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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. 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