Manual of Cosmetic Surgery and Medicine: Volume 1 - Body Contouring Procedures 9811949964, 9789811949968

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Mohan Thomas James D‘silva Editors

Manual of Cosmetic Surgery and Medicine Volume 1 - Body Contouring Procedures Foreword by Dr. Guillermo Blugerman MD

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Manual of Cosmetic Surgery and Medicine

Mohan Thomas • James D’silva Editors

Manual of Cosmetic Surgery and Medicine Volume 1 - Body Contouring Procedures

Editors Mohan Thomas Cosmetic Plastic Surgery Breach Candy Hospital and D. Y. Patil University Mumbai, Maharashtra, India

James D’silva Cosmetic Plastic Surgery Breach Candy Hospital and D. Y. Patil University Mumbai, Maharashtra, India

ISBN 978-981-19-4996-8    ISBN 978-981-19-4997-5 (eBook) https://doi.org/10.1007/978-981-19-4997-5 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

This book is dedicated to Sushruta, the First Plastic Surgeon, the Pioneer from India, and to all Stalwarts of the field who carved a path for all of us. Mohan Thomas M.D, FAACS

Foreword

It is indeed an honor to write the foreword to the six-volume Manual of Cosmetic Surgery and Medicine and particularly the first volume titled Body Contouring Procedures edited by Drs. Mohan Thomas and James D’silva. The area of body contouring has undoubtedly been one of the most advanced in recent years with the advent of new anatomical concepts, the introduction of safer advanced technology, and newer anesthetic techniques. Patient safety concepts are very important and should be applied when dealing with patients undergoing body contour surgery. It is essential to manage the patient’s desire and balance the surgical desire of the surgeon with regard to patient safety. From the first dermolipectomies described in Hippocratic writings to the current techniques of Lipoabdominoplasties have passed through centuries of evolution, leaving room in its wake to a flow of experiences and ideas that the young surgeon can collect from in these pages. The incorporation of liposuction into the arms of the cosmetic surgeon in the late 1970s took a paradigm shift in how patients’ consultations were approached and offered solutions that left less and less surgical marks on the skin surface by reducing scarring. We are happy to have introduced the use of Laser in Liposuction (LAL) in 1999 and to have introduced Radio Frequency Assisted Liposuction (RFAL) in 2009. Another aspect that has radically changed body contouring surgery was the advent of Bariatric Surgery and the emergence of post-bariatric sequelae that has opened up a new avenue for the cosmetic surgeons. I invite you to enjoy and absorb the knowledge shared in the pages of this manual: The wealth of knowledge shared by colleagues with a tremendous exposure in this subspeciality. You have the opportunity to learn from the success stories as well as mistakes producing these modern techniques, risks, and possible complications from the contributions made by these world leaders. This will help you to have better results with an ability to avoid any complications as well as manage these if you should have any. Buenos Aires, Argentina

Guillermo Blugerman, MD

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Preface

I have always thought of Aesthetic or Cosmetic Surgery as a Fusion of Art and Science. In many ways it is hard to define Aesthetic or Cosmetic Surgery as there are so many body parts involved: perceptions of beauty, ethnicities, and sometimes psychosomatic disorders as well. With reference to psychosomatic disorders, body dysmorphic disorders come first to my mind and the most common body part often associated with this disorder is the nose. There are cases wherein a patient has undergone ten plus surgeries on the nose with disastrous results. Recently, I have discovered another condition wherein this time it is gender based; men obsessed with their chest. Within the description of gynecomastia, there is often a “complaint of puffy nipples.” The one’s obsessing the most about their chest are single men between the ages of 25 and 35 and “Buffs” for the most part. There is a plethora of cosmetic surgical procedures out there ranging from Hair transplant to Rejuvenation of Hands, Surgery of the Face, Nose, Intimate parts and Body contouring procedures and now pretty feet. There is a segment of women that have taken on to high heeled and narrow shoes, early in life leading to Bunions and other Foot issues. I believe that this Surgical Manual is one of a kind, being a step-by-step presentation, comprehensive enough for private practitioners, students of the field, those starting practice, and surgeons already in practice ought to benefit from the schematics, pictures, and short video clips in relevant chapters. To my good fortune about two decades ago I came across the American Academy of Cosmetic Surgery which I gladly joined. Over the years, I have made many friends globally from whom I have learnt a lot and I greatly respect them. I am afraid to mention names for fear of missing someone out from the list of distinguished Cosmetic Plastic Surgeons. The Mission and Vision of the AACS, started by Dr. Richard Webster, a Plastic Surgeon, had a very good influence on me and spurred me to start a fellowship program in 2003 through a University and I have mentored many along the way. As a medical student in Pennsylvania I often came across Dr. Julian Newman, a stalwart as well. Cosmetic Surgery grew with inputs from many specialities such as General Surgeon—Dr. Ilouz (France), Gynecologist—Dr. Robert Fisher (Italy), and Dermatologist—Dr. Klein (USA) to mention a few. I am a great believer in mentorship and committed to creating a second and third line of surgeons who I hope one day would be better than me and I hope to learn from them as well as time goes by. The learning process is a continuum wherein I like many learn something every day. As a “Lifetime Student” I have learnt a lot from quarters other than surgical colleagues such as nursing staff as well as patients. Humility and kindness (empathy) are virtues that one must possess not only to be successful as a surgeon but also to serve the needs of the patients. In entering private practice, the most important thing one must learn is to assess, evaluate, and manage expectations of potential patients and obtain a Psychiatric Consultation to rule out Body dysmorphic disorder, depression, etc. when indicated. This is critical when taking up a decision to operate. In many ways, management of patient expectations and a gut feeling to pick up obsessive nature in patients who may seek out care are important virtues. Having con-

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Preface

ceived the idea of editing as well as contributing to the Manual I have tried to include Global Leaders in various fields as well as provide a platform for younger surgeons to be seen and recognized and “Undivide the great Divide.” Mumbai, India

Mohan Thomas, MD, FAACS

Acknowledgments

This is perhaps the simplest and yet the most challenging part of my writing as I fear leaving somebody out to mention. First of all, I thank my parents, wife and children, for providing me the education which was commendable considering they were just high school graduates and struggling to raise a family. My lack of finances and opportunities came as a blessing as I moved to the USA. I was welcomed with both hands and turned me into what I am today. There were many Mentors along this difficult journey from Medical School, Medical College of Pennsylvania, and postgraduate training at Mount Sinai Hospital, New  York, and several Fellowships with many Mentors in the field globally. I sincerely thank all my friends and colleagues at the AACS and many others, too many to mention. I truly salute and thank the various contributors from various parts of the world, different time zones, with their professional practices and family, for taking out their valuable time and submitting what I consider to be the cutting-edge information, in COVID times on webinars, conducted by us as well as this Six-Volume Surgical Manual. This is one of the largest body of academic work done in this field to-date. The first person who trained in my Fellowship program was Dr. James D’silva, a qualified Plastic Surgeon in his own right. He joined me in practice later and there was no looking back from there on and now has joined hands with me as a Co-Editor. All of the global and national contributors mentioned above have helped in this Academic Venture. Lastly, I thank Springer Nature and their amazing editorial team for believing in me and my pit-bull nature of not letting go of any project that I undertake. The Publishing House has done a wonderful job in editing, creating, marketing, and putting out this Manual for which many have toiled endless hours. Mohan Thomas MD, FAACS

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Contents

Part I Introduction to Body Contouring 1 The  Art and Science of Body Sculpting: Sculptor’s Perspective ���������������������������   3 Peter M. Schmid 2 Surgical  Anatomy of the Body in Relation to Lipocontouring�������������������������������  13 Mohan Thomas and James D’silva 3 Preoperative  Consultation and Evaluation���������������������������������������������������������������  33 Mohan Thomas and James D’silva Part II Lipo-contouring 4 Liposuction: Principles and Techniques�������������������������������������������������������������������  49 Martin Jugenburg and Waqqas Jalil 5 Upper Limb�����������������������������������������������������������������������������������������������������������������  73 Gregory Alouf 6 Lower- Limbs �������������������������������������������������������������������������������������������������������������  89 Kulwant Bhangoo 7 Back  Rolls and Their Treatment Options����������������������������������������������������������������� 123 Mohan Thomas and James D’silva 8 Back and Buttocks ����������������������������������������������������������������������������������������������������� 139 Mauro Dalmiro Soriano 9 Male Breast����������������������������������������������������������������������������������������������������������������� 151 Mohan Thomas and James D’silva 10 Large-Volume Liposuction����������������������������������������������������������������������������������������� 173 Mohan Thomas and James D’silva 11 Complications  in Body Contouring��������������������������������������������������������������������������� 193 Guillermo Blugerman Part III Hi-Definition Body Contouring 12 Hi Def Liposuction- My Technique ������������������������������������������������������������������������� 209 Carlos Mata, Michael Gadayev, Giovanni P. Ferrara, and Julie Kesserwani 13 Hi-Def  Liposuction in Males and Females��������������������������������������������������������������� 219 Grant Hamlet and Arian Mowlavi 14 Hi-Def Liposuction- My Way������������������������������������������������������������������������������������� 235 Aldo Perez

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Part IV Use of Technology for Lipo-contouring 15 Ultrasound Assisted Liposuction������������������������������������������������������������������������������� 251 Javier Palacios 16 Radio Frequency Assisted Liposuction��������������������������������������������������������������������� 257 Mohan Thomas and James D’silva 17 Laser Assisted Body Contouring������������������������������������������������������������������������������� 267 Zoran Žgaljardić and Ivonne Žgaljardić 18 Use  of J Plasma in Body Contouring������������������������������������������������������������������������ 287 Ehab Akkary Part V Abdominoplasty 19 Abdominoplasty Principles ��������������������������������������������������������������������������������������� 301 Aldo Perez 20 Lipoabdominoplasty Techniques������������������������������������������������������������������������������� 315 E. Antonio Mangubat 21 Lipoabdominoplasty��������������������������������������������������������������������������������������������������� 331 Julian Duran 22 TULUA Abdominoplasty: Unrestricted Liposuction and Wide Transverse Plication ��������������������������������������������������������������������������������� 341 Francisco Villegas 23 Secondary Abdominoplasty��������������������������������������������������������������������������������������� 359 Guillermo Blugerman, Diego Schavelzon, Victoria Schavelzon, and Guido Blugerman 24 Abdominoplasty  in Combination with Breast Surgery������������������������������������������� 375 Rene Calderon 25 Neoumbilicus��������������������������������������������������������������������������������������������������������������� 393 Mohan Thomas and James D’silva Part VI Body Contouring After Massive Weight Loss 26 Classification  of Contour Deformities After Massive Weight Loss: Utilization for Proper Treatment Planning��������������������������������������������������������������� 403 Erik J. Nuveen 27 Thighplasty ����������������������������������������������������������������������������������������������������������������� 411 Erik J. Nuveen 28 Upper Body Lifts��������������������������������������������������������������������������������������������������������� 425 Joachim Finckenstein 29 Brachioplasty (Arm Reduction)��������������������������������������������������������������������������������� 433 Jeffrey A. Swetnam 30 Circumferential  Body Lift with Breast Procedures������������������������������������������������� 453 Rene Calderon 31 Complications of Fat Transfer����������������������������������������������������������������������������������� 469 Sofia Santareno, Javier Palacios Ferat, Mohan Thomas, Cesar Velilla, Rene Calderon, Sandra Knight, Edwin Zara, and Gregory Alouf

Contents

Contents

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32 Spiral Lift��������������������������������������������������������������������������������������������������������������������� 491 Tarick Smiley and Rania Agha 33 Liposuction  Assisted Body Lift in a Patient with Massive Weight Loss�������������   505 E. Antonio Mangubat Part VII Gluteal Contouring 34 Modern  Concepts and Safety in BBL����������������������������������������������������������������������� 525 Carlos Mata, Giovanni P. Ferrara, and Michael Gadayev 35 Autologous Gluteoplasty��������������������������������������������������������������������������������������������� 535 Mohan Thomas and James D’silva 36 Body  Reshaping Using Implants������������������������������������������������������������������������������� 549 Shahin Javaheri 37 Gluteoplasty: Submuscular Implants����������������������������������������������������������������������� 567 Mario Gioia Part VIII Miscellaneous 38 Male  Body Contouring with Implants ��������������������������������������������������������������������� 585 J. Howell Tiller 39 Treatment  of Banana Rolls (Folds)��������������������������������������������������������������������������� 597 Aldo Perez 40 Hand Rejuvenation����������������������������������������������������������������������������������������������������� 607 Mohan Thomas and James D’silva

Editors and Contributors

About the Editors Mohan  Thomas  is an American Trained and Double BoardCertified Cosmetic Plastic and Facial Plastic Surgeon and a Senior Consultant at Breach Candy Hospital in Mumbai, India. He is also the Chief Mentor and Program Chair of the Advanced Fellowship in cosmetic surgery at the D.Y. Patil University. He has graduated from the Medical College, University of Pennsylvania, and completed his fellowships in Mt. Sinai Hospital, New  York. He has completed his Fellowships with the Master’s in Surgery of the Nose, Face, Body, and Breast in the USA, Europe, Mexico, and Latin America. He is chairman and managing director of Dr. Mohan Thomas Aesthetics, Mumbai. The institute under the leadership of Dr. Thomas has been a pioneer and is still a leader in the field of cosmetic surgery and medicine. He has been in practice for about two decades practicing the full scope of Cosmetic Surgery. Dr. Thomas has made significant notable contributions to the Plastic and Aesthetic surgery literature with more than 51 peer-reviewed publications in the American Academy of Cosmetic Surgery Journal, Plastic and Reconstructive Surgery Journal, Aesthetic Surgery Journal, Journal of Plastic Reconstructive and Aesthetic Surgery, Journal of Cutaneous and Aesthetic Surgery, Indian Journal of Plastic Surgery, and the prestigious Clinics of North America and 9 chapters in various textbooks. This publication is part of a 6 Volume Manual of Cosmetic Surgery and Medicine. Dr. Mohan Thomas is a past member of the board of trustees of the prestigious American Academy of Cosmetic Surgery (AACS) and a current member of the World Academy of Cosmetic Surgery (WAOCS) which are known for their commitment towards the development of the field of cosmetic surgery that delivers the safest patient outcomes through evidence-based information. As part of a Global task force he is committed to developing keyhole surgery, raising the safety standards with reduced operative times, innovative techniques, and superior results. He has a special interest in the very challenging Revision Cosmetic Surgery/Multiply operated patients.

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Editors and Contributors

James D’silva  is a Board-Certified Plastic Surgeon who has been in practice as a consultant at the Cosmetic Surgery Institute and Breach Candy Hospital in Mumbai. He practices the full scope of cosmetic surgery ranging from hair transplants, nose surgeries, face rejuvenation, male and female breasts, all types of body contouring including lifts and has a special interest in secondary cleft lip surgery, facial correction in facial palsy, and treatment of scars. He is part of the teaching faculty of the Cosmetic Surgery Fellowship program through the D.Y.  Patil University. His innumerable publications on cosmetic surgery and medicine are noteworthy and appear in most of the international peer-reviewed journals including the prestigious Clinics of North America and PRS. He along with Dr. Mohan Thomas with inputs from the world community has provided safety guidelines to be incorporated during Body Contouring and Brazilian butt lift which have benefitted the surgeons globally.

Contributors Rania  Agha, MD Dermatology, Summit Dermatology and Aesthetic Surgery, Oakbrook Terrace, IL, USA Ehab Akkary, MD  Akkary Surgery Center, Morgantown, WV, USA Akkary Surgery Center, Bridgeport, WV, USA Gregory Alouf, MD  Cosmetic Surgery, Salem, VA, USA Kulwant Bhangoo, MD  Cosmetic, Plastic and Reconstructive Surgery, Buffalo, NY, USA Guido  Blugerman, MD B&S Center of Excellence in Plastic Surgery, Buenos Aires, Argentina Guillermo Blugerman, MD  Aesthetic and Plastic Surgery, Buenos Aires, Argentina B&S Center of Excellence in Plastic Surgery, Buenos Aires, Argentina Rene Calderon, MD  Universidad Autonoma de Baja California (UABC), Tijuana, Mexico Cosmetic and Aesthetic Surgery, Tijuana, Mexico James D’silva, MS, MCh, DNB  Cosmetic Plastic Surgery, Breach Candy Hospital and D.Y. Patil University, Mumbai, Maharashtra, India Julian Duran, MD  Corpo D’oro, Bogota, DC, Colombia Giovanni P. Ferrara, MD  University of Nottingham, Nottingham, UK Joachim Finckenstein, MD  Starnberg, Germany Michael Gadayev, B.Sc. (Biology)  Arizona State University, Tempe, AZ, USA Mario Gioia, Degree in Medicine, Specialist in General Surgery, MD  Day Surgery Studio Nice, Napoli, Italy Grant Hamlet, MB, ChB  Hamlet Clinic, London, UK Waqqas Jalil, MD  Toronto Cosmetic Surgery Institute, Toronto, Ontario, Canada Shahin  Javaheri, MD  Plastic, Reconstructive and Cosmetic Surgeon, San Francisco, CA, USA

Editors and Contributors

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Martin Jugenburg, MD  Toronto Cosmetic Surgery Institute, Toronto, Ontario, Canada Julie Kesserwani, BS  Bachelor of Science, Natural Resource Plastic Surgery, Scottsdale, AZ, USA Sandra Knight, MD  Harmonyhealth cosmetic clinic, Kingston, Jamaica E.  Antonio  Mangubat, MD Director- La Belle Vie Cosmetic surgery Center, Tukwila, Seattle, WA, USA Carlos Mata, MD, MBA, FACS  Plastic and Reconstructive surgery, Scottsdale, AZ, USA Arian Mowlavi, MD, FACS  Long Beach Memorial Hospital, Hoag Presbyterian Hospital, Laguna Beach, California, USA Erik J. Nuveen, MD, DMD, FAACS  Cosmetic Surgery Affiliates, Oklahoma City, OK, USA Javier Palacios, MD  Cosmetic Plastic Surgery, Veracruz, Mexico Aldo Perez, MD  Aesthetic Plastic surgery, Cuernavaca, Morelos Mexico Department of Plastic Surgery, Universidad de Ciencias Medicas de la Habana, . Cuba Aesthetic Plastic Surgeon, Cuernavaca, Morelos, Mexico Sofia Santareno, MD  Plastic Surgery - The Dr Pure Clinic, Lisbon, Portugal Diego Schavelzon, MD  B&S Center of Excellence in Plastic Surgery, Buenos Aires, Argentina Victoria  Schavelzon, MD B&S Center of Excellence in Plastic Surgery, Buenos Aires, Argentina Peter  M.  Schmid, DO, FAACS Institute of Aesthetic Plastic Reconstructive Surgery, Longmont, CO, USA Tarick Smiley, MD  California Surgical Institute, Beverly Hills, CA, USA Mauro  Dalmiro  Soriano, MD Plastic Surgeon at Parque Sanatorium, Rosario, Santa Fe, Argentina Jeffrey  A.  Swetnam, MD, FACS, FAACS General Cosmetic Surgery, Facial Cosmetic Surgery and General Surgery, Fayetteville, AR, USA Mohan Thomas, MD, FAACS  Cosmetic Plastic Surgery, Breach Candy Hospital and D.Y. Patil University, Mumbai, Maharashtra, India J. Howell Tiller, MD  Board Certified Aesthetic Plastic Surgeon, Pensacola, FL, USA Cesar Velilla, MD  Evolution, Miami, MD, USA Francisco Villegas, MD. Plastic Surgeon  Private Practice at Clínica San Francisco, Tuluá, Colombia Plastic Surgery Unit, Universidad del Valle, Cali, Colombia Edwin Zara, MD  Cosmetic Surgery, Salem, VA, USA Ivonne  Žgaljardić, MD Plastic, Reconstructive and Aesthetic Surgeon, Opatija/Zagreb, Croatia Zoran  Žgaljardić, MD, PhD Maxillofacial Surgeon, Head and Neck Plastic Surgeon, Opatija/Zagreb, Croatia

Part I Introduction to Body Contouring

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The Art and Science of Body Sculpting: Sculptor’s Perspective Peter M. Schmid

The quintessential inspiration to mankind is the beauty of the human body. In our work as cosmetic surgeons we are entrusted by our patients to be the Michelangelo’s of Beauty, the master sculptors of image, emotion, and form. To artists and surgeons alike, the human body provides extraordinary possibilities for them to exhibit aesthetic finesse. To the unartistic template-reliant technician, the body’s complexity will impair outcomes. Working with a contemporary audience of heightened idealizations, patients today present with preconceived perceptions and place a priceless value on physical beauty. These expectations reflect the times with technology and savvy social media self-reconstructions of personal beauty that may be imagined but may or may not be achievable [1, 2]. Creating harmonious visual and emotional outcomes distinguishes the cosmetic surgeon from other surgical subspecialties. It is our love affair with human body that we are called as surgeons to discover new truths to deepen our understanding of the aesthetics of human form (Fig. 1.1).

Aesthetics is the formal study of art and relationship to beauty. Since the Renaissance, the gold standard for training in the figurative arts has been through intense study of the antique, the live model, and anatomy [3]. Contemporary training for the cosmetic surgeon is the Surgical Fine Arts in a structured, stimulating, and supportive environment. Art academia broadens the intellectual palate and refines the senses, expanding visual thinking and perspective, observation, fine motor skills, and performance. Human aesthetics is intricately composed of geometrics, contour, shape, volume, and form. Sculpting explores these qualities of beauty and serves an aesthetic bridge to cadaver dissection, surgery, and technology. Sculpting for Surgeons™ provides a learning platform from which the aesthetic sculptural arts and cadaver labs serve as a pillar for intellectual, conceptual, and personal growth. The physician learns the nuances of corporeal beauty and develops a fidelity in form while producing the anatomical human body in drawing or in clay. This aesthetic intelli-

Fig. 1.1  Female human form. (© 2021 Peter M. Schmid)

Supplementary Information The online version contains supplementary material available at [https://doi.org/10.1007/978-­981-­19-­4997-­5_1]. P. M. Schmid (*) Institute of Aesthetic Plastic Reconstructive Surgery, Longmont, CO, USA e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_1

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gence enables surgeons to develop unique vision and innovative artistic direction from which to deliberately sculpt their patients and advance one’s surgical art, acumen, and outcomes.

1.1 Surgeon and Sculptor To effectively integrate artistic principle into cosmetic practice, training in the sculptural arts requires divergent thinking in a stimulating learning environment (Fig. 1.2). In cosmetic surgery, the latest technology and aptitude in standard techniques does not assure favorable aesthetic outcomes, and this is where aesthetic prowess becomes the game changer. Aesthetic intelligence cannot be learned from one lecture, read in a book, or learned through social media. It is the continued scrutiny and analyzation of the live model, sculpting from skeleton to surface, emphasizing the aesthetic unity of form, connecting translations to the human patient, correcting surgical planning, and unfolding the infrastructural anat-

P. M. Schmid

omy. The sculpted human figure is the unequivocal model for studying human anatomy, as it emphasizes the interplay of three-dimensional concepts of mass, weight, and solidity, three-dimensional space (volume and depth), compositional three-dimensional modulations, and details of anatomical form [4]. It exercises a constructive “inside-out” performance-­ based experience touching on aesthetic landmarks, geometry, gender dichotomy, cultural aesthetics, dynamics, and harmony. Sculpting in clay explores natural convexities, concavities, transition zones, bony and adipomyofascial patterns, soft and hard forms, and the qualities of volume creating the values of light and shadowing. These aesthetic tools hone artistic perspective and transfer to the cadaver lab where one rethinks and rediscovers human anatomy and aesthetics. This exercise refines aesthetic judgment, while expanding mental constructs and proposals through conceptualization so relevant to the cosmetic surgery [5]. The experience accordingly promotes further passion for artistic discipline and refines aesthetic proficiencies in work. Art become a means to the end.

Fig. 1.2  Sculpting for surgeons live class. Additive aesthetic anatomy via clay directed by training from live model studies. (© 2021 Peter M. Schmid)

1  The Art and Science of Body Sculpting: Sculptor’s Perspective

1.2 Cadaver and Model The study of the human cadaver, our “Silent Teachers,” is abiding and invaluable [6]. The quest to understand the disposition of structures under the skin has inspired artists to undertake unconventional human dissections on corpses since the sixteenth century. Renaissance artists Leonardo da Vinci and Michelangelo took these studies further. Having acquired structural knowledge through anatomical dissections, they were determined to understand anatomy (Fig. 1.3). This knowledge, combined with exceptional discipline, artistic aptitude, and style, advanced their artistic skills and representations of the human figure, setting them apart from others in their field [7–9]. The Greek sculptors, infamous for canons and iconic human form, did not dissect, but displayed profound observational skills as sculptors of the living human body. The human cadaver provides a realistic anatomical model for dissection and education during implementation of surgi-

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cal specialty techniques, bereft of complications in a safe working environment [6, 10]. Current teaching of surgical skills and anatomy has evolved into a romance with state-of-­ the-art educational simulators from videos and digital cadavers to virtual dissection platforms (i.e., Visible Human Project) by the click or swipe of a finger [11, 12]. These learning platforms lead to a “focus on academic knowledge at the expense of manual training and craftmanship,” undermining the development of critical thinking, tactile muscle memory, and surgical skills (Roger Kneebone, MD, Imperial College, 2020). Though providing a safe environment for learning, there remain deficiencies inherent to the cadaver dissection lab. Death in the first hours distorts the body, disfiguring surface form, as the convexities of vitality become stiff and flattened. Dissection in itself is a destructive process to human structure, as one disassembles the body to delve into deeper tissue levels. Artistic training demands exhaustive study of the nude model conditioning the “eyes of the mind” and an artistic intelligence for human anatomy committed to memory.

Fig. 1.3  Clay sculpture detail and cadaver specimen of shoulder girdle and pectoralis major. (© 2021 Peter M. Schmid)

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1.3 Sculpting and the Senses Conditioned observation and the “power of seeing” is an acquired skill. In aesthetic anatomy, this process requires focused conscious practice in visual thinking and scrupulous reproduction of the human figure via drawing or sculpting. These activities detail concepts of line, light, shape, and form taught under the direction of a mentor. The challenge is to suspend one’s existing conceptions and see to understand aesthetics afresh. An unencumbered mind is free of homogenized interpretations, visual discrimination, preconceptions, opinions, and biases; free of the habitual calculating mind [13]. One must release preconceived ideas and judgments of beauty in the visual world, and “not only look at, but for each detail” [14]. Since the eyes see in two dimensions, touch intimately connects vision to three dimensions. Hands-on training in clay bridges cognitive and visual neural pathways. Representative sculpting incorporates additive and reductive technique utilizing the sculptor’s tools, via deliberate comparative study of “iconic” live female and male models from the head to the toe (Fig. 1.4). Working in clay tests hand and eye, and the armature is transformed into

P. M. Schmid

a representational human figure meticulously reproducing bone, muscle, and adipose dispositions defined by a passive pose or suspended animation, challenging artistic skills, visual interpretation, patterning, proportional relationship, scale processing, and critical judgment in reproducing form. The process engages visual thinking by imagining, abstracting, multi-perspective analysis, body thinking, and dimensional thinking processed with and without the measuring caliper [15, 16]. Sculpting and sketching synergistically borrow from both cerebral hemispheres, engaging neuroaesthetic processing areas of brain and the right prefrontal cortex, and can reorganize and reprogram hard-wired hemispheric cortical pathways through neuroplasticity in response to conditioning [17–19]. The artistically inclined surgeon works beyond scientific linear thinking by incorporating aesthetic insight, abstract, and ambidextrous thinking into practice [20, 21]. For many surgeons, the creative part of the brain has always been there, but never tapped into due to preconditioned linear thinking. Years of deliberate practice will transform thought and action. “Superior performance extends beyond the power of sight, and the ability to feel resides in touch” [22]. Sculpting and drawing introduces a new language and mental model to decipher anatomical structural relationships and human beauty [23]. Sculpting in clay requires the student to memorize anatomical relationships three-dimensionally in shape and disposition and seek to understand form as related to gesture and function. It strengthens the ability to visualize the human body transparently, imperative to the surgical eye. The sculpting process explores the definition and linear angulations of the male and flowing softness of the female body. Practice and time become automatic and unconscious by Fitts–Posner motor skill development, and muscle memory that with time may allow one to enter “in the zone” or flow experience [24, 25]. Over time, the committed student will refine aesthetic sensitivities and find an inherent “sixth sense” awareness to human form.

1.4 General Body Analysis: Studying the Model The chief forms of beauty are order and symmetry and definiteness. Aristotle [26]

Fig. 1.4  Sculpting instruments, clay, and visuo-tactile sculpture development. (© 2021 Peter M. Schmid)

Instantaneous visual reaction to the physical presence of an another form is called the “blink response” [27], perceiving appearance to be attractive, average, or unsightly. This aesthetically charged visual impulse is inherently hard-wired into our brains in infancy [28]. Cerebral maturation comes later as we develop more sophisticated perceptions and interpretations of beauty. To physically sense core and pose of the model, the artist should briefly mirror and assume the model’s position to

1  The Art and Science of Body Sculpting: Sculptor’s Perspective

sense the weight, strength, lassitude, strain, tension, or relaxation of muscles engaged. This positioning allows the viewer to experience the multisensory integration and energy of the pose of the model from the inside and the outside [4, 29]. Health, fitness, attractiveness, energy, masculinity, femininity, and emotion can be perceived from the model in his or her pose. The outward shape of the figure should serve as the focal point, provide linear clues to the subtleties of shape and form, then communicate a specific body type to the model be that triangular, rectangular, diamond-shaped, hourglass, or rounded.

1.5 Principal Masses Sculpting the human figure requires both deconstructive and reconstructive processes. Initially, the body is examined by imaginative visual dissection contemplating the underlying layers contributing to the surface shape and form, followed by physical reconstruction of the model in clay. The additive reconstructive approach to learning

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human anatomy is an invaluable three-dimensional proprio-spatial learning experience [30, 31]. To appropriately analyze the model, varied lighting by intensity, angulation, and distance from the body will bring out different accentuations and values of form. These basic principles of light define how the eye perceives form, distinguishing peaks and the valleys and the values of light through highlights and shadows of surface anatomy. The retina perceives images in two dimensions, while reconstructing the human body requires three-dimensional perspective. The bony infrastructure of the body consists of three principal masses: the oval (head), egg (thorax), and the trapezoid (pelvis) (Fig. 1.5). These large forms represent the rudimentary shapes of core skeletal form, connected vertically by the spine varying in length by curvatures and angulations. Using the head height as the standard unit for measurement, the principal body masses are sculpted, and the extremities of the armature are covered sparingly to represent the bony limbs. Primary masses create the infrastructure for many bony landmarks serving as measurements, orientation, and visual clues to the overlying soft tissues.

Fig. 1.5  Armature and clay building of masses: oval (head), egg (thorax), and trapezoid (pelvis). (© 2021 Peter M. Schmid)

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1.6 Sculpting Anatomical Shape and Form Representational sculpting proceeds by the additive process from which slips of clay are applied piece by piece, strand by strand to the armature building the human body. Sculpting anatomical detail demands mental constructs of origins and insertions of muscles and muscle and tendon shapes, consistently using the model as a reference point. The method of applying clay is directional, laying out muscle groups linearly transitioning between plane and three-dimensional convexities while building the infrastructure volume. The clay becomes systematically layered in “reverse dissection.” As the myofascial layers of the body are placed, structural anatomy is built, along with positive convex volumes of profile lines, transition zones, definition, and shadows by negative volume, all construction in exacting measures. Muscles

P. M. Schmid

and their attachments inherently display individual squareness, collective sinuous patterns, S-shaped curves, and planes throughout the body (Fig.  1.6). The body naturally ­demonstrates contour offsets, and rhythmic flow patterns as muscles join primary masses and course down the extremities. The artist’s eye is continuously tested for anatomical accuracy, symmetry, proportions, and deficiencies. The surface convexities of the various areas of the body reveal unique inflections, degrees, apogees, and transition points that reflect the cumulative shape of all underlying anatomy from bone to skin. As the plastic expression unfolds, certain aesthetics are deliberately enhanced and visually expressed. A fourth dimension unfolds through muscle accentuation and gestural expression. Understanding structural–shape associations relays important visual clues in live patients, as over time the eye recognizes surface form as related to specific underlying anatomy.

Fig. 1.6  Additive sculpting of thorax chest, and breast from skeleton to surface and breast form. (© 2021 Peter M. Schmid)

1  The Art and Science of Body Sculpting: Sculptor’s Perspective

1.7 Application of Art to the Science of Facial and Body Contouring Transitioning from studio to surgical suite with newly established ideas and perspectives, the cosmetic surgeon can now approach aesthetic challenges with deliberate aesthetic plans from conceptualization to management, be that prejuvenation, refinement, enhancement, rejuvenation, or reconstruction of human form. Artistically tailored techniques preserve patient-specific cosmetic needs sensitive to age, ethnicity, femininity, masculinity, self-expression, and expectations. Artistry avoids the Einstellung effect, the untailored cookie cutter, or antiquated philosophies of treatment. Sculptural awareness contemplates heightened preconceptions of beauty and the strategic surgical goals needed to achieve aesthetic aims and endpoints. Thus, outcomes remain true to the preservation of natural beauty. Patient examination requires multi-perspective lighting and with specific anatomical markings (anatomical, sculptural, aesthetic specific) outlining geometrics, proportions, details, depletions, or deficiencies. With attention to detail, appraisals assess skeletal and/or cartilaginous structural landmarks, muscle anatomy, fat tissue compartment dispositions, tendinous ligamentous or fibro-septal network integrity, and the status of the skin of the body equally by touch and visual inspection. Surgical objectives are accomplished through skillful application of additive, reductive, or synergistic sculpting materials and techniques to augment, reduce, reshape, contour, lift, or define human form (Fig. 1.7). Working from a palate of options, treatments entail safe and selective application of fillers, neuromodulators, skin resurfacing, autologous fat transfer, implants, tissue/fascial release and lifting, tightening, excisional surgery, or combinations thereof. Whether volume enhancement is in the face, breast, buttock, or body, treatment must address the multi-perspective profile lines, and complement and conform into the natural anatomical curves and surface to optimize visual enhancement, ratios, form, and balance. As artistic surgeons we must ethically guide the patient toward volumetric shape and curvatures that complement the patient’s frame and physique now and as the body ages. Facial augmentation is accountable to structural bony facial platforms, the overlying soft tissue layers including the fat compartments, and the concertina effect of aging and the skin [32]. Aesthetic treatment must complement ­anthropometrics, the malar platform, and the influence of the

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forehead and jawline. Treatments should always avoid curve distortion, over-enhancement, disfigurement, or deformity. Restoration should balance ogee curves, volumes, and bony contour and angulations respective to age and individual masculine or feminine secondary characteristics. Rhinoplasty remains a sophisticated sculptural procedure that addresses the most visible central feature on the human face. From computer imaging and conception to surgical alteration, rhinoplasty demands finesse in planning and execution as the surgeon refines, reduces, and alters the disposition of the nasal framework and overlying soft tissues. Tip shape and projection serves as the crucial defining point from which adjacent visual alterations are based. The artistic directive becomes the expression of the attitude of the nasal dorsum to the tip, all in relationship to the facial profile plateaus and feature by degrees and millimeters. Breast and buttock augmentation requires artistic planning with visual insight and sensitivity to size, shape, volume, orientation, projection, asymmetries, attitude, and the anticipation of the natural aging process. Breast and buttock augmentation requires a keen sense of figurative scale, symmetry, and proportion to complement the existing body curvatures and dimensions during performance of reductive, augmentation, or fat transfer techniques. Aesthetic impact is as much about proportion as it is about size. The breast and buttock should sync with the body contour, blend naturally, and reflect cultural values avoiding artificial or unnatural and inorganic “stuck on” shapes in appearance. Body contouring by cannula, energy, and tissue transfer simulates sculpting in clay by knife and wire loop. The aesthetic sculptural intent is to control surface form and light values by altering subcutaneous convexities, concavities, and transition zones. Contemporary artistic techniques of body sculpting lie far from the days of generalized liposuction, merely aspirating and reducing tissues by “non-thinking” technique or hands. What artistic training now brings to the table is an inspired artistic mindset by which the surgeon skillfully operates with “sculpting hands” and by visuo-­ tactile sense. Subcutaneous selective sculpting reduces, modifies, preserves, or feathers adipose disposition incrementally while accentuating or softening of myofascial shape translates to improved surface form. Creating either high- or low-definition torsos and extremities requires both an aesthetic plan and technical precision. The aesthetic details lie in the surgeons’ adept execution, as undertreatment conceals form and overtreatment skeletonizes, or can destroy, natural form. As discovered through clay sculpting,

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P. M. Schmid

Fig. 1.7  From visual conception and planning in the atelier to the operating room (OR): applying art to science. (© 2021 Peter M. Schmid)

1  The Art and Science of Body Sculpting: Sculptor’s Perspective

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one should avoid destroying form by excessive flattening of three-dimensional volumes, or creating unnatural severely etched or sharp linear forms, grid-like patterns, or horizontal lines. Vertical lines create the illusion of length and flow to the figure. Sculpted human form should have pleasing balances of negative and positive spaces and volumes, hierarchical light reflexes, and feathered peripheral zones avoiding abrupt step-offs end zones. Liposculpting the human figure in-the-round and by subtle blending into adjacent anatomical zones maintains a visual flow to the body. Fat is the surgeon’s advocate and serves as an aesthetic definer, and by degree of fullness reflects youth, beauty, and health.

1.8 Conclusion The Art of the Aesthetic Surgeon guided by artistic “visual enlightenment” can be founded in the Surgical Sculptural Arts. Aesthetic didactics establishes a unique paradigm shift from archaic philosophy and practices toward a surgical intelligentsia. Artist–technology associations working within collective mind inspire ideas and creativity, influencing innovative thought and aesthetic judgment. Driven by the passion for beauty of the human form, sculptural arts enable one to discover new levels of consciousness, and bridge unparalleled gaps and sensitivities to conceiving and treating the human body. Training in aesthetics ultimately disciplines the hand, mind, and eye, as the human body may now be addressed as art form. Aesthetic anatomy, intimately learned through sculptural study of the live model, the cadaver, and life, not only cultivates a deeper understanding of human beauty, but also provides perspective and aesthetic direction to deliberate modification of the human body upholding visual harmony and balance. These newly founded sensitivities advance cosmetic surgery to a whole new level of expertise, a value to novice or accomplished surgeon alike. Artistic temperament drives one to critically appraise one’s work and seek personal improvement by focused “perfect practice,” satisfying the desire to strive for perfection in the ideal. Beauty now lies in the mind and hands of the cosmetic surgeon. Sculpting for Surgeons™ is an original artistic platform by which the cosmetic surgeon can advance aesthetic skills and intellect to form sense and three-dimensional anatomy of the human body under a professional instructor [33]. As altering the appearance alters the patient’s self-perception and esteem, it is the impetus of the aesthetic surgeon to do all in his or her power to expand upon knowledge, understanding, planning, and technique to provide optimal results.

Contemplation. (© 2021 Peter M. Schmid)

References 1. Blair L, Shalmon M. Cosmetic surgery and the cultural construction of beauty. Art Educ. 2005;58(3):14–8. 2. Gilman SL. Making the body beautiful : a cultural history of aesthetic surgery. Princeton: Princeton University Press; 1999. p. xxii, 396 p. 3. Pevsner N. Academies of art, past and present. New York: Da Capo Press; 1973. p. x, xiv, 323 p. 4. Zuckert R. Sculpture and touch: Herder’s aesthetics of sculpture. J Aesthet Art Critic. 2009;67(3):285–99. 5. Sholt M, Gavron T. Therapeutic qualities of clay-work in art therapy and psychotherapy: a review. Art Ther. 2006;23(2):66–72. 6. Eisma R, Wilkinson T.  From “silent teachers” to models. PLoS Biol. 2014;12(10):e1001971. 7. Jones R.  Leonardo da Vinci: anatomist. Br J Gen Pract. 2012;62(599):319. 8. Eknoyan G.  Michelangelo: art, anatomy, and the kidney. Kidney Int. 2000;57(3):1190–201.

12 9. Vasari G, Bondanella JC, Bondanella P. The lives of the artists. The world’s classics. Oxford: Oxford University Press; 1991. p. xxiii, 586 p. 10. Reznick RK, MacRae H. Teaching surgical skills—changes in the wind. N Engl J Med. 2006;355(25):2664–9. 11. van Dijck J. Digital cadavers and virtual dissection. In: Bleeker M, editor. Anatomy live. Amsterdam: Amsterdam University Press; 2008. p. 29–48. 12. Ackerman MJ.  The visible human project. J Biocommun. 1991;18(2):14. 13. Beveridge WIB.  The art of scientific investigation. Rev. ed. New York: Norton; 1957, 178 p. 14. George WH. The scientist in action; a scientific study of his methods. London: Williams & Norgate; 1936. 3 p. l., 9–355 p. 15. Root-Bernstein RS, Root-Bernstein MI. Sparks of genius: the thirteen thinking tools of the world’s most creative people. Boston: Houghton Mifflin Co.; 1999. p. viii, 401 p. 16. Kruk KA, et al. Comparison of brain activity during drawing and clay sculpting: a preliminary qEEG study. Art Ther. 2014;31(2):52–60. 17. Di Dio C, Macaluso E, Rizzolatti G.  The golden beauty: brain response to classical and renaissance sculptures. PLoS One. 2007;2(11):e1201. 18. Brown S, et  al. Naturalizing aesthetics: brain areas for aesthetic appraisal across sensory modalities. NeuroImage. 2011;58(1):250–8. 19. Merzenich MM, Nahum M, Van Vleet TM. Changing brains: applying brain plasticity to advance and recover human ability, Progress in brain research. 1st ed. Amsterdam: Elsevier; 2013. p. xxvi, 466 pages. 20. Sperry R, Trevarthen CB.  Brain circuits and functions of the mind: essays in honor of Roger W. Sperry. Cambridge: Cambridge University Press; 1990. p. xxvi, 410 p.

P. M. Schmid 21. McKim RH. Thinking visually: a strategy manual for problem solving. Belmont: Lifetime Learning Publications; 1980. p. x, 210 p. 22. Colvin G.  Talent is overrated: what really separates world-class performers from everybody else. London: Nicholas Brealey; 2008. 23. Aristides J. Lessons in classical drawing: essential techniques from inside the Atelier. 1st ed. New York: Watson-Guptill Publications; 2012. 24. Fitts PM, Posner MI. Human performance. Basic concepts in psychology series. Belmont: Brooks/Cole Pub. Co; 1967. p. x, 162 p. 25. Csikszentmihalyi M. Flow: the psychology of optimal experience. 1st ed. New York: Harper & Row; 1990. p. xii, 303 p. 26. Hofstadter A, Kuhns R.  Philosophies of art and beauty; selected readings in aesthetics from Plato to Heidegger. The modern library of the world’s best books modern library giants. New York: Modern Library; 1964. p. xix, 701 p. 27. Goldstein A, Papageorge J. Judgments of facial attractiveness in the absence of eye movements. Bull Psychon Soc. 1980;15(4):269–70. 28. Ramsey JL, et al. Origins of a stereotype: categorization of facial attractiveness by 6-month-old infants. Dev Sci. 2004;7(2):201–11. 29. Chiba R, et  al. Human upright posture control models based on multisensory inputs; in fast and slow dynamics. Neurosci Res. 2016;104:96–104. 30. Waters JR, et  al. Human clay models versus cat dissection: how the similarity between the classroom and the exam affects student performance. Adv Physiol Educ. 2011;35(2):227–36. 31. Motoike HK, et al. Clay modeling as a method to learn human muscles: a community college study. Anat Sci Educ. 2009;2(1):19–23. 32. Pessa JE, et al. Concertina effect and facial aging: nonlinear aspects of youthfulness and skeletal remodeling, and why, perhaps, infants have jowls. Plast Reconstr Surg. 1999;103(2):635–44. 33. Schmid PM. Sculptural aesthetic surface anatomy of the face. Adv Cosmetic Surg. 2019;2(1):11–21.

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Surgical Anatomy of the Body in Relation to Lipocontouring Mohan Thomas and James D’silva

Body contouring using liposuction requires a fundamental understanding of subcutaneous fat and its anatomical relation to the underlying fascia in order to provide optimal results. Subcutaneous fat is variable in density, thickness, and adherence throughout the body. Illouz in the 1980s was the first to introduce Modern Liposuction and his presented technique has undergone many transformations to get to its present state due to the medical technological advances and use of newer drugs and physiological understanding in recent times. Better understanding of the biochemical and physiologic properties of the process of liposuction has improved the safety features in liposuction primarily by reducing blood loss. Body contouring by liposuction requires a complete knowledge of the anatomy of the area and understanding of the physiological basis of liposuction.

Apical fat layer

Mantle fat layer

Deep fat layer

2.1 Gross Anatomy Deposition of fat cells in the body is usually in the form of three layers as seen in Fig. 2.1: the apical fat layer, the mantle fat layer, and the deep fat layer. 1. Apical Layer of Fat: This layer is the most superficial of all fat layers and is continuous with the deepest aspect of the reticular dermis. These extend upward into the deep dermis in the form of peri-adnexal fat surrounding the sweat glands and hair follicles and also along the vascular arcade. This is usually visible as yellow dots on the undersurface of the thick split-thickness skin graft. Liposuction of this layer of fat is not possible without injury to the dermal vascular plexus. The understanding that superficial liposuction undertaken in this layer will cause skin shrinkage is faulty; rather, it may cause partialof full-­thickness skin loss. M. Thomas (*) ∙ J. D’silva Cosmetic Plastic Surgery, Breach Candy Hospital and D.Y. Patil University, Mumbai, Maharashtra, India

Fig. 2.1  The distribution of adipocyte layers as seen from the dermis to the muscular fascia. The apical and mantle layers should not be treated denoting “no man’s zone” of liposuction [1]. (Adapted from: Kaminski M.V. (2010) The Adipocyte Anatomy, Physiology, and Metabolism/Nutrition. In: Shiffman M. (eds) Autologous Fat Transfer. Springer, Berlin, Heidelberg. https:// doi.org/10.1007/978-­3 -­6 42-­0 0473-­5 _4)

2. Mantle Layer: This has columnar fat cells that are vertically oriented and are present at the interface of the dermis and the discrete sheet of facial fibrous tissue, as seen in Fig. 2.1. This layer is present in all body parts except in areas such as the eyelids, nasal bridge, and penis to name a few. In specific body parts such as the legs, this segment accounts for all the subcutaneous fat in the area. Its function is to protect, insulate, and cushion the area. 3. Deep compartment layer: This is the layer where fat deposition happens due to increasing weight. The size and shape of these fat deposits depend on the sex of the

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_2

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individual, their genetic predisposition, and the degree of obesity. The function of this layer is to store the excessive energy consumed by the person. This is the layer that needs maximum fat removal during lipocontouring.

2.2 Anatomy of the Abdomen The most common area being liposuctioned is the abdomen as it usually is the primary area of concern for both men and women. It is also a very challenging area due to its anatomy, very obvious results, comfort of the patient, and the unevenness arising due to weight gain. Abdominal fat is either located in the subcutaneous plane (outside the muscle) or viscera (part of omentum and between loops of intestine). Grossly, the division of abdomen can be done into an upper abdomen and a lower abdomen. In thin people, the skin is uniform to pinch and showcases the shape of the underlying muscle. Fat may deposit predominantly in the upper or lower abdomen in females or may be uniform such as in a male. In obese females there might be a distinct demarcation at or just above the umbilicus between the upper and lower abdomen called the waistline sulcus, which has an underlying diffuse fibrosis that corresponds with the superior extent of the Scarpa’s fascia. This is adherent superficially to skin and deeply to the abdominal muscle sheath requiring an extra effort to traverse during liposuction.

2.2.1 Skin • The skin over the anterior abdomen is thin. • Thick hair is often present in the lower midline of the male and pubic area in a female. • The inguinal ligament demarcates the abdomen from the thighs, and the skin in the area is very thin and forms the groin fold. Similar shallow groove is present below the iliac crest. • Striæ gravidarum or striæ albicantes are vertical white lines formed due to sudden abdominal distension secondary to pregnancy or obesity. • A brown pigmented streak visible often during pregnancy between the umbilicus and the pubic symphysis is called the linea nigra of pregnancy. Linea alba is a shallow furrow extending from the xiphoid process in the midline to below the umbilicus. • The position of the umbilicus is the middle line. Its position with respect to its height may vary; in an adult it is situated above the line dividing the middle of the body, and more specifically is situated 2–2.5 cm superior to the line joining the tubercles of the iliac crests.

2.2.2 Muscles Muscles of the abdomen (Fig. 2.2) • External oblique and the rectus abdominis are the only muscles that have an influence on form and shape of the abdomen. • The external oblique muscle originates as digitations that intersperse with those of serratus anterior and well marked in a muscular subject. • A small lumbar triangle is formed between the lateral margin of the external oblique muscle and the edge of the latissimus dorsi with its base formed by the iliac crest, and its floor by the internal oblique muscle. • Linea semilunaris is a curved line that is convex laterally and extending from the tip of the cartilage of the ninth rib superiorly to the public tubercle inferiorly, essentially marking the lateral border of the rectus abdominis muscle. At the level of the umbilicus, it is about 7 cm from the middle line. • Three transverse furrows are usually seen on the surface of the rectus abdominis muscle, which are primarily the tendinous intersections: the upper two are well demarcated and one is located at the tip of the xiphoid process and the second, midway between this and the umbilicus while the third, which is opposite the umbilicus, is not well defined. • The anatomical location of the umbilicus is considered to be the level of the fibrocartilage between the third and fourth lumbar vertebrae. • The rectus abdominis muscle takes the maximum brunt during increase in intra-abdominal pressure due to pregnancy, ascites, or obesity. This causes weakness in the linea alba. Once the intra-abdominal pressure is released, the muscle may not go back to its original tone and there may be separation of the two recti in the midline called diastasis recti. External Oblique Rectus Abdominis Tendinous Intersections Linea Alba Linea Semilunaris Umbilicus Groin Fold

Fig. 2.2  Muscle orientation of the flanks and the anterior abdominal wall

2  Surgical Anatomy of the Body in Relation to Lipocontouring

Applied Anatomy  The weakness of the abdominal muscles in the midline due to separation of the two recti is called diastasis recti. It can present as one of the four types as mentioned in Fig.  2.3 below. The treatment of this condition involves plication and tightening of the rectus sheath thus strengthening the abdominal wall. Sometimes a polypropylene mesh may be required as an extra support.

Diastasis around navel

Diastasis below navel

Diastasis above navel

Open diastasis

Fig. 2.3  Different types of diastases due to weakness of muscle wall

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2.2.3 Subcutaneous Tissue Fat distribution pattern is based on gender, age, and race of a person. Typically, the female body has a gynoid pattern of fat deposit with a curvilinear silhouette and increased tendency to accumulate fat in the lower body such as the hips, upper thighs, lower trunk, and buttocks. Males have an android pattern that has a linear shape with excess fat deposit occurring uniformly on the trunk. The waist-to-hip ratio (WHR) in a female is smaller (0.87) as compared to that in males (1.0). Racial differences in fat distribution are prominently visible in African-Americans who tend to accumulate more fat in the buttocks and hips, which is also the case in some communities in Western India (Fig. 2.4). According to observations and cadaver dissections by Lancerotto et al. in 2011 [2], three layers of fat are usually identified under the dermis in the abdominal region: a superficial adipose layer (SAT), a membranous layer (ML), and a deep adipose layer (DAT), as shown in Fig. 2.5a–c.

Fig. 2.4  Different layers of the abdominal wall fat deposits with relation to the waistline fibrosis

16 Fig. 2.5 (a) SAT (the superficial adipose tissue) has been dissected and reflected medially, while ML (membranous layer) has been isolated as a flap. (b) The membranous layer (ML) has been dissected and overturned medially with a small area dissected but left attached to the inguinal ligament (blue). (c) Deep adipose tissue (DAT) raised as a flap. (Adapted from: Lancerotto, L., Stecco, C., Macchi, V., Porzionato, A., Stecco, A., & De Caro, R. (2011). Layers of the abdominal wall: anatomical investigation of subcutaneous tissue and superficial fascia. Surgical and Radiologic Anatomy, 33(10), 835–842. https://doi.org/10.1007/ s00276-010-0772-8)

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a

b

c

2.2.3.1  Superficial Adipose Tissue (SAT) Superficial adipose tissue is also called Camper’s fascia by some authors. • This is the first layer of adipose tissue that is present just below the dermis.

• This layer has prominent fibrous septa with a honeycomb-­ like structure encasing large fat globules and has constant characteristics throughout the layer. • These well-defined septa (retinacula cutis superficialis) are oriented perpendicular to the skin surface and are mechanically very strong, anchoring the dermis to deeper tissues.

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Fig. 2.6  Different layers of the abdominal adipose tissue as a cut section

DERMIS

SUPERFICIAL ADIPOSE LAYER MEMBRANOUS LAYER

DEEP ADIPOSE TISSUE

• Its borders are ill defined both caudally and cranially, as it appears continuous inferiorly over the inguinal ligament into the thigh and cranially into the thorax as similar tissue. • The SAT has high structural stability and elastic properties. • Superficial adipose tissue (SAT) when removed exposes a membranous-looking fibrous layer, which is well organized macroscopically (Fig. 2.5a). • On dissection it is found as a continuous plane from the thorax to the inguinal ligament. • It is not uniform in thickness and appears as a well-defined white layer in the lower abdomen that thickens toward the inguinal ligament, where multilayered structure of collagen bundles layered in various angles is visible. • Medially this membrane fuses with the linea alba, cranially continues into the thorax, and caudally continues into the inguinal ligament and the osseous prominence of the iliac crest (Fig. 2.5b).

2.2.3.2 Deep Adipose Tissue (DAT): Sub-­Scarpa’s Fat • This is a more diffuse fat layer with smaller and flatter fat lobes that are ill defined with less consistent and obliquely oriented fibrous septa. • The thickness of this layer of tissue is different in different areas. • At the points of fixation of the membranous layer such as the inguinal ligament, bony prominences, and linea alba, DAT becomes thinner and tends to progressively reduce its fat component, while the network of collagen fibers (retinacula cutis profunda) becomes stronger and more tightly packed, connecting the deep aspect of the membranous layer to the deep fascia.

• There is great difference in the DAT among various individuals in terms of strength and thickness of the retinacula cutis as well as its fat contents. • Obliquely placed septa with good strength and elastic properties allow the subcutaneous tissue to slide over the deep fascia (Fig. 2.6). • The DAT compartment is clearly defined along the lines of adherence identified for the membranous layer; as a result the deep adipose compartment of the abdomen appears to be isolated from that of the thighs. • The deep fascia of the abdomen envelopes the abdominal muscles and is present deeper to the DAT.

2.2.3.3 Anatomical Importance [2] 1. The movements transmitted to the skin by the deeper muscular contractions are absorbed and dampened by the sliding system formed by the membranous layer (also called Scarpa’s fascia), the DAT, and the SAT. To prevent a bad scar adhesion between muscle and skin causing the transmission of these movements, it is imperative that these layers should be repaired in different layers. 2. The membranous layer provides a tissue plane for flaps in reconstructive surgery, that is, adipocutaneous propeller flaps can be raised just superficial to the DAT, or can be used as isolated ML–DAT flaps. 3. The anatomical difference between SAT and DAT should be kept in mind when undertaking liposuction in the abdomen. Large cannulas should be used deeper so as to aspirate fat from the DAT layer while the thin cannula should be used for SAT. Using large cannulas in the SAT layer will cause scaring and unevenness of the skin surface.

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4. The “contraction” in the skin after liposuction especially after ultrasound-assisted liposuction is due to the contraction of the membranous layer that is rich in elastic fibers. 5. Although the membranous layer appears to undergo a duplication in thickness with obesity, the fat layers, both, quadruplicate, and the thickness and the density of the retinacula is reduced as the size of the fat lobes increases that leads to altered mechanical and anatomical relations. According to Frank [3], aggressive liposuction of the superficial fatty layer, especially too close to the dermis. Can cause injury to the subdermal vascular plexus causing loss of vascularity of the subdermal fatty layer and thus causing necrosis of the overlying skin [4]. This happens because the arterial arcade traverses superficial to the Scarpa’s fascia, within the SAT, which can be damaged during superficial liposuction. • Liposuction of the deep fatty layer, deep to Scarpa’s fascia, can cause injury to the perforators connecting the named arteries to the supra-Scarpa arterial network since these run in the DAT. However, because of the great collateral supply, any vascular injury of the perforators is usually very well tolerated [5].

Fig. 2.7  The red areas are the zones of adherence caused by presence of dense fibrous tissue that attaches skin to the deep fascia and provides the shape as well as support and suspension to the soft tissue in the area [6]

1. Lateral Gluteal Depression

2. Gluteal Crease

3. Distal Posterior Thigh

4. Mid Medial Thigh

5. Inferolateral Iliotibial Tract

2.2.4 Zones of Adherence The zones of adherence (Fig. 2.7) are caused by presence of dense fibrous tissue that attaches skin to the deep fascia and provides the shape as well as support and suspension to the soft tissue in the area. • The superficial fascial system in these areas is adherent in a very dense manner to the underlying deep muscular fascia. • Because of this dense adherence, there tends to be a thin layer deep fat that is covered by the superficial fascial system. • The shape and the natural curve of the body is defined and maintained by these zones of adherence. • Liposuction if done aggressively in these areas of adherence does have a high risk of causing irregularities. There are a total of five zones of adherence throughout the trunk and lower extremity: • • • • •

The lateral gluteal depression Gluteal crease Distal posterior thigh Mid-medial thigh Inferolateral iliotibial tract

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2.2.5 Vascularity and Nerve Supply of the Subcutaneous Tissue

2.2.5.2 Nerves • The iliohypogastric, ilioinguinal, and the lower anterior intercostal nerves are the primary motor and sensory supply of the anterior and lateral abdominal wall. • The skin over the epigastric and supra-umbilical regions has a sensory innervation from the seventh, eighth, and ninth intercostal nerves. It also provides motor supply to the supra-umbilical part of the rectus abdominis muscle. The sensory supply of the skin at the level of the umbilicus comes from the tenth intercostal nerve, which also provides motor innervation that extends inferiorly to the level of the anterior superior iliac spine. The 11th and 12th intercostal nerves supply the skin from below the umbilicus to the level of the inguinal ligament and the groin. • All of these nerves have to pass through Camper’s fascia in order to innervate the skin. • Liposuction causes edema of the skin causing stretching of the nerve endings in the fascial layers of the skin causing a numbing feeling due to the disturbances in sensation.

2.2.5.1 Blood Supply and Lymphatics • Superior epigastric artery, which is the branch of the internal mammary artery, and inferior epigastric artery, which is a branch of the femoral artery, supply the anterior aspect of the abdomen in the vertical direction. The lateral aspect of the abdomen is supplied by the segmental arteries arising from the intercostal and lumbar arteries, horizontally (Fig. 2.8). • These vessels anastomose with each other as well as tributaries of the muscular branches. • These superficial abdominal vessels are situated superficial to the fascia Scarpa but found deep to the Camper’s fascia. • This layer marks an important anatomical landmark for surgery so as to avoid any damage to the vessels and lymphatics running through this layer. Fig. 2.8  Vascularity and nerve supply of the anterior abdominal wall

superior epigastric artery xiphoid process

T7

T8 T9 T10 T11 T12

lateral margin of rectus sheath intercostal arteries lumbar arteries

iliohypogastric nerve

L1 ilioinguinal nerve

deep circumflex iliac artery position of deep inguinal ring inferior epigastric artery

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2.2.5.3 Lymphatic Drainage The lymphatic vessels of the anterior abdominal wall lie both superficial and deep to the deep fascia.

2.2.6 Applied Anatomy

2. Majority of the superficial vessels are present superficial to the Scarpa’s fascia and they anastomose at the subdermal plexus, as seen in Fig.  2.10. Once the perforators from the deeper vessels are transected, the vascularity of the abdominal flap is based on the subdermal plexus being supplied by the superficial vessels.

1. The blood supply to the abdominal wall was previously described in a regional manner by Huger, consisting of three anatomically distinct zones [7] (Fig. 2.9). Zone I is the area supplied by the superior epigastric vessels and the deep inferior epigastric vessels situated in the upper and central midline area of the abdominal wall (in between the two linea semilunaris). Zone II consists of the whole infraumbilical area extending up to the anterior superior iliac spine laterally and the inguinal ligament inferiorly and supplied by the superficial inferior epigastric and superficial external pudendal arteries, which are the branches of the femoral artery and supply the superficial fascia and skin, while the deep inferior epigastric arteries (DIEAs) and deep circumflex iliac arteries supply the musculature of this lower area. Zone III is the area lateral to the linea semilunaris and is supplied by the lumbar and intercostal arteries arising from the aortic trunk. These arcades supply the lateral part of the abdominal wall and eventually they anastomose with the midline vascular structures. Incisions for abdominoplasty with limits of undermining of the abdominal pannus are based on this vascular supply.

Fig. 2.9  Delineated Huger’s zone on the anterior abdominal wall

Fig. 2.10  The abdominal skin being supplied by perforators as well as the subdermal plexus

Epidermis Dermis Subcutaneous tissue Fascia Muscle

Perforatory blood vessels to subdermal plexus

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2.3 Anatomy of the Back • The anatomy of back is unique; the dermis is very thick and the subcutaneous layer has a dense fibrotic fat. • The subcutaneous layer of the back is composed of fibrotic and compact superficial and intermediate layers and the underlying areolar layer is loose. • These anatomical implications make liposuction with traditional suction assisted liposuction (SAL) difficult in the back region. Technologies such as ultrasound assisted liposuction/power assisted liposuction (UAL/PAL) due to their tissue-penetrating capability tend to work well in the tough fibrous tissue of the back. • Liposuction causes only a moderate amount of fat removal but significantly improved shape is visible due to release of the tissue folds from their deeper attachments that cause back rolls. • Care should be taken while performing liposuction of the back, because of its fibrous nature. The muscles of the back are flat fan shaped and cover important structures such as the lungs and the renal triangle (Fig. 2.11). • Liposuction cannula should not be redirected forcibly as the fibrous attachments may redirect the cannula tip into the unsafe zone such as the intercostal space.

Trapezius

Fig. 2.12  The torso being divided into nine regions for ease of description with regard to the area of liposuction

Latissimus dorsi

• Suctioning from areas away from the thoracic cage such as going from the hip region to the posterior back should be avoided, as the possibility of intrathoracic penetration exists and because of the dense skin and the fibrous nature of the tissue, results are less than ideal. • The classic anatomy described by Sobotta [8] and Spalteholz [9] classified the back and the torso based on the underlying muscles. • Surgically speaking, they suggested dividing the torso into nine regions (Fig. 2.12): three paired on either side of the midline (scapular, lumbar, and supra-iliac) and three single (sacral, vertebral, and interscapular areas) in the central area.

External Oblique Posterior border Petit’s lumbar triangle

Gluteus maximus

Fig. 2.11  Muscles of the back

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2.3.1 Supra-Iliac Area • The supra-iliac region is the first region of the torso and is the most common site of adipose tissue accumulation in both men and women but very prominent in men. • The prominent bulge in this area is caused by the significant growth of the lamellar layer of fat in this region (Fig. 2.13). • The increased fat deposit in this layer gives the typical apple shape to the midriff. This causes loss of narrowing at the waistline especially in females having polycystic ovary disease.

2.3.2 Lumbar Area • The lumbar area is considered the second area of the torso and is situated just above the first one. • Rarely does it show significant fat collection enough to be treated by liposuction alone. • Often problems on the supra-iliac region appear because of the lumbar region. • Anatomically, this area has a very thin lamellar layer of fat that does not increase prominently in spite of significant fat deposits (Fig. 2.13). Applied Anatomy of Lumbar Area  Liposuction should be performed vertically or perpendicularly to the fat roll axis so that tunneling happens below the skin, and muscle adhesions Fig. 2.13  Typical fat deposits in the supra-iliac and the lumbar area

M. Thomas and J. D’silva

and new collagen thus formed will have a vertical framework, and when it heals it will support the back skin against gravity. The gravitational force is thus distributed in the vertical direction as if it were a sheer curtain panel heading in a standard way, as shown in Fig. 2.14a. If the direction of liposuction is transverse, the scar will form in the same direction as the fat roll axis and the tissue will remain unsupported giving the effect very similar to that of a sheer curtain Austrian festoon panel [10] (Fig. 2.14b).

2.3.3 Scapular area • The third area of the torso to present accumulation of fat is the scapular region. • The lamellar layer of fat greatly increases in thickness as compared to other areas and sometimes asymmetry of the fat bulges can also be observed. • There are some fat deposited in the areolar layer but never to the extent as seen in the lamellar layer. • When the lamellar layer shows localized adiposity, the subcutaneous panniculus is firm and does not slide easily over the muscular plane. • The best test to assess the overall thickness of the subcutaneous layer is the Illouz pinch test. It shows an increase in the overall thickness of the panniculus. • Surgical Anatomy  Deep and aggressive liposuction in this area can damage the cutaneous branches arising from the muscles causing a bloody liposuction return. Use of

2  Surgical Anatomy of the Body in Relation to Lipocontouring Fig. 2.14 (a) Outcome of vertical liposuction of the back rolls. (b) The effect after a horizontal liposuction

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a

b

vibration amplification of sound energy at resonance (VASERR) technology is safer due to the density of the subcutaneous tissue.

2.3.4 Interscapular area • The interscapular region is even firmer, more resistant, and more adherent than the previously discussed areas. • This is one region where there is increase in the fat deposits in both the lamellar and areolar layers to about the same level. • Surgical procedures when performed should always be in the deeper plane so as to preserve the superficial areolar layers and the cutaneous surface from unevenness. • Interscapular region showed hard, regular, immovable, and difficult bi-digital pinching fatty tissue and local firm skin with easy retraction, which could be noted immediately after the surgical procedure (Fig. 2.15).

Surgical Anatomy  Fat gets deposited in the lower cervical and upper thoracic vertebra segments in the interscapular region called the “buffalo hump.” It was among the first recognized manifestations of lipodystrophy (body fat changes) reported after the use of protease inhibitors in human immunodeficiency virus (HIV) treatment came into widespread use in the late 1990s. However, buffalo hump has been noticed even in untreated HIV-infected patients with the hump caused by lipodystrophy in the subcutaneous plane and in normal people due to posture causing abnormal curvature of the cervical spine and poor muscle tone [11].

2.3.5 Sacral Region • The fifth area to have localized fat deposits on the torso is the sacral region. It is anatomically located on the sacral bone flanked by the supra-iliac regions on either side.

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2.3.6 Gluteal Region In 2006, Cuenca-Guerra and Quezada [12] published four main criteria for gluteal aesthetics:

Fig. 2.15  Lipodystrophy of the interscapular region in an HIV positive patient

• Lateral depression: This is present on the lateral aspect of each buttock and its floor is formed by the greater trochanter. This is a zone of adherence and there is no muscle overlying this anatomical area. • Infragluteal fold: It is a horizontal crease that arises from the median intergluteal cleft and runs laterally below the ischial tuberosity with a slight upward convexity. • Supra-gluteal fossettes: Two hollows located on either side of the medial sacral crest. These hollows are flanked by the sacro-iliac joints and the posterior superior iliac spine laterally and by the erector spinae muscle medially. • V-shaped crease: Two lines that arise in the upper portion of the intergluteal cleft and extend toward the supra-­ gluteal fossettes.

2.3.6.1 Waist-to-Hip Ratio (WHR) The waist-to-hip ratio is a crucial measurement that is used in calculating the ideal aesthetics of the buttock, regardless of ethnicity (Fig. 2.17). It is the ratio taken between circumference taken at the most narrow part of the waist and the hip circumference taken at the level of maximum prominence of the buttocks [13]. The ratio is measured in posterior view and in lateral view (Fig.  2.17) with the most pleasing ratio being 0.65 and 0.7, respectively, in the posterior and lateral views. Waist-to-hip ratio is almost constant for all ethnic gluteal types; however, there is variation with regard to buttock size, lateral buttock fullness, and lateral thigh fullness that may be different among various ethnic types. In fact, Singh Fig. 2.16  Landmarks identifying the sacral region

• Skin is deeply adherent to the fibrous tissue overlying the spinous processes and posterior iliac spine forming a midline groove and dimples. “Sacral pad” is a pad of fat deposit inferiorly that obliterates the curve posteriorly. • Supra-gluteal fossettes one on either side over the sacro-­ iliac joint (marked with a blue outline in Fig. 2.16), created by the erector spinae muscle, the lumbosacral aponeurosis, and the insertion of the gluteus maximus muscle, and a V-shaped crease, arising in the proximal portion of the gluteal crease (marked by a red ellipse in Fig. 2.16), mark the borders of the sacral region. This is also referred to as “triangle of Venus.” Applied Anatomy  The sacro-iliac joints, the posterior iliac spine, as well as the coccyx are important landmarks for any gluteal cosmetic surgery.

a

b

a

b

Waist-to-Hip Ratio = a/b Fig. 2.17  The waist-to-hip ratio in posterior and lateral views [14]. (Adapted from: Abulezz T (2019) A Review of Recent Advances in Aesthetic Gluteoplasty and Buttock Contouring. Plast Surg Mod Tech 6: 147)

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Fig. 2.18  Different muscles, vessels, and nerves of the gluteal region Gluteus maximus m. (cut)

Inferior gluteal n.

Gluteus medius m. (cut)

Gluteus minimus m.

Superior gluteal a. and v. Superior gluteal n. Insertion of gluteus medius m. Inferior gluteal a.

Obturator internus m. Medial circumflex femoral a.

Pudental n. Quadratus femoris m.

Posterior femoral cutaneous n.

[13] proposed that a particular type of female body that men universally find most attractive is the one that has full buttocks and narrow waist, and he theorized and gave extensive evidence to support the concept that a waist-to-hip ratio (WHR) of 0.7 was the universal ideal female shape.

2.3.6.2 Muscles of the Gluteal Region (Fig. 2.18)  uperficial Layer of Muscles S • Gluteus maximus: It forms the major bulk of the buttocks and is 6–7 cm thick at its origin and hence an intramuscular implant can be easily placed in the intramuscular pocket. • Gluteus medius. • Gluteus minimus.  eep Layer of Gluteal Muscles D • Pyramidalis muscle: It is the reference for the location of important vessels and nerves deriving from the pelvis. It

covers the ischial foramen dividing it into superior and inferior parts. The superior gluteal artery and vein along with superior gluteal nerve pass from the superior gluteal foramen while the sciatic nerve, inferior gluteal vessels along with inferior gluteal nerve, pudendal nerve, and posterior cutaneous nerve of thigh pass from the inferior foramen. • Gemellus superior and inferior. • Obturator externus and internus. The gluteus maximus is the only gluteal muscle that is not inserted into the trochanter of the femur.

2.3.6.3 Cutaneous Adhesions as Extensions of the Ligaments in the Buttocks The interlacing ligaments from the spinous process of the sacrum, coccyx, lumbar spine, ischium, and also from the opposite side form dense connective tissue expansions along with the fibers of the gluteal fascia that inserts into the der-

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Fig. 2.19  Various cutaneous adhesions of the buttocks that maintain the buttock shape

mis. These preserve the intergluteal crease as well as form the inferior gluteal crease (Fig. 2.19).

2.3.7 A  pplied Anatomy: Danger Zone of the Buttock

• Buttock has the thickest areolar layer as compared to any other region in the human body. • Even normal people without increase in localized fat have a thick lamellar layer; hence liposuction undertaken in exactly this layer gives very good results. • Localized adiposity should be differentiated from hypertrophy of the gluteal muscles. This can be done by asking the patient to contract the gluteal muscle by squeezing the buttocks. Fat will slide over the contracted muscle.

• “Bermuda triangle” was a term coined by Illouz and emphasized by Fournier, which is the medial segment of each buttock having the maximum vascularity to be respected during fat suction. The superior vertex of the triangle is the sacral region and the base of the triangle is formed by the sulcus of buttocks (Fig. 2.20). • This area has the largest caliber vessels, and fat grafting during brazilian butt lift (BBL) should be undertaken absolutely subcutaneously in this area.

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Fig. 2.20  The Bermuda triangle marked in red

2.4 The Lower Extremity Thighs are one of the biggest concerns in people who are short and specially women of the Indian subcontinent. The major blood vessels as well as the nerve supply are well hidden in the deeper muscles, as seen in Fig. 2.21. The only area where injury to important structures is possible during liposuction is in the femoral triangle. The most common area of localized fatty deposits (lipo dysmorphia) on the thighs that causes the maximum concern and requests for treatment is the trochanteric area of the lateral thigh or saddlebag area (Fig. 2.22). The second most commonly requested area for liposuction treatment includes the upper portion of medial thighs most of the times, including the area from the adjacent anterior-medial or posterior-­ medial thighs (Fig.  2.22). Sometimes, the fatty deposition can extend along the entire internal medial thigh extending to the knee. These fat deposits cause a medial bulge below the inguinal ligament extending into the groin area. The fat of the anterior thigh is spread out more diffusely rather than being localized as in other anatomical locations. The fat in the supra-patellar area is another problem that most women request to be treated separately from the rest of the anterior thigh area. The supra-patellar area of the anterior thigh is many a times associated with fine waviness and crepey skin that may need skin tightening treatment along with fat removal. The posterior thigh is the area that is least requested for liposuction with a very regular exception being the proximal infragluteal fold or so-called “banana fold.” In

contrast to the rest of the posterior thigh, this fatty roll is a rather common problem (discussed in Chap. 20). There exists a distinct plane in the subcutaneous tissue, which is the lamellar layer present deep to the superficial fascia that allows passage of liposuction cannula with least resistance. This is the right layer in which fat deposits should be aspirated.

2.4.1 Trochanteric Regions • There is a significant fat deposit in the lamellar layer that makes the panniculus very heavy. • People who do not have a predisposition for localized adiposity have very good proportion between the areolar and the lamellar layers when they have normal weight. This proportion remains intact; even if they put on weight the body stays in shape and maintains the overall balanced contour. • When people have a localized deformity, it usually is caused by excessive fat deposition in the lamellar layer, which can be eight to ten times thicker than in normal people, while the areolar layer only doubles in thickness. • Therefore, liposuction treatment in the trochanteric region should be carried out at a deeper level maintaining a respectable 3  cm thickness of the overlying panniculus made of the areolar layer all over the area to achieve a uniform smooth aesthetic result unlike the 2 cm panniculus that has to be left behind in the abdomen.

28 Fig. 2.21 (a) The primary arterial and venous supply (femoral artery and vein) and femoral nerve as they pass below the inguinal ligament onto the anterior thigh below the muscles. (b) Lymphatic drainage of the lower limb into the superficial and deep inguinal group of lymph nodes

M. Thomas and J. D’silva

a

b

Superficial inguinal lymph nodes (1) (superior group) Deep inguinal lymph nodes (2)

Femoral vein (5) Saphenous opening (6)

Superficial inguinal lymph nodes (3) (inferior group)

1

5 4

Great saphenous vein (4)

2 3 6

Fig. 2.22  Images showing the medial, anterior, and trochanteric areas of fat deposits in a typical female pattern fat deposit

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2.4.2 Anterior Surface of the Thigh • Skin of the anterior thigh is thick and adheres firmly to the subcutaneous layer. • The subcutaneous tissue is almost entirely composed of the areolar layer that has round and turgid cells adherent firmly to the dermis (Fig. 2.23). • In thin patients the lamellar layer is practically nonexistent. • The muscle aponeurosis and the areolar layer are separated by the fascia superficialis. • Since the subcutaneous tissue and skin can slide very easily in this region, the thickness can be very easily assessed by the Illouz test and liposuction in this area has to be done with caution as most of the fat is superficial. It is very common for patients to complain of “cellulite” in this region. Applied Anatomy  Visible surface irregularities are very common with radical removal of fat from this region, which is seen in the form of unsightly waves.

2.4.3 External Surface of the Thigh • This area that is very similar to the anterior surface of the thigh has a thinner areolar layer with a nonexistent lamelFig. 2.23  The three surfaces of the thigh: anterior, external or lateral, and the posterior. The thickness of the areolar layer is less on the posterior, lower lateral while very prominent in the anterior, upper lateral and medial thighs

29

lar layer; hence this area is considered as a zone of adherence. • The fascia is between the areolar and the aponeurosis (ilio-tibial tract). As a result, release of skin fascia adhesions by liposuction can cause the panniculus to slide on the muscular level and leave tissue laxity in the supra-knee area.

2.4.4 Posterior Surface • The anatomical distribution of fat in this area and its histology is similar to that seen on its anterior surface. • Hence, liposuction should not be performed or performed with adequate caution on the posterior, external, and anterior surfaces of the thigh (Fig. 2.24).

2.4.5 Medial Thigh The medial thigh can be divided into three segments: upper, lower, and middle. • The upper third of the medial thigh has very thin skin with a thin soft areolar layer and a prominent lamellar layer even in thin people. The lamellar layer deposits more fat in people who have a tendency for localized adiposity while the areolar layer retains its same thickness. This region is good for liposuction.

30 Fig. 2.24  The thickness of subcutaneous layer in the upper and lower thigh

M. Thomas and J. D’silva Gluteal-thigh

SL DL

Leg

• The lower third of the thigh is prone to develop localized adiposity and is a good region for liposuction. • The central part of the medial surface is called a zone of adherence as the lamellar layer is absent and the areolar layer is similar to that on the lateral and posterior surfaces of the thigh. This area is not good for liposuction. Applied Anatomy  Functional problems result from rubbing of enlarged medial thighs during ambulation. The skin of the upper third being soft does not shrink completely after liposuction. It is important to be conservative when undertaking liposuction in this area.

2.4.6 Knees • This area has a very thin skin due to the need for skin mobility; as a result the areolar and lamellar layers are very thin except in people who have a tendency of localized adiposity. In such people increase in weight will cause increased fat deposit in the lamellar layer, which shows like a bulge in the inner knee and is very unsightly. • From the surgical point of view, only the medial surface of the knee should be considered for liposuction.

2.4.7 Legs • The legs have very poor subcutaneous cellular tissue that is dense and not suitable for liposuction. • On the anteromedial surface the skin is attached directly to the bone. The anterolateral surface has a strong muscular area covered by firm and thick skin and a thin layer of subcutaneous tissue formed by the areolar tissue.

• The superior part of the posterior surface is made of voluminous muscles (gastrocnemius and soleus) and is not indicated for surgery. Applied Anatomy  Liposuction in the legs should be undertaken with care using very fine cannulas as there is very high risk of compartment syndrome and even higher risk of unevenness. Gradual fat reduction can be achieved by undertaking injection lipolysis.

2.5 The Upper Extremity The arm is unique with respect to the subcutaneous tissue as the areolar layer (superficial) is located directly beneath the skin and the fat cells have a vertical orientation separated or encapsulated by arches of connective tissue (cutis retinacula) and has the lymphatics and vascular structures. The lamellar layer has a trabeculae-like structure for the passage of blood vessels, formed by the connective tissue along with the fat cells that are positioned in an elongated horizontal manner. Fat deposits are prominent in the deep layer if a person puts on weight and if a change in the diet is made the deep layer tends to lose fat; on the contrary, superficial fat is very minimally affected by changes in diet. • The posterolateral aspect of the arm has the maximum fat deposit that is primarily accumulated in the lamellar layer, as seen in Fig. 2.25. This area has no major vascular structures as the primary blood supply of the hand is through the brachial artery that is surrounded by the branches of the brachial plexus and is on the medial aspect of the arm in the bicipital groove. • The areolar layer usually does not deposit much fat as much as the lamellar (Fig. 2.26).

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Fig. 2.25  Anatomical basis of fat distribution in the arm according to Avelar: (1) anterior, (2) lateral, (3) posterior, and (4) medial zones of the arm. Zone 3 is prone to storing a large amount of deep lamellar fat

Fig. 2.26  The blood supply and nerve supply of the upper limb. Note that in the arm all the important vascular and nervous structures except the cephalic vein are under the deep fascia in the bicipital groove

Cephalic v. Brachial a. Musculocutaneous n.

Brachial v. Basilic v. Ulnar collateral a. Radial collateral a.

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M. Thomas and J. D’silva Anterolateral

2.7 Deep Vessels The deep lymphatic vessels from the upper abdomen accompany the deep superior epigastric arteries and drain into the parasternal lymph nodes while lymphatic vessels from the lower abdomen drain into the inferior epigastric, circumflex iliac, and then into the external iliac group of nodes. The lateral and posterior abdominal wall lymphatics accompany the lumbar arteries to drain into the lateral aortic and retro-­ aortic nodes.

Anteromedial

Posterolateral

Fig. 2.27  The maximum fat deposit as seen on the posterolateral aspect where there are no vital structures

• Illouz pinch test can help estimate the thickness of the panniculus as well as the amount of fat in the lamellar layer (Fig. 2.27). • The panniculus slides over the aponeurotic layer normally. When this layer is thick the panniculus does not slide because of the numerous perforating vessels. Applied Anatomy  Liposuction on the posterolateral aspect of the arm is safe but it has to be carried out at the lamellar layer (deeper). Liposuction should not be carried out in the areolar layer lest it causes deformities.

2.6 Superficial Vessels The superficial lymphatics run in association with the subcutaneous arteries and veins. Lymphatic vessels draining the lumbar and outer gluteal regions accompany the superficial circumflex iliac vessels supplying the area and draining into the lateral limb of the superficial inguinal lymph nodes. The infraumbilical skin is drained by the lymphatics that accompany the superficial inferior epigastric vessels draining into the medial group of superficial inguinal lymph nodes. The area above the umbilicus is drained by lymphatic vessels that run obliquely along the superficial superior epigastric vessels and drain to the pectoral and subscapular axillary nodes; also, there is some drainage to the parasternal nodes.

References 1. Kaminski MV.  The adipocyte anatomy, physiology, and metabolism/nutrition. In: Shiffman M, editor. Autologous fat transfer. Berlin, Heidelberg: Springer; 2010. https://doi. org/10.1007/978-­3-­642-­00473-­5_4. 2. Lancerotto L, Stecco C, Macchi V, Porzionato A, Stecco A, De Caro R.  Layers of the abdominal wall: anatomical investigation of subcutaneous tissue and superficial fascia. Surg Radiol Anat. 2011;33(10):835–42. https://doi.org/10.1007/ s00276-­010-­0772-­8. 3. Frank K, Hamade H, Casabona G, Gotkin RH, Kaye KO, Tiryaki T, et al. Influences of age, gender, and body mass index on the thickness of the abdominal fatty layers and its relevance for abdominal liposuction and abdominoplasty. Aesthet Surg J. 2019;39:1085. https://doi.org/10.1093/asj/sjz131. 4. Shiffman M.  Prevention and treatment of liposuction complications. In: Shiffman M, Di Giuseppe A, editors. Liposuction—principles and practice. 1st ed. New  York, NY: Springer New  York LLC; 2006. 5. Markman B, Barton FE Jr. Anatomy of the subcutaneous tissue of the trunk and lower extremity. Plast Reconstr Surg. 1987;80(2):248–54. 6. Rohrich RJ, Smith PD, et al. The zones of adherence: role in minimizing and preventing contour deformities in liposuction. Plast Reconstr Surg. 2001;107:1562–9. 7. Huger WE. The anatomic rationale for abdominal lipectomy. Am Surg. 1979;45(9):612–7. 8. Figge FHJ. Sobotta Atlas of human anatomy. Baltimore: Urban & Schwarzenber; 1977. 9. Spalteholz W. Atlas de anatomia humana. 5th ed. Espanha: Editora Labor; 1970. 10. Chamosa M.  Lipectomy of fat rolls. Aesthet Plast Surg. 2006;30(4):417–21. https://doi.org/10.1007/s00266-­006-­0029-­4. 11. Sharma D, Bitterly TJ.  Buffalo hump in HIV patients: surgical management with liposuction. J Plast Reconstr Aesthet Surg. 2009;62(7):946–9. https://doi.org/10.1016/j.bjps.2007.10.086. 12. Cuenca-Guerra R, Lugo-Beltran I. Beautiful buttocks: characteristics and surgical techniques. Clin Plast Surg. 2006;33:321–32. 13. Singh D.  Adaptive significance of female physical attractiveness: role of waist-to-hip ratio. J Pers Soc Psychol. 1993;65:293–307. 14. Abulezz T.  A review of recent advances in aesthetic gluteoplasty and buttock contouring. Plast Surg Mod Tech. 2019;6:147.

3

Preoperative Consultation and Evaluation Mohan Thomas and James D’silva

Goal of any consultation for cosmetic procedures should be to make sure that the expectations of patients are brought down to the level of realistic possibility of achieving the best result for them and to make sure that the surgeon and the patient are on the same page regarding the treatment process.

3.1 Consultation 3.1.1 Purpose of Consultation [1] A complete preoperative consultation improves surgical outcomes as they have to be value based and centered along patient requirements. There are several other relevant factors that a patient needs to know other than a good surgical result, such as desirable perioperative outcomes, including reduction in anxiety, adequate pain control system, quick recovery, and knowing about how soon a person can get back to a normal and professional life. Surgeons should also advise patients who consult for body contouring to lose some weight before undertaking the procedure to check the compliance of patients. It has to be conveyed very clearly to them that “body contouring is in the hands of the surgeon, but the nonconformity could be because of poor lifestyle habits.” The major focus of cosmetic surgeons’ training at the present moment is directed to prevent and manage perioperative complications, which is much relevant to modern cosmetic surgery practice. This training will majorly help in prevention of medical complications. For example, deep vein thrombosis (DVT) is a major worry in any body contouring procedure. It is the duty and responsibility of the cosmetic surgeon to make sure that the patient is covered well in terms of proper perioperative care regarding DVT.

M. Thomas (*) ∙ J. D’silva Cosmetic Plastic Surgery, Breach Candy Hospital and D.Y. Patil University, Mumbai, Maharashtra, India

Consultation enables the surgeon to analyze the patient for various medical conditions. A doctor with adequate medical experience can request for required tests that the patient has to do before a final call on surgery is taken. It is very important that such final call about surgery has to be made only after the test reports are analyzed completely. The experience of the surgeon also helps in making the right treatment plan. A simple differentiation of subcutaneous fat vs. visceral fat goes a long way in making the right plan and advising the same to the patient. It also becomes imperative on part of the surgeon to make it clear to overweight patients and/or patients looking for weight loss that body contouring procedure is not a weight loss surgery. About the postoperative care, patients should not have any surprises regarding standard protocols to be followed barring any untoward incidents.

3.2 A Preoperative Psychosocial Screen for Elective Facial Cosmetic Surgery Patients [2] It is well known through the literature that 10–20% of patients undergoing cosmetic procedures are unhappy with the results and report dissatisfaction. Poor perception about outcomes can be a cause for concern both for the treating physician and the patient as it can result in depression, anxiety, social ostracism and isolation, injuries to self-including suicide and homicide, absence from work, patient demands for corrections, increased complaints to regulatory bodies, litigation, and even placing adverse comments on social media. Choosing the right patient for cosmetic surgery after a detailed assessment reduces not only the extent of dissatisfaction but also patient management difficulties. Evaluation of the psychosocial risk factors in a patient and referring the patients with such risk factors for extensive psychological evaluation and management can improve the outcome of a cosmetic surgeon as well as improve the quality of care in a patient.

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_3

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Even though picking a patient with adverse psychologic risk factors is so important, there is absence of a clear roadmap that can help treating physicians to select inappropriate patients and guide them further. Patient characteristics to be chosen preoperatively, which indicate a possibility of patient dissatisfaction with results, have come from clinical experience only. There is not any serious clinical research that has been conducted in this regard. Napoleon’s study about the impact of personality disorders in elective cosmetic surgery patients is an exception, which found that satisfaction of the outcome was highly dependent on the patient personality type, with narcissistic and borderline personalities being regarded as more likely to be unsatisfied with the surgical outcome. In spite of there being a lack of empirical investigations, it is a general consensus that in young males preoperative anxiety and depression, body dysmorphic disorder and/ or dissatisfaction with previous surgeries, low self-esteem, and unrealistic patient expectations are the factors associated with unsatisfactory outcomes. Lavell and Lewis [3] derived the SAFE guide, based on which they suggested that the following four patient characteristics should be considered in order to determine patient suitability for cosmetic surgery: 1. Self-evaluation of attractiveness (positive self-image) 2. Anxiety (conscious awareness of generalized distress) 3. Fear (excessive involvement in detailed preparation for surgery) 4. Expectation (unrealistic anticipation of postsurgical life changes) According to the existing literature, the worse postoperative outcomes are associated with a generalized unhappiness of the patient with their physical appearance and an unfound concern with the shape and size of many different parts of the body, rather than the extent of concern with physical appearance, global self-esteem, or the extent of investment in appearance.

M. Thomas and J. D’silva Table 3.1  Histrionic personality Frequency in practice Areas of concern Demeanor

Compliance

Beneficial treatment Detrimental treatment Staff responses Legal issues

Relationship to physician

Breasts, eyes, and lips Coquettish, seductive, energetic, “Southern Belle” or “Damsel in Distress” roles are acted out Good, if special attention is paid to the issue of patient demands; otherwise, compliance can be problematic Reassuring; these patients are responsive if special attention is afforded to them; alert female staff to their behavioral tendencies Cold; analytic treatment is counterproductive; hurt feelings and sexual overtones are a reality with these patients Female staff generally dislike these patients; male staff may be attracted to them Moderate to high risk, if paired with a self-­ disorder; sexual harassment suits may arise from this population May assume role of mistress if surgeon is male; will avoid female physicians.

Diagnostic and statistical manual of mental disorders (DSM III-R) prevalence: this disorder is apparently common and is diagnosed much more frequently in females than in males Table 3.2  Borderline personality Frequency in practice Presenting complaints Demeanor

Compliance Beneficial treatment Detrimental treatment

Staff response

3.3 The Presentation of Personalities in Plastic Surgery [4] (Tables 3.1, 3.2, 3.3, 3.4, and 3.5)

Moderately high (9.5%)

Legal issues Relationship to physician

Moderately high (9.0%) Body dysmorphic disorder, cuts, and numerous areas of concern Self–other boundaries ore blurred; watch for immediate and unquestioned idealization of the physician They vacillate between all and nothing responses Assured; be consistent in time and place; avoid nebulous or qualified instructions; be very careful of injections and cautious of medications This patient can “split” the physician from all good to all bad; this can be done quickly and without warning; errors are translated easily into “bad” doctor The staff may consider these patients to be obtrusive and inappropriate Extremely high risk; these patients are frequently involved in malpractice suits directly or indirectly Physician is viewed as saint or satan

DSM III-R prevalence: borderline personality disorder is apparently common

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3  Preoperative Consultation and Evaluation Table 3.3  Dependent personality Frequency in practice Areas of concern Demeanor Compliance Beneficial treatment Detrimental treatment Staff response Legal issues Relationship to physician

Moderately high (12.0%) Superficial, breasts Warm, needy, and charming; they can be demanding Good, though they may require nurturant reinforcement Reassuring; warmth with personalized care will elicit positive results Business-like approach or group care is to be avoided The staff may designate these patients as “pets”; may be seen as demanding and spoiled Low risk Parent–child

DSM III-R prevalence: the disorder is apparently common and is diagnosed more frequently in females Table 3.4  Narcissistic personality Frequency in practice Areas of concern Demeanor Compliance Beneficial treatment Detrimental treatment Staff response Legal issues Relationship to physician

Very high (25%) Age-related, especially eyes and abdomens Arrogant, fashionable, and assertive; look for tanning salon skin color Good, if results are excellent and manifest early Assured; praise for this patient along with an air of confidence on the part of the physician is a must The casual approach, “folksy” style, low-rent office all present problems for this patient population The staff may consider these patients to be arrogant, pushy, and demanding High risk, fueled by grandiosity and entitlement Physician is perceived as simply another part of the patient’s self

DSM 11I-R prevalence: this disorder appears to be more common recently than in the past, but this may be due only to more professional interest in it Table 3.5  Obsessive-compulsive personality Frequency in practice Areas of concern Demeanor Compliance Beneficial treatments Detrimental treatments Staff response Legal issues

Relationship to physician

Infrequent (4.0%) Superficial Careful, precise, wordy, and vigilant Usually “to the letter” Assured; these patients respond well to written, defined, and precise instructions Impatience on the part of the staff or physician is perceived as rejection These patients are seen as “picky” Low risk; these patients keep meticulous records just for this eventuality, though the actual risk is minimal The physician can be used as a sounding board; physicians can have a negative transference to these questioning and cynical patients

DSM III-R prevalence: the disorder seems to be common and is more frequently diagnosed in males

3.4 Art of Consulting 3.4.1 Marketing • In the current times, marketing has gone digital. People get to know the doctor through various means on the Internet. • A strong presence on the Internet lets the word out. • The initiation of any consultation begins from marketing. • The pattern and the nature of promotions on the Internet give patients a fair idea about the doctor they are going to visit. • So, it is up to the doctor to put the right content on the Internet.

3.4.2 Role of Front Desk Staff • Front desk staff plays an important role in getting the patient in. • Front desk staff makes the first point contact with the patient on behalf of the clinic and doctor. Strong web presence and marketing along with efficient front desk communication increase the chances of patient opting to consult the doctor. • They also extend warmest welcome to the patient once they enter the clinic. • They hand over the clinical form to elicit the past history of the patient, which the patient has to fill.

3.4.3 Role of Nursing Staff • Nursing staff takes over the patient from the front desk staff. • They introduce themselves and take them to the nursing area to check vital parameters of the patient. This act gives patients a feel of the state of healthcare system of the clinic. • In case of liposuction patient, it is imperative to check the height and weight of the patient for body mass index (BMI) evaluation. • These assessments by the nursing staff help the doctor in assessing the gait pattern, built, and behavioral pattern of the patient before the doctor actually comes into contact with the patient.

3.4.4 Role of the Doctor • Doctor has to take inputs from the front desk and nursing staff to know more details about the patient before he/she actually sees the patient. • Based on the inputs given by the front desk personnel and the nursing staff, the doctor welcomes the patient into the consulting area and begins the consultation.

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• The doctor has to wish the patient and introduce himself/ herself to the patient. It is important for the doctor to introduce himself/herself even though the patient has come looking for that particular doctor because that certain gesture implies a thorough professional attitude. • During the due process of consultation, Doctor has to analyze the psychosocial aspects of the patient.

3.5 Evaluation 3.5.1 Evaluation of Social Status • Social status is an important aspect of any cosmetic procedure simply because of elective nature of most of such procedures. • It is essential to make patients understand whether they actually require cosmetic procedure or not. • The final call regarding opting for or against the procedure is always left to the patient.

3.5.2 Evaluation of Compliance of Patient • Compliance by patient in most cases leads to longstanding results. In fact, it is the duty of a patient to maintain the contoured body by adapting healthy lifestyle. • From the physician perspective, therapeutic compliance is of major importance for two reasons. Firstly, noncompliance with treatment advised can have a major effect on the final outcome, which is a direct clinical consequence. Secondly, noncompliance can have poor outcomes in those who are associated with comorbid conditions [5].

3.5.3 Evaluation of Diet Habits • Consulting a nutritionist helps keep track of the number of calories being consumed every day. There should not be any major fluctuation in weight after cosmetic body contouring procedures because that may lead to uneven fat deposits.

3.5.4 Psychiatric Evaluation • Psychiatry is one specialty that cosmetic surgeons give a lot of importance to. • Sometimes, opinion of a specialist would be of immense help to understand the mental status of the patient and their expectation levels. • Undertaking any cosmetic procedure on patients who are having mental health issues would be a disaster for both the patient and the doctor. • Psychiatric treatment makes the patient understand the scope and possibility of intended outcomes.

M. Thomas and J. D’silva

3.6 Patient History 3.6.1 Medical History Detailed medical Information regarding medicines prescribed or consumed for pulmonary or cardiac issues; bleeding tendencies; chronic conditions such as hypertension, diabetes mellitus, and thyroid issues; allergies if any; etc. should be extracted from the patient and recorded in detail. History should also be taken about connective tissue disorders such as rheumatoid arthritis, systemic lupus erythematosis (SLE), and Hashimoto’s disease.

3.6.2 Drug History Detailed history about medicines such as aspirin, nonsteroidal anti-inflammatory drugs, herbal medications and diet pills, antihypertensives, antidiabetics and anticoagulants, and hormones, especially in body builders, should be recorded. Allergies to medications should be prominently noted.

3.6.3 Family History Questions should inquire about history of bleeding tendencies or thromboembolism, fat gene, and diabetes in the family.

3.6.4 Past Surgeries Any anesthetic or bleeding complication from previous surgeries or any allergy to local anesthetic drug should be recorded. Also, healing and scar formation should be discussed. If the patient has undergone liposuction, then postsurgical maintenance has to be discussed and any gain or loss in weight recorded.

3.6.5 Psychiatric History 1. Any psychiatric illness in past? (a) Counseling may be required in perioperative period. (b) Patient may not adhere to postoperative regimen, which can lead to wound-healing complications. 2. Is the patient on any psychiatric drugs? 3. Evaluation of body dysmorphic disorder (BDD). (a) Patient with BDD will rarely be satisfied with the results that are considered great by other cosmetic surgeons and from other patients’ perspective. (b) These patients are more often to file lawsuits and create bad publicity for the surgeon.

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Recommendation has been made in many publications that aesthetic surgeons must obtain an assessment, a written confirmation, and clearance from the consultant psychiatrist that the patient is psychiatrically stable and does not have unrealistic expectations. This would offer protection to the surgeon in any adverse situation and also protect the patient as well.

3.6.6 Smoking History • Major body contouring surgery requires skin removal and the creation of large tissue flaps. Vasoconstriction is caused by nicotine and its products can result in necrosis of flap and associated infection causing major wound-­healing complications. Urine nicotine and cotinine tests can be a useful tool to ensure cessation of smoking at the time of surgery [6]. Smokers should discontinue smoking for at least 2 weeks before to 4 weeks after surgery if they want to undergo cosmetic procedures so as to reduce the chances of wound-healing complications and improve outcome [7].

3.6.7 Nutrition • A detailed history on the weight maintenance, exercise regimen, and diet plan should be recorded. • Preoperative tests should include complete blood count (CBC), liver and kidney function tests, electrolytes, albumin, and prealbumin [6] at the least. It is not necessary to screen for vitamin and micronutrient deficiencies. • The list in postbariatric body contouring should include CBC; serum electrolytes; bleeding profile, which includes prothrombin time, Indian rupee (INR), and partial thromboplastin time; ‘C’ reative protein and D-dimer; liver function tests, including serum albumin and prealbumin levels; electrocardio gram (ECG); chest radiograph; 2 dimentional echocardiography (2D ECHO); pulmonary function test (PFT); and Color Doppler of leg veins. Besides these, it is important to check levels of ferritin, thiamine, cyanocobalamin, folic acid, calcium, magnesium, as well as vitamin D3, which depends on the history of the weight loss, physical examination, and type of bariatric procedure [7] undertaken. Anemia: Most patients after bariatric surgery have iron deficiency anemia. Assessment and correction of iron levels are important before surgery. Blood loss is possible especially with large-volume liposuction as well as with extensive tissue excision as part of body contouring procedures and can worsen an existing anemia, especially when multiple procedures are undertaken at one time.

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3.7 Examination of Different Body Parts 3.7.1 Physical Examination • During physical examination the weight in kilograms and height in feet should be measured. Weight should be measured on every subsequent visit. • The body mass index (BMI) is calculated based on the formula: weight in kg/height in m2. • Depending on the patient’s requirements, the area of concern should be examined from all angles in sufficient light. • When examined for particular body part surgery, the components to be examined include skin, subcutaneous tissue or fat, muscles and their animation, and bony structure if involved.

3.7.2 Skin • The quality of skin should be noted, which should include examination of scars, pigmentation, dryness, and stretch marks (Fig. 3.1). • When examined for abdominal procedures, the skin should be assessed to check for vertical and horizontal excess and also for laxity in the different regions of the abdomen. • The elasticity of the skin is of importance because it determines the shrinkage that can take place after liposuction procedure. • Check for scars, type of scars, and scar adherence to deeper structures.

Fig. 3.1  Stretch marks over the abdomen and part of thighs

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3.7.3 Subcutaneous Fat • When examined for body contouring, the thickness of the subcutaneous fat of the anterior abdomen, flanks, and the back should be determined.

M. Thomas and J. D’silva

• Check for intra- or extra-abdominal fat deposits (Fig. 3.2). • Few patients may have both extra- (Fig.  3.3) and intra-­ abdominal fat deposits and few patients may have predominantly intra-abdominal fat deposits (Fig. 3.4).

Fig. 3.2  Patient presenting with extra-abdominal fat deposits

Fig. 3.3  Patient presenting with both intra-abdominal and extra-abdominal fat deposits

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Fig. 3.4  Patient presenting with predominant intra-abdominal fat deposits

• An abdomen that is protruding could be caused by a number of factors as mentioned below: –– Some male patients may be predisposed to depositing large fat stores in the intra-abdominal area; in such patients, the abdominal panniculus may be very thin in spite of the person presenting with an extremely protuberant abdomen. –– These patients are not the most ideal candidates for body contouring surgery such as liposuction and abdominoplasty. –– Another reason for a protruding abdomen is a thick panniculus as a result of massive weight loss (MWL). • Pinch test. –– It is to assess the elasticity of the skin as well as measure the amount of fat under the skin (thickness of the panniculus) in the area considered for treatment. –– If more than an inch of fat can be pinched, the area may be suitable (Fig. 3.5) for liposuction.

3.7.4 Abdominal Wall Laxity • The protruding abdomen may also be caused due to the laxity of abdominal wall.

Fig. 3.5  Demonstrating the pinch test

• Hernias should be looked for essentially, especially if there is an unusual protrusion in the abdominal wall. If present, check if the hernia is reducible and assess its contents which may be intestinal loops or visceral fat (Figs. 3.3 and 3.4). • Diver’s test (Fig.  3.6) can be performed to assess the abdominal laxity.

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• The patient is asked to stand with a straight back and told to relax the abdominal wall completely. This exposes the loose skin that may be present. • Another test is performed where the patient is asked to lie down in supine position and has to lift the neck and upper back with legs kept straight while the surgeon palpates the abdominal wall to check for bulges. • This helps in assessing the laxity and extent of rectus divarication as well as presence of hernias. • Supraumbilical divarication is usually seen in some men and women, whereas the infraumbilical rectus divarication was seen almost exclusively in women (Fig. 3.7).

M. Thomas and J. D’silva

• It may be difficult to assess laxity of abdominal wall in obese people with thick subcutaneous fat. • A clinical differentiation has to be made between subcutaneous and visceral fat as the no surgical body contouring technique can treat visceral fat. A simple way to differentiate is to pinch the abdomen skin while asking the patient to tighten the abdominal muscle; if pinch test is significant, then it is subcutaneous fat. • Another helpful test is for such patients to be asked to lie down supine and then observe their abdominal contour. If the abdominal shape appears concave below the rib cage, then they may require rectus fascia plication. This can be confirmed by a leg-raising test. If the concavity is not observed, then it is presumed that there is an excess of intra-abdominal fat deposits. • An abdominoplasty procedure on a patient having excess intra-abdominal fat is fraught with danger and a bad outcome.

3.7.5 Special Consideration in the Massive Weight Loss (MWL) Patient

Fig. 3.6  Picture showing patient performing a classic diver’s test

• Body shaping after massive weight loss requires combination of extensive procedures, which can cause significant morbidity and possible mortality; hence a comprehensive preoperative evaluation is mandatory. • The history and examination should include discussion on how the weight loss was done, surgery undertaken for weight loss, any medical issues, laboratory tests, and also examination of the abdomen for scars and hernias.

Fig. 3.7  Bodies with abdominal fat deposits and possible rectus divarication

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Fig. 3.8  A massive weight loss body

• The weight should have been stable for at least 3 months with a maximum of 1 kg fluctuation at the time of undergoing body contouring [6] (Fig. 3.8). • Weight loss usually stabilizes within 18–24 months following bariatric surgery, and body contouring surgery should be undertaken only after this weight stability is achieved. If undertaken during weight loss, the skin laxity will appear again thus defeating the purpose. • Patients have to be counseled that body contouring surgery after MWL is composed of multiple stages and hence can be considered as a process, as many procedures in different body parts with individual and compound risks and recovery times are required with added expense [8].

3.7.6 Other Features The examination of the abdomen should also include examination of the genital area and mons pubis. Fungal infection and excoriation has been known to occur under the skin folds of the abdominal pannus, which may cause suture line infection. Ptosis of the mons with excess fat must be noted, especially in patients who had very high BMI prior to the bariatric procedure. Examination should also include checking for buried penis or absence of testes or any deformity. While examining the back, attention should be paid to fat deposits in the waist, hips, flank, and lateral thigh regions.

Deviations in the spine (kyphosis), the depth of lumbar lordosis, and the extent of buttock’s projection also have to be noted.

3.8 Discussion About the Body Contouring Procedure [9] Not all the fat deposits in the body (fat deposits in various areas) respond the same to restriction of calories or burning of energy. Certain fat deposits are mobilized faster than others. It has been seen that calorie restriction and exercise in obese women cause preferential loss of intra-abdominal fat as compared to fat at the skin level. This can be explained in part by studies that show different fatty acid composition present in adipose tissue of different body sites. Studies by Phinney et al. [10] have shown that higher levels of saturated fat content is present in the subcutaneous fat of the abdomen as compared to that from the outer thigh, which has higher levels of polyunsaturated fatty acids. Different fatty acid composition in different adipocytes may result in varied response of those adipocytes to caloric restriction or excess. Body contouring procedures to be discussed (based on need) in aesthetic surgery include: • Liposuction • Lipoabdominoplasty • Lower body lift—a combined procedure designed to treat the lower trunk and outer thigh as a single unit

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M. Thomas and J. D’silva

• Belt lipectomy—the circumferential excisional tissue is located at a higher level on the back and flanks, as compared with a lower body lift • Medial thigh lift • Arm lift (brachioplasty) • Shaping of the upper body in a male (upper body lift) • Breast procedures (augmentation, lift) With regard to body contouring vast majority of patients often have unrealistic expectations, which may stem from misleading advertisements on the Internet, TV programs, social media, or unethical practice. Often, patients desire to look like their favorite celebrities and many who desire aesthetic surgery have body dysmorphic disorder, which can lead to troublesome lawsuits that can be emotionally and financially draining as well as detrimental to a surgeon’s career. Many celebrities have public relations (PR) team to take care of their social media handles. One of the main roles of the PR team is to make the pictures of those celebrities look “perfect.” To get to that perfect tag, those pictures are obviously edited. A detailed preoperative consultation is required to address the above issues to select the right candidate as well as to educate the patient before surgery. A good preoperative consultation that is recorded on paper as well as a video recording during explanation of procedure is ideal. Any last-minute changes before surgery should also be recorded and signed by patient. A detailed preoperative consult should be considered as an investment. It is very important for the patient to understand at the end of consultation that the body structure of each individual is unique and with surgery it can be aesthetically improved by 50%, and that they should not expect their body part to be made to fit like their ideal celebrity. Also, like other surgeries it does have its own complications, which can be managed. The purpose of a good consultation is also to build a rapport with the patient and to let them know that you are on their side.

3.8.1 Scars • The cosmetic surgeon should have a detailed discussion with the patient and make him/her understand about the presence of scars after the procedure, which will be visible prominently before they fade. These will never disappear. • The position of the scars should preferably be drawn on the patient to discuss its exact position. • Scar migration with gain and loss of body fat and weight, and relaxation of skin over time, should be explained.

Fig. 3.9  6-month postoperative scar over the abdomen after abdominoplasty without umbilical repositioning procedure

Fig. 3.10  10-month postoperative scar over abdomen and umbilicus after abdominoplasty with umbilical repositioning procedure

• Change in appearance of scar over time (Figs. 3.9 and 3.10), development of hypertrophic and keloid scars, and treatment modalities for this should also be discussed. • There is a significant possibility of skin irregularities and residual deformities in body shape if the patients put on weight after surgery (Fig. 3.11), which will require further corrective surgery.

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Fig. 3.12  Pneumatic compression device

Fig. 3.11  Irregular fat deposition after liposuction due to postsurgical weight gain

3.8.2 T  hromboembolism (Discussion as Part of Information During Consultation) • This is a major cause of morbidity and mortality among body contouring patients, especially those with MWL as the risk of postoperative bleeding has to be weighed against that of thromboembolic episodes. • The physical prophylaxes such as intermittent pneumatic compression (Fig. 3.12) along with graded compression stockings (Fig.  3.13) have to be routinely used before induction of anesthesia and should be continued. • These devices should be typically kept in place until the patient is fully mobile after surgery. • High-risk general surgical patients will require chemoprophylaxis with low-molecular-weight heparin (LMWH) once daily. This should be continued for 3–5 days depending on the stability of the patient under the care of an intensivist. • Usually, chemoprophylaxis is combined with mechanical prophylaxis using intermittent compression devices or graded compression stocking in patients who have multi-

Fig. 3.13  Compression stockings

ple risk factors. Once daily dosing and decreased heparin-­ induced thrombocytopenia are the advantages of LMWH; however, it is more costly. • LMWH should be started within 12  h of surgery and maintained for 3–5 days. Incentive spirometry is encouraged, and patients are taught to use their devices ten times per hour while awake.

3.8.3 Investment of Time • To achieve that perfect result in aesthetic surgery, it may be required to undertake more than one surgery and patients should be ready to invest their time and finances. • If the patient has multiple areas to be contoured, then multiple surgeries may be required for safety purposes. • After belt lipectomy surgery, patients usually require a minimum of 4 weeks to get back to limited activity and about 8 weeks to resume full normal physical activity.

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This may be further extended in patients who have undergone muscle tightening or hernia repair procedures. Same is true for other skin excision procedures as well.

3.8.4 Financial Considerations A dedicated staff should be appointed to discuss finances and if touch-ups are required postoperatively, the financial policy as per the clinic should be discussed.

3.8.5 Exclusion • Medically or psychiatrically unstable patients should not be undertaken for surgery. • Patients with significant cardiopulmonary disease and active smokers should be excluded. • Underage patients with no requirement for such procedures. • Noncompliant patients. At the conclusion of consultation, the patient should have a precise idea of what aesthetic surgery can, and more importantly what surgery cannot, achieve and have realistic expectations that will make them satisfied with the results. Surgery is half accomplished in a preoperative consultation.

3.9 Perioperative Patient Management 3.9.1 Pre-anesthetic Checkup • Explain that the tests are done to assess and prevent complications. • Should be done after lab and cardiopulmonary tests to determine American society of anaesthesiologists (ASA) grade, fitness for surgery, and if any specialist referral is required. A written clearance should always be obtained from cardiologist, pulmonary physician, and psychiatrist. • Rohrich et al. suggested that central body lifts be limited to patients with ASA grades of 1 (healthy) or 2 (mild systemic disease) [8].

3.9.2 Informed Consent [11] A consent paper signed by patient does not amount to informed consent. It can be challenged in court of law. • Informed legally valid consent includes explanation of the proposed procedure, and need for multiple procedures.

• Possible viable alternatives, risks and complications, option of second opinion by another board-certified surgeon, and consent for photography and use of photos for other patient education and publication in journals. • Informed consent is updated on timely basis as required. Diagrams wherever necessary should be drawn for documentation. • Medical records should contain the patient’s requirement preferably in their own hand writing and the doctor’s recommendations with the reasons for advising the same. • Preoperative photographs of the patient highlighting their concern should be taken along with the postoperative photographs every time they visit, which should be kept in a secure place on the computer or preferably in an external drive with a backup. • The patient should be explained about the procedure in lay terms and also given scientific name of the procedure so that they can read about it on the Internet. • The risks and complications associated with the procedure and/or the technology used must be explained in detail to the patient, as well as any viable options, surgical or nonsurgical, with their possible advantages or disadvantages along with risks, should be discussed. • The patient must make a knowledgeable decision concerning the surgery. • The areas to be treated must be listed completely, for example, different areas for liposuction, various steps of the circumferential body lift, etc., so that there is no inference that particular areas were not treated. • If any addition is done to the previously discussed and documented surgical plan on the day of surgery, then it should be recorded with an explanation and the procedure recorded in the written consent.

3.10 Preoperative Instructions • Preoperative instructions should be given in detail not only orally but also in a written format. Risks and complications should also be explained orally as well as in writing. • Liposuction preoperative instructions. • Information on liposuction [11] –– Blood transfusions are rare. –– Preoperative chest X-ray, electrocardiogram (EKG), and blood tests are necessary. –– Always assess for varicose veins before undertaking liposuction of the legs. If present it should be treated 3 months before liposuction of the legs. –– Absolutely do not gain weight before surgery. –– Cessation of smoking for at least 2 weeks before to 4 weeks after surgery.

3  Preoperative Consultation and Evaluation

–– Report history of excessive bruising and non-stoppage of bleeding to the physician. –– Report prior mental disorder, drug or alcohol addiction, or any treatment taken for the same to your physician. –– Please inform if you have high blood pressure and on medication, diabetes and on medication, thyroid and/ or asthma and on treatment. –– Anticoagulants (blood thinners) should be stopped after discussion with the physician who prescribed them at least 5 days prior to surgery, with INR to be checked prior to surgery. –– Medications such as aspirin, and vitamins such as vitamin C and E should be discontinued 2 weeks before surgery and can be started 1 week later. –– It is preferable not to schedule body contouring surgery in a female close to/during the menstrual period. –– Take a shower with chlorhexidine or povidone iodine skin cleansers a day prior to and on the day of surgery. –– All birth control pills and hormone replacement therapy having estrogen must be stopped 4 weeks prior to surgery to 2 weeks after it. –– Cytochrome P450 (CYP3A4) inhibitors: Cytochrome P450 3A4 inhibitors compete with enzymes that break down lidocaine; hence drugs like benzodiazepines can cause lidocaine toxicity during tumescent anesthesia even at a much lower dose. These medications should be avoided for 3–7 days prior to surgery. Carbamazepine, Cimetidine, Clarithromycin, Dexamethasone (Decadron), Diltiazem, Erythromycin, Flurazepam, Halcion, Medrol, Metoprolol (Lopressor), Metronidazole (Flagyl), Midazolam (Versed), Procardia, Propranolol (Inderal), Propofol (Diprivan), Restoril, Sertraline, Tetracycline, Thyroxine, Valium, and Xanax. –– Herbal Supplements: The American Society of Anesthesiologists recommend that patients should stop taking diet and herbal supplements 2–3 weeks before surgery since these interact with anesthetic drugs and may cause prolonged anesthesia.

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• Any bright red bleeding as opposed to blood-stained soakage has to be reported at the earliest. Blood-stained soakage after liposuction is expected especially on the first day. Any shortness of breath, pus discharge, or unusual pain should be immediately communicated. –– Prescription will be provided for antibiotics, painkillers, antacids, and a B-complex. Diet plans and limited physical activities are communicated to the patient in advance. –– Patient should be home bound for 2–3 days when only ambulation to the bathroom or within her/his room with help is recommended. Some soakage from the access points is to be expected. –– A review is usually recommended at 3–5 days after which showers can be started with waterproof dressings on. –– The garment (Fig. 3.14) can be removed and washed at any time after 5 h postoperative day. This garment can be gradually downsized over the next 4 weeks for a snug fit. –– Lymphatic drainage can be instituted after the third day. This can smoothen out any lumps as well as helps in reduction of the swelling. Edema in liposuctioned areas may last for many weeks.

3.11 Postoperative Instructions (Discussion as Part of Information During Consultation) These should be discussed with the patients before surgery. These should be reiterated post-surgery as well, to the patient and his/her relative. This becomes more important if patient is undergoing day care surgery.

Fig. 3.14  Pressure garment worn after full body liposuction surgery

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–– Ambulation can cause swelling of the legs, which can be relieved by elevation of the legs. If it is due to constriction of the lower edge of the garment, then the constriction should be released. –– Surgeon has to be notified about any fainting incidents. –– Emotional depression after surgery is common. –– All medications as prescribed and instructed have to be taken. –– Weight gain will cause fat deposition in all areas with a preponderance of fat deposition in non-operated areas. –– Final result after liposuction may take up to 3 months and any touch-up or revision resculpting should only be done after that period. –– No guarantees given or implied. –– All known benefits and options discussed in great length and all queries and concerns addressed.

3.12 Postoperative Concerns (Discussion to be Part of Information During Consultation) Postoperative concerns need to be brought to the notice of the patients. Discuss these with patients so that patient knows that you can manage these. 1. Anesthesia and surgical drug complications, which may include lignocaine toxicity, nausea and vomiting, drug allergies, etc. 2. Swelling and seroma (visible as localized fluid deposition). 3. Bruising and hematoma, especially in smokers. 4. Pain initially followed by a feeling of numbness, itching, and burning as the sensation returns. 5. Nerve damage; decrease or loss of sensation; paresthesia. 6. Delayed healing and prolonged drainage caused by infection, which may be limited to the incision or may spread causing septicemia (blood infection), cellulitis, and toxic shock syndrome. 7. Extensive skin necrosis with loss of skin (necrotizing fasciitis) is possible. 8. Thrombosis of the veins with or without pulmonary embolism, fat embolism, and pulmonary infarction. 9. Scar can be atrophic, hypertrophic, or keloidal, with pigmentation of the scar and/or overlying skin. 10. Hypotension and or bleeding may require fluid or blood transfusion. 11. Labial and scrotal edema may occur, which is temporary. 12. Blisters due to contact dermatitis or reduced superficial skin vascularity are possible.

13. Dissatisfaction with the outcome leading to touch-up procedures may be required to correct post-surgery problems. 14. Psychological disorders may appear during the recovery period. 15. Major complications such as lung and abdominal organ perforation are possible with injury to bowel, liver, and/ or bladder, which requires early diagnosis and major surgery. Lung perforation will cause breathing difficulties with lung collapse and emergency intervention. 16. Death is extremely rare but possible.

3.13 Summary Body contouring by liposuction is one of the most common elective cosmetic surgeries that is being performed world over. Though the outcomes are based on the art and craft of the surgeon, the safe perioperative phase depends on thorough evaluation of the patient and the right choice of patient. For any cosmetic procedure, the success depends largely on the consultation process and perioperative management. The result, good or bad, usually gets overshadowed by it. For a succesful procedure and an acceptable outcome, the surgical expectations of the patient need to be brought to a practical level wherein the expectations are realistic.

References 1. Thilen SR, Wijeysundera DN, Treggiari MM.  Preoperative consultations. Anesthesiol Clin. 2016;34(1):17–33. https://doi. org/10.1016/j.anclin.2015.10.003. 2. Honigman RJ, Jackson AC, Dowling NA.  The PreFACE.  Ann Plast Surg. 2011;66(1):16–23. https://doi.org/10.1097/ sap.0b013e3181d50e54. 3. Lavell S, Lewis CM.  SAFE: a practical guide to psychological factors in selecting patients for facial cosmetic surgery. Ann Plast Surg. 1984;12:256–9. 4. Napoleon A.  The presentation of personalities in plastic surgery. Ann Plast Surg. 1993;31(3):193–208. https://doi. org/10.1097/00000637-­199309000-­00001. 5. Sabaté E, editor. Adherence to long-term therapies: evidence for action. Geneva: World Health Organization; 2003. 6. Amy S, Colwell MD, Loren J, Borud MD. Optimization of patient safety in postbariatric body contouring: a current review. Aesthet Surg J. 2008;28(4):437–42. 7. Langer V. Body contouring following massive weight loss. Indian J Plast Surg. 2011;44(1):14–20. 8. Shrivastava P, Aggarwal A, Khazanchi RK. Body contouring surgery in a massive weight loss patient: an overview. Indian J Plast Surg. 2008;41(Suppl):S114–29. 9. Corcoran Flynn T, Narins RS. Preoperative evaluation of the liposuction patient. Dermatol Clin. 1999;17(4):729–34. https://doi. org/10.1016/s0733-­8635(05)70122-­4. 10. Phinney SD, Stern JS, Burke KE, Tang AB, Miller G, Holman RT. Human subcutaneous adipose tissue shows site-specific differences in fatty acid composition. Am J Clin Nutr. 1994;60(5):725–9. https://doi.org/10.1093/ajcn/60.5.725. 11. Shiffman MA.  Liposuction—principles and practice. 1st ed. New York: Springer; 2006. p. 333–41.

Part II Lipo-contouring

4

Liposuction: Principles and Techniques Martin Jugenburg and Waqqas Jalil

Liposuction is a cosmetic procedure to remove unwanted fat, which may be performed under local or general anesthesia. It requires three-dimensional (3D) understanding of the anatomy, of the adipose tissue, precision, skill, and artistry that is attained only with hands-on experience. There are many terms used to refer to this procedure, such as suction-assisted lipectomy, suction lipoplasty, liposculpting, and liposculpture. The concept of liposuction, suctioning out unwanted fat, traces its origins back to the early 1900s, but it was not until the 1970s that Illouz really popularized liposuction as we know it today (Table  4.1) [1, 2]. With the constantly growing worldwide body mass index (BMI), and given the fact that aside from using implants, fat contouring is the only way to really sculpt the body, it is not surprising that liposuction continues to grow and slowly become a major component, or an add-on to most procedures cosmetic plastic surgeons perform today. It is the second most common surgical procedures performed by board-certified plastic surgeons in the USA and is performed by 92% of all plastic surgeons. Overall, 289,261 liposuction procedures were performed by American Society of Aesthetic Plastic Surgeons (ASAPS) member surgeons in 2018 [10]. If we add to it liposuctions performed by dermatologists and other cosmetic physicians, liposuction is likely the most commonly performed cosmetic procedure worldwide. These numbers as evidenced by the last decade will only continue to increase every year.

Supplementary Information The online version contains supplementary material available at [https://doi.org/10.1007/978-­981-­19-­4997-­5_4].

M. Jugenburg (*) · W. Jalil Toronto Cosmetic Surgery Institute, Toronto, Ontario, Canada

Table 4.1  Liposuction history 1921

1974 1977

1987

1992 1992 1992 1998

French surgeon Charles Dujarier introduces concept of body contouring and fat removal, although the result of his attempt at body contouring resulted in gangrene and set back body contouring for years [1, 2] Drs. Arpad Fisher and Giorgio Fisher in Italy develop blunt tunneling technique on which liposuction is based [3] Dr. Illouz in France introduces wetting solution and develops modern suction-assisted liposuction [4]. Fournier then later added lidocaine to the wetting solution Klein published “tumescent” technique introducing epinephrine to help control bleeding via vasoconstriction (Klein solution: 0.05% lidocaine, 1:1,000,000 epinephrine, 10 mL sodium bicarbonate per 1 L of saline) [5] Hunstad formula (lactated ringers, 0.05–0.0125% lidocaine, 1:1,000,000 epinephrine) [6] Zocchi introduced ultrasonic-assisted liposuction [7] Apfelberg introduced laser-lipolysis [8] Power-assisted lipoplasty approved for use [9]

4.1 Preoperative Assessment The most important aspect of the preoperative assessment, which applies to all cosmetic procedures, not just liposuction, is to understand the patient’s goals and ensure these goals are realistic and achievable. We now live in the age of social media, where virtually everyone “tunes” their photos and videos, leading to a distorted perception of beauty and expectations. It is common practice for “influencers” to use various apps to adjust their bodies, and create illusion of muscular anatomy leading to anatomically impossible body shapes. As a result, even though most people understand that the photos they are looking at are not “authentic,” the result is still a warped sense of normalcy. Often patients bring in “wish pics” of what they want their desired results to be; this can be helpful for a surgeon because it can set the table for their expectations and allow one to have a frank discussion about what is achievable. Teasing out expectations and concerns from a patient is also helpful in identifying risk factors

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022 M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_4

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consistent with body dysmorphic disorder (BDD), which has a reported prevalence of 6–15% in patients seeking out cosmetic surgery procedures [11]. In general, patients who attempt to improve their appearance through not only surgery, but also diet, exercise, and healthy lifestyle, are more likely to be satisfied with their surgical results [12].

4.1.1 Past Medical History 4.1.1.1 Medical Conditions Beyond psycho-social issues, the other important factor in the assessment of patient eligibility is their general medical health. This is the one aspect that varies the most in the literature as every surgeon has different tolerances for various medical conditions. In general, it is of our opinion to turn away patients who are ASA (American Society of Anesthesiologists rating) >3 or 4. In addition to this if a patient is a smoker or on oral contraceptives, it is asked that they stop at least 2 weeks prior to surgical date. A complete medical history should be obtained from the patient, with focus on conditions that may affect safety of the procedure, or the quality of outcome (Table 4.2). 4.1.1.2 Previous Surgeries Previous surgical history is relevant, specifically abdominal procedures as they may predispose the patient to hernias and increase fibrosis and anatomic anomalies that increase the risk of abdominal perforation. In our experience, nonsurgical fat reduction treatments also increased fibrosis in treated areas. 4.1.1.3 Medications Patients should have their prescription drugs, nonprescription drugs, and various dietary supplements reviewed. Various medications (e.g., Selective Serotonin Reuptake Inhibitor (SSRIs)) can interfere with lidocaine metabolism in the liver and thus increase the risk of lidocaine toxicity [13], and these too should be discontinued 2 weeks prior to surgery. Other medications Table 4.2  Conditions affecting safety as well as quality of outcome Conditions affecting safety • Cardiac history • History of embolism • Implants in the surgical area • Immunosuppressive conditions • Coagulopathies

Conditions affecting quality of outcome • Polycystic Ovarian Syndrome (PCOS) • Ehlers-Danlos syndrome • Previous surgeries in the area (scarring/fibrosis) • Previous nonsurgical treatments  – Injectable  – Nonsurgical fat reduction

that can impact the risk of bleeding and should be stopped at least 2 weeks prior to surgery include: Non-steroidal antiinflammatory drugs (NSAIDs), anti-coagulants, Vitamin E, glucosamine, ginseng, ginkgo biloba, omega-3 fatty acids, and high fish diet. Patients with autoimmune or gastrointestinal (GI) disorders may be on medications that suppress the immune system, and these should be discontinued prior to surgery. Patients should be instructed in general to stop all nonprescription medications, vitamins, and supplements at least 2 weeks prior to surgery.

4.1.2 Physical Examination A thorough physical examination is crucial prior to planning the surgical procedure. Understanding the underlying anatomy (skeletal anatomy and fat distribution) allows the surgeon to plan the surgical procedure. A review of the surgical area for any abnormalities, such as prominent skeletal features, presence of a hernia, previous scars (which may make the surgical area more fibrotic, increase the risk of abdominal wall defects or hernias), will allow the surgeon to recognize potential danger zones early on. Skin contour and irregularities should be noted and discussed with the patient as they may be unaware of their presence and will not understand why they are there after surgery. In our practice it is routine to always have the patient take an in-office height and weight measurement during office visits and prior to surgery, which is then used to calculate their body mass index (BMI), and document it in the electronic medical records (EMR).  If their BMI is above the value of 30, it is our opinion to turn the patient away and suggest that they continue to lose weight. It is routine in the practice to cancel patients on day of surgery if their BMI ratio is found to be above 30. Once the issue of weight is settled, the surgeon then must assess the quality of the skin for the area in question for its elasticity/laxity, previous scars, and dermal thickness. If the patient has extremely poor elasticity and thin dermis, it is usually recommended that they look into excisional-based procedures. However, in the scenario where they fall in the “in-­ between” category of laxity (i.e., some laxity just not enough for excisional-based surgery), adjunct treatments may be discussed that may help with the skin laxity. However, we always stress that these adjunct treatments will not generate the same skin-tightening effect as excisional surgery. In summary, there is no consistent evidence about preoperative assessment but the authors tend to generally agree with Araco et al. [14] in excluding patients with body mass indexes greater than 30 or those with inelastic or redundant skin.

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4.1.3 Preoperative Investigations

Table 4.4  Effects of epinephrine in wetting solution

While a patient undergoing a very minor liposuction does not require any preoperative bloodwork, it is our practice to obtain a complete blood count (CBC) on all liposuction patients where we estimate aspiration volume to be over 1 L. Hemoglobin (Hgb) level indicates whether the patient is able to tolerate possible drop in hemoglobin as a result of a larger volume of liposuction. Additional bloodwork is obtained if past medical history raises any questions.

4.2 Wetting Solution Wetting solution can contain several medical ingredients and each surgeon can make their individual recipe. There is no one standard formulation for the wetting solution with surgeons adding individual medications in dosages that they are satisfied with. The effect of fluid infiltration into the tissue aids in swelling of the tissue that then allows the passage of cannulas and other devices through the tissue in a safe effective manner. Klein solution • 1 L normal saline • 50 cc of 1% lidocaine (500 mg) • 0.5–1.0 mg epinephrine • 10 cc of 8.4% NaHCO3 (10 mEq)

4.2.1 Wetting Solvents Solvent in the wetting solution initially used was normal saline (NS). Later, Ringer’s solution was developed where potassium chloride was added to the normal saline, and finally Hartmann’s solution (lactated Ringer’s [LR] solution) was developed where lactate was added to the Ringer’s solution. NS, Ringer’s, and LR are similar when used as wetting solution. Of these solutions, normal saline (0.9% NaCl) is most commonly used. LR has been associated with perioperative complications, such as deep venous thrombosis (DVT) [15] and alkalosis. Table 4.3 compares the constitution of the various wetting solutions. Table 4.3  Wetting solutions

Normal saline • 0.9% NaCl 154 mEq/L of sodium and chloride • It is the most commonly used solvent

Ringer’s solution • Ringer’s solution is a solution of various salts dissolved in water in order to create an isotonic solution • Usually contains NaCl, KCl, CaCl, and NaHCO3

Lactated Ringer’s (Hartmann solution) • Ringer’s solution, where lactate replaces NaHCO3

• Prolongs the anesthetic effect • Slows the absorption of lidocaine allowing higher dosage • Capillary vasoconstriction to reduce surgical blood loss

4.2.2 Epinephrine Epinephrine is an alpha and beta agonist that plays a key role in minimizing blood loss, lowering peak lidocaine levels, and prolonging the effect of the lidocaine. In the wetting solution, 1  mg/L provides consistently good vasoconstriction with low incidence of tachycardia, and requires 3–6 min for onset of action and 10–15 min for maximal effect. In our practice, we have increased our formulation to include 2 mg/L to shorten wait time for onset of action and to further minimize blood loss, without any negative systemic effect on the patients (Table 4.4). Areas of increased fibrous tissue tend to be associated with increased surgical bleeding, and these tissues require more wetting solution, more epinephrine, and longer time to set in. The most common adverse reaction to epinephrine is when a rapid absorption leads to supraventricular tachycardia. There may also be allergic reaction to bisulfite, which is an antioxidant often added to commercial epinephrine. There are other clinically relevant conditions where epinephrine may be contra-indicated such as: significant cardiovascular or peripheral vascular disease, hyperthyroidism, and others.

4.2.3 Anesthetic Local anesthetic can be added in various dosages to help anesthetize infiltrated areas, and thus avoid the need for general anesthesia. Lidocaine is the most commonly used anesthetic, and the dosage varies from surgeon to surgeon. Lidocaine, when injected intravenously, has a maximal safe dose of 5 mg/kg (7 mg/kg with epinephrine). However, because lidocaine toxicity is related to its plasma concentrations, and absorption from subcutaneous tissues is slow, maximum safe dose in liposuction is debated, and doses of up to 35  mg/kg of lidocaine in subcutaneous tissues have been shown to be safe [16, 17]. Ostad and colleagues [18] demonstrated lidocaine up to 55  mg/kg as being safe. Table 4.5 enumerates Klein’s recommendation and Table 4.6 mentions safety features regarding use of lidocaine in tumescent fluid. Because of potential lidocaine toxicity, however, some surgeons (including our clinic) avoid the use of lidocaine in their wetting solution all together without increased postoperative pain when the procedure is performed under general anesthesia [19].

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4.2.4 Tranexamic Acid Tranexamic acid is anti-fibrinolytic agent that inhibits the activation of plasminogen, and is used to reduce perioperative blood loss without increasing the risk of thromboembolism. As a result, it has gained popularity as an effective and safe adjunct to many surgical procedures [20, 21]. Cansancao et al. have shown a 43.8% decrease in blood component of the lipoaspirate, and blood loss was decreased by 56.2% in patients who received 10  mg/kg tranexamic acid intravenously preoperatively and postoperatively, compared to a placebo group [22–24].

4.2.5 Sodium Bicarbonate Sodium bicarbonate neutralizes the acidic pH of the local anesthetic, to make the infiltration in an awake patient less painful [25]. Adding 10 cc of 8.4% NaHCO3 (1 mEg/mL) to Table 4.5  Klein’s recommendations • 45 mg/kg in a thin patient • 50 mg/kg in a heavier patient • Maximal dose should be reduced 30% in patients taking drugs that may interfere with lidocaine metabolism (e.g., SSRIs) Table 4.6  Lidocaine in wetting solutions Lidocaine injected into subcutaneous tissues as part of a wetting solution has a higher toxic dose because of slower plasma absorption: • Subcutaneous fat is less vascularized • Presence of epinephrine causes vasoconstriction • Tumescent solution volume compresses blood vessels • Dilution of lidocaine in the wetting solution keeps the gradient for absorption low • Lidocaine is lipophilic and is sequestered by the fat • Unknown amount of lidocaine is removed from the patient during aspiration • Absorption half-life of lidocaine in wetting solution is 8–14 h, thus little of the total dose is in the systemic circulation at any given time Plasma lidocaine peaks at 12–14 h after injections, and local anesthesia effect can last up to 18 h, negating the need for long-lasting anesthetics such as bupivacaine and marcaine

1  L of NS results in 10  mEq/L of wetting solution, which significantly reduces the pain of infiltration and the burning of the acidic lidocaine. Please note adding NaHCO3 to solution containing bupivacaine results in precipitation of bupivacaine and should be avoided.

4.2.6 End Points of Wetting Solution The wetting solution is infiltrated to various end points, with increasing infiltrate volume leading to decreasing blood loss (Table 4.7) [26, 27]. Following the injection of the wetting solution, it is recommended to wait 5–20 min to allow for maximal vasoconstriction, thus minimizing blood loss during surgery. Patients with “soft” non-fibrotic fat are ready 5 min after infiltration, while fibrotic areas and areas with previous liposuction benefit from 20 min wait period. A variation on the infiltration technique is the simultaneous separation tumescence (SST) introduced by Del Vecchio [28] in which Del Vecchio demonstrated to have a more rapid onset of vasoconstriction.

4.3 Liposuction Surgery There are various surgical techniques surgeons can use to perform the liposuction procedure [29, 30]. The basic concept of aspirating fat can be achieved by simple syringe-­ based suction, or with a suction pump-assisted suction. A simple set of instruments can allow a surgeon to perform liposuction safely and effectively (Fig.  4.1). Liposuction cannulas can be attached to a syringe, or via suction tubing to a suction machine. The fat is aspirated into a simple container (Fig.  4.2) or, when fat grafting is performed, into a canister that allows for the fluid to be drained and fat to be re-injected (Figs. 4.3 and 4.4). Additionally, there are various instruments that can be used to pretreat the fat to facilitate aspiration. A more “sophisticated” set of instruments includes variety of tools to pretreat the fat, variety of cannulas to achieve different sculpting goals, and tools to post-treat the liposuction area (Fig. 4.5). Although most manufacturers would like to promote their tools as beneficial to patients in terms of lower blood loss, less bruising, and quicker recov-

Table 4.7  Estimated blood loss during the various techniques of liposuction Technique Dry Wet Superwet Tumescent

Amount of wetting solution infiltrated No wetting solution 200–300 cc of wetting solution per area 1 cc of wetting solution per 1 cc of fat to be removed 3–4 cc of wetting solution for each 1 cc of fat to be removed or until tissue becomes firm

Estimated blood loss as % of aspirate volume 20–45 4–30 1 1

4  Liposuction: Principles and Techniques

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Fig. 4.1  Typical liposuction instrument setup: aspiration canister and a stand, basic instruments to create liposuction port and for sutures; pitcher, bowl, and funnel

Fig. 4.3  Simple reusable liposuction canister with a luer lock: allows easy drainage of the separated tumescent fluid as well as aspiration of fine fat for fat grafting

Fig. 4.2  Simple reusable liposuction canister: autoclavable canister can be reused many times, and can be sterilized to allow placement on the instrument table if needed

Fig. 4.4  Reusable liposuction canister with a suction tubing adapter: allows larger-diameter suction and fat injection tubing to be connected, for large-volume fat grafting

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Fig. 4.5  A typical liposuction setup (left to right): an instrument tray used to sterilize liposuction canister and its stand is used as a container to hold and protect instruments and cannulas during a procedure. Sterile green towels for draping and gauze. Pitcher and a funnel for transferring harvested fat between canisters. Various liposuction cannulas are laid out for demonstration (during surgery, they would be in the instrument tray covered to protect them from contamination while not in use). Basic instruments are used to create liposuction ports and later to suture them, close, and fixate drains if needed. Piercing towel clips are used intraoperatively to close liposuction ports to avoid tumescent fluid leaking while the port is not being used. A small bowl contains liposuction

port protectors. These are essential for vibration application of sound energy at resonance (VASER), and can be used for standard suctionassisted lipoplasty (SAL) as well. Aspiration tubing with appropriate diameter is seen (MicroAire-compatible tubing displayed). VASER handpiece and VASER probes (and skin ports) are seen on the top, with MicroAire (power-assisted liposuction) PAL handpiece and power cord seen below. VASER is used to pretreat the fat and MicroAire is used to aspirate (VASER is used to pretreat fat in some patients; in others, MicroAire PAL with a basket cannula is used for the separation pretreatment of fat prior to aspiration). Bottom right shows an autoclavable canister with a stand, and tubing to connect it to a suction machine

ery, there are few independent studies to support these benefits. The undisputed benefit that these machines have is that they make the actual liposuction less physically straining on the surgeon.

Table 4.8  Power-assisted liposuction

4.3.1 Pretreatment Technologies 4.3.1.1 Power-Assisted Liposuction (PAL) The concept of power-assisted liposuction (PAL) vibration to break up fat was introduced by Dr. Malak and Rebelo [31]. MicroAire (MicroAire Surgical Instruments, Charlottesville, Virginia) system was first introduced in 1998 and is probably the best-known PAL where the cannula vibrates back and forth 3 mm at 2000–4000 cycles/min. The speed of cannula movement can be adjusted according to the surgeon’s preference. The mobilized subcutaneous fat is aspirated with conventional suction machines simultaneously while the ­ PAL cannula vibrates. Since PAL’s introduction, many plastic surgeons across the world have quickly adapted their

Advantages • Less tiring • Decreased OR time when compared to manual liposuction and other modalities • More versatile

Disadvantages • Added cost of the equipment • Vibration transmitted to the surgeon’s upper extremity • Noise associated with the device

• Easy to learn • Easy to perform • Breaks up fibrous fat easier than SAL • Pretreatment and aspiration with same tool and may be performed at the same time

practices to now incorporate PAL as the predominate method of liposuction (Table 4.8). Initial studies by Fodor et al. [32] found PAL was equal to SAL in safety, speed of recovery, and the aesthetic quality of

4  Liposuction: Principles and Techniques

Fig. 4.6  PAL—Authors’ preferred liposuction tool. We use PAL in virtually all but the simplest liposuction case. Relative low cost, speed, and efficiency of PAL make liposuction significantly less manually exhausting than simple manual liposuction. (1) Power generator, (2) power cord, (3) PAL handle, (4) bent basket cannula used to get around curved surfaces such as when liposuctioning flanks and lower back from a supine position, and (5) straight basket cannula used on flat surfaces

the results. The authors further mentioned that it was considerably superior in terms of “ease of fat extraction.” Therefore, treatment of fibrotic areas and speed of fat removal were found to be faster with PAL than with SAL [32]. This fact has been confirmed as many surgeons have noted the process of PAL to be less labor intensive than traditional SAL (especially in terms of fatigue reduction and time savings). PAL is our preferred liposuction tool in all cases except for very minor liposuction cases where manual liposuction is sufficient (Fig. 4.6).

4.3.1.2 Ultrasound-Assisted Liposuction (UAL) Ultrasound-assisted liposuction (UAL) was first introduced by Zocchi in 1992 [7] who employed ultrasonic energy to pretreat fat. Early machines used the ultrasonic probe to create oscillating sound waves leading to cavitation and cellular fragmentation. While early machines resulted in lipolysis, emulsification, and liquefaction of fat, modern machines use lower power to cavitate air bubbles in the wetting solution to separate fat cells while preserving their viability for fat transfer [33] (Fig. 4.7). The UAL probe may be either a hollow cannula through which low-pressure suction can pretreat and aspirate lipoaspirates, or more commonly a solid probe that requires subsequent aspiration of emulsified fat through a separate hollow cannula, as per SAL. The probe contains a piezoelectric crystal that converts incoming electrical energy into a mechanical vibration at an ultrasonic frequency of 20–30 kHz with a cyclical displacement of around 100 μm. When applied to adipose tissue, these alternating waves cause compression and rarefaction resulting in microcavities or bubbles that can expand with each cycle until a critical

55

Fig. 4.7  VASER instruments: (1) probe cover, (2) VASER handpiece, (3) skin port protectors, and (4) probes of various diameters, lengths, and various numbers of groove (more grooves mean more energy distribution, while fewer grooves result in more energy concentration at the tip for fibrous tissues)

diameter is reached beyond which they implode. This results in disruption of cells and/or generation of high levels of energy in various forms such as heat and light [34]. Adipocytes are thus lysed into an emulsion. When sufficient wetting solution is infiltrated, this ultrasonic energy instead induces cavitation of air bubbles in that solution, which are then responsible for very fine mechanical separation of fat without destroying adipocytes themselves. Schafer et al. [33] demonstrated 88.7% adipocyte viability after harvest of fat for autologous fat grafts, with third-generation UAL. Because heat can build up at the UAL probe if it remains in one place too long, there is a well-known risk of thermal injury with UAL. Sufficient amount of wetting solution (to absorb the thermal energy) and constant movement (to avoid overheating any one area) are needed to avoid thermal injury. Risk of dermal injury and seromas is also increased with UAL (Table 4.9). The seroma rates were overall higher with UAL, which can be up to 21% [36] versus less than 1% in SAL. Interestingly, when the authors analyzed to see if the benefits of UAL translated into improving overall patient satisfaction, swelling, or bruising, the data were inconclusive. UAL is most useful when treating fibrous tissue and secondary liposuction [35, 37, 38] and compared to SAL, UAL may have increased skin contraction and lower blood loss [39]. Even though there are studies that support the use of UAL, there are some studies that did not find any additional benefits and did not recommend UAL for routine use [40–42].

4.3.1.3 Laser-Assisted Liposuction (LAL) Laser-assisted liposuction (LAL) utilizes selective photothermolysis to disrupt adipocytes while leaving other tissues undamaged [43]. Apfelberg [8, 44, 45] was first to describe

M. Jugenburg and W. Jalil

56 Table 4.9  Ultrasound-assisted liposuction Advantages • Less tiring than SAL and PAL in fibrous tissues

Disadvantages • More time-consuming to pretreat the liposuction areas • Risk of thermal injury • Increased risk of seroma

• Finer aspirate • Ideal for fibrotic areas such as back, bra rolls, male chest, or previously liposuctioned areas • Lower blood loss

• More likely to require drains • Significant cost associated with the ultrasound machine • Hyperpigmentation • Sensory alteration

• Less ecchymoses

• Improved skin contraction • Further benefits remain controversial in the literature

• Longer learning curve [35] Table 4.10  Laser-assisted liposuction Advantage • Allows for use of smaller cannula • Less physical strain • Small incisions • Quicker recovery

Disadvantages • Prolonged pretreatment time • Increased risk of seromas • Additional cost of equipment • Risk of thermal injury

the use of YAG laser but found no clear benefit to the use of laser. Later, Blugerman [46] and others introduced Nd:yttrium aluminum garnet (Nd:YAG) laser, which they found lysed adipocytes, resulting in an oily aspirate containing free fatty acids, ruptured cellular debris, and the tumescent solution. They also found less intraoperative blood loss and less postoperative ecchymoses [47, 48]. The wavelengths currently used by laser lipolysis machines (pulsed 1440  nm, pulsed 1064  nm, pulsed 1320  nm, and CW980 nm diode) generate energy, which is absorbed by adipocytes and converted to heat resulting in cell rupture. Complications specific to laser-assisted liposuction are related to thermal injury, as damaging energy level at the treatment area can build up quickly. The other potential downside to laser lipolysis is that they require more time to remove same amount of fat than a PAL would (Table 4.10).

4.3.1.4 Radiofrequency-Assisted Liposuction (RFAL) Radiofrequency (RF) is another modality to deliver energy to the tissues during liposuction. RF energy is high-frequency oscillating electrical current applied to tissues to create a thermal effect to dissolve fat, contract collage, and induce subdermal remodeling and neocollagen formation [49–51]. Radiofrequency-assisted liposuction (RFAL) devices simultaneously coagulate fat, aspirate it, and contract the residual fibroseptal tissue.

4.3.1.5 Water-Assisted Liposuction Water-jet-assisted liposuction is a method for fat harvesting that relies on a fan-shaped water jet to assist liposuction. In this method, the liposuction tube is connected to a negative-­ pressure pump and the water pump so that the fan-shaped water can jet at a specified frequency during liposuction. With the assistance of water-jet force, adipocytes can be gently detached from the tissue and the mechanical injury to lipoaspirates thereby reduced. Thus, pulsating jets of wetting solution and simultaneous liposuction to anesthetize the surgical field, break up and aspirate adipocytes [52]. Because water-jet assistance was proved to improve the survival of grafted lipoaspirates, its mechanisms are quite important for investigators [53]; they did an in  vitro study specifically looking at water-jet liposuction’s ability to improve lipoaspirate viability. Their in vitro study revealed that cultured stromal vascular fraction cells in the group with water-­jet-­assisted liposuction have a greater capacity for adipogenic differentiation and endothelial differentiation, therefore showing convincing evidence that the fate of grafted fat was affected by water-jet force. With the assistance of water-jet force during the harvesting procedure, they could obtain lipoaspirate that was more viable and achieve a better survival result. There is some controversy regarding adipose-­derived stem cells (ADSCs) and their presence in certain liposuction techniques. Murphy et al. (2012) showed that harvesting ADSCs using BodyJet and BodyJet with SmartLipo lipoplasty technique produces a high yield/clinically useful ADSCs. Conversely, another study showed that when assessing water-assisted liposuction (WAL) alone, both with and without stem-cell enrichment, in cosmetic fat transplantation to the breast they saw no difference. The research on ADSCs (adipose-derived stem cells) and water-­assisted liposuction is still in its infancy; although there are some promising early results, its safety and clinical applications need further exploration.

4.3.2 Liposuction 4.3.2.1 Liposuction Technique Liposuction is a blind procedure, where the surgeon does not see what is being liposuctioned; rather the surgeon must use his or her hands to feel tissues to “see” what is being done. This procedure, probably more than any other in plastic surgery, is highly dependent on the surgeon’s experience. No amount of reading and watching replaces the experience of feeling of how liposuction is done. The operative hand holds and guides the cannula, while feeling for resistance (Fig. 4.8). The other hand serves to feel the surgical area, guiding the cannula, and should always provide tip feedback to the surgeon. The surgeon should at all times be aware of where the cannula tip is, to guide the procedure and to prevent perfora-

4  Liposuction: Principles and Techniques

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tion injury. This hand also helps to stabilize fatty pockets, and if needed guides or pushes the fat toward the cannula. This is the art of liposuction, feeling what the surgeon is doing, because otherwise this is a “blind” procedure: the surgeon does not see where exactly the instrument is located and what tissue layers are being addressed. The stepwise process of liposuction is summarized in Fig. 4.9.

4.3.2.2 Infiltration Prior to aspiration, the target area should be infiltrated with the wetting solution. Small areas or touch-ups may be infiltrated up to a wet endpoint. Any more significant liposuction should be infiltrated to a superwet or tumescent endpoint, and time should be given to allow the skin turn pale, indicating the epinephrine effect has set in. During the infiltration, the infiltration cannula should be moving back and forth to

Fig. 4.8  The operative hand is guiding the cannula into place while the non-operative hand provides the feedback about the spatial position of the tip of the cannula

allow the wetting solution to spread widely and rapidly. Del Vecchio’s SST takes that principle a step further, using the vibration of PAL to help spread the wetting solution. Infiltration of wetting solution is through sites that will then be converted to liposuction ports. As such, the selection of these sites is an important step (Fig.  4.10). These sites should allow easy access to the target area, while being hidden in natural body contour—areas known to be covered by clothes, within tattoos, or other lesions that may camouflage the subsequent scar. The attempt to hide scar should however not sacrifice the ability to easily and effectively reach the target area. Understand that liposuction may result in linear tunnels that may result in contour deformity or a fold. That understanding should help guide the placement of the liposuction ports. In cases of HiDef liposuction where the goal is an intentional, controlled contour deformity, the incision port can be placed in line with the desired contour. In other cases, such as in the lower abdomen, which is prone to horizontal folds, the liposuction ports should be placed such that liposuction will be performed as perpendicular as possible to the potential folds one wants to avoid.

4.3.2.3 Separation While some surgeons will proceed from infiltration directly to fat aspiration, pretreatment of the surgical areas with fat separation is an option. Separation, a pretreatment step described by Wall [54], has gained popularity among liposuction surgeons. Using a basket cannula with PAL without suction breaks up fatty deposit, breaks up or loosens the fibroseptous network, and allows the wetting solution to spread widely. The benefit of this pretreatment is better vasoconstriction in shorter amount of time, looser fat globules for

Liposuction Steps Separation

Infiltration

Aspiration

Fat Equalization

Infiltration:

Separation:

Aspiration:

Fat Equalization:

•

•

•

•

Basket cannula with PAL used to break up and separate any residual adipose lumps

•

Wet/lubricate the skin to facilitate manual massage to feel for irregular residual fat and to re-distribute lose fat globules

•

3mm basket cannula PAL or infiltration cannula are effective in assisting with this step

Wetting solution •

•

large volume liposuction or fat harvest •

no lidocaine added

•

NS with 2amp epi/L

routine liposuction •

• •

•

•

1g TXA/L may be added

SST may allow for shorter time before aspiration can take place.

•

single basket cannula with PAL

•

up to triple basket large diameter cannula with PAL for more aggressive separation

Cannula selection based on the liposuction need •

Fine cannulas vs large bore cannulas

•

up to triple basket large diameter cannula with PAL for more aggressive separation

Ultrasound - assisted separation •

NS 40cc 2% Xylocaine w Epi, and 2 amp Epi/L

Allow for sufficient time (>5min) for epinephrine to act. Typically by the time all the liposuction areas have been infiltrated, the first area is ready for separation

Basket cannula pre-tunneling

tools such as VASER emulsify fat with a theoretical advantage of less bleeding and smaller/finer fat fragments

•

When PAL/UAL is unavailable, simple infiltration cannula pre-tunneling can be used

•

Separation performed until no tissue resistance felt

Fig. 4.9  Stepwise process of a liposuction procedure

•

Ultrasound - assisted separation •

tools such as VASER emulsify fat with a theoretical advantage of less bleeding and smaller/finer fat fragments

•

When PAL/UAL is unavailable, simple infiltration cannula pre-tunneling can be used

•

Separation performed until no tissue resistance felt

58

M. Jugenburg and W. Jalil Table 4.11  Basic principles for optimizing aspiration • Port opening size less should be no less than 0.5 times the cross-section of the cannula • Enlarging port size beyond 1:1 ratio of port to cannula cross-­ section does not improve aspiration • In multiport cannulas, total port cross-section greater than 1.5 times the cannula cross-section adds no additional efficiency • Multiple smaller ports are more efficient than fewer larger ports

Fig. 4.10  Access points marked in red are placed in hidden areas from which different areas can be accessed for liposuction as marked by yellow arrows

easier and less traumatic aspiration, and the subsequent aspiration requiring less physical effort on the part of the surgeon. Its downside is the additional time required prior to actual aspiration. In our practice, we use a 5  mm single, double, or triple basket cannulas with PAL to rapidly separate fat in proposed treatment areas. In areas that are highly fibrotic, that may have scarring in the area, or in very thin patients, we prefer to use UAL as the pretreatment tool of choice.

4.3.2.4 Aspiration Aspiration efficiency is determined by various equipment factors, but none is more important than the cannula selection. Selecting the right cannula is a balance between choosing one that is delicate and will minimize the risk of contour deformities, and at the same time is efficient in aspirating the fat. There are not many publications dealing with the physics of liposuction cannulas. Fodor et al. [55] established the basic principles for optimizing aspiration (Table 4.11): We also know a larger cannula will be able to aspirate more efficiently and is less traumatic to the fat should fat transfer be considered.

In our practice, most body cases are performed with the following three cannulas: 5 mm straight basket cannula for routine liposuction when focusing on a specific area; 5 mm bent basket cannula to allow access around bony prominences (such as around ribs or pelvic bones) or around body contours; and 4  mm 12-hole long cannula for generalized liposuction or larger areas. When performing liposuction in a thinner patient, or for more finesse, we decrease the cannula diameter to 4 and 3 mm. In heavier patients, and when trying to aspirate larger volumes while being atraumatic (such as in more aggressive upper abdominal liposuction during lipoabdominoplasty), we use blunt tip Mercedes 6  mm cannula (Fig. 4.11). Skin protectors may be used when there is a concern about tissue injury at the port from the cannula. When performing the aspiration, the surgeon’s hand should move in broad strokes initially, to aspirate fat from the target area as uniformly as possible, fanning out and always moving. Staying in one place or one area for too long may result in overcorrection or contour deformities. A target area should be approached from at least two different ­directions, so that the liposuction strokes criss-cross in order to obtain smooth results. The simplest method to aspirate fat is use syringe suction. This technique was popularized by Toledo [56] and is appropriate for low-volume liposuction or in situations where suction-assisted lipoplasty is unavailable. It is ideal when treating limited areas and a more complex pump setup is not required. On the downside, it is more labor intensive, slower, and suction can be lost at access incisions. The most common aspiration modality, however, is suction-­assisted lipoplasty (SAL) where a remote liposuction pump creates the suction force. These pumps allow for variable suction pressure, are less straining on the surgeon, and allow for less effort and thus larger-volume liposuction. Suction setting on these pumps is adjustable. High suction means more rapid aspiration, but also increased risk of contour deformities and vascular injury. In our practice, we keep our suction set at 40 mmHg (max setting is 70). When handling fat, it is recommended that the surgeon places his or her hand flat on the surface, to feel the liposuction cannula under his or her hand. This will guide the liposuction process. Various degrees of pressure can be applied to modulate the amount of fat being aspirated. The pressure

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Fig. 4.11  Liposuction cannulas: there are a wide variety of liposuction cannulas in terms of diameter, length, number and distribution of ports, and shapes. (1) Curved VentX for ab etching, (2) curved luer lock cannula for aspiration or fat grafting on curved surfaces, (3) short cannula for areas where liposuction port cannot be placed sufficiently far from the treatment area, (4) cannula with a Toomey syringe adapter for manual liposuction or fat injection, (5) bent basket PAL cannula, (6) straight basket PAL cannula, (7) straight single port PAL cannula, (8) Del Vecchio multiport large-diameter cannula for rapid large-volume lipo-

suction, (9) large-diameter Mercedes-style cannula for large-volume atraumatic liposuction, (10) bent Del Vecchio-style multiport cannula for liposuction access to areas around curved surfaces, (11) multihole “cheese grader” cannula for gynecomastia, (12) multiport long cannula custom cannula with an adapter for PAL handles, (13) extra-long fine PAL-compatible cannula (allows access to lateral chest and axilla via groin incision), (14) large-diameter triple-basket cannula for aggressive separation, and (15) single port re-injection cannula for large-volume fat grafting

can be applied in a gradient, not as uniform pressure, to shape the liposuction area when trying to control the r­ esultant fat contour, as in high-definition liposuction. The non-­ dominant hand can also be used as a guard to limit the extent of the liposuction, to prevent the cannula from entering unwanted region.

4.3.3 Variations of Lipo Techniques

4.3.2.5 Fat Equalization In the past, once the aspiration was completed, the surgery was over. However, more recently, more and more surgeons have realized the value of fat equalization after liposuction. Toledo and Mauad [57] recommend the treatment areas should be thoroughly assessed by the pinch test and by wetting the surface and sweeping the hand or a roller over the surface to detect any contour irregularities. First described by Saylan [58], and later popularized by Wall [54], fat equalization or fat shifting is a great tool to ensure contour irregularities are avoided and the patient attains smooth results. The concept is that the residual fat after liposuction is further separated and massaged to spread out. Any residual lump is mechanically broken up with a cannula and then massaged to shift fat cells into surrounding areas, which then act as autografts and help smooth the contour.

In addition to the above stated techniques there are certain complementary techniques or technologies that can be added on to various techniques. These add-ons come in various forms and have been presented at numerous aesthetic conferences internationally with each stating improved results.

4.3.3.1 SST—Simultaneous Separation and Tumescence SST was described by Wall and Del Vecchio [59] and involves simultaneous infiltration and separation of fat for quick vasoconstriction, and immediate separation, in order to reduce operative time. SAFE Liposuction  Introduced and SAFELipo by Simeon Wall [54, 60],

popularized

as

SAFE liposuction is a three-step process of fat separation, aspiration, and fat equalization that aims to facilitate fat removal and minimize contour irregularities at the donor site. Wall Jr. described the SAFELipo technique using power-­ assisted liposuction tools and an exploded basket cannula

M. Jugenburg and W. Jalil

60

that is used to pretreat the donor site in order to facilitate a less traumatic aspiration of the donor fat. This is achieved by mechanical vibration and no suction. The result is separated and emulsified fat that can be removed under lower suction, with less bleeding and less trauma to the surrounding connective tissue. Subsequently, once the aspiration is completed, the exploded basket cannula again under no suction, and manual fat shifting, is used to equalize the residual fat and facilitate a smoother outcome. HiDef Lipo  Introduced by Mentz and Ersek [61, 62] and later modified and popularized by Alfredo Hoyos [63], this liposuction technique focuses more on body sculpting than on fat removal. Surgeons can utilize different forms of liposuction but what remains important in this technique is the need for careful preoperative markings that accomplish the goal of enhancing the underlying muscular anatomy thus simulating the appearance of an athletic physique for the patient. The surgeon must constantly keep in mind the need to retain fat in some areas, while aspirating from others.

4.3.4 Additional Treatments 4.3.4.1 Tissue Tightening Helium plasma-Renuvion®/J-Plasma® system (Apyx Med CORP, Clearwater Florida) is a device that is often used after the completion of liposuction. Its system combines the unique properties of cold helium plasma with the efficiency of RF energy [64, 65]. In our experience, this tool has demonstrated impressive short-term results when used in the abdominal area of patients with minimal skin laxity. The result is not skin contraction but instead skin adhesion to the deeper layer, making it difficult to pinch, and thus creating an illusion of skin tightening (Table 4.12). In our limited experience, it appears that the tightness is maximal at 2 weeks after surgery and significant tightness persists for about 3 months. At 1-year follow-up, some but not all patients still have demonstrable skin adhesion present. The results seem to be related to the treatment time. Apyx recommends four to six passes per area Table 4.12  Use of helium plasma and its advantages Advantages Ideal for patients who are not ready for excisional surgery Applicable to multiple areas on body

Disadvantages Cost of device Additional time to operation Learning curve and potential for increasing complications (burns) Lack of published studies demonstrating clinical efficacy

and this appears to result in significantly better and longer-­ lasting results compared to fewer than four passes. Other modalities include radiofrequency and laser-based devices that deliver energy in a controlled manner to induce tissue contraction as well. However, none of these devices are a replacement for actual skin excision procedure and their use should be limited to minimal skin laxity.

4.3.4.2 Hemoglobin Management When significant liposuction is planned, the possibility of significant blood loss should be considered. Baseline Hgb level should be obtained to ensure the patient is in a safe zone prior to the start of the procedure. Patients with low Hgb should be postponed until their Hgb levels normalize. Best hemoglobin management is prevention of blood loss and a good Hgb baseline. Efforts should be made to minimize blood loss during the surgery: • Sufficient infiltration of wetting solution. • Allowing for the epinephrine to act before commencing aspiration. • Cessation of liposuction when excessive bleeding noted. • Administration of drugs to minimize intraoperative blood loss (anti-hypertensives, tranexamic acid, etc.) • Atraumatic cannula selection. • Warming of intravenous (IV) fluids (hypothermia leads to coagulopathy). After surgery, the patient should be kept warm, well hydrated, and proper compression garment applied to minimize bleeding and third-spacing. Blood loss is of course inevitable outcome from any surgical procedure, especially liposuction where larger-volume aspirations can have a significant impact on a patient’s hemoglobin levels. In such situations, use of intraoperative cell salvage that helps to recycle patient’s blood avoids the need for transfusions. From anecdotal evidence, patients appear to recover better and quicker when their hemoglobin levels are replenished; however, at this time there are no studies to support that assertion.

4.4 Post-liposuction Massage Post-liposuction massage is a great adjunct to postoperative care. In the initial recovery phase, massage helps to evacuate residual fluid, blood, and oily debris to minimize postoperative edema and fluid retention (Fig. 4.12). In later stages of healing, it helps to ensure smooth results and minimal fibrosis. Massage is best used to create fresh blood flow and move any unwanted residual fluid or inflammation that might get stuck in one area. Patients are warned that initially it will be uncomfortable as their skin will be hypersensitive, however

4  Liposuction: Principles and Techniques

61

Fig. 4.12  Direction of lymphatic massage in the leg. The illustration also shows the group of lymph nodes toward which massage has to be done

with massage this hypersensitivity will resolve faster. We recommend to our patients to start massage soon after surgery. Although massage is done ideally directly in contact with skin, if a patient is wearing a garment they are encouraged to massage through the garment as well. When possible, patients should remove garments during massages, and massage several times a day. More is better when it comes to post-liposuction massage. A professional massage will be more effective as pain will prevent patients from massaging aggressively enough. For that reason, we recommend a professional massage at least once a week during the first 3 months. After 3 months, patients can decrease the frequency of daily massages and may stop professional massages.

4.5 Post-liposuction Garments There is a wide variety of postoperative garments that are used after liposuction, in order to minimize edema, provide compression support, and help shape the body. Fajas have been popular in South America and are now gaining popularity among liposuction patients in North America as well. The word Faja comes from the Spanish word for wrap. A Faja comes in a variety of styles, specific to supporting and aiding in the recovery of recent plastic surgery procedures. A Faja base coverage tends to always include coverage of the abdominal and surrounding area and can target specific addi-

tional areas (arms, breast coverage) as needed. The purpose is to provide smooth, even compression to aid patients in their recovery while reducing risk of seromas, swelling, and contouring the healing body. A proper fitting Faja is one that provides even compression without over-compressing. Patients should be free to remove their Fajas when they feel the need to do so. Taking a break from a Faja is encouraged. It is important, especially with postoperative patients, to always wear a barrier between their skin and garment/Faja in the initial weeks that is smooth and free from ribbing and wrinkling, and is seamless and a proper fit to allow for a smooth undergarment and layer of protection that can lay flat and provide a smooth barrier (no wrinkles or extra excessive material that cannot lay flat against skin), which is a protection between patients and garment. This will avoid and prevent fluid build-up that cannot travel to lymph system, indentations on skin, irritations, and other damage. Stage 1 Fajas are worn immediately following a surgical procedure and are made of a light, breathable cotton material with a light to medium level of compression that can be worn immediately post-surgery. After surgery, the fluid needs to be expelled and the surgeon will not be able to get all of it during the surgical process. This period is known as the “first stage” of postoperative recovery, and compression garments help with that process. After a cosmetic procedure, there is some amount of swelling and bruising and postsurgical gar-

62

ments (Fajas) can help with these issues as well. Stage 1 is worn immediately post-surgery and can be worn for up to 15 days at which time the transition takes place to a Stage 2 garment. For maximum recovery, patients should start wearing a second-stage garment as soon as they are finished with the first-stage garment. This allows the body to return to using its normal lymphatic functioning. When the lymphatic system is functioning properly, it will naturally flush the body of excess fluid and reduce swelling at which point the next stage is required. Stage 2 Faja assists in continued recovery and contouring results. Stage 2 Faja is of high compression levels worn after 10–15 days for a minimum of 3 months after surgery. This includes taking limited breaks from the Faja in the initial stages (only to clean the Faja, take a shower, or self or professional massage plus break periods to allow for renewed oxygen levels). In both Stages 1 and 2, Fajas should be worn 21–22 h a day initially, gradually reducing the time to 10–12 h a day or night at the 12-week mark. Stage 2 Faja often becomes a comfort level in recovery and is worn for a longer term. If a liposuction patient completes or is close to completing the suggested recovery period or wants to move to a lighter compression garment, a Stage 3 Faja can be worn as everyday wear while providing a level of support and maintaining an overall look and feel that is desired by the patient. Everyday wear is commonly used by patients who wish to obtain their most desired look. Shapewear is another term used for third-­ stage garments. Compression is minimal and comfort is an added benefit. If slight lines from Faja are noticed, allow for breaks (no Faja) and light moisturizing of the area to allow the area to recover. To aid in recovery, posture, and reduce swelling, the following are optional accessories such as 360 foam, lipo sheets, and ab boards that can be used under a Faja to increase comfort, reduce pain, increase compression levels, reduce swelling, ensure uniform compression, and contour the body.

4.6 Safety in Liposuction Although liposuction can be performed very safely, and the overwhelming majority of liposuction literature confirms its safety, risk of complications and mortality still persists [66]. Overall complication rate in liposuction can be 5%, although most of these complications are minor [67]. Complications leading to fatal outcomes include embolism (fat and thromboembolic), sepsis, necrotizing fasciitis, and organ perforation. Grazer and de Jong surveyed North American board-certified ASAPS members. They found 95 fatalities in 496,245 liposuction procedures, corresponding to 1 in 5224 or 19.1 per 100,000 mortality rate [68]. Pulmonary embo-

M. Jugenburg and W. Jalil Table 4.13  Liposuction complications Local complications • Medical  – Edema  – Seroma  – Ecchymoses  – Hematoma  – Infection  – Skin necrosis (“Lipo burn”)    Liposuction injury    Compression garment injury  – Neurological pathology • Cosmetic  – Over/under correction  – Surface irregularities  – Skin laxity  – Asymmetry  – Skin hyperpigmentation

Systemic complications • Hypothermia • Fluid imbalance  – Fluid overload  – Hypovolemia • Syncope • Blood loss • Embolism  – Thromboembolism  – Fat embolism    Micro    Macro • Perforations • Fulminant infection • Lidocaine toxicity • Death • Lipoembolism syndrome (LES)

 – Scarring

lism represented 23.4% of fatalities. Lidocaine toxicity could not be properly assessed due to lack of toxicology data; however, it remains a major suspect in unexplained deaths after liposuction. Most deaths reported in this study occurred during the first night suggesting that patients remain monitored in the early postoperative period. Proper patient selection, diagnosis, planning, meticulous surgical technique, as well postsurgical care are all factors in maximizing surgical outcome and minimizing the risk of medical and cosmetic complications (Table 4.13).

4.6.1 Edema Postoperative swelling is normal and expected with liposuction. Edema typically becomes apparent at 24–48 h after the procedure, and then continues to slowly resolve over the next 2–4 weeks. Swanson [69, 70] performed magnetic resonance imaging (MRI) studies that demonstrated 66% of the swelling resolved at 1 month, 87% at 3.3 months, and total resolution of swelling by 9.3 months after surgery. While all patients are expected to have edema after surgery, significant persistent edema can affect small proportion of patients [71]. Diuretics can help speed up resolution of edema. Edema that does not resolve with time may benefit from repeat liposuction and appropriate compression garments [72] (Table 4.14).

4.6.1.1 Seroma Postoperative seroma can occur after liposuction, with risk increasing proportionally with the amount of injury to the lymphatic circulation, and the amount of dead space created

4  Liposuction: Principles and Techniques Table 4.14  Methods to minimize postoperative edema • Compression garments • Leaving skin ports open to allow fluid to flow out • Use of drains • Postoperative massage • Diuretics Table 4.15  Management of persistent seromas • Acute seromas  – Needle aspirations and subsequent compression  – Drain placement • Chronic seromas  – Fluid aspiration and injection of an irritant (tetracycline 500 mg in 2 cc NS or triamcinolone)  – Curettage of the seroma cavity  – Excision of the seroma cavity

and localized trauma. Use of energy devices also increases the risk of seroma formations [73]. Localized seromas can occur in 3% of cases [71]. In our experience, when significant liposuction is performed leaving only a thin layer of subcutaneous fat behind, the use of drains to avoid seroma formation is essential. Some surgeons do not use drain and instead just leave incisions open to allow for free drainage over the next 24–48 h before those wounds close. Should a seroma develop, there are various measures one can take to manage it (Table 4.15). Long-term seroma tends to form a cyst-like lining and often needs to be surgically managed. The “cystic lining” can be a few layers thick or many layers thick. “Chemical cauterization” of the cystic cavity for better adhesions of the layers may be an option after drainage and curettage.

4.6.1.2 Ecchymoses Ecchymosis is normal and starts to form during the procedure and early after the procedure, typically peaking at 7–10 days. It can be severe if vasoconstriction was poor during the surgery, or if the patient was taking any anti-coagulant substances (pharmacologic or dietary). Severe ecchymoses can potentially indicate underlying skin necrosis or may be a cause of it. Patients should be seen the day after surgery to ensure there are no indications of skin necrosis, which would require urgent referral to a hyperbaric oxygen therapy, and topical creams to open the perfusion in the area. Dusky-­ looking skin may need a nitroglycerine ointment or cream to improve the micro circulation. When significant ecchymosis is noted during the procedure, or there is abnormal bleeding without an obvious etiology, adding tranexamic acid to the procedure may be helpful. In our practice we prophylactically administer IV tranexamic acid in patients with a history of easy bruising or administer it during the procedure if concerns about increased blood in the aspirate arise.

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4.6.1.3 Hematoma Hematoma should be a rare complication in a well-executed liposuction procedure. Proper patient selection and preparation, along with proper use of the wetting solution and liposuction technique should result in minimal bleeding during and after the surgery. When a hematoma appears intraoperatively, the blood should be aspirated with a cannula and compression applied for no less than 5  min. Additional wetting solution can be infiltrated into the area and liposuction should be performed in a different area while the epinephrine is allowed to act. Tranexamic acid can be added as an additional tool to help minimize blood loss. When a hematoma is identified postoperatively, it can be left alone when small, or drained if it is large enough to affect the contour [74]. 4.6.1.4 Infection Infection is extremely uncommon (