 1961.
Zenteno S, Montellano L. Plástia de aumento de panturrilha. Cir IberoLati­
noamericana 1986;XII.
the correct position of the implants in their respective
pockets.
The position of the scars mimicking the popliteal fossa
in calf implants and the gluteal fold in thigh implants is
almost imperceptible. Also, a good preoperative surgical
plan with adequate marking ensures the creation of an ade­
quate pocket for the placement of each implant and an
overall harmonious contour of the lower extremities with
good and sustainable results (Fig. 43.12).
REFERENCES
1. Carlsen L. Calf augmentation. A preliminary report. Ann Plast Surg
1979;2.
2. Finochietto R. Cirurgia Básica. Lópes Libreros Editores. Buenos
Aires; 1962.
3. Glicenstein J. Correção das aminotrofias dos membros por inclusão
de próteses de silicone. Rev Bras Cir 1979;69(3/4).
4. Karme F, Gomes B, Sjostedt C, et al. Prevenção e tratamento da
contratura capsular. Revista Bras Cir 1984;74(2):59–64.

479
© 2013 Elsevier Inc
Chapter 44 
Key Points
●
Proper patient selection involves careful assessment of
anatomic deformities and medical profile; lower BMI
patients are generally more favorable.
●
The evolution of wetting solutions has decreased
blood loss and made liposuction outcomes more
predictable.
●
Different cannula configurations are used, based on
their functional properties, to enable precision in
contouring.
●
Newer energy sources such as ultrasound and laser,
have expanded the available instrument panel.
Lipoplasty – history and principles
Peter B. Fodor
INTRODUCTION
First, a chronology of the development of lipoplasty abroad
and in the United States over a more than 30-year span is
presented. General principles fundamental to the procedure
are discussed in the second part of the chapter. Some
overlap between history and application of the procedure
was unavoidable.
Sequelae, esthetically unfavorable results, severe com­
plications (thromboembolic phenomena, hypothermia,
infection, etc.), as well as measures of prevention and treat­
ment will not be covered in detail and the reader is referred
to other chapters of the book.
Throughout the chapter, safety issues are emphasized.
EVOLUTION OF LIPOPLASTY
Lipoplasty spread from Europe and more than 30 years
elapsed before its introduction to the United States. During
that time, it has rapidly become the most frequently per­
formed cosmetic operation in the US, with 325 332 proce­
dures in 2011. The number of lipoplasties has increased
more than 158% in the last 10 years alone and is currently
the most commonly performed esthetic surgical operation
in the United States.1 This is far shy of the real numbers,
because our national society statistics are blinded to opera­
tions performed by non-plastic surgeons.
Organized plastic surgery played an important role in
furthering not only interest and technical advances in lipo­
plasty but also in the awareness of patient safety issues. To
this end, joint position papers have been published by our
national societies.
Since this is a relatively brief history, the contributions
of some gifted individuals may not have been included.
Illouz, briefly mentioned earlier, was responsible for
monumental advances. He began in 1977, first reporting on
his method in 1980.16–18 His most important contribution
was the introduction of blunt instrumentation, using a
Karman cannula attached to very high vacuum. There was
no undermining and no sharp instrumentation. In this way,
he removed fat while sparing the other important structures
between the undersurface of the dermis and the subjacent
muscle fascia. As a result, complications were dramatically
reduced, and the procedure became reproducible in the
hands of many other surgeons. The technique was adaptable
to a wide range of body regions and, for the first time, its
potential as a mainstay of esthetic surgery became apparent.
He first presented his blunt lipoplasty technique, which he
called “lipolysis,” at the Shirakabe Clinic in Osaka, Japan
in 1980. He was the first to introduce the “wet” technique,
infiltrating 200–300 cm3 of infusate regardless of the
expected volume of aspirate. Blood loss with this tech­
nique, as measured by the “lipocrit,” (the hematocrit deter­
mination in the infranatant portion of the decanted aspirate),
was reduced to approximately 8–10%. By the time his
milestone book, Body Sculpting by Lipoplasty, was pub­
lished in 1989,18 he became familiarized with the SuperWet
technique (the infusate-to-aspirate ratios of 1–1.5 : 1), which
he adopted.
The evolution of the wetting solutions will be discussed
later in this chapter. In respect to chronology, it is, however,
appropriate to mention here that a significant contribution
For additional online content visit

Part 7  Liposuction and fat grafting

479.e1
Chapter | 44  Lipoplasty – history and principles
The Initial Techniques of Fat Removal
The first known attempt to remove subcutaneous fat through
a small incision was carried out in 1921 in Paris, France,
by Charles Dujarrier, who operated on the calves of a Folies
Bergère dancer using a uterine curette. Details of the pro­
cedure are not known but, unfortunately, it ultimately
resulted in amputation of a leg. Following this, to the best
of our knowledge, no other similar attempt was carried out
for half a century.
Joseph Schrudde of Germany first reported on curetting
subcutaneous fat at the 1972 meeting of the International
Society of Aesthetic Plastic Surgery (ISAPS) in Rio de
Janeiro, Brazil. He termed the procedure “lipexheresis,”
which he stated “he had performed occasionally since
1964.” In 1975, he provided a more detailed report on the
procedure in Lagenbeck’s Archives of Surgery.2–6 Blind
long scissors undermining followed by the traumatic tech­
nique of using a sharp uterine curette frequently resulted in
prolonged drainage, lymphorhea, hematoma and even skin
necrosis.
The first surgeons to add suction for the purposes of fat
extraction, as opposed to just using curettage, were an
Italian father and son team – the Fishers, Arpad and George.
They presented their work in 1977.7 The tip of the instru­
ment was still sharp and, as a result, it severed not only fat
but also surrounding structures. The postoperative course
was again marred by complications and side effects not
unlike those resulting from lipexheresis. Therefore, the pro­
cedure was not enthusiastically received.
The next advance worthy of mention was that of Ulrich
Kesselring.8–10 Although he used sharp instrumentation
attached to suction, he was the first to recommend working
in the deep fat compartment just above the muscle fascia.
His results were superior to previous ones presented, in no
small measure due to his method of patient selection; he
performed the procedure only on young women with small
amounts of localized fat and elastic skin. Eventually, after
a great deal of lively debate with Yves Gerard Illouz at a
variety of plastic surgery meetings, Kesselring adopted
Illouz’s technique.
Bahman Teimourian was the first surgeon practicing in
the United States to make a significant contribution to the
evolution of lipoplasty. His work was independent from the
European surgeons. In 1976 he was still using scissors for
undermining, which he followed by curetting with a modi­
fied fascia lata stripper attached to suction. He boldly
extended his procedure to many body regions. His compli­
cation rate was 30%, characteristic of all curette techniques.
He first reported on his technique in 197911 and then later
as he modified it.12–15 Teimourian recognized the impor­
tance of separate tunnels, as opposed to a “windshield
wiper” type of approach to fat removal. He eventually
adopted a cannula technique instead of curettage.

480
PART | 7  Liposuction and fat grafting
Lipoplasty Wetting Solutions and
Corresponding Lipocrit Values
When applied to major volume removals, Xylocaine toxic­
ity25 and fluid overload could readily occur, potentially
resulting in major complications. Some plastic surgeons,
including a few with significant national reputations, not
only adopted the tumescent technique but arduously pro­
moted it. They advocated its application to larger and larger
volume removals. A “perfect storm” was in the making,
which predictably resulted in major lipoplasty complica­
tions and a growing number of fatalities nationally.22–24
By the early 1990s, while lipoplasty was the most com­
monly performed esthetic surgical procedure it also had
the lowest rate of complications. At this time, the “tumes­
cent technique,” which consists of infusing massive amounts
of wetting solutions, using tissue turgor as an endpoint,
was popularized. These solutions contain large amounts
of lidocaine (Xylocaine), attempting to provide simultane­
ous anesthesia for the procedure. Proponents of this
technique consider the need for an intravenous line and
the presence of an anesthesiologist during the procedure
unnecessary. The tumescent technique, as popularized
primarily by dermatologists,7 is the very gradual (up to
3 hours) installation of wetting solution until there is
tissue turgor, the skin surface is white, and it has a peau
d’orange appearance. Advocates of this technique state that
they inject between 3 and 6 cm3 of wetting solution per cm3
of estimated aspirate. Thus, many liters of lidocaine-
containing fluid may be injected, which amounts to a highly
variable clysis.
The volumes removed as reported by the advocates of
the technique often are much larger than with other methods.
However, the aspirate contains much more of the instilled
wetting solutions and cannot be compared with volumes by
volumes when smaller amounts of wetting solutions are
administered prior to aspiration. With the superwet method,
for example, the supernatant fat routinely comprises as
much as 75% to 80% of the aspirate. It is the reverse with
the tumescent technique.
For small to moderate volumes of removal, any wetting
solution technique is comparatively safe when performed
in a healthy, young, aerobically fit patient. The potentially
hazardous nature of massive wetting solution infusion tech­
niques as applied to large-volume lipoplasty can result in
fluid and lidocaine overload. This scenario was readily pre­
dictable22,23 as the trend for using the tumescent technique
for large-volume removals was adopted around 1994. As it
turned out, unfortunately, the incidence of major complica­
tions and fatalities associated with lipoplasty rose rapidly
after 1995 (Box 44.1). Consequently, the media and pub­
lic’s perception of the procedure changed from a safe to a
hazardous one.
was made in 1984 by Hetter, who added epinephrine to the
wetting solutions. This yet further decreased the aspirate
lipocrit values to 4–8%. His book, The Theory and Practice
of Blunt Suction Lipectomy, published in 1984, remains to
this day a highly recommended text for students of lipo­
plasty at any level.19,20
Concurrently, Pierre Fournier and Francis Otteni of
France were popularizing the use of syringes as the suction
source for lipoplasty.21 They also favored noncutting edge
cannulae. However, they unfortunately continued to advo­
cate the “dry technique;” no wetting solution preinjection.
As a result, with their method, lipocrits continued to hover
around 20–40%.
Wetting Solutions
When it comes to lipoplasty, safety is intimately interwoven
with the proper use of wetting solutions, a subject of
primary interest to me for many years.19,22–26
By 1986, having had significant clinical experience with
the procedure, I became convinced that the most rational
fluid volume infusion-to-aspirate ratio was 1–1.5 cm3 of
infusate per cm3 of estimated aspirate, which I then termed
the “superwet” technique. This was presented at many
plastic surgery meetings and eventually in the plastic surgi­
cal literature. As a result of this technique, the lipocrit
values were routinely reduced to 1%.
Soon after, in 1987, the tumescent technique was intro­
duced by a California dermatologist, Jeffrey A. Klein.
While lipocrit determinations using his approach also
hovered around 1% (not unlike the superwet technique),
excessive amounts of wetting solution containing local
anesthetic, as the sole anesthesia delivery system for the
procedure, were infused. Table 44.1 lists the lipocrit values
reported for different lipoplasty approaches.
TABLE 44.1  Lipoplasty Approaches and Percentage of
Blood Loss in the Aspirate as Determined by Lipocrit
Measurements
Technique
Year
Author
Lipocrit
Dry
1983
Fournier
20–40%
1992
Courtiss
Wet
1980
Illouz
8–10%
Wet + Epi Epinephrine
1984
Hetter
4–8%
Superwet
1986
Fodor
1%
1990
Samdal
1%
Tumescent
1993
Klein
1%

480.e1
Chapter | 44  Lipoplasty – history and principles
LIPOPLASTY BEGINS AND GAINS
POPULARITY IN THE US
In1982, Illouz presented his technique for the first time in
the United States at the Annual Meeting of the American
Society of Plastic and Reconstructive Surgeons (ASPRS,
now the American Society of Plastic Surgeons, ASPS) in
Hawaii. This incited a tremendous amount of interest
among American surgeons. Shortly thereafter, then ASPS
President Mark Gorney had the foresight to create the “Blue
Ribbon Committee.” He appointed Simon Fredericks as
Chair. The mission of this committee was to visit Illouz and
evaluate his work. Upon their return, the Blue Ribbon Com­
mittee published a report with an extensive set of
recommendations.
The committee also developed a strategy on how to
gradually introduce the procedure to other US surgeons. It
organized a number of teaching courses across the country,
which did not, however, include live surgery demonstra­
tions and were often taught by surgeons who had yet to
perform a case.
Not long after the Blue Ribbon Committee’s visit to
Illouz, another group of surgeons, led by Gregory Hetter,
also visited the French surgeon at their own expense. This
group, soon after their return in 1982, founded the Lipolysis
Society, subsequently renamed the Lipoplasty Society of
North America (LSNA). The primary mission of this new
society was to teach the procedure to American surgeons.
To this end, annually, about four “basic teaching courses,”
which routinely included live surgery, were presented by
the LSNA faculty. By the mid to late 1980s, the LSNA
teaching symposia were in full swing. Within a 10-year
period, more than 40 basic courses in lipoplasty were con­
ducted. This resulted in widespread familiarization and
adoption of the operation. Patient safety issues had a pivotal
role during these teachings. Illouz was a faculty member at
most of these courses. Fournier was also invited to some of
the early sessions.
By 1992, it appeared that LSNA had fulfilled its mission
and logic dictated that it should be amalgamated by the
American Society for Aesthetic Plastic Surgery (ASAPS).
This process, however, took yet another 10 years.
Lipoplasty by this time was now being performed by a
rapidly growing number of surgeons around the world.
Successful outcomes were consistently reproducible and,
when compared to subcutaneous fat and skin excision
procedures, the results of lipoplasty seemed almost
“magical.”.

481
Chapter | 44  Lipoplasty – history and principles
Ultrasound Technology Emerges
Beginning in 1987 and continuing to this day, there has
been, in my opinion, an ill-founded enthusiasm for mechan­
ical manipulation of adipocytes resulting in their fragmen­
tation prior to aspiration. One of these widely popularized
approaches is the use of ultrasound energy to emulsify the
fat. In 1987, Professor Nicolo Scuderi of Italy was the first
to describe ultrasound-assisted lipoplasty (UAL), after
which a plethora of publications endorsed the practice of
UAL.29–31
My initial impression of UAL was confirmed by a clini­
cal study on my first 100 cases.29 The protocol was to
compare traditional suction-assisted lipoplasty (SAL) per­
formed on one side with the results of UAL applied to the
contralateral side during the same operation. In this way,
patients served as their own control. It was concluded that
the benefits of UAL, using all the different UAL devices
available at that time, for the most part did not justify the
shortcomings associated with its use. It was felt, however,
that even at this early stage of the development of UAL
devices (first and second generation), the technology offered
some tangible benefits in treating body regions with fibrous
fat and in secondary lipoplasty.29
In 1997, a meeting in St. Louis, hosted by Leroy Young,
was organized with the objective of facilitating the exchange
of ideas between leading biophysicists with interest in how
ultrasound energy affects adipocytes. In addition to Ameri­
can board certified plastic surgeons, industry representa­
tives were also asked to participate. After meeting William
Cimino, one of the PhD biophysicists present, I had the
opportunity to offer my clinical contributions to him as he
The advantages of the superwet technique, as compared
to the tumescent technique, have been amply presented by
myself and others.26–28
Patient tolerance to initial fluid load and the ability to
maintain postoperative fluid and electrolyte balance are
determined by many factors, such as general health, age,
obesity, aerobic condition, volume of aspirate, and size of
the surface area suctioned. All of these factors should be
considered when determining the safe volume of infusate
and aspirate. Flow sheets documenting input and removal
volumes are recommended. Lipocrit measurements and
the percentage of supernatant fat in the aspirate also are
informative.
Xylocaine Toxicity
It is generally accepted that lidocaine up to 35 mg/kg,
injected in the subcutaneous fat in solutions containing
epinephrine, is safe. It is notable, however, that this dose is
in direct contrast with the original recommendation of less
than 7 mg/kg published in the Physicians’ Desk Reference.
Absorption rates vary significantly, and measurements of
peak plasma lidocaine levels are more meaningful than
absolute amounts of injected lidocaine in assessing
potential toxicity. The danger is amplified by the fact that
lidocaine absorption from the subcutaneous fat can peak as
late as 10 to 12 hours after injection, by which time the
patient usually has been discharged from the surgical facil­
ity. Other factors can affect lidocaine toxicity, such as the
amount of unbound versus protein-bound lidocaine. In turn,
protein binding is influenced by several factors, such as
stress, chronic disease, cigarette smoking, oral contracep­
tives, and anorexiants. Therefore, the correlation between
total plasma lidocaine concentration and the predictability
of specific toxicity occurring in a given patient is weak
at best.24
In summary, the benefits of the tumescent technique
(e.g., low blood loss and decreased need for colloid and
crystalloid replacement), are realized with the “superwet
technique,” but without the hazards of delayed fluid uptake
by large clysis, need for drainage, risk of pulmonary edema9
and potential for lidocaine toxicity. Table 44.2 compares the
tumescent and superwet techniques.
1982–1995: 12 deaths; primarily from sepsis, pulmonary
embolus
Widespread adoption of tumescent technique
1995–1997: 100 deaths; primarily from fluid overload
and lidocaine toxicity
BOX 44.1  Lipoplasty Fatalities in the United States
TABLE 44.2  Comparison of Superwet and Tumescent
Techniques
Superwet (~1 cm3/
cm3)
Tumescent (~3 cm3/
cm3)
Volume
removal
+ + +
+ + +
Blood loss
0– +
0– +
Ecchymosis
+
+
Time to inject
+
+ + +
Fluid load
+
+ + +
Tissue turgor
0– +
+ + +
Ease to sculpt
? ?
Lidocaine
load
0– +
+ + +

482
PART | 7  Liposuction and fat grafting
cannulae, preservation of the superficial layer of subcutane­
ous fat, moderate-pressure postoperative garments, and a
healthy postoperative lifestyle will produce a satisfactory
result in most instances.
As with all surgical procedures, prevention of unfa­
vorable results is far simpler than their subsequent
management. A comprehensive discussion of all aspects of
liposuction is beyond the scope of this chapter; therefore,
the “tips, tricks, and traps” I have found helpful in carrying
out the procedure will be emphasized. Specific treatments
for various body regions will not be described.
Applied Surgical Anatomy of the
Subcutaneous Fat
The superficial fascia, an important membrane in some
areas of the body and less well developed in others, divides
the subcutaneous fat into a superficial areolar and a deeper
laminar fat. Localized fat deposits are defined by the super­
ficial fascia enveloping the deposit and fusing with the
muscle fascia at the perimeter of the deposit. This fusion is
strong and is readily felt when a cannula pierces through it.
When a surgeon transgresses this resistance and inadver­
tently enters with suction the subcutaneous layer of fat,
depressions, divots, or dimples can result. In body regions
such as the neck, lower abdomen, and outer thighs, this
deep fascia layer is well defined. In the epigastrium, hip
rolls, knees, calves, and ankle, the superficial fascia is less
well defined and is more like a fibrous structure resembling
a honeycomb. The superficial fascia is anchored to the
undersurface of the dermis by vertical arches of connective
tissue, the retinacula cutis. When these are stretched beyond
their limits of elasticity, dimples or peau d’orange, as seen
in cellulite, occur.
The author believes that this entire superficial fibrous
fascia system, which extends between the superficial mus­
cular fascia and the undersurface of the dermis, is the
human derivative of the panniculus carnosus.60 The vertical
fibrous attachments play an essential role in skin contrac­
ture after liposuction.
In conventional lipoplasty, suction of the deep fat com­
partment is common. This is the workhorse area, where
the most improvement is seen in the majority of cases. The
beginner should concentrate on these areas. Suction of the
superficial layer, as well as cannula “discontinuous under­
mining” over and adjacent to the area suctioned, promotes
postoperative skin contracture. Therefore, with the superfi­
cial technique, the procedure can be used for larger remov­
als and can be offered to older patients and to patients
with more flaccid skin.36,37 Superficial suction does not
eliminate skin excisional body sculpting procedures. Prop­
erly performed superficial suction reduces the need for
dermolipectomies.
was developing vibration amplification of sound energy at
resonance (VASER). This third-generation ultrasound lipo­
plasty device, when compared to earlier devices, limited the
power of ultrasound energy delivery to levels which, while
sufficient to fragment adipocytes, were less harmful to sur­
rounding lymphatics, blood vessels, and nerves.32–34 I have
enjoyed assisting in the refinement of this technology and
carrying out its first clinical trials from the inception of the
technique in 1997 to the present. Today, there is abundant
independent clinical observation by a multitude of surgeons
that VASER-assisted lipoplasty (VAL), which the company
nowadays has termed as “liposelection,” produces a milder
postoperative course and augments the tendency for skin
contracture. However, these observations are challenging to
document objectively. Currently, there are a number of
clinical studies in progress which it is hoped will provide
scientifically valid evidence for these outcomes. There are
also recent findings showing that the number of stem cells
is not reduced in the adipoaspirate obtained with VASER
technology compared to traditional lipoplasty.35 (Rubin,
personal communication).
External Ultrasound-Assisted Lipoplasty (EUAL)
EUAL, combined with subsequent aspiration of the fat, also
has its proponents. Though EUAL may assist with disburs­
ing wetting solutions in the subcutaneous fat, other pro­
claimed benefits are yet to be proven.
Power-Assisted Lipoplasty Emerges
The technology of power-assisted lipoplasty (PAL)46,47 has
also been embraced by a large number of surgeons. This
mechanically propelled device lessens the effort expended
by the surgeon to extract fat, allowing him/her to concen­
trate more precisely on sculpting.
With power assistance, a mini sledgehammer-like
mechanism drives the tip of the cannula forward and back­
ward at a cpm of 2000–4000 and a stroke distance of 2 mm.
This facilitates subcutaneous fat penetration. As a conse­
quence, the surgeon’s physical effort is lessened, and he
or she can therefore be more focused on sculpting. I had
the good fortune to be involved early in the development
of this technology and designed the first clinical studies
conducted with it. We also performed endoscopic studies
comparing traditional lipoplasty and power-assisted lipo­
plasty. Under magnification, these studies demonstrated
how power-assisted lipoplasty was less traumatic to struc­
tures surrounding the fat being aspirated.48
FUNDAMENTALS OF LIPOPLASTY
The routine procedure, which consists of proper patient
selection, judicious use of wetting solutions, blunt-tipped