Download Volume 11 Issue C8 Body Contouring

Volume 11 • Issue C8
BODY CONTOURING
Smida Ramanadham, MD
Cosmetic
www.SRPS.org
Editor-in-Chief
Jeffrey M. Kenkel, MD
Editor Emeritus
Fritz E. Barton, Jr, MD
Contributing Editors
R. S. Ambay, MD, DDS
R. G. Anderson, MD
S. J. Beran, MD
S. M. Bidic, MD
G. Broughton II, MD, PhD
J. L. Burns, MD
J. S. Chatterjee, MRCS
A. Cheng, MD
J. Cheng, MD
C. P. Clark III, MD
H. J. Desai, MD
M. Dolan, MD
R. W. Ellison, MD
R. Ghaiy, MD
D. L. Gonyon, Jr, MD
A. A. Gosman, MD
J. R. Griffin, MD
K. A. Gutowski, MD
R. Y. Ha, MD
F. Hackney, MD, DDS
B. Harrison, MD
L. H. Hollier, MD
R. E. Hoxworth, MD
B. A. Hubbard, MD
J. E. Ireton, MD
K. Itani, MD
J. E. Janis, MD
R. K. Khosla, MD
C. J. Langevin, MD
J. E. Leedy, MD
J. A. Lemmon, MD
A. H. Lipschitz, MD
J. H. Liu, MD, MSHS
R. A. Meade, MD
M. Morales, MD
D. L. Mount, MD
K. Narasimhan, MD
A. T. Nguyen, MD
J. C. O’Brien, MD
J. K. Potter, MD, DDS
S. Ramanadham, MD
R. J. Rohrich, MD
S. Rozen, MD
M. Saint-Cyr, MD
T. Schaub, MD
M. Schaverien, MRCS
J. Seaward, MD
M. C. Snyder, MD
M. Swelstad, MD
J. F. Thornton, MD
M. J. Trovato, MD
A. P. Trussler, MD
J. G. Unger, MD
M. Vucovich, MD
R. I. Zbar, MD
Senior Manuscript Editor
Dori Kelly
Business Manager
Becky Sheldon
Corporate Sponsorship
Barbara Williams
30 Topics
Reconstruction
Breast Reconstruction
Cleft Lip and Palate
Craniofacial Anomalies
Eyelid Reconstruction
Facial Fractures
Hand: Congenital Anomalies
Hand: Extensor Tendons
Hand: Flexor Tendons
Hand: Peripheral Nerves
Hand: Soft Tissues
Hand: Wrist, Joints, Rheumatoid Arthritis
Head and Neck Reconstruction
Lip, Cheek, Scalp, and Hair Restoration
Lower Extremity Reconstruction
Microsurgery
Nasal Reconstruction
Plastic Surgery of the Ear
Trunk Reconstruction
Vascular Anomalies
Wounds and Wound Healing
Cosmetic
Blepharoplasty
Body Contouring
Breast Augmentation
Brest Reduction and Mastopexy
Brow Lift
Facelift
Neuromodulators and Injectable Fillers
Lasers and Light Therapy
Rhinoplasty
Skin Care
Selected Readings in Plastic Surgery (ISSN 0739-5523) is a series of monographs
published by Selected Readings in Plastic Surgery, Inc. For subscription
information, please visit our web site: www.SRPS.org.
This blank page is included for proper presentation in two-page view.
SRPS • Volume 11 • Issue C8 • 2016
BODY CONTOURING
Smida Ramanadham, MD
Division of Plastic Surgery, Boston University School of Medicine,
Boston, Massachusetts
INTRODUCTION
Body contouring procedures aim to create a firmer, tighter,
rejuvenated appearance by addressing lipodystrophy and
areas of skin redundancy.1 This is an area of tremendous
growth in plastic surgery, especially as the number of
bariatric cases continues to increase.2 Although some
patients present with focal areas of concern, others have
lost a substantial amount of weight and desire full-body
contouring. Multiple techniques and procedures exist to
address these issues while optimizing patient safety.
LIPOSUCTION
Liposuction is the most common cosmetic surgical
procedure in the United States. It is therefore important to
understand basic physiology and anatomy of fat and the
multiple modalities that exist for its removal.
Physiology of Body Fat
Because adipocytes specialize in the synthesis and storage
of fat, they are an important source of energy for the
organism and serve as an effective insulator.3,4 A certain
amount of adipose tissue is necessary to sustain animal life
during periods of food deprivation.
Catecholamines are responsible for lipolysis under
conditions of stress, such as fasting.5 Adipocytes possess
two different chemical receptors for catecholamines:
epinephrine and norepinephrine. b-1 receptors are
lipolytic and secrete lipase, whereas α-2 receptors block
lipolysis and are direct antagonists of the β-1 receptors.
a-2 receptors are numerous and active in well-localized
areas of fat deposition, such as steatomas and trochanteric
lipodystrophy, which might explain the apparent resistance
to weight loss at these sites.6,7 Furthermore, adipocytes
in the deep fat layer are more receptive to glucose and
incorporate faster than superficial adipocytes, so that it
takes less time for the deep cells to enlarge.7
Throughout life, fat cells multiply in number and
increase in size.8 Individual adipocytes triple in size during
the first year of life, continue to grow and multiply for the
next 5 years, and grow again during adolescence, without
substantial weight gain by the person.9 After adolescence,
no new adipocytes are formed.
The ultimate number of fat cells in the adult is
genetically determined and is therefore unique to the
individual. It is only slightly influenced by environmental
and nutritional factors at an early age and remains stable
in the face of changes in the basal metabolic rate and
other physiological alterations in later life. A person’s
body habitus, therefore, depends on the following: 1)
enlargement of the fixed number of adipocytes he or she
has at the beginning of adult life, and 2) fat cell replication
by post-adipocytes.
Salans et al.8 studied adipose cell size and number
in obese and non-obese patients. As a group, the obese
1
SRPS • Volume 11 • Issue C8 • 2016
patients had larger adipose cells than did the non-obese
patients. Cell size, however, varied considerably among
the fat depots of the participants in either group. Cell
size variations were also noted within subcutaneous and
deep sites of fat accumulation. The authors found two
patterns of obesity regarding the cellular character of the
adipose tissue mass: hyperplastic, with increased adipose
cell number and normal or increased size; and hypertrophic,
with increased cell size alone. Hyperplastic obesity is
characterized by an early age of onset and hypertrophic
obesity by late onset. The authors surmised that there are
two distinct periods in life during which hypercellularity
of the adipose tissue is most likely to occur: very early
within the first few years and again from age 9 to 13 years.
A 4-year longitudinal study of 132 participants
by Knittle et al.10 showed that the contribution of cell
number and size to the growth of the fat depot in nonobese children varies with age. Deviations from this
normal development were observed in obese children
shortly after 1 year of age. By age 11 years, obese children
exceeded the mean cell number found in non-obese adults,
and the earlier elevations in both cell number and size
were maintained throughout the study.
Borkan et al.11 described changes in adipose
tissue distribution with age. Newborns and children
have approximately 20% the adipose cell concentration
of adults. The proportion of fat in the trunk generally
increases with age, and a progressive internalization of
fat seems to occur. In particular, the abdomen shows an
increase in subcutaneous fat and correspondingly higher
intraabdominal fat content. The extremities tend to lose
fat from the subcutaneous tissue with age, shifting to a
pattern of intra- and intermuscular fat deposition.
Most human fat deposits consist of white adipose
tissue, the primary function of which is the storage
and mobilization of triglycerides and free fatty acids.
Alterations in the balance between the processes dictate
changes in adipose tissue mass and body weight gain
or loss. Brown adipose tissue is known to play a role in
thermogenesis of newborns, but its function in adults
is unclear.
Metabolic Effects of Liposuction
Adipose tissue is a metabolically active tissue. Among the
2
important secreted products of fat cells are leptin, resistin,
tumor necrosis factor-alpha, and adiponectin. The first
three products are increased in obese patients; the fourth,
adiponectin, improves glucose handling and decreases with
obesity. High levels of adiponectin, as seen when a person
loses weight, can lead to higher levels of insulin sensitivity,
a lessening of diabetic symptoms, and a better
cardiac profile.
Hypertrophic fat cells are less sensitive to insulin.
Ghrelin is a hormone that stimulates food intake in
humans. Ghrelin is produced by the gastric mucosa, the
pancreas, hypothalamus, kidneys, and pituitary gland.
Schreiber et al.12 evaluated the effects of liposuction and
diet on ghrelin, adiponectin, and leptin levels in an animal
model and reported a significant decrease in ghrelin (P
= 0.022) and an increasing trend in leptin levels (P >
0.05) after liposuction. No effect on adiponectin levels
was appreciated in that study, although the interim from
intervention to euthanasia was only 42 days. When
extrapolated to a human model, that period of time is not
long enough to observe an effect.
Giugliano et al.13 prospectively compared the
metabolic sequelae of large-volume liposuction (LVL)
(mean, 3540 mL) in obese and non-obese women. After
6 months of testing, the authors noted signs of less
insulin resistance, fewer circulating markers of vascular
inflammation, and increased levels of adiponectin. They
concluded that liposuction is safe and beneficial to
the patient.
Robles-Cervantes et al.14 found significantly lower
levels of glucose (P < 0.003), cholesterol (P < 0.05),
insulin secretion (P < 0.01), and adiposity (P < 0.001) in a
non-obese population at 3 weeks after liposuction. Insulin
levels, glucose-insulin relationship, and insulin sensitivity
remained unaltered.
Samdal et al.15 measured lipids, lipoproteins, sex
hormones, and insulin levels in seven women immediately
before and 4 weeks after suction lipectomy. The authors
reported a significant increase in high-density lipoprotein
(HDL) cholesterol and apolipoprotein A (P < 0.05)
postoperatively but no change in sex hormones or glucose
metabolism. On the basis of an average increase in HDL
cholesterol of 0.2 mmol/L, the authors hypothesized that
large-volume suction lipectomy might reduce the risk of
cardiovascular disease by as much as 30%.
SRPS • Volume 11 • Issue C8 • 2016
D’Andrea et al.16 prospectively evaluated 123
obese women for the metabolic effects of LVL over a
longer period of time. During 3 months of follow-up,
LVL resulted in significantly improved insulin sensitivity
(P < 0.04), resting metabolic rate (P < 0.001), serum
adipocytokines (P < 0.03), and inflammatory marker
levels (P < 0.001). The metabolic changes correlated
with a decreased fat mass and improved waist:hip ratio.
Interestingly, no difference was observed after 6 weeks,
paralleling the findings of the study conducted by RoblesCervantes et al.14
Liszka et al.17 studied the effect of lipectomy
on growth, fat cell number, hyperinsulinemia, and
hyperlipidemia in a Zucker rat model of type 2 diabetes.
The authors reported no consistent changes in serum
glucose or insulin levels. A significant decrease in lipid
levels was noted in the operated group (P < 0.05).
Further physiological effects of surgical removal of
subcutaneous adipose tissue were evaluated in 14 women
by Giese et al.18 All patients underwent LVL. At 4 months
postoperatively, decreases in body weight, body fat mass,
systolic blood pressure, and fasting insulin levels were
noted, suggesting that liposuction might be a valuable tool
for reducing some of the comorbidities associated with
obesity (Table 1).
Rizzo et al.19 concluded that in a female population,
dermolipectomy had similar effects on body mass index
(BMI), insulin-mediated glucose uptake, and degree of
inflammation after just 40 days.
Klein et al.20 evaluated the effects of LVL in seven
women with type 2 diabetes compared with eight nondiabetic women. In contrast to the aforementioned
studies, the authors found no significant effect on insulin
sensitivity or other metabolic markers for coronary heart
disease after 12 weeks (P > 0.05). Significant findings were
a decrease in fat mass (diabetics, P < 0.001; non-diabetics,
P = 0.002) and a decrease in leptin (P < 0.05), which is a
marker for fat mass.
Despite reports of the physiological benefits of
liposuction in obese patients, Matarasso et al.21 raised
concerns regarding the effect of liposuction on body
fat. The authors emphasized the importance of the
subcutaneous adipose tissue in helping to maintain
nutritional and thermodynamic metabolic functions. They
measured the amount of fat removed by LVL (>1000
mL) in 63 normal-weight to mildly obese patients and
monitored changes in total body fat and visceral adipose
tissue postoperatively. They reported that although largevolume subcutaneous liposuction removed relatively little
body fat, it led to substantial increases in the proportion
of visceral adipose tissue regarding subcutaneous fat.
The concern reported by the authors is that one might
actually increase the risk of metabolic complications of
obesity if LVL is undertaken. A study performed later by
Mohammed et al.22 showed no improvement in coronary
heart disease metabolic risk factors (glucose tolerance,
blood pressure, triglyceride, high-density lipoprotein,
and low-density lipoprotein cholesterol concentrations)
associated with abdominal obesity, despite long-term
reduction in body fat.
More recently, Ybarra et al.23 confirmed the
beneficial effects of abdominal liposuction on carbohydrate
and lipid metabolism. In a prospective study of 20 healthy
volunteers of normal or slightly above-normal weight,
the authors noted significant decreases in free fatty
acids (−35%, P < 0.001), glycerol (−63%, P < 0.005),
very-low-density cholesterol (−15%, P < 0.001), and
triglycerides (−21%, P < 0.002) 4 months after liposuction
was performed. At the same time, increases occurred in
HDL cholesterol (+10%, P < 0.03) and apolipoproteins
B (+15%, P < 0.0005), AI (+10%, P < 0.02), and AII
9 (+12%, P < 0.001). The serum levels of glucose (P =
0.75), insulin (P = 0.186), adiponectin (P = 0.787), and
C-reactive proteins (P = 0.177) were not significantly
altered by liposuction.
ANATOMY
The patterns of fat distribution in the body vary with the
sex, race, and age of the person. Heredity is also a factor.
Gender Differences
Vague and Finasse24 described the characteristic sites of
fat deposition according to sex. In general, women have a
proportionately higher percentage of total body fat than
do men, manifested by thicker adipose tissue throughout.
Women typically accumulate fat in the lower trunk, hips,
upper thighs, and buttocks—a gynoid pattern. In contrast,
3
SRPS • Volume 11 • Issue C8 • 2016
TABLE 1
Body Composition and Blood Chemistry Profile before and after Liposuction18
Factor
Before Surgery
4–6 wk after Surgery
4 mo after Surgery
Mean ± Standard Deviation
Weight loss, kg
NA
5.1
6.4
BMI, kg/m2
29.1 ± 2.3
27.3 ± 1.8
26.8 ± 1.5
Lean body mass, kg
43.8 ± 3.1
-
43.4 ± 3.6
Bone mineral content, kg
3.1 ± 0.4
-
3.17 ± 0.45
Body fat mass, kg
35.7 ± 6.3
-
30.1 ± 6.5
Percentage of body fat
44.6 ± 3.2
-
40.5 ± 4.5
Arm fat, kg
3.72 ± 1.48
-
2.8 ± 1.02
REE, kcal/d
1513 ± 171
1525 ± 158
1510 ± 122
Respiratory quotient
0.79 ± 0.04
0.82 ± 0.06
0.83 ± 0.03
Insulin, mIU/mL
14.9 ± 6.5
12.6 ± 4.1
7.2 ± 3.2
Glucose, mg/dL
91.9 ± 11.6
88.4 ± 9.3
88.7 ± 10.1
HOMA-IR
3.51 ± 0.52
2.77 ± 1.04
1.62 ± 0.23
Total cholesterol, mg/dL
214.3 ± 45.4
198.6 ± 25.6
202.9 ± 41.6
HDL cholesterol, mg/dL
64.9 ± 19
54.9 ± 13
64 ± 16.7
Triglycerides, mg/dL
96.9 ± 55
106.3 ± 61.1
90.6 ± 40.5
DHEA, ng/mL
10.7 ± 6.7
9.9 ± 5.8
10.6 ± 6.6
TSH, mIU/mL
2.6 ± 1.8
1.2 ± 0.7
1.6 ± 1.2
Total T4, mg/dL
8.4 ± 1.1
8.1 ± 1.1
7.9 ± 1.1
Hematocrit, %
39.9 ± 2.7
35.8 ± 4.8
39 ± 3.2
Systolic BP, mm/Hg
132.1 ± 7.3
121.8 ± 11.2
120.5 ± 8.8
Diastolic BP, mm/Hg
82.9 ± 6.9
76.9 ± 5.3
77.2 ± 7
Heart rate, bpm
79.9 ± 10.5
78.6 ± 10.7
75 ± 13
NA, not applicable; BMI, Body Mass Index; -, not measured; REE, resting energy expenditure; HOMA-IR, homeostatic
model assessment-insulin resistance; HDL, high-density lipoproteins; DHEA, dehydroepiandrosterone; TSH, thyroidstimulating hormone; BP, blood pressure.
4
SRPS • Volume 11 • Issue C8 • 2016
men tend to accumulate fat evenly around the trunk,
which is usually reflected by increased abdominal girth
and a thick torso, upper abdomen, and nape—an android
pattern. These gender variations have been explained in
terms of metabolic and embryological factors25 but are
finally determined genetically, as suggested by a study
of identical twins who were reared separately.26 The
environment alone does not seem to determine adult
body weight.
A cross-sectional sample of more than 41,000
German study participants from birth to age 62 years
revealed a pattern of sexual dimorphism in measurements
of height, weight, circumference, and BMI.27 Girls are
shorter at birth, but they increase in height at higher
rates than do boys up to age 12 years. Thereafter, an
obvious growth advantage is associated with male gender.
Female circumferences are always smaller, from birth to
senescence, whereas higher subcutaneous fat and total
body fat levels are associated with female gender.
Race Differences
Fat accumulation is also evidently related to racial and
ethnic differences.28 Compared with other races, African
Americans show increased fat accumulation in the
buttocks, a pattern that is magnified by lumbar lordosis.29
As reported by Weinsier et al.,30 weight reduction
programs achieve similar results for Caucasian and African
American women in terms of total weight loss and losses
of total fat, trunk fat, and waist circumference. However,
Caucasian women lost more intraabdominal adipose tissue
and less subcutaneous abdominal adipose tissue than did
African American women.
A meta-analysis to test the hypothesis that Japanese
persons have a greater amount of abdominal visceral fat
(AVF) relative to abdominal subcutaneous fat (ASF) than
do Caucasians31 compared mean values for AVF and ASF
areas for native Japanese, African American, and Caucasian
persons of both genders. After adjusting for ASF, age, and
sex, the difference in AVF between Japanese and Caucasian
women was lower than that between African American
and Caucasian women.
Age Differences
Another Japanese32 study tracked longitudinal changes in
subcutaneous fat distribution among Japanese women in
their 20s. Subcutaneous fat thickness was measured with
the B-mode ultrasound method at 14 points on the body.
Each participant was measured twice, once at baseline and
again 5 years later. The results showed that subcutaneous
fat thickness tends to increase with age except at the cheek,
neck, bust, and leg. Significant increases were detected,
especially at lower parts of the trunk, such as the waist (P
< 0.001) and the infragluteal region (P < 0.01). Despite
these increases, the circumferences measured did not
change, and weight also tended to decrease with age.
The authors found three patterns of subcutaneous fat
accumulation from age early 20s to age late 20s: 1) on the
whole trunk and upper arms, 2) around the waist, and 3)
on the abdomen and hips.
The interplay of gender, race, and age in body
morphology and fat deposition was exemplified by the
Amsterdam Growth and Health Study, which tracked the
development of central patterns of subcutaneous fat during
adolescence and adulthood.33 In adolescence, a decrease
was observed in extremity skinfolds for men but not for
women. For both sexes, the trunk skinfolds increased over
the entire study period. An increase was found in trunkextremity skinfold ratios in male participants but not in
female participants. The authors concluded that a central
pattern of body fat accumulation, occurring mainly in
male persons, seems to start in adolescence.
A comparison of body fat and skinfold
measurements between Chinese women from two age
cohorts34 showed notable differences in the distribution
of subcutaneous fat between younger and older Chinese
women, with the major differences in the abdominal and
subscapular skinfolds. In addition, the 20- to 30-year-old
cohort had more evenly distributed subcutaneous fat than
did the 40- to 50-year-old cohort.
Working with an American male population,
Bemben et al.35 showed a gradual decline in fat-free body
mass with increasing age, with a corresponding increase
in fat mass, from the youngest (20 years) to the oldest (79
years) age groups. Subcutaneous body fat in the proximal
trunk locations, especially the abdomen (P < 0.01), was
significantly higher with increasing age.
Wolanski36 identified the following stages of
subcutaneous fat tissue development in the United
States: preschool loss, prepubertal gain, adolescent loss,
5
SRPS • Volume 11 • Issue C8 • 2016
stabilization, adult gain, top fatness, and age loss. The
same pattern of growth of fat folds was found in different
ethnic groups, except level of thickness and age at turning
points. During adolescence, loss of fat is characteristic of
boys and stabilization of fat is characteristic of girls. Top
fatness in various populations occurred between the ages of
45 and 55 years. Relative to Peruvian natives, Caucasians,
and African Americans, fat tissues became more abundant
in Mexican American and Puerto Rican study participants
and was most abundant in the native Mexican group.
African American women have thicker fat folds than do
Caucasian women, but Caucasian men have thicker fat
folds than do African American men.
Genetics
Ramirez37 analyzed patterns of subcutaneous fat
distribution in healthy adolescents and their families.
The results showed a strong family resemblance for the
level of fatness and also between siblings of like sex for
fat distribution patterns. The patterns are apparent from
early adolescence and are evidence of a strong genetic
component in fat deposition and total body fat.
Fat Layers
The subcutaneous tissue in the torso and proximal
lower extremity is composed of two histological layers:
a superficial layer and a deep layer.38 The superficial
adipose layer is made up of compact, dense pockets of fat
contained within well-organized fibrous septa.39 The deep
adipose layer consists of looser, more areolar fat bound by
a haphazard network of partitions (Fig. 1).39
Of more clinical significance are the “surgical fat
layers,”40 which are three levels of subcutaneous fat, each
representing a zone of relative safety or caution during
suction lipectomy (Fig. 2). The deep and intermediate
layers are safe to treat, whereas the superficial layer of
densely compacted fat should be suctioned with extreme
caution because of the greater risk of deformities and skin
irregularities that can result.
Rohrich et al.41 described “zones of adherence”
that should be avoided to minimize contour deformities
during liposuction (Fig. 3). In these areas, the overlying
6
skin seems to adhere more tightly to the underlying fascia,
which tends to accentuate localized fat deposits. When
these areas are recognized preoperatively, marked contour
irregularities can be avoided during liposuction. The zones
of adherence are different in men and women.
Cellulite
Gynoid lipodystrophy is also known as cellulite, and
refers to the dimpling of the skin of the buttocks and
lower extremities, occurring most often in women. Illouz7
reported that cellulite is not a pathological condition
but rather the mechanical result of hypertrophy of the
superficial fat cells. The author postulated the mechanism
by which cellulite is formed. He proposed that the
superficial adipose layer is composed of fat within arches
made up of connective tissue and that the arches are firmly
anchored to the undersurface of the epidermis above
and the fascia superficialis below. The septa, which are
firmly attached at both extremities, expand and contract
like an accordion. As fat hypertrophy increases, so does
the tension within the fat pockets, and cellulite becomes
apparent because the anchor points do not give as the
chambers expand.
Lockwood42 found two types of cellulite: a primary
kind that is caused by hypertrophied fat cells in the
superficial fat (as reported by Illouz7) and a secondary
cellulite related to skin laxity. The latter occurs in women
who are 35 years or older and results from age, sun
damage, massive weight loss (MWL), or liposuction.
The author reported that with age and sun damage, the
entire skin-superficial fat-superficial fascial system (SFS)
relaxes and stretches. This results in ptotic soft tissues,
pseudo-fat deposit deformity, and cellulite. The underlying
mechanism is gravity acting on the fibrous septa of the
SFS. Unlike primary cellulite, cellulite related to skin
laxity is correctable by surgically tightening the skin and
superficial fascia.
With a study of 51 women who underwent
medically supervised weight-loss programs, Smalls et al.43
showed that weight loss does improve thigh cellulite.
However, they noted worsening of cellulite in a subgroup
with smaller starting BMI, smaller reductions in weight
with minimal reduction in thigh fat, and substantial
increases in tissue compliance. This correlates with the
SRPS • Volume 11 • Issue C8 • 2016
observation made by Lockwood42 regarding cellulite
related to skin laxity and the need for skin tightening in
conjunction with weight loss.
Figure 3. Zones of adherence where liposuction should be
avoided: 1, lateral gluteal depression; 2, gluteal crease; 3,
distal posterior thigh; 4, medial midthigh. 5, inferolateral
iliotibial tract. (Reprinted with permission from Rohrich
et al.41)
SUCTION LIPECTOMY
History of Suction Lipectomy
Figure 1. Differences in subcutaneous tissues in various
areas of the body. SL, superficial layer; DL, deep layer; SQF,
subcutaneous fat. (Reprinted with permission from Markman
and Barton.39)
Superficial
Intermediate
Deep
Figure 2. Surgical fat layers. (Modified from Rohrich et al.40)
Surgical procedures to contour specific areas of the body
were first described in the 1930s for the abdomen and
breasts.44 Since that time, the popularity of abdominal
and lower-extremity contouring steadily grew as a result
of contributions by Pitanguy,45,46 Regnault,47−49 and
others.50,51 Although these procedures were sophisticated, it
was not until Schrudde,52 Kesselring,53 and Illouz54 began
reporting their experience with suction-assisted lipectomy
that the concept of body sculpting became a reality.
Grazer55 traced the origin of suction lipectomy
to Dujarrier, who, in 1921, used a uterine curette to try
to remove fat from the knees of a well-known ballerina,
with disastrous consequences and eventual amputation
because of damage to the femoral artery. During the
1960s, Schrudde52 rekindled professional interest in the
removal of localized subcutaneous fat deposits through
a small stab incision. His method consisted primarily of
sharp curettage, with secondary suction only to clear the
resultant debris.
In 1978, Kesselring and Meyer56 added strong
suction to the sharp curettage method. Although their
results were generally excellent, others reported a high
incidence of complications,57−59 particularly seroma and
skin necrosis. Shortly afterward, Illouz54 and Fournier
7
SRPS • Volume 11 • Issue C8 • 2016
and Otteni59 minimized the curettage element of the
procedure and replaced it with a blunt cannula inserted
subcutaneously and connected to a vacuum pump
to aspirate the fatty tissue. Illouz54,60,61 also proposed
irrigation of the subcutaneous space with a hypertonic
saline solution with the belief that the fat cells would
swell and rupture. However, this process has not been
clinically confirmed.59
Hetter62 emphasized the importance of adequate
suction pressures for complete lipolysis, which resulted in
standardization of the vacuum pump. Teimourian63,64 and
Teimourian and Fisher65 popularized the use of smalldiameter cannulae to limit the amount of fat that could
be removed and minimize unsightly
postoperative depressions.
Modern innovations in suction lipectomy include
syringe liposculpture,66−68 superficial liposuction,69 the
tumescent technique,70−72 suspension of the superficial
fascia to decrease tension on the skin,73 ultrasound-assisted
liposuction (UAL),74−77 and power-assisted liposuction.78,79
questions should be directed toward the patient’s diet and
exercise regimen. Patients are also asked about their use of
prescription and over-the-counter weight loss medications
and/or dietary supplements. The continued use of these
substances during the perioperative period can raise the
surgical risk.81
Body dysmorphic disorder is an under-recognized
disorder that affects 7% to 15% of patients seeking
cosmetic surgery.82 Patients with body dysmorphic disorder
have an obsessive compulsion focused on an area of the
body. Treated surgically, these patients are likely to remain
dissatisfied with the results and seek further alterations.
If the disorder is suspected during initial consultation,
psychiatric referral is indicated.
A candidate for liposuction shows one or more of
the following during physical examination:40
1) deviation from the ideal male or female
aesthetic contour or silhouette
2) presence of asymmetries
3) presence of dimpling or cellulite
4) location of fat deposits (liposuction areas)
and zones of adherence
(non-liposuction areas)
Indications of and Evaluations for Suction Lipectomy
In 2004, Iverson and Lynch,80 writing for the Committee
on Patient Safety of the American Society of Plastic
Surgeons (ASPS), reviewed the scientific and clinical data
on liposuction and surveyed the practice of liposuction
as performed by ASPS members. The comprehensive
article was not meant to define the standard of care, but it
offers guidelines for practitioners to assist them in making
educated clinical decisions considering the multiple reports
of deaths attributed to liposuction.
Conventional wisdom holds that the best results
with liposuction are obtained when treating minimal
to moderate localized fat deposits that have been
unresponsive to diet and exercise in patients whose skin
is moderately elastic. In general, patients seeking body
contouring surgery should be in good general health and
have realistic expectations. Patients must not only be
committed to body contouring surgery but also willing
to undergo modifications in their diet, exercise, and
lifestyle.81
A thorough history should be obtained, and specific
8
Standard photographs are obtained to guide the
surgeon intraoperatively and to serve as a baseline for
postoperative assessment of results.40,83 The views must
be consistent for each anatomic area and of high enough
quality to allow comparisons of different techniques
and instrumentation.
Obtaining informed consent is a compulsory process
that protects both patient and physician. It is imperative
for the physician to explain the nature of the procedure,
alternative treatments, potential risks and complications,
and the financial responsibilities of the patient regarding
any secondary procedures.40
TECHNIQUE
Instruments
The tools used in body contouring have changed markedly
since the original large, sharp, single-hole cannulae.
During the last several decades, the instruments have
SRPS • Volume 11 • Issue C8 • 2016
evolved toward smaller cannulae with blunt tips and
multiple holes. These cannulae tend to be less traumatic to
the tissues and result in fewer superficial irregularities.
Wetting Solutions
The liposuction technique evolved along four different
paths: dry, wet, superwet, and tumescent (Table 2).72 The
dry and wet techniques are now of historical interest only.
The dry technique of liposuction was popularized
by Fournier and Otteni.59 Estimates of blood loss as a
percentage of the aspirated volume ranged from 5% to
54% (mean, 25%) in a series presented by Goodpasture
and Bunkis84 to 30% to 46% (mean, 35%) in LVL
performed by Courtiss et al.85 Rohrich et al.72 also
presented a report of estimated blood loss associated
with different liposuction techniques (Table 3). The dry
technique has fallen out of favor because of the associated
excessive blood loss.
Illouz61 pioneered the wet technique of liposuction,
which consisted of infusion of 100 to 300 mL of fluid into
each treatment site—regardless of the amount of fat to be
removed—and aspiration with blunt cannulae aided by
hydrotomy. Blood loss with the wet technique is estimated
to be 20% to 25% of the total aspirate.86,87
In 1983, Hetter87 added 1:400,000 epinephrine and
0.25% lidocaine to the formula presented by Illouz61 and
reported a smaller drop in the hematocrit postoperatively.
Thereafter, most series of liposuction by the wet technique
incorporated a dilute local anesthetic and low-dose
epinephrine in the subcutaneously injected solution. Blood
loss averaged <15% of the aspirate.84,86,88−90 This was often
reported as a smaller decrease in the hematocrit, from a
mean drop of 8.7 points without epinephrine to 6.6 when
epinephrine was added.91
The superwet technique was first advocated by
Fodor in 1986 (personal communication) and involves
injection into the subcutaneous tissue of a dilute solution
of local anesthetic and epinephrine in approximately equal
volume to the proposed volume of fat to be removed.
Blood loss with the superwet technique ranges from 1% to
4% of the aspirate.92−96
In the late 1980s, Klein71 reported a tumescent
technique that also resulted in decreased blood loss during
lipoplasty. The technique is performed with the patient
under local anesthesia, with or without sedation.97 The
skin and subcutaneous tissues are anesthetized by direct
infiltration of large volumes of a dilute solution of 0.1%
or 0.05% lidocaine and 1:1,000,000 epinephrine in
physiological saline. The ratio of infiltrate to aspirate is
approximately 3:1. The fluid engorges the targeted fatty
areas and makes for easier and more precise fat removal.
Blood loss from the tumescent technique is estimated to
be 1% of the aspirate.71,97-100
The relative merits of the superwet and tumescent
techniques continue to be debated. Proponents of the
superwet technique94,95 cite the following advantages:
• low blood loss, equivalent to that of the
tumescent technique
• low complication rate
• theoretically improved control of
fluid, epinephrine, and lidocaine
administration95,98,101
Advocates of the tumescent technique,98,101 on the other
hand, report that it does the following:
• enables improved safety
• improves aesthetic results
• decreases postoperative pain
• shortens convalescence
• requires minimal follow-up care by
the physician102
Infiltration Technique
The two critical issues in subcutaneous infiltration are fluid
delivery (for maintenance and resuscitation) and dosage
of lidocaine and epinephrine. Kaplan and Moy103 noted
that patients experience considerably less pain when the
subcutaneous solution is warmed to 40°C
before infiltration.
Hunstad and Aitken104 reviewed the background
and technical points of tumescent surgery, which is
associated with reduced blood loss and better pain control
and fluid management. Safety is ensured by monitoring
the volume of solution and amount of lidocaine that
is infiltrated.
9
SRPS • Volume 11 • Issue C8 • 2016
TABLE 2
Techniques of Liposuction and Their Infiltrates72
Technique
Infiltrate*
Dry
No infiltrate
Wet
200-300 mL/area
Superwet
1 mL infiltrate:1 mL aspirate
Tumescent
Infiltrate to skin turgor
2-3 mL infiltrate:1 mL aspirate
*Infiltrate can contain lidocaine, epinephrine, and/or sodium bicarbonate, depending on surgeon’s preference.
TABLE 3
Estimates of Blood Loss with Different Liposuction Techniques72
Technique
Estimate of Blood Loss as % of Volume
Dry
20-45
Wet
4-30
Superwet
1
Tumescent
1
TABLE 4
Plasma Lidocaine Levels and Symptoms of Toxicity112
Levels (µg/mL)
10
Symptoms
3-6
Subjective
Circumoral numbness, tinnitus, drowsiness, lightheadedness, difficulty focusing
5-9
Objective
Tremors, twitching, shivering
8-12
Seizures, cardiac depression
12-14
Unconscious, coma
20
Respiratory arrest
26
Cardiac arrest
SRPS • Volume 11 • Issue C8 • 2016
The two critical issues in subcutaneous infiltration
are fluid delivery (for maintenance and resuscitation)
and dosage of lidocaine and epinephrine. Trott et al.101
suggested the following guidelines for the
superwet technique:
• when aspirating <4 L, maintenance
intravenous fluids and subcutaneous
wetting solution alone are adequate
• when aspirating >4 L, it is safe to administer
maintenance fluids, subcutaneous
infiltration, and intravenous crystalloid at a
rate of 0.25 mL/mL of aspirate over 4 L
In a retrospective study of intraoperative fluid
ratios, Rohrich et al.105 noted a lower threshold for fluid
replacement of ≤5 L with superwet infiltration liposuction
in both small- and large-volume cases. No adverse effects
of volume overload occurred in the 89 patients in
the study.
Matarasso95 stated that patients absorb
approximately 1 mL of the injectate per mL of fat aspirate
and that approximately 20% of the injectate is removed via
liposuction. He therefore recommended supplementing his
patients so that the total amount of fluid administered—
injectate, intravenous, and postoperative fluid combined—
is approximately 2 to 3 mL per mL of aspirate. Close
clinical monitoring during high-volume aspirations, good
communication between surgeon and anesthesiologist, and
monitoring of urine output are essential factors for safe
liposuction. Klein71,98 recommended not administering any
supplemental intravenous fluid when using the
tumescent technique.
Epinephrine and Lidocaine
To reduce blood loss during liposuction, one must
add a dilute epinephrine solution to the subcutaneous
infiltrate.95,98,99,101,102,106,107 On the basis of normal
endocrine values, Burk et al.108 recommended a maximum
10 mg of epinephrine. An injected solution containing
epinephrine in a 1:1,000,000 concentration seems to
afford both hemostasis and safety.101
Brown et al. found that the peak plasma level
of epinephrine occurred 5 hours after infiltration and
was attributed to an exogenous source. Endogenous
109
norepinephrine levels remained stable throughout the
study. Total absorption was 25% to 32%. No toxic levels
were observed despite peak levels equivalent to major
physiological stress. The authors recommended patient
screening to ensure sufficient cardiac reserve to tolerate the
hemodynamic stress of surgery.
When mixed with epinephrine in solution, lidocaine
is absorbed slowly by the subcutaneous tissues and can
thus be used in relatively high doses. Klein110 reported that
a lidocaine dose of 35 mg/kg of body weight is safe. Peak
plasma concentrations at 12 hours did not reach toxic
levels in his series. Ostad et al.111 reported that lidocaine
doses ≤55 mg/kg are safe. Plasma levels of lidocaine and
their associated symptoms are presented in Table 4.112
Kenkel et al.113 prospectively tracked the serum
and lipoaspirate levels of lidocaine and its metabolite,
monoethylglycinexylidide (MEGX), in five women
during liposuction. MEGX is an active metabolite of
lidocaine that has 80% to 90% potency and approximately
equivalent toxicity. The time to peak concentration of
lidocaine ranged from 8 to 28 hours after infiltration; 64%
of lidocaine was absorbed systemically, and only 9.7%
was removed during the procedure. The peak lidocaine
+ MEGX concentration was within safe limits, with
therapeutic tissue levels declining after only 4 to 8 hours
postoperatively. The authors commented on the prolonged
time to peak systemic levels and relatively short duration
of effect at the tissue level.
In a series of prospective studies, the physiological
effects of LVL were evaluated by Kenkel et al.114,115 in five
female patients. The average volume of lipoaspirate was
4835 mL. Heart rate, blood pressure, mean pulmonary
arterial pressure, cardiac index, and central venous pressure
were monitored. Serum epinephrine level and core body
temperature were recorded. The cardiac index, heart rate,
and mean pulmonary arterial pressure were significantly
elevated (P < 0.05), but central venous pressure was not,
indicating adequate right heart compliance.
The intraoperative epinephrine level and cardiac
index correlated well; hypothermia was
prevalent intraoperatively.114
Electrolyte and plasma enzyme disturbance was
also evident during surgery, with patients exhibiting
hyponatremia, hypokalemia, hypoalbuminemia, and
hypoproteinemia. All measures returned to baseline
11
SRPS • Volume 11 • Issue C8 • 2016
levels in 4 to 24 hours. Transient elevations in aspartate
aminotransferase and alanine transaminase levels were
likely caused by local tissue trauma, not hepatic toxicity,
considering that creatine kinase was also elevated.115 The
authors recommended use of isotonic fluids to avoid
further hemodilution and emphasized the importance of
maintaining intraoperative normocarbia to
prevent complications.
Lidocaine Toxicity
The early signs of lidocaine toxicity are subjective and
can include circumoral numbness, drowsiness, and
lightheadedness. In a patient who has had general
anesthesia, the first signs might be cardiac abnormalities.
The treatment of lidocaine toxicity involves maintenance
of airway, ventilatory, and circulatory support and possible
cardiopulmonary resuscitation. Valium can help control
seizures by raising the brain threshold two-fold. Lipid
emulsion therapy (20% intralipid) can also be used to treat
toxicity, especially, when other measures are unsuccessful.
Some patients require specific medications to control
cardiac abnormalities.
Because of the risks involved with the use of
lidocaine, some have questioned whether it is necessary
to use lidocaine for liposuction. An intraindividual
comparison of pain when lidocaine was used on one side
of the body showed no statistically significant difference
in postoperative pain at 5 (P = 0.34), 30 (P = 0.34), 60 (P
= 1.0), and 120 minutes (P = 0.44) and on postoperative
day 1 (P = 0.19) between the lidocaine and no-lidocaine
sides.116 The authors recommended eliminating it because
of its potential toxicity. Their study was limited in design
and number of patients (n = 10). A recent intraindividual,
prospective, randomized, double-masked trial was
conducted. Visual analogue pain scale scores were reduced
by 0.5 points (P < 0.001) on the side on which lidocaine
was used in the infiltrate. This result lasted until 18 hours
after surgery. The authors deduced, however, that this was
not a clinically relevant difference in pain. They therefore
do not use this medication because of its associated risks.117
Although these studies question the efficacy of lidocaine,
many surgeons continue its use. Further investigation
should be conducted.
12
Traditional (Deep) Liposuction
The objective of suction lipectomy is to avulse
subcutaneous fat through a mechanically induced negative
pressure. The maximum vacuum that any pump can
produce at a given time and location is equal to the
current atmospheric pressure. Hetter62 described the
vacuum pump and how to calibrate it so that it can be
used at any elevation.
The distance between fat and vacuum source
includes the length of flexible tubing connecting the pump
to the cannula. Courtiss118 emphasized the significance of
cannular diameter and reminded us of Poiseuille’s law: For
each unit increase in radius of a tube, flow through the
tube rises exponentially; the longer the tube, the smaller
the flow.
Superficial Liposuction
Having presented his concept of superficial liposuction
at an international symposium in Brazil 3 years earlier,69
in 1992, Gasparotti119 presented his experience with
superficial liposuction in 2500 patients of various ages and
sizes. After the conventional technique was performed in
the deep adipose layer, the cutaneous fat layer was thick,
heavy, and susceptible to sagging from the effects of gravity
and edema. The level of suction was then shifted to the
superficial areolar layer of fat, making multiple, closely
spaced tunnels. A thin cannula was used in the subdermal
fat, undermining without aspiration was performed in
neighboring areas, and any remaining irregularities were
manually smoothed. The author stated that superficial
liposculpting is based on the controlled scar retraction
of the thin cutaneous adipose flap remaining after deep
treatment. The patient population was described as “young
people with slight adiposities; young, very fat patients
with flaccid skin; elderly patients either with aged or very
relaxed skin; and secondary liposuctions.” Superficial
liposuction is of particular benefit in defects of the outer
thigh, in the so-called banana deformity, and for
secondary liposuction.
Working independently of Gasparotti,119 Gasperoni
et al.
introduced superficial liposuction to the
congress of the International Society of Aesthetic Plastic
Surgery in Zurich, also in 1989. Five years later, they
published their results with massive all-layer liposuction
120,121
SRPS • Volume 11 • Issue C8 • 2016
(MALL) combining deep-level aspiration and subdermal
defatting.122 With this technique, the subdermal fat is
suctioned using thin, three-hole Mercedes cannulae with
diameters up to 2 mm. The authors’ experience consisted
of 404 procedures in 293 patients treated primarily for
large lipodystrophy and sagging skin in the abdomen,
inner thighs, and arms. The reported results were excellent.
In the opinion of Gasperoni et al., massive liposuction of
all fat layers is necessary to reduce, as much as possible, the
thickness of all the adipose layers and to promote effective
skin retraction.
In a follow-up article, Gasperoni and Gasperoni123
described the superficial fat layer, which is separated from
the deep fat layer by the SFS. The superficial layer has
vertical septa that can tether the skin to cause dimpling
or cellulite. The superficial fat is more structural and
contributes more to definition rather than to thinning
areas of the body, although subdermal liposuction can be
combined with deeper aspirations in specific zones. The
authors emphasized proper patient selection: ideally, a
patient who is not obese and has good skin quality. Skin
irregularities can be corrected with external ultrasound
or by internal release of tethering fascial bands. The
procedures can be performed under local or general
anesthesia. External ultrasound can be used before the
procedure to soften the fat and make it more regular
and even.123 Small-gauge, 1.8- to 2-mm Gasperoni
multipurpose Mercedes tip cannulae with circumferential
openings are used for subdermal suctioning. The same
cannulae are used in the deeper fat before use of the larger,
2.5- to 3-mm cannulae for scavenging; this poses less risk
of postoperative contour abnormalities and eases passage
of the larger diameter cannulae later. The advantages of
this technique are as follows:
1) effective skin retraction
2) progressive removal of fat for
predictable results
3) ability to treat thin areas
4) better treatment of cellulite
5) applicability to all patient types
Skin irregularities are common complications during the
immediate postoperative period and can be treated with
fat grafting.123
Superficial liposuction has been recommended for
the treatment of flaccid skin, for rippling irregularities after
deep aspiration, and for cottage-cheese or peau d’orange
skin deformity (cellulite). Whether subdermal liposuction
helps with skin retraction depends on the treatment site,
patient age, and volume of fat removed.124
Matarasso125 confirmed the importance of anatomic
site as a factor influencing the results of superficial suction
lipectomy. Patients who have flaccid, pseudoptotic
skin (type A) obtain maximum benefit from superficial
liposuction of the neck, dorsal rolls, outer thighs, and
banana deformity. Patients who have cellulite (type B)
respond best to superficial suction lipectomy of the outer
and anterior thighs. Generally, areas in which substantial
volume can be removed show the most improvement.
The buttocks are not amenable to treatment
by superficial liposuction. Where skin needs to be
lifted—e.g., the inner thighs—the procedure indicated is
excisional dermolipectomy rather than
superficial liposuction.
Pinto et al.126 presented an excellent overview of
the superficial technique of liposuction. The authors
highlighted the benefits of skin detachment in correcting
skin imperfections and enhancing secondary
skin retraction.
Syringe versus Vacuum Aspiration
In the late 1980s, Fournier127 and Toledo66 independently
reported superficial fat aspiration by syringe for the
correction of skin contour deformities. The method was
recommended for smoothing out superficial irregularities
after conventional liposuction and for the treatment
of patients with flaccid skin or cellulite. Toledo67,128
later updated his experience with syringe liposculpture
combined with superficial liposuction, lysis of fibrous
adherences, and subcutaneous fat injections.
Lewis68 compared the syringe technique to the
traditional pump aspiration method of suction lipectomy
in six patients by using one technique on either side. He
used a Tulip aspirator system (Tulip Medical Products, San
Diego, CA) with a larger opening (Toomey Syringe; Bard
Medical, Covington, GA) and a lock to hold the syringe
with vacuum to free one of the surgeon’s hands. Lewis
13
SRPS • Volume 11 • Issue C8 • 2016
reported less blood in the fat aspirate from the syringe
side and less postoperative bruising and morbidity with
the syringe technique. He speculated that the fluid added
to the cannula might have acted as a hydrotomy and
provided a cushion that decreases trauma to the
adipose tissue.
Mandel129 assessed the results of syringe
liposculpture and conventional liposuction in matched
groups of 10 patients each. He reported less blood loss in
syringe-treated patients. The syringe-treated patients also
“appeared to heal faster, return to work in a shorter period
of time, and have less pain.” Mandel concluded that the
advantages of syringe liposuction are that the fat can be
removed accurately and in precise quantities from different
areas, the aspirated material is not vaporized, blood loss is
decreased, the operating room environment is quiet, and
patient recovery is accelerated. The main disadvantage of
syringe liposculpture is prolonged operating time.
UAL
In 1993, Professor Zocchi of Modena, Italy, published
his research on ultrasonic energy to liquify excess body
fat. After treatment with a solid probe, the emulsified fat
was aspirated with a syringe instead of being removed by
a cannula attached to a vacuum pump. All practitioners
of UAL trace their enthusiasm for the technique to these
initial breakthroughs by Zocchi.74,75,77,130
UAL has expanded the indications for suction
lipectomy in body contouring, enabling surgeons to treat
areas that were previously considered to be out of bounds
because of inconsistent results with other techniques.131−133
Candidates for UAL range in age from late teens to mid70s and should be in general good health, of reasonable
body weight, and with at least moderate skin tone.77,131−133
Kenkel et al.134 compared the tissue effects of UAL
to traditional liposuction in a domestic pig model. The
authors found the ratio of hemoglobin to triglycerides
was lower after UAL with or without the sheath than after
traditional liposuction. Moreover, radiographic dye studies
of the post-perfusion vasculature in the treated areas
showed significantly less vascular disruption with UAL
than with traditional techniques.
The effects of traditional and UAL on adipose tissue
14
were also evaluated by Grippaudo et al.,135 who obtained
aspirates from 15 patients and measured triglycerides and
free fatty acids in the samples. Triglyceride levels were
higher after UAL; free fatty acids were similar in the two
groups. Schafer et al.136 subsequently evaluated acute
adipocyte viability of third-generation UAL devices and
noted 85.1% metabolically active adipocytes immediately
after aspiration. The authors’ early experience with fat
grafting using these cells was promising.
Song et al.137 showed that hypotonic solution can
significantly increase human adipocyte cell diameter. Fifty
percent normal saline achieved an 8% increase in diameter
at 45 minutes (P < 0.05). Twenty-five percent normal
saline showed an increase by 15% (P < 0.01%). The use of
25% normal saline in the solution can facilitate ultrasonic
lipoplasty by causing the adipocyte to swell, thinning its
cell membrane and becoming more fragile.
Although ultrasonic frequencies by definition are
outside the range of normal human hearing, during UAL
procedures, one hears a distinct, audible sound. Kenkel et
al.138 studied sound intensity during UAL and found that
all measurements obtained with two different machines
were within acceptable standards as defined by the United
States Occupational Safety and Health Administration
(known as OSHA). The authors concluded that UAL does
not pose a risk to patient, surgeon, or operating room
personnel.
Zocchi77 reported a large clinical experience with
UAL, encompassing more than 1000 patients operated
on between 1989 and 1996. After an initial learning
curve, minimal complications resulted from the procedure
despite treatment of patients of various ages in almost
every anatomic area. Two precepts considered essential
for the safe use of UAL are: 1) do not apply energy to dry
tissue; and 2) do not apply energy without motion of the
probe or cannula.
Scheflan and Tazi76 and Kloehn139 also reported
enhanced skin contraction and selectively improved
results with UAL. They used early model solid probes
and endured a steep learning curve. The hollow cannula
for UAL was developed in America by Maxwell and
Gingrass131 and adapted soon thereafter by Fodor and
Watson140 and Rohrich et al.132 All authors emphasized
the initial learning curve with its attendant risks of
dysesthesias, thermal injury, and contour deformity.
SRPS • Volume 11 • Issue C8 • 2016
Rohrich et al.40,141 reviewed the process of selecting
access incisions for UAL, which are confirmed with the
patient (Table 5). The incisions are only 3 to 5 mm long
and are made asymmetrically so as not to look like surgical
scars. The UAL procedure is considered to have
three stages:40
Stage I—Subcutaneous infiltration of fluids
to decrease blood loss and tissue density
Stage II—Ultrasound treatment to emulsify
subcutaneous fat
Stage III—Evacuation of emulsified fat and
final contouring
A perioperative log sheet is used to accurately
document events during liposuction. This record helps
in maintaining appropriate fluids and blood pressure.40
Rohrich et al.40,141 emphasized the importance of primary
and secondary end points for assessing completion of UAL
(Table 6).
Graf et al.142 presented a series of 348 patients
treated with a three-stage technique consisting of
infiltration, ultrasound-assisted sculpturing, and suctionassisted liposuction. The flanks and back were the most
common areas treated. Seromas were more frequent with
tumescent infiltration and became less frequent with a
superwet technique. The authors described their technical
evolution to cases with smaller volumes of liposuction and
higher energy settings and expressed satisfaction with the
resultant improved contour.
Perez and van Tetering143 reviewed 350 consecutive
cases of UAL for body contouring. They applied the basic
rules of Zocchi—no regard to energy times, body areas,
or tissue planes—in a two-stage technique consisting of
tumescent infiltration and then UAL and simultaneous
aspiration. The advantages of this technique were selective
destruction of adipose tissue and preservation of soft-tissue
elements, which led to less bruising and pain, fewer skin
irregularities, and faster postoperative recovery than with
conventional techniques. No burns were seen despite
prolonged energy times. Disadvantages included the
procedure’s cost to the patient and additional training for
the surgeon.
A common mistake by surgeons just learning the
UAL technique is to overtreat and continue UAL to
final contour. Since much of the already destroyed tissue
is still in the subcutaneous space awaiting evacuation,
overtreatment invariably produces a contour deformity.
Adherence to the end points mentioned above is critical to
the success of UAL.
The trend has been toward the use of solid probes
and away from hollow cannulae. Beckenstein and
Grotting144 presented a review their experience with solidprobe UAL in 100 consecutive cases. Their report includes
the advantages and disadvantages of the technology.
Jewell et al.145 reported their experience with
the second-generation ultrasound technology for
liposuction—the VASER device. The VASER system uses
small-diameter solid probes “with grooves near the tip
to increase fragmentation efficiency. The grooved probe
design redistributes the ultrasound energy, transferring
some of the vibration energy from the front of the tip to
a region just proximal to the tip.” The device in VASER
mode emits pulsed energy rather than continuous energy.
With the vibration energy “off” more than 50% of the
time, the potential for thermal injury at the treatment
site is decreased. The probes are smaller and lighter than
previous UAL probes. The probes’ various sizes and
grooves produce different pit configurations for different
soft tissues. By increasing the number of rings, one sees
an increase in lateral fragmentation. The authors reviewed
their results in 77 patients and found the VASER system
to be safe and efficient for body contouring surgery.
de Souza Pinto et al.146 presented their experience
with VASER liposuction. To increase fat emulsification
and use less energy, probe selection should correlate
with the consistency of the fat to be treated. At a given
diameter, probes with more grooves emulsify fat tissue
more efficiently, although they do not penetrate fibrous
tissue as well. Probes with fewer grooves and smaller
diameters penetrate fibrous tissue more easily. Pulsed
energy delivery further reduces the power needed and is
indicated for use in more delicate areas or to achieve a finer
contour. The authors described their technique, including
power and time limits and complementary use of suctionassisted lipoplasty (SAL) and power-assisted lipoplasty
(PAL), and presented case examples. They achieved 70%
to 90% cellular disruption with the VASER liposuction
and fewer complications as a result of the lower
applied energy.
15
SRPS • Volume 11 • Issue C8 • 2016
TABLE 5
Access Incisions for Ultrasound-Assisted Liposuction by Anatomic Area40
Anatomic Areas
Access Site
Breast (male)
Lateral inframammary fold
Lateral back
Lateral bra line
Vertical back
Midline
Flank/hip
Lateral gluteal fold/lateral lower hip/flank
Abdomen
Lateral lower abdomen/suprapubic region
Buttock
Lateral gluteal fold
Lateral thigh
Lateral gluteal fold
Posterior thigh
Lateral gluteal fold
Medial thigh
Medial gluteal crease (posterior)
Anterior thigh
Inguinal crease
Upper arm
Posterior radial proximal humerus (prone)
Distal radial humerus (supine)
TABLE 6
Primary and Secondary End Points for
Ultrasound-Assisted Liposuction and Suction-Assisted Lipoplasty40
End Point
Ultrasound-Assisted Liposuction
Primary
Loss of tissue resistance
Blood in aspirate
Final contour
Symmetric pinch test results
Secondary
Treatment time
Treatment volume
Treatment time
Treatment volume
A series of VASER liposculpture cases presented
by Hoyos and Millard147 is testimony to the wide range
of patients who can be treated with this three-stage
technique. The authors applied VASER in multiple modes
to different fat layers—e.g., continuous mode in the
intermediate fat and low-energy pulse mode for superficial
definition. The reported seroma rate was 6.5%, with a
2.9% port burn rate and a steep learning curve. The results
presented are impressive.
16
Suction-Assisted Lipoplasty
In 2010, Masoumi Lari et al.148 presented their
study evaluating patient satisfaction after UAL. Six
hundred nine patients were evaluated. Eighty percent
were completely or mostly satisfied, and 75% would
recommend this treatment to others. Groups associated
with increased satisfaction include women (P = 0.009),
patients who did not gain weight after the UAL procedure
(P < 0.001), patients who were content with their body
appearance (P < 0.001), patients whose dress sizes
SRPS • Volume 11 • Issue C8 • 2016
decreased after UAL (P = 0.001), and patients with
confidence in their body (P < 0.001).
External UAL
The standard device for external UAL delivers energy in
the range of 1 to 1.5 W/cm2 and is used in conjunction
with subcutaneous infiltration. The combination of the
two modalities delivers power in the range of 3 W/cm2.
Either a 5- or 10-cm head is used after subcutaneous
infiltration. A surgical coupler must be used for proper
transmission of ultrasound energy and safety. Times
range from 2 to 16 minutes depending on treatment site
(Table 7).149 Once the application of energy is completed,
traditional liposuction is used for fat removal.40 The
safety of external ultrasonic lipoplasty was confirmed by
Rosenberg and Cabrera149 in a review of 160 consecutive
patients.
The benefit of external ultrasound in body
contouring has been questioned. Rohrich et al.150
compared lipoaspirates of four body regions in six women
treated for 7 minutes with the following: a) traditional
liposuction; b) internal UAL; c) external UAL; or d)
external massage. Histological analysis of the specimens
showed 70% to 90% cellular disruption with internal
UAL and no clinically significant effect of external
ultrasound or massage on adipocytes.
These findings were confirmed clinically by
Lawrence and Cox,151 who evaluated 19 patients (25
sites) in a double-blind study of external ultrasound
versus traditional tumescent liposuction. The results were
assessed 1 month postoperatively by patients through a
questionnaire and by physicians using a visual analogue
scale. Histological specimens were also inspected.
Although four of 19 patients observed an advantage on the
external ultrasound side, the doctors found no difference
between treatment and control sides in 14 of 19 patients.
PAL
PAL is the latest technology said to further refine
suction lipectomy.152 Introduced in the 1990s, power
liposuction used compressed air and has been called
“vibroliposuction,” although it now operates by means of
a gas or electric turbine.153 The majority of PAL systems
currently rely on electricity and a variable-speed motor to
generate a reciprocating motion and produce a cannula
excursion of 2 to 4 mm, which is supposed to mimic the
surgeon’s hand movement. This is its main advantage: the
surgeon exerts less force to complete a case and is thus
less fatigued. Its major disadvantage is the vibration of
the handpiece, which can translate to the surgeon’s hand.
There is also noise associated with some of the
PAL systems.
Reporting the results of an intraindividual
comparison of PAL versus traditional SAL in 30 patients,
Fodor and Vogt78 found no difference between sides
regarding speed of recovery or aesthetic result. Fat
extraction was easier with PAL than with
conventional SAL.
Laser Liposuction
Laser lipolysis or lipoplasty has been used extensively
in Europe and Latin America and only recently in the
United States and Japan. The technique uses a pulsed
1064-nm neodymium-doped yttrium aluminium garnet
(Nd:YAG) laser to transmit low-level energy to adipocytes,
which expand and rupture.154 A flexible fiberoptic light
is inserted into the tissue through a 1-mm cannula
under local anesthesia. The position of the cannula is
monitored via transillumination from a red guiding
beam. Histological analyses of the effects of the pulsed
Nd:YAG laser on human fat tissue have shown reversible
cellular damage (tumefaction), irreversible tissue damage
(lysis), and reduced bleeding compared with conventional
lipoplasty.154
Ichikawa et al.155 traced the histological effects of
the pulsed Nd:YAG laser on human tissue. Excised human
skin and subcutaneous fat were irradiated with a 1064nm laser at 40 Hz and 150 mJ and 100-ms-long pulses
and was compared with non-irradiated tissue. Increased
destruction of human adipocytes was appreciated in the
irradiated human tissue, which showed degenerated cell
membrane, vaporization, liquefaction, carbonization,
and heat-coagulated collagen fibers. The acute thermal
effect in vivo was evaluated by laser liposuction of the rat
liver, which had areas of necrosis 1 mm in diameter—i.e.,
energy scatter and a thermal conduction effect by the
tissue. Interestingly, Brown et al.154 reported no effect on
17
SRPS • Volume 11 • Issue C8 • 2016
TABLE 7
Ultrasound-Assisted Liposuction by Body Area149
Body Area
Abdomen
Hips
12-16
6
Outer thighs
6-8
Inner thighs
4-6
Anterior thighs
4-6
Knees
2-4
Neck
3-4
Arms
6-8
Flanks
6-8
Breasts (gynecomastia)
human and porcine adipocytes by the 635-nm low-level
laser using similar techniques, contradicting the
previous studies.
Mordon et al.156 compared a pulsed 1064-nm
Nd:YAG and continuous-wave 980-nm diode laser. The
advantage of the diode laser is better efficiency, higher
power, and smaller size and weight than the Nd:YAG
laser, yet with similar absorption coefficient. The authors
found similar histological effects on adipocytes with
the two lasers at similar energy settings but inferred an
advantage to the higher power diode laser. In a review of
534 procedures in which the 980-nm diode laser was used
for lipolysis, contour correction and skin retraction were
observed almost immediately.157 No scarring, infection,
burns, hypopigmentation, bruising, swelling, or edema
occurred. Ecchymoses were observed in all patients but
resolved in less than 1 week. The authors concluded that
small-volume liposuction can be performed safely.
A comparison study by Kim and Geronemus158
evaluated the safety and efficacy of a 1064-nm Nd:YAG
laser in a group of patients with small focal areas of fat.
18
Liposuction Time (min)
6-8 (per side)
The authors reported 37% clinical improvement and 17%
reduction in fat volume shown by quantitative magnetic
resonance imaging (MRI) compared with controls. The
higher the energy is, the greater the volume of reduction
will be. A 5-cm3 reduction of fat volume was observed
with 3000 J, and a 20-cm3 volume reduction was obtained
with 12,000 J. Common side effects were mild bruising
and swelling. Large-volume areas might require high
amounts of total energy.
Goldman159 reported a series of 82 patients who
underwent submental treatment of lipodystrophy with an
Nd:YAG laser at 1064-nm wavelength using 6-W power,
40-Hz frequency, 150-mJ energy, and 100-ms pulse
width. Standard suction was then applied to remove the
laser lipolysis debris. The author noted a marked cosmetic
improvement. Comparative histology of samples obtained
immediately after the procedure and 40 days later
showed initial rupture of adipocyte membranes, collagen
coagulation, and channels in fatty tissue. Small blood
vessels were coagulated. Clinical skin-tightening effects
and collagen reorganization were noted during follow-up.
Complications included two instances of asymmetry.
SRPS • Volume 11 • Issue C8 • 2016
Di Bernardo and Reyes160 reported improved
skin tightening with laser-assisted lipoplasty (LAL). The
authors noted elasticity improvement of 26% and skin
shrinkage of 17% at 3 months post-procedure. This was
a statistically significant improvement compared with
baseline (P < 0.01). When evaluating 10 women for
whom the abdomen was treated with SAL on one side and
LAL on the other, the authors again noted improved skin
stiffness and tightness with LAL at 3 months compared
with the SAL-treated side.161
It is apparent that new technology and devices
are available for fat removal. Ahmad et al.,162 in 2011,
surveyed 1713 members of the American Society for
Aesthetic Plastic Surgery (ASAPS) regarding their
experience with these modalities and management of
complications. The response rate was 28.7%. Those who
responded performed 50 to 100 cases annually using
primarily SAL (51.4%), UAL, and PAL, with few (10.5%)
using LAL devices mainly because of concern regarding
increased complications. UAL, LAL, and SAL were
commonly associated with complications.
Suction Lipectomy in Men
In his first survey, Dillerud163 found that proportionately
more men (15%) than women (2.8%) were dissatisfied
with the outcome of suction lipectomy procedures and
speculated that stricter criteria might be needed for
liposuction in men. A later survey conducted by Dillerud
and Håheim,164 however, recorded no appreciable
difference in satisfaction with suction lipectomy between
the sexes.
Men who request abdominal suction lipectomy
must be examined with particular care, because much
of the abdominal protuberance can be caused by
intraabdominal fat that cannot be corrected with suction
lipectomy.165 Periumbilical hernia must also be ruled out.
Mentz et al.166 described differential liposuction
of the abdomen to better delineate the musculature in
male athletes. In a technique they call etching, the authors
performed localized superficial liposuction to deepen the
natural grooves and furrows and enhance muscle definition
in eight men. They reported achieving good to excellent
results with minimal associated risks. Caution should be
used when applying this technique, because it can lead to
an excessively high rate of contour irregularities.
LVL
LVL was defined by the Liposuction Task Force of the
American Society of Plastic Surgeons as lipoaspirate
volume >5000 mL. As the liposuction technique became
more refined over the next 15 years, more and more
patients (and their physicians) sought larger and larger
lipoaspirates. LVL is a safe procedure when performed
in properly selected, healthy patients in the appropriate
environment. Because of the magnitude of the operation
and amount of fluids infiltrated and removed, special
attention must be paid to resuscitation to avoid volume
overload. Rohrich et al.40 recommended maintenance
intravenous fluids for the first 5 L of aspirate and
replacement of further losses with 0.25 mL administered
intravenously for every 1 mL aspirated exceeding 5 L.
Additionally, lidocaine is decreased to 15 mL of 1%
xylocaine/L and a Foley catheter is used.
Cárdenas-Camarena et al.167 treated 161 patients
during a 4-year period. Lipoaspirate volumes ranged
between 5 and 22.3 L, with a mean of 8.7 L. The average
reduction of hemoglobin and hematocrit at 1 week was
3.8% and 12%, respectively. No major complications
were noted. Two cases (1.2%) of superficial cutaneous
necrosis, 18 (11.2%) seromas, and 24 (14.9%) palpable
irregularities were included. Patient satisfaction was 92%.
A similar study by Albin and de Campo168
encompassed 181 patients. Two (1.1%) patients developed
pulmonary embolism, and one (0.6%) had deep
venous thrombosis.
Other Applications of Liposuction
McEwan et al.169 and Dowden et al.170 reported
suction lipectomy in the management of hematomas
and fat necrosis developing after facelifts and other
nonsurgical trauma. Several authors171−176 have also
used liposuction to remove lipomas. Spinowitz177 and
Collins et al.178 cited reports of suction lipectomy for
the correction of axillary hyperhidrosis,179−181 buffalo
hump,182 and lymphedema.181,183−185 To these we can add
benign symmetric lipomatosis (Madelung disease),180
cherubism,186 and flap debulking and defatting.181,187,188
The reader is encouraged to study these reports before
embarking on suction lipectomy for special applications.
19
SRPS • Volume 11 • Issue C8 • 2016
As the number of patients who use human
immunodeficiency virus (HIV) protease inhibitors
increases and the drugs are taken for ever-longer
times, syndromes involving abnormal fat distribution
might occur. The syndromes include the presence of a
cervicodorsal fat pad, centralized lipodystrophy of the
trunk and face, and hypertrophy of adipose tissue in the
breasts of women. Wolfort et al.189 described suctionassisted lipectomy in the treatment of lipodystrophy
syndromes attributed to HIV-protease inhibitor use. Their
study showed that these areas are amenable to treatment
with liposuction. Rohrich and Kenkel190 described the use
of UAL for the management of these patients whom they
deemed “more fibrous.”
Complications Associated with Liposuction
Gargan and Courtiss58 characterized the risks of suction
lipectomy as undesired sequelae (such as surface contour
irregularities, hypesthesia, edema, ecchymosis, and
discoloration) and as potential complications (such as
excessive blood loss, hematoma, seroma, infection,
thrombosis, fat emboli, and skin necrosis). Hypesthesia of
the treated areas is not considered a complication but an
inevitable consequence of the procedure. Normal sensation
usually returns within 3 to 6 months of suctioning.
The most common postoperative sequelae of suction
lipectomy are contour irregularities. The frequency of
contour irregularities is inversely related to the surgeon’s
experience with the procedure. Visible waviness or ridging
on the surface after liposuction can be kept to a minimum
by proper patient selection and thorough preoperative
evaluation, use of small cannulae inserted through
multiple incisions, cross-radial tunneling, combined
superficial and deep suction, and feathering of the
treatment areas.
Because contour irregularities might respond
to massage, they should be treated conservatively for
at least 6 months after the initial surgery. Chang191−193
recommended the use of multiple techniques for
correction of post-liposuction contour deformities.
Methods of correction include liposuction in the area of
protuberance, liposuction around the area of depression,
simultaneous fat grafting, dermolipectomy for sagging
skin, and grid pattern markings for liposuction. For mild
20
irregularities, limited additional liposuction is used; for
more severe defects, liposuction is directly applied to
areas of protuberance and around areas of depression in
combination with fat grafting or dermolipectomy. Scar
release with pretunneling, planning the incision location,
fat harvest, and injection techniques are discussed. The
technique of autologous fat grafting in the treatment
of iatrogenic abnormalities or aesthetic improvement is
discussed later in the monograph. In 2004, the author193
advocated liposuction after grid pattern markings, which,
in his experience, yielded fewer contour irregularities.
A survey of plastic surgeons in the United States
and Canada presented by Pitman and Teimourian194
in 1985 disclosed an overall complication rate of 9.3%
after suction lipectomy. An additional 20.7% of patients
were judged to have unfavorable results as manifested by
superficial waviness (from overly aggressive fat removal)
and asymmetry (from insufficient suction within an area).
Unfortunately, despite the popularity of liposuction
and its well-documented safety record, reports of fatalities
related to liposuction continue to emerge. Rao et al.195
identified five deaths after tumescent liposuction among
48,527 deaths referred to the Office of the Chief Medical
Examiner of the City of New York between 1993 and
1998. Critical review showed that three patients died as a
result of intraoperative hypotension and bradycardia. One
of the patients had a postmortem lidocaine concentration
of 5.2 mg/L. One patient died of fluid overload, and
one died as a complication of deep venous thrombosis.
Although the above analysis suggests that lidocaine
contributed to the deaths, no objective evidence supported
that theory.196,197
Hughes198 sent out a questionnaire to 1432 boardcertified plastic surgeons, all active members of the
American Society of Aesthetic Plastic Surgery. The 754
respondents (53%) reported 94,159 lipoplasties among
them: 66% liposuction alone, 14% lipoplasty with
abdominoplasty, and 20% lipoplasty with other than
abdominoplasty. The reported complications associated
with lipoplasty are listed in Table 8.198 Combining
liposuction with other procedures dramatically increases
the mortality rate (Table 9).198
In 2006, Matarasso et al.199 surveyed members of
the ASPS and reported a 15% response rate, representing
the experience of 497 board-certified plastic surgeons
SRPS • Volume 11 • Issue C8 • 2016
who performed 20,029 abdominal contouring procedures
during a 12-month period: 55% full abdominoplasties,
35% liposuction, and 10% limited abdominoplasties.
The risk of complications did not rise with increasing
volumes of fat removal, at least regarding wound
infection, blood transfusion, anesthetic complications,
pulmonary embolism, and malpractice actions. Contour
irregularities—the most common local complication—
were reported in 9.2% of 7010 abdominal
liposuction procedures.
On the basis of the findings by a lipoplasty task
force, many ASAPS members have modified their
technique to enhance aesthetic outcomes and patient
safety (Table 10).198 The importance of operating in an
accredited surgical facility is clearly emphasized in
this review.198
Grazer and de Jong200 reported the results of a
survey of 1200 actively practicing, board-certified plastic
surgeons. Ninety-five fatalities occurred among nearly
500,000 lipoplasties, for a mortality rate of 1 in 5,224, or
approximately 19 in 100,000. Of these deaths, 23% were
caused by pulmonary thromboembolism. Because this was
a random survey, it is difficult to estimate morbidity and
mortality associated with the procedure. In their discussion
of this article, Rohrich and Muzaffar201 listed guidelines for
safety with liposuction (Table 11).
Reported complications of the tumescent technique
include pulmonary edema202 and several cases of acute
median nerve compression from injection of fluid in the
arm.203,204 In early 1998, the ASPS issued a warning based
on the findings of the lipoplasty task force. The statement
defined LVL as that with which more than 5 liters of
aspirate is removed. Members were cautioned to carefully
balance the volumes of infusion fluid and suction aspirate
in these cases because of the longer operating times and
the potential for life-threatening complications. The report
recommended that physicians performing the procedure
be properly trained in lipoplasty surgery and that
instructional courses on lipoplasty include comprehensive
fluid resuscitation information and the physiology of fluid
diffusion pertaining to large-volume lipoplasty.205
Several problems are associated specifically with
UAL, including seroma formation, hyperpigmentation,
thermal injury, and dysesthesias.132 Measures to minimize
or eliminate complications include adopting a three-stage
technique, skirting areas prone to hyperpigmentation
(e.g., the medial thigh), and guiding treatment time by the
previously mentioned end points.
Other complications, such as infection, can be
minimized by maintaining a sterile field and not touching
the barrel of the suction cannula. The most likely site of
infection (e.g., the inner thigh) should be treated last,
and incisions around the anus and vagina should be
avoided because of the risk of contamination. Skin loss
is rare. Some ulceration or friction injury to the skin at
the entrance site caused by incorrect use of the cannula,
tension on the skin margins, or an incision that is too
small is more common.
Mateu and Hernandez206 presented a report of
three cases of cutaneous hyperpigmentation occurring
after liposuction. The authors thought the cause was
multifactorial, from a combination of hemosiderin
deposition by ecchymosis, the pressure of the bandage,
and possibly friction in the inlet holes of the cannula. Oral
iron therapy, exogenous drug administration (particularly
estrogen), and sun exposure might be contributing factors
in the development of hyperpigmentation
after liposuction.
Goddio124 studied skin retraction in 458 participants
representing 500 suction lipectomy procedures. The neck
seemed to be the site most amenable to liposuction, which
alone improved or eliminated preexisting skin looseness
better than in any other part of the body. The results of
liposuction in the face deteriorated over time, and the
author advocated a combination of facelift and suction
lipectomy when skin and fat ptosis is present in the face.
Pitman et al.207 reviewed their experience with
147 patients (136 women, 11 men) who had undergone
outpatient liposuction by the tumescent technique with
>1000 mL of aspirate (mean, 2229 mL) and no other
concurrent procedure. All areas of the body were treated,
and most patients underwent simultaneous treatment
of multiple areas. The average fraction of aspirate was
78% fat, 7.8% blood. The average estimated blood loss
for all patients was 180 mL, and the average decrease
in hematocrit was 1.7%. Swelling and bruising were
minimal, and complications were nil. Patients experienced
little or no pain postoperatively and were discharged 1 or 2
hours after surgery.
21
SRPS • Volume 11 • Issue C8 • 2016
TABLE 8
Nonfatal Complications from Lipoplasty Alone and
in Combination with Abdominoplasty198
Complication
%
Rate
Skin slough
0.0903
1/1,107
Ultrasound-assisted lipoplasty skin burns
0.0712
1/1,404
Deep vein thrombophlebitis
0.0329
1/3,040
Pulmonary embolus
0.0266
1/3,759
Excessive blood loss
0.0149
1/6,711
Fluid overload
0.0138
1/7,246
Fat emboli
0.0053
1/18,868
Cannula penetration of abdominal cavity
0.0021
1/47,619
Lidocaine toxicity
0.0021
1/47,619
Surgical shock
0.0011
1/90,909
TABLE 9
Deaths from Lipoplasty during a 2-year Period198
Procedure (N = 94,159)
%
Rate
Lipoplasty alone
0.0021
1/47,415
Lipoplasty with other procedures, excluding abdominoplasty
0.0137
1/7,314
Lipoplasty with abdominoplasty, with or without other procedures
0.0305
1/3,281
Dillerud163 analyzed the complications and
undesired results of suction lipoplasty in more than
2000 patients (3511 procedures). As a rule, only healthy
patients were operated on, although stable diabetics and
patients with well-controlled hypertension were accepted
for surgery as were moderately obese patients. A BMI >35
was a contraindication to suction lipectomy. The overall
complication rate in the series presented by Dillerud
was 1.2% and included excessive bleeding, allergic skin
reaction or dermatitis, anesthesia-related complication,
superficial phlebitis, pneumonia, hypertrophic scar, and
persistent dysesthesia. Undesired results were reported in
22
10.8% of patients and consisted largely of asymmetry,
under-resection, and skin irregularities. The medial thigh,
buttocks, ankle, and face were least amenable to suction,
as reflected by the high percentage of complications and
undesired results in those areas.
Dillerud and Håheim164 later surveyed long-term
patient satisfaction with the results of blunt suction
lipectomy by questionnaire. The authors found an overall
satisfaction rate of 76%; 6% of patients were dissatisfied,
14% were less satisfied, and 4% were unsure. Liposuction
of the buttocks was the cause of the greatest dissatisfaction,
SRPS • Volume 11 • Issue C8 • 2016
TABLE 10
Changes in Lipoplasty Technique198
Change in Technique
% Respondents Changing
Technique or Evaluation
Less likely to perform in combination
35.1
Stricter patient selection criteria
33.3
Generally remove less fat in one session
31.1
Limit length of surgery
31.1
Have modified anesthesia technique
20.4
Additional patient monitoring procedures
11.1
Other
25.8
TABLE 11
Safety Guidelines in Liposuction201
Guideline
1
Appropriate patient selection (ASA class I, within 30% of ideal body weight)
2
Use of superwet techniques of infiltration
3
Meticulous monitoring of volume status (urinary catheterization, noninvasive hemodynamic
monitoring, communication with anesthesiologist)
4
Judicious fluid resuscitation*
For aspirate ≤5 L, maintenance fluid plus subcutaneous infiltrate
For aspirate >5 L, maintenance fluid plus subcutaneous infiltrate plus 0.25 mL of intravenously
administered crystalloid per milliliter of aspirate >5 L
5
Overnight monitoring of large-volume (>5 L total aspirate) liposuction patients in an appropriate health
care facility
6
Use of pneumatic compression devices in cases performed with the patient under general anesthesia or
lasting longer than 1 h
7
Maintaining total lidocaine doses below 35 mg/kg (wetting solution)
*Individualized based on patient’s urine output and hemodynamics.
and patients were most pleased with the outcome of
treatment for pseudogynecomastia and in the submental
area. No substantial difference was noted in subjective
assessment of outcome between men and women.
Illouz208 summarized his vast experience with
liposuction and its complications in a Clinics review.
Broughton et al.209 reported satisfaction data provided by
patients who had undergone liposuction by two plastic
surgeons. The majority of respondents were satisfied with
their results, particularly in the neck, hip, and buttocks.
Weight gain and fat return were reported in 43% and
65% of patients, respectively; the abdomen was the most
23
SRPS • Volume 11 • Issue C8 • 2016
common site of fat return. Most patients said they would
undergo the procedure again and would recommend it to
others. Most patients also reported having less than 1 week
of discomfort and narcotic use. Dissatisfaction related to
preexisting low self-esteem.
In another patient satisfaction study, Rohrich et
al. concluded that weight gain after liposuction did not
notably affect satisfaction with the procedure. Among
patients who gained weight postoperatively, no appreciable
lifestyle changes—such as diet and exercise—had been
implemented, which factored into the results of surgery
and the patients’ opinions of self-appearance. The patient
undergoing liposuction should embrace positive lifestyle
habits, and this lesson should be reinforced by the
plastic surgeon.
210
body contouring, along with the use of isoproterenol and
phosphatidylcholine and the mechanism of lipolysis.217
The technique described includes multiple-site injection of
phosphatidylcholine in typical doses of 100 mg for every
5 × 5 cm area. Three to six treatments usually are required,
with a 2-week interval between sessions.
Rittes218 studied 50 patients of ideal weight who
received injections of phosphatidylcholine into focal fat
deposits at various sites. Seventy percent of patients had
four treatments, 20% had two, and 10% had one. The
interval between treatments averaged 15 days. Bruising,
edema, and erythema were evident for 48 to 72 hours,
with post-inflammatory nodules and hematomas observed
for up to 30 days. Pre- and post-procedural photographs
were compared. All patients showed improvement that
lasted up to 4 years. Multiple reviews of mesotherapy urge
further scientific evaluation until its clinical use can
be endorsed.219
The question of whether pregnancy permanently
reverses the positive effects of suction lipectomy was
addressed by Ahkami.211 The author found that the
measurements achieved by suction lipectomy are
unaffected by pregnancy, assuming the patient has a
normal gravid weight gain and maintains a proper diet
after giving birth. Retroperitoneal and paraspinous muscle
hemorrhage and necrotizing fasciitis have been reported to
occur after liposuction.212−214
Various substances have been used, including
amino acids and vitamins, primarily in Europe and South
America. Today, one injectable for fat lipolysis has been
approved by the U.S. Food and Drug Administration
(FDA): Kybella, deoxycholic acid, received FDA approval
in June 2015 for the dissolution of submental fat.220
Mesotherapy
GYNECOMASTIA
As reported by Brown,215 mesotherapy was first described
by Pistor in 1952 in the context of multiple local
superficial injections of procaine. Mesotherapy is defined
as the treatment of the mesoderm and simply describes the
method of drug delivery.215
Gynecomastia is a common and distressing condition in
male patients and is defined as the presence of palpable
breast tissue. It can be normal in the newborn, pubescent,
and elderly populations. Sixty percent of boys develop
this transiently, and it can be present in 30% to 70%
of adults.221 The etiology of gynecomastia includes
developmental and drug-induced causes, hypogonadism,
tumors, systemic illnesses, congenital disorders, and
familial, idiopathic, and miscellaneous causes (Table
12).222,223 The common drugs that can lead to abnormal
breast enlargement in men are listed in Table 13.222 A
thorough history must be obtained, and a thorough
physical examination must be performed. The findings
should direct any additional blood work and imaging
studies.224 If further treatment is warranted, it should be
based on the patients’ underlying goals.221
Intralesional injections of phosphatidylcholine
were first presented in 1988 as treatment of xanthelasma.
Traditionally, phosphatidylcholine is combined with
deoxycholate for the treatment of adipose tissue.215
Rotunda and Kolodney216 differentiated mesotherapy
from phosphatidylcholine injections through an extensive
comparative review of the literature. They sought to
distinguish between the techniques and concluded that
neither is substantiated by clinical studies.
The Plastic Surgery Educational Foundation Device
and Technique Assessment Committee reviewed the scant
literature on the safety and efficacy of mesotherapy for
24
The goal of surgical treatment is to restore normal
male breast contour; mainstays of treatment include
SRPS • Volume 11 • Issue C8 • 2016
TABLE 12
Causes of Gynecomastia222,223
Developmental/physiological
Neonatal
Pubertal
Aging
Drug-induced
Hypogonadism (decreased androgen synthesis or increased androgen resistance)
Primary
Acquired (trauma, infection, torsion, radiation exposure, mumps, chemotherapy)
Congenital
Secondary
Hypogonadotropic hypogonadism
Kallmann syndrome
Pituitary failure (infarction, infection, neoplasm)
Tumors (increased estrogen production)
Steroid-producing (adrenal, testis)
Human chorionic gonadotropin-producing (testis and others)
Aromatase-producing (testis)
Bronchogenic carcinoma
Systemic
Thyrotoxicosis (altered testosterone/estrogen binding)
Renal failure (acquired testicular failure)
Cirrhosis (increased substrate for peripheral aromatization)
Adrenal (adrenocorticotropic hormone deficiency or congenital adrenal hyperplasia)
Congenital disorders
Klinefelter syndrome
Enzyme defects of testosterone synthesis (might be late onset)
Vanishing testis syndrome (anorchia)
Androgen resistance syndromes
True hermaphroditism and related conditions
Increased peripheral tissue aromatase
Familial
Miscellaneous
Human immunodeficiency virus
Chest wall trauma
Psychological stress
Spinal cord injury
Malnutrition/refeeding (increased substrate for peripheral aromatization)
Herpes zoster infection
Cystic fibrosis
Alcoholism
Myotonic dystrophy
Idiopathic
25
SRPS • Volume 11 • Issue C8 • 2016
TABLE 13
Drug-Induced Gynecomastia222
I. Drug classes associated with gynecomastia
Estrogens
Gonadotropins
Androgens (aromatizable)
Anti-androgens (cyproterone, flutamide)
Cancer chemotherapy agents (especially alkylating agents)
Calcium channel blockers (verapamil, nifedipine, diltiazem)
Angiotensin-converting enzyme inhibitors (captopril, enalapril)
Anti-hypertensives (methyldopa, reserpine)
Digitalis preparations
Dopamine blockers (phenothiazines, metoclopramide, domperidone)
Central nervous system agents (tricyclics, diazepam, phenytoin, diethylpropion)
Drugs of abuse (marijuana, heroin, methadone, amphetamines)
Anti-tuberculous agents (isoniazid, ethionamide, thiacetazone)
II. Individual drugs commonly associated with gynecomastia
Cimetidine
Spironolactone
Ketoconazole
III. Miscellaneous drugs related to gynecomastia
Amiodarone
Auranofin
Clomiphene
Etretinate
Metronidazole
Omeprazole
Penicillamine
Sulindac
Theophylline
liposuction and excision.225 Rohrich et al.226 refined the
classification system presented by Simon et al.227 and
incorporated UAL into the management algorithm (Table
14). The authors classify gynecomastia based on the
26
degree of hypertrophy, whether the tissue is glandular or
fibrous, and the degree of ptosis. They successfully treated
53 (87%) of 61 patients with liposuction alone. Skin
excision is reserved for extreme cases with severe ptosis.
SRPS • Volume 11 • Issue C8 • 2016
TABLE 14
Classification and Management of Gynecomastia226
Classification
Treatment
Grade I: minimal hypertrophy (<250 g of breast tissue)
without ptosis
IA: primarily glandular*
UAL or SAL†
IB: primarily fibrous*
UAL
Grade II: moderate hypertrophy (250500 g of breast tissue)
without ptosis
IIA: primarily glandular*
UAL or SAL
IIB: primarily fibrous*
UAL
Grade III: severe hypertrophy (>500 g of breast tissue) with
grade I ptosis
Glandular or fibrous*
UAL ± staged excision‡
Grade IV: severe hypertrophy with grade II or III ptosis
Glandular or fibrous*
UAL ± staged excision‡
*Fatty and glandular tissue is determined by a pinch test medially, laterally, and beneath the nipple-areola complex.
†UAL, ultrasound-assisted liposuction; SAL, suction-assisted lipoplasty.
‡Delayed excision of remaining ptotic breast skin and/or breast parenchyma is performed 6 to 9 months after
ultrasound-assisted liposuction to allow maximal skin retraction.
Their technique consists of a lateral inframammary crease
incision, obliteration of the zone of adherence at the
inframammary fold, and tapering of the boundaries to
avoid a depression under the nipple-areola complex. An
anterior axillary incision is used only with extreme caution
because this site typically has little adipose tissue and can
result in either a burn or skin retraction from the scar.228
Hodgson et al.229 reviewed 13 men who were treated
for gynecomastia with UAL. An inframammary incision
was used in most cases; occasionally, an additional anterior
axillary fold incision was needed. Technical details include
plastic ports, continuous saline irrigation, a probe sheath,
continuous movement, and avoidance of end hits. The
inframammary fold was disrupted. The average volume
of lipoaspirate was 504 mL per breast. No complications
were reported. Patient self-assessment scores were excellent,
and only one patient requested a secondary procedure.
Rosenberg230 used traditional liposuction for the
treatment of gynecomastia. The author later recommended
a combination of 7-mm and 2.4-mm cannulae to remove
the relatively heterogeneous fatty fibrous tissue.231 Patients
returned to full activities in 48 hours and were left with
minimal scars from the procedure.
Several multimodal one-stage approaches have
been described. Bracaglia et al.232 applied a multimodal
approach in 45 patients with various degrees of
gynecomastia. Standard liposuction was performed via
three incisions, two lateral axillary and one central, with
a pull-through technique. The authors reported a 4.4%
hematoma rate.
Ramon et al.233 reviewed a 17-patient experience
with gynecomastia of variable severity. They used a
multimodal approach consisting of cross-chest, powerassisted liposuction via a contralateral periareolar
27
SRPS • Volume 11 • Issue C8 • 2016
incision combined with an endoscopically assisted
pull-through technique. The advantages of cross-chest
access are scar placement in the periareolar border
and not traveling across the convex chest wall, as with
the inframammary and lateral axillary incisions. The
endoscope allows removal of fibrous tissue under direct
vision. No complications were reported. Jarrar et al.234
also incorporated the endoscope in treatment of their
patients and noted that it remained safe and effective and
resulted in increased patient satisfaction. Hammond et
al.230 reviewed their experience with single-stage, combined
UAL with the pull-through technique in 15 patients. A
periareolar incision was used for the entire procedure. The
overall complication rate was 18.5%.
Excisional techniques are also commonly
performed. Tashkandi et al.235 reported using a singlestage subcutaneous mastectomy and circumareolar
concentric skin reduction with deepithelialization in 24
consecutive patients with high-grade gynecomastia. A 3-0
polypropylene, intradermal, circumareolar pursestring
suture was used for skin closure. Mild skin redundancy
was noted in all patients postoperatively, but no
secondary procedures were deemed necessary. Aiache236
described an excisional technique for the treatment of
residual deformities of gynecomastia after traditional
liposuction. The author cautioned against removal of
central or peripheral adipose tissue without addressing
the underlying mammary tissue. Gheita237 described a
technique that uses a horizontal ellipse, leaving the nipple
on a superior pedicle. This technique avoids a vertical
scar and is specially designed for a male breast. Tu et al.238
performed an eccentric mastectomy concentrating on the
inferior pole with a zigzag periareolar incision. Liposuction
is used for additional contouring. One hematoma was
noted in their series, but all patients were satisfied with
their results.
More recently, microdebriders and arthroscopic
cartilage shavers are being used to address the fibrous
component of gynecomastia. Benito-Ruiz et al.239 used
the cartilage shaver with liposuction in 40 patients. After
a follow-up period of 6 to 18 months, the authors noted
that all patients were satisfied despite hematomas in three.
They concluded that this technique does have a learning
curve but can achieve good results in patients with grade II
and III conditions or as a first-stage treatment in patients
with grade IV. Goh et al.240 incorporated a microdebrider
28
for fibrous gynecomastia. Drains and fibrin glue were
also used. The author noted no hematomas or seromas,
and all eight patients were satisfied with their outcomes.
Petty et al.241 performed a retrospective study and divided
their patients into groups: open excision, excision plus
liposuction, liposuction alone, and liposuction plus
arthroscopic shaver. No difference in overall complications
(P < 0.2) or reoperation (P < 0.325) was observed among
the groups. The authors did note that the highest results
were achieved in the liposuction plus shaver group. This
finding was statistically significant when compared with
the excision plus liposuction group (P < 0.0001). The
authors concluded that the shaver is a safe and effective
method to be incorporated into the treatment plan.
GLUTEAL AUGMENTATION
The gluteal area has received increasing attention in body
contouring surgery, particularly after MWL. Weight
loss causes flatness in the gluteal area where fullness is
desired. Although body lifts address ptosis and excess
skin, they fail to address projection and definition.242
Cuenca-Guerra and Quezada243 analyzed more than 100
anatomic measurements in 1320 photographs to try to
define the characteristics of an aesthetically pleasing gluteal
region. Four important aesthetic areas were identified in
the attractive buttock: a lateral depression, an infragluteal
fold, supragluteal fossettes, and a V-shaped crease.
Anthropometric analysis of gluteal projection yielded five
gluteal types for which treatment plans could be defined.
Type 1—corrected with a combination
of liposuction and various designs of
submuscular gluteal implants
Type 2—round, small-based, high-profile
gluteal implant and liposuction
Type 3—almond-shaped, wide-based, lowprofile gluteal implant and liposuction
Type 4—wide-based, high-profile implant
and liposuction if needed
Type 5—corrected by dermocutaneous
adjustments
Centeno244 described eight aesthetic units of the
gluteal region that should be considered when formulating
SRPS • Volume 11 • Issue C8 • 2016
the preoperative plan, for the placement of the incision,
and during the postoperative evaluation. They include
two symmetrical “flank” units, a “sacral triangle” unit, two
symmetrical gluteal units, two symmetrical thigh units,
and one “infragluteal diamond” unit.
Many authors245-256 have described modalities to
augment the buttocks for increased projection and to
decompress the surrounding areas with liposuction to
sculpt the gluteal region. Modalities include prosthetic
augmentation with implants versus autologous
augmentation using fat injections or dermal flaps. Varying
incisions, planes of dissection, and implant types have
been described. Mendieta245 divided the buttocks into
an upper, a middle, and a lower zone, each with its own
subdivisions. The author’s evaluation takes into account
buttocks volume, shape, and skin quality and laxity
to determine the appropriate modality of treatment,
including liposuction, fat grafting, skin excision, and
gluteal implants. The author reviews his technique and
experience with intramuscular placement of solid
silicone implants.
Gonzalez246 presented a review of the surface
anatomic landmarks to keep in mind for the safe
placement of intramuscular gluteal implants based on his
experience with 746 patients. Infection was less frequent
with the use of drains, antibiotics, and a drape over the
perianal area. The most common complication was small
superficial wound dehiscence, which occurred in 14% of
patients and was managed conservatively. Aboudib et al.247
also described the intramuscular placement of implants
with improved complication rates. The dissected pockets
are 2 cm deep through an intergluteal fold incision. The
authors noted a 3.9% incidence of seroma, a 5.8% wound
dehiscence rate, and one case in which the implant was
removed secondary to infection. Serra et al.248 described
a modified technique in which undermining was limited,
adhesive sutures were placed, and a 3-cm midline dermal
fat base was preserved attached to the sacrum. Using this
technique in their intramuscular implant, the authors
noted a decreased complication rate, from 35% to 5%.
It has been noted that with intramuscular placement
of implants, muscle atrophy and implant rotation can
ensue. Serra et al.,249 in a separate study, assessed changes
in 23 female patients using computed tomography and
three-dimensional volumetric reconstruction. The authors
noted that during the course of 12 months, the initial
muscle atrophy seen at 3 months improved, with 4.3%
remaining on the right and 2.6% on the left at 12 months.
In all 23 patients, they noted rotation of oval implants
from a vertical to oblique orientation along the length of
muscle fibers. These findings had no clinical effects and
did not cause clinical limitations.
Many different techniques are reported with
limited data on which provide fewer complications with
improved results. A survey conducted among ASPS
members noted that 68% preferred an intramuscular
plane and approximately half preferred a single incision
in the gluteal cleft versus two incisions. Complication
rates were 38% on average, with the most common
complications being wound dehiscence, prolonged pain,
and seroma.250 A systematic review also noted a higher
rate of wound complications (10%) that led to seroma,
infection, and hematoma. The review indicated that the
intramuscular XYZ technique is associated with the least
number of complications compared with the submuscular,
intramuscular, and subfacial plane techniques.
Autologous modalities for buttocks augmentation
are also commonly used. Autologous flaps and fat
injections have become popular because of the rising
number of patients who seek body lift procedures after
MWL.251 The gluteal region in these patients tends to be
already deflated and flattens further with elevation. The
autologous flaps used for correction are based on regional
perforating vessels and typically derive from tissue that
would otherwise be discarded.242
Rohde and Gerut252 described their technique
for improving gluteal contour in 62 patients who had
undergone bariatric surgery. With this technique, a
medially based axial flap is designed in the upper buttock
and lumbar area. This is a random flap with perforators
from the superior gluteal artery, lateral sacral artery, and
fourth lumbar artery. The flap is rotated into a prefascial
pocket and sutured while advancing the buttock skin
superiorly. Drains and fibrin sealant complete the closure.
Wound dehiscence and seroma were the most common
complications in the series; one patient had fat necrosis.
The loss of gluteal projection and shape is
proportional to the amount of lower body lift performed.
Sozer et al.253 presented a report of 20 patients who
underwent circular (belt) lipectomy in combination with
29
SRPS • Volume 11 • Issue C8 • 2016
dermal fat flaps for body contouring after MWL. The
superomedially based dermal fat flap is rotated caudally
180 degrees into a subcutaneous pocket on either side.
This refinement adds 30 minutes to the operative time,
but the shape and projection of the buttocks are much
improved. Patient satisfaction was high despite minor
complications in seven cases.
Raposo-Amaral et al.251 described their experience
with bilateral dermal fat rotation flaps in nine women.
The flaps are designed on the hip and rotated into the
buttocks; they are based on gluteal artery perforators
with deepithelialized extensions from posterior and
flank incisions. After 11 months of follow-up, buttock
projection was maintained. Computed tomographic (CT)
scans of two patients at 6 months showed viable flaps.
Three patients (33%) had complications: a hematoma, a
seroma, and widened scars.
Colwell and Borud242 used superior gluteal artery
perforator flaps for autologous gluteal augmentation in 18
patients who underwent body lift procedures after MWL.
Perforating vessels were identified preoperatively along a
line extending from the posterior superior iliac spine to the
greater trochanter; two large perforators were usually seen
6 to 9 cm from the midline. The central tissue was excised
between the two deepithelialized oval flaps to decrease
central bulk, and the flaps were rotated and inset 5 cm
above the inferior gluteal crease in a suprafascial plane.
The autologous augmentation required an additional 60
minutes to complete. Wound dehiscence was the most
common complication. One flap suffered major
fat necrosis.
Sozer et al.254 described a split-muscle flap for
autologous augmentation. A dermal fat flap is designed
in the standard fashion; however, the anterior muscle
fibers are raised with the flap cranially to caudally before
insetting in a pocket created above the gluteal fascia. The
authors noted decreased fat necrosis rates and increased
mobility when using this technique.
Autologous fat injections have been applied to
multiple anatomic areas as volumetric filler. Murillo255
described a 7-year, 162-patient experience with fat
injections in the buttocks. The average injection was 700
mL. The fat was harvested from multiple sites with a
5-mm cannula, was decanted, and was then injected with
the same cannula into the upper two-thirds of the gluteus
muscle. Six patients were followed with serial MRI studies
30
that showed retention of the intramuscular fat for up to
12 months. Clinically, only 20% volume loss occurred
and patient satisfaction was high. Patient satisfaction
studies indicate that at follow-up of 12 to 24 months, the
majority of patients have very good to excellent satisfaction
with gluteal augmentation with lipografts.256
ABDOMINOPLASTY
Indications for Abdominoplasty
The goals of abdominoplasty are to improve the contour
and external appearance of the abdominal wall while
leaving well-concealed scars and a natural-looking
umbilicus. Redundant skin, excessive adipose tissue,
musculoaponeurotic diastasis, and scar deformities
including striae are seen to variable degrees in patients
seeking abdominoplasty.
Adipose deformities of the abdomen are
concentrated primarily above the umbilicus, below the
umbilicus, or at the waistline.47 Generalized obesity with
increased intraabdominal fat is typical of male patients.
Elderly women usually present with a lower abdominal
apron of skin and fat. General contraindications to
abdominoplasty are certain medical comorbidities,
gross obesity with a BMI >30, future pregnancy, and
supraumbilical abdominal scars.
Classification of Abdominal Deformities
Matarasso257 classified abdominal deformities based on the
severity of the skin, fat, and muscular flaccidity. Rohrich
et al.40 reported use of a modified Matarasso classification
that is based on clinical assessment of the degree of skin
redundancy, amount of abdominal fat, skin thickness and
tone, and status of the abdominal musculature.
Surgical Anatomy of the Abdominal Wall
Huger258 studied the changes in blood supply of the
abdominal wall after abdominoplasty and recognized three
vascular zones:
Zone I: between the lateral borders of the
rectus sheath from the costal margin to
a horizontal line drawn between the two
anterior superior iliac spines, supplied by
SRPS • Volume 11 • Issue C8 • 2016
the deep epigastric arcade
Zone II: below the horizontal line between
the anterior superior iliac spine to the
pubic and inguinal creases; supplied by the
external iliac artery, circumflex iliac, and
external pudendal systems
Zone III: superior to zone II and lateral
to zone I; supplied by the intercostal,
subcostal, and lumbar arteries
Depending on the technique used, one or two zones
can be sacrificed, leaving the resulting flap perfused via
Zone III. Current lipoabdominoplasty techniques might
preserve Zones I and III with limited discontinuous
undermining of the abdominal flap.
Sensation to the abdomen is supplied by the
intercostal nerves T7−T12. The lateral cutaneous branches
perforate the intercostal muscles at the midaxillary line and
travel within the subcutaneous plane. Anterior cutaneous
nerves travel between the traversus and internal oblique
muscles to penetrate the posterior rectus sheath, eventually
entering the rectus muscles. Grazer and Klingbeil57
emphasized the relation of the superficial nerves to various
abdominoplasty incisions. The author noted that the
lateral femoral cutaneous nerve is susceptible to injury
during flap-sculpting incisions near the groin, where the
nerve emerges from the inguinal ligament at a point close
to the anterior superior iliac spine. This nerve supplies
sensation to the skin in the lateral aspect of the thigh.
Damage can cause loss of sensation or painful neuromas.
Abdominoplasty Technique
Preoperative markings are made with the patient both
supine and upright to document the status of the rectus
muscle and the effect of gravity on the abdominal wall.
Most patients require as much or more lateral resection
than medial resection during abdominoplasty to reverse
the pattern of truncal skin relaxation. The specific pattern
of excision in any particular case ultimately depends
on the location of the lipodystrophy.49 The trend is to
accommodate bathing suit preferences by modifying the
lateral limb angles, which helps preserve maximum blood
supply to the abdominal flap. Liposuction and/or posterior
dart incisions in continuity with the abdominoplasty can
be used for a more circumferential reduction of the trunk.
The basic steps of the classic abdominoplasty
procedure are as follows: skin flap undermining to
xiphoid from symphysis pubis, midline fascial plication in
diamond pattern for waist definition, and lower abdominal
skin resection. The umbilicus is placed at the intersection
of a line connecting the highest point of the iliac crests
with another line bisecting the abdomen from sternum
to pubis.259 The skin is closed in layers with absorbable
suture material. Closed suction drains are placed under the
abdominal flap, or progressive tension sutures are placed to
minimize dead space.
Lockwood260 presented his technique of lateral
tension abdominoplasty and body lifts. It includes limited
direct undermining, increased lateral skin resection with
highest-tension wound closure along the lateral limbs,
two-layer SFS repair, and substantial truncal liposuction.
This technique improves waist contour, decreases central
tension, and maintains scar position. The author presented
a thorough review of his intraoperative and postoperative
management techniques for both abdominoplasty and
body lifts.261,262 Of note is his use of postoperative drains,
permanent suture in the SFS to maintain scar position,
and patient position in lateral decubitus for body lifts.
Pollock and Pollock263 presented a description of
their technique of abdominoplasty with liposuction and
progressive tension sutures to reduce the risk of seroma
and necrosis without drains. The deep sutures advance
and anchor the abdominal flap, distributing tension and
reducing dead space. No drains were used in their series of
65 patients, and no seromas were reported.
Harley and Pickford264 described their series of
69 patients in which a difference in thickness of the
subcutaneous tissues was noted between the upper
and lower abdominal flaps. The mismatch is seen
superficial and deep to Scarpa’s fascia and causes a stepoff and unfavorable result during closure. The authors
recommended thinning the deep subcutaneous tissue of
the abdominal flap to achieve a closer match in thickness.
Lipoabdominoplasty combines aggressive abdominal
and flank liposuction with central undermining for
midline fascial plication and superficial skin resection.
Matarasso257,265 initially gave technical guidelines for
safe concomitant liposuction and abdominoplasty and
recommended caution when suctioning the upper central
flap. Graf et al.266 showed preservation of abdominal
perforators 1mm in diameter after lipoabdominoplasty
31
SRPS • Volume 11 • Issue C8 • 2016
with limited upper abdominal undermining. This was
evaluated with color Doppler flowmetry in 20 patients
15 days after surgery. Blondeel et al.267 compared the
effects on blood vessels within the subcutaneous tissue
of the abdomen seen with UAL versus conventional
liposuction. Both cadaver tissue and fresh abdominoplasty
specimens were examined. No difference was observed
between the groups, although extravasation occurred
in both groups. The low rate of central flap necrosis in
the lipoabdominoplasty literature indicates that this
extravasation might not be clinically relevant.
Saldanha et al.268 presented a report of 125
patients who underwent lipoabdominoplasty combining
liposuction of the upper abdomen with limited upper
abdominal undermining and standard infraumbilical skin
excision while maintaining a thin layer of tissue beneath
Scarpa’s fascia. Midline fascial plication is achieved with a
narrow retractor. The advantage of this technique is that it
preserves the perforating vessels, nerves, and lymphatics.
Two seromas were aspirated. The authors also compared
lipoabdominoplasty in a normal weight group and an
overweight group and noted improved aesthetic scores
postoperatively in both groups. However, the gain was
higher in the overweight group. See also a published
comment by Mestak et al.269
Brauman270 published his results with
lipoabdominoplasty in a series of 43 patients. The surgical
technique used was similar to that used in other reports.
Preoperatively, the author determined the total volume of
intraabdominal fat by radiographic means and concluded
that in cases of small intraabdominal fat volume, diastasis
repair is indicated only in cases with substantial abdominal
wall laxity. The procedure is performed with the patient
under local anesthesia and sedation.
Avelar271 described his technique of
abdominolipoplasty without continuous undermining.
Topographic evaluation of every patient with diastasis
helps to define the distance between the muscles.
Liposuction is uniformly performed over the entire
abdomen while preserving the perforating vessels. Midline
plication is selectively performed. The skin is resected at
full thickness with a star-shaped neoumbilicus, and the
wound is closed in multilayered fashion with absorbable
sutures. The most common complication was seroma.
Cárdenas-Camarena272 recounted a 7-year
32
experience with circumferential lipoabdominoplasty in
310 women. His technique involves suction-assisted
lipectomy combined with abdominoplasty and limited
central undermining. The average amount of lipoaspirate
was 3700 mL; 86% of patients were considered to be
overweight. Minor complications occurred in 20% and
major complications in 1.3%; 46 patients (15%) required
autologous blood transfusions.
Lipoabdominoplasty was applied to 60 patients after
MWL by Espinosa-de-los-Monteros et al.273 The average
BMI in this population was 31. The author reported a
22% wound complication rate and no patient requiring
rehospitalization. Increased weight and dimension of the
pannus and a BMI of ≥35 significantly worsened the
complication rate.
Hunstad and Jones274 described their technique of
circumferential abdominal tumescent lipoabdominoplasty
with improved abdominal contour and shape compared
with abdominoplasty alone. Although skin necrosis
is a perceived risk, the authors noted a low level of
this complication with increased patient satisfaction
when performed using a proper technique of vascular
preservation by use of a tumescent infiltrate.
A fleur de lis excision is indicated for lower medial
obesity with substantial panniculus adiposus. This pattern
of resection incorporates the vertical wedge incision in
the upper abdominal midline presented by Castañares
and Goethel275 and the shallow-W excision in the
lower quadrants presented by Regnault.47,48 The vertical
component can be continued as high as the xiphoid and
as low as the perineum for simultaneous reduction of the
mons pubis.275,276 The operation improves the abdominal
contour and redefines the patient’s waist.
Persichetti et al.277 described their abdominoplasty
technique performed in 42 patients with preexisting
median or paramedian incisions. An anchor-like incision
was preferred. Seromas occurred in 7% of patients, all
of whom were obese and diabetic. Minor skin necrosis
occurred in one case.
Costa et al.278 presented their results with a modified
vertical abdominoplasty technique in 48 patients after
MWL. The advantages of the technique are improved
abdominal contour with vertical and horizontal correction
of redundancies; minimal lateral undermining; and
SRPS • Volume 11 • Issue C8 • 2016
decreased operative time, bleeding, and cost because of the
rapid en bloc resection. The authors applied the technique
to patients without preexisting vertical scar. The most
common complication was epidermolysis at the inverted
T-junction and umbilicus in 8%.
Bracaglia et al.279 described an “inverted-y” excision
that combines a horizontal and vertical component and
addresses both the horizontal and vertical laxity of the
abdomen and flanks. This technique, called a vest over
pants technique, also addresses the double-roll deformity
that occurs in post-bariatric patients. The authors’ series
included 16 patients. One seroma and four wound
dehiscences were noted.
Agha-Mohammadi and Hurwitz280 reported
managing upper abdominal laxity after MWL with
a reverse abdominoplasty and inframammary fold
reconstruction. Eighty-eight procedures were performed,
and 53 of them were combined with a circumferential
body lift. The authors were able to achieve the desired
results and address upper abdominal and lower thoracic
laxity in all patients. The complication rate was 5%.
Musculofascial Repair
Regnault48 asserted that most women who have
had multiple pregnancies have some laxity of the
musculoaponeurotic fascia, if not true diastasis recti. The
author therefore performs anterior sheath plication in
90% of patients requesting abdominoplasty. Similarly,
Pitanguy45 routinely reinforces the musculoaponeurotic
wall as part of the abdominoplasty procedure, even though
he documented only 3% of patients with diastasis recti in
his series of 539 consecutive abdominoplasties.
Nahas281 developed an objective classification
for abdominoplasty based on the musculoaponeurotic
deformity. The author recommended specific treatments to
optimize correction of the abdominal deformity.
Talisman et al.282 analyzed the results of
abdominoplasty in a series of 18 patients, three of whom
had undergone substantial diastasis repair (>12 cm).
The three patients had bladder pressures >24 cmH2O
intraoperatively and >20 cmH2O postoperatively,
compared with mean bladder pressures of 8 cmH2O
intraoperatively and 15 cmH2O postoperatively in patients
who had not undergone diastasis repair. All patients
who had undergone diastasis repair experienced varying
degrees of respiratory distress postoperatively, and one
required reintubation. Two patients had histories of
pulmonary thromboembolic events and were treated with
anticoagulants after the respiratory difficulties. The authors
cautioned against aggressive correction of large diastasis
with ensuing increased intraabdominal pressure.
Van Uchelen et al.283 assessed the long-term
durability of vertical plication of the anterior rectus
sheath after abdominoplasty. Questionnaires were sent
to 70 women who had undergone diastasis repair with
absorbable suture material as part of an abdominoplasty,
and 63 responded. Forty of the 63 respondents were
willing to attend a follow-up consultation and undergo
ultrasonography to gauge the competence of the fascia. At
a mean of 64 months postoperatively, 40% of patients had
residual or recurrent diastasis. The authors recommended
against the use of absorbable material for musculofascial
plication. Alternative techniques consisting of vertical and
lateral plication might improve the waistline and prevent
epigastric bulging.
Mestak et al.,284 on the other hand, conducted a case
controlled study to assess diastasis repair with absorbable
suture. Physical and ultrasonographic examinations were
performed, and a patient questionnaire was assessed. Fiftyone patients were examined during a follow-up period
of 12 to 41 months. The authors noted no difference in
inter-recti distance between the study group and a control
group of nulliparous women. A P value was not recorded
in this study.
Nahas et al.285 presented a report of two cases of
recurrent diastasis recti after abdominoplasty. Preoperative
CT scans showed wide lateral insertion on the costal
margins. Correction was by posterior rectus sheath
imbrication, anterior rectus sheath advancement, and
rectus muscle mobilization to the midline. Postoperative
CT scans verified correction of the diastasis. de Castro
et al.286 presented long-term results achieved after
plication. Thirty-eight patients who had undergone
abdominoplasty between 1 and 5 years previously were
selected for the study. All patients underwent physical and
ultrasonographic examinations to evaluate rectus diastasis
recurrence in the supraumbilical and infraumbilical
regions. The authors noted no recurrence in the 5-year-
33
SRPS • Volume 11 • Issue C8 • 2016
postoperative group but two in the 1-year-follow-up group
and concluded that recurrence is not directly related to
length of follow-up.
Weissman et al.287 evaluated simple continuous
versus mattress continuous suture techniques for plication.
Wound closure pads were sutured and plastic bags
were inflated beneath the suture repair line to varying
pressures. Tears were longer with the simple continuous
suture pattern, and the author concluded that continuous
horizontal mattress pattern sutures were superior in terms
of time and damage.
Umbilicoplasty
The aesthetically pleasing navel shows a pronounced
dimple, invagination of the surrounding tissue, and slight
superior hooding. Dubou and Ousterhout257 studied 100
participants of normal weight and found that regardless of
sex and race, the umbilicus lay at the level of the superior
iliac crests and midway between the xiphoid and pubis.
Rodriguez-Feliz et al.288 noted that the ideal location of
the umbilicus is approximately 15.05 cm from the pubis.
This umbilicopubic distance is a useful tool in insetting
the umbilicus after abdominal closure. The umbilicopubic
distance was found to increase in taller patients but was
not influenced by BMI.
After periumbilical defatting and rectus plication,
the umbilical pedicle is shortened as necessary and affixed
to the midline fascia in its new position.48,289 Two to four
transfixing sutures are taken through the skin flap, rectus
fascia, and umbilical island. Le Louarn and Pascal290
emphasized high tension superiorly above the umbilicus
with caudal tension placed on the superior abdominal
flap to create invagination of the periumbilical tissue and
decrease tension on the lower abdominal flap.
Akbas et al.291 described a technique of neoumbilical
formation with a vertical elliptical incision, incorporating
the umbilical stalk into the fascial plication and suturing
the umbilical skin to the rectus fascia. This is combined
with midline upper abdominal liposuction to maintain an
umbilical dimple and midline sulcus. The authors reported
two complications (13%) occurring in 15 female patients,
one dehiscence and one umbilical prolapse.
Baroudi289 described techniques for correction
34
of secondary deformities and construction of a new
umbilicus. Typically, a 4- to 6-cm circular plug of fat
is resected from the chosen site for the new navel and
sutures are placed through the skin and fascia to create a
depression. A bolster is fitted, and sutures are tied over it
for compression. These are removed in 12 to 16 days.
Sugawara et al.292 reconstructed the umbilicus with
a single V-shaped flap elevated around the newly excavated
umbilical fossa. The flap is shaped into a cone, inverted
into the fossa with the skin side down, and anchored at the
bottom. The skin defect is closed primarily, leaving dog
ears at the margin of the umbilicus.
Cló and Nogueira293 described another method
of constructing a new umbilicus. With this method, the
authors create a small X-shaped incision at the site of
the umbilicus on the abdominal flap. This creates four
V-shaped flaps that are sutured to the aponeurosis, creating
a natural appearing umbilicus.
Hypertrophic periumbilical scars usually disappear
by 18 months. No revision should be contemplated before
that time.
Mini-abdominoplasty
In 1986, Wilkinson and Swartz294 described a limited
abdominoplasty for body contouring in patients who
have mostly infraumbilical excess of skin and fat. The
defining characteristics of the limited technique are short
upturned incision lines, skin resection, plication of the
fascia, liposuction, umbilical stalk separation, and closure
of the umbilicus in the midline.295 Wilkinson295 now
applies the limited abdominoplasty procedure to patients
who formerly required full abdominoplasty with relocation
of the umbilicus. Undermining at the fascial level allows
the umbilicus to descend approximately 2 cm (umbilical
“float”), which eliminates skin laxity in the upper
abdomen.
Greminger296 described a mini-abdominoplasty
to correct lower abdominal flaccidity and regional fat
deposition. The procedure was based on the theory
that musculofascial support below the semicircular
line is weaker than above the line because of absent
posterior rectus fascia. The surgical technique consists
of a single incision, shorter than that used for the classic
SRPS • Volume 11 • Issue C8 • 2016
abdominoplasty, and limited undermining to the level
of the umbilicus. The author recommended the miniabdominoplasty for patients whose deformity was too
slight to be corrected by standard abdominoplasty and too
severe for suction lipectomy.
Gradel297 advocated abdominoplasty through
a limited incision for patients with mild to moderate
abdominal lipodystrophy, flaccidity or bulging of the
abdominal wall, and mild to moderate infraumbilical skin
excess. The flap is developed through a suprapubic incision
12 to 16 cm long. Superior dissection and muscular
plication are facilitated by transecting the umbilical
pedicle.
Walgenback and Shestak298 adopted a technique
that combines aggressive superwet liposculpture of the
abdomen with modified open technique to address
skin excess and fascial plication. This “marriage”
abdominoplasty can be tailored to fit the patient’s needs;
a full abdominoplasty is not required in every patient.
Redundant abdominal fat and skin are addressed by
umbilical float for minimal supraumbilical skin excess and
endoscopic upper midline plication. This technique helps
shorten the scar length, sensory changes, and recovery
period in abdominal contouring surgery.
Occasionally, the distance between a dropped
umbilicus and a high mons veneris is too short, in which
case mons reduction is indicated to lengthen the hairless
abdominal flap and to place the scar within the
pubic hair.295
The use of liposuction without skin resection has
been evaluated and can be applied to a select patient
population. Omranifard299 compared 40 patients who
had undergone class II abdominoplasty and had been
randomly prospectively assigned to one of two groups: a
mini-abdominoplasty with rectus plication and a matched
UAL group. The mean weight of tissue removed in both
groups was 2 kg. The UAL group had significantly longer
operative times but shorter recovery and less analgesic
requirement. Complications were more frequent in the
UAL group, with 80% of patients experiencing minor
complications. After 6 months, 90% of the UAL patients
were satisfied with their skin laxity improvement.
Dabb et al.300 followed 32 patients who underwent
circumferential UAL and direct abdominal wall plication
through a periumbilical incision as an alternative to
conventional abdominoplasty. The patients had minimal
skin laxity, moderate fatty tissue, midline diastasis, and no
concerns regarding striae. The total amount of lipoaspirate
averaged 2400 mL. Patient satisfaction was acceptable and
surpassed expectations. One patient desired further skin
excision, and another requested further liposuction. The
seroma rate was 15.6% despite the use of drains.
Abdominoplasty in Male Patients
Mladick301 reviewed body contouring in men and
described technical factors specific to the male
abdominoplasty. Men generally have thicker, less elastic
skin than women have. Except in cases of MWL and
a redundant skin apron, the soft-tissue excision during
abdominoplasty in a male patient is less extensive than
in a woman. Also, because the male pubic hair is not as
well defined, the lower incision should be placed higher in
men.
Matarasso302 reviewed his experience with male
body contouring and distinguished between the male
and female torso. Men tend to have more intraabdominal
fat and thicker, less distensible skin than women have,
which makes men better candidates for SAL. Eighty-four
percent of the author ’s male patients underwent SAL
only for abdominal contouring. Full abdominoplasty or a
panniculectomy is more common than limited excisional
surgery in men seeking body cont3ouring.
Lockwood303 noted that men with prominent
abdomens who are both diet- and exercise-resistant might
have familial fat deposits and substantial rectus diastasis. If
examination reveals a rectus diastasis, the author considers
it the primary indication for endoscopically assisted
abdominoplasty without skin resection. Liposuction of any
fat deposits can be accomplished at the same time.
Perioperative Management
Kryger et al.304 reviewed a 6-year experience with 153
consecutive abdominoplasties, 92% of which were
performed with the patient under conscious sedation
with local anesthetic infiltration. Eighty percent of the
patients had adjunctive cosmetic procedures performed,
and 8% underwent abdominal hernia repairs. No medical
35
SRPS • Volume 11 • Issue C8 • 2016
complications or conversions to general anesthesia were
reported. Seventy-three percent were discharged home
after the procedure. Three patients were readmitted to the
hospital for postoperative nausea. Minor complications
were noted in 11%, with seroma being the most common
(6.5%). Patient satisfaction was high, recall was minimal,
and most patients were likely to request conscious sedation
for further procedures. The authors noted the benefits of
rapid recovery and a high margin of safety.
Mast305 presented a retrospective study of 35 full
abdominoplasties; 17 cases were done as inpatient and 18
as outpatient procedures. No difference in complication
rate was noted. Postoperative pain and nausea were
controlled adequately in either case and patient satisfaction
was similar.
Mentz et al.306 compared the use of a regional
infusion pain pump plus standard orally and/or
intramuscularly administered pain medication versus
standard orally and intramuscularly administered pain
medication alone in abdominoplasty. Each group consisted
of 10 women who had undergone full abdominoplasty
with midline rectus plication. The infusion pump group
resumed normal activities sooner, required less narcotic
administration, and reported better recovery compared
with the control group.
Patient satisfaction after abdominoplasty is
generally high. Bolton et al.307 evaluated 30 consecutive
female patients who had undergone abdominoplasty
pre- and postoperatively in terms of body self-image,
psychological investment in appearance, and general
psychosocial function. Body image was greatly improved,
with positive changes in the patients’ assessments of their
overall appearance, self-consciousness levels, and how
often they avoided body exposure during sexual activity.
No differences were recorded in psychological investment
in appearance or psychosocial function. Staalesen et
al.308 presented a systematic review of outcomes of
abdominoplasty to evaluate the benefits and risks of the
procedure. The authors identified one small controlled
study that indicated a positive effect on quality of life, one
prospective study reporting minor complications averaging
25%, and 14 additional studies. A major complication was
venous thromboembolism in 2% to 8% in three series.
The authors concluded that quality of evidence of positive
health effects for these patients is low based on all
studies’ outcomes.
36
Complications Associated with Abdominoplasty
In 1977, Grazer and Goldwyn309 published the results
of a survey of members of the ASPS on complications
of abdominoplasty. The report is based on 958 replies
representing a minimum of 10,490 abdominoplasties.
In decreasing order of occurrence were wound infection,
dehiscence, hematoma, and skin loss. Hematomas
developed in more than 600 cases. Almost half of all
respondents had to drain serum or blood from at least one
patient, and 39% of surgeons reported skin loss in at least
one patient. In addition, 47% of surgeons reported that
postoperative contracture of the umbilicus was a frequent
occurrence. Not surprisingly, the frequency
of complications was inversely related to the
surgeon’s experience.
An updated survey of members of the ASPS
on abdominal contouring received 15% responses,
representing a total of 20,029 cases including
abdominal liposuction, limited abdominoplasty, and full
abdominoplasty.200 Ninety-two percent of respondents had
been in practice longer than 5 years, and 57% classified
themselves as aesthetic surgeons. The complication rates
of abdominoplasty were similar to those reported in the
literature and did not vary with years in practice. The
deep venous thrombosis (0.04%) and pulmonary embolus
(0.02%) rates were lower than in previous studies. No
deaths were reported.
Hensel et al.310 reviewed the records of 199
abdominoplasty cases treated during a 15-year period in
an attempt to identify factors that affected outcome. The
overall complication rate was 32%; 1.4% were major
complications. The revision rate was 43%. Patients were
divided into four groups based on tobacco use, diabetes,
and hypertension with no significant different shown in
revision rates or major complications among the groups
(P > 0.05). No statistically significant difference was
shown between patients who underwent concomitant
intraabdominal procedures with abdominoplasty
and patients who underwent abdominoplasty alone.
Complications were magnified in obese patients (86%).
Similarly, Vastine et al.311 noted an 80% complication rate
among obese patients who underwent abdominoplasty.
The complications were mainly wound related.
Kim and Stevenson312 compared the results in
patients who underwent abdominoplasty with and without
flank liposuction. The abdominoplasty + liposuction group
SRPS • Volume 11 • Issue C8 • 2016
was substratified into standard liposuction and UAL.
The average amount of lipoaspirate was 763 mL. Seroma
occurred in 38% of the abdominoplasty group and 29% of
the abdominoplasty + liposuction group; seroma rates were
no higher in UAL than in conventional SAL. Obesity was
the only factor that contributed to seroma in both groups.
Chaouat et al.313 reviewed the records of 258
women who had undergone abdominoplasty at their
clinic during the previous 5 years. The authors reported a
significantly higher rate of skin necrosis for patients who
had undergone T-type abdominoplasty (35.5%) than for
those who had undergone infraumbilical plasties (1.4%)
or full abdominoplasties with horizontal scars (4.6%) (P <
0.001). The revision rate was 29% and highly dependent
on the patient’s willingness and the surgeon’s judgment.
The authors emphasized the importance of proper
informed consent and lengthy discussions with patients
before surgery.
Manassa et al.314 reviewed the results of 132
abdominoplasties in 71 smokers and 61 non-smokers.
Even though all patients were asked to refrain from
smoking preoperatively, only 14% stopped before and
41% temporarily stopped after surgery. Wound dehiscence
was 3.2 times more frequent in smokers, who also had
significantly longer hospital stays (P < 0.01). Seroma,
hematoma, and infection were not significantly affected by
smoking (P > 0.05). The number of cigarettes smoked had
no effect on wound healing.
van Uchelen et al.315 presented a review of 101
consecutive abdominoplasties in 86 patients with longterm follow-up. The authors found an alarming 10%
incidence of injury to the lateral femoral cutaneous
nerve. An analysis presented by Pitanguy316 of his 30year experience with body contouring surgery, including
1300 abdominoplasties, revealed seroma to be one of
the most common complications (Table 15). The author
discussed how refinements in the technique—such as
preventing seroma by avoiding desiccation of the dissected
tissues, maintaining rigorous hemostasis, and appropriate
placement of drains—reduced the frequency and severity
of complications. He reported incorporating a “plaster
shield” for the first 2 postoperative days to maintain firm
pressure over the abdominal flap and promote adhesion.
Neaman et al. published a retrospective study
of 1008 patients in a community setting and noted a
317
complication rate of 32.6% and a seroma rate of 15.4%.
Liposuction was performed in 469 of the patients and
was significantly associated with seroma (P < 0.05). The
authors concluded that conservative undermining was
associated with decreased seroma rate.
Post-bariatric patients experience a higher overall
complication rate. Staalesen et al.318 reviewed 190
patients and compared the complication rates in postbariatric patients with those of a control group. The
author noted early complication rates of 48% in the
post-bariatric group compared with 29% in the control
group (P = 0.02). No predictive factors were identified.
Greco et al.319 reported the results for 222 patients who
underwent abdominoplasty or panniculectomy and
noted a complication rate of 63% in the bariatric group.
Thirty-four percent had wound-related complications.
Seroma was noted in 14%, infection in 12%, healing
disturbance in 11%, and hematoma in 6%. The authors
noted a significant increase in complication rates in the
post-bariatric group (P < 0.01). The American Society
of Anesthesiologists Physical Status classification was the
most predictive of risk (P = 0.01), and BMI >30 was the
next most predictive (P < 0.01).
To address the high seroma rates, scarpae fascia
preservation has been recommended. Costa-Ferreira et
al.320 performed a randomized clinical study assessing
the technique. Patients were randomly assigned a classic
full abdominoplasty or one in which scarpae fascia and
the deep fat compartment in the infraumbilical area was
preserved. Eighty patients were included in each group.
No statistically significant differences were observed
between groups regarding demographics, aesthetic results,
and all complications except seroma. The preservation
group had a higher reduction of 65.5% on total drain
output, 3 days on time to drain removal (P < 0.0001),
and 86.7% on seroma rate (P = 0.001). This technique
preserves lymphatic vessels of the deep connective tissue,
preserves blood supply, and creates opposing raw surfaces
that contribute to greater adhesion.
Revision Surgery
Matarasso et al.321 presented a report of 24 patients who
had undergone abdominoplasty and revision procedures
(6% revision rate). The patients were grouped into those
37
SRPS • Volume 11 • Issue C8 • 2016
TABLE 15
Complications of Abdominoplasty at the Ivo Pitanguy Clinic, 1955–1998316
Complication
1955–1960
1961–1979
1980–1998
(n = 32)
(n = 637)
(n = 631)
%
Dehiscence
6.2
2.8
1
Serosanguineous collection
15.6
4.2
0.3
Infection
3.1
0.6
0.1
Hypertrophic scar
3.1
2.9
1.3
Residual fat
3.1
0.9
0.5
2
1
0.3
Wide umbilical scar
who underwent revision surgery within 18 months and
after 18 months from the abdominoplasty. Liposuction
was the most common secondary procedure in both
groups, and this did not change with the type or
invasiveness of the primary operation. Revision surgery
was associated with a 4% complication rate. The authors
later presented a retrospective review of 562 patients
who underwent abdominal contouring procedures.322
Seventy-three patients underwent secondary procedures.
Forty-six of the 73 had charts available for review. Thirtyfour patients underwent secondary liposuction, and 12
underwent full abdominoplasty. Secondary procedures
were performed an average of 5 years after the primary
procedures, with liposuction being performed significantly
sooner than secondary abdominoplasty (P = 0.002). The
authors further described five common scenarios and
provided surgical recommendations.
Kadri et al.323 described the need for tissue
expansion in some revision procedures. The report
describes a high scar with elevated pubic hairline. The
authors expanded the abdominal tissue and were thereby
able to successfully lower the abdominal scar.
Combination Procedures
Reporting the results of a survey, Voss et al.324 found
38
higher morbidity, longer operative times, and longer
hospital stays when abdominoplasty was combined with
other common gynecological operations than when either
procedure was performed separately. Of note, 6.6% of
patients who underwent combined procedures experienced
pulmonary emboli within 18 days of the operation
whereas no pulmonary emboli occurred in patients who
underwent single procedures.
Hunter et al.325 confirmed a high risk of pulmonary
embolism in patients with combined abdominal lipectomy
and intraabdominal gynecological procedures and urged
caution when using this approach. The use of perioperative
warfarin can reduce the incidence of pulmonary embolism
in these patients and does not promote increased bleeding.
Pitanguy and Ceravolo326 noted no difference
in the frequency of clinical complications whether
abdominoplasty was performed alone or in combination
with gynecological surgery, except for an increased need
for blood replacement with combined procedures. In their
experience, the aesthetic results are also similar in
either situation.
Shull and Verheyden327 noted apparent safety of
combined plastic and gynecological surgical procedures
in a series of 33 patients, each of whom was matched
with two controls. Other than a substantially greater
SRPS • Volume 11 • Issue C8 • 2016
requirement for blood transfusion in the combined surgery
group, the authors found no increased morbidity, and
the hospital length of stay was shorter by 2 days when
the procedures were combined. To avoid complications,
the authors recommend continued pressure monitoring;
warmed inspired gases, intravenous fluids, and warming
blankets to prevent hypothermia; autologous blood
replacement as needed; and concerted preoperative
planning of the procedures by both surgeons.
Gemperli et al.328 analyzed the medical records
of 103 patients who had undergone abdominoplasty at
the time of other intraabdominal procedures. Of these,
24 underwent mini-abdominoplasty with or without
liposuction and the remainder underwent standard full
abdominoplasty. Autologous blood transfusions were
required in only three patients; the maximum blood loss
was 500 mL. One seroma and one minor skin slough
developed, but no infections, embolisms, or other major
complications occurred. The authors concluded that
abdominoplasty in combination with intraabdominal
operation is a safe procedure when performed by a wellschooled surgical team.
Hester at al.329 reviewed the records of 563 patients
who underwent abdominoplasty alone (n = 117) or in
combination with other major surgical procedures, either
aesthetic (n = 216) or intraabdominal/pelvic (n = 230).
The authors found similar morbidity and complication
rates among the three groups regardless of the complexity
of the procedures. The only identifiable risk factor in
predicting major morbidity (pulmonary embolism)
associated with the surgery was patient obesity.
Cardoso de Castro and Cupello330 analyzed 60 cases
of simultaneous abdominoplasty and breast reduction
surgery and reported a complication rate similar to that
of either procedure alone. Similarly, Stevens et al.331
retrospectively evaluated two populations: one group of
264 patients underwent abdominoplasty alone, and a
second group of 151 patients underwent simultaneous
breast surgery. No major complications were reported,
and no differences in minor complications were observed
between the groups. Type of breast surgery and BMI had
no effect on complications.
Wallach332 combined abdominoplasty with other
procedures through the abdominoplasty incision in 29
patients. Thirty ancillary procedures were performed via
the same incision, including flank liposuction in 23, breast
augmentation in six, and rib harvest for rhinoplasty in
one. The inferior mammary fold was repaired in all cases
of breast augmentation. The total complication rate was
4.3%, with seroma being most common. The author
also used the abdominoplasty specimen as a source of
autologous filler material and for fat, fascia, and dermis
grafts. The advantages are minimal scarring and distant
donor sites. Yoho et al.333 reviewed the risks of cosmetic
surgical procedures, including abdominoplasty.
BARIATRIC SURGERY
Morbid obesity has become an epidemic in the United
States, one that places a large financial stress on medical
insurers and public health resources. The classic treatment
consists of diet and exercise, although a person’s genetic
makeup and complex behavioral issues blunt their effects.
Medical management with pharmacological intervention
has been generally unsuccessful. Multimodality weight
loss through diet and exercise and/or pharmacological
intervention has short-term success at best.
Bariatric surgery is currently the only effective
therapy for morbid obesity, producing rapid weight
loss along with measurable improvement or resolution
of comorbidities. Bariatric procedures are typically
classified as restrictive, malabsorptive, or a combination
of both. Purely malabsorptive procedures that interrupt
the digestive process, such as jejunoileal bypass and
biliopancreatic diversion, bring about substantial weight
loss but at the risk of eventual nutritional deficiencies, and
they require careful long-term patient follow-up. Restrictive
procedures alter the size of the stomach, limiting volume
of intake. Vertical banded gastroplasty and adjustable
gastric bands fit into this category. They are associated
with less operative and postoperative risk, but the rate of
weight loss is slower. The more common techniques used
in the United States today are a combination of restrictive
and malabsorptive procedures, such as a Roux-en-Y
gastric bypass. This procedure can be performed either
laparoscopically or via an open approach and consists of
creating a small gastric pouch that is anastomosed to a
Roux limb, with the biliopancreatic limb attached distally
to reduce the absorptive surface area of the bowel.
Patients who have lost a massive amount of
39
SRPS • Volume 11 • Issue C8 • 2016
weight present a very different profile than those who
have not been obese; therefore, they cannot be placed in
the same category as cosmetic patients. In conjunction
with their extreme physical deformity after weight loss,
the physiological and psychological impact of bariatric
surgery is prevalent throughout the post-bariatric state.
Patients with resulting excess skin can subsequently
encounter problems with hygiene, intertriginous rashes,
skin breakdown, functional status, and self-esteem.2
Nutritional deficiencies are more common in patients who
have undergone gastric bypass. The incidence of anemia is
>50%, and vitamin and mineral deficiencies occur in up to
40%. These factors, in addition to venous varicosities and
poor quality of skin, place these patients at increased risks
for complications.334 The patients’ mood, expectations,
and body image should be evaluated. Importance is placed
on counseling and setting appropriate expectations for
recovery and outcome.2,335
Rubin et al.336 reviewed management of post-gastric
bypass in patients presenting for body contouring surgery.
Patients are considered for body contouring surgery
approximately 12 to 18 months after a bariatric procedure
and must maintain a stable weight for a minimum of 3
months to ensure nutritional and metabolic homeostasis.
The operative risk is increased in obese patients; therefore,
a goal BMI of 30 to 35 is appropriate. Colwell and
Borud334 reported similar results but stated that BMI
should ideally be 32 or less for improved results.280
Medical issues can affect surgical outcomes.
Despite an initial loss of 10% of body weight, which is
associated with improvements in blood pressure, plasma
glucose, lipid levels, and hemostatic factors, unresolved
conditions of which the surgeon should be aware include
psychosocial dysfunction, diabetes mellitus, cardiac
disease, sleep apnea, pulmonary disease, gastroesophageal
reflux, and concurrent medications.1,2,336,337 Prophylaxis
for deep vein thrombosis is essential because obesity is
an independent risk factor for deep vein thrombosis and
pulmonary embolism.336 Nutritional adjustments depend
on the type of bariatric procedure that was performed.
After MWL, patients are at risk for anemia and vitamin
deficiencies, including deficiencies in vitamins B12, C,
D, and K, calcium, folate, thiamine, zinc, and selenium.
Patients should be tested for subclinical protein deficiency,
cobalamin deficiency, iron deficiency, and folate deficiency;
if a deficiency is present, the levels should be corrected
40
before undertaking body contouring. Albumin and
prealbumin should be monitored because they are good
markers for overall nutritional status. Fluid management
should be monitored intraoperatively with a urinary
catheter, and the use of colloid and autologous blood
products should be considered.336 Wound complications
can be avoided by allowing the bariatric patient to reach
his or her ideal weight and stop smoking and by using
drains, conservative undermining, and
prophylactic antibiotics.
Cavallini et al.338 studied the effects of intraoperative
warming on coagulation in two matched patient groups
undergoing elective plastic surgery. Each patient had a
complete coagulation profile drawn 1 hour preoperatively
and immediately after surgery. One group was covered
with only sterile drapes, and the other was covered with a
forced-air skin warming blanket and had warmed fluids
infused. Core temperatures were significantly different
at the conclusion of the 2-hour operation (P = 0.0005).
Activated partial thromboplastin times (P = 0.0005) and
bleeding times (P = 0.0005) were significantly elevated
in the control hypothermic group. No difference in
hematoma rate or blood loss was observed.
Fischer et al.335 reviewed the American College of
Surgeons National Surgical Quality Improvement Program
database to evaluate which of the above-mentioned factors
contribute to morbidity. The authors noted that minor
wound complications occurred in 6.3% of 1797 patients,
major surgical morbidity in 6.8%, and medical morbidity
in 2.2%. Multiple comorbidities (P = 0.014), history of
bleeding disorders (P = 0.026), and preoperative albumin
(P = 0.03) were associated with increased odds of minor
wound complications. Shermak et al.339 further evaluated
risk factors for delayed wound healing and seroma, the
two most common complications. A major risk factor
was weight of skin excised, with a 9% increase in risk for
each pound (P = 0.001). This relationship was found only
in those patients with BMI >30 (P = 0.01). BMI alone
increased risk of seroma by 5% for each unit above 30
(P = 0.02). Diabetes was also associated with increased
risk (P = 0.02). Coon et al.340 confirmed that aggregate
complications of seroma and wound dehiscence correlated
with number of concomitant procedures (P < 0.001).
No increase was noted on a per-procedure basis. These
authors concluded that multiple procedures can safely be
combined in addition to staging.
SRPS • Volume 11 • Issue C8 • 2016
Venous Thromboembolism
Venous thromboembolism deserves special attention
because it is a dreaded complication that occurs in patients
undergoing body contouring and is reported to occur in
as many as 9% of cases.341 A survey of ASPS members
performing post-bariatric procedures revealed that 40% of
surgeons reported deep venous thrombosis (DVT) in their
patients. Thirty-four percent reported pulmonary emboli,
and 7% reported death resulting from pulmonary emboli.
Thirty-nine to 43% of survey respondents, however, did
not use chemoprophylaxis in their patients; 84% of them
were concerned regarding bleeding and 50% thought there
was lack of evidence for its use. Academic surgeons were
more likely to use chemoprophylaxis (P < 0.05).342
The Caprini risk-assessment model is a weighted
risk stratification tool initially published in 1991.343
Figure 4 shows the 2005 model.344 This, along with
recommendations by the American College of Chest
Physicians, aims to guide surgeons in caring for patients
after MWL. In 2008, Hatef et al.345 conducted a
retrospective study to examine whether the Caprini
scoring system could stratify risk for patients undergoing
body contouring. Three hundred sixty patients were
evaluated. Those with a BMI >30 (P = 0.007 for DVT)
and those receiving hormonal therapy (P < 0.001 for
DVT; P = 0.003 for pulmonary embolism) had increased
risk of venous thromboembolism. Patients undergoing
circumferential abdominoplasty were also found to be
at an increased risk for venous thromboembolism with
a frequency of 7.7% of DVT. Enoxaparin decreased the
DVT rate in these patients by a statistically significant
amount (P = 0.006). The authors concluded that patients
with a score >4 were at increased risk as were those
undergoing circumferential abdominoplasty.
The Venous Thromboembolism Prevention
Study Network was established to examine venous
thromboembolism in plastic surgery patients. In 2011,
the incidence of venous thromboembolism in patients
who received no chemoprophylaxis was evaluated, and
the Caprini Risk Assessment Model (RAM) for plastic
surgery patients was validated.343 Inclusion required a
score of 3 or higher, general anesthesia, and admission
postoperatively. DVT and pulmonary embolism incidence
was assessed within a 60-day postoperative period. In 1126
historically controlled patients, the incidence of venous
thromboembolism was 1.7%; one in nine (11%) patients
with a score >8 had VTE. Patients with a score >8 were
significantly more likely to have venous thromboembolism
than those with a score of 3−4 (P < 0.001), 5−6 (P <
0.001), and 7−8 (P = 0.015). In patients with scores of
7−8 and >8, venous thromboembolism was not limited
to the immediate (1−14 days) postoperative period;
more than 50% of cases of venous thromboembolism
were diagnosed late (>15 days). RAM effectively riskstratified plastic surgery patients with scores >8; the
incidence of venous thromboembolism was 11% when no
chemoprophylaxis was used in the patients.346
Postoperative enoxaparin was then evaluated to
assess whether its use prevented symptomatic venous
thromboembolism in patients at high risk (score >7).
Patients with a score of 3 or higher received postoperative
enoxaparin for the duration of the inpatient stay. Venous
Thromboembolism Prevention Study historical control
patients received no chemoprophylaxis for 60 days after
surgery. The primary study outcome was symptomatic
60-day venous thromboembolism. Risk reduction was
present in patients with a Caprini score >8 (P = 0.18)
and a score of 7 to 8 (2.6% versus 1.2%; P = 0.23) who
received postoperative enoxaparin. Logistic regression
was limited to patients at highest risk (Caprini score >7)
and showed that length of stay ≥4 days (P = 0.007) and
Caprini score >8 (P = 0.027) were independent predictors
of venous thromboembolism. When controlling for this,
postoperative enoxaparin was protective against venous
thromboembolism (P = 0.042).347 The group also noted
no clinically relevant or statistically significant increase
in reoperative hematoma when enoxaparin was used for
prophylaxis (P = 0.169).348
In 2012, the Venous Thromboembolism Prevention
Study Network sought to compare the predictive capacities
of the 2005 and 2010 Caprini risk score.349 The 2010
model reweighted certain risk factors and added new risk
factors to be included in patient assessment (Table 16).349
The authors found that use of the 2010 Caprini Risk
Assessment Model resulted in a systematic increase in the
aggregate risk score. The median 2010 Caprini score was
significantly higher than the median 2005 Caprini score (P
< 0.001). When compared with the 2010 model, the 2005
model was able to better separate the patients with lowest
and highest risk from one another. Patients classified as
“super-high” risk (Caprini score >8) using the 2005 model
41
SRPS • Volume 11 • Issue C8 • 2016
Choose all that apply:
Each Risk Factor Represents 1 Point
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Age 41–60 years
Minor surgery planned
History of prior major surgery (<1 month)
Varicose veins
History of inflammatory bowel disease
Swollen legs (current)
Obesity (BMI >25)
Acute myocardial infarction
Congestive heart failure (<1 month)
Sepsis (<1 month)
Serious lung disease including pneumonia (<1 month)
Abnormal pulmonary function (COPD)
Medical patient currently at bed rest
Other risk factors:
Each Risk Factor Represents 2 Points
•
•
•
•
•
•
•
•
Each Risk Factor Represents 3 Points
•
•
•
•
•
•
•
•
•
•
Age over 75 years
History of DVT/PE
Family history of thrombosis*
Positive factor V Leiden
Positive prothrombin 20210A
Elevated serum homocysteine
Positive lupus anticoaguiant
Elevated anticardiolipin antibodies
Heparin-induced thrombocytopenia
Other congenital or acquired thrombophilia
If yes, type:
*most frequently missed risk factor
Age 60–74 years
Arthroscopic surgery
Malignancy (present or previous)
Major surgery (>45 minutes)
Laparoscopic surgery (>45 minutes)
Patient confined to bed (>72 hours)
Immobilizing plaster cast (<1 month)
Central venous access
Each Risk Factor Represents 5 Points
•
•
•
•
•
Elective major lower extremity arthroplasty
Hip, pelvis, or leg fracture (<1 month)
Stroke (<1 month)
Multiple trauma (<1 month)
Acute spinal cord injury (paralysis) (<1 month)
For Women Only (Each Represents 1 Point)
• Oral contraceptives or hormone replacement therapy
• Pregnancy or postpartum (<1 month)
• History of unexplained stillborn infant, recurrent
spontaneous abortion (>3), premature birth with
toxemia or growth-restricted infant
Total Risk Factor Score:
Figure 4. 2005 Caprini Risk Assessment Model. BMI, Body Mass Index; COPD, chronic obstructive pulmonary disease; DVT,
deep vein thrombosis; PE, pulmonary embolism. (Modified from Caprini.344)
42
SRPS • Volume 11 • Issue C8 • 2016
TABLE 16
Differences between the 2005 and 2010 Versions of the Caprini Risk Assessment Models349
Variable
Operative time, min
Body Mass Index, kg/m2
SVT
Cancer
2005 Caprini Model
2010 Caprini Model
Measure
Points
Measure
Points
0-44
1
0-59
1
≥45
2
60-119
2
120-179
3
≥180
5
30-39
1
40-49
2
≥50
3
≥25
1
NRF
0
History
3
History
2
History
2
Current
2
Current
3
SVT, superficial venous thrombophlebitis; NRF, not a risk factor.
were significantly more likely to incur a 60-day venous
thromboembolism event when compared with patients
classified as super-high risk using the 2010 guidelines (P =
0.021). The authors concluded that the 2005 Caprini Risk
Assessment Model provides superior risk stratification for
plastic
surgery patients.349
PANNICULECTOMY
In most cases, panniculectomy is medically indicated to
remove the excessive amount of lower abdominal tissue
that overhangs the pubic area. This pannus predisposes
the patient to chronic skin infection, lymphedema, and
postural difficulties. The procedure consists of direct
excision of the redundant pannus without undermining
or fascial plication. Prayer et al.350 presented a review of
the preoperative, intraoperative, and postoperative care
of a very complex patient undergoing panniculectomy.
The authors described a safe, complication-free procedure
based on a precise plan and team effort.
Manahan and Shermak351 reviewed their experience
with panniculectomy after MWL in 23 patients with an
average BMI of 43.7. The authors defined panniculectomy
as an abdominal skin resection of more than 10 pounds,
pannus suspension, horizontal fascial plication, and layered
closure over drains. The average weight of the pannus
in their series was 16.1 lb. Multiple other procedures
were performed in conjunction with panniculectomy.
Results: 20% received blood transfusion; 20% experienced
wound healing complications; seromas occurred in 28%;
and uncomplicated healing was achieved in 44%. No
thromboembolic events or deaths occurred in that series.
Brown et al.352 noted an increased complication rate in
the “super obese” patient. To address this, the authors
evaluated 14 patients with BMI >50 and resection volume
>5000 g. Nine patients underwent primary closure, and
five underwent open wound management. In the primary
43
SRPS • Volume 11 • Issue C8 • 2016
closure group, four patients were readmitted and three
underwent reoperation for wound complications. No
readmissions or reoperations were necessary in the open
wound management group. The authors recommended
consideration of open wound management for this
subgroup of patients.
Techniques combining removal of horizontal and
vertical skin excess have been described. O’Brien et al.353
described fleur-de-lis panniculectomy in 100 patients. This
was compared with a group of 30 patients who underwent
a traditional procedure. The complication rate was 17%
total, with 17 occurring in the fleur-de-lis group and two
in the traditional group. The difference between groups
was not statistically significant (P = 1). Male patients,
however, experienced more complications (P = 0.034).
The authors concluded that this is a safe technique with
improved symptom correction and cosmetic outcome.
Cooper et al.354 compared three groups of patients
undergoing fleur-de-lis panniculectomy, transverse incision
with minimal undermining, and transverse incision with
extensive undermining. Patient satisfaction surveys showed
that 81% of patients were satisfied with the results despite
a total complication rate of 43%. The complication rate
was higher for those with hypertension (P = 0.04). No
notable relationship in complication or satisfaction rates
was found among the three groups. Leahy et al.355 also
described a unique technique combining horizontal and
vertical excisions. Complication rates were reported.
Increased tissue resection was associated only with an
increase in transfusion rates (P < 0.01).
Aly356 stated that most patients who do not lose
enough weight after bariatric surgery will not lose more
after interim operations. For the patient with MWL,
combination panniculectomy procedures impose
additional risk secondary to increased operative time and
poor aesthetic outcomes. A recurrent hanging panniculus
can occur after a panniculectomy for chronic panniculitis
or lymphedema. Recurrent hernias from excessive weight
are common after panniculectomy, and infection rates
tend to be high.
Multiple studies have evaluated the safety of
panniculectomy in combination with other abdominal
or pelvic procedures. Olejek and Manka357 reported that
their experience with panniculectomy in combination with
surgery to treat gynecological cancer included 90 patients
44
with an average BMI of 47. The goal of the study was to
show that a panniculectomy performed in the same setting
as the oncological procedure provides better exposure in
obese patients without increasing the number of operative
complications. The average weight of the pannus excised
was 4900 gm. Use of the harmonic scalpel resulted in 8%
delayed healing versus 17% without the harmonic scalpel.
Two deaths occurred in this very difficult population: one
as a result of myocardial infarction and one as a result of a
pulmonary embolus. Wallace et al.358 assessed 15 patients
who underwent panniculectomy with gynecological
surgery. Two of the patients experienced complications.
A significant finding for prediction of a negative outcome
was association of hypertension and advanced age with
increased risk of postoperative transfusion (P < 0.02).
Hardy et al.359 evaluated the benefit of panniculectomy
combined with pelvic surgery in patients with BMI >40.
Thirty-six patients underwent concomitant hysterectomy,
and 14 did not. The authors noted no differences for any
variable, including BMI (P = 0.1), blood loss (P = 0.95),
or total complication rate. Ortega et al.360 retrospectively
reviewed patients undergoing panniculectomy alone or in
combination with hernia repair or cholecystectomy. The
authors also noted no increase in complication rates with
combined procedures.
BODY LIFT
A body lift is indicated in patients with circumferential
truncal skin excess or lipodystrophy. These conditions
occur seen primarily after MWL as the excess skin
descends inferomedially from the characteristic areas
of fat deposition. It is vital to assess skin quality and
the severity of skin, fat, and muscle laxity. As described
by Lockwood,361 the abdomen, thigh, and buttock
can be treated as a single unit with this procedure.
Circumferential lift procedures have been modified since
the 1960s to include the following: 1) circumferential
abdominal lipectomy, 2) belt lipectomy, and 3) lower
body lift.362 A circumferential abdominal lipectomy
primarily addresses circumferential skin and removes dog
ears that can be seen with abdominoplasty alone. It does
not effectively lift the buttock or thigh. Belt lipectomy
was initially described by Gonzales-Ulloa363 and modified
by Aly et al.364 This places the scar about the iliac crest
but improves waist definition and addresses the lower
SRPS • Volume 11 • Issue C8 • 2016
back more effectively. The lower body lift, described by
Lockwood,261 places the scar more inferiorly. It thereby
lifts the buttock and lateral thigh more effectively but can
result in a loss of waist definition.363
Aly et al.364 reviewed the University of Iowa
experience with belt lipectomy in 32 consecutive patients,
emphasizing the importance of accurate preoperative
markings. The authors’ operative technique incorporates
both lateral decubitus and supine positions. Not surprising
in a procedure of this magnitude, 37.5% seromas, 9.3%
pulmonary emboli, and one dehiscence required surgery.
Nevertheless, the patients achieved marked improvement.
This operation is not recommended for obese patients.
Nemerofsky et al.365 reviewed 200 body lifts
performed during a 4-year period. The patients were
classified into three types depending on BMI before
the body lift: type I, <28 BMI; type II, 28 to 32 BMI;
and type III, >32 BMI. The surgical technique and
preoperative markings are illustrated. Posterior markings
were made in the flexed position to limit tension in the
buttocks area. Nonabsorbable SFS dermal sutures were
used to evert the incision edges. The senior author used
a circumferential standing preparation to facilitate an
efficient, three-position technique: supine and lateral
decubitus positions. A 2-day hospital stay, prolonged
drain care (5 weeks), and lower extremity venous Doppler
study are standard. The overall complication rate was
50%, the most frequently occurring complication being
skin dehiscence (32.5%). Higher maximum BMI, larger
changes in BMI, history of smoking, and male gender
were associated with more frequent complications.
BMI at body lift did not affect complications although
it did lengthen the hospital stay and correlated with
poor aesthetic outcome. Nemerofsky et al. altered their
technique during the study to reduce complications and
reported that both the markings and suture technique (as
described above) contributed to their success. However, no
data were provided.
Capella366 also described how patient classifications
based on BMI, as above, can aid in preoperative patient
education. Type 1 patients will likely achieve ideal contour,
whereas type III patients are least likely to achieve this
ideal. The classification also determines the extent of
liposuction and staging of the medial thighs. The author
described his first 425 body lifts and noted a complication
rate of 49.7%. He noted that a higher pre-bariatric surgery
BMI was associated with greater risk of complication (P
< 0.01). Increased change in BMI before and after weight
loss was also associated with greater risk (P < 0.03). BMI
at time of body lift had no effect (P < 0.1). Smoking was
also found to have an increased risk of skin dehiscence and
necrosis (P < 0.01).
Rohrich et al.367 presented a large series of 151
patients who underwent central body lifting during a
12-year period by means of liposuction and extended
abdominoplasty. The average preoperative weight was
130 kg, and 25.2% of cases were classified as MWL.
The area of excision is estimated with a “grasp test.” An
aggressive deep venous protocol consisting of enoxaparin
and pneumatic compression devices to the calves was
applied in all cases. Patients underwent surgery in the
prone position and then in a supine position. UAL and
conventional SAL by the superwet technique were used
circumferentially in all cases. The average lipoaspirate
volume was 4 liters. An extended abdominoplasty and
midline plication with permanent suture were performed.
Absorbable sutures were used for deep closure because
of suture extrusion and lack of scar improvement with
nonabsorbable sutures. The average operative time was 3.4
hours, and the average length of stay was 2.1 days. The
total complication rate in the series was 28.5%, with the
most commonly occurring complication being seroma
(14.6%). The seromas were treated by sclerosing the cavity
with doxycycline if drain output after 14 days was still
high. The DVT/pulmonary embolism rate in the series was
1.9%. Skin dehiscence and necrosis occurred in 2.6%.
Pascal and Le Louarn368 described a technique of
body lift with high lateral tension. The authors emphasized
preoperative markings, high superior tension above the
umbilicus, a dermal fat flap for buttock augmentation,
and multiple suspension sutures at the trochanteric region
between the SFS and the underlying fascia. Complications
were minimal in 40 cases.
Single-stage Resections
Lockwood73,261 described an extended resection anteriorly
and inferiorly on either side of the pubis to add medial
thigh lift to lower body lift in one operation. The markings
are made with the patient’s hips flexed and abducted to
allow overcorrection. The incision lies in the perineal
crease and extends along the lateral mons pubis curving
45
SRPS • Volume 11 • Issue C8 • 2016
into the bikini line. Posteriorly, the incision curves
downward to the top of the gluteal crease and might
cross the midline. Undermining in the upper thigh avoids
the femoral lymphatics. The author emphasized the
importance of complete SFS and dermal suspension.
Hurwitz369 conducted a retrospective study of singlestage total body lift after MWL and traced the course of
eight patients. The procedure combined lower body lifts,
upper body lifts, and circumferential abdominoplasty.
Ultrasound-assisted lipoplasty, medial thighplasty, and
brachioplasty were performed concurrently. To ensure
accurate markings, the patient is placed in the standing
and recumbent positions to draw the incisions for the
lower body lift, medial thighplasty, and circumferential
abdominoplasty. A Wise-pattern skin excision is
marked for the breast portion of the procedure and
the inframammary fold is moved superiorly. A reverse
abdominoplasty with which the incisions do not cross
the anterior midline and the lateral extensions continues
posteriorly to remove the upper back redundancy is then
performed, as is liposuction of specific areas.
The procedure begins with the patient in the prone
position for the posterior lower body lift. The upper
body lift is next completed and the mid-back skin excess
is removed with minimal undermining. Large braided
absorbable sutures are used for closure. The patient is then
turned supine and the abdominoplasty is completed with
minimal lateral undermining. For the anterior upper body
lift, an upper abdominal incision is made and the lift area
below the incision is excised or deepithelialized to use in
breast autoaugmentation. The abdominal flap is elevated
and secured to the sixth rib periosteum with multiple
permanent #0 braided polyester sutures. A mastopexy and
either autoaugmentation or implant augmentation can
be used in women, whereas UAL and tissue removal are
indicated for male patients with gynecomastia. All patients
received at least 1 unit of autologous blood; one patient
received 4 units of blood. Operative times ranged from 7
to 12 hours, and hospital length of stay was 3 to 4 days.
The most common complications were skin dehiscence
(50%) and wound seromas (40%). Endermologie was used
in all patients postoperatively for edema reduction.
Hurwitz et al. subsequently described the
experience of 75 cases during a 5-year period. Fiftynine patients underwent a single-stage procedure, 15 a
370
46
two-stage procedure, and one a three-stage procedure.
In patients younger than 55 years with a BMI <30, no
difference was noted in choice of procedure (P = 0.882).
An increased trend toward major complications was
associated with multiple stages but was not statistically
significant (P = 0.19). Seventy-six percent of patients
encountered wound healing problems. Despite this,
patients had improved satisfaction scores.
Complications
Common complications include skin dehiscence, seroma,
skin necrosis (primarily in the suprapubic region),
infection, and bleeding.366 Klitzinger et al.371 sought to
identify the common complications and associated risk
factors in a review of 50 patients. The author noted that
70% of patients experienced at least one complication.
Ten percent were major complications requiring surgical
revision, 60% presented with wound dehiscence, and 34%
with seroma. Complications were related to maximum
BMI before weight loss (P = 0.02) and age (P = 0.03).
Despite the high percentage of complications, a quality-oflife study presented by Koller et al.372 described improved
body image after body lift.
LOWER EXTREMITY
Medial Thigh Lift
The medial thigh is a difficult and troublesome area to
correct. Knowledge of the anatomy in this region and
appropriate preoperative classification of the underlying
problem are paramount in achieving an adequate result.
The medial thigh has a relatively thin dermal component
overlying two layers of adipose tissue with a poorly defined
fascial layer. The deep layer of the superficial perineal
fascia, however, is distinct and attaches to the ischiopubic
rami. Anteriorly, this fascia is contiguous over the pubis
with the fascia of Scarpa and posteriorly fuses with the
posterior border of the urogenital diaphragm. The junction
of the perineum and medial thigh, deep and lateral to the
vulvar soft tissue, is the fascia of Colles.373
The earliest signs of aging in this region are skin
laxity and lipodystrophy. It is vital to appropriately
evaluate patients preoperatively. A classification system has
been created to guide the process. Patients are divided into
SRPS • Volume 11 • Issue C8 • 2016
MWL and non-MWL groups. Patients in the non-MWL
group are divided into four types. Type 1 patients have
lipodystrophy with no skin laxity, making liposuction an
appropriate treatment. Type 2 patients have skin laxity
confined to the proximal third of the medial thigh with
lipodystrophy. Liposuction with a horizontally oriented
skin excision is recommended. As the degree of laxity
progresses from proximal to the entire thigh, the size of
the vertical resection increases.373 Patients in the MWL
group are divided into two types. Type 1 patients have skin
laxity over the entire thigh but no lipodystrophy (often
noted as deflated). A horizontal vector lift is recommended
for these patients. Type 2 patients have skin laxity with
lipodystrophy (non-deflated), and a two-stage procedure
is recommended with a lower body lift and liposuction of
the thigh during the first stage and then a medial thigh lift
6 months later.373
not address the circumferential tissue excess present in
most patients who have experienced MWL. A vertical
excision has therefore been added. Two philosophies
exist regarding the vertical excision. One relies on the
same vertical vector of lift combined with a horizontal
vector. Through further refinements, the vertical lift is
replaced with a horizontal oblique pull, which completely
eliminates the tension in the groin, theoretically
minimizing scar migration and vulvar distortion (Fig.
5).373 This eliminates the need for tension closure to the
fascia of Colles. Liposuction and superficial dissection
planes preserving the lymphatic channels and saphenous
veins limit postoperative edema.
As surgical experience with post-bariatric body
contouring mounts, the technique of medial thigh lift
continues to evolve from the traditional vertical vector lift
of Lockwood to the horizontal vector approach. Many
medial thigh lift techniques have been proposed over the
years, but the procedure has not gained wide acceptance
because of postoperative problems such as inferiorly
displaced and wide scars, vulvar distortion, and early
relapse. Wound healing problems are unfortunately too
common in the post-bariatric population.
In summary, it is necessary to determine the quality,
location, and degree of skin excess and the extent of
lipodystrophy. This will determine whether liposuction
can be performed alone or whether skin excision must
be added. The extent of laxity along the medial thigh
determines the orientation and extent of excision.376
The fascial anchoring technique presented by
Lockwood73,260,261,374 is recommended to reduce the
frequency of wound complications. Le Louarn and
Pascal375 modified the technique to include a short
horizontal scar combined with suction lipectomy of the
upper inner thigh, excision of a crescent of redundant skin,
and anchoring of the inferior thigh flap to the deep layer
of the superficial perineal fascia (fascia of Colles) without
undermining or deepithelialization of the flaps.
Lockwood261 reported no problems related
to inferior scar migration, labial separation, or early
recurrence of ptosis in 18 patients who were followed
for up to 24 months. Le Louarn and Pascal375 presented
a 2-year, 25-patient experience with the short-scar
technique. Delayed wound healing, scar widening, scar
migration, and need for further excision were noted
as complications.
The traditional Lockwood horizontal excision does
Both techniques depend on meticulous layered
closure with sutures of various sizes. Some surgeons do not
use drains.
UPPER EXTREMITY
Brachioplasty
Brachioplasty was first described in 1930 for the treatment
of the pendulous arms of obese women. In the 1950s,
Correa Iturraspe and Fernandez377 described this procedure
for the aesthetic improvement of the upper arm. Since
that time, a better understanding of the etiology of upper
arm aging has been gained and many modifications of the
procedure have subsequently been described to optimize
aesthetic results.
Glanz and Gonzalez-Ulloa378 reviewed the effects
of aging on the female arm and attributed the softtissue descent and flaccidity to a loss of adipose tissue
and stretching of the anchoring septa. Working with
radiographs and measuring at the midhumeral level, the
authors calculated a ratio of upper to lower soft-tissue
mass, the coefficient of Hoyer. The 1:1 ratio seen at age
10 years gradually increases with age and gravitational
descent. By age 40 years, the ratio is 1:1.4, and by age 70
years, it is 1:2.2.
47
SRPS • Volume 11 • Issue C8 • 2016
Lockwood379 stated that upper arm flabbiness is the
direct result of a loosening of the connections of the arm
SFS to the axillary fascia itself. Age, weight fluctuations,
and gravitational pull yield a “loose hammock” effect,
resulting in substantial ptosis of the posteromedial arm.
Classification systems of aesthetic arm deformities
abound. Regnault and Daniel380 denoted skin excess as
mild, moderate, or major. Teimourian and Malekzadeh381
recognized four groups of patients according to the degree
of skin laxity and fat present; his recommendations
for management are group-specific and range from
liposuction to excisional techniques to a combination of
both. Appelt et al.382 presented a new classification system
for evaluation of the upper extremity in the patient who
has experienced MWL and suggested an algorithm for
selecting the appropriate technique of upper extremity
contouring (Fig. 6). The classification system takes into
account the quantity of skin and fat excess and the
location of skin excess. Liposuction is recommended for
fat excess in all groups that have a pinch test result >1.5
cm. Skin excess is treated by limited brachioplasty when
proximal; by traditional brachioplasty when involving
the entire extremity; and by continuing the excision to
the lateral chest wall for severe redundancy, as occurs in
the MWL population. Staged liposuction with excision
or single multimodality therapy is recommended for the
most severe types. A Z-plasty is used for every incision
crossing the axilla to prevent scar contracture. The authors
reported that they routinely use closed suction drains and
compressive garments. The most common complication
in their series was hypertrophic scarring. El Khatib383
described a modification with five stages of increasing
adipose tissue and degree of ptosis and recommended a
treatment strategy for each grade of deformity (Table 17).
Although excision is the mainstay of treatment,
a “one-size-fits-all” procedure no longer holds true; the
operation must be designed to fit the individual patient.384
Careful examination of the deformity must be performed
with special attention to skin quality and quantity and
amount of lipodystrophy.385 The deformity most often
occurs from the elbow to the axilla and can extend distally
to the forearm or proximally onto the chest wall. Hurwitz
and Neavin386 described a complex deformity that includes
sagging of the upper arm along the posterior margin,
inferior dislocation of the posterior axillary fold, enlarged
and cavernous axilla, flattened and elongated anterior
48
A
B
Figure 5. A and B show different views of markings for
horizontal and vertical resection. (Modified from Mathes and
Kenkel.373)
axillary fold, and lateral chest skin laxity leading to midtorso transverse rolls. A combination of excision and/or
liposuction ensues to correct these deformities.
Many authors387−389 have recommended direct
elliptical excision of the redundant tissue and placement
of the incision medially along a line connecting the
axillary dome to the medial epicondyle. In contrast,
Knoetgen and Moran390 reported placing the incision
within the intermuscular septum, where it is thought to
be well hidden in the groove. However, that placement
is sometimes associated with increased wound healing
complications secondary to the poor quality of skin in
that region. Nguyen and Rohrich,391 on the other hand,
reported placing the incision posteriorly. Although the scar
can be noticeable from behind, the skin is of better quality
and the location results in a more direct excision of skin
excess and lipodystrophy. Some think that this posterior
scar can flatten the natural rounding of the posterior
arm.386 Bracaglia et al.,392 in contrast, described a wavy
S-shaped incision they termed the Kris knife brachioplasty.
With that incision, minimal undermining is performed
and the S pattern elicits a normal contour by dividing
the arm into three portions, which allows lifting and
distribution of forces and results in less retraction strength.
Despite initial incision placement, brachioplasty scars
are notorious for widening, healing complications, and
hypertrophic scarring.
Lockwood379 sought to address these complications
by modifying the brachioplasty procedure. With braided
nylon sutures, he anchored the superficial fascia of the
arm flap to the axillary fascia in the proximal edge of the
SRPS • Volume 11 • Issue C8 • 2016
Patient with upper arm
lipodystrophy
Excess fat?
Yes
No
Skin laxity?
No
Yes
Type I
UAL/SAL
Type II
Location of excess skin?
Type III
Location of excess skin?
Proximal 1/3
Entire upper arm
Arm and chest wall
Limited medial
brachioplasty plus
UAL/SAL
Traditional
brachioplasty plus
UAL/SAL
Extended
brachioplasty plus
UAL/SAL
Proximal 1/3
Entire upper arm
Arm and chest wall
Limited medial
brachioplasty
Traditional
brachioplasty
Extended
brachioplasty
Figure 6. Algorithm for treatment of upper arm lipodystrophy. UAL, ultrasound-assisted liposuction; SAL, suction-assisted
liposuction. (Modified from Appelt et al.382)
wound. The aesthetic results in five patients followed
for 6 to 12 months were considered good. Simultaneous
liposuction of the arm was performed in four patients.
Complications included a seroma and one case of
under-resection.
Many techniques have been described, including
excision alone or with the addition of liposuction.
Liposuction can, subsequently, be performed alone and
to varying extents if the patient does not have skin laxity.
Liposuction can be performed on the unresected portion
of the arm. This helps to debulk and improve overall
contouring. It can be done only on the resected part
and can decrease fat content and damage to vasculature,
nerves, and lymphatics in the region and increase the
ease of resection. The entire arm can be addressed
circumferentially, providing complete improvement of the
overall contour.393,394 It must be noted that liposuction can
increase the amount of swelling and edema. Liposuction
has the potential to exaggerate the volume. Therefore,
when edema has resolved, it might be noted that the arm
is under-corrected.393 The technique described by Pascal
and Le Louarn395 combines circumferential liposuction
and superficial skin excision to protect underlying
nerves and lymphatics. The markings aim at maximum
lymphatics preservation. Liposuction is performed
throughout the arm, with superficial liposuction only in
the area of planned excision. The excision is superficial and
no undermining is performed. A three-layer closure and
an axillary Z-plasty complete the procedure; no drains are
used. No seromas or nerve injuries were reported in
21 cases.
49
SRPS • Volume 11 • Issue C8 • 2016
Gussenoff et al.396 evaluated 101 patients who
underwent brachioplasty. Ninety-six percent of the
patients underwent a concomitant procedure, and 24%
underwent liposuction of the arm. Thirty-six patients
experienced complications that included seroma,
dehiscence, infection, and hematoma. A trend was shown
toward increased complications with liposuction and
excision (P = 0.05). Bossert et al.394 reported that in their
follow-up study of 144 patients, 64 underwent liposuction
in addition to resection. No difference was observed in
complication rates (P = 0.5) or revision rates (P = 0.9)
between the two groups.
Nguyen and Rohrich391 noted two patients with a small
wound dehiscence and one with a hypertrophic scar
in their review of 21 patients undergoing liposuctionassisted posterior brachioplasty. No revisions were noted.
Limited-incision brachioplasty with suction-assisted
liposuction and UAL are being used to possibly decrease
the complication rates, as described by Trussler and
Rohrich.385 Despite the complications associated with this
procedure, patient satisfaction remains high as evidenced
by the 94% of patients who stated that their goals were
met with the procedure improving their self-esteem in a
survey conducted by Symbas and Losken.401
Additional techniques have been described to
address distal excess about the elbow397 and proximal
excess along the chest wall.398 These can be combined with
standard brachioplasty techniques.
CONCOMITANT PROCEDURES AND STAGING
Baroudi387 and Guerrero-Santos389 listed the
potential complications of brachioplasty, which include
highly visible scars, persistent vascular congestion, edema
and lymphedema from excessive skin resection and tension
on closure, and cutaneous nerve injury from a dissection
that strayed below the superficial fascia. Knoetgen and
Moran390 conducted a retrospective and cadaveric study
and presented a review of their experience performing
brachioplasty in 40 patients. The authors reported a 5%
rate of medial antebrachial cutaneous nerve injury. In
that study, cadaver dissections of 10 upper limbs revealed
some variability in the course of the medial antebrachial
cutaneous nerve, although the course tended to run in
close proximity to the intermuscular septum. The nerve
penetrated the deep fascia a mean 14 cm proximal to the
medial epicondyle and then divided into an anterior and
a posterior branch. The anterior branch continued on
to the anterior forearm. The medial brachial cutaneous
nerve consistently ran posterior to the basilic vein and
could be injured with more posterior incisions. Zomerlei
et al.399 noted a 17% and 45% major and minor
complication rate, respectively. Most commonly noted
were hypertrophic scarring in 24% and infection in 15%.
The revision rate for correction of contour deformities
and hypertrophic scaring was 23%. Migliori et al.400
noted a hypertrophic scar rate of 40%, seroma 10%,
and wound dehiscence 5% in their series of 29 patients.
50
Unlike patients undergoing cosmetic surgery who
might present with one specific area of concern, patients
who have experienced MWL present with whole-body
deformities resulting from the weight loss. It is, therefore,
not uncommon that these patients want multiple
procedures done concomitantly to reduce overall recovery
time and costs. This involves a thorough preoperative
analysis of each patient’s primary concerns, comorbidities,
length of operative time for the combined procedures, and
the vectors of tension (Fig. 7). Coon et al.340 reported their
experience with multiple-procedure cases. Six hundred
nine patients who had experienced MWL constituted 661
cases involving 1070 procedures. The length of hospital
stay increased with the number of procedures performed
(P < 0.001). Second-stage cases (n = 60) had similar
complication rates and lengths of hospital stay. Seroma
and dehiscence were strongly correlated with number
of procedures (P < 0.001), as were tissue necrosis and
infection (P = 0.02), whereas hematoma was unrelated (P
= 0.25). Major complications did not increase in multipleprocedure cases. The authors concluded that multiple
procedures can be combined safely and surgical staging
can be offered as a viable alternative for patients who are
unable to undergo combined procedures. Additionally, it
is recommended that total operative time be kept below 6
to 7 hours at one setting to minimize the risks associated
with general anesthesia and to minimize the risk of venous
thromboembolism. With multiple stages, a minimum of 3
months is encouraged between each stage.334
SRPS • Volume 11 • Issue C8 • 2016
TABLE 17
Classification of Brachial Ptosis: Strategy for Treatment383
Stage
Classification
Treatment
1
Minimal adipose tissue deposit
(<300 mL lipoaspirate) with no ptosis
Circumferential liposuction
2a
Moderate adipose tissue deposit with grade
1 ptosis* (<5 cm)
Staged circumferential liposuction
2b
Severe adipose tissue deposit with grade
2 ptosis* (5-10 cm)
Liposuction of the lower posterior and medial
arm assisted short longitudinal
scar brachioplasty
3
Severe adipose tissue deposit (>500 mL
lipoaspirate) with grade 3 ptosis* (>10 cm)
Liposuction of the lower posterior and medial
arm assisted short longitudinal
scar brachioplasty
4
Minimal or no adipose tissue deposit with
grade 3 ptosis
Traditional brachioplasty†
*Grade of ptosis is determined by measuring the distance from the brachial sulcus to the lowermost border of the
pendulous skin.
†As described by El Khatib.383
Stage I
Lower body lift
Breast or arm
Stage II
Breast or arm
Medial thigh
Upper back
Stage III
Facial rejuvenation
Figure 7. Typical approach to staging for patients who have undergone massive weight loss, desire total body contouring,
and have acceptable medical profiles. (Modified from Coon et al.340)
51
SRPS • Volume 11 • Issue C8 • 2016
REFERENCES
Effect of lipectomy on growth and development of
hyperinsulinemia and hyperlipidemia in the Zucker rat. Plast
Reconstr Surg 1998;102:1122−1127.
2. Bossert RP, Rubin JP. Evaluation of the weight loss patient
presenting for plastic surgery consultation. Plast Reconstr
Surg 2012;130:1361−1369.
18. Giese SY, Bulan EJ, Commons GW, Spear SL, Yanovski
JA. Improvements in cardiovascular risk profile with largevolume liposuction: A pilot study. Plast Reconstr Surg
2001;108:510−521.
1. Shermak MA. Body contouring. Plast Reconstr Surg
2012;129:963e−978e.
3. Bjorntorp P, Ostman J. Human adipose tissue dynamics
and regulation. Adv Metab Disord 1971;5:277−327.
4. Arner P. Human adipose function, development,
metabolism. In: Hetter GP (ed): Lipoplasty: The Theory
and Practice of Blunt Suction Lipectomy. Boston: Little
Brown; 1984.
19. Rizzo MR, Paolisso G, Grella R, Barbieri M, Grella E,
Ragno E, Grella R, Nicoletti G, D’Andrea F. Is dermolipectomy
effective in improving insulin action and lowering
inflammatory markers in obese women? Clin Endocrinol
2005;63:253−258.
5. Lafontan M, Berlan M, Carpene C. Fat cell adrenoceptors:
Inter- and intraspecific differences and hormone regulation.
Int J Obes 1985;9[Suppl 1]:117−127.
20. Klein S, Fontana L, Young VL, Coggan AR, Kilo C,
Patterson BW, Mohammed BS. Absence of an effect of
liposuction on insulin action and risk factors for coronary
heart disease. N Engl J Med 2004;350:2549−2557.
6. Arner P. Role of antilipolytic mechanisms in adipose
tissue distribution and function in man. Acta Med Scand
Suppl 1988;723:147−152.
21. Matarasso A, Kim RW, Kral JG. The impact of liposuction
on body fat. Plast Reconstr Surg 1998;102:1686−1689.
7. Illouz YG. Study of subcutaneous fat. Aesthetic Plast Surg
1990;14:165−177.
8. Salans LB, Cushman SW, Weismann RE. Studies of human
adipose tissue: Adipose cell size and number in non-obese
and obese patients. J Clin Invest 1973;52:929−941.
9. Hirsch J, Knittle JL. Cellularity of obese and non-obese
human adipose tissue. Fed Proc 1970;29:1516−1521.
10. Knittle JL, Timmers K, Ginsberg-Fellner F, Brown RE,
Katz DP. The growth of adipose tissue in children and
adolescents: Cross-sectional and longitudinal studies of
adipose cell number and size. J Clin Invest 1979;63:239−246.
11. Borkan G, Hults DE, Gerzof SG, Robbins AH, Silbert CK.
Age changes in body composition revealed by computed
tomography. J Gerontol 1983;38:673−677.
12. Schreiber JE, Singh NK, Shermak MA. The effect
of liposuction and diet on ghrelin, adiponectin, and
leptin levels in obese Zucker rats. Plast Reconstr Surg
2006;117:1829−1835.
13. Giugliano G, Nicoletti G, Grella E, Giugliano F, Esposito
K, Scuderi N, D’Andrea F. Effect of liposuction on insulin
resistance and vascular inflammatory markers in obese
women. Br J Plast Surg 2004;57:190−194.
14. Robles-Cervantes JA, Yánez-Diaz S, Cardenas-Camarena
L. Modification of insulin, glucose and cholesterol levels in
non-obese women undergoing liposuction: Is liposuction
metabolically safe? Ann Plast Surg 2004;52:64−67.
22. Mohammed BS, Cohen S, Reeds D, Young VL, Klein S.
Long-term effects of large volume liposuction on metabolic
risk factors for coronary heart disease. Obesity (Silver Spring
Md.) 2008;16:2648–2651.
23. Ybarra J, Blanco-Vaca F, Fernández S, Castellví A, Bonet
R, Palomer X, Ordóñez-Llanos J, Trius A, Vila-Rovira R, Pérez
A. The effects of liposuction removal of subcutaneous
abdominal fat on lipid metabolism are independent of
insulin sensitivity in normal–overweight individuals. Obes
Surg 2008;18:408−414.
24. Vague G, Finasse R. Comparative anatomy of adipose
tissue. In: Handbook of Physiology. Washington: American
Physiological Society; 1965.
25. Sheldon WH, Stevens SS, Tucker WB. Varieties of Human
Physique. New York: Hafner Publishing Co; 1963.
26. Stunkard AJ, Sørenson TI, Hanis C, Teasdale TW,
Chakraborty R, Schull WJ, Schulsinger F. An adoption study
of human obesity. N Engl J Med 1986;314:193−198.
27. Greil H. Patterns of sexual dimorphism from birth to
senescence. Coll Antropol 2006;30:637−641.
28. Fournier PF, Otteni FM. Lipolysis in blacks, including
treatment of steatopygia. In: Hetter GP (ed): Lipoplasty: The
Theory and Practice of Blunt Suction Lipectomy. Boston: Little
Brown; 1984.
29. Markman BS. Anatomic and metabolic aspects of
adipose tissue. Semin Plast Surg 1987;1:158−172.
15. Samdal F, Birkeland KI, Ose L, Amland PF. Effect of
large-volume liposuction on sex hormones and glucoseand lipid metabolism in females. Aesthetic Plast Surg
1995;19:131−135.
30. Weinsier RL, Hunter GR, Gower BA, Schutz Y, Darnell
BE, Zuckerman PA. Body fat distribution in white and
black women: Different patterns of intraabdominal and
subcutaneous abdominal adipose tissue utilization with
weight loss. Am J Clin Nutr 2001;74:631−636.
16. D’Andrea F, Grella R, Rizzo MR, Grella E, Grella R, Nicoletti
G, Barbieri M, Paolisso G. Changing the metabolic profile by
large-volume liposuction: A clinical study conducted with
123 obese women. Aesthet Plast Surg 2005;29:472−478.
31. Tanaka S, Horimai C, Katsukawa F. Ethnic differences
in abdominal visceral fat accumulation between Japanese,
African-Americans, and Caucasians: A meta-analysis. Acta
Diabetol 2003;40[Suppl 1]:S302−S304.
17. Liszka TG, Dellon AL, Im M, Angel MF, Plotnick L.
32. Murakami M, Hikima R, Arai S, Yamazaki K, Iizuka
52
52
SRPS • Volume 11 • Issue C8 • 2016
S, Tochihara Y. Short-term longitudinal changes in
subcutaneous fat distribution and body size among
Japanese women in the third decade of life. Appl Human Sci
1999;18:141−149.
Brown; 1984.
33. Van Lenthe FJ, Kemper HC, van Mechelen W, Twisk
JW. Development and tracking of central patterns of
subcutaneous fat in adolescence and adulthood: The
Amsterdam Growth and Health Study. Int J Epidemiol
1996;25:1162−1171.
51. Juri J, Juri C, Raiden G. Reconstruction of the umbilicus
in abdominoplasty. Plast Reconstr Surg 1979;63:580−582.
50. Jackson IT, Downie PA. Abdominoplasty: The
waistline stitch and other refinements. Plast Reconstr Surg
1978;61:180−183.
52. Schrudde J. Lipexeresis as a means of eliminating local
adiposity. Aesthetic Plast Surg 1980;4:215−226.
34. Fu FH, Fung L. Distribution of subcutaneous fat
and equations for predicting percent body fat from
skinfold measurements: A comparison between Chinese
females from two age cohorts. J Sports Med Phys Fitness
1995;35:224−227.
53. Kesselring UK. Regional fat aspiration for body
contouring. Plast Reconstr Surg 1983;72:610−619.
35. Bemben MG, Massey BH, Bemben DA, Boileau RA,
Misner JE. Age-related patterns in body composition for
men aged 20-79 yr. Med Sci Sports Exerc 1995;27:264−269.
55. Grazer FM. Suction-assisted lipectomy, suction
lipectomy, lipolysis, and lipexeresis. Plast Reconstr Surg
1983;72:620−623.
36. Wolanski N. Comparison of growth patterns of
subcutaneous fat tissue in Mexican and Polish with US and
Peruvian populations. Hum Biol 1998;25:467−477.
56. Kesselring UK, Meyer R. A suction curette for removal of
excessive local deposits of subcutaneous fat. Plast Reconstr
Surg 1978;62:305−306.
37. Ramirez ME. Subcutaneous fat distribution in
adolescents. Hum Biol 1993;65:771−782.
57. Grazer FM, Klingbeil JR. Body Image: A Surgical
Perspective. St. Louis: Mosby; 1980.
38. Goss CM (ed): Gray’s Anatomy of the Human Body. 29th
ed. Philadelphia: Lea & Febiger; 1973.
58. Gargan TJ, Courtiss EH. The risks of suction
lipectomy: Their prevention and treatment. Clin Plast Surg
1984;11:457−463.
39. Markman B, Barton FE Jr. Anatomy of the subcutaneous
tissue of the trunk and lower extremity. Plast Reconstr Surg
1987;80:248−254.
40. Rohrich RJ, Beran SJ, Kenkel JM. Ultrasound-assisted
Liposuction. St. Louis: Quality Medical Publishing; 1998.
41. Rohrich RJ, Smith PD, Marcantonio DR, Kenkel JM. The
zones of adherence: Role in minimizing and preventing
contour deformities in liposuction. Plast Reconstr Surg
2001;107:1562−1569.
42. Lockwood TE. Superficial fascial system (SFS) of the
trunk and extremities: A new concept. Plast Reconstr Surg
1991;86:1009−1018.
43. Smalls LK, Hicks M, Passeretti D, Gersin K, Kitzmiller
WJ, Bakhsh A, Wickett RR, Whitestone J, Visscher MO. Effect
of weight loss on cellulite: Gynoid lypodystrophy. Plast
Reconstr Surg 2006;118:510−516.
44. Babcock W. Plastic reconstruction of the female breasts
and abdomen. Am J Surg 1939;43:260.
45. Pitanguy I. Abdominal lipectomy: An approach to it
through an analysis of 300 consecutive cases. Plast Reconstr
Surg 1967;40:384-391.
46. Pitanguy I. Abdominal lipectomy. Clin Plast Surg
1975;2:401−410.
54. Illouz YG. Body contouring by lipolysis: A 5-year
experience with over 3000 cases. Plast Reconstr Surg
1983;72:591−597.
59. Fournier PF, Otteni FM. Lipodissection in body
sculpturing: The dry procedure. Plast Reconstr Surg
1983;72:598−609.
60. Illouz YG. Une nouvelle technique pour les
lipodystrophies localisées [in French]. Rev Chir Esthet
1980;6:10-12.
61. Illouz YG. Illouz’s technique of body contouring by
lipolysis. Clin Plast Surg 1984;11:409−417.
62. Hetter GP. Optimum vacuum pressures for lipolysis.
Aesthetic Plast Surg 1984;8:23−26.
63. Teimourian B. Different technique for lipodystrophy.
Presented at the Annual Meeting of the District of Columbia
Metropolitan Association of Plastic Surgeons, Washington,
District of Columbia, 1978.
64. Teimourian B. Suction lipectomy. Presented at the
Annual Meeting of the American Society for Aesthetic
Plastic Surgery, Orlando, Florida, 1980.
65. Teimourian B, Fisher JB. Suction curettage to remove
excess fat for body contouring. Plast Reconstr Surg
1982;68:50−58.
47. Regnault P. Abdominal dermolipectomies. Clin Plast
Surg 1975;2:411−429.
66. Toledo LS. Liposculpture of the face and body.
In, Toledo LS, Pinto ES (ed): Annals of the International
Symposium on Recent Advances in Plastic Surgery. Sao Paolo:
RAPS International Corporation; 1990:177.
48. Regnault P. Abdominoplasty by the W technique. Plast
Reconstr Surg 1975;55:265−274.
67. Toledo LS. Syringe liposculpture: A two-year experience.
Aesthetic Plast Surg 1991;15:321−326.
49. Regnault P, Daniel RK. Abdominoplasty. In, Regnault
P, Daniel RK (ed): Aesthetic Plastic Surgery. Boston: Little
68. Lewis CM. Comparison of the syringe and pump
aspiration methods of lipoplasty. Aesthetic Plast Surg
53
SRPS • Volume 11 • Issue C8 • 2016
1991;15:203−208.
69. Gasparotti M. Superficial liposuction for flaccid
skin patients. In, Toledo LS, Pinto ES (ed): Annals of the
International Symposium on Recent Advances in Plastic
Surgery. Sao Paolo: RAPS International Corporation;
1990:443.
70. Vogt PA. Abdominal lipoplasty technique. Clin Plast Surg
1989;16:279−288.
71. Klein JA. The tumescent technique: Anesthesia
and modified liposuction technique. Dermatol Clin
1990;8:425−437.
72. Rohrich RJ, Beran SJ, Fodor PB. The role of subcutaneous
infiltration in suction-assisted lipoplasty: A review. Plast
Reconstr Surg 1997;99:514−519.
73. Lockwood TE. Transverse flank-thigh-buttock lift
with superficial fascial suspension. Plast Reconstr Surg
1991;87:1019−1027.
74. Zocchi M. Clinical aspects of ultrasonic liposculpture.
Perspect Plast Surg 1993;7:153-174.
75. Zocchi ML. Ultrasonic-assisted lipectomy. In, Habal MB,
Lineaweaver WC, Parsons RW, Woods JE (ed): Advances in
Plastic and Reconstructive Surgery. Chicago: Mosby; 1995.
76. Scheflan M, Tazi H. Ultrasonically assisted body
contouring. Aesthetic Surg J 1996;16:117-122.
77. Zocchi ML. Ultrasonic assisted lipoplasty: Technical
refinements and clinical evaluations. Clin Plast Surg
1996;23:575−598.
78. Fodor PB, Vogt PA. Power-assisted lipoplasty (PAL): A
clinical pilot study comparing PAL to traditional lipoplasty
(TL). Aesthetic Plast Surg 1999;23:379−385.
87. Hetter GP. The effect of low-dose epinephrine on the
hematocrit drop following lipolysis. Aesthetic Plast Surg
1984;8:19−21.
88. Mladick RS, Morris RL. Sixteen months’ experience
with the Illouz technique of lipolysis. Ann Plast Surg
1986;16:220−234.
89. Apfelberg DB, Lash H, Maser MR, White DN.
Computerized suction lipectomy aspirator monitor for
improved results in suction lipectomy. Plast Reconstr Surg
1988;82:896−903.
90. Clayton DN, Clayton JN, Lindley TS, Clayton JL. Large
volume lipoplasty. Clin Plast Surg 1989;16:305−312.
91. Hetter GP (ed): Lipoplasty: The Theory and Practice of
Blunt Suction Lipectomy. Boston: Little Brown; 1984.
92. Jurkiewicz MJ, Rohrich RJ, Mathes SJ, Ariyan S. Suction
Lipectomy. In, Jurkiewicz MJ, Mathes SJ, Krizek TJ, Ariyan
S (ed): Plastic Surgery: Principles and Practice. St. Louis: CV
Mosby; 1990.
93. Samdal F, Amland PF, Bugge JF. Blood loss during
liposuction using the tumescent technique. Aesthetic Plast
Surg 1994;18:157−160.
94. Samdal F, Amland PF, Bugge JF. Blood loss during
suction-assisted lipectomy with large volumes of
dilute adrenaline. Scand J Plast Reconstr Hand Surg
1995;29:161−165.
95. Matarasso A. Superwet anesthesia redefines largevolume liposuction. Aesthetic Surg J 1997;17:358−364.
96. Karmo FR, Milan MF, Stein S, Heinsimer JA. Blood loss in
major lipoplasty procedures with the tumescent technique.
Aesthetic Surg J 1998;18:30−35.
79. Young VL. Power-assisted lipoplasty. Plast Reconstr Surg
2001;108:1429−1432.
97. Lillis PJ. Liposuction surgery under local anesthesia:
Limited blood loss and minimal lidocaine absorption. J
Dermatol Surg Oncol 1988;14:1145−1148.
80. Iverson RE, Lynch DJ, American Society of Plastic
Surgeons Committee on Patient Safety. Practice advisory on
liposuction. Plast Reconstr Surg 2004;113:1478−1490.
98. Klein JA. Tumescent technique for local anesthesia
improves safety in large-volume liposuction. Plast Reconstr
Surg 1993;92:1085−1098.
81. Rohrich RJ, Raniere J Jr, Beran SJ, Kenkel JM. Patient
evaluation and indications for ultrasound-assisted
lipoplasty. Clin Plast Surg 1999;26:269−278.
99. Pitman GH. Reducing blood loss associated with
lipectomy. Plast Reconstr Surg 1993;91:962−963.
82. Glaser DA, Kaminer MS. Body dysmorphic disorder and
the liposuction patient. Dermatol Surg 2005;31:559−560.
100.Tsai RY, Lai CH, Chan HL. Evaluation of blood loss
during tumescent liposuction in Orientals. Dermatol Surg
1998;24:1326−1329.
83. Gherardini G, Matarasso A, Serure AS, Toledo LS,
DiBernardo BE. Standardization in photography for body
contour surgery and suction-assisted lipectomy. Plast
Reconstr Surg 1997;100:227−237.
101.Trott SA, Beran SJ, Rohrich RJ, Kenkel JM, Adams WP
Jr, Klein KW. Safety considerations and fluid resuscitation
in liposuction: An analysis of 53 consecutive patients. Plast
Reconstr Surg 1998;102:2220−2229.
84. Goodpasture JC, Bunkis J. Quantitative analysis of blood
and fat in suction lipectomy aspirates. Plast Reconstr Surg
1986;78:765−772.
102.Klein JA. Tumescent liposuction and improved
postoperative care using tumescent liposuction garments.
Dermatol Clin 1995;13:329−338.
85. Courtiss EH, Choucair RJ, Donelan MB. Large-volume
suction lipectomy: An analysis of 108 patients. Plast Reconstr
Surg 1992;89:1068−1079.
103.Kaplan B, Moy RL. Comparison of room temperature
and warmed local anesthetic solution for tumescent
liposuction: A randomized double-blind study. Dermatol
Surg 1996;22:707−709.
86. Illouz YG, de Villers YT. Body Sculpturing by Lipoplasty.
Edinburgh: Churchill Livingstone; 1989.
54
104.Hunstad JP, Aitken ME. Liposuction and tumescent
SRPS • Volume 11 • Issue C8 • 2016
surgery. Clin Plast Surg 2006;33:39−46.
1995;19:13-20.
105.Rohrich RJ, Leedy JE, Swamy R, Brown SA, Coleman
J. Fluid resuscitation in liposuction: A retrospective
review of 89 consecutive patients. Plast Reconstr Surg
2006;117:431−435.
121.Gasperoni C, Salgarello M, Emiliozzi P, Gargani
G. Subdermal liposuction. Aesthetic Plast Surg
1990;14:137−142.
106.Hetter GP. Blood and fluid replacement for lipoplasty
procedures. Clin Plast Surg 1989;16:245−248.
122.Gasperoni C, Salgarello M. MALL liposuction: The
natural evolution of subdermal superficial liposuction.
Aesthetic Plast Surg 1994;18:253−257.
107.Pitman GH, Holzer J. Safe suction: Fluid replacement
and blood loss parameters. Perspect Plast Surg 1991;5:79-89.
123.Gasperoni C, Gasperoni P. Subdermal liposuction: Longterm experience. Clin Plast Surg 2006;33:63−73.
108.Burk RW III, Guzman-Stein G, Vasconez LO. Lidocaine
and epinephrine levels in tumescent technique liposuction.
Plast Reconstr Surg 1996;97:1379−1384.
124.Goddio AS. Skin retraction following suction lipectomy
by treatment site: A study of 500 procedures in 458 selected
subjects. Plast Reconstr Surg 1991;87:66−75.
109.Brown SA, Lipschitz AH, Kenkel JM, Sorokin E, Shepherd
G, Grebe S, Oliver LK, Luby M, Rohrich RJ. Pharmacokinetics
and safety of epinephrine use in liposuction. Plast Reconstr
Surg 2004;114:756−763.
125.Matarasso A. Superficial suction lipectomy: Something
old, something new, something borrowed.... Ann Plast Surg
1995;34:268−272.
110.Klein JA. Tumescent technique for regional anesthesia
permits lidocaine doses of 35 mg/kg for liposuction. J
Dermatol Surg Oncol 1990;16:248−263.
111.Ostad A, Kageyama N, Moy RL. Tumescent anesthesia
with a lidocaine dose of 55 mg/kg is safe for liposuction.
Dermatol Surg 1997;22:921−927.
126.Pinto EB, Indaburo PE, Muniz Ada C, Martínez YP, Gerent
KM, Iwamoto H, Miziara AC. Superficial liposuction: Body
contouring. Clin Plast Surg 1996;23:529−548.
127.Fournier PF. Why the syringe and not the suction
machine? J Dermatol Surg Oncol 1988;14:1062-1071.
128.Toledo LS. Syringe liposculpture. Clin Plast Surg
1996;23:683−693.
112.Matarasso A. Lidocaine in ultrasound-assisted
lipoplasty. Clin Plast Surg 1999;26:431−439.
129.Mandel MA. Syringe liposculpture revisited. Aesthetic
Plast Surg 1993;17:199−203.
113.Kenkel JM, Lipschitz AH, Shepherd G, Armstrong
VW, Streit F, Oellerich M, Luby M, Rohrich RJ, Brown
SA. Pharmacokinetics and safety of lidocaine and
monoethylglycinexylidide in liposuction: A microdialysis
study. Plast Reconstr Surg 2004;114:516−524.
130.Zocchi ML. Basic physics for ultrasound-assisted
lipoplasty. Clin Plast Surg 1999;26:209−220.
114.Kenkel JM, Lipschitz AH, Luby M, Kallmeyer I, Sorokin E,
Appelt E, Rohrich RJ, Brown SA. Hemodynamic physiology
and thermoregulation in liposuction. Plast Reconstr Surg
2004;114:503−513.
132.Rohrich RJ, Beran SJ, Kenkel JM, Adams WP Jr, DiSpaltro
F. Extending the role of liposuction in body contouring
with ultrasound-assisted liposuction. Plast Reconstr Surg
1998;101:1090−1102.
115.Lipschitz AH, Kenkel JM, Luby M, Sorokin E, Rohrich
RJ, Brown SA. Electrolyte and plasma enzyme analyses
during large-volume liposuction. Plast Reconstr Surg
2004;114:766−775.
116.Perry AW, Petti C, Rankin M. Lidocaine is not necessary
in liposuction. Plast Reconstr Surg 1999;104:1900−1902.
117.Danilla S, Fontbona M, de Valdés VD, Dagnino B, Sorolla
JP, Israel G, Searle S, Norambuena H, Cabello R. Analgesic
efficacy of lidocaine for suction-assisted lipectomy
with tumescent technique under general anesthesia: A
randomized, double-masked, controlled trial. Plast Reconstr
Surg 2013;132:327−332.
118.Courtiss EH. Suction lipectomy: A retrospective analysis
of 100 patients. Plast Reconstr Surg 1984;73:780−796.
119.Gasparotti M. Superficial liposuction: A new application
of the technique for aged and flaccid skin. Aesthetic Plast
Surg 1992;16:141−153.
120.Gasperoni C, Salgarello M. Rationale of subdermal
liposuction related to the anatomy of subcutaneous fat
and the superficial fascial system. Aesthetic Plast Surg
131.Maxwell GP, Gingrass MK. Ultrasound-assisted
lipoplasty: A clinical study of 250 consecutive patients. Plast
Reconstr Surg 1998;101:189−202.
133.Tebbetts JB. Minimizing complications of ultrasoundassisted lipoplasty: An initial experience with no related
complications. Plast Reconstr Surg 1998;102:1690−1697.
134.Kenkel JM, Robinson JB Jr, Beran SJ, Tan J, Howard BK,
Zocchi ML, Rohrich RJ. The tissue effects of ultrasoundassisted lipoplasty. Plast Reconstr Surg 1998;102:213−220.
135.Grippaudo FR, Matarese RM, Macone A, Mazzocchi M,
Scuderi N. Effects of traditional and ultrasonic liposuction
on adipose tissue: A biochemical approach. Plast Reconstr
Surg 2000;106:197−199.
136.Schafer ME, Hicok KC, Mills DC, Cohen SR, Chao JJ.
Acute adipocyte viability after third- generation ultrasoundassisted liposuction. Aesthetic Surg J 2013;33:698–704.
137.Song AY, Bennett JM, Marra KG, Cimino WW, Rubin
JP. Scientific basis for the use of hypotonic solutions with
ultrasonic liposuction. Aesthetic Plast Surg 2006;30:233−238.
138.Kenkel JM, Johns DF, Rohrich RJ, Adams WP Jr,
Roeser RJ. Hearing and ultrasound-assisted liposuction:
The effect on surgeon and patient. Plast Reconstr Surg
2000;106:150−153.
55
SRPS • Volume 11 • Issue C8 • 2016
139.Kloehn RA. Liposuction with “sonic sculpture”: Six years’
experience with more than 600 patients. Aesthetic Surg Q
1996;16:123-128.
140.Fodor PB, Watson J. Personal experience with
ultrasound-assisted lipoplasty: A pilot study comparing
ultrasound-assisted lipoplasty with traditional lipoplasty.
Plast Reconstr Surg 1998;101:1103−1116.
141.Rohrich RJ, Raniere J Jr, Kenkel JM, Beran SJ. Operative
principles for optimizing results in circumferential body
contouring with ultrasound-assisted lipoplasty. Clin Plast
Surg 1999;26:305−316.
142.Graf R, Auersvald A, Damasio RC, Rippel R, de Araujo LR,
Bigarelli LH, Franck CL. Ultrasound- assisted liposuction: An
analysis of 348 cases. Aesthetic Plast Surg 2003;27:146−153.
143.Perez JA, van Tetering JP. Ultrasound-assisted
lipoplasty: A review of over 350 consecutive cases using a
two-stage technique. Aesthetic Plast Surg 2003;27:68−76.
144.Beckenstein MS, Grotting JC. Ultrasound-assisted
lipectomy using the solid probe: A retrospective
review of 100 consecutive cases. Plast Reconstr Surg
2000;105:2161−2174.
145.Jewell ML, Fodor PB, de Souza Pinto EB, Al Shammari
MA. Clinical application of VASER-assisted lipoplasty: A pilot
clinical study. Aesthetic Surg J 2002;22:131−146.
146.de Souza Pinto EB, Abdala PC, Maciel CM, dos Santos
Fde P, de Souza RP. Liposuction and VASER. Clin Plast Surg
2006;33:107−115.
147.Hoyos AE, Millard JA. VASER-assisted high-definition
liposculpture. Aesthetic Surg J 2007;27:594−604.
148.Masoumi Lari SJ, Roustaei N, Roshan SK, Chalian
M, Chalian H, Honarbakhsh Y. Determinants of patient
satisfaction with ultrasound-assisted liposuction. Aesthetic
Surg J 2010;30:714–719.
laser for laser lipolysis. Lasers Surg Med 2005;36:43−46.
156.Mordon S, Eymard-Maurin AF, Wassmer B, Ringot J.
Histologic evaluation of laser lipolysis: Pulsed 1064-nm
Nd:YAG laser versus CW 980-nm diode laser. Aesthetic Surg J
2007;27:263−268.
157.Reynaud JP, Skibinski M, Wassmer B, Rochon P, Mordon
S. Lipolysis using a 980-nm diode laser: A retrospective
analysis of 534 procedures. Aesthetic Plast Surg 2009;33:28–
36.
158.Kim KH, Geronemus RG. Laser lipolysis using a novel
1064-nm Nd:YAG laser. Dermatol Surg 2006;32:241−248.
159.Goldman A. Submental Nd:YAG laser-assisted
liposuction. Lasers Surg Med 2006;38:181−184.
160.DiBernardo BE, Reyes J. Evaluation of skin tightening
after laser-assisted liposuction. Aesthet Surg J 2009;29:400–
407.
161.DiBernardo BE. Randomized, blinded split abdomen
study evaluating skin shrinkage and skin tightening in laserassisted liposuction versus liposuction control. Aesthet Surg
J 2010;30:593–602.
162.Ahmad J, Eaves FF III, Rohrich RJ, Kenkel JM. The
American Society for Aesthetic Plastic Surgery (ASAPS)
Survey: Current trends in liposuction. Aesthet Surg J
2011;31:214–224.
163.Dillerud E. Suction lipoplasty: A report on
complications, undesired results, and patient satisfaction
based on 3511 procedures. Plast Reconstr Surg
1991;88:239−246.
164.Dillerud E, Håheim LL. Long-term results of blunt
suction lipectomy assessed by a patient questionnaire
survey. Plast Reconstr Surg 1993;92:35−42.
165.Lewis CM. Lipoplasty in males. Clin Plast Surg
1989;16:355−360.
149.Rosenberg GJ, Cabrera RC. External ultrasonic
lipoplasty: An effective method of fat removal and skin
shrinkage. Plast Reconstr Surg 2000;105:785−791.
166.Mentz HA III, Gilliland MD, Patronella CK. Abdominal
etching: Differential liposuction to detail abdominal
musculature. Aesthetic Plast Surg 1993.;17:287−290.
150.Rohrich RJ, Morales DE, Krueger JE, Ansari M, Ochoa
O, Robinson J Jr, Beran SJ. Comparative lipoplasty analysis
of in vivo-treated adipose tissue. Plast Reconstr Surg
2000;105:2152−2158.
167.Cárdenas-Camarena L, Tobar-Losada A, Lacouture AM.
Large-volume circumferential liposuction with tumescent
technique: A sure and viable procedure. Plast Reconstr Surg
1999;104:1887−1899.
151.Lawrence N, Cox SE. The efficacy of external
ultrasound-assisted liposuction: A randomized controlled
trial. Dermatol Surg 2000;26:329−332.
168.Albin R, de Campo T. Large-volume liposuction in 181
patients. Aesthetic Plast Surg 1999;23:5−15.
152.Young VL, PSEF DATA Committee. Power-assisted
lipoplasty. Plast Reconstr Surg 2001;108:1429−1432.
153.Rebelo A. Power-assisted liposuction. Clin Plast Surg
2006;33:91−105.
154.Brown SA, Rohrich RJ, Kenkel J, Young VL, Hoopman J,
Coimbra M. Effect of low-level laser therapy on abdominal
adipocytes before lipoplasty procedures. Plast Reconstr Surg
2004;113:1796−1804.
155.Ichikawa K, Miyasaka M, Tanaka R, Tanino R, Mizukami
K, Wakaki M. Histologic evaluation of the pulsed Nd: YAG
56
169.McEwan CN, Jackson IT, Stice RC. The application of
liposuction for removal of hematomas and fat necrosis. Ann
Plast Surg 1987;19:480−481.
170.Dowden RV, Bergfeld JA, Lucas AR. Aspiration of
hematomas with liposuction apparatus: A technical note. J
Bone Joint Surg 1990;72:1534−1535.
171.Field LM. Liposuction surgery: A review. J Dermatol Surg
Oncol 1984;10:530−538.
172.Rubenstein R, Roenigk HH Jr, Garden JM, Goldberg NS,
Pinski JB. Liposuction for lipomas. J Dermatol Surg Oncol
1985;11:1070−1074.
SRPS • Volume 11 • Issue C8 • 2016
173.Coleman WP III. Noncosmetic applications of
liposuction. J Dermatol Surg Oncol 1988;14:1085−1090.
174.Spinowitz AL. The treatment of multiple lipomas by
liposuction surgery. J Dermatol Surg Oncol 1989;15:538−540.
175.DeFranzo AJ, Hall JH Jr, Herring SM. Adiposis dolorosa
(Dercum’s disease): Liposuction as an effective form of
treatment. Plast Reconstr Surg 1990;85:289−292.
176.Nichter LS, Gupta BR. Liposuction of giant lipoma. Ann
Plast Surg 1990;24:362−365.
177.Spinowitz AL. Liposuction surgery: An effective
alternative for treatment of lipomas. Plast Reconstr Surg
1990;86:606.
192.Chang KN. Long-term results of surgical correction of
postliposuction contour irregularities. Plast Reconstr Surg
2002;109:2141−2145.
193.Chang KN. The use of intraoperative grid
pattern markings in lipoplasty. Plast Reconstr Surg
2004;114:1292−1297.
194.Pitman GH, Teimourian B. Suction lipectomy:
Complications and results by survey. Plast Reconstr Surg
1985;76:65−72.
195.Rao RB, Ely SF, Hoffman RS. Deaths related to
liposuction. N Engl J Med 1999;340:1471−1475.
196.Klein JA. Deaths related to liposuction. N Engl J Med
1999;341:1001.
178.Collins PC, Field LM, Narins RS. Liposuction surgery
and autologous fat transplantation. Clin Dermatol
1992;10:365−372.
197.Rigel DS, Wheeland RG. Deaths related to liposuction. N
Engl J Med 1999;341:1002−1003.
179.Shenaq SM, Spira M, Christ J. Treatment of bilateral
axillary hyperhidrosis by suction-assisted lipolysis
technique. Ann Plast Surg 1987;19:548−551.
198.Hughes CE III. Reduction of lipoplasty risks
and mortality: An ASAPS survey. Aesthetic Surg J
2001;21:120−127.
180.Crisostomo RF Jr. Hyperhidrosis axillae treated by
liposuction curettage. Am J Cosmet Surg 1989;6:
117-120 1989.
199.Matarasso A, Swift RW, Rankin M. Abdominoplasty
and abdominal contour surgery: A national plastic surgery
survey. Plast Reconstr Surg 2006;117:1797−1808.
181.Apesos J, Chami R. Functional applications of suctionassisted lipectomy: A new treatment for old disorders.
Aesthetic Plast Surg 1991;15:73−79.
200.Grazer FM, de Jong RH. Fatal outcomes from
liposuction: Census survey of cosmetic surgeons. Plast
Reconstr Surg 2000;105:436−446.
182.Narins RS. Liposuction surgery for a buffalo hump
caused by Cushing’s disease. J Am Acad Dermatol
1989;21:307.
201.Rohrich RJ, Muzaffar AR. Fatal outcomes from
liposuction: Census survey of cosmetic surgeons
[discussion]. Plast Reconstr Surg 2000;105:447.
183.Sando WC, Nahai F. Suction lipectomy in the
management of limb lymphedema. Clin Plast Surg
1989;16:369−373.
202.Gilliland MD, Coates N. Tumescent liposuction
complicated by pulmonary edema. Plast Reconstr Surg
1997;99:215−219.
184.Brorson H, Svensson H. Complete reduction of
lymphoedema of the arm by liposuction after breast cancer.
Scand J Plast Reconstr Surg Hand Surg 1997;31:137−143.
203.Lombardi AS, Quirke TE, Rauscher G. Acute median
nerve compression associated with tumescent fluid
administration. Plast Reconstr Surg 1998;102:235−237.
185.Brorson H, Svensson H. Liposuction combined with
controlled compression therapy reduces arm lymphedema
more effectively than controlled compression therapy alone.
Plast Reconstr Surg 1998;102:1058−1067.
204.Grazer FM, Meister FL. Complications of the
tumescent formula for liposuction. Plast Reconstr Surg
1997;100:1893−1896.
186.Dubin B, Jackson IT. The use of liposuction to contour
cherubism. Plast Reconstr Surg 1990;86:996−998.
187.Hallock GG. Defatting of flaps by means of suctionassisted lipectomy. Plast Reconstr Surg 1985;76:948−952.
188.Baird W, Nahai F. The use of lipoplasty in contouring
and debulking flaps. Clin Plast Surg 1989;16:395−399.
189.Wolfort FG, Cetrulo CL Jr, Nevarre DR. Suctionassisted lipectomy for lipodystrophy syndromes
attributed to HIV-protease inhibitor use. Plast Reconst Surg
1999;104:1814−1820.
190.Rohrich RJ, Kenkel JM. Suction-assisted lipectomy
for lipodystrophy syndromes attributed to HIVprotease inhibitor use [discussion]. Plast Reconstr Surg
1999;104:1821−1822.
191.Chang KN. Surgical correction of postliposuction
contour irregularities. Plast Reconstr Surg 1994;94:126−136.
205.American Society of Plastic Surgeons. ASPRS urges
members to exercise caution in lipoplasty procedures: Task
force calls for scrutiny of training, large volume removals.
PSNews Bulletin 1998 [January 26].
206.Mateu LP, Hernandez JJ. Cutaneous hyperpigmentation
caused by liposuction. Aesthetic Plast Surg 1997;21:230−232.
207.Pitman GH, Aker JS, Tripp ZD. Tumescent liposuction: A
surgeon’s perspective. Clin Plast Surg 1996;23:633−641.
208.Illouz YG. Complications of liposuction. Clin Plast Surg
2006;33:129−163.
209.Broughton G II, Horton B, Lipschitz A, Knekel JM, Brown
SA, Rohrich RJ. Lifestyle outcomes, satisfaction, and attitude
of patients after liposuction: A Dallas experience. Plast
Reconstr Surg 2006;117:1738−1749.
210.Rohrich RJ, Broughton G II, Horton B, Lipschitz A, Kenkel
JM, Brown SA. The key to long-term success in liposuction: A
guide for plastic surgeons and patients. Plast Reconstr Surg
57
SRPS • Volume 11 • Issue C8 • 2016
2004;114:1945−1952.
211.Ahkami S. Suction lipectomy preceding pregnancy and
postpartum results. Int Surg 1991;76:105−108.
212.Talmor M, Fahey TJ II, Wise J, Hoffman LA, Barie PS.
Large-volume liposuction complicated by retroperitoneal
hemorrhage: Management principles and implications
for the quality improvement process. Plast Reconstr Surg
2000;105:2244−2248.
213.Buescher TM. Paraspinous muscle hemorrhage as a
potential source of liposuction mortality. Plast Reconstr Surg
2000;106:740−741.
214.Heitmann C, Czermak C, Germann G. Rapidly fatal
necrotizing fasciitis after aesthetic liposuction. Aesthetic
Plast Surg 2000;24:344−347.
215.Brown SA. The science of mesotherapy: Chemical
anarchy. Aesthetic Surg J 2006;26:95−98.
216.Rotunda AM, Kolodney MS. Mesotherapy and
phosphatidylcholine injections: Historical clarification and
review. Dermatol Surg 2006;32:465−480.
217.Matarasso A, Pfeifer TM, PSEF DATA Committee.
Mesotherapy for body contouring. Plast Reconstr Surg
2005;115:1420−1424.
218.Rittes PG. The use of phosphatidylcholine for
correction of localized fat deposits. Aesthetic Plast Surg
2003;27:315−318.
219.Rohrich RJ. Mesotherapy: What is it? Does it work? Plast
Reconstr Surg 2005;115:1425.
220.No authors listed. Deoxycholic acid injectable for
submental fat dissolution. Dermatologist 2015;23:8.
221.Carlson HE. Approach to the patient with
gynecomastia. J Clin Endocrinol Metab 2011;96:15–21.
222.Glass AR. Gynecomastia. Endocrinol Metab Clin North
Am 1994;23:825−837.
223.Neuman JF. Evaluation and treatment of gynecomastia.
Am Fam Physician 1997;55:1835−1844.
224.Dickson G. Gynecomastia. Am Fam Physician
2012;85:716−722.
liposuction in the treatment of gynecomastia. Plast Reconstr
Surg 2005;116:646−653.
230.Rosenberg GJ. Gynecomastia: Suction lipectomy
as a contemporary solution. Plast Reconstr Surg
1987;80:379−386.
231.Rosenberg GJ. A new cannula for suction removal of
parenchymal tissue of gynecomastia. Plast Reconstr Surg
1994;94:548−551.
232.Bracaglia R, Fortunato R, Gentileschi S, Seccia A,
Farallo E. Our experience with the so-called pull-through
technique combined with liposuction for management of
gynecomastia. Ann Plast Surg 2004;53:22−26.
233.Ramon Y, Fodor L, Peled IJ, Eldor L, Egozi D, Ullmann Y.
Multimodality gynecomastia repair by cross-chest powerassisted superficial liposuction combined with endoscopicassisted pull-through excision. Ann Plast Surg 2005;55:
591-594.
234.Jarrar G, Peel A, Fahmy R, Deol H, Salih V, Mostafa A.
Single incision endoscopic surgery for gynaecomastia. J
Plast Reconstr Aesthet Surg 2011;64:e231−e236.
235.Tashkandi M, Al-Qattan MM, Hassanain JM, Hawary
MB, Sultan M. The surgical management of high-grade
gynecomastia. Ann Plast Surg 2004;53:17−20.
236.Aiache AE. Secondary surgery for failed gynecomastia
correction from liposuction. Aesthetic Surg J 1998;18:95−98.
237.Gheita A. Gynecomastia: The horizontal ellipse method
for its correction. Aesthetic Plast Surg 2008;32:795–801.
238.Tu LC, Tung KY, Chen HC, Huang WC, Hsiao HT.
Eccentric mastectomy and zigzag periareolar incision for
gynecomastia. Aesthetic Plast Surg 2009;33:549–554.
239.Benito-Ruiz J, Raigosa M, Manzano M, Salvador L.
Assessment of a suction-assisted cartilage shaver plus
liposuction for the treatment of gynecomastia. Aesthetic
Surg J 2009;29:302–309.
240.Goh T, Tan BK, Song C. Use of the microdebrider for
treatment of fibrous gynaecomastia. J Plast Reconstr Aesthet
Surg 2010;63:506−510.
225.Wollina U, Goldman A. Minimally invasive esthetic
procedures of the male breast. J Cosmet Dermatol
2011;10:150–155.
241.Petty PM, Solomon M, Buchel EW, Tran NV.
Gynecomastia: Evolving paradigm of management
and comparison of techniques. Plast Reconstr Surg
2010;125:1301–1308.
226.Rohrich RJ, Ha RY, Kenkel JM, Adams WP Jr.
Classification and management of gynecomastia: Defining
the role of ultrasound-assisted liposuction. Plast Reconstr
Surg 2003;111:909−923.
242.Colwell AS, Borud LJ. Autologous gluteal augmentation
after massive weight loss: Aesthetic analysis and role of the
superior gluteal artery perforator flap. Plast Reconstr Surg
2007;119:345−356.
227.Simon BE, Hoffman S, Kahn S. Classification and
surgical correction of gynecomastia. Plast Reconstr Surg
1973;51:48−52.
243.Cuenca-Guerra R, Quezada J. What makes buttocks
beautiful? A review and classification of the determinants of
gluteal beauty and the surgical techniques to achieve them.
Aesthetic Plast Surg 2004;28:340−347.
228.Hammond DC, Arnold JF, Simon AM, Capraro PA.
Combined use of ultrasonic liposuction with the pullthrough technique for the treatment of gynecomastia. Plast
Reconstr Surg 2003;112:891−895.
229.Hodgson EL, Fruhstorfer BH, Malata CM. Ultrasonic
58
244.Centeno RF. Gluteal aesthetic unit classification: A tool
to improve outcomes in body contouring. Aesthetic Surg J
2006;26:200−208.
245.Mendieta CG. Gluteoplasty. Aesthetic Surg J
SRPS • Volume 11 • Issue C8 • 2016
2003;23:441−455.
246.Gonzalez R. Augmentation gluteoplasty: The XYZ
method. Aesthetic Plast Surg 2004;28:417−425.
247.Aboudib JH, Serra F, de Castro CC. Gluteal
augmentation: Technique, indications, and implant
selection. Plast Reconstr Surg 2012;130:933–935.
248.Serra F, Aboudib JH, Marques RG. Reducing wound
complications in gluteal augmentation surgery. Plast
Reconstr Surg 2012;130:706e–713e.
249.Serra F, Aboudib JH, Marques RG. Intramuscular
technique for gluteal augmentation: Determination and
quantification of muscle atrophy and implant position
by computed tomographic scan. Plast Reconstr Surg
2013;131:253e–259e.
250.Mofid MM, Gonzalez R, de la Peña JA, Mendieta CG,
Senderoff DM, Jorjani S. Buttock augmentation with silicone
implants: A multicenter survey review of 2226 patients. Plast
Reconstr Surg 2013;131:897–901.
251.Raposo-Amaral CE, Cetrulo CL Jr, Guidi Mde C,
Ferreira DM, Raposo-Amaral CM. Bilateral lumbar
hip dermal fat rotation flaps: A novel technique for
autologous augmentation gluteoplasty. Plast Reconstr Surg
2006;117:1781−1788.
252.Rohde C, Gerut ZE. Augmentation buttock-pexy using
autologous tissue following massive weight loss. Aesthetic
Surg J 2005;25:576−581.
253.Sozer SO, AqulloFJ, Wolf C. Autoprosthesis buttock
augmentation during lower body lift. Aesthetic Plast Surg
2005;29:133−137.
254.Sozer SO, Agullo FJ, Palladino H. Split gluteal muscle
flap for autoprosthesis buttock augmentation. Plast Reconstr
Surg 2012;129:766–776.
255.Murillo WL. Buttock augmentation: Case studies of fat
injection monitored by magnetic resonance imaging. Plast
Reconstr Surg 2004;114:1606−1614.
256.Nicareta B, Pereira LH, Sterodimas A, Illouz YG.
Autologous gluteal lipograft. Aesthetic Plast Surg
2011;35:216–224.
257.Matarasso A. Abdominolipoplasty. Clin Plast Surg
1989;16:289−303.
258.Huger WE Jr. The anatomic rationale for abdominal
lipectomy. Am Surg 1979;45:612−617.
259.Dubou R, Ousterhout DK. Placement of the umbilicus in
an abdominoplasty. Plast Reconstr Surg 1978;61:291−293.
260.Lockwood T. High-lateral-tension abdominoplasty with
superficial fascial system suspension. Plast Reconstr Surg
1995;96:603−615.
261.Lockwood T. Lower body lift with superficial fascial
system suspension. Plast Reconstr Surg 1993;92:1112−1122.
264.Harley OJ, Pickford MA. CT analysis of fat distribution
superficial and deep to the Scarpa’s fascial layer in the
mid and lower abdomen. J Plast Reconstr Aesthet Surg
2013;66:525−530.
265.Matarasso A. Liposuction as an adjunct to a
full abdominoplasty revisited. Plast Reconstr Surg
2000;106:1197−1202.
266.Graf R, de Araujo LR, Rippel R, Neto LG, Pace DT,
Cruz GA. Lipoabdominoplasty: Liposuction with reduced
undermining and traditional abdominal skin flap resection.
Aesthetic Plast Surg 2006;30:1−8.
267.Blondeel PN, Derks D, Roche N, Van Landuyt KH,
Monstrey SJ. The effect of ultrasound-assisted liposuction
and conventional liposuction on the perforator vessels in
the lower abdominal wall. Br J Plast Surg 2003;56:266−271.
268.Saldanha OR, De Souza Pinto EB, Mattos WN Jr, Pazetti
CE, Lopes Bello EM, Rojas Y, dos Santos MR, de Carvalho
AC, Filho OR. Lipoabdominoplasty with selective and safe
undermining. Aesthetic Plast Surg 2003;27:322−327.
269.Mestak O, Kullac R, Mestak J, Nosek A, Krajcova A,
Sukop A. Reply: Evaluation of the long-term stability of
sheath plication. Plast Reconstr Surg 2013;131:852e.
270.Brauman D. Liposuction abdominoplasty: An evolving
concept. Plast Reconstr Surg 2003;112:288−298.
271.Avelar JM. Abdominoplasty combined with lipoplasty
without panniculus undermining: Abdominolipoplasty-A
safe technique. Clin Plast Surg 2006;33:79−90.
272.Cárdenas-Camarena L. Aesthetic surgery of the
thoracoabdominal area combining abdominoplasty and
circumferential lipoplasty: 7 years’ experience. Plast Reconstr
Surg 2005;116:881−890.
273.Espinosa-de-los-Monteros A, de la Torre JI, Rosenberg
LZ, Ahumada LA, Stoff A, Williams EH, Vásconez LO.
Abdominoplasty with total abdominal liposuction for
patients with massive weight loss. Aesthetic Plast Surg
2006;30:42−46.
274.Hunstad JP, Jones SR. Abdominoplasty with thorough
concurrent circumferential abdominal tumescent
liposuction. Aesthetic Surg J 2011;31:572–590.
275.Castañares S, Goethel JA. Abdominal lipectomy:
A modification in technique. Plast Reconstr Surg
1967;40:378−383.
276.Dellon AL. Fleur-de-lis abdominoplasty. Aesthetic Plast
Surg 1985;9:27−32.
277.Persichetti P, Simone P, Scuderi N. Anchor-line
abdominoplasty: A comprehensive approach to abdominal
wall reconstruction and body contouring. Plast Reconstr Surg
2005;116:289−294.
262.Lockwood T. The role of excisional lifting in body
contour surgery. Clin Plast Surg 1996;23:695−712.
278.Costa LF, Landecker A, Manta AM. Optimizing
body contour in massive weight loss patients: The
modified vertical abdominoplasty. Plast Reconstr Surg
2004;114:1917−1923.
263.Pollock T, Pollock H. Progressive tension sutures in
abdominoplasty. Clin Plast Surg 2004;31:583−589.
279.Bracaglia R, Tambasco D, D’Ettorre M, Gentileschi S.
‘‘Inverted-Y’’: A modified vest-over-pants abdominoplasty
59
SRPS • Volume 11 • Issue C8 • 2016
pattern following bariatric surgery. Aesthetic Plast Surg
2012;36:1179–1185.
280.Agha-Mohammadi S, Hurwitz DJ. Management of
upper abdominal laxity after massive weight loss: Reverse
abdominoplasty and inframammary fold reconstruction.
Aesthetic Plast Surg 2010;34:226–231.
281.Nahas FX. An aesthetic classification of the abdomen
based on the myoaponeurotic layer. Plast Reconstr Surg
2001;108:1787−1795.
282.Talisman R, Kaplan B, Haik J, Aronov S, Shraga A,
Orenstein A. Measuring alterations in intra-abdominal
pressure during abdominoplasty as a predictive value for
possible postoperative complications. Aesthetic Plast Surg
2002;26:189−192.
283.Van Uchelen JH, Kon M, Werker PM. The long-term
durability of plication of the anterior rectus sheath
assessed by ultrasonography. Plast Reconstr Surg
2001;107:1578−1584.
284.Mestak O, Kullac R, Mestak J, Nosek A, Krajcova A,
Sukop A. Evaluation of the long-term stability of sheath
plication using absorbable sutures in 51 patients with
diastasis of the recti muscles: An ultrasonographic study.
Plast Reconstr Surg 2012;130:714e–710e.
285.Nahas FX, Ferreira LM, Mendes Jde A. An efficient way
to correct recurrent rectus diastasis. Aesthetic Plast Surg
2004;28:189−196.
286.de Castro EJ, Radwanski HN, Pitanguy I, Nahas F. Longterm ultrasonographic evaluation of midline aponeurotic
plication during abdominoplasty. Plast Reconstr Surg
2013;132:333–338.
287.Weissman O, Zmora N, Rozenblatt SM, Tessone A,
Nardini GG, Zilinsky I, Winkler E, Haik J. Simple continuous
suture versus continuous horizontal mattress suture for
plication of abdominal fascia: Which is better? Aesthetic Plast
Surg 2012;36:1015–1018.
288.Rodriguez-Feliz JR, Makhijani S, Przybyla A, Hill D, Chao
J. Intraoperative assessment of the umbilicopubic distance:
A reliable anatomic landmark for transposition of the
umbilicus. Aesthetic Plast Surg 2012;36:8–17.
289.Baroudi R. Umbilicoplasty. Clin Plast Surg
1975;2:431−448.
290.Le Louarn C, Pascal JF. High superior tension
abdominoplasty. Aesthetic Plast Surg 2000;24:375−381.
291.Akbas H, Güneren E, Eroğlu L, Uysal OA. Naturallooking umbilicus as an important part of abdominoplasty.
Aesthetic Plast Surg 2003;27:139−142.
292.Sugawara Y, Hirabayashi S, Asato H, Yoshimura K.
Reconstruction of the umbilicus using a single triangular
flap. Ann Plast Surg 1995;34:78−80.
Reconstr Surg 1986;77:779−784.
295.Wilkinson TS. Limited abdominoplasty techniques
applied to complete abdominal repair. Aesthetic Plast Surg
1994;18:49−55.
296.Greminger RF. The mini-abdominoplasty. Plast Reconstr
Surg 1987;79:356−365.
297.Gradel J. Umbilical technical maneuvers to facilitate
abdominoplasty with limited incisions. Aesthetic Plast Surg
1991;15:251−256.
298.Walgenbach KJ, Shestak KC. “Marriage”
abdominoplasty: Body contouring with limited scars
combining mini-abdominoplasty and liposuction. Clin Plast
Surg 2004;31:571−581.
299.Omranifard M. Ultrasonic liposuction versus surgical
lipectomy. Aesthetic Plast Surg 2003;27:143−145.
300.Dabb RW, Hall WW, Baroody M, Saba AA.
Circumferential suction lipectomy of the trunk with anterior
rectus fascia plication through a periumbilical incision: An
alternative to conventional abdominoplasty. Plast Reconstr
Surg 2004;113:727−732.
301.Mladick RA. Male body contouring. Clin Plast Surg
1991;18:797−813.
302.Matarasso A. The male abdominoplasty. Clin Plast Surg
2004;31:555−569.
303.Lockwood T. Rectus muscle diastasis in males: Primary
indication for endoscopically assisted abdominoplasty. Plast
Reconstr Surg 1998;101:1685−1691.
304.Kryger ZB, Fine NA, Mustoe TA. The outcome of
abdominoplasty performed under conscious sedation: Sixyear experience in 153 consecutive cases. Plast Reconstr Surg
2004;113:1807−1817.
305.Mast BA. Safety and efficacy of outpatient full
abdominoplasty. Ann Plast Surg 2005;54:256−259.
306.Mentz HA, Ruiz-Razura A, Newall G, Patronella CK.
Use of a regional infusion pump to control postoperative
pain after an abdominoplasty. Aesthetic Plast Surg
2005;29:415−421.
307.Bolton M, Pruzinsky T, Cash TF, Persing JA. Measuring
outcomes in plastic surgery: Body image and quality
of life in abdominoplasty patients. Plast Reconstr Surg
2003;112:619−625.
308.Staalesen T, Elander A, Strandell A, Bergh C. A
systematic review of outcomes of abdominoplasty. J Plast
Surg Hand Surg 2012;46:139–144.
309.Grazer FM, Goldwyn RM. Abdominoplasty assessed by
survey, with emphasis on complications. Plast Reconstr Surg
1977;59:513−517.
293.Cló TC, Nogueira DS. A new umbilical reconstruction
technique used for 306 consecutive abdominoplasties.
Aesthetic Plast Surg 2012;36:1009–1014.
310.Hensel JM, Lehman JA Jr, Tantri MP, Parker MG, Wagner
DS, Topham NS. An outcomes analysis and satisfaction
survey of 199 consecutive abdominoplasties. Ann Plast Surg
2001;46:357−363.
294.Wilkinson TS, Swartz BE. Individual modification of
body contour surgery: The “limited” abdominoplasty. Plast
311.Vastine VL, Morgan RF, Williams GS, Gampper
TJ, Drake DB, Knox LK, Lin KY. Wound complications
60
SRPS • Volume 11 • Issue C8 • 2016
of abdominoplasty in obese patients. Ann Plast Surg
1999;42:34−39.
312.Kim J, Stevenson TR. Abdominoplasty, liposuction of
the flanks, and obesity: Analyzing risk factors for seroma
formation. Plast Reconstr Surg 2006;117:773−779.
313.Chaouat M, Levan P, Lalanne B, Buisson T, Nicolau
P, Mimoun M. Abdominal dermolipectomies: Early
postoperative complications and long-term unfavorable
results. Plast Reconstr Surg 2000;106:1614−1618.
314.Manassa EH, Hertl CH, Olbrisch RR. Wound healing
problems in smokers and nonsmokers after 132
abdominoplasties. Plast Reconstr Surg 2003;111:2082−2087.
315.van Uchelen JH, Werker PM, Kon M. Complications
of abdominoplasty in 86 patients. Plast Reconstr Surg
2001;107:1869−1873.
316.Pitanguy I. Evaluation of body contouring surgery
today: A 30-year perspective. Plast Reconstr Surg
2000;105:1499−1514.
317.Neaman KC, Armstrong SD, Baca ME, Albert M, Vander
Woude DL, Renucci JD. Outcomes of traditional cosmetic
abdominoplasty in a community setting: A retrospective
analysis with other procedures in a bariatric surgery unit.
Am J Surg 2010;200:235-240.
318.Staalesen T, Olsén MF, Elander A. Complications of
abdominoplasty after weight loss as a result of bariatric
surgery or dieting postpregnancy. J Plast Surg Hand Surg
2012;46:416-420.
319.Greco JA III, Castaldo ET, Nanney LB, Wendel JJ,
Summitt JB, Kelly KJ, Braun SA, Hagan KF, Shack RB.
The effect of weight loss surgery and body mass index
on wound complications after abdominal contouring
operations. Ann Plast Surg 2008;61:235-242.
320.Costa-Ferreira A, Rebelo M, Silva A, Vásconez
LO, Amarante J. Scarpa fascia preservation during
abdominoplasty: Randomized clinical study of efficacy and
safety. Plast Reconstr Surg 2013;131:644–651.
321.Matarasso A, Wallach SG, Rankin M, Galiano RD.
Secondary abdominal contour surgery: A review of
early and late reoperative surgery. Plast Reconstr Surg
2005;115:627−632.
322.Matarasso A, Schneider LF, Barr J. The incidence
and management of secondary abdominoplasty and
secondary abdominal contour surgery. Plast Reconstr Surg
2014;133:40–50.
323.Kadri OM, Moosa S, Mofid MM. Abdominoplasty
revision using tissue expansion. Aesthetic Plast Surg
2013;37:538–540.
324.Voss SC, Sharp HC, Scott JR. Abdominoplasty combined
with gynecologic surgical procedures. Obstet Gynecol
1986;67:181−185.
325.Hunter GR, Barney MF, Crapo RO, Broadbent TR, Reily
WF, Jensen RL. Perioperative warfarin therapy in combined
abdominal lipectomy and intraabdominal gynecological
surgical procedures. Ann Plast Surg 1990;25:37−41.
326.Pitanguy I, Ceravolo MP. Our experience with combined
procedures in aesthetic plastic surgery. Plast Reconstr Surg
1983;71:56−65.
327.Shull BL, Verheyden CN. Combined plastic and
gynecological surgical procedures. Ann Plast Surg
1988;20:552−557.
328.Gemperli R, Neves RI, Tuma P Jr, Bonamichi GT, Ferreira
MC, Manders EK. Abdominoplasty combined with other
intraabdominal procedures. Ann Plast Surg 1992;29:18−22.
329.Hester TR Jr, Baird W, Bostwick J III, Nahai F,
Cukic J. Abdominoplasty combined with other major
surgical procedures: Safe or sorry? Plast Reconstr Surg
1989;83:997−1004.
330.Cardoso de Castro C, Cupello AM. Analysis of 60 cases
of simultaneous mammaplasty and abdominoplasty.
Aesthetic Plast Surg 1989;14:35−41.
331.Stevens WG, Cohen R, Vath SD, Stoker DA, Hirsch EM.
Is it safe to combine abdominoplasty with elective breast
surgery? A review of 151 consecutive cases. Plast Reconstr
Surg 2006;118:207−212.
332.Wallach SG. Maximizing the use of the abdominoplasty
incision. Plast Reconstr Surg 2004;113:411−417.
333.Yoho RA, Romaine JJ, O’Neil D. Review of the
liposuction, abdominoplasty, and face-lift mortality and
morbidity risk literature. Dermatol Surg 2005;31:733−743.
334.Colwell AS, Borud LJ. Optimization of patient safety
in postbariatric body contouring: A current review. Aesthet
Surg J 2008;28:437–442.
335.Fischer JP, Wes AM, Serletti JM, Kovach SJ.
Complications in body contouring procedures: An analysis
of 1797 patients from the 2005 to 2010 American College of
Surgeons National Surgical Quality Improvement Program
databases. Plast Reconstr Surg 2013;132:1411–1420.
336.Rubin PJ, Nguyen V, Schwentker A. Perioperative
management of the post-gastric-bypass patient presenting
for body contour surgery. Clin Plast Surg 2004;31:601−610.
337.Davidson SP, Clemens MW. Safety first: Precautions for
the massive weight loss patient. Clin Plast Surg 2008;35:
173–183.
338.Cavallini M, Baruffaldi Preis FW, Casati A. Effects
of mild hypothermia on blood coagulation in patients
undergoing elective plastic surgery. Plast Reconstr Surg
2005;116:316−321.
339.Shermak MA, Rotellini-Coltvet LA, Chang D. Seroma
development following body contouring surgery for
massive weight loss: Patient risk factors and treatment
strategies. Plast Reconstr Surg 2008;122:280–288.
340.Coon D, Michaels J V, Gusenoff JA, Purnell C, Friedman
T, Rubin JP. Multiple procedures and staging in the massive
weight loss population. Plast Reconstr Surg 2010;125:
691–698.
341.Reish RG, Damjanovic B, Colwell AS. Deep venous
thrombosis prophylaxis in body contouring: 105
consecutive patients. Ann Plast Surg 2012;69:412−414.
61
SRPS • Volume 11 • Issue C8 • 2016
342.Clavijo-Alvarez JA, Pannucci CJ, Oppenheimer
AJ, Wilkins EG, Rubin JP. Prevention of venous
thromboembolism in body contouring surgery: A
national survey of 596 ASPS surgeons. Ann Plast Surg
2011;66:228−232.
343.Caprini JA, Arcelus JI, Hasty JH, Tamhane AC, Fabrega
F. Clinical assessment of venous thromboembolic risk in
surgical patients. Semin Thromb Hemost 1991;17[Suppl
3]:304-312.
344.Caprini JA. Thrombosis risk assessment as a guide to
quality patient care. Dis Mon 2005;51:70-78.
345.Hatef DA, Kenkel JM, Nguyen MQ, Farkas JP, Abtahi F,
Rohrich RJ, Brown SA. Thromboembolic risk assessment and
the efficacy of enoxaparin prophylaxis in excisional body
contouring surgery. Plast Reconstr Surg 2008;122:269–279.
346.Pannucci CJ, Bailey SH, Dreszer G, Fisher Wachtman
C, Zumsteg JW, Jaber RM, Hamill JB, Hume KM, Rubin JP,
Neligan PC, Kalliainen LK, Hoxworth RE, Pusic AL, Wilkins
EG. Validation of the Caprini Risk Assessment Model in
plastic and reconstructive surgery patients. J Am Coll Surg
2011;212:105–112.
347.Pannucci CJ, Dreszer G, Wachtman CF, Bailey SH,
Portschy PR, Hamill JB, Hume KM, Hoxworth RE, Rubin JP,
Kalliainen LK, Pusic AL, Wilkins EG. Postoperative enoxaparin
prevents symptomatic venous thromboembolism in
high-risk plastic surgery patients. Plast Reconstr Surg
2011;128:1093–1103.
348.Pannucci CJ, Wachtman CF, Dreszer G, Bailey SH,
Portschy PR, Hamill JB, Hume KM, Hoxworth RE, Kalliainen
LK, Rubin JP, Pusic AL, Wilkins EG. The effect of postoperative
enoxaparin on risk for reoperative hematoma. Plast Reconstr
Surg 2012;129:160–168.
349.Pannucci CJ, Barta RJ, Portschy PR, Dreszer G, Hoxworth
RE, Kalliainen LK, Wilkins EG. Assessment of postoperative
venous thromboembolism risk in plastic surgery patients
using the 2005 and 2010 Caprini Risk Score. Plast Reconstr
Surg 2012;130:343–353.
350.Prayer M, Youngberg B, Pfister S. Panniculectomy:
An option for people who are morbidly obese. AORN J
2003;77:782−794.
351.Manahan M, Shermak MA. Massive panniculectomy
after massive weight loss. Plast Reconstr Surg
2006;117:2191−2197.
352.Brown M, Adenuga P, Soltanian H. Massive
panniculectomy in the super obese and super-super obese:
Retrospective comparison of primary closure versus partial
open wound management. Plast Reconstr Surg 2014;133:
32–39.
2008;61:188–196.
355.Leahy PJ, Shorten SM, Lawrence WT. Maximizing the
aesthetic result in panniculectomy after massive weight
loss. Plast Reconstr Surg 2008;122:1214–1224.
356.Aly A. Massive panniculectomy after massive weight
loss [discussion]. Plast Reconstr Surg 2006;117:2198.
357.Olejek A, Manka G. Panniculectomy in gynecologic
cancer surgical procedures by using a harmonic scalpel.
Acta Obstet Gynecol Scand 2005;84:690−694.
358.Wallace SA, Mericli AF, Taylor PT, Drake DB.
Panniculectomy and abdominoplasty in patients
undergoing gynecologic surgery: A single center case series
of 15 combined procedures. Ann Plast Surg 2013;71:88–92.
359.Hardy JE, Salgado CJ, Matthews MS, Chamoun G, Fahey
AL. The safety of pelvic surgery in the morbidly obese with
and without combined panniculectomy: A comparison of
results. Ann Plast Surg 2008;60:10–13.
360.Ortega J, Navarro V, Cassinello N, Lledó S. Requirement
and postoperative outcomes of abdominal panniculectomy
alone or in combination with other procedures in bariatric
surgery unit. Am J Surg 2010;200:235-240.
361.Lockwood TE. Maximizing aesthetics in lateral-tension
abdominoplasty and body lifts. Clin Plast Surg 2004;31:523-537.
362.Richter DF, Stoff A, Velasco-Laguardia FJ, Reichenberger
MA. Circumferential lower truncal dermatolipectomy. Clin
Plast Surg 2008;35:53–71.
363.Gonzalez-Ulloa M. Belt lipectomy. Br J Plast Surg
1960;13:179-186.
364.Aly AS, Cram AE, Chao M, Pang J, McKeon M. Belt
lipectomy for circumferential truncal excess: The University
of Iowa experience. Plast Reconstr Surg 2003;111:398−413.
365.Nemerofsky RB, Oliak DA, Capella JF. Body lift: An
account of 200 consecutive cases in the massive weight loss
patient. Plast Reconstr Surg 2006;117:414−430.
366.Capella JF. Body lift. Clin Plast Surg 2008;35:27–51.
367.Rohrich RJ, Gosman AA, Conrad MH, Coleman J.
Simplifying circumferential body contouring: The central
body lift evolution. Plast Reconstr Surg 2006;118:525−535.
368.Pascal JF, Le Louarn C. Remodeling bodylift with high
lateral tension. Aesthetic Plast Surg 2002;26:223−230.
369.Hurwitz DJ. Single-staged total body lift after massive
weight loss. Ann Plast Surg 2004;52:435−441.
370.Hurwitz DJ, Agha-Mohammadi S, Ota K, Unadkat J.
A clinical review of total body lift surgery. Aesthet Surg J
2008;28:294–303.
353.O’Brien JA, Broderick GB, Hurwitz ZM, Montilla R,
Castle J, Dunn RM, Akyurek M, Lalikos JF. Fleur-de-lis
panniculectomy after bariatric surgery: Our experience. Ann
Plast Surg 2012;68:74–78.
371.Kitzinger HB, Cakl T, Wenger R, Hacker S, Aszmann
OC, Karle B. Prospective study on complications following
a lower body lift after massive weight loss. J Plast Reconstr
Aesthet Surg 2013;66:231–238.
354.Cooper JM, Paige KT, Beshlian KM, Downey DL, Thirlby
RC. Abdominal panniculectomies: High patient satisfaction
despite significant complication rates. Ann Plast Surg
372.Koller M, Schubhart S, Hintringer T. Quality of life and
body image after circumferential body lifting of the lower
trunk: A prospective clinical trial. Obes Surg 2013;23:561–566.
62
SRPS • Volume 11 • Issue C8 • 2016
373.Mathes DW, Kenkel JM. Current concepts in medial
thighplasty. Clin Plast Surg 2008;35:151−163.
389.Guerrero-Santos J. Brachioplasty. Aesthetic Plast Surg
1979;3:1−14.
374.Lockwood TE. Fascial anchoring technique in medial
thigh lifts. Plast Reconstr Surg 1988;82:299−304.
390.Knoetgen J III, Moran SL. Long-term outcomes
and complications associated with brachioplasty: A
retrospective and cadaveric study. Plast Reconstr Surg
2006;117:2219−2223.
375.Le Louarn C, Pascal JF. The concentric medial thigh lift.
Aesthetic Plast Surg 2004;28:20−23.
376.Kenkel JM, Eaves FF III. Medial thigh lift. Plast Reconstr
Surg 2008;122:621–622.
377.Correa Iturraspe MC, Fernandez JC. Brachial
dermolipectomy [in Spanish]. Prensa Med Argent
1954;41:2432-2436.
378.Glanz S, Gonzalez-Ulloa M. Aesthetic surgery of the
arm: Part I. Aesthetic Plast Surg 1981;5:1−17.
379.Lockwood T. Brachioplasty with superficial fascial
system suspension. Plast Reconstr Surg 1995;96:912−920.
380.Regnault P, Daniel RK. Upper extremity. In, Regnault
P, Daniel RK (ed): Aesthetic Plastic Surgery: Principles and
Techniques. Boston: Little Brown; 1984.
381.Teimourian B, Malekzadeh S. Rejuvenation of the upper
arm. Plast Reconstr Surg 1998;102:545−551.
382.Appelt EA, Janis JE, Rohrich RJ. An algorithmic
approach to upper arm contouring. Plast Reconstr Surg
2006;118:237−246.
383.El Khatib HA. Classification of brachial ptosis: Strategy
for treatment. Plast Reconstr Surg 2007;119:1337–1342.
384.Matarasso A. Discussion: Liposuction of the arm
concurrent with brachioplasty in the massive weight loss
patient: Is it safe? Plast Reconstr Surg 2013;131:368–370.
385.Trussler AP, Rohrich RJ. Limited incision medial
brachioplasty: Technical refinements in upper arm
contouring. Plast Reconstr Surg 2008;121:305–307.
386.Hurwitz DJ, Neavin T. L brachioplasty correction of
excess tissue of the upper arm, axilla, and lateral chest. Clin
Plast Surg 2008;35:131–140.
387.Baroudi R. Body sculpturing. Clin Plast Surg
1984;11:419−443.
388.Grazer FM. Body contouring. In, McCarthy JG (ed):
Plastic Surgery. Philadelphia: Elsevier Health Sciences; 1989.
391.Nguyen AT, Rohrich RJ. Liposuction-assisted posterior
brachioplasty: Technical refinements in upper arm
contouring. Plast Reconstr Surg 2010;126:1365–1369.
392.Bracaglia R, D’Ettorre M, Gentileschi S, Mingrone G,
Tambasco D, “Kris Knife” brachioplasty after bariatric surgery
and massive weight loss. Aesthetic Plast Surg 2013;37:640–
642.
393.Aly A. Discussion: Liposuction of the arm concurrent
with brachioplasty in the massive weight loss patient: Is it
safe? Plast Reconstr Surg 2013;131:366–367.
394.Bossert RP, Dreifuss S, Coon D, Wollstein A, ClavijoAlvarez J, Gusenoff JA, Rubin JP. Liposuction of the arm
concurrent with brachioplasty in the massive weight loss
patient: Is it safe? Plast Reconstr Surg 2013;131:357–365.
395.Pascal JF, Le Louarn C. Brachioplasty. Aesthetic Plast Surg
2005;29:423−429.
396.Gusenoff JA, Coon D, Rubin JP. Brachioplasty and
concomitant procedures after massive weight loss: A
statistical analysis from a prospective registry. Plast Reconstr
Surg 2008;122:595–603.
397.González-Ulloa M. The callous elbow and aging of the
upper arm. Aesthetic Plast Surg 1989;14:53−57.
398.Pitanguy I. Aesthetic plastic surgery of the upper and
lower limbs. Aesthetic Plast Surg 1980;4:363−372.
399.Zomerlei TA, Neaman KC, Armstrong SD, Aitken
ME, Cullen WT, Ford RD, Renucci JD, VanderWoude DL.
Brachioplasty outcomes: A review of a multipractice cohort.
Plast Reconstr Surg 2013;131:883–889.
400.Migliori FC, Ghiglione M, D’Alessandro G, Serra
Cervetti GG. Brachioplasty after bariatric surgery: Personal
technique. Obes Surg 2008;18:1165–1169.
401.Symbas JD, Losken A. An outcome analysis of
brachioplasty techniques following massive weight loss.
Ann Plast Surg 2010;64:588–591.
63
This is your life.
Whether you’re performing a routine
cosmetic procedure or a difficult
burn repair, having the right tool for
unexpected complications is critical.
This is your website.
The new Plastic and Reconstructive
Surgery Online
The intuitive, all-new, next-generation electronic journals
platform from Lippincott Williams & Wilkins comes loaded
with personalized options for its journal subscribers, including
customizable state-of-the-art capabilities, self-service
options tailored to your information preferences, rich media
content, improved search options, better article readability
in HTML and better tools to help you manage content that’s
vital to your practice and patient care.
Register online at prsjournal.com
Not a subscriber? Visit prsjournal.com to subscribe and
find out more
We thank the
Aesthetic Surgery Journal
and
Plastic and Reconstructive Surgery
for their support.
Now Indexed in MEDLINE!
Submit Your Manuscript Today
Aesthetic Surgery Journal (ASJ) is a peer-reviewed international
journal focusing on scientific developments and clinical techniques
in aesthetic surgery. An official publication of the 2200-member
American Society for Aesthetic Plastic Surgery (ASAPS), ASJ is also
the official English-language journal of twelve major international
societies of plastic, aesthetic, and reconstructive surgery representing
South America, Central America, Europe, Asia, and the Middle East,
and the official journal of The Rhinoplasty Society.
Submit your manuscript!
www.aestheticsurgeryjournal.com
Order Today:
(800) 818-7243 (US & Canada)
(805) 499 9774 (Other countries)
www.aestheticsurgeryjournal.com
Published by