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

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Chapter | 44  Lipoplasty – history and principles
(Redux), steroids, diuretics, cathartics, and other potentially
hazardous medications. In addition to alcohol and recre­
ational drug dependence, taking megadoses of certain vita­
mins and other over-the-counter remedies is common, for
example, consumption of vitamin E, which can influence
clotting.
Testing for hepatitis B or C, or the human immuno­
deficiency virus, although prudent, does not remove all
risks.
Complete physical examination should evaluate patients
for pre-existing orthopedic and neurologic conditions that
may be aggravated when the patient is put under anesthesia
on the operating table.
From an esthetic standpoint, the ideal patient (BMI less
than 24.9) for lipoplasty is a relatively healthy, thin, young,
person with highly localized subcutaneous fat excess:
“figure faults” (Fig. 44.1) with taut skin.
The average candidate (BMI 25–2 9.9) is over 40 years
of age, weighs 7–9 kg (15 to 20 pounds) over ideal weight,
has a history of weight fluctuations, and has some degree
of skin relaxation and/or striae. Although such a patient will
experience some improvement from lipoplasty, which may
incorporate superficial suction, autologous fat transfer
(AFT), and intraoperative and postoperative Endermologie,
he or she should be informed that subsequent suctioning
and dermolipectomy may be necessary for the most optimal
result (Fig. 44.2).
The less than ideal patient (BMI over 30) is older, is
more than 9 kg (20 pounds) overweight or generally obese,
has a history of weight fluctuations, and has clearly loose
skin. Striae, soft tissue ptosis with cascading folds of redun­
dant skin, the beginning of abdominal ptosis, banana rolls
(sometimes multiple), inner thigh ptosis, or a combination
of these features are present on physical examination. In
this group, patients older than 55 years seem more readily
satisfied with the results of the procedure than their younger
counterparts. The patient should repeatedly be informed
before surgery of the limitations imposed by their anatomy.
A more conservative approach followed by secondary suc­
tioning, after interim skin contraction, and eventual der­
molipectomy may be required. Regardless of age and how
close to the ideal candidate a patient is, sufficient preopera­
tive discussion(s) to bring postoperative expectations to a
realistic level is essential (Figs 44.3 and 44.4).
Visual inspection is not sufficient for adequate preop­
erative evaluation. Palpation for skin turgor, elasticity, and
strength is important. If pinched skin does not return
instantly to normal position, lipoplasty by itself is a poor
choice. The pinch test demonstrates the difference between
body regions with excess localized fat deposits and the sur­
rounding areas. For example, pinching the hypogastric area
in a patient who is a good candidate should demonstrate
thickness several folds over fat lateral to it. Patients readily
Creative combinations of different techniques allow a
customized approach for each patient. With experience, the
conventional and superficial suction techniques can be
combined skillfully. For example, when suctioning the
abdomen, superficial and deep suction are used in the epi­
gastrium. In the hypogastric area, the deep fat under the
Scarpa fascia is suctioned primarily. Most suction in the
neck is superficial to the platysma and hence is in the super­
ficial layer.
Errors in fat removal from the superficial layer are
highly visible. Fat removal from this layer should be as
even as possible; otherwise, grooves and irregularities
may result. Avoidance is far simpler than subsequent
treatment. If a problem caused by excessive extraction is
recognized at the time of the initial procedure, whether in
standard or superficial suction, fat reinjected at that time
seems to survive better than when done as part of a later
procedure. This is only a personal and, as such, an anec­
dotal observation.
Patient Selection
Patient evaluation is the most important step for the surgeon.
Wrong choices in psychological, medical, physical, and
esthetic evaluation lead to unsatisfactory results, nagging
patients, more difficult repeat surgical interventions, and
lawsuits.
The psychologically unfit patient, or an individual with
low self-esteem, marked anxiety, fear, paranoia, or unreal­
istic expectations can be difficult to diagnose preopera­
tively. Time spent with patients showing them representative
photographs, encouraging patients to provide magazines or
other pictures illustrating their expectations, and the pro­
spective patient’s attitudes toward previous esthetic surgi­
cal outcomes and surgeons, are all important. When in
question, it is best to avoid surgery. The impression of
needing an extensive psychological evaluation or a psycho­
metric analysis in order to accept a patient for surgery is a
warning sign by itself.
A comprehensive medical evaluation is in order for the
lipoplasty patient as it is for other esthetic procedures.
Specifically, it should rule out a history of chronic lung
disease, bleeding disorders, thromboembolic disease, and
acute or chronic systemic diseases. For example, use of
oral contraceptives places the patient at higher risk for
pulmonary embolus. Lifestyle and dietary habits can lead
to protein deficiency and fluid or electrolyte imbalance.
In addition to bulimia, many people have bizarre dietary
habits; others exercise excessively without adequate nutri­
tional support and are chronically malnourished, with
low iron source, low albumin levels, low potassium levels,
or all three. Others may have taken medications such
as fenfluramine-phentermine (Fen-Phen), dexfenfluramine

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Chapter | 44  Lipoplasty – history and principles
Physics and Equipment
Physics is often forgotten by most surgeons. As previously
mentioned, in 2005 we took a critical look at all compo­
nents of a suction system; vacuum source, tubing, cannulae
and collection canisters, on a bench model using applesauce
mixed half and half with saline, which was compared and
found to correspond well to in vivo data.57
Vacuum Source, Tubing, and Cannulae
There are two ways to move the dislodged fat down the
cannula or tube. The first is to have an air line to the tip of
the cannula or an open wound where air enters the lumen
and carries the fat fragments back down the tube towards
the vacuum. Such systems work with pressures of one-
quarter to one-half atmosphere (190–380 mmHg at sea
level). The other is to produce so nearly an absolute vacuum
that tissue fluids “boil.”
The molecules from the boiling tissue fluids push the
fatty fragments down the cannula towards the vacuum. At
20° C (68° F) tissue fluids vaporize, or “boil,” when the
surrounding pressure has been reduced to 17 mmHg. This
is achieved by typical vacuum pumps, but it can also be
achieved when a closed syringe plunger is withdrawn and
near-vacuum is achieved. This is the basis for syringe-
driven suction (SDS). The suction pump is the traditional
approach, but good results can be achieved with either
method. The advantages of the syringe technique are: the
elimination of aerosols and noise, a closed “anaerobic”
system, the ease of washing and storing harvested fat, and
the ease of transporting the equipment to another facility.
However, the syringe technique may be more time-
consuming and untidy. I personally favor syringes for the
initial infiltration of wetting solutions for small fat remov­
als, touchup procedures, and harvesting fat for the purpose
of autologous fat transfer; I favor the pump for removals of
size. The skill of the surgeon is far more important than the
type of suction source employed.
Briefly, cannulae should be blunt at the tip, with the
opening(s) located sufficiently proximal from the tip to
avoid inadvertent removal of subdermal fat. The shortest
cannula that can be used to reach the area to be defatted
allows for the best control by the surgeon. With smaller-
lumen cannulae, the suction power and, therefore, the rate
of removal is exponentially reduced. The finer the tunnels,
the fewer waves and surface irregularities occur. Cannula
diameter is reduced as the procedure progresses from initial
debulking to fine sculpting and from a deeper to a more
superficial level. Multihole cannulas extract fat quickly and
therefore require greater attention. Cobra cannulas, which
have their openings at the tip, and other combinations of
cutting tip designs are useful in fibrous areas such as the
treatment of gynecomastia, the epigastrium, or the perium­
bilical area. Their use requires diligence.
Our data showed57 that small changes in vacuum
(2–3 mmHg) do not appreciably impact aspiration rate,
especially when the system includes either a smaller diam­
eter cannula or the smaller diameter (6.35 mm) suction
tubing. The most significant effect is the tubing’s internal
diameter (ID). For example, the 9.5 mm in ID tubing
attached to a 3.0 mm cannula had a slightly higher aspira­
tion rate than the 6.35 mm ID tubing without any cannula
attached to it. When using the smaller 6.35 mm ID tubing,
the variation in aspiration rate for the different diameter
cannulae was small, showing that the tubing diameter dom­
inated flow rates.
Biohazards
Biohazards have not yet been proven to be associated with
the use of suction pumps.61 Vaporization of tissue fluids
raises the possibility that bacterial and viral particles may
be exhausted into the operating room. It is recommended
that a special filter be placed between the collection jar and
the pump to reduce this risk. These filters can stop particles
larger than 0.3 µm, have a large surface area to allow good
air flow, and are reasonably priced. It is recommended that
such filters be used with all machines at all times.

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PART | 7  Liposuction and fat grafting
A
B
FIG. 44.1  (A, B, C) A 20-year-old woman before and 6 months after lipoplasty for figure faults of the upper and lower abdomen, outer thighs,
inner thighs, inner knees, banana rolls, hip rolls. A total amount of 1820 cm3 was removed.

485
Chapter | 44  Lipoplasty – history and principles
C
FIG. 44.1  Continued
A
FIG. 44.2  (A, B, C) A 40-year-old woman before and 1 year after lipoplasty of the upper and lower abdomen, hip rolls, outer and inner thighs,
inner knees. The total volume removed was 3560 cm3.
Continued

486
PART | 7  Liposuction and fat grafting
B
C
FIG. 44.2  Continued

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Chapter | 44  Lipoplasty – history and principles
A
B
FIG. 44.3  (A, B, C) A 50-year-old woman before and 8 months after lipoplasty of the upper and lower abdomen, hip rolls, outer and inner
thighs, inner knees. A total amount of 4100 cm3 was removed.
Continued

488
PART | 7  Liposuction and fat grafting
C
FIG. 44.3  Continued
A
FIG. 44.4  (A, B, C) A 63-year-old woman before and 18 months after lipoplasty of the upper and lower abdomen, hip rolls, outer and inner
thighs. A total amount of 5720 cm3 was removed. Traditional and superficial suction was carried out.

489
Chapter | 44  Lipoplasty – history and principles
B
C
FIG. 44.4  Continued

490
PART | 7  Liposuction and fat grafting
relate to this demonstration. It helps them to understand that
not all fat is to be removed, that what remains will be in
better proportion to the rest of the body, and that what is
left is more important than what is removed. For example,
in men with large “beer bellies,” the pinch test often dem­
onstrates that the epigastric area has an amount of fat
similar to the area lateral to it, which renders this type of
patient a poor candidate for liposuction. In these individu­
als, most of the fat is intraabdominal (greater omentum) and
retroperitoneal.
Showing preoperative photographs, especially from the
posterior view, to patients during consultation is an impor­
tant tool to demonstrate what can and, as importantly, what
cannot be done about their concerns.
Preoperative Markings
Patient markings are carried out in a standing position and
usually are done in a topographic manner. Using indelible
marking pens of different colors is useful. Sights of
maximum removal and depressions or valleys are appropri­
ately noted. In addition to the localized fat deposits to be
suctioned, the areas to be augmented with autologous fat
transfer (AFT) are marked. Undesirable skin adhesions to
underlying tissue (such as the folds between back rolls),
and location of folds to be created (such as better definition
of the gluteal folds or design of abdominal etching) are
similarly marked. Access incisions needed to reach the
areas to be suctioned are placed as close as possible. Shorter
cannulas provide better control. When cannula (without
suctioning) discontinuous undermining is planned to facili­
tate skin contraction beyond the borders of suctioning (as
in larger cases of gynecomastia), this is also drawn. Photo­
graphs taken with the markings in place are used to confirm
the surgical plans with the patient and serve as documenta­
tion of what was treated. Standardized circumferential
multiple-view preoperative and postoperative photographs
are also taken.
Postoperative garment size is determined prior to
surgery.
Surgical Intervention
Prepping and Patient Positioning
Prepping, whether circumferential (in the standing
position) or sequential (on the operating table), is deter­
mined by the body areas to be treated and the surgeon’s
preference. Surgeon’s preference also dictates optimal
patient positioning. Before induction of anesthesia, the
different patient positions on the operating table required
for a given procedure and the placement of access inci­
sions are checked and adjusted as necessary. Attention is
given to padding pressure points (to protecting bony
prominences), and care is taken in turning and in prevent­
ing injury to the extremities, brachial plexus, face, chest,
and genitalia. The neck should be placed in the normal
postural position to avoid pinching of the cervical
roots.
Infusion of Wetting Solutions
Several different formulations of wetting solutions have
been recommended. These formulations do not differ sig­
nificantly from each other. For the most part, they are iso­
tonic in nature and contain low concentrations of epinephrine
and lidocaine. The formulation I currently favor is shown
in Box 44.2.
The SuperWet technique, for the reasons detailed earlier
in the chapter, is routinely used. In general terms, 1 cm3 of
wetting solution for each 1–1.5 cm3 of estimated aspirate is
infused. Sequential infusion, as opposed to infusing all
areas to be suctioned at once, lessens acute fluid load by
clysis and variability of tissue distortion by the wetting
solutions. Uniform layering of infusion facilitates sculpt­
ing. While for small volumes, such as treatment of necks
or inner knees, 60-ml Toomey syringes with infusion can­
nulae can be used, infusion pumps are better suited for
removal of larger volumes.
As a general rule, the volume of wetting solutions
administered to a patient undergoing a lipoplasty procedure
should not be more than 5000 ml. The lidocaine load should
not exceed 35 mg/kg of body weight.
Lidocaine is mixed in the solution to provide pre-
emptive and some postoperative analgesia. This use of
local anesthetics in the wetting solutions is notably dif­
ferent from the use of lidocaine as proposed with the
tumescent technique. Although small volume removals
can be performed safely with the analgesia provided by
the lidocaine contained in the wetting solutions, this
author is of the definite opinion that wetting solutions
are not a practical or safe anesthesia delivery system
for major-volume lipoplasty. General or epidural anesthesia
is recommended.
Sequential/segmental infusion
1–1.5 ml infusate/ml of estimated aspirate
1000 ml Ringer's Lactate + 0.5–1 ml epinephrine
1/1000 + 25 ml
0.25% lidocaine + 1 ml (40 mg) gentamicin ±
hyaluronidase
BOX 44.2  Table Infusion Formulation for
Superwet Technique

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Chapter | 44  Lipoplasty – history and principles
Pretunneling Extraction
and Mesh Undermining
Pretunneling (i.e., passing the cannula when no suction is
attached) helps to define the proper plane. The feel in the
superficial layer is “gritty”, whereas the feel in the deep fat
is smoother. A cannula that is too pointed or has a sharp tip
does not as readily provide this important tactile feedback.
Suction, once applied, detracts from the tactile sense.
Passing the cannula in regular radiating tunnels, a pseudo-
plane that better defines the fat to suction is developed. The
easy movement of the cannula stops where the superficial
fascia fuses at the periphery of the localized fat deposits.
When no suction is attached, a puncture wound into the
superficial fat causes no lasting effect. Therefore, pretun­
neling is helpful to define the depth and extent of suction.
The extraction should be in radial, not coalescing, tunnels,
with long even strokes and additional passes as guided by
the preoperative markings. The edges of the deposits are
feathered, and “mesh undermining” without suction is
extended laterally as needed. Cross tunneling and suction
at right angles to the first tunnels can result in additional
fat extraction. It is important to compare the extracted area
for evenness, within itself and to the surrounding untreated
areas, visually and by palpation. Wetting the surface and
looking from different angles as practiced in car body repair
shops can also help.
Beware of over-resection! Perform the pinch and roll
tests often. Avoid a side-to-side windshield wiper motion,
which promotes dead space and pseudobursa formation.
The cannula lumen is not turned against the deep dermal
surface unless an indentation is being created on purpose,
such as in abdominal and pectoral chest etching or creation
of a gluteal fold. Persistent overworking or a bloody area
is avoided.
Knowing when to stop is the hardest part of all endeav­
ors. What is left behind, not how much is extracted, deter­
mines the quality of the result. When the aspirate turns
bloody, it is time to move to the next tunnel. If the skin
appears lax, especially over the abdomen and inner or outer
thighs, it is reasonable to stop or, based on the surgeon’s
skill and experience, to proceed with the superficial tech­
nique. Be careful and remember that secondary suction
after initial skin contracture, performed some months later,
is an option.
Esthetic sense is hard to describe and is more innate
than learned.
Over-resections performed in an attempt to comply with
a patient’s preoperative wishes for a “flat stomach” or
“skinny straight thighs” may not be in proportion with the
esthetically natural curves of the body, which should be
known and respected. For example, when a less than
ideal amount of fat is left over the trochanter in a female
patient with residual hip rolls, she will appear masculinized
in the posterior view. Similarly, a scaphoid abdomen
void of any periumbilical fullness is not feminine in
appearance.
Small refinements can be made with fine cannulas
attached to low suction or to syringes. Autologous fat after
anaerobic washing and decanting can be transferred to fill
areas of pre-existing depressions or over-resection. Selec­
tive division of retinacula curis combined with rolling
massage and injection of a thin layer of autologous fat fol­
lowing superficial suction has resulted in limited improve­
ment in the appearance of cellulite.
When extraction is complete, the edges of the extracted
area are loosened with mesh undermining by passing a very
blunt cannula into the surrounding area without suction.
This maneuver tends to break up the edge and allow some
recontouring of the adjacent tissue. The theory behind such
a maneuver is that there are three phases to the improve­
ment seen after lipoplasty: (a) immediate fat cell extraction,
(b) subsequent fat cell death, and (c) fibrosis and retraction.
Mesh undermining is believed to cause some additional fat
cell death at the periphery, which allows a more even
transition.
When Performing PAL
The PAL cannula in my experience was found to break up
fibrous fat much more readily. This is clearly evident during
treatment of gynecomastia, hip rolls, back rolls, of the epi­
gastric area and secondary lipoplasty, all known to be quite
labor intensive with traditional lipoplasty (TL). It is the
device of my choice for “debulking” a large localized fat
deposit. PAL significantly shortens operating time in com­
parison with TL. For example, during the initial phase of
the procedure, it is not uncommon to be aspirating as much
as 100 ml per minute. Once experience is gained with it,
the device is also found to be a useful surgical tool for
performing superficial suction, with the exception of sub­
mental suctioning, for which I find the bulk of the handle
of the instrument to be cumbersome. In general, using PAL
is less fatiguing. The power-assisted cannula is moved at a
speed slow enough to allow for the instrument to break up
the resistance that it is encountering. Therefore in fibrous
areas, the cannula movement is slower. At the appropriate
speed, a sensation of gliding through the tissues with con­
siderable ease is imparted to the operator’s hand. The end­
point of suctioning is subjectively determined by the
surgeon by using the same esthetic criteria and guidelines
that apply to lipoplasty in general.
Based on microscopic studies, performed on specimens
from a few patients, the aspirate obtained with PAL was
found to be as suitable for autologous fat transfer (AFT) as
is the fat obtained with TL.46

492
PART | 7  Liposuction and fat grafting
On the down side, there was some degree of surgeon
discomfort noted in using PAL because of the vibration of
the instrument transmitted to the operator’s hand. The
vibration is diminished by decreasing the speed of cannula
movement. There appears to be no noticeable diminution
in the efficiency of the instrument as long as it is operated
at least 80% of full power (4000 cpm). There is also some
noise associated with operating the PAL cannula. While this
adds to the noise already present, however, the sound gener­
ated by the suction machine muffles to a degree that coming
from the PAL instrument.
Early on in one’s experience, it might be wise to use
PAL primarily as a debulking instrument, treating larger
body areas such as the outer thighs, hip rolls and the
abdomen.
When Performing UAL
The fat is emulsified concurrently (hollow cannula technol­
ogy) or before (solid probe technology) its extraction. To
date, the process of emulsification is not fully understood.
Although cavitation has been proposed as the principal
mechanism, the micro “sledge hammer” effect, imparted by
the application of the ultrasound energy to the adipose
tissue, also may play an important role.
Larger removals, lower blood loss, better skin contraction/
retraction, faster recovery, and smoother postoperative skin
surfaces have not been demonstrated convincingly enough
to justify general replacement of traditional lipoplasty with
UAL. Currently, it is best used in combination with the
traditional technique. In addition to expense, however, there
is also to consider a tedious learning curve for the surgeon,
imposition on the staff, and side effects particular to UAL.
These include larger access incisions, longer surgical times,
and higher seroma and dysesthesia rates. Thermal damage
can occur at the access incisions and at distant sites, but
appropriate training can minimize most of these. In UAL,
the following measures are recommended: skin protectors
at incision sites, a wet surgical towel between the shaft of
the cannula and the subjacent skin in contact with it, con­
stant cannula movement while ultrasound energy is being
delivered, avoiding extensive ultrasound times in one loca­
tion, avoiding “end hits,” and keeping the cannula at least
1 cm below the deep surface of the dermis. These general
recommendations apply to all UAL devices currently avail­
able in the United States. The more powerful the unit is, the
steeper the learning curve and the lower the relative safety
of the device. The novice UAL surgeon is advised to begin
with a lower setting, especially if using one of the more
powerful devices. A wet environment is mandatory for fat
emulsification. The superwet technique used in combination
with UAL adequately satisfies this requirement without the
hazards imposed by the tumescent approach. As long as the
superficial layer of fat is not exposed to ultrasound energy,
the more severe complications, such as permanent pigmen­
tary and prolonged, if not permanent, sensory changes,
fibrosis, and extensive skin sloughs, can be mostly avoided.
The solid probe approach, unlike the hollow cannula
method, does not provide the surgeon with continuous
visual feedback of the emulsified fatty material. Still, the
solid probe technique may prove to be safer because the
subcutaneous structures (nerves, lymphatics, blood vessels,
and deep dermis) are not suctioned up against the tip of the
cannula, where most of the ultrasound energy is being deliv­
ered. The perceived benefits of the third-generation UAL
device (VASER) have already been commented on in this
chapter.
When first beginning UAL, the value of proper training,
cautious graduated experience, and solid surgical judgment
cannot be overemphasized.
When Performing Superficial Lipoplasty
In conventional liposuction, suction of the deep fat com­
partment is recommended. Superficial liposuction,36,37 as
well as just cannula undermining, in the superficial com­
partment, helps promote postoperative skin contracture.
Therefore, when superficial technique is added, larger
volumes of fat can he aspirated from any given area, and
the procedure can be offered to older patients and patients
with more flaccid skin. Also, if skin excision is unavoid­
able, it will not need to be as extensive.
Fat removal from the superficial layer should be per­
formed as evenly as possible, otherwise grooves and irregu­
larities may result. With experience, one can skillfully
combine both deep and superficial suction. For example,
when suctioning the abdomen, superficial and deep suction
can be used in the upper abdomen, especially in the midline,
while fat under Scarpa’s fascia is primarily suctioned in the
lower abdomen.
For several years now, suctioning of the superficial fat
compartment has been an accepted procedure in certain
areas of the body. For example, suction of tile submental
region has always been primarily superficial to the platysma
and, therefore, in the superficial layer. Because of this,
impressive results in the neck are common when suction is
used alone. Similarly, good skin contracture is the rule with
suction of gynecomastia, inner knees, ankles and epigastric
regions.
Superficial or deep suction does not totally eliminate
skin excisional body sculpting procedures. Creatively com­
bining these different procedures allows one to custom
tailor the surgical plan for each patient. However, I do not
approve of the use of a sharp cannula to penetrate even

493
Chapter | 44  Lipoplasty – history and principles
more superficially to a level just subjacent to the dermis. In
my view, this is a dangerously aggressive technique that
places the deep dermal plexus in jeopardy. This technique
has the potential for creating surface irregularities, chronic
pigmentary changes and skin sloughs.
In general, for superficial suction, smaller caliber blunt
cannulae with openings near the tip work better. For a
vacuum source, the suction machine or the syringe aspira­
tion technique can be used equally well. I recommend sur­
geons become familiar with both.
Large Volume Removals
An arbitrary classification of lipoplasty patients according
to the volume of aspirate currently used by the author is listed
in. Large-volume lipoplasty is defined as removal in excess
of 5000 cm3 of supernatant fat in one operative session. In
my judgment, this should be considered only in patients of
low anesthetic risk (American Society of Anesthesiologists
class I), who are at least in average aerobic shape and have
preoperative hemoglobin and hematocrit measurements of
above 11 g/l and 30%, respectively. A bleeding time is per­
formed to detect coagulopathy. An erythrocyte sedimenta­
tion rate, although nonspecific, detecting cryptic disease
processes, is also informative.
Large-volume lipoplasty carries a significantly higher
risk. Patient tolerance for this procedure is a function of
several different factors, and as such, safety considerations
need to be accordingly observed. In addition to age and
general health, the percentage of body surface area to be
treated is important. The fluid shifts that occur after lipo­
plasty are not unlike those that occur after a second- degree
burn. If the area of injury exceeds 15% of body surface
area, morbidity rises disproportionately. The palmar surface
of the patient’s own hand and fingers represents 1% of the
body surface.
The need to monitor fluid shifts and hemodynamic
changes requires close intraoperative and postoperative
monitoring, which is best provided by an accredited surgical
facility. Injudicious ambulatory discharge of large-volume
lipoplasty patients may lead to many potentially dire conse­
quences, such as hypovolemia, oliguria, fat embolism syn­
drome, shock, renal shutdown, pulmonary embolism, and
myocardial infarction.
Large volumes can be removed safely in properly
selected patients (Fig. 44.5). Our general guidelines for the
preoperative, intraoperative, and postoperative care of lipo­
plasty patients are listed in Boxes 44.3–44.5. It should be
stressed that the amount of wetting solutions (crystalloids)
delivered alters the amounts of intravenous fluids required
over time. Close communication with the anesthesiologist
and careful patient monitoring are essential.
FIG 44.5 APPEARS ONLINE ONLY
SECONDARY LIPOPLASTY
Even today, after significant physician education initiatives
undertaken nationally and internationally, patients present­
ing to my practice for a secondary operation far outnumber
patients seeking primary lipoplasty. Unfortunately, many of
these patients did not select their surgeon wisely. Approxi­
mately half are not good candidates for further surgery.
For the rest, depending on the deformity, the secondary
procedure will consist of additional lipoplasty alone or
combined with autologous fat transfer, and some patients
will also require skin resection procedures. Despite certain
limitations of secondary surgery, most of these patients are
Low anesthetic risk: ASA class I
Erythropoietin for hematocrit <35%
Discontinue Fen-Phen and other potentially hazardous
prescription drugs
Evaluate risk for thromboembolic phenomena and treat
accordingly
Rule out lifestyle and dietary habits leading to protein
deficiency and fluid and electrolyte imbalance
Should be in at least average aerobic shape
BOX 44.3  Safety Issues in Large-Volume Lipoplasty:
Preoperative Considerations
Body heat preservation; silver cap, Bair Hugger, warm infu­
sion fluids
Anesthesia: general or epidural (not local)
Superwet technique (not tumescent!!!)
Low or only keep, open volumes of intravenous fluids
Foley catheter
Sequential pneumonic leg compression
± chemoprophylaxis for thromboembolism
BOX 44.4  Safety Issues in Large-Volume Lipoplasty:
Intraoperative Considerations
Overnight observation
Early ambulation
Sequential pneumonic leg compression
± chemoprophylaxis for thromboembolism
Patient able to void before discharge
Hematocrit at 24 hours (of questionable value)
BOX 44.5  Safety Issues in Large-Volume Lipoplasty:
Postoperative Considerations

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Chapter | 44  Lipoplasty – history and principles
FIG. 44.5  (A, B) A 58-year-old woman before and 7 months after large volume lipoplasty (no skin excision) using traditional and superficial
approaches of the upper and lower abdomen. A total volume of 5800 cm3 was removed. No skin excision was carried out.
A
B

494
PART | 7  Liposuction and fat grafting
FIG. 44.6  A 41-year-old patient before and two years after secondary lipoplasty of the abdomen (A) and inner thighs (B) including autologous
fat transfer and Colles fascia anchor medial thigh plasty.
A
B
very satisfied and grateful for the improvement obtained
(Fig. 44.6). An algorithm and recommendations for evalu­
ation and care of these patients have been discussed in
detail.62
CONCLUSION
Lipoplasty, when properly performed, is indeed a wonder­
ful body sculpting method with results that approach
“magic”. Looking at it in a historical context is helpful for
gaining an overall perspective.
The suggestions made in this chapter aim to assist sur­
geons with patient safety and how to avoid unfavorable
lipoplasty results. Experience with less complex proce­
dures, combined with judicious application of new technol­
ogy, is strongly recommended before advancing to more
complex procedures and approaches.
REFERENCES
1. American Society for Aesthetic Plastic Surgery, 2007–2009 Cos­
metic Surgery National Data Bank Statistics.
2. Rogers B. Joseph Schrudde, MD of Cologne: the father of lipoplasty.
Lipoplasty Society of North America; Lipoplasty Newsletter 1991;
8(1):6–7.
3. Schrudde J. Lipexeresis in the correction of local adiposity. First
Congress of the International Society of Aesthetic Plastic Surgery
(abstract) Rio de Janeiro 1972.
4. Schrudde J. Lipexeresis as a means of eliminating local adiposity.
Aesth Plast Surg 1980;4:215.
5. Schrudde J. Suction curettage for body contouring. Plast Reconstr
Surg 1982;69:903–9.
6. Schrudde J. Lipexeresis (liposuction) for body contouring. Clin Plast
Surg 1984;11:445–6.
7. Hetter GP, Fodor PB. Aspirative lipoplasty. In: Georgiade S, Riefkohl
R, Scott Levin L, editors. Plastic Maxillofacial and Reconstructive
Surgery. 3rd ed. Chapter 58. 1998. p. 685.

494.e1
Chapter | 44  Lipoplasty – history and principles
POSTOPERATIVE MANAGEMENT
The postoperative care of lipoplasty patients is straightfor­
ward. For treatment of discomfort, analgesics and often just
muscle relaxants suffice. Attention is paid to prevent urinary
retention and to ensure fluid and electrolyte balance.
A pressure garment is applied to provide even tension;
a localized tourniquet effect is to be avoided. Padding with
a sponge-like material can assist in accomplishing this.
Tension should be relieved periodically, for example, by
temporarily undoing the hook-and-loop closure of an
abdominal binder.
Orthostatic hypotension is not uncommon, especially in
patients who underwent large volume removals. It almost
invariably is transient in nature and responds to simple
measures. If not, the patient should be evaluated immedi­
ately for the need for intravascular volume expansion to
prevent oliguria, hypoxia, hemoconcentration, and embolic
phenomena. Prompt treatment with oral fluids or, if neces­
sary, crystalloids and/or hetastarch (Hespan) administration
is imperative. Blood transfusion is used only as a last resort.
It seldom, if ever, is necessary, as long as the safety guide­
lines for large-volume removals outlined earlier in this
chapter are followed. In the author’s lipoplasty practice,
extending over 25 years, not a single patient received het­
erologous blood transfusion. Autologous transfusions also
have been eliminated by the superwet technique. Pretreat­
ment with erythropoietin of patients with preoperative
hematocrit < 5% and in whom the estimated removals
exceed 4000 cm3 of supernatant fat is a consideration, as
opposed to postponing surgery.
The first dressing change is at 3 to 5 days, at which time
access incision sutures are removed.
Perioperative antibiotics, postoperative Endermologie,
or massage and ultrasound treatments can be used in accor­
dance with the surgeon’s preference and what is practical
for a given patient. Although ultimately the results are
indistinguishable at 1 year, physical therapy modalities are
comforting during convalescence. The worried or anxious
patient is especially well served by these measures.
The remodeling of the tissues and the survival of fat
grafts are relatively complete 3 months after the procedure.
The ankles may take 6–9 months. Changes continue for as
long as a year while collagen contracture and fatty remodel­
ing progress.
Adipocyte regrowth is limited to nonexistent following
lipoplasty. Some patients eat with abandon and gain weight
primarily in body areas not suctioned. However, most
patients experience a renewed enthusiasm for a lifestyle
that incorporates a healthy diet and a moderate exercise
program. These patients experience additional weight loss,
often far in excess of what was suctioned.
Gradual resumption of exercise or beginning exercise
can begin safely 3 to 4 weeks after the procedure.
Nutritional counseling is often greatly appreciated by
the post-lipoplasty patient.

495
Chapter | 44  Lipoplasty – history and principles
33. Cimino WW. Ultrasonic surgery: power quantification and efficiency
optimization. Aesth Surg J 2001;21:233–40.
34. Garcia O, Nathan M. Comparative analysis of blood loss in suction-
assisted lipoplasty and 3rd-generation internal ultrasound-assisted
lipoplasty, Aesth Surg J 2008;28:430–5.
35. Panetta NJ, Gupta M, Kwan MD, et al. Tissue harvest by means of
suction-assisted or third-generation ultrasound-assisted lipoaspira­
tion has no effect on osteogenic potential of human adipose-derived
stromal cells. Plast Reconstr Surg 2009;124(1):65–73.
36. Fodor P. Superficial liposuction. Aesth Surg J 1993;13:10–4.
37. Gasparotti TL. Superficial Liposculpture: Manual of Technique.
Berlin: Springer Verlag; 1993.
38. Courtiss EH. Reduction mammaplasty by suction alone. Plast
Reconstr Surg 1993;92:1276.
39. Matarasso A. Cosmetic follow up suction mammaplasty: the use of
suction lipectomy to reduce large breasts. Plast Reconstr Surg 2000;
105(7):2604–7.
40. Fodor PB. Discussion: Suction mammaplasty: The use of suction
lipectomy to reduce large breasts. Plast Reconstr Surg 2000;105(7):
2608.
41. Carlson HE. Current concepts: Gynecomastia. N Engl J Med 1980;
303:795–9.
42. Fodor PB. Management of gynecomastia problems. Plast Reconstr
Surg 1992;2(3).
43. Fodor PB. Breast cancer in a patient with gynecomastia. Plast Recon­
str Surg 1989;84:976–9.
44. Simon BE, Hoffman SD, Kahn S. Classification and surgical correc­
tion of gynecomastia. Plast Reconstr Surg 1973;51:48–52.
45. Mladick RA. Lipoplasty of the calves and ankles. Plast Reconstr
Surg 1990; 86(1):84–93.
46. Fodor P, Vogt P. Power-assisted lipoplasty (PAL): a clinical pilot
study comparing PAL to traditional lipoplasty (TL). Aesth Plast Surg
1999;23:379–85.
47. Fodor P. Power-assisted lipoplasty. Aesth Surg J 2001;21(1):
90–2.
48. Fodor P. Power-assisted lipoplasty, operative techniques. Plast
Reconstr Surg 2002;8(1):23–37.
49. Neira R, Solarte E, Reyes MA, et al. Low level assisted lipoplasty;
A new technique. In Proceedings of the World Congress on Lipo­
plasty, Dearborn, MI. 2000.
50. Neira R, Arroyave J, Ramirez H, et al. Fat liquefaction: effects of
low-level laser energy on adipose tissue. Plast Reconstr Surg
2002;110(3):912–22; discussion: 923–925.
51. Brown S, Rohrich R, Kenkel JM, et al. Unable to confirm in
the laboratory and/or clinically that LLLT alters adipocytes; Evalu­
ation of low-level laser therapy (LLLT) on abdominal adipocytes;
impact for lipoplasty procedures. Plast Reconstr Surg 2004;113(6):
1796–804.
52. Fodor P. Discussion: Evaluation of low-level laser therapy (LLLT)
on abdominal adipocytes; impact for lipoplasty procedures. Plast
Reconstr Surg 2004;113(7):1805–6.
53. Fodor P, Apfelberg D, Rosenthal S et al. Progress report on multi­
center study of laser-assisted liposuction. Aesth Plast Surg 1994;18:
259–64.
54. Kenkel JM, Lipschitz AH, Luby M et al. Hemodynamic physiology
and thermoregulation in liposuction. Plast Reconstr Surg 2004;114(2):
503–14.
8. Kesselring UK. Suction curettage to remove excess fat for body
contouring (Letter). Plast Reconstr Surg 1982;69:572.
9. Kesselring UK. Regional fat aspiration for body contouring. Plast
Reconstr Surg 1983;72:610–8.
10. Kesselring UK, Meyer R. Body sculpturing with suction assisted
lipectomy. In: Regnault P, Daniel RK, editors. Aesthetic Plastic
Surgery. Boston: Little, Brown and Co; 1984. p. 681–5.
11. Teimourian B. Invited Lecture, A new approach to the removal of
fat in lipodystrophies, Southern Medical Association meeting, Las
Vegas, NV. 1979.
12. Teimourian B. Invited Lecture, Body contouring, Southern Medical
Association meeting, San Antonio, TX. 1980.
13. Teimourian B. Invited Lecturer and Panelist, Suction Lipectomy,
American Society for Aesthetic Plastic Surgery meeting, Orlando,
FL. 1980.
14. Teimourian B, Fisher JB. Suction curettage to remove excess fat for
body contouring, Plast Reconstr Surg 1981;68(1):50.
15. Teimourian B. Suction lipectomy and body contouring. St. Louis:
Mosby; 1987. p. 45–60.
16. Illouz YG. Shirakabe Clinic in Osaka, Japan 1980; the first Interna­
tional presentation on BLUNT lipoplasty technique, that he had
practiced since 1977. Surgical demonstration.
17. Illouz YG. Body contouring by lipolysis; a 5 year experience with
over 3000 cases. Plast Reconstr Surg 1983;72:591–87.
18. Illouz YG. Body Sculpting by Lipoplasty. New York: Churchill Liv­
ingstone; 1989.
19. Hetter GP. The effect of low dose epinephrine on the hematocrit drop
following lipolysis. Aesth Plast Surg 1984;8(1):19.
20. Hetter GP. Lipoplasty: the Theory and Practice of Blunt Suction
Lipectomy. Boston: Little, Brown & Co; 1984.
21. Fournier PF. Liposculpture: ma technique. Arnette, Paris. 1989.
22. Fodor P. Wetting solutions in aspirative lipoplasty: a plea for safety
in liposuction. Aesth Plast Surg 1995; 19:379–80.
23. Fodor P. Lipoplasty – another plea for safety! Aesth Plast Surg
1997;22(6):399–400.
24. Fodor P. Moderator: Safety Considerations in Lipoplasty,
Expert Exchange, Perspectives in Plastic Surgery 1999;13(2):
113–24.
25. Fodor P. Lidocaine toxicity issues in lipoplasty. Aesth Surg J 2000;
20(1):56–8.
26. Rohrich R, Beran S, Fodor P. The role of subcutaneous infiltration
in suction-assisted lipoplasty: a review. Plast Reconstr Surg 1997;
99(2):514–9.
27. Fodor P. Defining wetting solutions in lipoplasty. Plast Reconstr Surg
1999;103(5):1519–20.
28. Fodor P, Watson J. Wetting solutions in ultrasound-assisted lipo­
plasty. Clin Plast Surg 1999;26(2):289–93.
29. Fodor P, Watson J. Personal experience with ultrasound-assisted
lipoplasty. Clin Plast Surg 1999;26(2):1103–16.
30. Scuderi N, DeVita R, d’Andrea F, et al. Nuove prospective nella
liposuzione: La lipoemulsificazione. Giorn Chir Plast Riconstr Estet
1987;2:1.
31. Zocchi ML. Ultrasonic-assisted lipoplasty; Technical refinements
and clinical evaluations. Clin Plast Surg 1996;23:575.
32. Jewell M, Fodor P, de Souza Pinto E, et al. Clinical application of
VASER-assisted lipoplasty: a pilot clinical study. Aesth Surg J 2002;
22(2):131–46.

496
PART | 7  Liposuction and fat grafting
55. Kenkel JM, Lipschitz AH, Shepherd G, et al. Pharmacokinetics and
safety of lidocaine and monoethylglycinexylidide in liposuction: a
microdialysis study. Plast Reconstr Surg 2004;114(2):515–25.
56. Kenkel JM. Efficacy of lidocaine for pain control in subcutaneous
infiltration during liposuction. Aesth Surg J March 2009;29:2,
122–8.
57. Fodor P, Cimino W. Suction-assisted lipoplasty: physics, optimiza­
tion and clinical verification. Aesth Surg J 2005;25(3):234–46.
58. Fodor P. Non-surgical Ultrasonic Lipoplasty. Sherrell Aston; In
press.
59. Teitelbaum SA, Burns JL, Kubota J, et al. Noninvasive body con­
touring by focused ultrasound; safety and efficacy of the Contour 1
device in a multicenter, controlled, clinical study. Plast Reconstr
Surg 2007;120(3):779–89.
60. Fodor PB. From the panniculus carnosus (PC) to the superficial
fascia system (SFS). Aesth Plast Surg 1993;17:179.
61. Cukier J. Circumventing potential problems: suction lipoplasty bio­
hazards aerosol, and exhaust mist – the clouded issue. Plast Recon
Surg 1989;83(3):494–7.
62. Fodor P. Secondary lipoplasty. Aesth Surg J 2002;22(4):337–48.
Fig. 44.5 can be found online
Bonus images for this chapter can be found online at

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© 2013 Elsevier Inc
Part 7  Liposuction and fat grafting
Chapter 45 
Key Points
●
Tumescent local anesthesia (TLA) leads to pain
reduction and hydrodissection to result in a more
predictable outcome.
●
TLA leads to homogenization of fat tissue.
●
The Hamburg formula is recommended today.
●
Two different kinds of local anesthetic drugs reduce
the risk of toxicity by half.
●
Infiltration speed = 200 ml/min.
●
A maximum of 10 liters can be infiltrated in an 80 kg
patient.
●
Hydrodissection allows fat debulking under anatomical
considerations in different levels.
Tumescent local anesthesia
for liposuction
Gerhard Sattler
INTRODUCTION
As a prerequisite of any pain-related medical treatment, the
matter of anesthesia is of greatest importance. Usually the
anesthesiological part of the whole medical treatment has
a preparatory character, but is not an essential part of the
actual therapy. When tumescent local anesthesia (TLA) was
performed for the first time, the primary motivation for the
invention was to be able to perform liposuction surgery on
an outpatient basis, since most dermatologists in the United
States at that time did not have hospital privileges to be able
to perform liposuction.
It was a secondary observation to experience a dramati­
cally reduced rate of complications in liposuction. For the
first time in medical history the local anesthesia itself
became an important active part of the surgical interven­
tion. Comparable to the mobilization of a skin flap, the TLA
fluid prepares the surgical site by hydrodissection for a
more predictable treatment outcome. Today, understanding
of TLA has reached an even more advanced state of impor­
tance. As more experience in liposuction surgery enables
the surgeon to have a better and more refined imagination
in debulking fat and mobilizing different tissue planes and
at the same time where to avoid fat removal, we have
learned how liposuction surgery should be performed.
Today we have explored the subcutaneous anatomy and
have a clear comprehension of the interaction in the subcu­
taneous honeycomb-type structure of connective tissue in
which the fat lobules are embedded. Depending on the body
area we can find two, three or four planes of fat layers, each
being separated by anatomically described fascias. For a
predictable liposuction surgery today, extended knowledge
about the subcutaneous anatomy is needed in order to
achieve the potential esthetic results in body sculpturing.
By conditioning the fat tissue with the TLA fluid, a hydrodis­
section process will expose the subcutaneous anatomy to
the liposuction cannula and will enable the surgeon to ori­
entate himself in the multiple fat tissue levels. Also, the
extended amounts of fluid will lead to a homogenization of
the fat tissue itself due to the high fluid volume and the
resulting diffusion pressure.
HISTORICAL BACKGROUND
When the first liposuction surgery was performed by Arpad
and Georgio Fischer in Rome in 1975, a suction unit for
abortion was used to curettage and remove fat from the
human body through a hollow cannula.
Amongst others, the French surgeons Illouz and Fournier
in 1978 started to inject saline solution in fairly minimal
amounts (up to 300 ml per surgery) and this showed some
improvement with regards to the ease of cannula penetra­
tion through the subcutaneous space and also a diminished
amount of bleeding. In 1984, to my personal knowledge,
Lawrence Field performed an abdominal liposuction on
his own wife using a dilute formula of local anesthesia
of 0.1%.
In 1985 Jeffrey Klein, a dermatologist from San Juan
Capistrano, California, performed his first case using the
original TLA formula (Table 45.1). Dr. Klein is trained
also in internal medicine, pharmacology, biostatistics and
mathematics.

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PART | 7  Liposuction and fat grafting
prilocaine, which are metabolized through different path­
ways. Lidocaine is mostly metabolized in the liver by cyto­
chrome CYP 3A4 to monoethylglycinexylidide (MEGX)
and then to glycine xylidide.
Prilocaine is metabolized in the liver but also in the
kidneys and the lungs.
Usually the elimination half-life of lidocaine is about 90
to 120 minutes for most patients. This may be prolonged in
patients with hepatic impairment or congestive heart failure.
Since patients today expect marked improvements after
undergoing a liposuction procedure in terms of body sculp­
turing, in many cases four to five areas of the body need to
be prepared and anesthetized by the TLA. This sets the need
for high volumes of TLA fluid in one session for liposuc­
tion. Consequently the TLA formula we are using today is
a modified Hamburg solution with an exact concentration
of 0.038%.
When J. Klein performed his first case with TLA, he
used 35 mg/kg bodyweight as a maximum amount of local
anesthetic. In a patient of 70 kg the total amount of drug
used would be 2450 mg. This is about 5 liters of the clas­
sical Klein formula.
Patrick Lillis published data explaining that 55 mg up
to 90 mg/kg bodyweight would be safe. Today most of the
dedicated uses of TLA use 55 mg/kg of bodyweight. In a
70 kg patient this allows us to use approximately 7.5 liters
of the Klein formula. With our sure dilute formula we are
able to use approximately 9.5 liters of TLA fluid, still taking
into account that we use two different kinds of local anes­
thetic, which reduces the risk of toxicity to half.
PREOPERATIVE PREPARATION
The prepared bags of TLA solution are connected to an
infusion pump which should be able to determine the speed
of infiltration, currently infiltrated amount, and maximum
amount of fluid. Preferably the solution should be pre­
heated, at least to room temperature. While the infiltration
process is ongoing the patient should be kept in warm
blankets and supplied with a warm air system. Blunt or
sharp cannulas can be used as infiltration devices; these are
called rainbow cannulas. We use a sharp needle system
using 12 outlets simultaneously so a slow administration of
fluid can be accomplished in an acceptably short period of
time (Fig. 45.1). At an infiltration speed of 200 ml/min, 10
liters of TLA fluid can be infiltrated in about 50 minutes
(Fig. 45.2 and Box 45.1).
A quick manner of fluid infiltration will lead in the first
step to an “interseptal hydrodissection” (Fig. 45.3), since
these tissue planes offer the lowest resistance for the TLA
fluid to spread. After a short time, depending on the rising
interstitial tissue pressure, the TLA fluid will penetrate the
fascias and will surround the fat lobules, which we call
At that time TLA was called the “tumescent technique
for liposuction surgery” or “tumescent liposuction”.
Today1 we use the term “tumescent local anesthesia”
(TLA). The formula is composed of a combination of a
local anesthetic drug (short acting), epinephrine, bicarbon­
ate, and optional triamcinolone, diluted in physiologic
saline solution. Today we use the so called “Hamburg
Formula”, which has been described by Friedrich and Sch­
neider-Affeld (Table 45.2).
The subcutaneous infiltration of large volumes of this
formula causes the targeted tissue to become swollen and
firm, or tumescent, and permits procedures to be performed
on patients without general anesthesia while minimizing
blood loss due to the vasoconstrictive effect of epinephrine2
and also reduces the resorption of the local anesthesia drug
in order to avoid lidocaine toxicity.
The major advantage of the Hamburg Formula is the use
of two short-acting local anesthesia drugs, lidocaine and
TABLE 45.1  Klein Formula
Original Tumescent Anesthesia Formula
(Described by Jeffrey Klein)
lidocaine 1%
50.0 ml
bicarbonate 8.4%
6.0 ml
epinephrine (1 : 1000)
1.0 ml
(triamcinolone 10 mg
1.0 ml)
NaCl 0.9%
1000.0 ml
__________
~0.0475 (0.05%) % concentration
1028.0 ml
TABLE 45.2  Hamburg Formula
Tumescent Local Anesthesia Formula (Preparation
Described by Schneider-Affeld and Friedrich)
lidocaine 2%
10.0 ml
prilocaine 2%
10.0 ml
bicarbonate 8.4%
6.0 ml
epinephrine (1 : 1000)
0.7 ml
(triamcinolone 10 mg
1.0 ml)
NaCl 0.9%
1000.0 ml
__________
~0.038 % concentration
1027.7 ml

499
Chapter | 45  Tumescent local anesthesia for liposuction
FIG. 45.1  Administration devices for TLA.
FIG. 45.2  Infiltration towards the state of tumescence.
FIG. 45.3  Interseptal hydrodissection.
1. Interseptal hydrodissection
2. Paralobular distribution
3. Intralobular penetration
4. Homogenization of the fat tissue
BOX 45.1  While the Infiltration of the TLA Fluid is
Ongoing, 4 Different Stages of Fluid Distribution can
be Described
In order to standardize the individual circumstances of
a patient as well as tissue character, enough TLA fluid is
needed to achieve a situation of maximum firmness of the
skin surface. This could be compared to the firmness of an
orange or a watermelon.
A time of penetration allows the fluid to distribute
throughout all levels of the subcutaneous anatomy, which
leads to a situation of “homogenization of the fat tissue”.
“paralobular distribution” (Fig. 45.4). Increasing amounts
of fluid will cause the fat lobules to absorb the TLA fluid.
This stage is called the “intralobular penetration” (Fig.
45.5). After more and more fluid is added, the complete
extent of all the fat levels is flooded by the TLA fluid, which
after 30 minutes of diffusion we call the “state of tumes­
cence” (Fig. 45.6).
How to know how much to use? Which is the best amount
of fluid for a safe and predictable liposuction surgery?
FIG. 45.4  Paralobular distribution.

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PART | 7  Liposuction and fat grafting
When after 30 minutes of penetration time firmness on the
skin surface still exists, then the “state of tumescence” has
been achieved. If the skin surface should show severe soft­
ness, additional fluid infiltration is indicated in order to
avoid unnecessary shearing and avulsion forces during the
liposuction surgery.
SURGICAL TECHNIQUE
For a superior liposuction surgery outcome, smooth skin
surfaces as well as firm and tight skin textures without
irregularities of the outer circumferential lines are essential.
When fat tissue presents itself in a unique homogenized
kind, the aspiration process will also show a unique kind
FIG. 45.5  Intralobural penetration and homogenization of the sub­
cutaneous tissue.
FIG. 45.6  Physiodynamics of tumescent fluid.
of aspiration characteristic. If we have no homogenization
of the fat tissue, we will not able to expect an even tissue
aspiration. In cooking, this compares to raw potatoes,
cooked potatoes, and mashed potatoes. Each state of potato
will demonstrate its own aspiration characteristics; mixing
these three types will never offer evenness after removal
due to aspiration.
Furthermore, the hydrodissection of the subcutaneous
space separates the horizontal fascia planes from the differ­
ent fat compartments. This allows the surgeon to perform
a fat debulking procedure under anatomical considerations
at different levels (Fig. 45.7).
OPTIMIZING OUTCOMES
Performing liposuction surgery under solely local anes­
thetic treatment, relevant aspects of the surgical perfor­
mance for an improved procedure and cosmetic outcome
need to be addressed.
Active positioning of the patient during surgery per­
formed under local anesthesia allows the patient to move
on the operating table; a patient can stretch, bend, tense
muscles, and will position as advised actively, so the
surgeon is able to shape and sculpt a three-dimensional part
of the human body. By tensing the muscle, the underlying
firmness gives the surgeon better judgment in regard to the
depth of anatomical levels.
In regard to safety, TLA demonstrates the issues of local
anesthesia. There is always a range of action. This disad­
vantage in regard to safety is a very important point. A
FIG. 45.7  Fat removal in the state of homogenization of the subcu­
taneous tissue.

501
Chapter | 45  Tumescent local anesthesia for liposuction
administered by an experienced anesthesiologist. In con­
clusion, this combination of TLA with anesthesiologic
therapy allows the performance of liposuction with the
comfort of a general anesthesia but under local anesthesia.
POSTOPERATIVE CARE
It is mandatory and should be possible that the patient
walks around immediately to prevent deep vein thrombosis
and to use the muscle pump for better drainage. As the
FIG. 45.8  Endoscopic view of best case situation after liposuction.
Completely “fat-free“ subcutaneous field including unharmed connec­
tive tissue fibers of the dermis.
potential injury from perforation of the underlying struc­
tures (such as the abdominal wall) by the liposuction
cannula would be noticed by the patient immediately, so
undesired injuries can be prohibited before they even
happen. Also, the softening effect on the fat by the TLA
fluid severely reduces the force needed to push the liposuc­
tion cannula forward. This increases the surgeon’s control
of his own fine-motor-sensitivity (Fig. 45.8).
After a liposuction under TLA, the situation of open
drainage will occur; having extensive amounts of saline
solution present in the surgical area has an exceptional
advantage. Blood will not coagulate in the presence of
saline solution and therefore the postoperative liposuction
period will show a pronounced wash-out situation with the
open drainage of reddish-colored fluid through the distal
incisions of the surgical field. This leads to less bruising,
less pain, and less swelling, as well as a lesser potential for
infection during the postoperative period (Fig. 45.9).
Due to the biopharmacologic properties of local anes­
thetic drugs, they all demonstrate a pronounced bacterio­
static activity, which also enables the TLA solution to have
this bacteriostatic character. By using this TLA formula, we
are actually using an antiseptic fluid, which reduces the risk
of potential bacterial infection.
In many cases using TLA for liposuction, additional
anesthesiologic therapy is beneficial. The use of TLA
still allows the use of additional sedative drugs like mid­
azolam, remifentanil, or propofol. These drugs should be
FIG. 45.9  Atraumatic lipoaspiration in tumescent local anesthesia
uses an open drainage technique. The higher the volume of the tumes­
cent fluid, the more intense the wash-out effect will be.

502
PART | 7  Liposuction and fat grafting
small incisions are left open, thick gauze pads or diapers
are used on top of the compression garment for the first 2
days. Mild lymphatic drainage beginning on the very first
day is recommended and continued for 2 weeks or longer.
COMPLICATIONS AND
CONTRAINDICATIONS
See Box 45.2.
REFERENCES
1.
Sattler G, Sommer B, Hanke CW. Tumescent Local Anesthesia.
Springer Verlag Berlin Heidelberg. 1. Auflage. 2000.
2.
Acosta AE. Clinical parameters of tumescent anesthesia in skin
cancer reconstructive surgery. A review of 86 patients. Arch Derma­
tol 1997;133:451–4.
FURTHER READING
Breuninger H. Geschichte der Tumeneszenz-Anästhesie. Akt Dermatol
2009;35:290–2.
Grassegger A, Haussler R. [Is the use of tumescence anesthesia in general
anesthesia contraindicated?] Anaesthesist 2001;50(10):794.
Hanke CW, Sattler G, Sommer B. Textbook of Liposuction. Informa
Healthcare. 2007.
Hempel V. [Is the use of tumescence anesthesia in general anesthesia
contraindicated?] Anaesthesist 2001;50(5):363–4.
Klein JA. The tumescent technique for liposuction surgery. Am J Cosmet
Surg 1987;4:263–7.
Sattler G, Sommer B, Hanke CW. Lehrbuch der Liposuktion. Georg
Thieme Verlag. 1. Auflage. 2003.
Selzle KET, Kamionek I, Kuropka R, Schonath M. [Tumescence local
anesthesia in venous surgery]. Zentralbl Chir 2001;126:517–21.
Weinberg GL, Laurito CE, Geldner P, et al. Malignant ventricular dys­
rhythmias in a patient with isovaleric acidemia receiving general
and local anesthesia for suction lipectomy. J Clin Anesth 1997;9:
668–70.
Possible complications during the use of TLA fluids can be:
●
Intravascular infiltration
●
Fluid overload
●
Anesthetic drug toxicity
●
Intolerance/allergic reaction to local anesthetic drug
●
Tachycardia
Possible contraindications for the use of TLA fluids
can be:
●
Intolerance to epinephrine
●
Known allergy to one or more of the substances used
in the TLA formula
●
A liposuction procedure performed with TLA within the
last 36 hours
BOX 45.2  Complications

503
© 2013 Elsevier Inc
Chapter 46 
Key Points
●
Correction after the occurrence of a complication in
lipoplasty is very difficult, hence prevention of
complications is crucial.
●
Surgical tips for preventing complications are given
(see video clip 1).
●
Maintainance of the multiple spheres and angles of the
body rather than converting the region into a single
plane is important.
●
Perform circumferential liposuction using a smaller
diameter cannula.
●
Superficial suction leads to dimple depression
(“contour irregularities”). Deep suction leads to
adhesions.
●
Perform serial liposuction procedures rather than large
volume liposuction.
●
Prevent lethal complications, using the time gap
protocol.
●
Early ambulation is vital.
Treatment of liposuction complications
Kim Youn Hwan, Cha Sang Myun and Hwang Weon Jung
INTRODUCTION
Numerous cannulae and instruments have been introduced
for use in liposuction.1–3 The tumescent technique and the
concept of ultrasonic or laser lipolysis are now widely
accepted to assist in more advanced and safe liposuction
procedures.4 Even with the considerable advancements
in techniques aided by various new instruments, the com­
plications related to liposuction, however minor, are still
a concern.5 Moreover, numerous previous studies in the
literature have focused on and highlighted safety consider­
ations in liposuction. There is a lack of strategy and treat­
ment guidelines for complications of liposuction. In this
chapter, a good guideline for the treatment of complications
from liposuction is provided, which range from life-
threatening to esthetic complications.
COMPLICATIONS AND THEIR
MANAGEMENT
Life-threatening or Systemic Complications
Fat Embolism Syndrome (FES)
There is still confusion regarding fat embolism (FE) and fat
embolism syndrome (FES). FES is a phenomenon second­
ary to FE. Hence, FES is a more accurate term regarding
complications after liposuction, because the patient suffers
a cascade of symptoms. The incidence of FES in liposuc­
tion is currently unknown.
The classic triad includes respiratory distress, cerebral
dysfunction, and petechial rash. Other signs and symptoms
include thrombocytopenia, anemia, tachycardia, hypocalce­
mia, and fever.
Diagnosis using ventilation–perfusion scan may show
the matching defects.6-8 Differential diagnoses include fluid
overload, pulmonary edema, aspiration pneumonia and
various other causes of acute respiratory distress syndrome
(ARDS).9 Most of all, differentiation of FES from pulmo­
nary embolism is important because the treatment is very
different. Heparin can be harmful, for obvious reasons, in
the early management of FES.
There are no definite preventive measures for FES.
However, using small caliber cannulae and serial suction
rather than megaliposuction is generally recommended.
Treatments using intravenous ethanol, heparin, and low
molecular weight dextran have largely fallen from favor.
Medical management now consists mainly of high-dose
corticosteroids, which have been shown to prevent the
development of FES in several prospective randomized
trials.10–12 The role of corticosteroids is considered to inhibit
the inflammatory reaction to the presence of fat in the cir­
culatory system after liposuction.
Deep Vein Thrombosis (DVT) and
Pulmonary Embolism (PE)
There are three major factors that are important in the
development of DVT and PE. The first is the development
Part 7  Liposuction and fat grafting

504
PART | 7  Liposuction and fat grafting
The ideal ratio of subcutaneous fluid to total aspirate is
controversial. The surgeon must weigh the risks between
excessive blood loss (inadequate subcutaneous fluid)
and pulmonary edema (excess subcutaneous fluid). Fluid
shifts between interstitial fluid and plasma volume can
result in intravasation (hypervolemia) or extravasation
(third spacing). Excessive infiltration obviously should be
avoided. According to our 14-year experience with 2398
cases, the need for blood transfusions is rare. It must be
remembered that 2000 ml aspiration of supernatant fat is
regarded as a decrease in hemoglobin count by 1. Some of
the drawbacks of blood transfusions include potential infec­
tion, transfusion mismatch, circulatory overload, micro­
thrombi, and postoperative anemia.
Healthy normovolemic patients can tolerate a moderate
reduction in hemoglobin count with multiple compensatory
mechanisms. In clinical settings, normal tissue oxygenation
is maintained with hematocrits as low as 20, if the subject
is healthy and remains normovolemic.16
Lidocaine Toxicity
Early signs and symptoms of lidocaine toxicity include
lightheadedness, restlessness, drowsiness, tinnitus, slurred
of venous stasis, the second is the activation of a blood
coagulation cascade, and the third is injury to the vascular
endothelium (Virchow’s triad).13
Preoperative and early postoperative ambulation is
crucial for preventing this event. Epidural anesthesia will
increase blood flow to the lower extremity, lessen stagnant
blood flow, and may reduce thrombotic complications.
Shortening the anesthesia time may be beneficial; hence
serial liposuction rather than large volume liposuction is
recommended. Compression garments to the ankles avoid
a tourniquet effect at the knee.
For high-risk patients, intermittent pneumatic pressure
devices rather than continuous devices may be beneficial.
Low-dose subcutaneous heparin (2500 U every 12 hours,
beginning 2 hours preoperatively) may further reduce the
incidence of DVT but it should be remembered that it can
also simultaneously increase the risk of bleeding. For most
practitioners, fractionated heparin appears preferable to
unfractionated heparin.
Initial therapy consists of intravenous heparin, usually
by a bolus dose of 5000 to 10 000 U.
A heparin drip at approximately 1000 U/h is then titrated
to maintain an activated partial thromboplastin time (aPTT)
of approximately twice the normal length. This necessitates
hospitalization and frequent blood tests. Oral anticoagulant
therapy with warfarin is usually initiated shortly thereafter
and continued for a minimum of 6 weeks. Prothrombin time
(PT) levels must be monitored during follow up to maintain
an INR in the therapeutic range.
Extended Infection
Liposuction involves heavy manipulation of the superficial
fascial system, resulting in the possibility of ascending
infections via the fascial system, and there have been
reports of necrotizing fasciitis from these procedures.14
Although infection in simple liposuction cases is rare, com­
bined procedures including abdominoplasty and brachio­
plasty for reduced skin laxity may cause serious infections.
Hematomas and seromas can become sources of infection,
hence meticulous hemostasis and drainage of seromas is
important to prevent infection (Figs 46.1 and 46.2). More­
over, maintaining aseptic techniques throughout the proce­
dure is of utmost importance, especially during positional
changes of the patient.
Wound cultures should be obtained whenever possible
and antibiotic treatment instituted according to sensitivities.
Local drainage is recommended when necessary.
Hypovolemia/Anemia
Tumescent infiltration provides profound hemostasis in
large volume liposuction.15 Bloodless aspiration virtually
eliminates the possible sequelae of shock and hypovolemia.
FIG. 46.1  Mycobacterium infection on right upper arm after lipo­
suction procedure.

505
Chapter | 46  Treatment of liposuction complications
FIG. 46.2  Severe wound infection on right posterior thigh with a
draining sinus. (From Kim YH, et al. Analysis of postoperative complica­
tions for superficial liposuction: A review of 2398 cases. Plast Reconstr
Surg 2011;127:863–871. with permission.)
FIG. 46.3  Contour irregularities on abdomen after superficial lipo­
suction which were induced by too superficial suction.
FIG. 46.4  Severe sunken deformities on abdomen after conventional
liposuction procedures which were caused by overzealous suctioning
with a large caliber cannula. Hemosiderin procedures color deformity
in tissues.
speech, metallic taste in the mouth, and numbness of the
lips and tongue. These subjective signs may be seen at
plasma levels between 3 and 6 µg/ml. Shivering, muscle
twitching, and tremors may occur as plasma levels reach
5–9 µg/ml, followed by convulsions, CNS depression, and
then coma at plasma levels greater than 10 µg/ml. As levels
increase above this, respiratory depression and eventually
cardiac arrest can occur.17
Multiple variables add to patient risk. Conservative
treatment is advised in patients taking oral contraceptives,
beta blockers, and tricyclic antidepressants, because
these medications increase serum lidocaine levels. In addi­
tion, hypovolemia, hypocalcemia, hypophosphatemia, and
hypoalbuminemia may exacerbate the effects of lidocaine.
Pre-existing liver disease slows lidocaine breakdown. Pre­
vention of lidocaine toxicity begins with strict adherence to
the currently accepted maximal recommended dose of
35 mg/kg. Early recognition of symptoms is important
when they occur.
Treatments consist of hyperventilation and administra­
tion of benzodiazepines, which lower seizure threshold.
The airway should be protected to prevent aspiration.
Esthetic Complications
Contour Irregularities (Figs 46.3–46.7)
The most common complications of liposuction are under­
correction (insufficient fat removal), overcorrection (exces­
sive fat removal), and irregular fat removal (with palpable
and visible irregularities), which can be categorized as
contour irregularities. From an esthetic viewpoint, post­
operative contour irregularities can be devastating and
decrease patient satisfaction dramatically.
Improper selection of patients with sagging tissues and
over-resection of those with good tissues can lead to soft
tissue irregularities that are irreparable despite multiple

506
PART | 7  Liposuction and fat grafting
vacuum pressure between 250 and 400 mmHg, in order to
prevent over-resection and destruction of normal adipose
architectures, which are the main causes of contour
irregularities.
Pinto et al divided the fatty layers into two: superficial
dense and deep loose areolar layers.3 This concept is well
established in the recent era. Compared to the deep adipose
layer, the superficial adipose layer has minimal fatty
tissues.19 Overzealous suctioning or manipulation of the
superficial layer can cause complications. However, Illouz
et al identified a further intermediate layer. The intermedi­
ate layer exists in the subdermal fat, approximately 5 mm
below the skin. Intermediate level liposuction results in
more skin retraction than does deeper level suctioning and
in fact produces almost the same amount of contraction as
superficial suctioning, without the risk of complica­
tions.1,20,21 Suctioning of the superficial layer should be
done minimally to avoid complications such as skin irregu­
larities and ischemia, with focus on suctioning the interme­
diate layer and detaching the superficial layer above from
the underlying tissues to achieve maximal skin redraping.
For prevention of postoperative contour irregularity,
Gasperoni2 recommended that the progression of the cannula
gauge in use be made from small to large. However, for the
refinement and final contouring of the superficial layer, a
decreasing gauge size order is more convenient.2,19
Moreover, suctioning the very superficial layer must be
avoided by using low pressure settings, and the cannula’s
suction ports should be positioned in a downward direction
during suction procedures.
According to our series, decreased complication rates
resulted after the introduction of ultrasonic energy (UAL,
ultrasound-assisted liposuction). In particular, the incidence
of contour irregularities has decreased significantly since
using UAL.19 Ultrasound emits energy to the area corre­
sponding to the area of its probe, and resolves thick and
fibrous subcutaneous connective tissues. Compared to the
linear movement of the suction tip of the power-assisted
liposuction (PAL) alone, it seems that the ultrasound deliv­
ers the energy more evenly on the suctioned area (Fig. 46.8
and video clip 1).
Possible treatments for areas with irregularities include
fat suction, injection, subcision, fat shifting or mobilization,
and skin resection
It is important to distinguish between contour depres­
sions due to undersuction of surrounding areas (false
depression) and oversuction of the depressed area (true
depression). False depressions can easily be solved by
resuctioning. However, true depression due to very super­
ficial liposuction cannot be corrected by resuctioning, as
resuctioning amplifies the irregularities in liposuction.
These true depressions can be corrected only by fat grafts
or fat shifting techniques.
repair techniques. These contour irregularities may be
minimal in a young patient, but with aging, the accompany­
ing loss of soft tissue support and reduction of muscle mass
are likely to worsen the irregularities progressively.
A member of the surgical team should keep a chart with
the same markings as on the patient and note the amount
of aspiration from each area. By keeping the preoperative
photographs visible during surgery, the surgeons should be
aware of what the deformities looked like while the patient
was in a standing position. Poor position of the patient on
the operating table can be the cause of the irregularities.18
During liposuction, it is important to set the maximum
FIG. 46.5  Contour irregularities on lateral aspect of thigh with
induction of fibrous and dense tissues.
FIG. 46.6  Severe contour irregularity at the trunk and thigh regions.
For correction of the problem, exact preoperative markings and the dis­
tinguishing of false and true depression is important. (From Kim YH, et al.
Analysis of postoperative complications for superficial liposuction: A
review of 2398 cases. Plast Reconstr Surg 2011;127:863–871. with
permission.)

507
Chapter | 46  Treatment of liposuction complications
of the body. Hence, when we find such deformities of
the intermediate and deep adipose layers, using the pinch,
pizzaiolo test, and the refinement test during surgery (Figs
46.9 and 46.10), we try to correct it immediately. After­
wards, refinement or secondary touch operations are also
considered and proceeded with after the healing process is
finished. Balanced application of immediate and delayed
corrections regarding contour irregularities can yield more
esthetic final outcomes, which leads to increased patient
satisfaction.
A new concept was introduced recently. Saylan was the
first to describe a technique called “liposhifting” as a safe
and simple method to treat contour irregularities.22 The fat
is loosened around and under the defect with the cannula,
not applying suction and obstructing the open end with a
finger or a plug (Fig. 46.11). Some cannulas may be more
aggressive than the blunter tipped ones, but crisscross and
fan-shaped patterns with multiple layers should be utilized.
The subdermal tissues in the area of the defect are treated
in the same manner as the surrounding fat, by utilizing
tunnels with no sweeping motions. The fat in the
There are some debates regarding immediate correction
and delayed correction of contour deformities after super­
ficial liposuction. In fact, it is very difficult to precisely
evaluate the sunken areas and the areas with insufficient fat
removal during the surgery. Hence delayed correction, after
all the healing process has finished, is generally accepted.21
If too much fat is aspirated from a localized point to a
visible level during the procedure, Gasperoni2 recom­
mended correction of the depression immediately by inject­
ing some of the aspirated fat.
Our strategies regarding management of contour irregu­
larities involve both immediate and delayed correction
techniques. According to our experience, when severe
sunken deformities are found during surgery, the outcome
becomes more exaggerated and it often leads to asymmetry
FIG. 46.7  Postoperative contour irregularity at the submental area
in a patient with severe skin laxity.
FIG. 46.8  Two probes of external ultrasound were applied for
maximal effect to soften fatty layers, which decreased overall compli­
cation rates of liposuction; especially the contour irregularities. (From
Kim YH, et al. Analysis of postoperative complications for superficial
liposuction: A review of 2398 cases. Plast Reconstr Surg 2011;127:863–
871, with permission.)
FIG. 46.9  Refinement test performed during the surgery, and fre­
quent checking of the suction area can be helpful for contouring the
body and for preventing oversuction and undersuction.

508
PART | 7  Liposuction and fat grafting
surrounding tissues is moved or shifted into the defect by
rolling a cannula over the tissue with moderate pressure
until the defect is at least flat. Fat can also be mobilized by
massage. Resuctioning, fat grafting and fat shifting are
useful tools for correcting contour irregularities, and since
several procedures are always required, informed consent
is also crucial in the treatment.23
Most of the literature on liposuction does not point
out the dangerous and risky areas where contour irregu­
larities commonly occur, and which lead to undesirable
results and difficulty in correction. The following body
areas need great care in order to prevent contour
irregularities.
Inner Thighs
This area is difficult to treat as it presents tissue with not
only less tension and more skin flaccidity but also more
restricted access and mobilization, since it has important
anatomic structures. Nevertheless, we routinely proceed
with superficial liposuction.24
Anterior Face of the Thigh
Only the most exaggerated lipodystrophies in this location
should be treated, and always with caution in order to aspi­
rate as superficially as possible with a fine-caliber cannula.
The deep layer should be kept intact as much as possible
since the consistency of the fat tissues here is looser, and
excessive aspiration could cause depressions and collapse
of the fat tissue, followed by substantive flaccidity.
Buttocks
Most surgeons have regarded the buttocks as having redun­
dant fat, hence they are an uncommon area for contour
irregularities to occur. However, we have seen many com­
plicated cases in this area (Fig. 46.12).
This is an area subject to trauma, so the fat tissue in this
area should not be diminished. Its loose collagen makes
the fatty structures weaker, so that lipoplasty may result
in flaccidity. Therefore, we prefer to suction only the
periphery to improve its contour, and use a 3 mm cannula
superficially.25
Skin Necrosis
The most devastating complication of superficial liposuc­
tion is skin loss. Skin loss does occur but it is rare with
suction-alone procedures. The skin loss can vary from
smaller areas to areas large enough to require skin grafting.
In severe cases, loss of the entire superficial abdominal wall
skin can occur.
There are a variety of factors causing skin loss, the
most important of which is smoking. The next most impor­
tant factor is improper intraoperative management of fluid
FIG. 46.11  Fat shifting and rolling technique using a cannula for
correction of contour irregularity at the posterior thigh region.
FIG. 46.10  Pinch test during the surgery.

509
Chapter | 46  Treatment of liposuction complications
FIG. 46.12  Loose collagen of the hip makes fatty structures weaker,
and lipoplasty of these regions may result in hip drooping and contour
abnormality.
FIG. 46.13  Improper infiltration of tumescent solution with heavy
manipulation of the superficial fatty layer can cause severe skin loss
on the abdomen and inner thigh.
FIG. 46.14  Infection can cause skin loss, which has occurred at the
brachial region after superficial liposuction in this patient.
replacement, resulting in impairment of the microcircula­
tion in the elevated flaps (Figs 46.13 and 46.14). Patients
should be encouraged to cease smoking at least several
weeks before the procedure, and patients undergoing suc­
tioning in their lower extremities should be warned thor­
oughly of the risks of nicotine-induced skin necrosis. The
other main cause is the application of circular compressive
garments which can be too tight and can induce a stasis that
induces DVT and ensuing pulmonary emboli. To avoid
compression, the garment must be <24 mmHg (venous
pressure), but >18 mmHg to be efficient. In practical terms,
the garment should be easy to put on and to remove26
(Fig. 46.15).
Small areas of necrosis can usually be treated without
grafting, hence conservative treatment using the natural
healing process is proceeded with before excision and revi­
sion with secondary wound closure. Hyperbaric oxygen and
prostaglandin E1 may be used as adjuvant treatments for
enhancement of blood supply. Major flap necrosis requiring
large advancements may benefit from the use of a tissue
expander, which requires multiple operations and a long
term for correction.
Seromas
There were reports about UAL being associated with a
somewhat higher incidence of seroma formation.19,27
Seromas are extremely rare in PAL-alone procedures. They
usually occur when liposuction is combined with traditional
body contour operations. Pseudobursae occur in under­
mined spaces where there is repeated fluid formation and
accumulation even after aspiration or drainage. The inci­
dence appears to have increased with the greater number of
outpatient combined SAL and body contour procedures. It

510
PART | 7  Liposuction and fat grafting
FIG. 46.16  Seroma at the upper abdomen; serial drainage with
application of antibiotics is required.
FIG. 46.17  Immediate hyperpigmentation of the thigh after liposuc­
tion, which often resolves spontaneously.
FIG. 46.15  Compressive garments should be easy to put on and to
remove without being too tight.
is rare to see a pseudobursa after liposuction, but more
commonly after large abdominoplasty procedures.
The placement of drains after the procedure and fre­
quent clinical follow up are recommended for careful
examination of seroma formation (Fig. 46.16). Administra­
tion of antibiotics may be required for prevention of
infection.
Hyperpigmentation (Fig. 46.17)
Hyperpigmentation is usually a direct result of temporarily
impaired circulation to a given area. It may be caused by
oversuctioning and injury to the dermis above the suction
site. The pigmentation mechanism is similar to the hyper­
pigmentation seen with stasis ulcers (hemosiderin). Patients
with pre-existing circulatory impairments should be consid­
ered carefully before selection for surgery. It can be pre­
vented by avoiding overly superficial aspiration of the
subdermal elements, especially in the legs.
Hyperpigmentation disappears spontaneously as the
injured tissue heals in about 4 to 6 months. Recommended
treatment is ultrasound massage of the affected areas and
avoidance of exposure to sunlight. A skin bleaching cream
has been effective.
Asymmetry (Fig. 46.18)
Asymmetry is caused by oversuctioning, inadequate fanning
of the cannula, excess fat removal in an area, and the use
of a larger than necessary cannula for the area of suction.
For the most part, this is a preventable complication.
Prevention can be ensured by careful preoperative
markings of the patient in the standing position, proper

511
Chapter | 46  Treatment of liposuction complications
FIG. 46.18  Overzealous suction on bilateral thigh resulted in
contour irregularity and asymmetry. (From Kim YH, et al. Analysis of
postoperative complications for superficial liposuction: A review of 2398
cases. Plast Reconstr Surg 2011;127:863–871, with permission.)
FIG. 46.19  Depressed scar seen on suction site, caused by thermal
damage from the cannula.
cannula selection and adequate fanning of the cannula.
Paying attention to the amount of liposuction wetting solu­
tion that is infiltrated and the amount removed during lipo­
suction helps reduce the occurrence of asymmetry.
Symmetric positioning of the patient on the operation
table is important.
Treatment involves precise patient marking and judi­
cious design of secondary revision suction procedures so
the causes of asymmetry are avoided and remedied.
Scar (Fig. 46.19)
The formation of a scar is unusual after a suction-alone
procedure, although it can occur if the dermis is stripped of
its blood supply. The use of a large cannula is more likely
to cause this problem when suctioning close to the skin.
The other cause is thermal damage of the incision site,
hence prevention of thermal damage by the suction cannula
FIG. 46.20  Chronic induration of the lower extremity after calf
liposuction.
FIG. 46.21  Ultrasound-assisted massage (Endermologie) can be
helpful for decreasing pain and chronic induration after liposuction.
is important. Using protective material (such as a wet towel
or gauze pad) on the incision site is recommended.
The defects may be remedied by ultrasound massage
and judicious autologous fat injection. Secondary revision
is often not required.
Chronic Induration (Fig. 46.20)
Chronic induration can be caused by disturbances in the
circulation, edema, and cellulitis associated with low grade
infection. Oversuction must be avoided.

512
PART | 7  Liposuction and fat grafting
11. Lindeque BG, Schoeman HS, Dommisse GF, et al. Fat embolism and
the fat embolism syndrome: A double blind therapeutic study. J Bone
Joint Surg 1987;69:128–31.
12. Schonfeld SA, Ploysongsang Y, DiLisio R, et al. Fat embolism pro­
phylaxis with corticosteroids: A prospective study in high risk
patients. Ann Intern Med 1983;99:438–43.
13. Hull RD, Raskob GE, Firsh J. Prophylaxis of venous thromboembo­
lism: an overview. Chest 1986;89:374s–83s.
14. Grazer FM, de Jong RH. Fatal outcomes from liposuction: Census
survey of cosmetic surgeons. Plast Reconstr Surg 2000;105:
436–46.
15. Klein JA. The tumescent technique for local anesthesia improves
safety in large volume liposuction. Plast Reconstr Surg 1993;92:
1085–98.
16. Singh G, Chaudry KI, Chaudry H. Crystalloid is as effective as blood
resuscitation of hemorrhagic shock. Ann Surg 1982;215:377–82.
17. Samdal F, Amland PF, Bugge JF. Plasma lidocaine levels during
suction-assisted lipectomy using large doses of dilute lidocaine with
epinephrine. Plast Reconstr Surg 1994;93:1217–23.
18. Toledo LS, Mauad R. Complications of body sculpture: prevention
and treatment. Clin Plast Surg 2006;33:1–11.
19. Kim YH, Cha SM, Naidu SK, et al. Analysis of postoperative com­
plications for superficial liposuction: A review of 2398 cases. Plast
Reconstr Surg 2011;127:863–71.
20. Illouz YG. Present results of fat injection. Aesth Plast Surg 1988;
12:175–81.
21. Illouz YG. Body contouring by lipolysis: A 5-year experience with
over 3000 cases. Plast Reconstr Surg 1983;72:591–7.
22. Saylan Z. Liposhifting: treatment of postliposuction irregularities.
Int J Cosm Surg 1999;7:71–3.
23. Shiffman MA, Blugerman G. Fat shifting for the treatment of skin
indentations. In: Shifman MA, Di Giuseppe A, editors. Liposuction
Principles and Practice. Heidelberg: Springer; 2006. p. 354–6.
24. Bolivar de Souza Pinto E, Erazo IPJ, Prado Filho FS, et al. Superfi­
cial liposuction. Aesth Plast Surg 1996;20:111–22.
25. Bolivar de Souza Pinto E, da Silva Moia SM, Machado MN, et al.
Morphohistologic analysis of fat tissue in areas treated with lipo­
plasty. Aesth Surg J 2002;22:513–8.
26. Illouz YG. Complications of liposuction. Clin Plast Surg 2006;
33(1):129–63.
27. Troilius C. Ultrasound-assisted lipoplasty: is it really safe? Aesth
Plast Surg 1999;23:307–11.
Measures designed to increase circulation, such as
ultrasound-assisted massage (Endermologie). (Fig. 46.21)
and exercise may be helpful.20
CONCLUSION
Treatments regarding complications of liposuction are not
simple. Careful application of the liposuction technique is
important, and also a thorough preoperative explanation of
possible complications is crucial. Moreover, prevention is
more important than treatment after the complication has
occurred.
Liposuction in a multidimensional plane rather than a
single plane with small diameter cannulas in the intermedi­
ate layer can prevent serious complications. Serial suction
with some time lag rather than large volume liposuction is
recommended, with early ambulation postoperatively.
REFERENCES
1. Illouz YG. Illouz’s technique for body contouring by lipolysis. Clin
Plast Surg 1984;11:409–17.
2. Gasperoni C, Gasperoni P. Subdermal liposuction: Long-term expe­
rience. Clin Plast Surg 2006;33:63–73.
3. Pinto EB, Indaburo PE, Muniz Ada C, et al. Superficial liposuction.
Body contouring. Clin Plast Surg 1996;4:529–48.
4. Mann MW, Palm MD, Sengelmann RD. New advances in liposuc­
tion technology. Semin Cutan Med Surg 2008;27:72–82.
5. Gasparotti M. Superficial liposuction: a new application of the tech­
nique for aged and flaccid skin. Aesth Plast Surg 1992;16:141–53.
6. Christman KD. Death following suction lipectomy and abdomino­
plasty. Plast Reconstr Surg 1986;78:428.
7. Laub Jr D, Laub D. Fat embolism after liposuction. Ann Plast Surg
1990;25:48–52.
8. Ross R, Johnson GW. Fat embolism after liposuction. Chest
1988;93:1294–5.
9. Skarzynski JJ, Slavin Jr JD, Spencer RP, et al. Matching ventilation
perfusion images in fat embolism. Clin Nucl Med 1986;11:40–1.
10. Alho A, Saikku K, Eerola P, et al. Corticosteroids in patients with a
high risk of fat embolism syndrome. Surg Gynecol Obstet 1978;147:
358–62.

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© 2013 Elsevier Inc
Chapter 47 
Key Points
●
The most important step in fat grafting the body is
analysis of the defect. The bird’s-eye view is an
important vantage point.
●
Avoiding donor site contour irregularities is best
accomplished by limiting the amount of fat harvested
from any one area.
●
In the body, a 14- to 16-gauge 15 cm Coleman
cannula may be used for more efficiency.
●
Any existing adhesion that causes surface dimpling
needs to be released at the time of fat grafting. It is
usually best to release after most of the fat grafting has
been performed in order to avoid fat migration.
●
Subcutaneous adhesions or scars should be released
prior to fat grafting with a V-dissector or W-dissector.
●
Fat grafts may increase or decrease in volume over
time and it is important that patients understand this
preoperatively
Fat grafting in body contouring surgery
Sydney R. Coleman and Jordan Jacobs
INTRODUCTION
Structural fat grafting is an essential tool for practitioners
performing body contouring surgery. It can be an adjunctive
therapy in primary body contouring as well as a corrective
modality in iatrogenic corporeal deformities.1–4 A detailed
three-dimensional analysis of the areas to be treated is key
to successful outcomes.
PREOPERATIVE PREPARATION
Analysis of the defect is the most important step in struc­
tural fat grafting of the body. The surgeon must be able to
appreciate the deformities that the patient sees. The prob­
lems should be clearly documented using a combination of
photography and drawings. Failure to accurately recognize
the specific deformities that the patient wants corrected will
make the benefits of the surgery equally difficult for the
patient to appreciate.
Photographs of the body from eight directions are
a standard part of the preoperative process. These should
be taken from across the room with the patient in front
of a blue background. Topographic abnormalities, however,
can be difficult to visualize on two-dimensional photo­
graphs. Photographs taken from above the patient
(“birds-eye”) or with reproducible downlighting can help
to highlight the contour deformities, depressions and
irregularities.
Preoperative planning is done on tracings of the patient’s
body using many views. A purple marker is used to delin­
eate areas of planned fat removal for harvesting while a
green marker indicates areas of planned fat grafting. A red
marker serves to identify access sites. The patient is photo­
graphed in a standing position so that these markings may
be referred to intraoperatively with the patient in either the
supine or prone position. If necessary, the photos may be
reviewed intraoperatively on a laptop.
General anesthesia, local anesthesia with sedation, and
occasionally epidural anesthesia are used. A low dose epi­
nephrine and lidocaine solution is placed in harvest sites as
well as the areas to be fat grafted, especially if it is antici­
pated that adhesions need to be released.
SURGICAL TECHNIQUE
Access incisions for fat harvesting are chosen based on the
specific anatomic regions. Recipient site incisions are gen­
erally 2 mm long and are placed to allow fat infiltration
from at least two directions. Access sites are most often
marked preoperatively, but occasionally it is necessary to
add an additional incision during the procedure.
The amount of infiltration solution to use depends on
the amount of fat to be harvested. A solution containing
0.5% lidocaine with 1 : 200 000 epinephrine is used for
smaller volumes while a tumescent solution containing
1 : 400 000 epinephrine infiltrated in about 1 ml for each ml
planned to be harvested is used for moderate to large
volumes. Using a tumescent technique is not recommended
as this delivers a lipoaspirate that is too dilute and requires
many syringes and rounds of centrifugation.
Curved or straight cannulas connected to Coleman
10 ml or 30 ml syringes are initially used to harvest
lipoaspirate from the torso. The gentle slope of the cannula
allows its path to follow the natural curves of the body. It
Part 7  Liposuction and fat grafting

514
PART | 7  Liposuction and fat grafting
Fat placement should obviously be concentrated in the
areas of greatest deficiency. However, it is equally impor­
tant to feather out into surrounding areas to create an inte­
grated correction. In this situation, placement of fat should
extend from deep against the muscular fascia to an imme­
diately subdermal plane.7 It is important to avoid linear
placement in more superficial planes, as this can cause
noticeable lumps.
While the 9 cm infiltration cannula will work in most
cases, the 15 cm Coleman style I or III cannula can be
helpful when trying to avoid making additional incisions or
when there is fat leakage due to the access incision being
too close to the placement site.
All areas of infiltration should be approached from at
least two directions. This provides more structural integrity
as the fat is laid down in a cross-hatched fashion. In this
specific situation, access incisions in the buttock and thigh
were chosen to allow placement perpendicular and longitu­
dinal to the buttocks crease (Figs 47.1–47.4).
OPTIMIZING OUTCOMES
Delicate handling of fat, with limited exposure to air, is
important to maintain maximum viability of the graft.
However, despite meticulous technique, patients should be
informed that a certain percentage of the fat graft will not
survive.8
The level of placement of the fat depends on the desired
outcome. Fat layering in deeper planes is most appropriate
for large contour changes, such as the thighs or buttocks.
In these cases, the thicker 16 gauge 15 cm cannulas with
blunt tips are used. Fat placement in more superficial planes
corrects specific grooves or depressions.
POSTOPERATIVE CARE
Microfoam® tape is placed in one to two layers over areas
of fat grafting. Reston foam can be placed over areas that
have been suctioned for fat harvesting in order to increase
compression on the harvest sites and also to relieve any
potential pressure over adjacent grafted areas. A girdle
or binder can then be placed to apply gentle pressure on
the Reston foam; however, care should be taken to avoid
elastic compression over recently grafted areas. Such com­
pression could precipitate migration of the placed fat or
irregularities.
Avoiding pressure on grafted areas is very important in
the postoperative period. For instance, if grafting has been
performed to either the buttocks crease or sacrum, the
patient is instructed to either sit far forward or lean back­
ward so that the weight distribution is not directly on the
site of grafting. Massaging of the grafted areas should not
begin before 4 weeks postoperatively. Early massage before
is important that the architecture of the fat tissue be main­
tained during harvesting. The intact fat parcel must be able
to pass through the lumen of a small infiltration cannula
(17-gauge). This usually coincides to the lumen of a 10 ml
Luer-Lock syringe. The initial lipoaspirate can range from
10–90% fat tissue, so centrifugation should be used to
remove the nonliving components. Once the harvested
tissue is centrifuged (3000 rpm for 2–3 minutes), it sepa­
rates into three layers. The top layer consists of oil from
ruptured fat cells, the bottom layer is blood and lidocaine,
while the middle layer contains fat. The top and bottom
layers should be removed and the fat transferred into
smaller syringes for injection.
No-one has clearly shown a correlation between donor
site location and viability of fat grafts.5,6 For this reason,
donor sites are usually selected based on areas whose
contour will improve with liposuction. The abdomen and
medial thighs are the two most common donor areas.
Infiltration cannula size ranges from 16 to 18 gauge and
9 to 15 cm in length. We prefer to use shorter cannulas,
but switch to a longer cannula at times to avoid making
additional incisions. When using a longer cannula, thinner
gauges are preferable, and we only switch to thicker
gauges when significant resistance is encountered. Longer
cannulas increase the chance of the tip moving into deeper
planes and damaging underlying structures. We alternate
between straight and curved cannulas depending on the
topography.
We use two 3 ml Luer-Lock syringes to infiltrate fat in
the body. Each syringe is filled with 2.5 cm3 of fat to allow
easier manipulation. In contrast to the 1 ml syringes, the
3 ml syringes can be reused repeatedly without the plungers
sticking. Infiltration volumes range from 1 cm3 for minor
irregularities to 500–600 cm3 for volume augmentation in
thighs, buttocks, or arms.
Example: Correction of Buttocks
Crease Deformity
When the crease that defines the junction of the buttock and
posterior thigh extends too far laterally, the legs appear
shorter and the buttocks larger. Placement of fat from at
least two directions can help increase the definition of these
two areas. Access incisions should be placed in the medial
buttock crease, lateral to the buttocks crease’s most lateral
extent, and either cephalic or caudad to the crease. Fat
placement begins with a blunt style I 9 cm cannula. If there
is difficulty with this cannula, a Coleman style III 7 cm
cannula may be used to prime the incision. Placement
begins superficially and gradually progresses deeper, in a
layer-by-layer fashion. Fat infiltration is performed only as
the cannula is removed, not while being advanced. This
allows more precision and control during the infiltration.

515
Chapter | 47  Fat grafting in body contouring surgery
A
B
C
D
FIG. 47.1  Views of a patient with over-suctioning of the hips, upper, outer thighs and buttocks (A–D) and 10 months after correction (E and
F). Not only are the irregularities smoother, but her body proportion now reflects a more feminine, healthy appearance.
Continued

516
PART | 7  Liposuction and fat grafting
E
F
FIG. 47.1  Continued
the fat graft has become stable can lead to disruption of the
fragile revascularization or displacement or migration of
the newly transplanted fat.
COMPLICATIONS AND THEIR
MANAGEMENT
Although fat grafting is generally considered a safe proce­
dure, complications can occur. The incidence decreases
dramatically as the experience of the surgeon increases.
Infection
Infection, while uncommon with fat grafting, can be one of
the most bothersome complications. Sterile technique
should be observed at all times. Intraoperative antibiotics
are routinely used, but, unless there is a specific indication,
postoperative antibiotics are not necessary. Early postop­
erative follow up will usually allow diagnosis of an infec­
tion and antibiotic therapy should be promptly initiated.
Damage to Underlying Structures
Even with use of a blunt cannula, damage to underlying
nerves, arteries, veins, and glands is possible. While
permanent injuries are very rare, it can be very distressing
for both the patient and surgeon. Routine follow up and reas­
surance are usually key to maintaining a good relationship.
Embolization after Intravascular Injection
Concern about intravascular injection of fillers dates back
to 1926.9 This complication can be one of the most devas­
tating. Intravenous fat injection can obviously travel to the
lungs and cause a pulmonary fat embolism, while intra-
arterial injection can cause ischemia of distal tissues or
blindness.10
Esthetic Complications
The most common complications of fat grafting are esthetic
in nature. Inadequate correction remains the most common
patient complaint. It is important that patients understand
preoperatively that complete correction during body con­
touring may require two or three treatments of fat
grafting.
The presence of irregularities after fat grafting, the
second most common complication, can be due to surgical
technique, the intrinsic nature of the patient’s body, or
fat migration postoperatively. The incidence significantly

517
Chapter | 47  Fat grafting in body contouring surgery
FIG. 47.2  Patient presented following a liposuction procedure which flattened her outer thighs and made her buttocks sag (A & C). Eleven
years after her second of two fat grafting procedures to the outer thighs and buttock crease (B & D), she now has a normal, much more youth­
ful proportion.
A
B
C
D

518
PART | 7  Liposuction and fat grafting
A
B
FIG. 47.3  Patient presented after liposuction to her outer thighs and buttock creases. The resulting creases in her lower buttocks, which extend
out to the outer thighs, interrupt the continuous flow of her buttocks into her thighs, and make her buttocks appear to sag.
C
decreases as the surgeon gains more experience.11 In addi­
tion, fat grafts have the potential to grow after placement.
This has been observed both with and without relation to
weight gain. In cases of breast or buttock augmentation, this
phenomenon may be desirable.
If the patient desires to have the correction reduced, the
best treatment in this situation is liposuction. In cases of an
isolated lump, it is sometimes easier to make a small inci­
sion, especially when this can be placed in an inconspicu­
ous area, and directly remove it. Injection of steroids into
areas of excess fat grafting is not recommended, as the
results are unpredictable and the overlying skin may become
thinned or hypopigmented.
A rather common technical complication is the creation
of a new deformity from overaggressive suctioning of
donor sites. Rather than harvesting from a single area, it is
advisable to harvest small amounts over several areas.
Swelling
Preparing patients for the swelling and bruising that accom­
pany fat grafting is very important. The amount of swelling
that a patient experiences is dependent on a number of
factors: volume of fat injected, anatomic location, specific
technique and instruments used, medications, and the
age and genetic makeup of the patient. Elevation and exter­
nal pressure, directed at minimizing swelling, are very
effective. Certain medications (arnica montana and brome­
lain) can help reduce swelling and bruising and speed
recovery.
CONCLUSION
Fat grafting is an increasingly popular technique for both
primary and secondary body contouring.12 It has potential
applications over the entire body. It is important for the
surgeon to recognize the learning curve that accompanies
the path to successful outcomes. As with most procedures,
patient satisfaction is dependent on an accurate preoperative
analysis and a realistic postoperative expectation. It is espe­
cially important that patients understand the potentially
dynamic volume of fat grafts, and the potential for second­
ary procedures. While the incidence of complications is
relatively low compared to open body contouring pro­
cedures, it is important to promptly recognize and treat
them.

519
Chapter | 47  Fat grafting in body contouring surgery
A
B
FIG. 47.4  Views of a patient with liposuction defects of the buttock crease before (A, C) and 6 years after (B, D) correction. Note the more
natural appearance in the after photos, as well as the subtle “lift” seen in the side views that can be achieved by restoring the normal buttock/
thigh contour.
C
D

520
PART | 7  Liposuction and fat grafting
REFERENCES
1. Coleman SR. Structural fat grafts: The ideal filler? Clin Plast Surg
2001;28:111.
2. Coleman SR. Structural lipoaugmentation. In: Narins RS, editor.
Safe Liposuction and Fat Transfer. New York: Marcel Dekker; 2003.
p. 409–23.
3. Ellenbogen R. Autologous fat injection. Plast Reconstr Surg
1991;88:543.
4. Coleman SR. Structural Fat Grafting. St. Louis: Quality Medical
Publishing; 2004.
5. Ullmann Y, Shoshani O, Fodor A, et al. Searching for the favorable
donor site for fat injection: In vivo study using the nude mice model.
Dermatol Surg 2005;31:1304.
6. Rohrich RJ, Sorokin ES, Brown SA. In search of improved fat
transfer viability: A quantitative analysis of the role of centrifugation
and harvest site. Plast Reconstr Surg 2004;113:391.
7. Ersek RA, Chang P, Salisbury MA. Lipolayering of autologous fat:
An improved technique with promising results. Plast Reconstr Surg
1998;101:820–6.
8
Coleman SR. Long-term survival of fat transplants: Controlled dem­
onstrations. Aesth Plast Surg 1995;19:421.
9. Miller C. Cannula Implants and Review of Implantation Techniques
in Esthetic Surgery. Chicago: The Oak Press; 1926.
10. Coleman SR. Avoidance of arterial occlusion from injection of soft
tissue fillers. Aesth Surg J 2002;22:555.
11. Coleman SR. Structural fat grafting: more than a permanent filler.
Plast ReconstrSurg 2006;118(Suppl. 3):108S–20S.
12. Kaufman MR, Bradley JP, Dickinson B et al. Autologous fat transfer
national consensus survey: trends in techniques for harvest, prepara­
tion, and application, and perception of short- and long-term results.
Plast Reconstr Surg 2007;119:323–31.

521
© 2013 Elsevier Inc
Chapter 48 
Key Points
●
Moderate augmentation (100–200 ml) of the breast is
successfully achieved by autologous lipoinjection
without major complications if appropriately
performed in selected patients.
●
Breasts augmented with fat injection are soft and show
natural texture and appearance, and patients are free
from concerns associated with foreign materials (and
related complications and potential implant
replacement or removal).
●
The surviving fat volume varies substantially among
patients, and multiple factors likely affect clinical
results; patient factors include skin redundancy of the
breast and availability of fat.
●
Surgeons need to improve quality (such as tissue
viability and progenitor/adipocyte ratio) of fat grafts
and infiltration techniques.
●
Aspirated fat tissue should be appropriately harvested
and stored, and quickly processed and infiltrated to
place aliquots or noodles of fat grafts as diffusely as
possible.
●
Supplementation of vascular stromal fraction
containing adipose progenitor cells may boost the
efficacy and safety of lipoinjection to the breasts.
Minimal scar breast augmentation using
autologous fat grafting
Kotaro Yoshimura, Noriyuki Aoi, Hitomi Eto, Kentaro Doi and Harunosuke Kato
INTRODUCTION
Adipose tissue has been considered an organ of energy
storage, the largest endocrine organ, a soft tissue filler (aug­
mentation by micro-fat grafting), and a cosmetically unnec­
essary tissue discarded by liposuction. Adipose tissue
physiologically turns over very slowly. Adipocytes have a
life span of 10 years;1 several thousands of adipocytes die
and are replaced with new adipocytes every second in our
body. Adipose tissue has many cells other than adipocytes,
though adipocytes constitute more than 90% of adipose
tissue volume. Through collagenase digestion, cellular com­
ponents other than adipocytes are extracted as a cell pellet,
which is called stromal vascular fraction (SVF). SVF con­
tains adipose stromal cells (ASC), vascular endothelial cells
(VEC), pericytes, adipose-resident macrophages, etc. (Fig.
48.1). It was found that the adipose stromal cell population
contains not only monopotent progenitor cells responsible
for the tissue turnover, but also multipotent mesenchymal
stem cells,2 which are now called adipose (-derived) stem
cells. These are regarded as a potent tool for cell-based
therapies, comparable to bone marrow-derived mesenchy­
mal stem cells, because they can be obtained in a large
amount through a less invasive approach. For adipose tissue
engineering/regeneration, it is a critical point to understand
the physiological roles and functions of ASC; this popula­
tion, working together with VEC and stem/progenitor
cells recruited from bone marrow, is a main player for
adipose tissue engineering, which means adipogenesis and
angiogenesis.
Autologous fat transplantation is one of the promising
cosmetic treatments for facial rejuvenation and soft-tissue
augmentation due to minimal incisional scars and lack of
complications associated with foreign materials. However,
certain problems remain, such as unpredictability and a low
rate of graft survival due to partial necrosis. Implantation
of prostheses has been a golden standard for breast augmen­
tation, but complications such as capsular contracture
remain to be resolved. Recently, autologous fat injection
has been re-evaluated as a potential alternative to artificial
implants for breast augmentation.3 This re-evaluation may
reflect recent advances in autologous fat transfer and the
radiological detection of breast cancer.
In this chapter, biological principles and surgical tech­
niques of fat injection for breast augmentation are discussed
as well as our novel approach of autologous fat grafting
called cell-assisted lipotransfer (CAL),4,5 which is concur­
rent transplantation of aspirated fat tissue and adipose pro­
genitor cells (Fig. 48.2).
PREOPERATIVE PREPARATION
There seem to be several patient factors that may affect
the clinical result of lipoinjection; skin redundancy of the
Part 7  Liposuction and fat grafting

522
PART | 7  Liposuction and fat grafting
FIG. 48.2  Scheme of cell-assisted lipotransfer (CAL). Relatively adipose-derived stromal/stem cells (ASC)-poor aspirated fat tissue is converted
to ASC-enriched tissue by supplementation with ASCs isolated from a part of the lipoaspirates. The ASCs are attached to the aspirated fat tissue, which
is used as a scaffold in this strategy. SVF, stromal vascular fraction.
Lipoinjection
Lipoaspirates
(Progenitor-poor)
Graft material
(Progenitor-normal)
Centrifugation
Cell isolation
SVF
Adipose
Adipose
Adipose
Liposuction
21.4±5.8
60.7±8.5
17.9±3.8
102
103
104
105
102
103
104
105
CD31
CD34
102
103
104
105
102
103
104
105
CD34
CD45
62.8±5.2
36.8±5.2
Liposuction
Liposuction
Liposuction aspirates
SVF
Collagenase
digestion
Granulocytes
Monocytes
Lymphocytes
Endothelial cells
Other cells
ASCs
CD90
CD34
FIG. 48.1  From liposuction to isolation of adipose stem/progenitor cells. Stromal vascular fraction (SVF) can be obtained through collagenase
digestion of the lipoaspirates. SVF contains many blood-derived cells (CD45+) and adipose-derived cells (CD45−); the latter is further divided into
CD31+/CD34+ endothelial cells (ECs), CD31−/CD34+ adipose progenitor cells (ASCs) and CD31−/CD34− other cells.

523
Chapter | 48  Minimal scar breast augmentation using autologous fat grafting
FIG. 48.3  Three-dimensional system for measuring breast volume.
Two cameras take photos with striped light shed on the breast. A software
program calculates the volume over the standard plane. Using this system,
breast volume can be measured while the patient is in a standing
position.
breasts, age, BMI, personal quality or character of fat
tissue, adhesive scars, breast implant and its capsule, sys­
temic disease such as autoimmune disease, oral cortico­
steroid, etc.4,6 Good candidates are those who have
sufficient fat at donor sites and the redundant breast skin
with healthy vascularity and without scars. Lipoinjection
can be performed in any patients from teens to 70s, but
patients with low BMI (less than 18) are not good can­
didates due to difficulty in harvesting a sufficient volume
of fat tissue without severe morbidity. Patients who want
a large-volume (250–400  ml) augmentation, are not good
candidates because augmentation volume achieved by a
single session of lipoinjection is limited (100–200  ml).
No particular preparation is generally needed preopera­
tively. However, for breast reconstruction patients with
adhesive scars, an external negative pressure device
(Brava®, Brava LLC, Miami FL, USA) possibly improve
clinical outcomes. For young patients with small breasts
and tight skin, injection volume is limited due to the tight
skin envelope. In these cases, a secondary lipoinjection
(replacement with fat tissue after temporary breast implant)
would be recommended. This allows for her breast skin to
be stretched by the implants.
For preoperative examination, physical measurements
(maximum and bottom breast circumferences, etc.), mam­
mogram, MRI, echogram, photograph, and videograph are
performed. We also adopted a 3-dimensional measurement
system that enables a volumetric evaluation of the breast
mound in a standing position (Fig. 48.3). An echogram is
easy to perform at every patient’s visit and sensitive enough
to detect small cyst formation. Long follow up with an
annual mammogram up to 5 years is recommended to
detect abnormal signs such as calcifications.
SURGICAL TECHNIQUE
Breast Augmentation
Donor sites are usually the thighs alone or the thighs and
the abdomen or flanks, decided according to the patient’s
preference and BMI. After the liposuction site is infiltrated
with saline solution with epinephrine (0.001%) under
general anesthesia, adipose tissue is suctioned using a
cannula with 2–3 mm inner diameter and a conventional
liposuction machine. We use screw-type syringes (with a
threaded plunger) to allow for precise control and avoid a
flushing injection (Fig. 48.4). To reduce the time of the
procedure, two syringes are used; while one syringe is
being used for an injection, the other is filled with the graft
material in preparation for the next injection. A 16- or
18-gauge needle (150 mm long) is used for lipoinjection
and inserted subcutaneously from the inframammary fold
or areolar margin (Fig. 48.5A). The operator takes care to
insert and place the needle horizontally (parallel to the
body), in order to avoid causing a pneumothorax. The
needle is inserted in several layers and directions, and is
continuously and gradually retracted as the plunger is
advanced (Fig. 48.5B). This technique is used to obtain a
diffuse distribution of the graft material. The grafts are
placed into the fatty layers on, around, and under the
mammary glands (but not into the mammary glands), and
also into the pectoralis muscles. After training, it is not hard
for an operator to recognize the mammary gland or pecto­
ralis fascia as a harder tissue than the fat or muscle tissue.
Injection is discontinued when the skin tension becomes
tense; injection volume is usually 200–300 ml for each
breast in Asian patients.
Breast Implant Replacement
For patients with implants, lipoinjection can be performed
simultaneously with implant removal.7 Breast implants are
removed through a periareolar incision, which is placed at
a caudal third of the areolar margin. The lipoinjection is
begun at the deepest layer (under the implant capsule when
the implant was subglandular) and completed with the
injection into the most superficial subcutaneous layer.
During the injection, the operator can insert fingers into the
implant capsule and recognize the location of the injection
needle (Fig. 48.6). Injection into the mammary glands or
into the capsular cavity is not performed. Finally, the cap­
sular cavity is irrigated with saline to remove any fat tissue
injected and the periareolar incision is closed.
PREPARATION PROCEDURES OF
GRAFT MATERIALS
Conventional Lipoinjection
Lipoaspirates are harvested by suction-assisted liposuction
and centrifuged (1200 g, 3 min), and put into a metal jar
(1000 ml), which is placed in water with crushed ice. As
the centrifugation reduces the adipose volume by 25–35%,
the volume reduction should be taken into account in tissue
harvesting (Fig. 48.7).

524
PART | 7  Liposuction and fat grafting
FIG. 48.5  Schematic instruction of the injection method for breast augmentation. (A) The needle is inserted from either one of two points on
the areola margin or one of two points at the inframammary fold in various directions and planes to achieve a diffuse distribution. (B) A small amount
of fat tissue is injected as thin strings (1 ml fat corresponds to a 10 cm long string) with a long needle while the needle is continuously withdrawn.
A
A
FIG. 48.4  Injection devices. A high-pressure
injection can be performed with a disposable syringe
with a threaded plunger. A 150-mm long 16- or
18-gauge needle is connected to the syringe with a
connecting tube threaded at both ends. The injection
needle is rigidly manipulated by an operator, while
an assistant rotates the plunger according to the oper­
ator’s instruction. (A) a 10 cm3 LeVeen™ inflator
(Boston Scientific Corp., MA); (B) a 20 cm3 screw
injector original syringe (Medical U&A, Japan).
A
B

525
Chapter | 48  Minimal scar breast augmentation using autologous fat grafting
FIG. 48.6  Schematic illustration of the injection method for implant replacement. (A) Using a long needle attached to a syringe with a threaded
plunger, the fat tissue is injected into layers other than the mammary gland and capsular cavity. While injecting, the fingers are inserted through a
periareolar skin incision into the implant capsule to determine the location of the needle tip. (B) The needle is inserted either through a periareolar
incision or at one of several points on the infra-mammary fold. The needle is aimed in various directions and into different planes to achieve a diffuse
distribution.
Medial
Lateral
A
Botton layer (1st floor)
Subcutaneous layer (4th floor)
No injection into
mammary gland
A
Before
After
1200g
Water
Oil
FIG. 48.7  Effects of centrifugation on aspirated adipose tissue. The
adipose portion was concentrated into 71% of the original volume after
centrifugation for 3 minutes at 1200 g and the volume of the fluid and oil
portions was significantly increased. However, the number of adipose-
derived stromal cells (ASC) contained in the adipose portion was not
significantly changed by the centrifugation. Thus, centrifugation at 1200 g
led to condensation of cell numbers per volume of adipocytes and ASC
by 25% and 43%, respectively, and improved the ASC : adipocyte ratio by
14%.
Cell-Assisted Lipotransfer (CAL)
Aspirated fat tissue has a significantly lower progenitor/
mature-cell ratio,5 and this low ASC/adipocyte ratio may
be one of reasons for long-term atrophy of transplanted
adipose tissue as demonstrated before4,5,8 (Fig. 48.8).
Enrichment of adipose progenitor cells by supplementation
of SVF improves/normalizes progenitor/adipocyte ratio
and is also suggested to augment final volume retention. In
this strategy, progenitor-poor aspirated fat tissue is con­
verted to progenitor-enriched (but not more than normal)
fat tissue.
Full-CAL
In full-CAL, SVF is isolated from additionally harvested
lipoaspirates (Fig. 48.9). The SVF is isolated as described
below. During the processing period, liposuction is con­
tinued and lipoaspirates are centrifuged (700 g, 3 min) for
preparation of graft materials. The freshly isolated SVF was
added to the centrifuged fat tissue, followed by gentle
mixing and a 5–10 min incubation to achieve appropriate
cell adhesion to the centrifuged fat tissue (Fig. 48.10).

526
PART | 7  Liposuction and fat grafting
FIG. 48.8  Comparison of human aspirated and excised (intact) fat tissue obtained from a single site of a single patient. Macroscopic views
(A, B), schematic views (C, D), electromicroscopic (F, G, H and I; red scale bars = 200 µm, white scale bars = 40 µm), and whole mount staining
images (E and J; scale bars = 100 µm). The basic structure of adipose tissue was preserved in the aspirated fat tissue, but some adipocytes and capil­
laries were disrupted. Vascular vessels, especially those of large size, were notably less in aspirated fat tissue compared to the excised fat tissue. ASC
yield from aspirated fat tissue was considerably less (about a half) than that from excised fat tissue, suggesting that aspirated adipose tissue is relatively
progenitor-poor fat tissue.
Aspirated adipose
Excised adipose
A
F
G
H
I
E
J
B
C
D
Mini-CAL
The difference of mini-CAL from full-CAL is that addi­
tional lipoaspirate is not harvested and only the fluid portion
of liposuction aspirates is used for isolation of SVF (Fig.
48.9). This method is used when patients are thin and addi­
tional adipose tissue cannot be harvested.
SVF ISOLATION PROCEDURE
Processed lipoaspirate cells (PLA) cells and liposuction
aspirate fluid (LAF) cells are both so-called SVF; they are
separated from the fatty and fluid portions of liposuction
aspirates, respectively.9 PLA or both cells are used in full-
CAL, while only LAF cells are used in mini-CAL (Fig.
48.9). For PLA cells, suctioned fat tissue is digested with
0.075% collagenase in phosphate-buffered saline (PBS) for
30 min on a shaker at 37°C. After centrifugation (800 g,
10 min), mature adipocytes and connective tissues (floating
tissue) are discarded. The cell pellets are resuspended in
Dulbecco’s modified Eagle’s medium (DMEM) and passed
through a 100 mm mesh filter. To eliminate remaining col­
lagenase, the cell pellets are repeatedly washed with resus­
pension in DMEM and following centrifugation at least
three times. The process takes about 80 min (Fig. 48.10).
For LAF cells, the suctioned fluid is centrifuged (400 g,
10 min) and the pellets are resuspended in distilled water
(for 30 s) for erythrocyte lysis, followed by osmic normal­
ization by adding 10% volume of 10× PBS (or 9% NaCl
solution). After centrifugation (and filtration), cell pellets
are obtained as SVF; the process takes about 20 min. For
both PLA and LAF cells, cell counting for erythrocytes and
nucleated cells is performed using a blood test cell counter;
this takes 1 min.
Representative cases are shown in Figs 48.11–48.13.

527
Chapter | 48  Minimal scar breast augmentation using autologous fat grafting
FIG. 48.9  Concept of cell-assisted lipotransfer (CAL). The adipose
portion (yellow) of liposuction aspirates is centrifuged and used as
injection material in conventional lipoinjection. In CAL, relatively
progenitor-poor aspirated fat tissue is converted to progenitor-enriched
fat tissue by supplementation with the stromal vascular fraction (SVF).
The SVF can be obtained from adipose and fluid portions of liposuction
aspirates. In mini-CAL, which is used in thin patients, only the fluid
portion (pink) of the liposuction aspirate is used for the isolation of
the SVF, while another volume of liposuction aspirate is additionally
harvested for SVF isolation in full-CAL, which is performed in fatty
patients.
Thin patients
Centrifuged fat
Conventional
Mini-CAL
SVF
Centrifuged fat
Centrifuged fat
Adipose
Adipose
Fatty patients
Full-CAL
SVF
Adipose
Adipose
FIG. 48.10  Time course for CAL surgery. The operation begins with the harvesting of fat tissue for the isolation of SVF cells. While the cell isola­
tion process is performed in a cell-processing room, liposuction and centrifugation for graft material are performed in the operating room. After adding
isolated SVF to the centrifuged fat tissue, the mixture is injected into the breast. The entire procedure takes approximately 3.5–4 hours to complete.
1h
2h
3h
4h
Operating room
Liposuction
aspirates
Cell-processing
room
Liposuction
(Right thigh)
Liposuction
(Left thigh)
Lipoinjection
Centrifugation
(Implant removal)
Collagenase digestion
Cell isolation
Isolated cells
OPTIMIZING OUTCOMES
Understanding of Cellular Events
in Fat Grafting
The grafted nonvascularized adipose tissue is placed under
ischemia (hypoxia with low nutrition) and is temporarily
nourished only by plasmatic diffusion from the surrounding
host tissue for a few days until direct capillary supply is
formed.9 In response to injury and cell death, many growth
factors and proteinases are released from damaged tissue
and activated platelets10 (Fig. 48.14). Inflammatory cells are
infiltrated and inflammatory cytokines such as interleukins
are secreted. During the repair process, adipocytes, known
to be very sensitive to hypoxia, can die within 24 hours and
subsequently endothelial cells start to die when the isch­
emia is prolonged. ASC are likely to be as resistant to
ischemia as bone marrow-derived mesenchymal stem
cells,11 which can be functional up to 72 hours under severe
ischemia (Fig. 48.15).
Our recent studies showed that most adipocytes are
likely to die within a few days (Fig. 48.16) and some of
them are replaced with next generation adipocytes by 12
weeks.11 From the surface of grafted fat tissue, adipocyte
remodeling starts and progresses slowly toward the center
and the rate of the adipocyte regeneration determines the
final volume retention of fat grafting. In the case that stem/
progenitor cells die due to prolonged severe conditions, the
area is not properly replaced with new adipocytes and
rather filled with fibrosis and calcification (Fig. 48.17). Oil
cysts are being absorbed even after 3 months; the time
course of the absorption depends on the size of lipid drop­
lets, but takes weeks or months. Thus, nonvascularized
adipose grafting can be called adipose tissue regeneration
rather than adipose tissue survival, and we believe that this
is seen in other nonvascularized tissue grafting such as skin
or composite tissue grafting (Fig. 48.17).

528
PART | 7  Liposuction and fat grafting
FIG. 48.11  Case 1 (breast augmentation). Preoperative views (A and B) and postoperative (C and D) views at 24 months. A 30-year-old woman
underwent breast augmentation with CAL (310 ml in each breast). Her breasts were augmented dramatically with an 8.0 cm increase in breast circum­
ference at 24 months. The breast mounds were soft with no subcutaneous indurations. An original inframammary fold on the left breast is slightly
visible, but injection scars are not visible.
A
B
C
D
FIG. 48.12  Case 2 (breast augmentation). Preoperative view (A) and postoperative (B) view at 12 months. A 36-year-old woman whose body mass
index was 17.3 underwent breast augmentation with CAL (245 ml in each breast). The breast mounds were soft with no subcutaneous indurations or
visible scars at 12 months.
A
B