C L I N I C S I NP L A S T I C

S U R G E R Y

Clin Plastic Surg 33 (2006) 13–25

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Liposuction: Techniquesand GuidelinesJoseph P. Hunstad, MD, FACS

a,*, Marguerite E. Aitken, MD, MFAb

& Cannulae & Arms

& Cannulae of ultrasound-assisted lipoplasty& Safety guidelines& Current technique& Estimating the aspiration volume& Syringe technique& Suction-assisted lipoplasty& Superficial liposuction& Subdermal lipo& Differential liposuction& Ultrasound-assisted liposuction& Power-assisted liposuction& Liposuction of specific regions& Face/neck& Abdomen

a The Hunstad Center, 8605 Cliff Carmeron Drive, Suiteb Plastic Surgery Associates, P.C., Grand Plaza Place,MI 49503, USA* Corresponding author.E-mail address: jph1@hunstadcenter.com (J.P. Hunstad).

0094-1298/06/$ – see front matter © 2005 Elsevier Inc. All rightsplasticsurgery.theclinics.com

& Back& Buttocks& Hip rolls& Thighs& Calves/ankles& Touchup liposuction& Dressings& Postoperative care& Troubleshooting& Dissatisfied patients& Undesirable outcomes& Summary& References

Schrudde first introduced the closed lipectomy, asharp excisional technique using uterine curettes inthe early 1970s [1]. Kesselring [2], and separatelyFischer [3], conceived evacuating the fat also usingsharp suction techniques. Although Fischer sharplyseparated the fat to be removed using a planotome,Kesselring connected suction to a double-bladedsharp curette for fat removal. He advocated mini-mal fluid, fat removal in layers and diffuse under-mining of the areas being treated.Illouz, however, in 1977, introduced the revolu-

tionary concept of tunneling, rather than under-mining, in a layered fashion using a blunt-tippedcannula [3]. The ‘‘wet technique’’ gained wideacceptance, rapidly growing in popularity in theUnited States through the efforts of Hetter, Grazer,

and Teimourian [1]. Many improvements havebeen made to the technique since its inception,including changes to the injected fluid, cannu-lae design, ultrasonic liposuction, and power-assisted liposuction.Early liposuction procedures saw careful selection

of patients in whom good results could be antici-pated. This included those with lipodystrophy orlocalized adiposity that could be removed easilywith suctioning. As the field expanded and experi-ence was gained over the ensuing years, more andmore patients were considered appropriate candi-dates, including obese patients in whom largevolumes of fat could be safely suctioned [4]. Wefind in the United States that it is unrealistic toexpect every patient to be at their ideal body

100, Charlotte, NC 28269, USA220 Lyon Street NW, Suite 700, Grand Rapids,

reserved. doi:10.1016/j.cps.2005.09.003

Fig. 1. (A) Multiple sizes of the pyramid tip cannula designed by Hetter. (B) Details of the pyramid tip.

14 Hunstad & Aitken

weight. Many have tried multiple diets and exercise,unsuccessfully. Although this is not a procedure forweight loss, it can achieve improved body contour,overall size decrease, and act as a stimulus forfurther weight loss.

Cannulae

Illouz’s first description used a large-diameter can-nula, allowing a very aggressive removal of adiposetissue. Fat was pulled into the cannula openings,held there by vacuum pressure, and avulsed withcannula movement. As the technique began to beperformedbyother surgeons around theworld, indi-cations came to include patients who only neededbody contouring for localized pockets of stubbornadiposity. This technique has evolved from essen-tially a ‘‘bump removal’’ procedure to a sophisti-cated body shaping and contouring method withcannula size reduction for more precise control ofthe fat removal and less risk of creating wavinesscommonly seen with a large-diameter cannula (per-sonal communication with Mladick, 1996). Thisfurther allowed more gradual fat removal and de-creased the risk of overresection and asymmetry.Although the original single-port, blunt-tipped

suction cannulae became popular, improvementsfor newer, more effective suction methods weresubsequently introduced.Today, cannula openings can be one sided or

unidirectional, or they may be omni-directional

Fig. 2. Mercedes tip with evenly spaced ports equidi-stant from tip.

and located circumferentially. The Pyramid or LasVegas tip, designed by Hetter, has one distal andtwo proximal ports for suction in a unidirectionalpattern and concentrated proximally, not adjacentto the skin [Fig. 1].This is in comparison to the so-called Mercedes

tip cannulae [Fig. 2], in which the ports are spacedevenly around the circumference of the cannulaeand equidistant from the tip. When concernedwith skin protection in areas such as over difficultbony prominences, more superficial suctioning,or in densely adherent areas, we prefer a directionalblunt-tipped proximally concentrated cannula suchas the Pyramid cannula. In areas such as the neckand face, Klein directional flattened cannulae[Fig. 3] glide easily through the relatively thin tis-sues, preserving the subdermal plexus of vessels.In the back and thicker areas, where dense adherenttissues exist, we employ basket cannulae [Fig. 4] avery aggressive open cutting tipped tool for fat aspi-ration in deeper tissues only.

Cannulae of ultrasound-assisted lipoplasty

In 7% to 10% of our patients, we find the ultra-sound very helpful to liquefy fat before removal,particularly in the male back, chest, and for sec-ondary procedures. Although bifunctional ultra-sound cannulae that both liquefy and suctionare available, we prefer to use a solid probe can-nula. This maintains the liquid environment in

Fig. 3. Klein directional flattened cannulae for faceand neck areas.

Fig. 4. Basket cannula compared with the Mercedestip cannula.

Fig. 5. Aspirated fat demonstrating the majority of theaspirate is yellow fat.

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which ultrasound is most effective, dispersing theultrasound energy more quickly and acceleratingthe procedure.

Fig. 6. Topographical diagram demonstrates feather-ing of the suction planned onto other body areas.

Safety guidelines

Our patients undergo liposuction procedures inour accredited facility. We also prefer general anes-thesia provided by an experienced anesthesiologistfor better control of the airway in all positions, forimproved patient comfort, and for overall relaxa-tion of the patient and surgeon. Those patientsrequiring or preferring to overnight in our facility,do so fully monitored, with a registered nurse at thebedside, and are released the following morning.Recent recommendations made by the task force

assembled by the American Society of Plastic Sur-geons (ASPS) were prompted by reports of anes-thetic complications, including deaths related toliposuction, and defined in the Practice Advisoryon Liposuction, 2004 [5]. Anesthetic options shouldbe selected by the anesthesia provider and plasticsurgeon based on the overall health of the pa-tient the estimated volume of the aspirate to beremoved, and the postoperative dismissal plan. Al-though anesthesia may be delivered by either ananesthesiologist, a Certified Registered Nurse Anes-thetist, or by another qualified health care provider,under physician supervision, the primary responsi-bility for the providing the anesthetic should be aphysician [5]. Due to the risk of vasodilatation,hypotension, and fluid overload, it was not recom-mended by the task force that spinal or epiduralanesthesia be used in the office setting. Combina-tion anesthesia, such as intravenous, intramuscular,or oral analgesia with moderate sedation titratedto the patients comfort level can be an effectiveadjunct to infiltration anesthesia [5].For treating obese patients, the ASPS Advisory

group noted that there is an increased rate of com-plications associated with higher volumes of aspi-rates and number of regions treated [5]. It is theirrecommendation to treat those patients in whomtotal aspirates are expected to reach >5000 mL

more cautiously by performing the procedure inan accredited facility or acute care hospital, andwith the proper monitors and qualified overnightstaff. In addition to these measures outlined forlarge-volume procedures, to avoid the need fortransfusion, aspirates should contain mainly fat[Fig. 5].Relative contraindications to liposuction include

disease states such as diabetes, bowel, pulmonary,or bladder dysfunction, coronary artery disease,and immunodeficiency states, males with signifi-cant intraabdominal fat and huge girth, and pa-tients with unrealistic expectations. They require arealistic explanation of results that may fall belowtheir desire.

Current technique

The patient is marked standing in the photo suitepreoperatively. Areas to be treated are drawn in atopographical manner, anticipating the featheringof the technique at the margins [Fig. 6]. Access sites

Fig. 8. Upper instrument is a stepped awl device forcreating graded entry sites, lower instrument is athree-hole infiltration cannula.

16 Hunstad & Aitken

are discussed with the patient and agreed upon. Theauthor has preferences for typical access sites; how-ever, certain patient requests are common, andthese are taken into consideration as long as itseems feasible with cannula length, patient size,and area to be treated.The patient is placed supine on either the operat-

ing room (OR) gurney or table, depending onthe areas to be treated. Sequential compression de-vices are placed on the patient and activated priorto the induction of general anesthesia. Intubationis via endotracheal tube due to the need unlessthe patient will remain supine in which a laryngealmask airway could be appropriate. The patient isproperly padded and warmed using a Bair hugger(Arizant Health Care, Eden Prairie, Minnesota),tumescent fluid and IV fluids are warmed, andgeneral anesthesia induction is performed. The en-try sites are prepped with betadine, and the tumes-cent fluid is infiltrated. The modified Hunstadtumescent fluid (warmed Lactated Ringers plus25 mg Lidocaine and 1000 μg epinephrine) in thehalf strength is used, unless the estimated aspira-tion volume is considered large. If so, we fur-ther reduce the lidocaine to one quarter strength(12.5 mg/L).The volume of fluid infiltrated depends on the

tissue characteristics. Lighter, fluffier fat, such asthe abdomen, takes up more tumescence as thetissues expand and fill. More dense tissues, suchthe back, are less distensible and fill more quicklywith infiltration fluid. The endpoint is a firm, full,turgid, blanching tissue with a positive fountainsign [Fig. 7] [6].Peau’ de orange is undesirable due to the super-

ficial nature of this fluid. Instead, infiltration shouldbe into all layers, from the loose areolar planeabove the deep muscle fascia to above the super-ficial fascia, tunneling the cannula throughout.

Fig. 7. Fountain sign demonstrating adequately infil-trated tissues.

Typically, a long 3-mm, multihole, blunt-tippedinfiltration cannula (Byron, Tucson, Arizona) isused for this [Fig. 8]. Infiltration fluid is perfusedthrough all areas to be suctioned and beyond.

Estimating the aspiration volume

For the plastic surgeon with limited experience,it can be helpful to preoperatively estimate thevolume of anticipated fat removal to properly infil-trate the tissues, to have the warmed tumescentfluids readily available in the OR, and to antici-pate postoperative care plans. The 60-cc Toomeysyringe technique can be a helpful method of esti-mating these volumes. The aspirated volume usingthe proper tumescent technique is significantlylarger than using the standard infiltration tech-nique. Preoperatively, the surgeon should pinchthe excess fat, imagining the size of a Toomey60-cc syringe. Next, the number of syringes neededto equal the fat present should be counted andthe volume to remove estimated through calcula-tion [Fig. 9]. Intraoperatively, the surgeon shouldliposuction to within 10% of the estimated vol-ume and measure the fat to verify adequacy ofremoval [7].In the early 1980s, standard liposuction was

taught with 10 passes of the cannula in a singletunnel followed by cannula repositioning, 10 morepasses, and so on. This can leave skip areas andcause a washboard deformity. Now, we approacheach area creating many tunnels, each with a singlepass of the cannula, pulling it back completely ineach pass. We perform all-layer liposuction inmost regions, starting at the superficial plane andsuctioning downward below the superficial fasciauntil reaching the deep fascia. The topographicalmarkings made preoperatively are indicators ofthe treated areas and the point at which to beginfeathering out the technique.Asymmetries are addressed with careful attention

to the volumes infused and aspirated. Clinical ex-amination after the procedure endpoint is reached

Fig. 9. Syringe (60 cc) technique to estimate the volume to be aspirated. (A) Diagram of the number of syringes tobe filled with aspirated fat. (B) Estimate the total volume anticipated for removal, 600 cc.

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should then be adequate to recognize and treatmost asymmetries.

Fig. 10. Remote location for liposuction pump createsan inviting, quieter OR.

Syringe technique

The syringe technique popularized by Toledo [8]can be either an effective primary tool for all lipo-suction procedures or a useful inexpensive optionfor treatment of minor local areas. It has beenreported before in the Clinics of Plastic Surgery[9], and continues to be, in this day of power-assisted liposuction, an excellent option for limitedtreatment areas in a manner identical to thosetreated with machine vacuum pumps. It is simplya combination of a Toomey tip syringe connectedto the liposuction cannula with suction applied tothe proximal end of the syringe. A locking ringholds the plunger back, creating the vacuum forsuctioning. There is no tubing attached, which en-ables the operator to have more freedom, improvedcontrol, and enhanced precision. The other advan-tages of the syringe technique are (1) low cost,(2) silent OR, (3) accurate quantifiable volumes,and (4) ideal for harvest for fat injection. The dis-advantages of this technique are that the suctioncan be lost at the access sites, particularly whenusing the short cannula or in small areas beingtreated. There is a definite need for an assistant inthe OR, and it can be a relatively slow processcompared with the motorized techniques. How-ever, the gradual achievement of the final contourcan be a benefit, as it decreases the chance ofcreating depressions and overresection. Difficultareas such as the face and neck are particularlywell suited for syringe technique, especially for

touchup liposuction or for use with fat injection.When treating large areas with significant volumesto be removed, larger, more aggressive cannulaewill enable effective evacuation.

Suction-assisted lipoplasty

Suction-assisted lipoplasty, otherwise known asSAL, is the workhorse of liposuction. We use a re-mote liposuction pump to create a more invitingatmosphere in the OR (quieter) [Fig. 10]. Topo-graphical lines made preoperatively assist the sur-geon in identifying areas in need of treatment. Agraded awl device creates the perfect hemostaticaccess site in the skin fitting the cannula to be used[Fig. 11]. The technique of suctioning inside of apinch of tissue is not commonly used during the

Fig. 11. Graded stepped awl shown with cannula ofcomparable diameter to level of the awl. Machinedchannel on side of awl opens puncture-resistant ac-cess sites.

18 Hunstad & Aitken

process of liposuction, due to the possibility of in-consistent removal of fat from the overlying skin.We prefer the radial tunneling method of fanningout the cannula creating individual tunnels inmulti-ple layers from which fat is removed sequentially atdifferent levels. We begin the process in the upperlevel of fat and gradually descend below the super-ficial fascia as the tissues are reduced in thickness.

Superficial liposuction

Techniques of superficial liposuction, such as de-scribed by De Souza Pinto, Lewis, Gasparotti, andToledo, and performed in the tissues above thesuperficial facial system, are applicable in any re-gion of the body where significant skin retractionis desired [10]. Even in the most skilled surgicalhands, however, it carries with it a higher risk ofskin injury and must be differentiated from sub-dermal liposuction. Relying upon skin retraction,the technique is particularly valuable for the infra-gluteal fold when dermal sutures can result in but-tock ptosis.

Subdermal lipo

Suctioning very superficially below the dermis canbe very dangerous, and risk interruption of the deli-cate vascular plexus, carrying with it a high risk ofsubsequent waviness and irregularities. There arefew indications for this technique. Some exam-ples include the creation of a gluteal crease andfor body etching.

Differential liposuction

Gilliland and Mentz used this term to describe theuse of precise suction techniques to create a space

devoid of fat outlining, for instance, the rectusmuscles and their inscriptions, abdominal etch-ing [11].

Ultrasound-assisted liposuction

Ultrasound energy applied to liposuction is usefulwhen treating tissues that are extremely fibrous andfor secondary procedures. Backs and male abdo-mens and breasts are all good examples of excellenttimes to use this technique. The procedure requiresthe surgeon to use caution with regard to the skin,as burning the skin can occur due to the frictionand heat created with the cannula. Skin protectorsare recommended. Originally, ultrasound used forindustrial purposes was modified by Zocchi withsolid cannulae, creating collapsing cavernous tis-sues [12]. This was a two-stage process, with emul-sification followed by the use of skin rollersexpelling the liquefied fat.American surgeons requested the development of

a hollow cannula that allowed both delivery ofultrasound waves and simultaneous fat aspiration.It was believed that this simultaneous applicationof energy and aspiration would to speed up theoverall process. As delivery of the energy is mosteffective in a fluid environment, we prefer to deliverultrasonic energy to achieve emulsification with-out aspiration. This is clinically determined bythe loss of resistance to cannula passage. Post-emulsification evacuation is then performed usingpower-assisted liposuction (PAL)/SAL techniques.We perform about 10% of all liposuction proce-dures using the ultrasound machine, and we use asolid cannula. Suctioning out the fat is performedidentically to standard suction, beginning at a su-perficial point and suctioning down toward the fas-cia. This technique appears to be efficient, usingless time than without the ultrasound machine.Care should be taken to treat each side symmetri-cally and to avoid end-hits in the skin.

Power-assisted liposuction

PAL, developed initially by Microaire (MicroAireSurgical Instruments, Charlottesville, Virginia) hasbecome important to liposuction. It functions simi-larly to SAL with a cannula that rapidly shifts backand forth in the tissues to more quickly and easilydirect the fenestrations to fatty deposits in needof removal [Fig. 12]. The benefits are many, andinclude causing less physician fatigue, which proba-bly allows for a more thorough complete liposuc-tion result. Fat is more rapidly removed, decreasingOR time, we find less resistance to cannulae passageand an increase in accuracy overall, particularly

Fig. 12. (A) Microaire power-assisted liposuction machine and (B) its implementation in the OR.

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in those areas near the entry sites, lessening thechance of leaving residual fatty deposits.

Liposuction of specific regions

Although patients will present with obvious local-ized areas of fat deposition, treatment shouldencompass the individual as a whole, and carefulconsideration of the entire body is recommendedto assure proper contouring. For instance, treat-ment of the hips and waist, but failure to addressneighboring regions of the body such the lateralthigh or the back, can result in an unbalancedappearance and patient dissatisfaction. Table 1summarizes the approach that we use in our prac-tice for the varying regions of the body presentingfor liposuction.

Table 1: The Hunstad approach to specific regions f

Location Entry sites

Abdomen Groin, umbilicus, inframammBack Bra-line (single or paired),

buttocks, axillaHip rolls ButtocksOuter thigh Gluteal crease, groinCircumferential thigh Groin, gluteal crease, kneeNeck Postauricular submentalArms Anterior posterior axilla, elbButtocks Infragluteal, apical buttockInner thigh Groin, infragluteal

Face/neck

Liposuction of the neck is a commonly performedadjuctive procedure to platysmoplasty and rhyti-dectomy procedures. It is useful for those patientswith mild to significant thickness of the neck tis-sues, and often continues up onto the face. Occa-sionally, a patient suffering the ill effects of steroiduse may be encountered requesting face and neckliposuction; however, more often it is the obesepatient or one with a familial tendency who willpresent for this procedure. We inject the tumescentsolution via a hand-held spring loaded injectionsystem [Fig. 13A]. For either neck or face liposuc-tion, a small directional cannula (1.5–3 mm) isrecommended, keeping the ports directed awayfrom the skin to avoid dermal trauma with dim-pling and scarring caused by damage to the delicate

or treatment

PositionRange ofinfused volume Drain

ary Supine 3–6 L YesProne 3–6 L Yes

Prone -> supine 1–3 L NoProne 1–3 L NoProne -> supine 4–6 L NoSupine 1/2 L No

ow Supine 1–2 L NoProne 2–3 L NoProne -> supine 1–2 L No

Fig. 13. (A) Hand-held infuser for tumescent fluid infiltration of the face. (B) Small Klein directional flat-tippedcannulae useful for the face and neck sculpting.

20 Hunstad & Aitken

subdermal vascular plexus [Fig. 13B]. This is alsoan ideal time for use of the syringe technique to freethe surgeon from the tethering of the tubing, tomore accurately measure the volumes removedand more gradually reach the desired endpoint. Acrisscross technique is important to treat the areawithout leaving residual waviness. This can be per-formed through a minute incision in the submen-tal crease, behind the lobule in a postauricularposition, or at the root of the helix. A slight under-correction is strongly advised due to the improve-ment seen secondary to reabsorption of the tumescentsolution and damaged fat cells [13]. The pinchtechnique can be used to assess adequacy of aspi-ration, symmetry, and resulting contour. Signifi-cant bruising and swelling can be uncomfortable,and the patient is encouraged to use a compressiveneck garment postoperatively. Marginal mandibu-lar nerve palsy is not unexpected with thorough oraggressive suctioning of the neck or over the man-dible and jowls, and the patient should be warnedin advance.

Abdomen

Indications for liposuction of the abdomen [Figs. 14and 15] include those with minimal to moderateskin laxity and diastasis recti. Access sites preferredby these authors are in the bilateral bikini lines,which allow the entire lower abdomen to be ade-quately suctioned, in addition to the anterolateralhips. An intraumbilical access site is also used tosuction the upper abdomen. The fat of the abdo-men tends to be relatively soft and fluffy, absorbingthe tumescence rapidly. One should be aware of thespeed in which this fat can be suctioned, payingparticular attention to the volumes being removedto avoid overresection defects. Although we prefer

PAL, the syringe technique works well here to moregradually achieve the final contour. Care shouldbe taken to thoroughly evaluate the abdomen forpossible hernias or abdominal wall defects, whichcould lead to intraabominal perforation. The de-fects usually exist in the midline, and we believe amidline entry site should be avoided in the lowerabdomen. Paired inguinal entry sites are preferred.Liposuction should gradually descend to a deeperlevel (below the superficial fascia) as more andmore fat is removed. The potentially lethal sequelaeof abdominal liposuction require a fully informedpatient consent preoperatively and a knowledge-able practitioner.

Arms

The arms respond well with impressive retractionand redraping, and should be treated in a cir-cumferential manner. Although the majority ofcomplaints will be the inferior aspect of the arm,slenderizing the entire arm will produce a moreoptimal result. Care should be taken to avoid over-suctioning the medial arm area where the fat isthin, soft, and fluffy, and can be quite easily over-done. Patient selection again plays an importantrole for this area, as some patients will presentwith the ‘‘bat wing’’ deformity and nonretractableskin, unlikely to be improved with liposuction. Weemphasize to all patients that liposuction thins, itdoes not tighten or lift!The entry sites for this area are in the axilla and

the elbow. The ulnar and volar forearms, too, canbe improved with liposuction, creating a morecomplete result, and can be accessed via the ante-cubital fossa. Postoperatively, Ace-wraps, from thebase of the fingers wrapped upwardly to the axillawith lessening pressure, can be safely removed the

Fig. 15. (A,B) Preoperative and early postoperative photos of abdominal liposuction.

Fig. 14. (A–D) Preoperative and postoperative photos of abdominal liposuction.

21Liposuction

Fig. 16. (A,B) Preoperative and postoperative photos of back liposuction.

22 Hunstad & Aitken

next day, and patients experience a very promptrecovery from this procedure.

Back

The back is a commonly treated area [Fig. 16],which is accessed by these authors through bilateralor unilateral bra-line and gluteal sites. It has moredensely adherent, fibrous tissues, and we use thebasket cannula for aggressive cutting-type resec-tion and release of the tethered rolls beneath thescapula. A roll or bump may be used to gently flexthe patient at the midline to more easily address thelumbar region.

Buttocks

Liposuction of the buttocks [Fig. 17] is often dis-puted as a safe procedure due to the risk of buttockptosis following removal of supportive fat or struc-tural tissues. The buttocks, previously thought tobe off limits to liposuction for fear of the develop-ment of ptosis, are routinely treated. The so-called

Fig. 17. (A,B) Preoperative and postopera

Bermuda triangle, the area defined by the glutealapex and the trochanters, is not off limits as longas a uniform thickness of fat is maintained and athorough tumescent infiltration is performed. Thisinfiltration is critical to hydrate the tissues, allow-ing easy cannula passage, minimizing the chance ofelastic fiber trauma, and promoting excellent skinretraction. Maintaining the supportive pillars origi-nally described by Gasparotti [14] of the lower glu-teal attachments will keep the position of the buttocksintact, while improving the contour, achieving anoverall reduction in the size, and allowing the skinto redrape and retract properly. The access sites forthis area are the gluteal apex and paired infraglu-teal entry sites.

Hip rolls

Significant improvement can be achieved with re-duction in the size and contour of the hip rolls,primarily for the female patient. Commonly this isapproached in combination with back liposuctionor the lateral thigh. Entry sites are bilateral superior

tive results of buttocks liposuction.

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gluteal region, below the bikini line, and anteriorlyin the inguinal crease.

Thighs

The thighs [Fig. 18] are a location that can be suc-tioned from many directions depending on thearea being treated. Although in the past we usedprimarily the frog-leg position for circumferentialthighs or saddlebag deformity, our approach hasevolved into the use of sequential supine andprone positioning.Particular attention must be paid to the effect of

the buttock on the lateral thigh and infraglutealarea. In relaxation, it may appear that the trochan-teric deformity is quite severe, only to disappearwith contraction of the buttocks. This change maysuggest that the deformity of the lateral thigh is lesssevere, and the bulging seen on exam is actuallydue to the ptosis of the buttocks. Attention maythen be turned to the buttock as the source of theproblem [15].Recovery after thigh liposuction is much more

significant with circumferential thigh liposuctionthan with lateral or medial thigh due to the cir-

Fig. 18. (A–D) Preoperative and postoperative photos (1

cumferential nature of the procedure. Despite this,patients who desire only medial or lateral thigh suc-tioning should be considered for circumferentialthigh liposuction as it effectively diminishes the‘‘heavy look’’ of the thigh and creates a longer,leaner appearance to the leg. Over 90% of our pa-tients choose circumferential thigh liposuction.Entry sites for the thigh include the inguinal creaseand the infragluteal crease and occasionally theperipatellar and posterior knees as indicated.

Calves/ankles

Requests for contouring of the lower leg are muchless common. Because there is only a single layerof subcutaneous tissues between the skin and thedeep fascia, this area is less forgiving in terms ofresulting waviness and irregularities. Prolongedswelling is not unusual following treatment of thisdifficult area. Entry sites include paired poplitealfossa, paired peri-achilles tendon, and pretibial, al-though these are not ideal. Care must be taken toavoid injury to the underlying muscle, which cancause significant swelling and potentially a com-partment syndrome. Postoperatively, compression

year) following circumferential thigh liposuction.

24 Hunstad & Aitken

hose, leg elevation, and sequential compressive gar-ments can lessen themorbidity.

Touchup liposuction

Because anatomy and fat distribution vary by na-ture, liposuction is prone to require frequent touch-ups. When multiple bilateral areas are treated itis very possible to achieve a less than perfectlysymmetric result. In these cases, however, a slightundercorrection is muchmore preferable to an over-correction. Although touchup liposuction underlocal anesthesia is easily performed, fat graftingis a much more involved procedure and shouldbe avoided if possible. The financial consider-ations for touchup procedures are individualized,yet should be spelled out ahead of time and agreedto by the patient.

Dressings

Evenly dispersed gentle postoperative compres-sion is the goal. According to Illouz, this pressureshould be between 17 and 21 mm of mercury tobe both effective and harmless, as higher pressuresmay contribute to venous stasis [16]. This can beachieved through the use of compressive garmentswith the appropriate size chosen. Foam placedwithin the garments is used to more effectively dis-tribute the pressure, especially at the flexion pointsand areas of possible creasing where it is helpfulat minimizing bruising.

Postoperative care

Patients are routinely seen back in the office 1 to2 days following surgery to assess their healing andanswer any questions. Patients are sent home witha compressive garment over the area treated andexpected to wear it for 3 to 8 weeks. Commonly,there is significant drainage from the entry sitesunless drains are placed. If drains are placed, theyare connected to a high-vacuum wall suction tofacilitate more rapid fluid evacuation. For patientswho overnight, they remain connected to suctionuntil discharge. At the first postoperative visit, areasof skin that appear mottled are treated topicallywith a steroid cream to improve blood flow anddiminish swelling.

Troubleshooting

It is important to remember that it is much easierto remove too much fat than to replace it. Cannulasize and aggressive suctioning techniques such asPAL or ultrasound-assisted liposuction may lead

to subtle asymmetries that should be addressed.Skin retraction can be quite impressive followinga thorough liposuction. Subsequent skin retrac-tion and fibrosis of the local tissues occurs fora number of weeks following surgery. An ob-vious defect at the time of surgery should be rec-ognized and treated appropriately. Intraoperativelipo-filling is very effective in this regard, and fatinjections can be performed in the same settingas the overresection to fill these areas to a certainextent. Appropriate methods of fat harvest must beused to achieve the best result. It should be remem-bered that more than one injection may be neces-sary, depending on the size of the defect.

Dissatisfied patients

It has been our experience that liposuction patientstypically have a certain excess volume of fat overall.It is difficult for them to lose weight, and thereforethey appeal to their plastic surgeon to assist themwith this process. However, these same patientsmay have a tendency to fail to maintain their pre-operative weight and instead gain weight post-operatively. To avoid the complaints typical at the6-month postop visit, we have developed a systemthat includes a careful analysis of the patient’s pre-operative and postoperative weight. Without thepatient’s preoperativeweightmeasurement, address-ing weight gain after surgery becomes problematic.Furthermore, we always measure the true fat aspi-rate volume (omitting the fluid) and subtract thisweight from the patient’s preoperative weight, giv-ing us the all-important GOAL WEIGHT. If apatient returns to the office and complains thatthe liposuction procedure was incompletely per-formed, that a certain treated area continues to befull, and insists upon a revision or redo operation,having these numbers is critical. When we share thepreoperative weight, the weight of the remove fat,and their goal weight, it serves to diffuse a difficultsituation and prompts the patient into more effec-tive weight loss and exercise. If when patientsreturn to the office they are over their goal weight,it can only be assumed that they have gained thisweight since the time of surgery. If they subse-quently desire additional liposuction surgery, theyare much more willing to appropriately pay for it.

Undesirable outcomes

Preoperative evaluations and discussions of resultsthe patient may expect from surgery are critical.There is only one chance for preoperative photos,weight measurement, and informed consent. Al-though normally liposuction results can be lifelongchanges with proper weight management, patients

Table 2: From ASPS practice advisory onliposuction, 2004

Postoperative complications

Minor Small hematomas, seromasMinor contour irregularities

More severe Fluid overloadInfectionSkin perforationsLidocaine toxicityMajor contour defectsSkin necrosis, thermal injuryAdverse anesthetic reactionPulmonary embolus/fat embolus

Severe May require additional surgeryDeath

Abbreviation: ASPS, American Society of Plastic Surgeons.Data from Iverson RE, et al. Practice advisory on liposuc-tion. Plast Reconst Surg 2004;113(5):1478–90.

25Liposuction

must be warned of the possibility of contour ir-regularities, asymmetries, or numbness. Howeverrare, anesthetic and respiratory complications, trans-fusion requirements, and possible death completethe list of adverse events secondary to liposuction[see Table 2].

Summary

The apparent simplicity of liposuction and the easewith which it is performed, may lull the noviceplastic surgeon into overlooking the evolutionarydevelopments that have brought it to today’s levelof popularity in body contouring surgery. Patientswho may benefit from liposuction range widelyfrom the thin patient desiring contouring of local-ized areas of stubborn adiposity to the obese pa-tient in whom diet has failed to control weight.One of the major drawbacks of liposuction is itsability to thin, but not tighten. Reliance upon skinretraction to affect a proper outcome will only leadto disappointment, and this patient may insteadbenefit from an excisional-type procedure. Carefulpatient selection, education, and proper adminis-tration of the technique as a primary or an adjuc-

tive tool will help deliver the most desirable aes-thetic result.

References

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[2] Kesselring UK. Regional fat aspiration for bodycontouring. Plast Reconst Surg 1983;72(5):610–23.

[3] Illouz YG. Body contouring by lipolysis: a 5 yearexperience with over 3000 cases. Plast ReconstSurg 1983;72(5):591–7.

[4] Hunstad JP. Body contouring in the obese pa-tient. Clin Plast Surg 1996;23(4):647–69.

[5] Iverson RE, Lynch DJ. Practice advisory on lipo-suction. Plast Reconstr Surg 2004;113:1478–90.

[6] Hunstad JP. The tumescent technique: an evolu-tion. Presented at the 11th annual meeting of theLipoplasty Society of North America. NewOrleans; 1993.

[7] Hunstad JP. The tumescent technique: an evolu-tion. Lipoplasty Newsletter 1994; Vol. 11, No. 29.

[8] Toledo L, Lewis CM. Why I use the syringe insuperficial liposculpture. New York: Springer-Verlag; 1993.

[9] Hunstad JP. Addressing difficult areas in bodycontouring with emphasis on combined tumes-cent and syringe techniques. Clin Plast Surg1996;23(1):57–80.

[10] De Souza Pinto EB. Superficial liposuction.In: Zaoli G, Zocchi ML, editors. Aesthetic plasticsurgery. Zaoli (Italy): Piccin; 2003. p. 153.

[11] Mentz 3rd HA, Gilliland MD, Patronella CK. Ab-dominal etching: differential liposuction to de-tail abdominal musculature. Aesthetic Plast Surg1993;17(4):287–90.

[12] Zocchi M. Ultrasonic liposculpturing. AestheticPlast Surg 1992;16(4):287–98.

[13] Lambros V. Fat contouring in the face and neck.Clin Plast Surg 1992;19(2):401–14.

[14] Gasparotti M. Superficial liposuction: a newapplication of the technique for aged and flaccidskin. Aesthetic Plast Surg 1992;16(2):141–53.

[15] Illouz YG. Body sculpturing by lipoplasty. Edin-brough: Churchill Livingstone; 1989. p. 81.

[16] Illouz YG. History and current concepts of lipo-plasty. Clin Plast Surg 1996;23(4):721–30.