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Lower- Limbs
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KulwantBhangoo
6
Since the advent of liposuction in the early 1980s, this procedure has undergone tremendous advances making it one of
the most commonly performed cosmetic surgery procedures
today. According to the statistics compiled by the American
Society of Plastic Surgeons, liposuction is one of the two
most commonly performed cosmetic surgery procedures in
the United States. In 2019, almost 300,000 liposuction procedures were performed. [1, 2]
Liposuction is performed in many areas of the body,
including the face, neck, breast, upper extremities, chest,
abdomen, and the lower extremities. Although it is the most
commonly performed cosmetic surgery procedure for both
males and females, over 90% of liposuction cases were performed in females. Of all the areas in the body, it is most
frequently performed in the lower extremities (Fig.6.1).
The increasing demand for this procedure is related to the
fact that in modern society, emphasis is placed not only on
body weight, but also on contour and shape (Fig. 6.2).
Liposuction is a fundamental tool as far as sculpturing and
contouring of the body is concerned. It is not meant for
weight reduction, but for removing fat from areas which are
not amenable to dieting and exercise (Figs.6.3 and 6.4).
Fig. 6.1 Lower extremities are the most commonly requested areas for liposuction
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 981- 19- 4997- 5_6].
K. Bhangoo (*)
Cosmetic, Plastic and Reconstructive Surgery, Buffalo, NY, USA
© 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_6
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Fig. 6.2 Emphasis is not only on being lean, but also on being sculpted
K. Bhangoo
6.1 Historical Prospective andEvolution
ofLiposuction
The rst recorded case of liposuction is that of a French surgeon, Charles Dujarrier, who, in 1920, used a uterine curette
to remove fat from the knees of a ballerina, Mademoiselle
Geoffre. This resulted in an unfortunate complication resulting in gangrene of the lower extremity due to vascular damage and necessitating eventual amputation. This was followed
by a lull in this procedure until early 1960 when a German
physician, Joseph Schruddle, performed “lipexeresis” which
means “fat removal” in Latin, again with sharp uterine
curettes.
The second generation of liposuction was performed
by a Swiss physician, Ulrich Kesselrling and an Italian
father and son team, Arpad and Giorgio Fisher in the late
1970s. They introduced the concept of using a hollow
metal cannula attached through a tube to a vacuum pump,
called “cellulosuction tome.” The French surgeon, Yves
Gerard Illouz, in the late 1970s is credited as being the
“Father of Modern Liposuction.” He revolutionized liposuction by introducing blunt tip cannulas and inltration
of uid into the subcutaneous tissues. The blunt cannulas
extracted fat without injury to the nerves and blood vessels (Fig. 6.5). He used hypotonic solution containing
hyaluronidase in an effort to lyse the fat and facilitate
liposuction. Since then, the procedure has been rened
both with regard to wetting solutions and advancement in
instrumentation.
The modalities used for liposuction include syringe liposuction, popularized by the French surgeon, Pierre Fournier,
standard suction-assisted liposuction, using blunt cannulas
and suction machine (SAL), power-assisted liposuction
(PAL), ultrasonic liposuction (UAL), vaser liposuction
(VAL), laser assisted liposuction (LAL), and water-assisted
liposuction “WAL.” Each of these will be discussed in detail
later.
Figs. 6.3 and 6.4 Liposuction indicated for suctioning areas of lipodystrophy not corrected by diet or exercise as shown in these gures
Fig. 6.5 Blunt liposuction cannulas extract fat without damaging
nerves and blood vessels
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6.2 Anatomic Considerations
It is critical to understand the anatomic distribution of fat in
different parts of the body. For the most part, the fat is divided
in two layers separated by a fascial system called Scarpa’s
fascia (Fig.6.6). The supercial component is composed of
dense fat lobules separated by well-organized brous septa.
[3, 4] The deeper layer contains more loose areolar fatty tissue bonded together in a haphazard manner by a network of
brous partitions; this layer is particularly dense in buttocks,
thighs, and lower extremities. It is safe to treat the middle
and deep layers; however, liposuction of the supercial layer
should be performed with caution as it may lead to complications, such as dimpling, contour irregularities, waviness and,
in some cases, vascular compromise and necrosis of the
overlying skin.
It is also vital to understand and to recognize “zones of
adherence” or areas where the supercial fascial system is
densely adherent to the underlying muscles and deep fascia.
Because of this, there is lesser deeper fat covered by overlying supercial layers. The “zones of adherence” which are
present throughout the trunk and lower extremities, are
responsible for the contours of the lateral gluteal area, the
gluteal crease, medial thigh, and the ilio-tibial track. These
areas of adherence are responsible for dening the natural
curves and contours of the body. [5] In treating these areas of
adherence, caution must be exercised, as these are areas that
are at high risk for complications of contour irregularities.
Another anatomic consideration to carefully note is the
presence of cellulite (Figs.6.7 and 6.8). Any presence of cellulite should be discussed with the patient. It is crucial to
recognize and to document the presence of cellulite because
91
Fig. 6.6 Honeycomb appearance of supercial layer of fat above
Scarpa’s fascia
Figs. 6.7 and 6.8 Cellulite occurs due to adipose bulges separated by
brous septa
simple liposuction of areas of cellulite can accentuate the
deformity post-operatively. Some surgeons recommend needle subcision of areas of cellulite to transact the areas of
brous bands before performing liposuction. [6, 7]
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K. Bhangoo
6.3 Preoperative Assessment
During the initial consultation, it is necessary to assess the
patient’s goals and expectations. It must be emphasized to
the patient that this procedure is not meant for weight reduction; but rather for sculpturing and removing fat from areas
of excess localized deposits, called lipodystrophy. It is a procedure meant for sculpturing and not for debulking. It is
important to emphasize to the patient that the areas of liposuction are the ones which do not respond to traditional
weight loss and exercise. The patient must be informed that,
following liposuction, if one puts on weight, this will result
in irregularities and unevenness. Simply put, during liposuction, fat cells are removed from the body and, if the patient
gains weight, then fat will deposit in adjacent areas of residual fat cells, resulting in lumps and bumps. This will be demonstrated later in the chapter as a complication.
It is reported that at least 7–15% of patients seeking cosmetic surgery suffer from “body dysmorphic syndrome
(BDS).” In this disorder, the patients have a distorted concept
of their body image and, operating on these patients, will
inevitably result in dissatisfaction and grief in spite of getting a satisfactory outcome. [8] It is necessary to recognize
patients who suffer from this disorder, and surgery should be
avoided, as the patient will very likely be unhappy with the
outcome even if the results are optimal.
It is important to stand the patient in front of a mirror and
delineate the areas of concern. This will eliminate misunderstanding post-operatively. It is also essential to obtain high
quality photographs of the anterior, posterior, and oblique
views. This will be helpful during the intra-operative planning. More importantly, it becomes a permanent record of
the patient’s pre-operative deformity. Patients frequently will
forget what their pre-operative deformities were, and these
pre-operative photographs can graphically demonstrate the
extent of improvement and help resolve post-operative
disputes.
It is also essential to obtain an informed consent. This will
explain to the patient the nature of the proposed surgery,
alternatives, risks, and possible complications. The consent
should be signed by the patient and witnessed by one of the
staff members. This document can become instrumental in
the event of post-operative legal dispute as to outcome and in
the event of complications.
During the initial consultation, it is necessary to obtain a
detailed medical history and inquire about the patient’s medical conditions, such as diabetes, cardio-pulmonary disease,
medications, some of which can cause bleeding and which
should be avoided. Taking nonsteroidal anti-inammatory
drugs, aspirin, sh oil, and hormones, such as oral contraceptives, herbal supplements, and vitamins, should be avoided
as these may predispose to excessive bleeding. Patients
should be warned that in smokers there is increased morbidity, such as more ecchymosis, prolonged swelling, and sometimes other complications, such as hematoma and impaired
healing. [9] It is essential to explain to the patient that, contrary to common belief, liposuction is not a minor procedure.
The patient should be warned that this procedure results in
signicant tissue trauma and can have serious
complications.
Lastly, measurements should be taken of the areas to be
treated; such as circumference of the hips, upper thighs, mid
thighs and knees, and document these. It is helpful in detecting asymmetries on the two sides pre-operatively. Such
asymmetries and other deformities, such as contour deformities, areas of depression, cellulite, and dimpling should be
demonstrated to the patient prior to surgery. This will assist
in demonstrating to the patient the degree of improvement
post-operatively. Outcome expectation should be assessed to
measure up to the deliverables post-operatively.
6.4 Operative Plan
6.4.1 Anesthesia
Different types of anesthesia can be used for liposuction. The
type of anesthesia will depend on the extent and location of
the treatment area. These include local anesthesia for small
areas, intravenous (IV) sedation for moderate areas, or general anesthesia for large areas. Regional block and spinal and
epidural anesthesia can also be safely used during liposuction. The decision with regard to the type of anesthesia will
depend on multiple factors including the anticipated length
of the procedure, the number of areas being treated, the
extent of liposuction, the health of the patient and the
patient’s pain tolerance and preference.
6.5 Prophylactic Measures
Before commencing the procedure, certain prophylactic
measures are important. These include a warming blanket to
avoid hypothermia.
While doing liposuction of the lower extremities, the
upper part of the body should be covered with warming blankets. Parts of the body not being treated such as the contralateral extremity should remain covered to conserve body heat.
In order to prevent hypothermia, intravenous IV solutions
and wetting solutions should be warmed. Ambient temperatures should be increased. It is important to avoid hypothermia
as hypothermia will result in increased coagulation disorders, blood loss, wound infection, and cardiac arrhythemias.
[10–12]
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Sequential compression devices should be placed on the
legs to prevent deep vein thrombosis during and immediately
post-operatively while in the hospital and followed by
thrombo-embolus deterrent (TED) compression stockings at
home for a few days (Fig.6.9).
Antibiotic prophylaxis is usually administered. It is
common to use the rst-generation cephalosporin, which is
given prior to induction of anesthesia. This can be continued for a few days post-operatively. In patients who have a
history of post-operative nausea and vomiting, pre-operative administration of scopolamine patches behind the ears
or Ondansetron tablet given 1h prior to surgery is helpful.
Fig. 6.9 Sequential compression devices for preventing deep vein
thrombosis
It is also necessary for the circulating nurse to be diligent
in recording the amount of wetting solution injected and
document the volume of the aspirate from each treatment
area. This will help ensure symmetric treatment of each area.
When circumferential liposuction is planned, it is helpful
to prep the patient in the standing position prior to administration of anesthesia. The patient should not be given any
sedatives or tranquilizers prior to surgery. The patient is
made to stand next to the operating table on a stool.
Circumferential prep is then carried out with an antiseptic
solution. The patient is then transferred onto the operating
table covered with a sterile drape with the help of a nurse to
avoid contamination of the sterile drape. The patient is then
covered with the sterile drape prior to administration of the
anesthesia. After administration of the anesthesia, the cover
is removed and the patient is appropriately draped. This
saves time for doing the skin prep after anesthesia and also
facilitates circumferential prepping which will be difcult
with the patient asleep.
6.6 Markings
The areas to be liposuctioned should be marked preoperatively with the patient standing upright. The areas of
lipodystrophy involving the hips, lateral thighs, anterior
thighs, medial thighs, posterior thighs, and medial knees
should be marked with a surgical marking pen (Figs.6.10,
6.11, and 6.12a, b). This will not only delineate the areas to
be liposuctioned intra-operatively, but also conrm with the
Fig. 6.10 Markings for
lipodystrophy lateral thighs
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Fig. 6.11 Markings for hip
and lateral thighs
K. Bhangoo
a
Fig. 6.12 (a, b) Markings for lateral thighs, anterior thighs, and medial thighs
patient that the areas to be liposuctioned are, indeed, the ones
which the patient desires. It is essential that the patient does
not receive any premedications prior to surgery to facilitate
marking with the patient upright.
b
bags, anterior thighs, medial thighs, medial knees, calves,
and ankles (Figs.6.13, 6.14, 6.15, and 6.16). This can be
supplemented with a supine and alternating lateral decubitus position for postero-lateral aspects of the thighs. When
both anterior and posterior aspects of the lower extremity
have to be liposuctioned, such as the anterior and lateral
6.7 Positioning
thighs and the buttock areas, then a prone-supine position is
necessary (Fig.6.17a, b). It necessitates ipping the patient
Positioning will depend on the areas to be liposuctioned. In
the lower extremity, supine position can be utilized for treatment of lateral hips, lateral trochanteric areas or saddle
over and sometimes reprepping and redraping the patient for
a second time. In contrast, a supine lateral approach allows
for one time circumferential liposuction, but may limit visu-
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Fig. 6.13 Supine position allows access to hips, lateral thighs, posterior thighs, and medial thighs
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Fig. 6.16 Access to posterior thighs
a
Fig. 6.14 Access to hips
Fig. 6.15 Access to lateral thighs
b
Fig. 6.17 (a, b) Prone position allows access to hips, gluteal region,
and posterior thighs
alization when trying to compare the two sides. When placing the patient in a prone position, care should be taken to
protect the eyes. [13] Care should be taken to pad and protect all appropriate areas, including the head, arms, breasts,
genitalia, hips, and knees, in order to prevent nerve injuries.
[14] In order to facilitate movement of the cannula, the table
can be gently exed 15°–20° in a slight Trendelenburg
position.
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Hips and Lateral Thighs
Medial and
Medial knees
Gluteal and Hips
and Banana Rolls
Medial
Thighs
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K. Bhangoo
6.8 Incisions
Incisions for liposuction in the lower extremity should be
made large enough to accommodate the largest cannula to be
used. This is usually 4mm or sometimes 5mm. The diagram
shows the sites of incision for access to the hips, lateral
thighs, anterior thighs, medial thighs, medial knees, calves,
and ankles, as well as the posterior gluteal region (Figs.6.18,
and 6.19). Access through multiple sites can be used to facilitate cross-hatching and prevent contour irregularities. When
Anterior
Thighs
and Calf
bilateral incisions are used, they should be placed symmetrically in order to disguise them. One should not hesitate to
make additional incisions to enhance access and minimize
the risk of inadequate access. The patient should be positioned appropriately in order to facilitate adequate access
when treating areas around curves. Some surgeons will leave
the incisions open to allow for drainage; however, the author
prefers to compress the treated areas to evacuate all uid and
then close the incisions in two layers using subcuticular layer
and a surface closure with absorbable catgut sutures.
Incisions should be placed to allow for multi-directional
access and minimize the risk of depressions, contour
irregularities, end hits and dimples. The upper, lateral thigh,
and hips can be approached through a proximal thigh incision
which should be placed far enough below the anterior superior iliac spine to prevent interference with proper excursion
of the liposuction cannula and injury to the anterior superior
iliac spine. Distal thigh incisions can be placed medially.
When treating the hips and anks, the incisions should be
placed just above the buttocks yet low enough to be concealed
by a bikini. Posterior hip and lateral thighs can be approached
through an incision just below the gluteal crease. The knees
and calves can be approached through an incision in the postero-medial aspect, just below the popliteal fossa.
Fig. 6.18 Incisions for hips, lateral, anterior and medial thighs, and
medial knees
Infragluteal Fold
Fig. 6.19 Incisions for gluteal area and hips, medial thighs, posterior
thighs, and infragluteal region
6.9 Wetting Solutions
It was Illouz who in the late 1970s introduced the subcutaneous uid inltration or the so-called wetting solutions. This
was a major advance in liposuction. Wetting solutions are
composed of isotonic uid, usually normal saline or Ringer’s
lactate, with some additives such as local anesthetics, usually
lidocaine, or epinephrine for vaso-constriction. Use of a wetting solution reduces blood loss and also facilitates the
removal of fat due to hydrodissection. Before the advent of
wetting solutions, liposuction was done in a dry technique
resulting in signicant blood loss, ranging between 40% and
50% of the aspirate [15–17].
The commonly used wetting solution is composed of 1
liter of Ringer’s lactate to which is added 20cc of lidocaine
and 1cc of 1 in 1000 epinephrine to give a dilution of 1in
1,000,000. Some surgeons add sodium bicarbonate which
decreases the acidity and reduces pain but this is usually not
required when the procedure is done under general
anesthesia.
The wetting solution can be used as a “Wet technique” in
which 200–300cc of inltrate is injected into the treatment
area resulting in a ratio of 1 to 2 for liposuction aspirate. The
super wet technique introduced by Fodor in 1986 results in a
1 to 1 ratio. [18] Tumescent solution introduced by Klein in
1985 involves extensive administration of the wetting solution under high pressure causing skin turgor and creates a
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ratio of 2 to 3.1 inltrate to aspirate. [19, 20] This is usually
done when the procedure is being done under local anesthesia to reduce blood loss. The high pressure inltration results
in compressing the blood vessels and creating an avascular
eld acting as an internal tourniquet. However, the disadvantage of this technique when doing a large area is the risk of
causing uid overload and pulmonary edema.
Studies show that the blood loss is similar between the
tumescent technique and the super wet technique which is
the one that is used by the author. The super wet technique
used Fodor involves aspiration of 1cc of inltrate administered in a 1 to 1 ratio. [20] It is most commonly used by most
liposuction surgeons. This technique results in signicant
reduction of blood loss, demonstrating a range of 1–4%
blood loss in the aspirate. When using tumescent technique
and inltrating large volumes of uid, care should be taken
to monitor the urine output and vital signs to ensure that
there is no uid overload. Furthermore, when large amounts
of uids are administered, patients run the risk of pulmonary
edema which can occur immediately post-operatively or
sometimes 24h later. It is important to monitor uid balance
because in the super wet technique at least 70% of the inltrated uid remains in the tissues, in the so-called third space.
These factors should be taken into account by the anesthesiologist during IV uid administration.
Wetting solutions are infused into the areas to be liposuctioned using a blunt needle and a handle with a wetting
device (Fig.6.20). For large areas, the solution can be placed
in an IV bag and surround it with a sphygmomanometer cuff
which is inated (Fig.6.21). Motorized inltrating devices
can also be used (Fig.6.22a, b).
Figure 6.23 shows aspirate is bloody without wetting
solution.
Figure 6.24 shows less bloody aspirate with wetting
solution.
Figure 6.25 shows bloodless aspirate with superwet wetting technique.
Fig. 6.20 Blunt long needle and handle with wetting device for inltrating wetting solution
Fig. 6.21 Wetting solution in
IV bag compressed by
sphygmomanometer cuff
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K. Bhangoo
a
Fig. 6.22 (a, b) Motorized devices for inltration of wetting solution
Fig. 6.23 Bloody aspirate
with dry technique or without
wetting solution
b
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