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SRPS SELECTED READINGS IN PLASTIC SURGERY Would like to thank SRPS SELECTED READINGS IN PLASTIC SURGERY B O D Y CONTOURING ANDREW TRUSSLER MD VOLUME 10: NUMBER 22 For their support of plastic surgery education as a Platinum Education Partner 2 0 0 8 OUR EDUCATIONAL PARTNERS Selected Readings in Plastic Surgery appreciates the generous support provided by our educational partners. PLATINUM PARTNERS facial aesthetics SILVER PARTNER SRPS 10 (20), 2008 ǯǯ ȬȬȱȱ ě¢ȱǯȱǰȱǯǯ ȱȱȱ ǯȱǯȱǰȱǯǰȱǯǯ ȱȱȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ ȱ řŖȱ ǯȱǯȱ¢ǰȱǯǯ ǯȱǯȱǰȱǯǯ ǯȱǯȱǰȱǯǯ ǯȱȱǰȱǯǯǰȱǯǯ ǯȱǯȱǰȱǯǯ ǯȱǯȱȱǰȱǯǯ ǯȱ¢ǰȱǯǯ ǯȱǰȱǯǯ ǯȱǯȱ ǰȱǯǯ ǯȱǯȱĜǰȱǯǯ ǯȱǯȱ ǰȱǯǯ ǯȱ ǯȱ ǰȱǯǯ ǯȱǯȱ ¡ ǰȱǯǯ ǯȱǯȱǰȱǯǯ ǯȱǯȱ¢ǰȱǯǯ ǯȱǯȱǰȱǯǯ ǯȱ£ǰȱǯǯ ǯȱǯȱǰȱǯǯ ǯȱǯȱǰȱǯǯ ǯȱǯȱȂǰȱǯǯ ǯȱǯȱĴǰȱǯǯǰȱǯǯǯ ǯȱǯȱǰȱǯǯ ǯȱȬ¢ǰȱǯǯ ǯȱǯȱ¢ǰȱǯǯ ǯȱǯȱǰȱǯǯ ǯȱǯȱǰȱǯǯ ǯȱǯȱǯȱǰȱǯǯ Ğȱȱ ȱ ǰȱǰȱȱ ȱǱȱǰȱǰȱȱ ȱȱȱ ȱȱȱȱȱ ¢ȱȱ ȱ¡¢ȱ ȱȱ¢ȱ ǰȱǰȱȱȱ ȱȱȱ¢ ȱ ¢ȱȱ ȱĞ ¢ ¢¢ ȱȱȱȱ ȱȱ ĞȱȱȱȦ ȱǱȱ¡ǰȱȱ ȱǱȱ¢ ȱ ȱ ȱȱȱ¡¢ ȱ ¢ȱȱȱ ȱȱȱȱ ȱ ȱȱȱ ȱ ȱ ȱ ¢ȱ ¢ȱ ȱȱȱȱ ȱǱȱĞȱ ȱǱȱȱ ȱǱȱ¡ȱ ȱȱ ȱ ȱȱȱ ȱ ȱȱȱ ȱ ¢ȱ ȱǱȱ¡ȱ ȱǱȱǰȱǰȱǰȱȱ ȱĜȱȱ ǯǯȱ¡ȱřŜŚŜŜ ȱȱŝśŘřśȬşşşŞȱ ȓǯ ȱĜ ǯǯȱ¡ȱŘŜŚ ȱȱŝŜŖŖŚ ŞŗŝȬŘŝŝȬŖŖŜś ŞŗŝȬŞŞŝȬŗŜŝŝȱ¡ ȓǯ ȱȱȱȱ¢ȱǻȱŖŝřşȬśśŘřǼȱȱȱ¡¢ȱŞȱȱȱ¢ȱ¢ȱ ȱȱȱȱ¢ǰȱǯȱȱȱȱȱřŖȱȱȱȱŘȱȱřȱ¢ǯȱ ȱȱȱȱȱȱȱŗśȱȱȱȱǞřŖŖȱǰȱȱǞřśŖȱȱȱǯǯȱȱȱ ȱȬȱȱȱȱǞŘŖŖȱǰȱǞŘśŖȱȱȱǯǯȱȱ££ȱȱǞŜŖȱȱŗśȱ ǯȱ¢ȱȱȱȱȱȱȱȱȱǞŘŖŖȱǰȱǞŘśŖȱȱȱ ǯǯȱȱȱȱȱ ǯǯȱȱȱǯ ȱȱ¢ȱȱȱ¢ȬȱǲȱŗŖŖƖȱ¢ǯ 247. T?nseth KA, Hokland BM, Tindholdt TT, et al: Patientreported outcomes after breast reconstruction with deep inferior epigastric perforator flaps. Scand J Plast Reconstr Surg Hand Surg 41:173, 2007. 248. Drazan L, Vesely J, Hyza P, et al: Bilateral breast reconstruction with DIEP flaps: 4 years’ experience. J Plast Reconstr Aesthet Surg, Aug 16, 2007 [Epub ahead of print]. DOI: 10.1016/j.bjps.2007.06.028. 249. Munhoz AM, Arruda E, Montag E, et al: Immediate skinsparing mastectomy reconstruction with deep inferior epigastric perforator (DIEP) flap. Technical aspects and outcome. Breast J 13:470, 2007. 250. Schaverien MV, Perks AG, McCulley SJ: Comparison of outcomes and donor-site morbidity in unilateral free TRAM versus DIEP flap breast reconstruction. J Plast Reconstr Aesthet Surg 60:1219, 2007. 251. Nahabedian MY, Tsangaris T, Momen B: Breast reconstruction with the DIEP flap or the muscle-sparing (MS-2) free TRAM flap: Is there a difference? Plast Reconstr Surg 115:436, 2005. 252. Serletti JM: Breast reconstruction with the TRAM flap: pedicled and free. J Surg Oncol 94:532, 2006. 253. Glasberg SB, D’Amico RA: Use of regenerative human acellular tissue (AlloDerm) to reconstruct the abdominal wall following pedicle TRAM flap breast reconstruction surgery. Plast Reconstr Surg 118:8, 2006. 254. Bajaj AK, Chevray PM, Chang DW: Comparison of donor-site complications and functional outcomes in free musclesparing TRAM flap and free DIEP flap breast reconstruction. Plast Reconstr Surg 117:737, 2006. 255. Futter CM, Webster MHC, Hagan S, et al: A retrospective comparison of abdominal muscle strength following breast reconstruction with a free TRAM or DIEP flap. Br J Plast Surg 53:578, 2000. 256. Futter CM, Weiler-Mithoff E, Hagen S, et al: Do pre-operative abdominal exercises prevent post-operative donor site complications for women undergoing DIEP flap breast reconstruction? A two-centre, prospective randomised controlled trial. Br J Plast Surg 56:674, 2003. 257. Yan XQ, Yang HY, Zhao YM, et al: Deep inferior epigastric perforator flap for breast reconstruction: experience with 43 flaps. Chin Med J (Engl)120:380, 2007. 258. Kroll SS, Schusterman MA, Reece GP, et al: Breast reconstruction with myocutaneous flaps in previously irradiated patients. Plast Reconstr Surg 93:460, 1994. 259. Williams JK, Bostwick J 3rd, Bried JT, et al: TRAM flap breast reconstruction after radiation treatment. Ann Surg 221:756, 1995. 260. Williams JK, Carlson GW, Bostwick J 3rd, et al: The effects of radiation treatment after TRAM flap breast reconstruction. Plast Reconstr Surg 100:1153, 1997. 261. Tran NV, Chang DW, Gupta A, et al: Comparison of immediate and delayed free TRAM flap breast reconstruction in patients receiving postmastectomy radiation therapy. Plast Reconstr Surg 108:78, 2001. 262. Rogers NE, Allen RJ: Radiation effects on breast reconstruction with the deep inferior epigastric perforator flap. Plast Reconstr Surg 109:1919, 2002. 263. Spear SL, Ducic I, Low M, Cuoco F: The effect of radiation on pedicled TRAM flap breast reconstruction: outcomes and implications. Plast Reconstr Surg 115:84, 2005. 264. Guerra A, Metzinger S, Bidros R, et al: Breast reconstruction with gluteal artery perforator (GAP) flaps: a critical analysis of 142 cases. Ann Plast Surg 52:118, 2004. 265. Guerra AB, Soueid N, Metzinger SE, et al: Simultaneous bilateral breast reconstruction with superior gluteal artery perforator (SGAP) flaps. Ann Plast Surg 53:305, 2004. 266. Clark CP 3rd, Rohrich RJ, Copit S, et al: An anatomic study of the internal mammary veins: clinical implications for freetissue-transfer breast reconstruction. Plast Reconstr Surg 99:400, 1997. 267. Feng LJ: Recipient vessels in free-flap breast reconstruction: a study of the internal mammary and thoracodorsal vessels. Plast Reconstr Surg 99:405, 1997. 268. Hefel L, Schwabegger A, Ninkovic M, et al: Internal mammary vessels: anatomical and clinical considerations. Br J Plast Surg 48:527, 1995. 269. Vath SD, Dupin CL, Allen RJ: Internal mammary vessels as a recipient site for free flap breast reconstruction. Semin Plast Surg 16:109, 2002. 270. Shaw WW: Discussion of “The internal mammary artery and vein as a recipient site for free-flap breast reconstruction: a report of 110 consecutive cases,” by CL Dupin et al. Plast Reconstr Surg 98:690, 1996. 271. Schwabegger AH, Gschnitzer C, Ninkovic MM: Contour deformity at the internal mammary recipient site. Br J Plast Surg 52:674, 1999. 272. Majumder S, Batchelor AG: Internal mammary vessels as recipients for free TRAM breast reconstruction: aesthetic and functional considerations. Br J Plast Surg 52:286, 1999. 273. Nahabedian MY, Momen B, Galdino G, et al: Breast reconstruction with free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Plast Reconstr Surg 110:466, 2002. 274. Hamdi M, Blondeel P, Van Landuyt K, Monstrey S: Algorithm in choosing recipient vessels for perforator free flap in breast reconstruction: the role of the internal mammary perforators. Br J Plast Surg 57:258, 2004. 275. Serletti JM, Moran SL, Orlando GS, Fox I: Thoracodorsal vessels as recipient vessels for the free TRAM flap in delayed breast reconstruction. Plast Reconstr Surg 104:1649, 1999. 276. Ninkovic MM, Schwabegger AH, Anderl H: Internal mammary vessels as a recipient site. Clin Plast Surg 25:213, 1998. 277. Evans GRD, David CL, Loyer EM, et al: The long-term effects of internal mammary chain irradiation and its role in the vascular supply of the pedicled transverse rectus abdominis musculocutaneous flap breast reconstruction. Ann Plast Surg 35:342, 1995. 278. Temple CL, Strom EA, Youssef A, Langstein HN: Choice of recipient vessels in delayed TRAM flap breast reconstruction after radiotherapy. Plast Reconstr Surg 115:105, 2005. 279. Nahabedian MY: The internal mammary artery and vein as recipient vessels for microvascular breast reconstruction: are we burning a future bridge? Ann Plast Surg 53:311, 2004. 280. Munhoz AM, Ishida LH, Montag E, et al: Perforator flap breast reconstruction using internal mammary perforator branches as a recipient site: an anatomical and clinical analysis. Plast Reconstr Surg 114:62, 2004. 281. Haywood RM, Raurell A, Perks AG, et al: Autologous free tissue breast reconstruction using the internal mammary perforators as recipient vessels. Br J Plast Surg 56:689, 2003. 53 BODY CONTOURING Andrew Trussler MD [email protected] Dept. of Plastic Surgery, UTSMC 1801 Inwood Rd, 5th Floor, Dallas TX 75390-9132 INTRODUCTION The common perception of beauty in the human body has undergone a dramatic change in the past three centuries, culminating in a preoccupation not only with body weight, but also with body contour. The emphasis placed by modern society on a lean, youthful appearance is largely responsible for the increased demand for surgical procedures designed to produce an ideal aesthetic shape. Liposuction is the most common cosmetic surgical procedure in the United States. According to the American Society for Aesthetic Plastic Surgery, in 2004 there were 324,891 liposuction procedures performed in the U.S.; in 2007, this number had climbed to 456,828, a 41% increase. These statistics highlight the importance placed on body shape and weight by our society.1 PHYSIOLOGY OF BODY FAT Because adipocytes specialize in the synthesis and storage of fat, they are an important source of energy for the organism as well as an effective insulator.2,3 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.4 Adipocytes possess two different chemical receptors for catecholamines, epinephrine and norepinephrine. Beta-1 receptors are lipolytic and secrete lipase, while α-2 receptors block lipolysis and are direct antagonists of the β-1 receptors. Alpha-2 receptors are numerous and active in well-localized areas of fat deposition, such as steatomas and trochanteric lipodystrophy, which may explain these sites’ apparent resistance to weight loss.5,6 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.6 Throughout life fat cells multiply in number as well as increase in size.7 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 significant weight gain by the individual.8 After adolescence no new adipocytes are formed. The ultimate number of fat cells in the adult is genetically determined and 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 physiologic alterations in later life. A person’s body habitus, therefore, depends on (a) enlargement of the fixed number of adipocytes he or she begins adult life with and (b) fat-cell replication by postadipocytes. SRPS Volume 10, Number 22, 2008 Salans, Cushman, and Weismann7 studied adipose cell size and number in non-obese and obese patients. As a group, obese patients have larger adipose cells than do non-obese patients; cell size, however, varies considerably among the fat depots of individuals of either group. Cell size variations also exist within subcutaneous and deep sites of fat accumulation. The authors find two patterns of obesity with respect to 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; hypertrophic, by a late onset. They surmise 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 subjects by Knittle and associates9 showed that the contribution of cell number and size to the growth of the fat depot in non-obese children varies with age. Deviations from this normal development were observed in obese children shortly after 1 year of age. By age 11, obese children exceeded the mean cell number found in nonobese adults, and the earlier elevations in both cell number and size were maintained throughout the study. Borkan and colleagues10 described changes in adipose tissue distribution with age. Newborns and children have about 20% the adipose cell concentration of adults. The proportion of fat in the trunk generally increases with age, and there also appears to be a progressive internalization of fat. 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, whose primary function 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. 2 METABOLIC EFFECTS OF LIPOSUCTION Adipose tissue is a metabolically active tissue. Among the 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 and colleagues11 evaluated the effects of liposuction and diet on ghrelin, adiponectin, and leptin levels in an animal model and demonstrated a significant decrease in ghrelin and leptin levels after liposuction. No effect on adiponectin levels was appreciated in this study, though the interim from intervention to sacrifice was only 42 days. When extrapolated to a human model, this period of time is not long enough to see an effect. Giugliano and coworkers12 prospectively compared the metabolic sequelae of large volume liposuction (mean 3540mL) 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 conclude that liposuction is safe and beneficial to the patient. Robles-Cervantes et al13 found significantly lower levels of glucose, cholesterol, insulin secretion, and adiposity in a non-obese population at 3 weeks after liposuction. Insulin levels, glucose-insulin relationship, and insulin sensitivity remained unaltered. Samdal et al14 measured lipids, lipoproteins, sex hormones, and insulin levels in 7 women immediately before and 4 weeks after suction lipectomy. The authors report significant increase in HDL cholesterol and apolipoprotein A1 postoperatively, but no change in sex hormones or glucose metabolism. On the basis of an average increase in HDL cholesterol of 0.2mmol/L, they hypothesize that large-volume SRPS Volume 10, Number 22, 2008 suction lipectomy may reduce the risk of cardiovascular disease by as much as 30%. D’Andrea and associates15 evaluated 123 obese women prospectively for the metabolic effects of largevolume liposuction (LVL) over a longer period of time. During 3 months of follow-up, LVL resulted in significantly improved insulin sensitivity, resting metabolic rate, serum adipocytokines, and inflammatory marker levels. These metabolic changes correlated with a decreased fat mass and improved waist:hip ratio. Interestingly, no difference was seen after 6 weeks, paralleling the findings in the RoblesCervantes study. Liszka and coworkers16 studied the effect of lipectomy on growth, fat cell number, hyperinsulinemia, and hyperlipidemia on a Zucker rat model of Type 2 diabetes. The authors report no consistent changes in serum glucose or insulin levels. A significant decrease in lipid levels was noted in the operated group. Further physiologic effects of surgical removal of subcutaneous adipose tissue were evaluated in 14 women by Giese and colleagues.17 All patients underwent large-volume liposuction. At 4 months postoperatively there was a decrease in body weight, body fat mass, systolic blood pressure, and fasting insulin levels, suggesting that liposuction may be a valuable tool for reducing some of the comorbidities associated with obesity. Rizzo and associates18 concluded that dermolipectomy had similar effects on BMI, insulin mediated glucose uptake, and degree of inflammation after just 40 days in a female population. Klein et al19 evaluated the effect of large volume liposuction in 7 Type II diabetic females and compared it to 8 non-diabetic females. 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. Significant findings were a decrease in fat mass and in leptin, a marker for fat mass. Despite reports of the physiologic benefits of liposuction in obese patients, Matarasso, Kim, and Kral20 raise concerns about the effect of liposuction on body fat. The importance of the subcutaneous adipose tissue in helping to maintain nutritional and thermodynamic metabolic functions is stressed. The authors measured the amount of fat removed by largevolume (>1000mL) liposuction in 63 normal-weight to mildly obese patients and monitored changes in total TABLE 1 Body Composition and Blood Chemistry Profile Before and After Liposuction (Modified from Giese SY, Bulan EJ, Commons GW, et al: Improvements in cardiovascular risk profile with large-volume liposuction: a pilot study. Plast Reconstr Surg 108:510, 2001.) 3 SRPS Volume 10, Number 22, 2008 body fat and visceral adipose tissue postoperatively. “Although large-volume subcutaneous liposuction removed relatively little body fat, it led to significant increases in the proportion of visceral adipose tissue [with respect to subcutaneous fat].” Their concern is that one may actually increase the risk of metabolic complications of obesity if large-volume liposuction is undertaken. Clearly, further studies are needed. More recently Ybarra and coworkers21 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 report significant decreases in free fatty acids (-35%), glycerol (-63%), very-low-density cholesterol (-15.2%), and triglycerides (-21.3%) at 4 months post-liposuction. At the same time there were increases in HDL cholesterol (+10%) and apolipoproteins B, AI, and AII. The serum levels of glucose, insulin, adiponectin, and C-reactive proteins were not significantly altered by liposuction. ANATOMY The patterns of fat distribution in the body vary with sex, race, and age of the subject. Heredity is also a factor. Gender Differences Vague and Finasse22 described the characteristic sites of fat deposition according to sex. In general, women have a proportionately higher percentage of total body fat than 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, 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 embryologic factors23 but are finally determined genetically, as suggested by a study of identical twins reared separately.24 The environment alone does not appear to determine adult body weight. A cross-sectional sample of more than 41,000 German subjects aged from birth to 62 years revealed 4 a pattern of sexual dimorphism in measurements of height, weight, circumference, and body mass index.25 Girls are shorter at birth, but they increase in height at higher rates than boys up to age 12. Thereafter, males show an obvious growth advantage. Female circumferences are always smaller, from birth to senescence, while subcutaneous fat and total body fat levels are always higher in females. Racial Differences Racial and ethnic differences in fat accumulation are also evident.26 Compared with other races, blacks show increased fat accumulation in the buttocks, a pattern that is magnified by lumbar lordosis.27 As reported by Weinsier and colleagues,28 weightreduction programs achieved similar results for white and black American women in terms of total weight loss and losses of total fat, trunk fat, and waist circumference. However, white women lost more intraabdominal adipose tissue and less subcutaneous abdominal adipose tissue than did black women. A meta-analysis to test the hypothesis that Japanese have a greater amount of abdominal visceral fat (AVF) relative to abdominal subcutaneous fat (ASF) than Caucasians29 compared mean values for AVF and ASF areas for native Japanese, African-Americans, and Caucasians of both genders. After adjusting for ASF, age, and sex, the difference in AVF between Japanese and Caucasian females was lower than that between African-American and Caucasian females. Age Differences Another Japanese study tracked longitudinal changes in subcutaneous fat distribution among Japanese women in their 20s.30 Subcutaneous fat thickness was measured at 14 points on the body using the B-mode ultrasound method; each subject 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 and infragluteal region. 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 SRPS Volume 10, Number 22, 2008 the early 20s to the late 20s: (1) on the whole trunk and upper arm; (2) around the waist; and (3) on the abdomen and hips. The interplay of sex, ethnicity, and age in body morphology and fat deposition is exemplified by the Amsterdam Growth and Health Study, which tracked the development of central patterns of subcutaneous fat in adolescence and adulthood.31 In adolescence, a decrease was seen in extremity skinfolds for men but not for women. For both sexes, the trunk skinfolds increased over the entire period of study. An increase was found in trunk–extremity skinfold ratios in males, but not in females. The authors conclude that a central pattern of body fat accumulation, mainly seen in males, seems to start in adolescence. A comparison of body fat and skinfold measurements between Chinese females from two age cohorts 32 showed significant differences in the distribution of subcutaneous fat between younger and older Chinese females, with the major differences in the abdominal and subscapular skinfolds. In addition, the 20–30 years cohort had a more evenly distributed subcutaneous fat than the 40–50 years cohort. Working with an American male population, Bemben and colleagues 33 demonstrated a gradual decline in fat-free body mass with increasing age, with a corresponding increase in fat mass, from the youngest (20yo) to the oldest (79yo) age groups. Subcutaneous body fat in the proximal trunk locations, especially the abdomen, was significantly higher with increasing age. Wolanski 34 identifies the following stages of subcutaneous fat tissue development in the United States: preschool loss, prepubertal gain, adolescent loss, stabilization, adult gain, top fatness, and age loss. The same pattern of fatfolds growth was found in different ethnic groups, except level of thickness and age at turning points. Adolescent loss is characteristic of boys and stabilization of girls. Top fatness in various populations occurred between 45 and 55 years of age. Relative to Peruvian natives, white and black Americans, fat tissues became more abundant in Mexican American and Puerto Rican subjects and was most abundant in the native Mexican group. American black females have thicker fatfolds than white, but white males’ fatfolds are thicker than those of blacks. Genetics Ramirez 35 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 the fat distribution patterns. These 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 histologic layers, a superficial and a deep.36 The superficial adipose layer is made up of compact, dense pockets of fat contained within well-organized fibrous septa. 37 The deep adipose layer consists of looser, more areolar fat bound by a haphazard network of partitions (Fig 1).37 Fig 1. Differences in subcutaneous tissues in various areas of the body. (Reprinted with permission from Markman B, Barton FE Jr: Anatomy of the subcutaneous tissue of the trunk and lower 5 SRPS Volume 10, Number 22, 2008 extremity. Plast Reconstr Surg 80:248, 1987.) More clinically significant are the “surgical fat layers,”38 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 always safe to treat, while the superficial layer of densely compacted fat should be suctioned with extreme caution because of the greater risk of deformities and skin irregularities afterwards. Fig 2. Surgical fat layers. (Reprinted with permission from Rohrich RJ, Raniere J Jr, Kenkel JM, Beran SJ: Operative principles for optimizing results in circumferential body contouring with ultrasound-assisted lipoplasty. Clin Plast Surg 26(2):305, 1999.) Rohrich and others 39 describe “zones of adherence” that should be avoided to minimize contour deformities during liposuction (Fig 3). In these accentuate localized fat deposits. When these areas are recognized preoperatively, significant 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 most often seen in women. Illouz believes that “cellulite is not a pathologic condition but simply the mechanical result of hypertrophy of the superficial fat cells.”6 He postulates the mechanism by which cellulite is formed as follows: The superficial [adipose] layer is composed of fat within arches made up of connective tissue...These arches are firmly anchored to the undersurface of the epidermis above and the fascia superficialis below...Since [the septa] are firmly attached at both extremities...they expand and contract like an accordion...As fat hypertrophy increases, so does the tension within...fat pockets...[and] cellulite becomes apparent because the anchor points do not give as the chambers expand. Illouz (1990) Fig 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 RJ, Smith PD, Marcantonio DR, Kenkel JM: The zones of adherence: role in minimizing and preventing contour deformities in liposuction. Plast Reconstr Surg 107:1562, 2001.) areas the overlying skin appears to adhere more tightly to the underlying fascia, which tends to 6 Lockwood40 finds two types of cellulite, a primary kind that is due to hypertrophied fat cells in the superficial fat (Illouz’s) and a secondary cellulite related to skin laxity. The latter is seen in women 35 years or older, and results from age, sun damage, massive weight loss, or liposuction. “With age and sun damage, the entire skin–superficial fat–SFS [superficial fascial system] relaxes and stretches, resulting in ptotic soft tissues, pseudo-fat deposit deformity, and cellulite.”40 The underlying mechanism is gravity acting on the fibrous septa of the SFS. Unlike primary cellulite, cellulite of laxity is correctable by surgically tightening the skin and superficial fascia. In a study of 51 female patients who underwent medically supervised weight loss programs, Smalls SRPS Volume 10, Number 22, 2008 and coworkers41 demonstrated 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 significant increases in tissue compliance. This correlates with Lockwood’s observation regarding cellulite of laxity and the need for skin tightening in conjunction with weight loss. SUCTION LIPECTOMY HISTORY Surgical procedures to contour specific areas of the body were first described in the 1930s for the abdomen and breasts.42 Since that time, the popularity of abdominal and lower-extremity contouring steadily grew as a result of contributions by Pitanguy,43,44 Regnault,45–47 and others.48,49 Although these procedures were quite sophisticated, it was not until Schrudde,50 Kesselring,51 and Illouz52 began reporting their experience with suction-assisted lipectomy that the concept of body sculpting became a reality. Grazer53 traces 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 Schrudde50 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 Meyer54 added strong suction to the sharp curettage method. Although their results were generally excellent, others reported a high incidence of complications,55–57 particularly seroma and skin necrosis. Shortly afterwards Illouz52 as well as Fournier and Otteni58 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. Illouz52,59,60 also proposed irrigation of the subcutaneous space with a hypertonic saline solution in the belief that the fat cells would swell and rupture, but this process has never been confirmed clinically.58 Hetter61 stressed the importance of adequate suction pressures for complete lipolysis, which resulted in standardization of the vacuum pump. Teimourian62–64 popularized the use of small-diameter cannulas to limit the amount of fat that could be removed and minimize unsightly postoperative depressions. Modern innnovations in suction lipectomy include syringe liposculpture,65–67 superficial liposuction,68 the tumescent technique,69–71 suspension of the superficial fascia to decrease tension on the skin,72 ultrasoundassisted liposuction, 73–76 and power-assisted 77,78 liposuction. INDICATIONS AND EVALUATION In 2004 Iverson,79 writing for the Committee on Patient Safety of the American Society of Plastic Surgeons, reviewed the scientific and clinical data on liposuction and surveyed the practice of liposuction as performed by ASPS members. This comprehensive article is not meant to define the standard of care, but offers guidelines for practitioners to assist them in making educated clinical decisions in light of 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 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 be willing to undergo modifications in their diet, exercise, and lifestyle.80 A thorough history should be obtained and specific questions should be directed toward their diet and exercise regimen. Patients are also asked about their use of both prescription and over-the-counter weight loss medications and/or dietary supplements. The continued use of these substances during the perioperative period may raise the surgical risk.80 Body dysmorphic disorder is an underrecognized disorder that affects 7–15% of patients seeking cosmetic surgery.81 These patients have an obsessive 7 SRPS Volume 10, Number 22, 2008 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 the initial consultation, psychiatric referral is indicated. A candidate for liposuction shows one or more of the following on physical examination:38 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) Standard photographs are taken to guide the surgeon intraoperatively and to serve as a baseline for postoperative assessment of results.38,82 The views must be consistent for each anatomic area and of high enough quality to allow comparisons of different techniques and instrumentation. An informed consent is a compulsory process which 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 with regard to any secondary procedures.38 TABLE 2 Techniques of Liposuction and Their Infiltrates (Reprinted with permission from Rohrich RJ, Beran SJ, Fodor PB: The role of subcutaneous infiltration in suction-assisted lipoplasty: a review. Plast Reconstr Surg 99:514, 1997.) The dry technique of liposuction was popularized by Fournier and Otteni.58 Estimates of blood loss as a percentage of the aspirated volume range from 5–54% (mean 25%) in Goodpasture and Bunkis’s series83 to 30–46% (mean 35%) in Courtiss’ large-volume liposuctions.84 (Table 3). The dry technique has fallen out of favor due to the excessive blood loss associated with it. TABLE 3 Estimates of Blood Loss with Different Liposuction Techniques TECHNIQUE Instruments The tools used in body contouring have changed markedly since the original large, sharp, single-hole cannulas. Over the last several decades the instruments have evolved toward smaller cannulas with blunt tips and multiple holes. These cannulas 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).71 The dry and wet techniques are now of historical interest only. 8 (Reprinted with permission from Rohrich RJ, Beran SJ, Fodor PB: The role of subcutaneous infiltration in suction-assisted lipoplasty: a review. Plast Reconstr Surg 99:514, 1997.) Illouz60 pioneered the wet technique of liposuction, which consisted of infusion of 100–300mL of fluid into each treatment site—regardless of the amount of fat to be removed—and aspiration with blunt cannulas aided by hydrotomy. Blood loss with the wet technique is estimated to be 20–25% of the total aspirate.85,86 In 1983 Hetter86 added 1:400,000 epinephrine and 0.25% lidocaine to Illouz’s formula and reported a smaller drop in the hematocrit postoperatively. SRPS Volume 10, Number 22, 2008 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.85,87–90 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 198692,93 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 1–4% of the aspirate.94–97 In the late 1980s Klein70 reported a tumescent technique that also resulted in decreased blood loss during lipoplasty. The technique is performed under local anesthesia with or without sedation.98 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 physiologic 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.98–102 The relative merits of the superwet and tumescent techniques continue to be debated. Proponents of the superwet technique95,96 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 administration96,103,104 Advocates of the tumescent technique,99,103,104 on the other hand, believe that it • enables improved safety • improves aesthetic results • decreases postoperative pain • shortens convalescence • needs minimal follow-up care by the physician105 Infiltration Technique The two critical issues in subcutaneous infiltration are fluid delivery (for maintenance and resuscitation) and dosage of lidocaine–epinephrine. Kaplan and Moy106 note that patients experience considerably less pain when the subcutaneous solution is warmed to 40°C before infiltration. Hunstad and Aitken107 review 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. The two critical issues in subcutaneous infiltration are fluid delivery (for maintenance and resuscitation) and dosage of lidocaine–epinephrine. Trott et al104 suggest the following guidelines for the superwet technique: • when aspirating <4L, maintenance intravenous fluids and subcutaneous wetting solution alone are adequate • when aspirating >4L, it is safe to administer maintenance fluids, subcutaneous infiltration, and intravenous crystalloid at a rate of 0.25mL/mL of aspirate over 4L In a retrospective study of intraoperative fluid ratios, Rohrich and colleagues108 noted a lower threshold for fluid replacement of up to 5L with superwet infiltration liposuction in both small- and large-volume cases. No adverse effects of volume overload were appreciated in the 89 patients in the study. Matarasso96 states that patients absorb approximately 1mL of the injectate per mL of fat aspirate, and roughly 20% of the injectate is removed via liposuction. He therefore supplements his patients so that the total amount of fluid given—injectate, intravenous, and postoperative fluid combined—is roughly 2–3mL 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 in safe liposuction. Klein99,100 does not recommend any supplemental intravenous fluid when using the tumescent technique. 9 SRPS Volume 10, Number 22, 2008 Epinephrine and Lidocaine To reduce blood loss during liposuction, one must add a dilute epinephrine solution to the subcutaneous infiltrate.96,101,103–105,109,110 On the basis of normal endocrine values, Burk et al111 recommend a maximum 10mg of epinephrine. An injected solution containing epinephrine in 1:1,000,000 concentration seems to afford both hemostasis and safety.104 Brown and others112 found the peak plasma level of epinephrine occurred 5 hours after infiltration and was attributed to an exogenous source. Endogenous norepinepherine levels remained stable throughout their study. Total absorption was 25–32%. No toxic levels were demonstrated despite peak levels equivalent to major physiologic stress. The authors recommend 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 thus can be used in relatively high doses. Klein81,113 believes a lidocaine dose of 35mg/kg of body weight is safe. Peak plasma concentrations at 12h never reached toxic levels in his series. Ostad and colleagues 114 believe that lidocaine doses up to 55mg/kg are safe. Plasma levels of lidocaine ranging from 0.9–3.6mcg/mL typically occur 8–14h after surgery but can be detected for up to 24h (Table 4).115 TABLE 4 Plasma Lidocaine Levels and Symptoms of Toxicity (Reprinted with permission from Matarasso A: Lidocaine in ultrasound-assisted lipoplasty. Clin Plast Surg 26(3):431, 1999,) Kenkel and coworkers116 prospectively tracked the serum and lipoaspirate levels of lidocaine and its metabolite, monoethylglycinexylidide (MEGX), in 5 10 women during liposuction. MEGX is an active metabolite of lidocaine that has 80–90% potency and roughly equivalent toxicity. The time to peak concentration of lidocaine ranged from 8–28h 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 4–8h postoperatively. The authors comment 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 physiologic effects of large-volume liposuction were evaluated by Kenkel et al117,118 in 5 female patients. The average volume of lipoaspirate was 4835mL. The patients’ 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 but CVP was not, indicating adequate right heart compliance. The intraoperative epinephrine level and cardiac index correlated well; hypothermia was prevalent intraoperatively. 117 Electrolyte and plasma enzyme disturbance was also evident during surgery, with patients exhibiting hyponatremia, hypokalemia, hypoalbuminemia, and hypoproteinemia. All measures returned to baseline levels in 4–24h. Transient elevations in aspartate aminotransferase and alanine transaminase levels were likely due to local tissue trauma, not hepatic toxicity, as creatine kinase was also elevated.118 The authors recommend use of isotonic fluids to avoid further hemodilution and stress the importance of maintaining intraoperative normocarbia to prevent complications. Lidocaine Toxicity The early signs of lidocaine toxicity are subjective and may include circumoral numbness, drowsiness, and light-headedness. In a patient who has had general anesthesia, the first signs may be cardiac abnormalities. The treatment of lidocaine toxicity involves maintenance of airway, ventilatory and circulatory support, and possible cardiopulmonary SRPS Volume 10, Number 22, 2008 resuscitation. Valium may help control seizures by raising the brain threshold two-fold. Some patients may require specific medications to control cardiac abnormalities. Because of the risks involved with the use of lidocaine, some have questioned whether it is necessary in liposuction. An intraindividual comparison of pain when lidocaine was used on one side of the body only showed no statistically significant difference in postoperative pain at 5, 30, 60, and 120 minutes whether lidocaine was used or not.119 The authors recommend eliminating it because of its potential toxicity. Their study was limited in design and number of patients (10), but it raises an interesting point that should be investigated further. Traditional (Deep) Liposuction The objective in 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. Hetter61 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. Courtiss120 underscored 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,68 in 1992 Gasparotti121 published his experience with superficial liposuction in 2500 patients of all 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 is used in the subdermal fat, undermining without aspiration is carried out in neighboring areas, and any remaining irregularities are smoothed manually. The author states that superficial liposculpting is “based on the controlled scar retraction of the thin cutaneous adipose flap remaining after the [deep] treatment.” The patient population consisted of “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 from Gasparotti, 122,123 Gasperoni and Salgarello 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 (MALL) combining deeplevel aspiration and subdermal defatting.124 In this technique the subdermal fat is suctioned using thin, 3hole Mercedes cannulas with diameters up to 2mm. The authors’ experience consists 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 their opinion, 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, the authors125 describe the superficial fat layer, which is separated from the deep fat layer by the superficial fascial system. 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, though subdermal liposuction can be combined with deeper aspirations in specific zones. The authors emphasize proper patient selection: ideally, a patient who is not obese and has good skin quality. Skin irregularities may 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 prior to the procedure to soften the fat and make it more regular and even.125 Small-gauge, 1.8–2mm Gasperoni Multipurpose Mercedes tip cannulas with 11 SRPS Volume 10, Number 22, 2008 circumferential openings are used for subdermal suctioning. The same cannulas are used in the deeper fat prior to using the larger, 2.5–3mm cannulas for scavenging; this poses less risk of postoperative contour abnormalities and eases passage of the larger diameter cannulas later. The advantages of this technique are 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 in the immediate postoperative period and can be treated with fat grafting.125 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.126 Matarasso127 confirms 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— eg, the inner thighs—the procedure indicated is excisional dermolipectomy rather than superficial liposuction. De Souza Pinto and associates128 offer an excellent overview of the superficial technique of liposuction and highlight the benefits of skin detachment in correcting skin imperfections and enhancing secondary skin retraction. Syringe vs Vacuum Aspiration In the late 1980s Fournier129 and Toledo65 independently reported superficial fat aspiration by syringe for the correction of skin contour deformities. The method was recommended for smoothing out superficial 12 irregularities after conventional liposuction and for the treatment of patients with flaccid skin or cellulite. Toledo66,130 later updated his experience with syringe liposculpture combined with superficial liposuction, lysis of fibrous adherences, and subcutaneous fat injections. Lewis67 compared the syringe technique to the traditional pump aspiration method of suction lipectomy in 6 patients, one technique on either side. He used a Tulip® aspirator system with a larger opening (Toomey) and a lock to hold the syringe with vacuum to free one of the surgeon’s hands. Lewis reports less blood in the fat aspirate from the syringe side and less postoperative bruising and morbidity with the syringe technique on follow-up. He speculated that the fluid added to the cannula may act as a hydrotomy and provide a cushion that decreases trauma to the adipose tissue. Mandel131 assessed the results of syringe liposculpture and conventional liposuction in matched groups of 10 patients each. He reports less blood loss in syringe-treated patients, who also “appeared to heal faster, return to work in a shorter period of time, and have less pain.” Mandel concludes 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. Ultrasound-assisted Liposuction (UAL) In 1993 Professor Zocchi of Modena, Italy, published his researches 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.73,74,76,132 UAL has expanded the indications for suction lipectomy in body contouring, enabling surgeons to treat areas that were previously considered to be outof-bounds because of inconsistent results with other techniques.133–135 Candidates for UAL range in age from SRPS Volume 10, Number 22, 2008 late teens to mid-70s and should be in general good health, of reasonable body weight, and with at least moderate skin tone.76,133–135 Kenkel et al136 compared the tissue effects of ultrasound-assisted liposuction to traditional liposuction in a domestic pig model. They 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 postperfusion vasculature in the treated areas showed significantly less vascular disruption with UAL than with traditional techniques. The effects of traditional and ultrasound liposuction on adipose tissue were also evaluated by Grippaudo and coworkers,137 who obtained aspirates from 15 patients and measured triglycerides and free fatty acids in the samples. Triglyceride levels were higher following ultrasound-assisted liposuction; free fatty acids were similar in the two groups. Song138 demonstrated that hypotonic solution can significantly increase human adipocyte cell diameter. The use of 25% normal saline in the solution may facilitate ultrasonic lipoplasty by causing the adipocyte to swell, thinning its cell membrane and becoming more fragile. While ultrasonic frequencies by definition are outside the range of normal human hearing, during ultrasound-assisted liposuction procedures one hears a distinct, audible sound. Kenkel et al139 studied sound intensity during UAL and found that all measurements obtained with two different machines were within acceptable standards as defined by the U.S. Occupational Safety and Health Administration (OSHA). The authors conclude that UAL does not pose a risk to patient, surgeon, or operating room personnel. Zocchi76 reports a large clinical experience with UAL encompassing more than 1000 patients operated on between 1989 and 1996. After an initial learning curve, the author reports minimal complications from the procedure despite treating patients of all ages in almost every anatomic area. Two precepts considered essential for the safe use of UAL are: 1) never apply energy to dry tissue; and 2) never apply energy without motion of the probe or cannula. Scheflan and Tazi140 as well as Kloehn141 also report enhanced skin contraction and selectively improved results with ultrasound-assisted liposuction. They used early-model solid probes and endured a steep learning curve. The hollow cannula for UAL was developed in America by Maxwell133 and adopted soon thereafter by Fodor142 and Rohrich.134 All authors emphasize the initial learning curve with its attendant risks of dysesthesias, thermal injury, and contour deformity. Rohrich et al143 review the process of selecting access incisions for UAL, which are confirmed with the patient (Table 5). The incisions are only 3–5mm long and are made asymmetrically so as not to look like surgical scars. The UAL procedure is considered to have three stages:38 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 TABLE 5 Access Incisions for UAL by Anatomic Area (Reprinted with permission from Rohrich RJ, Beran SJ, Kenkel JM: Ultrasound-assisted Liposuction. St Louis, Quality Med Pub, 1998.) A perioperative log sheet is used to accurately document events during liposuction. This record helps in maintaining appropriate fluids and blood pressure.38 The authors143 stress the importance of primary and 13 SRPS Volume 10, Number 22, 2008 secondary endpoints for assessing completion of UAL (Table 6). TABLE 6 Primary and Secondary Endpoints for UAL and SAL (Reprinted with permission from Rohrich RJ, Beran SJ, Kenkel JM: Ultrasound-assisted Liposuction. St Louis, Quality Med Pub, 1998.) Graf and colleagues144 present a series of 348 patients treated with a 3-stage technique consisting of infiltration, ultrasound-assisted sculpturing, and suction-assisted 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 describe their technical evolution to cases with smaller volumes of liposuction and higher energy settings and expressed themselves satisfied with the resultant improved contour. Perez and van Tetering145 review 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 followed by 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 carry out UAL to final contour. Since much of the already-destroyed tissue is still in the subcutaneous space awaiting evacuation, overtreatment invariably produces a 14 contour deformity. Adherence to the endpoints mentioned above is critical to the success of UAL. Over the last few years the trend has been toward the use of solid probes and away from hollow cannulas. Beckenstein and Grotting146 review their experience with solid-probe UAL in 100 consecutive cases, including advantages and disadvantages of the technology. Jewell and coauthors147 report 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.”147 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 review their results in 77 patients and find the VASER system to be safe and efficient for body contouring surgery. De Souza Pinto and associates148 present 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 diameter 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 describe their technique, including power and time limits and complementary use of SAL and PAL, with case examples. They claim 70–90% cellular disruption with the VASER and fewer complications as a result of the lower applied energy. A series of VASER liposculpture cases by Hoyos and coworkers149 is testimony to the wide range of patients that can be treated with this 3-stage technique. SRPS Volume 10, Number 22, 2008 The authors apply VASER in multiple modes to different fat layers—eg, continuous mode in the intermediate fat; low-energy pulse mode for superficial definition. The reported seroma rate was 6.5%, with a 2.94% port burn rate and a steep learning curve. The results presented are impressive. External Ultrasound-assisted Liposuction The standard device for external UAL delivers energy in the range of 1–1.5W/cm2 and is used in conjunction with subcutaneous infiltration. The combination of the two modalities delivers power in the range of 3W/cm2. Either a 5- or 10cm head is used following subcutaneous infiltration. A surgical coupler must be used for proper transmission of ultrasound energy and safety. Times range from 2–10 minutes depending on treatment site (Table 7).150 Once the application of energy is completed, traditional liposuction is used for fat removal.38 The safety of external ultrasonic lipoplasty was confirmed by Rosenberg and Cabrera150 in a review of 160 consecutive patients. TABLE 7 UAL Times by Body Area (Reprinted with permission from Rosenberg GJ, Cabrera RC: External ultrasonic lipoplasty: an effective method of fat removal and skin shrinkage. Plast Reconstr Surg 105:785, 2000.) The benefit of external ultrasound in body contouring has been questioned. Rohrich and others151 compared lipoaspirates of four body regions in 6 women treated for 7 minutes with a) traditional liposuction; b) internal UAL; c) external ultrasoundassisted liposuction; or d) external massage. Histologic analysis of the specimens showed 70–90% cellular disruption with internal UAL and no significant effect of external ultrasound or massage on adipocytes. These findings were confirmed clinically by Lawrence and Cox,152 who evaluated 19 patients (25 sites) in a double-blind study of external ultrasound vs traditional tumescent liposuction. The results were assessed 1 month postoperatively by patients through a questionnaire and by physicians using a visual analog scale. Histologic specimens were also inspected. Although 4/19 patients saw an advantage in the external ultrasound side, the doctors found no difference between treatment and control sides in 14/19 patients. Power-assisted Lipoplasty Power-assisted lipoplasty (PAL) is the latest technology said to further refine suction lipectomy.153 Introduced in the 1990s, power liposuction used compressed air and has been called “vibroliposuction,” though it now operates by means of a gas or electric turbine.154 The majority of PAL systems currently rely on electricity and a variablespeed motor to generate a reciprocating motion and produce a cannula excursion of 2–4mm, 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 vs traditional SAL in 30 patients, Fodor and Vogt155 found no difference between sides with regard to 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 1064nm Nd:YAG laser to transmit low-level energy to adipocytes, which expand and rupture.156 A flexible fiberoptic light is inserted into the tissue through a 1mm cannula under local anesthesia. The position of the cannula is monitored via transillumination from a red guiding beam. Histologic analyses of the effects of the pulsed Nd:YAG laser on human fat tissue have demonstrated reversible cellular damage (tumefaction); irreversible tissue damage (lysis); and 15 SRPS Volume 10, Number 22, 2008 reduced bleeding compared with conventional lipoplasty.156 Ichikawa157 traced the histologic effects of the pulsed Nd:YAG laser on human tissue. Excised human skin and subcutaneous fat were irradiated with a 1064nm laser at 40Hz and 150mJ and 100ms-long pulses and compared with non-irradiated tissue. An 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 demonstrated areas of necrosis 1mm in diameter—ie, energy scatter and a thermal conduction effect by the tissue. Interestingly, Brown et al156 reported no effect on human and porcine adipocytes by the 635nm low-level laser using similar techniques, contradicting the previous studies. Mordon et al158 compared a pulsed 1064nm Nd:YAG and CW 980nm 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 histologic effects on adipocytes with the two lasers at similar energy settings, but infer an advantage to the higher-power diode laser. Further safety studies are indicated. A comparison study by Kim and colleagues159 evaluated the safety and efficacy of a 1064nm Nd:YAG laser in a group of patients with small focal areas of fat. The authors report 37% clinical improvement and 17% reduction in fat volume on quantitative MRI compared with controls. The higher the energy, the greater the volume of reduction. A 5cm3 reduction of fat volume was observed with 3000J and a 20cm 3 volume reduction was obtained with 12000J. Common side effects were mild bruising and swelling. Large-volume areas may require high amounts of total energy. Goldman160 reported a series of 82 patients who underwent submental treatment of lipodystrophy with an Nd:YAG laser at 1064nm wavelength using 6W power, 40Hz frequency, 150mJ energy, and 100ms pulse width, followed by standard suction to remove the laser lipolysis debris. The author notes a significant 16 cosmetic improvement. Comparative histology of samples taken immediately after the procedure and 40 days after showed initial rupture of adipocyte membranes as well as collagen coagulation and channels in fatty tissue. Small blood vessels were coagulated. Clinical skin tightening effects and collagen reorganization was noted on follow-up. Complications included two instances of asymmetry. Suction Lipectomy in Men In his first survey, Dillerud 161 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. Dillerud’s later survey, 162 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, since much of the abdominal protruberance may be caused by intraabdominal fat that cannot be corrected by suction lipectomy.163 Periumbilical hernia must also be ruled out. Mentz and coworkers164 described differential liposuction of the abdomen to better delineate the musculature in male athletes. In a technique they call etching, the authors perform localized superficial liposuction to deepen the natural grooves and furrows and enhance muscle definition. They report good to excellent results and minimal risks in 8 men. Caution should be used when applying this technique, as it can lead to an excessively high rate of contour irregularities. Large-volume Liposuction Large-volume liposuction was defined by the Liposuction Task Force of the American Society of Plastic Surgeons as lipoaspirate volume greater than 5000mL. As the liposuction technique became more refined over the next 15 years, more and more patients (and their physicians) sought larger and larger lipoaspirates. Large-volume liposuction is a safe procedure if performed in properly selected, healthy patients in the appropriate environment. Because of the magnitude of the operation and amount of fluids infiltrated and SRPS Volume 10, Number 22, 2008 removed, special attention must be paid to resuscitation to avoid volume overload. Rohrich, Beran, and Kenkel 38 recommend maintenance intravenous fluids for the first 5L of aspirate and replacement of further losses with 0.25mL IV for every 1mL aspirated over 5L. Additionally, lidocaine is decreased to 15mL of 1% xylocaine/L and a Foley catheter is used. A couple of outcome studies of large-volume liposuction are reviewed. Cardenas-Camarena and coworkers165 treated 161 patients during a 4-year period. Lipoaspirate volumes ranged between 5L and 22.3L with a mean of 8.7L. The average reduction of hemoglobin and hematocrit at 1 week was 3.8% and 12%, respectively. No major complications were noted. There were 2 cases (1.2%) of superficial cutaneous necrosis, 18 (11.2%) seromas, 24 (14.9%) palpable irregularities, and 92% patient satisfaction. A similar study by Albin and de Campo166 encompassed 181 patients. Two patients (1.1%) developed pulmonary embolism and one patient (0.6%) had deep venous thrombosis. Other Applications of Liposuction McEwan and colleagues167 as well as Dowden et al168 report suction lipectomy in the management of hematomas and fat necrosis developing after facelifts and other nonsurgical trauma. Several authors169–174 have also used liposuction to remove lipomas. Spinowitz175 and Collins et al176 cite reports of suction lipectomy for the correction of axillary hyperhidrosis,177–179 buffalo hump, 180 and 179,181–183 lymphedema. To these we can add benign symmetric lipomatosis (Madelung’s disease), 179 cherubism,184 and flap debulking and defatting.179,185,186 The reader is encouraged to study these reports before embarking on suction lipectomy for special applications. As the number of patients who use HIV protease inhibitors increases, and the drugs are taken for everlonger times, syndromes involving abnormal fat distribution may be seen. These 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 and colleagues187 describe suction-assisted 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 Kenkel 188 described the use of ultrasound-assisted liposuction for the management of these patients who they deem as “more fibrous.” Complications Gargan and Courtiss189 characterize the risks of suction lipectomy as undesired sequelae, such as surface contour irregularities, hypesthesia, edema, ecchymosis, and discoloration, and 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. There frequency 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 cannulas inserted through multiple incisions; cross-radial tunneling; combined superficial and deep suction; and feathering of the treatment areas. Because contour irregularities may respond to massage, they should be treated conservatively for at least 6 months after the initial surgery. Chang190–192 uses multiple techniques for correction of postliposuction contour deformities. Methods of correction include liposuction in the area of protruberance, liposuction around the area of depression, simultaneous fat grafting, dermolipectomy for sagging skin, and grid pattern markings for liposuction. For mild 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 will be 17 SRPS Volume 10, Number 22, 2008 discussed later in this review. More recently the author192 advocates liposuction following grid pattern markings, which in his experience yields fewer contour irregularities. A survey of US and Canadian plastic surgeons published by Pitman and Teimourian193 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, Ely, and Hoffman194 identified 5 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 3 patients died as a result of intraoperative hypotension and bradycardia. One of these patients had a postmortem lidocaine concentration of 5.2mg/L. One patient died of fluid overload and one died as a complication of deep venous thrombosis. While the above analysis suggests that lidocaine contributed to the deaths, there was no objective evidence of this.195,196 Hughes197 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 of lipoplasty are listed in Table 8. Combining liposuction with other procedures dramatically increases the mortality rate (Table 9). In 2003 Matarasso198 surveyed members of the American Society of Plastic Surgeons and reported a 15% response rate, representing the experience of 497 board-certified plastic surgeons who performed 20,029 abdominal contouring procedures over 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 with respect to wound infection, 18 blood transfusion, anesthetic complications, pulmonary embolism, and malpractice actions. Contour irregularities were reported in 9.2% of 7010 abdominal liposuction procedures—the most common local complication. TABLE 8 Nonfatal Complications from Lipoplasty Alone and in Combination with Abdominoplasty (Reprinted with permission from Hughes CE 3rd: Reduction of lipoplasty risks and mortality: an ASAPS survey. Aesthetic Surg J 21:120, 2001.) TABLE 9 Deaths from Lipoplasty, 9/1/98 to 8/31/2000 (N=94,159) (Reprinted with permission from Hughes CE 3rd: Reduction of lipoplasty risks and mortality: an ASAPS survey. Aesthetic Surg J 21:120, 2001.) On the basis of the findings by a lipoplasty task force, many ASAPS members have modified their SRPS Volume 10, Number 22, 2008 technique to enhance aesthetic outcomes and patient safety (Table 10). The importance of operating in an accredited surgical facility cannot be understated and is clearly emphasized in this review.197 TABLE 10 Changes in Lipoplasty Technique (33% of Respondents) (Reprinted with permission from Hughes CE 3rd: Reduction of lipoplasty risks and mortality: an ASAPS survey. Aesthetic Surg J 21:120, 2001.) Grazer and de Jong’s199 reported the results of a survey of 1200 actively practicing, board-certified plastic surgeons. There were 95 fatalities in nearly 500,000 lipoplasties, for a mortality rate of 1 in 5,224, or roughly 19 in 100,000. Of these deaths, 23% were due to pulmonary thromboembolism. The fact that this was a random survey makes it difficult to estimate morbidity and mortality associated with the procedure. In his discussion of this paper, Rohrich200 lists guidelines for safety in liposuction (Table 11). Reported complications of the tumescent technique include pulmonary edema201 and several cases of acute median nerve compression from injection of fluid in the arm.202,203 In early 1998 the American Society of Plastic Surgeons issued a warning based on the findings of the lipoplasty task force. The statement defined large-volume liposuction as that in 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 recommends 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 largevolume lipoplasty.”204 TABLE 11 Safety Guidelines in Liposuction (Reprinted with permission from Rohrich RJ: Discussion of “Fatal outcomes from liposuction: census survey of cosmetic surgeons” by FM Grazer and RH de Jong. Plast Reconstr Surg 105:447, 2000.) Several problems are associated specifically with UAL, including seroma formation, hyperpigmentation, thermal injury, and 134 dysesthesias. Measures to minimize or eliminate complications include adopting a 3-stage technique, skirting areas prone to hyperpigmentation (eg, the medial thigh), and guiding treatment time by the previously mentioned endpoints. 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 (eg, 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; more common is some ulceration or friction injury to the skin at the entrance site from incorrect use of the cannula, tension on the skin margins, or an incision that is too small. Pardo Mateu and Chamorro Hernandez205 present 3 cases of cutaneous hyperpigmentation following 19 SRPS Volume 10, Number 22, 2008 liposuction. They believe the etiology to be 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 may be contributing factors in the development of hyperpigmentation after liposuction. Goddio126 studied skin retraction in 458 subjects 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 advocates a combination of facelift and suction lipectomy when there is skin and fat ptosis in the face. Pitman, Aker, and Tripp 206 reviewed their experience with 147 patients (136 women, 11 men) who had outpatient liposuction by the tumescent technique with >1000mL of aspirate (mean 2229mL) and no other concurrent procedure. All areas of the body were treated, and most patients had 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 180mL, 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. Dillerud 161 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 well as moderately obese patients. A body mass index greater than 35 was a contraindication to suction lipectomy. The overall complication rate in Dillerud’s series 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 10.8% of patients and consisted largely of asymmetry, underresection, and skin irregularities. 20 The medial thigh, buttocks, ankle, and face were least amenable to suction as reflected by the high percentage of complications and undesired results in these areas. Dillerud 162 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, and patients were most pleased with the outcome of treatment for pseudogynecomastia and in the submental area. There was no significant difference in subjective assessment of outcome between men and women. Illouz 207 summarizes his vast experience of liposuction and its complications in a Clinics review. Broughton and coworkers208 reported satisfaction data provided by liposuction patients operated on 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 was reported in 43% and 65% of patients repectively; the abdomen was the most common site of fat return. Most patients said they would have the procedure again and would recommend it to others. Most patients also reported having less than one week of discomfort and narcotic use. Dissatisfaction related to pre-existing low self-esteem. In another patient satisfaction study, Rohrich and associates209 conclude that weight gain after liposuction did not significantly affect satisfaction with the procedure. Among patients who gained weight postoperatively there were no appreciable lifestyle changes such as diet and exercise, which factored into the results of surgery and their opinion on selfappearance. In conclusion, the liposuction patient should embrace positive lifestyle habits, and this lesson should be reinforced by the plastic surgeon. The question of whether pregnancy permanently reverses the positive effects of suction lipectomy was addressed by Ahkami.210 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. SRPS Volume 10, Number 22, 2008 Retroperitoneal and paraspinous muscle hemorrhage and necrotizing fasciitis have been reported following liposuction.211–213 Mesotherapy Mesotherapy was first described by Michel 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.214 Intralesional injections of phosphatidylcholine were first presented in 1988 as treatment of xanthelasma. Currently phosphatidylcholine is combined with deoxycholate for the treatment of adipose tissue. 214 Rotunda et al215 differentiate mesotherapy from phosphatidylcholine injections through an extensive comparative review of the literature. They seek to distinguish between the techniques and conclude that neither is substantiated by clinical studies. The PSEF Device and Technique Assessment (DATA) Committee reviewed the scant literature on the safety and efficacy of mesotherapy for body contouring, along with the use of isoproterenol and phosphatidylcholine and the mechanism of lipolysis.216 The technique described includes multiple-site injection of phosphatidycholine in typical doses of 100mg for every 5x5cm area. Three to 6 treatments are usually required, with a 2-week interval between sessions. Rittes and colleagues217 studied 50 patients of ideal weight who had injections of phosphatidylcholine into focal fat deposits in various sites. Seventy percent of patients had 4 treatments, 20% had 2 treatments, and 10% had one treatment. The interval between treatments averaged 15 days. Bruising, edema, and erythema were evident for 48–72 hours, with postinflammatory nodules and hematomas seen for up to 30 days. Pre- and postprocedural 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.218 Gynecomastia Ultrasound-assisted liposuction (UAL) plays a major role in the treatment of gynecomastia. Rohrich and colleagues219 refined Simon’s classification system220 and incorporated UAL into the management algorithm (Table 12). The etiology of gynecomastia includes developmental and drug-induced causes, hypogonadism, tumors, systemic illnesses, congenital disorders, and familial, idiopathic, and miscellaneous causes221, 222 (Table 13). The common drugs that may lead to abnormal breast enlargement in men are listed in Table 14. The authors classify gynecomastia based on the degree of hypertrophy, whether the tissue is glandular or fibrous, and the degree of ptosis. They successfully treated 53/61 patients (87%) with liposuction alone. Skin excision is reserved for extreme cases with severe ptosis. Their technique consists of a lateral inframammary crease incision, obliteration of the zone of adherence at the inframammary fold, and tapering TABLE 12 Classification and Management of Gynecomastia (Reprinted with permission from Rohrich RJ, Ha RY, Kenkel JM, and Adams WP Jr: Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. Plastic and Reconstructive Surgery® 111:909, 2003.) 21 SRPS Volume 10, Number 22, 2008 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.223 TABLE 13 Causes of Gynomastia incision was needed. Technical details include plastic ports, continuous saline irrigation, a probe sheath, continuous movement, and avoidance of end-hits. The inframmary fold was disrupted. The average volume of lipoaspirate was 504mL per breast. No complications were reported. Patient self-assessment scores were excellent, and only one patient requested a secondary procedure. TABLE 14 Drug-Induced Gynecomastia (Reprinted with permission from Glass AR:Gynecomastia endocrinol Metab Clin North Am 23: 825, 1994.) (Adapted from Glass AR Gynecomastia Endocrinol Metab Clin North Am 23:825, 1994; and Neuman JF:Evaluation and treatment of gynocomastia Am Fam Physician 55: 1835, 1997.) Hodgson and others224 reviewed 13 men who were treated for gynecomastia with ultrasonic liposuction. An inframammary incision was used in most cases; occasionally an additional anterior axillary fold 22 Rosenberg225 used traditional liposuction for the treatment of gynecomastia. Later the author recommended a combination of 7mm and 2.4mm cannulas to remove the relatively heterogeneous fattyfibrous tissue.226 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 and coworkers227 applied a multimodal approach in 45 patients with various degrees of gynecomastia. Standard liposuction was performed via three incisions, two lateral axillary and SRPS Volume 10, Number 22, 2008 one central, with a pull-through technique. The authors report a 4.4% hematoma rate. Ramon and associates228 reviewed a 17-patient experience with gynecomastia of variable severity. They used a multimodal approach consisting of crosschest, power-assisted liposuction via a contralateral periareolar incision combined with endoscopicassisted 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. There were no complications reported. Hammond and coworkers223 reviewed their experience with single-stage, combined ultrasonic liposuction with the pull-through technique in 15 patients. A periareolar incision was used for the entire procedure. The overall complication rate was 18.5%. Tashkandi and others229 report using a single-stage 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 is used for skin closure. Mild skin redundancy was noted in all patients postoperatively, but no secondary procedures were deemed necessary. Aiche230 describes an excisional technique for the treatment of residual deformities of gynecomastia after traditional liposuction. The author cautions against removing central or peripheral adipose tissue without addressing the underlying mammary tissue. GLUTEAL AUGMENTATION The gluteal area has received increasing attention in body contouring surgery, particularly after massive weight loss. Cuenca-Guerra and colleagues231 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 was corrected with liposuction; a combination of liposuction and various designs of submuscular gluteal implants was used to correct Types 2 to 4; and Type 5 was corrected by dermocutaneous adjustments. Centeno and others232 describe eight aesthetic units of the gluteal region that should be considered when formulating the preoperative plan, for the placement of the incision, and in 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 authors have described modalities to augment the buttocks for increased projection and to decompress the surrounding areas with liposuction to sculpt the gluteal region. Mendieta233 divides the buttocks into an upper, a middle, and a lower zone, each with its own subdivisions. His evaluation takes into account buttocks volume, shape, and skin quality/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. Gonzalez234 reviews 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. The safety of gluteal implants has been questioned and has led to the development of autologous modalities for buttocks augmentation in the United States. Autologous flaps and fat injections have become popular due to the rising number of patients who seek body lift procedures after massive weight loss.235 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.236 23 SRPS Volume 10, Number 22, 2008 Rohde and colleagues237 describe their technique to improve gluteal contour in 62 post-bariatric surgery patients. 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 their 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 al238 present 20 patients who underwent circular (belt) lipectomy in combination with dermal fat flaps for body contouring after massive weight loss. The superomedially based dermal fat flap is rotated caudally 180° into a subcutaneous pocket on either side. This refinement adds 30 minutes to the operative time, but the shape and projection of the buttocks is much improved. Patient satisfaction was high despite minor complications in 7 cases. Raposo-Amaral and others235 describe their experience with bilateral dermal fat rotation flaps in 9 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. CT scans of 2 patients at 6 months showed viable flaps. Three patients (33%) had complications: a hematoma, a seroma, and widened scars. Colwell and associates236 used superior gluteal artery perforator flaps for autologous gluteal augmentation in 18 patients who underwent body lift procedures after massive weight loss. 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 6–9cm 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 5cm above the inferior gluteal crease in a suprafascial plane. The autologous augmentation required an additional 60 minutes to complete. Wound 24 dehiscence was the most common complication. One flap suffered major fat necrosis. Autologous fat injections have been applied to multiple anatomic areas as a volumetric filler. Murillo239 describes a 7-year, 162-patient experience with fat injections in the buttocks. The average injection was 700cc. The fat was harvested from multiple sites with a 5mm cannula, decanted and then injected with the same cannula into the upper twothirds of the gluteus muscle. Six patients were followed with serial MRI studies and showed retention of the intramuscular fat for up to 12 months. Clinically there was only 20% volume loss and high patient satisfaction. ABDOMINOPLASTY INDICATIONS The goals of abdominoplasty are to improve the contour and external appearance of the abdominal wall while leaving well-concealed scars and a naturallooking 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 may be concentrated primarily above the umbilicus, below the umbilicus, or at the waistline.45 Generalized obesity with increased intraabdominal fat is typical of male patients, while elderly women usually present with a lower abdominal apron of skin and fat. General contraindications to abdominoplasty are significant medical comorbidities, gross obesity with a BMI >30, future pregnancy, and supraumbilical abdominal scars. CLASSIFICATION Matarasso240 classifies abdominal deformities based on severity of the skin, fat, and muscular flaccidity, and selects the most appropriate surgical technique for abdominal contouring. Rohrich and colleagues38 use a modified Matarasso classification that is based on clinical assessment of the degree of skin redundancy, SRPS Volume 10, Number 22, 2008 amount of abdominal fat, skin thickness and tone, and status of the abdominal musculature. SURGICAL ANATOMY Huger241 studied the changes in blood supply of the abdominal wall after abdominoplasty and recognized three vascular zones: Zone I, midabdomen, supplied by the deep epigastric arcade Zone II, lower abdomen, supplied by the external iliac artery Zone III, lateral abdomen, supplied by the intercostals, subcostal, and lumbar arteries Depending on the technique employed, one or two zones may be sacrificed, leaving the resulting flap perfused via Zone III. Current lipoabdominoplasty techniques may preserve Zones I and III with limited discontinuous undermining of the abdominal flap. Matarasso initially gave technical guidelines for safe concomitant liposuction and abdominoplasty, and recommended caution when suctioning the upper central flap.240,242 Graf243 demonstrated preservation of abdominal perforators 1mm in diameter after lipoabdominoplasty with limited upper abdominal undermining. This was evaluated with color Doppler flowmetry in 20 patients 15 days after surgery. Blondeel et al244 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. There was no difference between the groups, though extravasation was seen in both. The low rate of central flap necrosis in the lipoabdominoplasty literature may show that this extravasation may not be clinically relevant. Grazer245 emphasizes the relation of the superficial nerves to various abdominoplasty incisions, and notes that the lateral femoral cutaneous nerve is susceptible to injury during the flap sculpting incisions near the groin, where the nerve emerges from the inguinal ligament at a point close to the anterior–superior iliac spine. 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 given case ultimately depends on the location of most of the fat.47 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 may 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 a 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.246 The skin is closed in layers with absorbable suture material. Closed suction drains are placed under the abdominal flap. Lockwood247 presents 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 superficial fascial system (SFS) repair, and significant truncal liposuction. This technique improves waist contour, decreases central tension, and maintains scar position. The author thoroughly reviews his intraoperative and postoperative management for both abdominoplasty and body lifts.248,249 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 Pollock250 present 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 25 SRPS Volume 10, Number 22, 2008 anchor the abdominal flap, distributing tension and reducing dead space. No drains were used in his series of 65 patients and no seromas were reported. A lipoabdominoplasty combines aggressive abdominal and flank liposuction with central undermining for midline fascial plication and superficial skin resection. Saldanha and coworkers251 report on 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 performed by means of a narrow retractor. The advantage of this technique is that it preserves the perforating vessels, nerves and lymphatics. Two seromas were aspirated. Brauman 252 published his results with lipoabdominoplasty in a series of 43 patients. The surgical technique employed was similar to 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 when there is significant abdominal wall laxity. The procedure is performed using local anesthesia with sedation. describes his technique of Avelar 253 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 full thickness with a star-shaped neoumbilicus and the wound is closed in multilayered fashion with absorbable sutures. The most common complication was seroma. Cardenas-Camarena254 recounts a 7-year experience with circumferential liposuction–abdominoplasty in 310 women. His technique involves suction-assisted lipectomy combined with abdominoplasty and limited central undermining. The average amount of lipoaspirate was 3700cc; 86% of patients were considered to be overweight. Minor complications 26 occurred in 20% and major complications in 1.3%; 46 patients (15%) required autologous blood transfusions. Lipoabdominoplasty was applied to 60 patients after massive weight loss by Espinosa-de-los-Monteros and colleagues.255 The average BMI in this population was 31. The author reports 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. A fleur de lis excision is indicated for lower medial obesity with significant panniculus adiposus. This pattern of resection incorporates Castanares’s vertical wedge incision in the upper abdominal midline256 with Regnault’s shallow-W excision in the lower quadrants.45,46 The vertical component can be carried as high as the xiphoid and as low as the perineum for simultaneous reduction of the mons pubis.256,257 The operation improves the abdominal contour and redefines the patient’s waist. Persichetti and colleagues 258 describe their abdominoplasty technique in 42 patients with preexisting median or paramedian incisions. An anchor-like incision is preferred. Seromas occurred in 7% of patients, all of whom were obese and diabetic. Minor skin necrosis was seen in one case. Fernando da Costa and others259 present their results with a modified vertical abdominoplasty technique in 48 patients after massive weight loss. The advantages of the technique are improved abdominal contour with vertical and horizontal correction of redundancies; minimal lateral undermining; and decreased operative time, bleeding, and cost thanks to the rapid en bloc resection. The authors applied the technique to patients without a preexisting vertical scar. The most common complication was epidermolysis at the inverted T-junction and umbilicus in 8%. MUSCULOFASCIAL REPAIR Regnault46 believes that most women who have had multiple pregnancies have some laxity of the musculoaponeurotic fascia, if not true diastasis recti, and therefore performs anterior sheath plication in 90% of patients requesting abdominoplasty. Likewise SRPS Volume 10, Number 22, 2008 Pitanguy 43 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. Nahas260 developed an objective classification for abdominoplasty based on the musculoaponeurotic deformity. The author recommends specific treatments to optimize correction of the abdominal deformity. Talisman and colleagues261 analyzed the results of abdominoplasty in a series of 18 patients, 3 of whom had significant diastasis repair (>12cm). These 3 patients had bladder pressures >24cmH20 intraoperatively and >20cmH20 postoperatively, compared with mean bladder pressures of 8cmH20 intraoperatively and 15cmH20 postoperatively in patients who did not have diastasis repair. All diastasis repair patients had varying degrees of respiratory distress postoperatively, and one required reintubation. Two of them had history of previous pulmonary thromboembolic events and were treated with anticoagulants after their respiratory difficulties. The author cautions against aggressive correction of large diastasis with ensuing increased intraabdominal pressure. Van Uchelen and associates262 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. Of these, 40 were willing to attend a follow-up consultation and submit to an ultrasound to gauge the competence of the fascia. At a mean 64 months postoperative, 40% of patients had residual or recurrent diastasis. The authors recommend against the use of absorbable material for musculofascial plication. Alternative techniques consisting of vertical and lateral plication may improve the waistline and prevent epigastric bulging. Nahas263 reports 2 cases of recurrent diastasis recti after abdominoplasty. Preoperative CT scans demonstrated 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. UMBILICOPLASTY The aesthetically pleasing navel shows a pronounced dimple, invagination of the surrounding tissue, and slight superior hooding. Dubou and Ousterhout246 studied 100 subjects of normal weight and found that, regardless of sex or race, the umbilicus lay at the level of the superior iliac crests and midway between the xiphoid and pubis. After periumbilical defatting and rectus plication, the umbilical pedicle is shortened as necessary and affixed to the midline fascia in its new position.46,264 Two to four transfixing sutures are taken through the skin flap, rectus fascia, and umbilical island. Pascal265 emphasizes 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 and colleagues266 describe 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. They report 2 complications in 15 female patients (13.3%), one dehiscence and one umbilical prolapse. Baroudi264 describes techniques for correction of secondary deformities and construction of a new umbilicus. Typically a 4–6cm 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 12–16 days. Sugawara and colleagues267 reconstruct 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. Hypertrophic periumbilical scars usually disappear by 18 months. No revision should be contemplated before this time. 27 SRPS Volume 10, Number 22, 2008 MINI-ABDOMINOPLASTY In 1986 Wilkinson and Swartz268 described a limited abdominoplasty for body contouring in patients who had mostly infraumbilical excess of skin and fat. The defining characteristics of the limited technique are short, upturned incison lines; skin resection; plication of the fascia; liposuction; umbilical stalk separation; and closure of the umbilicus in the midline. 269 Wilkinson269 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 about 2cm (umbilical “float”), which eliminates skin laxity in the upper abdomen. Greminger270 reported 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 for the classic 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. Gradel271 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 12–16cm long. Superior dissection and muscular plication are facilitated by transecting the umbilical pedicle. Shestak272 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 28 changes, and the 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.269 The use of liposuction without skin resection has been evaluated and can be applied to a select patient population. Omranifard and colleagues273 compared 40 class II abdominoplasty patients who were randomly assigned prospectively to one of two groups, a miniabdominoplasty with rectus plication and a matched UAL group. The mean weight of tissue removed in both groups was 2kg. 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 274 followed 32 patients who underwent circumferential ultrasound-assisted liposuction and direct abdominal wall plication through a periumbilical incision as an alternative to conventional abdominoplasty. These patients had minimal skin laxity, moderate fatty tissue, midline diastasis, and no concerns about striae. The total amount of lipoaspirate averaged 2400cc. Patient satisfaction was acceptable and surpassed their expectations. One patient desired further skin excision and another requested further liposuction. There was a 15.6% seroma rate despite the use of drains. ABDOMINOPLASTY IN MALES Mladick 275 reviews body contouring in men and describes technical points specific to the male abdominoplasty. Men generally have thicker, less elastic skin than women. Except in cases of massive weight loss 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. SRPS Volume 10, Number 22, 2008 Matarasso276 reviews his experience with male body contouring and distinguishes between the male and female torso. Men tend to have more intraabdominal fat and thicker, less distensible skin than women, which makes men better candidates for SAL; 84% of the author’s male patients had SAL-only for abdominal contouring. Full abdominoplasty or a panniculectomy is more common than limited excisional surgery in men seeking body contouring. Lockwood277 believes that men with prominent abdomens who are both diet- and exercise-resistant may have familial fat deposits and significant rectus diastasis. If examination reveals a rectus diastasis, he considers it the primary indication for endoscopically assisted abdominoplasty without skin resection. Liposuction of any fat deposits can be done at the same time. abdominoplasty. Each group consisted of 10 women who had full abdominoplasty with midline rectus plication. The infusion pump group resumed normal activities sooner, required less narcotic administration, and rated their recovery as better than the control group. Patient satisfaction after abdominoplasty is generally high. Bolton et al281 evaluated 30 consecutive female abdominoplasty patients preand postoperatively in terms of body self-image, psychological investment in appearance, and general psychosocial function. Body image was significantly improved, with positive changes in the patients’ assessments of their overall appearance, selfconsciousness levels, and how often they avoided body exposure during sexual activity. No differences were recorded in psychological investment in appearance or psychosocial function. PERIOPERATIVE MANAGEMENT COMPLICATIONS Kryger and coworkers278 review a 6-year experience with 153 consecutive abdominoplasties, 92% of which were performed with the patient under conscious sedation with local anesthetic infiltration. There were 80% adjunctive cosmetic procedures and 8% abdominal hernia repairs. No medical complications or conversions to general anesthesia were reported; 73% were discharged home after their procedure; and 3 patients were readmitted to the hospital for postoperative nausea. Minor complications were noted in 11%, seroma being the most common (6.5%). Patient satisfaction was high, recall was minimal, and most were likely to request conscious sedation for further procedures. The authors claim the benefits of rapid recovery and a high margin of safety. Mast and associates279 present a retrospective study of 35 full abdominoplasties; 17 cases were done as inpatient and 18 as outpatient surgeries. No difference in complication rate was noted. Postoperative pain and nausea were controlled adequately in either case and patient satisfaction was similar. Mentz and others280 compared the use of a regional infusion pain pump plus standard oral/intramuscular pain medication versus standard oral and intramuscular pain medication alone in In 1977 Grazer and Goldwyn282 published the results of a survey of members of the American Society of Plastic Surgeons on complications of abdominoplasty. The report is based on 958 replies representing a minimum 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 American Society of Plastic Surgeons on abdominal contouring received 15% responses, representing a total of 20,029 cases including abdominal liposuction, limited abdominoplasty, and full abdominoplasty.283 Ninetytwo 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 29 SRPS Volume 10, Number 22, 2008 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 and others284 reviewed the records of 199 abdominoplasty cases performed over a 15-year period in an attempt to identify factors that affected the outcome. The overall complication rate was 32%; 1.4% were major complications. The revision rate was 43%. Minor complications were significantly higher in smokers and in patients with diabetes or hypertension. There was no statistically significant difference between patients who had concomitant intraabdominal procedures with abdominoplasty and patients who had abdominoplasty alone. Complications were magnified in obese patients (86%). Similarly, Vastine and colleagues 285 note 80% complications of abdominoplasty in obese patients. The complications were mainly wound related. Kim and colleagues286 compared the results in patients who had abdominoplasty with and without flank liposuction. Liposuction patients were substratified into standard or ultrasound-assisted liposuction. The average amount of lipoaspirate was 763cc. 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 and coworkers287 reviewed the records of 258 women who had abdominoplasty at their clinic over 5 years. The authors report a significant higher rate of skin necrosis for patients who had a T type abdominoplasty (35.5%) than for those with infraumbilical plasties (1.4%) or full abdominoplasties with horizontal scars (4.6%). The revision rate was 29% and highly dependent on the patient’s willingness and the surgeon’s judgment. The authors stress the importance of proper informed consent and lengthy discussions with patients prior to surgery. Manassa et al288 reviewed the results of 132 abdominoplasties in 71 smokers and 61 non-smokers. Even though all patients were asked to refrain from smoking perioperatively, only 14% stopped before and 41% (temporarily) after surgery. Wound dehiscence was 3.2X more frequent in smokers, who also had 30 significantly longer hospital stays. Seroma, hematoma, and infection were not significantly affected by smoking. The number of cigarettes smoked had no effect on wound healing. A review of 101 consecutive abdominoplasties by Van Uchelen et al,289 with long-term follow-up of 86 patients, found an alarming 10% incidence of injury to the lateral femoral cutaneous nerve. Pitanguy’s analysis of his 40+ year experience with body contouring surgery, including 1300 abdominoplasties, reveals seroma to be the most common complication (Table 15). TABLE 15 Complications of Abdominoplasty at the Ivo Pitanguy Clinic, 1955-98 (%) (Reprinted with permission from Pitanguy I: Evaluation of body contouring surgery today: a 30-year perspective. Plast Reconstr Surg 105:1499, 2000.) Pitanguy discusses how refinements in the technique, such as preventing seroma by avoiding dessication of the dissected tissues, maintaining rigorous hemostasis, and appropriate placement of drains, reduced the frequency and severity of complications. He also incorporates a “plaster shield” for the first 2 postop days to maintain firm pressure over the abdominal flap and promote adhesion. REVISION SURGERY Matarasso and others291 present a group of 24 previous abdominoplasty patients who underwent revision procedures (6% revision rate). The patients were grouped into those who were operated 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. There was a 4% complication rate on revision. SRPS Volume 10, Number 22, 2008 COMBINATION PROCEDURES Reporting the results of a survey, Voss, Sharp, and Scott292 found higher morbidity, longer operative times, and longer hospital stays when abdominoplasty was combined with other common gynecologic operations than when either procedure was done separately. Perhaps more significantly, 6.6% of patients who had combination surgery had a pulmonary embolus within 18 days of the operation, whereas no pulmonary emboli occurred in patients who had single procedures. Hunter and colleagues293 confirmed a high risk of pulmonary embolus in patients with combined abdominal lipectomy and intraabdominal gynecologic procedures and urged caution when using this approach. The use of perioperative warfarin may reduce the incidence of pulmonary embolism in these patients and does not promote increased bleeding. Pitanguy and Ceravolo294 believe there is no difference in the frequency of clinical complications whether abdominoplasty is done by itself or in combination with gynecologic 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 Verheyden295 noted apparent safety of combined plastic and gynecologic surgical procedures in a series of 33 patients, each of whom was matched with two controls. Other than a significantly greater requirement for blood transfusion in the combinedsurgery group, the authors found no increased morbidity and the hospital length of stay was shorter by 2 days when the surgeries were combined. To avoid complications the authors recommend continued pressure monitoring; warmed inspired gases and intravenous fluids as well as warming blankets to prevent hypothermia; autologous blood replacement as needed; and concerted preoperative planning of the procedures by both surgeons. Gemperli and associates296 analyzed the medical records of 103 patients who had abdominoplasty at the time of other intraabdominal procedures. Of these, 24 had mini-abdominoplasty with or without liposuction and the rest had a standard full abdominoplasty. Autologous blood transfusions were required in only 3 patients; the maximum blood loss was 500mL. One seroma and one minor skin slough developed, but there were no infections, embolism, or other major complications. The authors conclude that abdominoplasty in combination with intraabdominal operation is a safe procedure when performed by a well-schooled surgical team. Hester at al297 reviewed the records of 563 patients who underwent abdominoplasty alone (117) or in combination with other major surgical procedures, either aesthetic (216) or intraabdominal/pelvic (230). They found similar morbidity and complication rates among the three groups regardless of the complexity of the procedure. The only identifiable risk factor in predicting major morbidity (pulmonary embolism) from the surgery was patient obesity. Cardoso de Castro and Cupello298 analyzed 60 cases of simultaneous abdominoplasty and breast reduction surgery and report a complication rate similar to that of either procedure alone. Likewise Stevens and colleagues299 retrospectively evaluated two populations: One group of 264 patients underwent abdominoplasty alone and a second group of 151 patients had simultaneous breast surgery. There were no major complications reported and no differences in minor complications between the groups. The type of breast operation and the BMI had no effect on complications. Wallach et al300 combined abdominoplasty with other procedures through the abdominoplasty incision in 29 patients. There were 30 ancillary procedures via the same incision, including flank liposuction in 23, breast augmentation in 6, 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%, seroma being most common. The authors 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 and others301 review the risks of cosmetic surgical procedures including abdominoplasty. 31 SRPS Volume 10, Number 22, 2008 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 pharmacologic intervention has been generally unsuccessful. Multimodality weight loss through diet and exercise and/or pharmacologic 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 significant weight loss but at the risk of eventual nutritional deficiencies, and require careful, long-term patient follow-up. Restrictive procedures alter the size of the stomach, limiting volume of intake. Vertical banded gastrioplasty and adjustable gastric bands fit into this category. They pose less operative and postoperative risk, but the rate of weight loss is slower. The more common techniques used in the U.S. 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. Massive weight loss patients present a very different profile than those who have not been obese. In conjunction with their extreme physical deformity after weight loss, the physiologic impact of bariatric surgery is prevelant throughout the postbariatric state. Nutritional deficiencies are more common in gastric bypass patients. The incidence of anemia is >50% and vitamin and mineral deficiencies occur in up to 30–40% of patients following gastric bypass. 32 Rubin and coworkers302 review the management of the postgastric bypass patient presenting for body contouring surgery. Patients are considered for body contouring surgery approximately 12–18 months after a bariatric procedure and must maintain a stable weight for a minimum of 2 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. Laparoscopic bariatric procedures decrease the risk of herniation, yet open techniques are still common. Simple hernia repair can be done in conjunction with body contouring surgery, but a large hernia necessitating component separation and ample undermining for correction should not be combined with aggressive body contouring procedures. Medical issues may 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 the surgeon should be aware of include psychosocial dysfunction, diabetes mellitus, cardiac disease, sleep apnea, pulmonary disease, gastroesophageal reflux, and concurrent medications.302 Prophylaxis for deep vein thrombosis is essential because obesity is an independent risk factor for deep venous thrombosis and pulmonary embolus.302 Nutritional adjustments depend on the type of bariatric procedure that was performed. Patients should be tested for subclinical protein deficiency, cobalamin deficiency, iron deficiency, and folate deficiency; if a feficiency is present, the levels should be corrected prior to undertaking body contouring. Fluid management should be monitored intraoperatively with a urinary catheter, and the use of colloid and autologous blood products should be considered.302 Wound complications can be avoided by allowing the bariatric patient to reach his/her ideal weight and stop smoking, and by using drains, conservative undermining, and prophylactic antibiotics. Cavallini and colleagues303 studied the effects of intraoperative warming on coagulation in two matched patient groups undergoing elective plastic surgery. All patients had a complete coagulation profile drawn 1 hour preoperatively and immediately SRPS Volume 10, Number 22, 2008 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. Activated partial thromboplastin times and bleeding times were significantly elevated in the control hypothermic group. No difference in hematoma rate or blood loss was seen. 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 and collegues304 review the preoperative, intraoperative, and postoperative care of a very complex patient undergoing panniculectomy. The authors present a safe, complication-free procedure based on a precise plan and team effort. Manahan and Shermak305 review their experience with panniculectomy after massive weight loss in 23 patients with average BMI of 43.7. The authors define panniculectomy as an abdominal skin resection of more than 10lbs, pannus suspension, horizontal fascial plication, and layered closure over drains. The average weight of the pannus in their series was 16.1lbs. Multiple other procedures were performed in conjunction with panniculectomy. Results: 20% received a blood transfusion; 20% had wound healing complications; seromas occurred in 28%; and uncomplicated healing was seen in 44%. There were no thromboembolic events or deaths. Aly306 states that most patients who do not lose enough weight after bariatric surgery will not lose more after interim operations. Combination panniculectomy procedures impose additional risk to the massive weight loss patient 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. Olejek and Manka’s307 experience with panniculectomy in combination with gynecologic cancer surgery included 90 patients with an average BMI of 47kg/m. The goal of the study was to show that a panniculectomy performed in the same setting as the oncologic procedure gives better exposure in obese patients without increasing the number of operative complications. The average weight of the pannus excised was 4900gm. Use of the harmonic scalpel resulted in 8% delayed healing vs 17% without the harmonic scalpel. There were 2 deaths in this very difficult population: one myocardial infarction and one pulmonary embolus. BODY LIFT A belt lipectomy is indicated for patients with generalized adiposity encircling the torso and including the back and upper buttocks. Belt lipectomies are commonly used to treat patients after massive weight loss, but also can be applied to other aesthetic patients with defined areas of skin excess. Carwell and Horton308 described a circumferential torsoplasty indicated for patients after considerable weight loss. The authors believe the technique helps improve the buttocks and lateral thighs as well as the trunk and abdomen. Aly and coworkers309 review the University of Iowa experience with belt lipectomy in 32 consecutive patients, stressing the importance of accurate preoperative markings. The authors’ operative technique incorporates both lateral decubitus positions and supine position. Not surprising in a procedure of this magnitude, they report 37.5% seromas, 9.3% pulmonary embolus, and one dehiscence requiring surgery. Nevertheless, their patients demonstrated significant improvement. This operation is not recommended for obese patients. Nemerofsky and coworkers310 review 200 body lifts performed over a 4-year period. The patients were classified into three types depending on body mass index before the body lift: type I, <28 BMI; type II, 33 SRPS Volume 10, Number 22, 2008 between 28 and 32; type III, >32. The surgical technique and preoperative markings are illustrated. Posterior markings were made in the flexed position to limit tension in the buttocks area. Nonabsorbable SFSdermal sutures were used to evert the incision edges. The senior author uses a circumferential standing preparation to facilitate an efficient, three-position technique: supine and lateral decubitus. 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 frequent 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 though it did lengthen the hospital stay and correlated with poor aesthetic outcome. Nemerofsky altered his technique during the study to reduce complications and believes that both the markings and suture technique (above) contributed to his success, though no data were provided. Rohrich et al311 present a large series of 151 patients who underwent central body lifting over a 12-year period by means of liposuction and extended abdominoplasty. The average preoperative weight was 130kg and 25.2% were classified as massive weight loss. 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 were operated while prone and then changed to a supine position. Ultrasound-assisted liposuction and conventional SAL by super-wet technique were used circumferentially in all. 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 length of stay was 2.1 days. The total complication rate in the series was 28.5%, the most common being seroma in 14.6%. The seromas were treated by sclerosing the cavity with doxycycline if drain output after 14 days was still high. The deep venous thrombosis/pulmonary embolus rate in their series 34 was 1.9%. Skin dehiscence and necrosis occurred in 2.6%. Pascal and Le Louarn312 describe a technique of body lift with high lateral tension. They emphasize 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 Lockwood72,248 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 into the bikini line. Posteriorly the incision curves downward to the top of the gluteal crease and may cross the midline. Undermining in the upper thigh avoids the femoral lymphatics. The author stresses the importance of complete SFS and dermal suspension. A retrospective study by Hurwitz313 of single-stage total body lift after massive weight loss traces the course of 8 patients. The procedure combines 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 IMF is moved superiorly. A reverse abdominoplasty in which the incisions do not cross the anterior midline and the lateral extensions continue posteriorly to remove the upper back redundancy is then performed, as well as liposuction of specific areas. The procedure begins in the prone position for the posterior lower body lift, then the upper body lift is 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 SRPS Volume 10, Number 22, 2008 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 mulptiple permanent #0 braided polyester sutures. A mastopexy and either autoaugmentation or implant augmentation can be employed in women, while UAL and tissue removal are indicated in male patients with gynecomastia. All patients received at least 1 unit of autologous blood; one patient received 4 units of blood. Operative times ranged 7–12 hours, and hospital length of stay was 3–4 days. The most common complications were skin dehiscence (50%) and wound seromas (40%). Endermologie was used in all patients postoperatively for edema reduction. scar widening, scar migration, and need for further excision were noted as complications. The traditional Lockwood horizontal excision does not address the circumferential tissue excess seen in most massive weight loss patients, and therefore a vertical excision has 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 316 (Fig 4). Liposuction and superficial dissection planes preserving the lymphatic channels and saphenous veins limit postoperative edema. LOWER EXTREMITY Medial Thigh Lift As surgical experience with postbariatric body contouring mounts, the technique of medial thigh lift continues to evolve. 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 postbariatric population. The fascial anchoring technique of Lockwoood’s72,247,248,314 is recommended to reduce the frequency of wound complications. Le Louarn et al315 modified it 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 (Colles’) without undermining or deepithelialization of the flaps. Lockwood reports no problems related to inferior scar migration, labial separation, or early recurrence of ptosis in 18 patients followed for up to 24 months.248 Le Louarn’s group present a 2-year, 25-patient experience with the short-scar technique. Delayed wound healing, Fig 4. Markings for a horizontal and vertical resection. (Reprinted with permisssion from Mathes DW and Kenkel JM:Current concepts in medial thighplasty. Clinics in Plastic Surgery 35: 151, 2008.) The combined horizontal and vertical excision for medial thigh lift relies on Colles’ fascia dissection and suture fixation. The dissection plane for vertical excision traverses only the superficial fascia and uses the saphenous vein as a marker. Both techniques depend on meticulous layered closure with sutures of various sizes. Some surgeons do not use drains. UPPER EXTREMITY Glanz and Gonzalez-Ulloa317 reviewed the effects of aging on the female arm and attributed the soft-tissue descent and flaccidity to a loss of adipose tissue and stretching of the anchoring septa. Working with radiographs and measuring at midhumeral level, the authors calculated a ratio of upper to lower soft-tissue mass, or coefficient of Hoyer. The 1:1 ratio seen at age 35 SRPS Volume 10, Number 22, 2008 Fig 5. Algorithm: patient with upper arm lipodystrophy. UAL, ultrasound-assisted liposuction; SAL, suction-assisted liposuction. (Reprinted with permisssion from Appelt EA, Janis JE and Rohrich RJ: An algorithmic approach to upper arm contouring. Plastic and Reconstructive Surgery® 118:237, 2006.) 10 gradually increases with age and gravitational descent, so that by the age of 40 it is 1:1.4 and by age 70 it is 1:2.2. Lockwood318 believes upper arm flabbiness is the direct result of a “loosening of the connections of the arm superficial fascial system to the axillary fascia itself, with age, weight fluctuations, and gravitational pull that yields a ‘loose hammock’ effect, resulting in significant ptosis of the postero-medial arm.” Classification systems of aesthetic arm deformities abound. Regnault319 denotes the skin excess as mild, moderate or major. Teimourian320 recognizes 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 and colleagues 321 present a new classification system for evaluation of the upper extremity in the massive weight-loss patient and 36 suggest an algorithm for selecting the appropriate technique of upper extremity contouring (Fig 5). 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 >1.5cm. 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 seen in the massive weight-loss population. Staged liposuction with excision or single multi-modality 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 routinely use closed suction drains and compressive garments. The most common complication in their series was hypertrophic scarring. SRPS Volume 10, Number 22, 2008 Most authors recommend direct elliptical excision of the redundant tissue and place the incision medially along a line connecting the axillary dome to the medial epicondyle.322–324 In contrast, Knoetgen et al325 place the incision within the intermuscular septum. In a review of their brachioplasty experience in 40 patients, the authors report a 5% rate of medial antebrachial cutaneous nerve injury. Cadaver dissections of 10 upper limbs revealed some variability in the course of the medial antebrachial cutaneous n., though it tended to run in close proximity to the intermuscular septum. The nerve penetrated the deep fascia a mean 14cm proximal to the medial epicondyle, divided into an anterior and posterior branch, and the anterior branch continued onto the anterior forearm. The medial brachial cutaneous nerve consistently ran posterior to the basilic vein and could be injured with more posterior incisions. Lockwood modified the brachioplasty procedure by anchoring with braided nylon sutures the superficial fascia of the arm flap to the axillary fascia in the proximal edge of the wound.318 The aesthetic results in 5 patients followed for 6–12 months were considered good. Simultaneous liposuction of the arm was done in 4 patients. Complications included a seroma and one case of underresection. The technique described by Pascal and coworkers326 combines circumferential liposuction and superficial skin excision to protect underlying nerves and lymphatics. Their 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 threelayer closure and an axillary Z-plasty complete the procedure; no drains are used. There were no seromas or nerve injuries reported in 21 cases. Additional techniques have been described for both distal excess about the elbow327 and proximally along the chest wall.328 These can be combined with standard brachioplasty techniques. Baroudi322 and Guerrerosantos324 list 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. Current refinements using limited incisions, liposuction, and posteriorly oriented scars may help prevent these complications. BIBLIOGRAPHY 7. Salans LB, Cushman SW, Weismann RE: Studies of human adipose tissue. Adipose cell size and number in 1. 2007 Cosmetic Surgery National Data Bank Statistics. 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Rohrich RJ, Raniere J Jr, Beran SJ, Kenkel JM: Patient evaluation and indications for ultrasound-assisted 81. 1997. 97. in major lipoplasty procedures with the tumescent technique. Aesthetic Surg J 18(1):30, Jan/Feb 1998. 98. gery and suction-assisted lipectomy. Plast Reconstr Surg Lillis PJ: Liposuction surgery under local anesthesia: limited blood loss and minimal lidocaine absorption. J Standardization in photography for body contour sur- Dermatol Surg Oncol 14:1145, 1988. 99. Klein JA: Tumescent technique for local anesthesia 100:227, 1997. improves safety in large-volume liposuction. Goodpasture JC, Bunkis J: Quantitative analysis of Reconstr Surg 92:1085, 1993. blood and fat in suction lipectomy aspirates. Plast 100. Reconstr Surg 78:765, 1986. 84. Karmo FR, Milan MF, Stein S, Heinsimer JA: Blood loss lipoplasty. Clin Plast Surg 26(2):269, 1999. Gherardini G, Matarasso A, Serure AS, et al: 83. 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Aesthetic Plast Surg 103. 8:19, 1984. 87. improves safety in large-volume liposuction, by JA Grazer FM: Quantitative analysis of blood and fat in suction lipectomy aspirates (Discussion). Plast Reconstr 88. Klein (Discussion). Plast Reconstr Surg 92:1099, 1993. 104. Trott SA, Beran SJ, Rohrich RJ, et al: Safety considera- Surg 78:770, 1986. tions and fluid resuscitation in liposuction: an analysis Mladick RS, Morris RL: Sixteen months’ experience of 53 consecutive patients. Plast Reconstr Surg 102:2220, with the Illouz technique of lipolysis. Ann Plast Surg 16:220, 1986. 89. Pitman GH: Tumescent technique for local anesthesia 1998. 105. Klein JA: Tumescent liposuction and improved postop- Apfelberg DB et al: Computerized suction lipectomy erative care using tumescent liposuction garments. aspirator monitor for improved results in suction lipec- Dermatol Clin 13(2):329, 1995. tomy. Plast Reconstr Surg 82:896, 1988. 106. Kaplan B, Moy RL: Comparison of room temperature 90. 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Plast Surgery. Principles and Practice. St Louis, CV Mosby, 95. Hunstad JP, Aitken ME: Liposuction and tumescent surgery. Clin Plast Surg 33:39, 2006. Jurkiewicz MJ, Mathes SJ, Krizek TJ, Ariyan S (eds), Plastic 94. A randomized double-blind study. 111. Burk RW III, Guzman-Stein G, Vasconez LO: Lidocaine adrenaline. Scand J Plast Reconstr Hand Surg 29:161, and epinephrine levels in tumescent technique liposuc- 1995. tion. Plast Reconstr Surg 97:1379, 1996. SRPS Volume 10, Number 22, 2008 112. Brown SA et al: Pharmacokinetics and safety of epi- Reconstructive and Aesthetic Plastic Surgery, Brazil, March nephrine use in liposuction. Plast Reconstr Surg 114:756, 1989. 2004. 113. 130. Klein JA: Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J 131. Ostad A, Kageyama N, Moy RL: Tumescent anesthesia tion. Dermatol Surg 22:921, 1997. 132. Matarasso A: 116. Kenkel JM et al: Pharmacokinetics and safety of lido- Lidocaine in ultrasound-assisted Maxwell GP, Gingrass MK: Ultrasound-assisted Plast Reconstr Surg 101:189, 1998. 134. Rohrich RJ, Beran SJ, Kenkel JM, et al: Extending the role of liposuction in body contouring with ultrasound- microdialysis study. Plast Reconstr Surg 114:516, 2004. assisted liposuction. Plast Reconstr Surg 101:1090, 1998. Kenkel JM et al: Hemodynamic physiology and ther- 135. Plast Reconstr Surg Tebbetts JB: Minimizing complications of ultrasoundassisted lipoplasty: an initial experience with no relat- 114:503, 2004. ed complications. Plast Reconstr Surg 102:1690, 1998. Lipschitz AH et al: Electrolyte and plasma enzyme analyses during large-volume liposuction. 136. Plast Kenkel JM, Robinson JB Jr, Beran SJ, et al: The tissue effects of ultrasound-assisted lipoplasty. Plast Reconstr Reconstr Surg 114:766, 2004. 121. Basic physics for ultrasound-assisted caine and monoethylglycinexylidide in liposuction: a moregulation in liposuction. 120. Zocchi ML: lipoplasty: a clinical study of 250 consecutive patients. lipoplasty. Clin Plast Surg 26(3):431, 1999. 119. Mandel MA: Syringe liposculpture revisited. Aesthetic lipoplasty. Clin Plast Surg 26(2):209, 1999. 133. 115. 118. Clin Plast Surg Plast Surg 17:199, 1993. with a lidocaine dose of 55 mg/kg is safe for liposuc- 117. Syringe liposculpture. 23(4):683, 1996. Dermatol Surg Oncol 16:248, 1990. 114. Toledo LS: Surg 102:213, 1998. Perry AW, Petti C, Rankin M: Lidocaine is not neces- 137. Grippaudo FR, Matarese RM, Macone A, et al: Effects sary in liposuction. Plast Reconstr Surg 104:1900, 1999. of traditional and ultrasonic liposuction on adipose tis- Courtiss EH: Suction lipectomy: A retrospective analy- sue: sis of 100 patients. Plast Reconstr Surg 73:780, 1984. 106:197, 2000. Gasparotti M: Superficial liposuction: A new applica- 138. tion of the technique for aged and flaccid skin. Aesthetic a biochemical approach. Plast Reconstr Surg Song AY, Bennett JM, Marra KG, et al: Scientific basis for the use of hypotonic solutions with ultrasonic lipo- Plast Surg 16:141, 1992. suction. Aesthetic Plast Surg 30:233, 2006. 122. Gasperoni C et al: Subdermal liposuction. Presented at the Tenth International Congress of ISAPS, September 1989. ultrasound-assisted liposuction: the effect on surgeon 123. Gasperoni C et al: Subdermal liposuction. and patient. Plast Reconstr Surg 106:150, 2000. 124. Gasperoni C, Salgarello M: MALL liposuction: The nat- 139. Aesthetic Plast Surg 14:137, 1990. 140. ural evolution of subdermal superficial liposuction. Gasperoni C, Gasperoni P: 141. 126. Surg Quart 16(2):123, Summer 1996. 142. 128. sound-assisted lipoplasty: by treatment site: a study of 500 procedures in 458 ultrasound-assisted lipoplasty with traditional lipoplas- Matarasso A: Superficial suction lipectomy: Something a pilot study comparing ty. Plast Reconstr Surg 101:1103, 1998. 143. Rohrich RJ, Raniere J Jr, Kenkel JM, Beran SJ: Operative old, something new, something borrowed....Ann Plast principles for optimizing results in circumferential Surg 34:268, 1995. body contouring with ultrasound-assisted lipoplasty. Clin Plast Surg 26(2):305, 1999. De Souza Pinto EB, Erazo Indaburo P, da Costa Muniz A, et al: Superficial liposuction. Body contouring. Clin 129. Fodor PB, Watson J: Personal experience with ultra- Goddio AS: Skin retraction following suction lipectomy selected subjects. Plast Reconstr Surg 87:66, 1991. 127. Kloehn RA: Liposuction with “sonic sculpture”: six years’ experience with more than 600 patients. 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Plast Reconstr Surg 88:239, 1991. 162. tion lipectomy assessed by a patient questionnaire sur- of 100 consecutive cases. Plast Reconstr Surg 105:2161, vey. Plast Reconstr Surg 92:35, 1993. 163. Jewell ML, Fodor PB, de Souza Pinto EB, Al Shammari MA: Clinical application of VASER-assisted lipoplasty: 164. musculature. Aesthetic Plast Surg 17:287, 1993. 165. 33:107, 2006.I Hoyos A et al: 150. Rosenberg GJ, Cabrera RC: VASER-assisted high-definition cent technique: liposculpture. Aesthetic Surg J 27:594, 2007. External ultrasonic shrinkage. Plast Reconstr Surg 105:785, 2000. Reconstr Surg 104:1887, 1999. Albin R, de Campo T: Large-volume liposuction in 181 167. McEwan CN: patients. Aesthetic Plast Surg 23:5, 1999. removal of hematomas and fat necrosis. Ann Plast Surg 19:480, 1987. 168. Lawrence N, Cox SE: The efficacy of external ultratrial. Dermatol Surg 26:329, 2000. Young VL, PSEF DATA Committee: 171. Coleman WP III: Noncosmetic applications of liposuc- 172. Spinowitz A: The treatment of multiple lipomas by Surg Oncol 11:1070, 1985. tion. J Dermatol Surg Oncol 14:1085, 1988. liposuction surgery. J Dermatol Surg Oncol 15:538, 1989. 173. DeFranzo AJ, Hall JH Jr, Herring SM: Adiposis dolorosa (Dercum’s disease): Liposuction as an effective form of treatment. Plast Reconstr Surg 85:289, 1990. Plast Reconstr Surg 113:1796, 174. Ichikawa K, Miyasaka M, Tanaka R, et al: Histologic 175. Spinowitz AL: Liposuction surgery: An effective alternative for treatment of lipomas (Letter). Plast Reconstr Surg 86:606, 1990. Mordon S et al: Histologic evaluation of laser lipolysis: pulsed 1064-nm Nd:YAG laser versus CW 980-nm Nichter LS, Gupta BR: Liposuction of giant lipoma. Ann Plast Surg 24:362, 1990. sis. Lasers Surg Med 36:43, 2005. 176. Collins PC, Field LM, Narins RS: Liposuction surgery diode laser. Aesthetic Surg J 27:263, 2007. and autologous fat transplantation. 159. Kim KH, Geronemus RG: Laser lipolysis using a novel 10:365, 1992. 160. 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J Bone Joint Surg 72A:1534, 1990. Power-assisted 33:91, 2006. Dowden RV, Bergfeld JA, Lucas AR: hematomas with liposuction apparatus. 169. lipoplasty. Plast Reconstr Surg 108:1429, 2001. 155. The application of liposuction for lipoplasty analysis of in vivo-treated adipose tissue. sound-assisted liposuction: a randomized controlled 154. Plast Rohrich RJ, Morales DE, Krueger JE, et al: Comparative Plast Reconstr Surg 105:2152, 2000. 153. a sure and viable procedure. 166. lipoplasty: an effective method of fat removal and skin 152. Cardenas-Camarena L, Tobar-Losada A, Lacouture AM: Large-volume circumferential liposuction with tumes- 149. 151. Mentz HA III, Gilliland MD, Patronella CK: Abdominal etching: Differential liposuction to detail abdominal de Souza Pinto EB, de Souza Pinto Abdala PC, Maciel CM, et al: Liposuction and VASER. Clin Plast Surg Lewis CM: Lipoplasty in males. Clin Plast Surg 16:355, 1989. a pilot clinical study. Aesthetic Surg J 22:131, 2002. 148. Dillerud E, Håheim LL: Long-term results of blunt suc- lipectomy using the solid probe: a retrospective review 2000. 147. Dillerud E: Suction lipoplasty: a report on complica- SRPS Volume 10, Number 22, 2008 179. Apesos J, Chami R: Functional applications of suction- 196. assisted lipectomy: A new treatment for old disorders. Aesthetic Plast Surg 15:73, 1991. 180. caused by Cushing’s disease. 181. 182. (letter). N Engl J Med 341(13):1001, 1999. 197. Narins RS: Liposuction surgery for a buffalo hump Apr 2001. 198. Matarasso A et al: Abdominoplasty and abdominal Sando WC, Nahai F: Suction lipectomy in the manage- contour surgery: ment of limb lymphedema. Clin Plast Surg 16:369, 1989. Plast Reconstr Surg 117:1797, 2006. Brorson H, Svensson H: Complete reduction of lym- 199. phoedema of the arm by liposuction after breast cancer. Brorson H, Svensson H: Liposuction combined with a national plastic surgery survey. Grazer FM, de Jong RH: Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast Reconstr Scand J Plast Reconstr Surg Hand Surg 31:137, 1997. 183. Hughes CE 3rd: Reduction of lipoplasty risks and mortality: an ASAPS survey. Aesthetic Surg J 21:120, Mar- J Am Acad Dermatol 21:307, 1989. Rigel DS, Wheeland RG: Deaths related to liposuction Surg 105:436, 2000. 200. Rohrich RJ, Muzaffar AR: Discussion of “Fatal out- controlled compression therapy reduces arm lym- comes from liposuction: census survey of cosmetic sur- phedema more effectively than controlled compression geons” by FM Grazer and RH de Jong. Plast Reconstr therapy alone. Plast Reconstr Surg 102:1058, 1998. Surg 105:447, 2000. 184. Dubin B, Jackson IT: The use of liposuction to contour cherubism. Plast Reconstr Surg 86:996, 1990. plicated by pulmonary edema. 185. Hallock GG: Defatting of flaps by means of suction- 99:215, 1997. 186. Baird W, Nahai F: The use of lipoplasty in contouring 187. Wolfort FG, Cetrulo CL Jr, Nevarre DR: Suction-assist- assisted lipectomy. Plast Reconstr Surg 76:948, 1985. 201. 202. administration. Plast Reconstr Surg 102:235, 1998. 203. formula for liposuction (Editorial). Plast Reconstr Surg 100:1893, 1997. Plast Reconstr Surg 204. caution in lipoplasty procedures; Task Force report calls lipectomy for lipodystrophy syndromes attributed to for scrutiny of training, large volume removals. HIV-protease inhibitor use” by FG Wolfort, CL Cetrulo Chicago, Am Soc Plast Reconstr Surg, Jan 26, 1998. 205. Gargan TJ, Courtiss EH: The risks of suction lipectomy. Plast Surg 21:230, 1997. Pitman GH, Aker JS, Tripp ZD: Tumescent liposuction. 207. Illouz YG: Complications of liposuction. Clin Plast Surg 208. Broughton G et al: Lifestyle outcomes, satisfaction, and A surgeon’s perspective. Clin Plast Surg 23(4):633, 1996. Chang KN: Long-term results of surgical correction of postliposuction contour irregularities. Plast Reconstr 33:129, 2006. Surg 109:2141, 2002. attitude of patients after liposuction: a Dallas experi- Chang KN: ence. Plast Reconstr Surg 117:1738, 2006. The use of intraoperative grid pattern markings in lipoplasty. Plast Reconstr Surg 114(5):1292, 209. Pitman GH, Teimourian B: Rohrich RJ et al: The key to long-term success in liposuction: a guide for plastic surgeons and patients. Plast 2004. 193. Aesthetic 206. Chang KN: Surgical correction of postliposuction contour irregularities. Plast Reconstr Surg 94:126, 1994. Pardo Mateu L, Chamorro Hernandez JJ: Cutaneous hyperpigmentation caused by liposuction. Their prevention and treatment. Clin Plast Surg 11:457, 192. PSNews Bulletin: ASPRS urges members to exercise Rohrich RJ, Kenkel JM: Discussion of “Suction-assisted 1984. 191. Grazer FM, Meister FL: Complications of the tumescent HIV-protease inhibitor use. Jr, and DR Nevarre. Plast Reconstr Surg 104:1821, 1999. 190. Lombardi AS, Quirke TE, Rauscher G: Acute median ed lipectomy for lipodystrophy syndromes attributed to 104:1814, 1999. 189. Plast Reconstr Surg nerve compression associated with tumescent fluid and debulking flaps. Clin Plast Surg 16:395, 1989. 188. Gilliland MD, Coates N: Tumescent liposuctioni com- Reconstr Surg 114:1945, 2004. Suction lipectomy: Plast Reconstr 210. Ahkami S: Suction lipectomy preceding pregnancy and 194. Rao RB, Ely SF, Hoffman RS: Deaths related to liposuc- 211. Talmor M, Fahey TJ 2nd, Wise J, et al: Large-volume tion. N Engl J Med 340(19):1471, 1999. liposuction complicated by retroperitoneal hemor- 195. Klein JA: Deaths related to liposuction (letter). N Engl rhage: management principles and implications for the Complications and results by survey. postpartum results. Int Surg 76:105, 1991. Surg 76:65, 1985. J Med 341(13):1001, 1999. 43 SRPS Volume 10, Number 22, 2008 quality improvement process. 212. Plast Reconstr Surg Buescher TM: Paraspinous muscle hemorrhage as a bined with endoscopic-assisted pull-through excision. potential source of liposuction mortality (letter). Plast Ann Plast Surg 55:591, 2005. 229. Heitmann C, Czermak C, Germann G: Rapidly fatal necrotizing fasciitis after aesthetic liposuction. Aesthetic 215. 230. Brown SA: The science of mesotherapy: chemical anar- 231. beautiful? A review and classification of the determi- Rotunda AM, Kolodney MS: Mesotherapy and phos- nants of gluteal beauty and the surgical techniques to phatidylcholine injections: historical clarification and achieve them. Aesthetic Plast Surg 28:340, 2004. 232. Matarasso A, Pfeifer TM, PSEF DATA Committee: 115:1420, 2005. Surg J 26:200, 2006. Mendieta CG: Gluteoplasty. Aesthetic Surg J 23:441, 234. Gonzalez R: 235. Raposo-Amaral CE et al: Bilateral lumbar hip dermal 2003. fat rotation flaps: a novel technique for autologous aug- Rohrich RJ, Ha RY, Kenkel JM, Adams WP Jr: mentation gluteoplasty. Plast Reconstr Surg 117:1781, 2006. 236. Reconstr Surg 111:909, 2003. tion after massive weight loss: aesthetic analysis and role of the superior gluteal artery perforator flap. Plast Plast Reconstr Surg 51:48, 1973. Reconstr Surg 119:345, 2007. 237. autologous tissue following massive weight loss. Am 23:825, 1994. Aesthetic Surg J 25:576, 2005. Neuman JF: Evaluation and treatment of gynecomastia. 238. Hammond DC et al: Combined use of ultrasonic lipo- 239. Hodgson EL et al: Ultrasonic liposuction in the treat- 225. Rosenberg GJ: Gynecomastia: Suction lipectomy as a 226. Rosenberg GJ: A new cannula for suction removal of Plast Reconstr Surg 114:1606, 2004. 240. Matarasso A: 241. Huger WE Jr: The anatomic rationale for abdominal 242. Matarasso A: ment of gynecomastia. Plast Reconstr Surg 116:646, 2005. Clin Plast Surg lipectomy. Am Surg 45:612, 1979. Liposuction as an adjunct to a full abdominoplasty revisited. Plast Reconstr Surg 106:1197, Plast Reconstr 2000. Surg 94:548, 1994. 243. Graf R et al: Lipoabdominoplasty: liposuction with reduced undermining and traditional abdominal skin pull-through technique combined with liposuction for flap resection. Aesthetic Plast Surg 30:1, 2006. management of gynecomastia. Ann Plast Surg 53:22, 2004. Abdominolipoplasty. 16:289, 1989. contemporary solution. Plast Reconstr Surg 80:379, 1987. Bracaglia R et al: Our experience with the so-called Murillo WL: Buttock augmentation: case studies of fat injection monitored by magnetic resonance imaging. ment of gynecomastia. Plast Reconstr Surg 112:891, 2003. 224. parenchymal tissue of gynecomastia. Sozer SO et al: Autoprosthesis buttock augmentation during lower body lift. Aesthetic Plast Surg 29:133, 2005. suction with the pull-through technique for the treat- 227. Rohde C, Gerut ZE: Augmentation buttock-pexy using Glass AR: Gynecomastia. Endocrinol Metab Clin North Am Fam Physician 55:1835, 1997. 223. Colwell AS, Borud LJ: Autologous gluteal augmenta- Simon BE, Hoffman S, Kahn S: Classification and surgical correction of gynecomastia. 222. the XYZ Plast Reconstr Surg 115:1425, 2005. ing the role of ultrasound-assisted liposuction. Plast 221. Augmentation gluteoplasty: method. Aesthetic Plast Surg 28:417, 2004. Rohrich RJ: Mesotherapy: What is it? Does it work? Classification and management of gynecomastia: defin- 220. Aesthetic 233. 2003. 219. Centeno RF: Gluteal aesthetic unit classification: a tool to improve outcomes in body contouring. Rittes PG: The use of phosphatidylcholine for correction of localized fat deposits. Aesthetic Plast Surg 27:315, 218. Cuenca-Guerra R, Quezada J: What makes buttocks chy. Aesthetic Surg J 26:95, 2006. Mesotherapy for body contouring. Plast Reconstr Surg 217. Aiache AE: Secondary surgery for failed gynecomastia correction from liposuction. Aesthetic Surg J 18:95, 1998. review. Dermatol Surg 32:465, 2006. 216. Tashkandi M et al: The surgical management of highgrade gynecomastia. Ann Plast Surg 53:17, 2004. Plast Surg 24:344, 2000. 214. Ramon Y et al: Multimodality gynecomastia repair by cross-chest power-assisted superficial liposuction com- Reconstr Surg 106:740, 2000. 213. 228. 105:2244, 2000. 244. Blondeel PN et al: The effect of ultrasound-assisted liposuction and conventional liposuction on the perfo- 44 SRPS Volume 10, Number 22, 2008 245. 246. 247. rator vessels in the lower abdominal wall. Br J Plast value for possible postoperative complications. Surg 56:266, 2003. Aesthetic Plast Surg 26:189, 2002. Grazer FM, Klingbeil JR: Body Image—A Surgical 262. Van Uchelen JH, Kon M, Werker PM: The long-term Perspective. St Louis, CV Mosby, 1980, Ch 3, p 36. durability of plication of the anterior rectus sheath Dubou R, Ousterhout DK: Placement of the umbilicus assessed by ultrasonography. in an abdominoplasty. Plast Reconstr Surg 61:291, 1978. 107(6):1578, 2001. Lockwood T: High-lateral-tension abdominoplasty with superficial fascial system suspension. 263. Plast Plast Reconstr Surg Nahas FX et al: An efficient way to correct recurrent rectus diastasis. Aesthetic Plast Surg 28:189, 2004. Reconstr Surg 96:603, 1995. 264. Baroudi R: Umbilicoplasty. Clin Plast Surg 2:431, 1975. 248. Lockwood T: Lower body lift with superficial fascial 265. Le Louarn C, Pascal JF: 249. Lockwood T: The role of excisional lifting in body con- 266. Akbas H et al: Natural-looking umbilicus as an impor- tour surgery. Clin Plast Surg 23(4):695, 1996. tant part of abdominoplasty. Aesthetic Plast Surg 27:139, 250. Pollock T, Pollock H: Progressive tension sutures in 2003. 251. Saldanha OR, De Souza Pinto EB, Mattos WN Jr, et al: system suspension. Plast Reconstr Surg 92:1112, 1993. abdominoplasty. Clin Plast Surg 31:583, 2004. abdominoplasty. Aesthetic Plast Surg 24(5):375, 2000. 267. 252. 253. body contour surgery: the “limited” abdominoplasty. concept. Plast Reconstr Surg 112:288, 2003. Plast Reconstr Surg 77:779, 1986. Avelar JM: Abdominoplasty combined with lipoplasty 269. 7 years’ experience. 270. Greminger RF: Plast 271. Gradel J: Umbilical technical maneuvers to facilitate The mini-abdominoplasty. Plast Reconstr Surg 79:356, 1987. Reconstr Surg 116:881, 2005. Espinosa-de-los-Monteros A et al: Limited abdominoplasty techniques Surg 18:49, 1994. Cárdenas-Camarena L: Aesthetic surgery of the thoracumferential lipoplasty: Wilkinson TS: applied to complete abdominal repair. Aesthetic Plast coabdominal area combining abdominoplasty and cir- abdominoplasty with limited incisions. Aesthetic Plast Abdominoplasty with total abdominal liposuction for patients with mas- Surg 15:251, 1991. 272. sive weight loss. Aesthetic Plast Surg 30:42, 2006. 256. Wilkinson TS, Swartz BE: Individual modification of Brauman D: Liposuction abdominoplasty: an evolving ty?a safe technique. Clin Plast Surg 33:79, 2006. 255. Reconstruction of the umbilicus 1995. 268. without panniculus undermining: abdominolipoplas254. Sugawara Y et al: using a single triangular flap. Ann Plast Surg 34:78, Lipoabdominoplasty with selective and safe undermining. Aesthetic Plast Surg 27(4):322, 2003. High superior tension Walgenbach KJ, Shestak KC: “Marriage” abdominoplasty: body contouring with limited scars combining Castanares S, Goethel JA: Abdominal lipectomy: A mini-abdominoplasty and liposuction. Clin Plast Surg modification in technique. Plast Reconstr Surg 40:378, 31:571, 2004. 1967. 273. Omranifard M: Ultrasonic liposuction versus surgical lipectomy. Aesthetic Plast Surg 27:143, 2003. 257. Dellon AL: Fleur-de-lis abdominoplasty. Aesthetic Plast 258. Persichetti P et al: Anchor-line abdominoplasty: a com- the trunk with anterior rectus fascia plication through a prehensive approach to abdominal wall reconstruction periumbilical incision: an alternative to conventional and body contouring. Plast Reconstr Surg 116:289, 2005. abdominoplasty. Plast Reconstr Surg 113:727, 2004. Surg 9:27, 1985. 259. Fernando da Costa L, Landecker A, Manta AM: 274. 275. 276. Nahas FX: An aesthetic classification of the abdomen 277. plasty. Plast Reconstr Surg 101:1685, 1998. 108:1787, 2001. Talisman R et al: Measuring alterations in intra-abdominal pressure during abdominoplasty as a predictive Lockwood T: Rectus muscle diastasis in males: primary indication for endoscopically assisted abdomino- based on the myoaponeurotic layer. Plast Reconstr Surg 261. Matarasso A: The male abdominoplasty. Clin Plast Surg 31:555, 2004. Reconstr Surg 114:1917, 2004. 260. Mladick RA: Male body contouring. Clin Plast Surg 18(4):797, 1991. Optimizing body contour in massive weight loss patients: the modified vertical abdominoplasty. Plast Dabb RW et al: Circumferential suction lipectomy of 278. Kryger ZB, Fine NA, Mustoe TA: The outcome of abdominoplasty performed under conscious sedation: 45 SRPS Volume 10, Number 22, 2008 six-year experience in 153 consecutive cases. Plast gynecological surgical procedures. Reconstr Surg 113:1807, 2004. 279. Mast BA: Safety and efficacy of outpatient full 294. abdominoplasty. Ann Plast Surg 54:256, 2005. 280. Mentz HA et al: Use of a regional infusion pump to Reconstr Surg 71:56, 1983. 295. cological surgical procedures. Ann Plast Surg 20:552, 1988. 296. Plast 1992. 297. other major surgical procedures: Safe or sorry? Plast Reconstr Surg 83:997, 1989. a national plastic surgery survey. 298. Hensel JM, Lehman JA Jr, Tantri MP, et al: An outcomes plasty. Aesthetic Plast Surg 14:35, 1989. 299. abdominoplasties. Ann Plast Surg 46:357, 2001. with elective breast surgery? A review of 151 consecutive cases. Plast Reconstr Surg 118:207, 2006. 300. Ann Plast Surg 42:34, 1999. Kim J, Stevenson TR: Abdominoplasty, liposuction of 301. ture. Dermatol Surg 31(7):733, 2005. Chaouat M, Levan P, Lalanne B, et al: Abdominal der- agement of the post-gastric-bypass patient presenting for body contour surgery. Clin Plast Surg 31:601, 2004. Plast Reconstr Surg 303. Manassa EH et al: Wound healing problems in smokers Cavallini M et al: Effects of mild hypothermia on blood coagulation in patients undergoing elective plastic sur- Plast Reconstr Surg 111:2082, 2003. gery. Plast Reconstr Surg 116:316, 2005. 304. Prayer M, Youngberg B, Pfister S: Panniculectomy?an Van Uchelen JH, Werker PMN, Kon M: Complications option for people who are morbidly obese. AORN J of abdominoplasty in 86 patients. Plast Reconstr Surg 77:782, Apr 2003. 107:1869, 2001. Pitanguy I: today: 305. Evaluation of body contouring surgery a 30-year perspective. 2006. 306. Aly A: Massive panniculectomy after massive weight 307. Olejek A, Manka G: Panniculectomy in gynecologic Matarasso A et al: Secondary abdominal contour surgery: a review of early and late reoperative surgery. Manahan M, Shermak MA: Massive panniculectomy after massive weight loss. Plast Reconstr Surg 117:2191, Plast Reconstr Surg 105:1499, 2000. loss (Discussion). Plast Reconstr Surg 117:2198, 2006. Plast Reconstr Surg 115:627, 2005. cancer surgical procedures by using a harmonic scalpel. Voss SC, Sharp HC, Scott JR: Abdominoplasty com- Acta Obstet Gynecol Scand 84:690, 2005. bined with gynecologic surgical procedures. Obstet 308. Hunter GR et al: Perioperative warfarin therapy in combined abdominal lipectomy and intraabdominal Carwell GR, Horton CE Sr: Circumferential torsoplasty. Ann Plast Surg 38:213, 1997. Gynecol 67:181, 1986. 293. Rubin PJ, Nguyen V, Schwentker A: Perioperative man- long-term unfavorable results. and nonsmokers after 132 abdominoplasties. 292. 302. molipectomies: early postoperative complications and 106:1614, 2000. 291. Yoho RA et al: Review of the liposuction, abdominoplasty, and face-lift mortality and morbidity risk litera- ma formation. Plast Reconstr Surg 117:773, 2006. 290. Wallach SG: Maximizing the use of the abdominoplasty incision. Plast Reconstr Surg 113:411, 2004. the flanks, and obesity: analyzing risk factors for sero- 289. Stevens GW et al: Is it safe to combine abdominoplasty Vastine VL, Morgan RF, Williams GS, et al: Wound complications of abdominoplasty in obese patients. 288. Cardoso de Castro C, Branco Cupello AM: Analysis of 60 cases of simultaneous mammaplasty and abdomino- analysis and satisfaction survey of 199 consecutive 287. Hester TR Jr et al: Abdominoplasty combined with Reconstr Surg 59:513, 1977. Plast Reconstr Surg 117:1797, 2006. 286. Abdominoplasty combined with Matarasso A et al: Abdominoplasty and abdominal contour surgery: 285. Gemperli R et al: other intraabdominal procedures. Ann Plast Surg 29:18, Grazer FM, Goldwyn RM: Abdominoplasty assessed by survey, with emphasis on complications. 284. Shull BL, Verheyden CN: Combined plastic and gyne- Aesthetic Plast Surg 29:415, 2005. patients. Plast Reconstr Surg 112:619, 2003. 283. Plast Bolton M et al: Measuring outcomes in plastic surgery: body image and quality of life in abdominoplasty 282. Pitanguy I, Ceravolo MP: Our experience with combined procedures in aesthetic plastic surgery. control postoperative pain after an abdominoplasty. 281. Ann Plast Surg 25:37, 1990. 309. Aly AS, Cram AE, Chao M, et al: Belt lipectomy for circumferential truncal excess: the University of Iowa experience. Plast Reconstr Surg 111:398, 2003. 46 SRPS Volume 10, Number 22, 2008 310. Nemerofsky RB, Oliak DA, Capella JF: Body lift: an 319. and Techniques. Boston, Little Brown, 1984, Ch 28. loss patient. Plast Reconstr Surg 117:414, 2006. 311. Rohrich RJ, Gosman AA, Conrad MH, Coleman J: 320. Teimourian B, Malekzadeh S: 321. Appelt EA et al: An algorithmic approach to upper arm Rejuvenation of the 322. Baroudi R: Body sculpturing. Clin Plast Surg 11:419, 323. Grazer FM: Body Contouring. In: McCarthy JG (ed), 324. Guerrerosantos J: Brachioplasty. Aesthetic Plast Surg 325. Knoetgen J et al: Long-term outcomes and complica- upper arm. Plast Reconstr Surg 102:545, 1998. Simplifying circumferential body contouring: the central body lift evolution. Plast Reconstr Surg 118:525, Regnault P, Daniel RK: Upper Extremity. In: Regnault P and Daniel RK (eds), Aesthetic Plastic Surgery—Principles account of 200 consecutive cases in the massive weight contouring. Plast Reconstr Surg 118:237, 2006. 2006. 312. Pascal JF, Le Louarm C: Remodeling bodylift with high 313. Hurwitz DJ: Single-staged total body lift after massive 314. Lockwood TE: Fascial anchoring technique in medial 315. Le Louarn C et al: The concentric medial thigh lift. Aesthetic Plast Surg 28:20, 2004. tions associated with brachioplasty: a retrospective and 316. Mathes DW, Kenkel JM: Current concepts in medial cadaveric study. Plast Reconstr Surg 117:2219, 2006. 317. Glanz S, Gonzalez-Ulloa M: Aesthetic surgery of the 1984. lateral tension. Aesthetic Plast Surg 26:223, 2002. Plastic Surgery. Philadelphia, WB Saunders, 1990, Ch 81. weight loss. Ann Plast Surg 52:435, 2004. 3:1, 1979. thigh lifts. Plast Reconstr Surg 82:299, 1988. thighplasty. Clin Plast Surg 35:151, 2008. arm. Part I. Aesthetic Plast Surg 5:1, 1981. 318. 326. Brachioplasty. Aesthetic Plast Surg 29:423, 2005. 327. Gonzalez-Ulloa M: The callous elbow and aging of the upper arm. Aesthetic Plast Surg 14:53, 1989. Lockwood T: Brachioplasty with superficial fascial system suspension. Plast Reconstr Surg 96:912, 1995. Pascal JF et al: 328. Pitanguy I: Aesthetic plastic surgery of the upper and lower limbs. Aesthetic Plast Surg 4:363, 1980. 47 SRPS Volume 10, Number 22, 2008 48

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