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Fig. 12.7 Female 3
Abdominal etching;
preoperative markings
followed by postoperative
result. Patient was 44years
old who had 1.6L of fat
aspirated from the abdominal
region via UAL (VASER)
PAL
C. Mata et al.
Fig. 12.8 Female 4
Abdominal etching;
preoperative markings
followed by post-operative
result. Patient was 24years
old who had 3.1L of fat
aspirated from the abdominal,
ank, and back region via
UAL (VASER) PAL.RF
device known as Renuvion
was also used
12.7 Surgical Techniques [11–13]
The sequence followed during liposuction is critical. It is
usually advocated to start with a superwet inltration technique and perhaps even a modied tumescent technique to
refrain from stretching and distorting the broseptal network. Undue laxity created with an excess of solution is detrimental to an optimal outcome.
Upon placing the wetting solution—based on the liposuction surgeon’s preference—the undermining of the zones of
adherence, the supercial and deep fat compartment should
commence. This is typically performed in keeping with the
principles of “SAFE Lipo.” SAFE is an acronym which
stands for separation, aspiration, and fat equalization that
was pioneered by Simone Wall. The senior author prefers the
VASER ultrasound system to perform the separation of the
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215
fat via sound waves, and is believed to cause less bleeding
and skin retraction up to 6%.
Once the break-up of the fat has been achieved, the “loose
fat” is ready for liposuction. It is best to use aspiration cannulas that avoids damaging the subdermal plexus by favoring
those with the opening facing away from the dermis. It is
important to understand the concept of deep and supercial
fat layers; especially, when addressing the abdominal musculature during abdominal etching.
The aim is to aspirate the lipocytes found in the linea alba
as well as the linea semilunaris, creating hills and valleys
that look like more prominent abdominal muscles. This can
be further enhanced by aspirating lipocytes along the edges
of the rectus abdominis muscle for a more athletic appearance. In other words by removing fatty tissue in certain locations, both in the deep and supercial planes, we create
depressions that enhance the contours of the supercial fat
purposely left above the abdominal muscles (Figs. 12.9,
12.10, and 12.11).
In the remaining areas to be addressed, only fat in the
deep layer needs to be removed. As the proportion between
deep and supercial fat content varies from patient to patient
and in different areas constant assessment needs to be performed. This is accomplished by pinching the skin and roll-
ing the fat over the cannula in order to visualize the thickness
of the skin and supercial fat.
The senior author believes that it is best to start on the
superolateral aspect of the torso and proceed caudally
towards the pubic area. An acceptable sequence would be:
axilla, bra roll, ank, hip, below the inframammary crease,
upper abdomen, mid abdomen and nally lower abdomen
and mons pubis region. This progression is then repeated on
the contralateral side. Thereafter, the patient is ipped and
the sequence is followed in reverse from bottom to top: hip,
love handle, anks, mid back, bra roll and nally axilla.
Once the liposuction is completed, fat grafting can be performed to augment the chest in men and breast in females; as
well as, in the arms. The effects of abdominal etching can be
further enhanced by placing a minimal amount of fat for the
“six/eight pack” region to augment the “hill” of the rectus
muscle. Once a satisfactory result is achieved by lipoplasty
and HD contouring, Renuvion’s J-Plasma is used to tighten
the broseptal network thus tightening the skin and further
enhancing the highlights.
A drain should be placed in the front and/or the back if
liposuction exceeds 1000cc per side, or if VASER was utilized. Choice of drain is not important; however, it should be
noted that at drains may be more painful when removed
Fig. 12.9 Senior author Dr. Carlos using VASER ultrasound. Patient is
in the supine position whilst the probe is positioned below Scarpa’s fascia and moved back and forth, parallel to the linea semilunaris in order
to accentuate it. Video Link: https://rb.gy/yq8lsy https://rb.gy/reyu6u
Fig. 12.10 Senior author Dr. Mata performing PAL liposuction. The
cannula position is constantly repositioned to aspirate the supercial
and deep fat that is located on the same horizonal plane as the linea
semilunaris. Video Link: https://rb.gy/uz8jix
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C. Mata et al.
Fig. 12.11 Senior author Dr. Mata utilizing Renuvion by Apyx
Medical (80% power at 2.0L) The probe is placed under the subdermis
and four passes of the RF device in the same location is done before
fanning out and moving to other areas. Video Link: https://rb.gy/hfq6e3
compared to round drains. If drains are used all dependent
liposuction holes should be closed. If the liposuction surgeon
prefers not to use drains then the liposuction holes that are
the most dependent and inferior should be left open to drain.
12.8 Postoperative Care [6, 7, 10, 11]
Postoperative care will distinguish an average result from an
outstanding one. Seroma formation will be what limit the
HD liposuction result the most as these small. uid collections will ultimately lead to brosis. Immediately upon clos-
Fig. 12.12 Immediate postoperative of an abdominal etching patient.
Topifoam strips are placed superior to the linea alba and linea semilunaris in order to prevent the accumulation of serious uid during
recovery
ing and cleaning the patient, Topifoam is placed over the
valleys created and left in place for 5-7 days in order to prevent pooling of serous uid which would later be replaced by
brous tissue. An additional layer of circumferential foam is
placed to avoid undue tension created by the creases from the
compression garment the patient will wear initially
(Figs.12.12 and 12.13).
Drains are removed on postoperative days 6–10
depending on output, preferably less than 30cc per day.
The Topifoam is worn for six weeks as tolerated. The
patient progresses through different compression garments depending on progress and time after surgery. A
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12.10 Summary ofHD Liposuction
As the popularity of liposuction increases throughout the
globe, new technological advances seek to make the procedure more effective and less labor intensive. These innovations in technology include ultrasound and laser devices that
attempt to “melt” fat. Power assistance and various types of
suction cannulas aim to yield better results than traditional
liposuction in greatly reduced time and with reduced surgeon
fatigue. High-denition liposuction refers to the combination of regular liposuction with ultrasound, power, and suction assistance along with tailored aspiration of fat in order
to contour the body and give a more toned and slim look.
12.11 Closing Points
HD liposuction can only be achieved by carefully balancing
the patient’s expectations (often shaped by social media) and
their own anatomy. Palpation is key in identifying the
patient’s natural musculature, in order to explain what is
achievable and will look natural. Attempting to create
inscriptions that are incongruous with the patient’s anatomy
will lead to unsatisfactory results.
Fig. 12.13 Immediate postoperative of an abdominal etching patient.
One large Topifoam pad is placed above the strips of foam which is then
secured to the patient via compression garment
second garment is used 2–4 weeks postoperatively until 6
weeks to 3 months as is necessary.
12.9 Complications ofHD Liposuction [6,
7,13]
Serious complications like complete skin necrosis, severe
scarring, and contour irregularities have been observed postoperatively. However, the most common complication is
hyperpigmentation. During the removal of fat from the supercial layer, melanocytes react to the irritation due to excessive
mechanical and thermal trauma by producing more melanin.
Another common complication includes formation of seromas
in areas that have undergone light or aggressive liposuction.
Additionally, the use of high energy devices like VASER
or laser liposuction is known to cause burns under the skin if
not performed correctly. Novice surgeons are more likely to
witness supercial burns located at port sites as well as burns
from the “end hits” of the probe, contour irregularities, and
temporary dysesthesia caused by keeping the probe stationary for too long. These mistakes made by inexperienced surgeons often are predicated on inadequate inltration prior to
the use of VASER.
References
1. Flynn TC, Coleman WP II, Field LM, Klein JA, Hanke CW.History
of liposuction. Dermatol Surg. 2000;26:515–20.
2. Matarasso A, Swift RW, Rankin M.Abdominoplasty and abdominal
contour surgery: A national plastic surgery survey. Plast Reconstr
Surg. 2006;117:1797–808.
3. Ersek RA, Salisbury AV.Abdominal etching. Aesthetic Plast Surg.
1997;21:328–31.
4. Mentz HA III, Gilliland MD, Patronella CK.Abdominal etching:
Differential liposuction to detail abdominal musculature. Aesthetic
Plast Surg. 1993;17:287–90.
5. Hoyos AE, Millard JA.VASER-assisted high- denition liposculpture. Aesthet Surg J. 2007;27:594–604.
6. Illouz YG.Body contouring by lipolysis: A 5- year experience with
over 3000 cases. Plast Reconstr Surg. 1983;72:591–7.
7. Kim YH, Cha SM, Naidu S, Hwang WJ.Analysis of postoperative
complications for supercial liposuction: a review of 2398 cases.
Plast Reconstr Surg. 2011;127:863–71.
8. Wall SH Jr, Lee MR.Separation, aspiration, and fat equalization:
SAFE liposuction concepts for comprehensive body contouring.
Plast Reconstr Surg. 2016;138:11921201.
9. Wall SW.SAFE circumferential liposuction with abdominoplasty.
Clin Plast Surg. 2010;37:485501.
10. Nagy MW, Vanek PF Jr. A multicenter, prospective, randomized,
single-blind, controlled clinical trial comparing vaser-assisted
lipoplasty and suction-assisted lipoplasty. Plast Reconstruct Surg.
2012;129(4):681e–9e.
11. Chia CT, Neinstein RM, Theodorou SJ.Evidence-based medicine:
liposuction. Plastic Reconstruct Surg. 2017;139(1):267e–74e.
12. Saldanha O, Ordenes AI, Goyeneche C. More lipoabdominoplasty with anatomical denition. Plast Reconstruct Surg.
2020;146(4):766–77.
13. Husain TM, Salgado CJ, Mundra LS. Abdominal etching:
surgical technique and outcomes. Plast Reconstruct Surg.
2019;143(4):1051–60.
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andFemales
GrantHamlet andArianMowlavi
13.1 Introduction toHigh-Denition
Liposuction (HDL)
High-denition liposuction (HDL) describes a higher standard of body contouring when compared to traditional liposuction. Superior HDL outcomes have been recognized as
being stunning in appearance when viewed from all angles.
This means contouring in a circumferential manner, termed
360, as well as providing detailed contouring highlights,
coined three-dimensional liposculpture. HDL requires the
fusion of advanced medical tools and artistry to create
extraordinary contour aesthetics that optimize genderspecic aesthetics with muscle highlights when indicated.
Muscle highlights must be accurate and detailed representing the actual muscle architecture both in static as well as
dynamic form. This degree of muscle unveiling has been
coined four-dimensional (4D) liposuction. In order to achieve
HDL results, several factors must be fullled and these
include proper patient selection, customized surgical planning, accurate preoperative markings, and mastery in
ultrasound- assisted liposuction [1].
13
13.2 Proper Patient Selection
Proper patient selection is one of the most critical prerequisites to achieving HDL body contouring results. This involves
assessing the degree of fat excess, amount of skin redundancy, and quality and extent of skin texture changes.
Obviously, the degree of excess fat will intimately affect the
scope of fat removal. This is because HDL body contouring
G. Hamlet (*)
Hamlet Clinic, London, UK
e-mail: grant@thehamletclinic.com
A. Mowlavi
Long Beach Memorial Hospital, Hoag Presbyterian Hospital,
Laguna Beach, California, 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_13
Fig. 13.1 VASER ultrasonic tower
demands comprehensive fat removal using ultrasoundassisted liposuction with VASERR technology (Fig.13.1).
Additionally, consideration of not only fat excess but also
skin redundancy is paramount to achieving HDL results.
This is because over aggressive fat removal can result in an
overlying skin looseness that can compromise contour aesthetics. Suboptimal results are observed by botched liposuc-
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G. Hamlet and A. Mowlavi
tion outcomes such as back and abdominal skin rolls, cellulite
appearing thighs, and even focal divots.
When skin redundancy is minimal, then skin redraping
will address skin laxity concerns due to skin retraction. Skin
retraction occurs from self-tightening of the cutaneous retinacular ligaments or broseptal network after removal of fat.
These ligaments act like cable chords that will snap the skin
up when the fat cells that act like shock absorbers are
removed. This is especially true when comprehensive and
circumferential fat is removed via ultrasound-assisted liposuction in line with HDL protocol. When skin redundancy
was moderate, patients were previously offered less aggressive fat removal plan, termed mid denition liposuction. This
was advocated inlocalized areas as long as more conservative fat removal did not compromise overall transformation.
Today, patients with moderate skin redundancy are recommended a novel, minimally invasive combined helium activated plasma and radiofrequency treatment. This treatment,
termed Renuvion technology, utilizes a sleek wand that
administers thermal contraction of collagen molecules in the
cutaneous retaining ligaments that result in tightening of the
skin. Finally, when the skin redundancy is severe, then simultaneous invasive surgical excision in addition to ultrasoundassisted liposuction is recommended.
Finally, skin texture changes must be accounted for when
ensuring proper patient selection. Poor skin texture changes
such as stretch marks cannot be improved by liposuction
alone nor Renuvion technology. When skin texture changes
are focal, they may be amenable to surgical excision. When
poor skin texture is more extensive and not amenable to excision, then patients demonstrate a contraindication to liposuction contouring. When considering skin texture, patient’s age
must also be acknowledged as aging is directly related to loss
of a recoil protein, called elastin. Loss of elastin can adversely
affect the skin’s ability to self-tighten when the underlying
fat is removed. It is felt that this important elastin protein
starts to become depleted in the skin after the age of 45. To
summarize, the patient’s age and changes in skin texture
should be taken into account when designing and thus recommending a customized surgical plan.
360 degrees of liposuction are typically performed, larger
volumes of tumescent inltration and aspiration are routinely
employed. As such, your customized surgical plan should
estimate total volume of tumescent being inltrated and aspirated. Patients undergoing liposuction must be limited to 5L
of tumescent solution inltration and aspiration in an outpatient setting. This recommendation follows an approximate
1:1 volume of inltration and aspiration advocated in a traditional wet technique [2]. This universally accepted liposuction, safety, volume limit has been established to avoid
adverse effects related to volume shifts as well as lidocaine
toxicity. In addition, liposuction surgical design must take
into account gender-specic contour aesthetics. For example, males prefer more linear contour lines such as described
by a bold, pentagonal shaped chest, or a square buttock. This
is in contrast to females who desire smoother and rounder
contour lines. This is best appreciated by the hourglass
female silhouette that is characterized by exaggerated curves
with a narrow waistline and prominent lateral hip and buttocks. Next, the amount of skin redundancy and skin texture
changes must be acknowledged. When skin redundancy is
present, then a plan to tighten the skin using minimally invasive Renuvion or more invasive surgical excisions must be
employed [3]. When skin texture changes are focal, then
strategic skin excisions can be used to eliminate problem
spots. When skin textures are extensive, then patients may be
determined to be poor candidates for high-denition liposuction body contouring. Finally, fat transfer must be recognized as an essential component of HDL results. This is
because certainly there will be areas of the body that will
require lling. Examples include augmentation of the breast
and buttock in females, chest masculinization in male, or
even lling of divots observed in botched liposuction cases.
In summary, a sound surgical liposuction plan can only be
designed by actually mapping out your patients’ specic
needs. As such, to best explain the nuances of a successful
surgical liposuction plan, we must present patient markings.
13.4 Accurate Preoperative High-
Denition Liposuction Markings
13.3 Sound, Customized Surgical Plan
Once proper patient evaluation has been completed and a
prospective client has been found to be an HDL candidate,
then a sound, customized surgical plan must be designed.
First, a comprehensive surgical plan must be created that
addresses all of the areas of concern in the patient in a 360°
manner. Concern areas may include the abdomen, anks,
back, buttock and lateral hips, arms, medial thighs, and/or
lateral thighs. Anticipated volumes of fat removal must be
calculated from each area of concern and tabulated. Since
Accurate preoperative markings are critical to achieving
high-denition liposuction (HDL) results. First, HDL relies
on the ability to perform 360° of contouring. This means
appropriate contouring of not only the front and back of the
body but also the sides. In fact, nuances related to achieving
HDL results rely on achieving appropriate transitions of the
front and back sides of the body through the sides.
Circumferential preoperative markings will help guide your
liposuction during creation of your masterpiece sculpture.
An important component to your sculpting is consideration
of gender differences. Adhering to gender-specic contour
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a
Fig. 13.2 (a–c) Female high-denition liposuction preoperative markings
a
b
b
c
c
Fig. 13.3 (a–c) Male high-denition liposuction preoperative markings.
aesthetic standards is quintessential to achieving stunning
results (Figs.13.2 and 13.3). For example, female body’s are
created with exaggerated curves which are round and smooth
in contour (Table 13.1). This is in contrast to male structure
which are created with linear lines that are pentagonal in the
chest [4] or square in the buttock (Table 13.2). A buttock that
is augmented in size, such as during a Brazilian buttock lift,
and a waistline that is maximally narrowed, coined a snatched
waist, must be bridged through a linear and smooth transition
described by the shape of a Tilde Curve “~”. In summary,
remember that your preoperative markings will ultimately
dene your surgical maneuvers.
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Table 13.1 Female high-denition liposuction preoperative markings
Abdominal
markings
Back markings Lower back Central vertical line: Denes the spine
Linea alba (central
vertical line) Slightly narrower than males
Extends down to the belly button only
Wider as it gets lower
Sculpted after inscriptions done in order to avoid over widening
Inscriptions
(horizontal lines)
Semilunaris line Curved down from lateral aspect of areola and down to the pubic symphysis
External oblique Must be maximally debulked as it denes the female waistline
Upper/middle
back
Buttocks Ports: Two upper lateral ports at the venous dimples and single upper central port at apex of
Thighs Medial thighs (a diamond) must carve out from anterior and posterior aspect; have three separate
3 lines instead of 4 for males
Inscriptions not necessarily straight
May be at different levels on each side
Sculpt lower inscription from belly button
Sculpt upper inscription from inframammary crease
Sculpt middle inscription from both belly button and inframammary crease
Create the 4 packs
Highest packs are the weakest and smallest
Lower packs are the largest and most prominent
Sculpt from top down using lateral inframammary port and then from pubic tubercle from bottom up
Lateral vertical line: Denes paravertebral line lateral to the paraspinal muscles (much narrower
paraspinous muscles than the male)
Central inferior diamond—Must core out in females when compared to males
Negative zone (waistline) spans across a line extending from the dimple (PSIS, venous dimple) to
iliac crest inferiorly and up to the costal margin superiorly
Transition zone spans across a line extending from the venous dimple to iliac crest superiorly down
to the upper curve of the buttocks proper; must debulk only after coring out the negative zone and
building of the buttocks proper so that it provides a smooth linear transition zone
Do not overdo debulking as can have too much skin redundancy; must debulk just enough to soften
the mid lateral back crease
intergluteal crease and two inferior ports at the ischial tuberosity
Buttocks proper shape more rounded and tapered superiorly (in comparison to males)
Need to round out inferior medial buttocks (J shape)
Fill out mid-lateral buttocks depression/dimple
Shaping of the buttocks performed to graft only into the fatty layer
planes-anterior/central/posterior (use palm of hand to create planes); do not over debulk
Posterior thigh—Bordered by lateral and medial diamonds; do not lipo or will lose support of
infragluteal crease. May debulk minimally only supercially; do not go deep or will lose buttocks
support
Lateral thighs (minimize debulking if going for a bubble butt) serves as a transition zone from the
mid lateral buttock down to the lower legs
G. Hamlet and A. Mowlavi
Table 13.2 Male high-denition liposuction preoperative markings
Abdominal
markings
Linea alba (central
vertical line) Slightly wider than females
Inscriptions
(horizontal lines)
Extends down to the belly button only
Wider as it gets lower
Sculpt after inscriptions done in order to avoid over dening
4 lines instead of 3 for females
1st inscription in the inframammary crease
4th inscription line near or at the belly button
Inscriptions not necessarily straight
Inscriptions not necessarily at same level on each side
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Table 13.2 (continued)
Abdominal
markings
Back
markings
Linea alba (central
vertical line) Slightly wider than females
Packs (rectus muscle) 6 pack versus 4 pack in females
Highest pack weakest
Middle pack > lower pack the largest and most prominent
Upper packs wider and shorter in height
Lower packs narrower and taller in height
Chest proper (Pec) Must masculinize the male chest; pentagonal shape with strong linear borders
Lateral pec line linear and borders the lateral chest/axilla (must be debulked)
Medial pec line linear and borders the sternal line (must be etched)
Inferior pec line must be linear and strong bordering the upper inscription
Debulk central mid (periareolar region)—Gynecomastia (must be debulked)
Semilunaris line Curved down from lateral aspect of areola and down to the pubic symphysis
Not a straight line but not as curved as female
May not be continuous (infrequently broken up by serratus anterior ngers)
Sculpt from top down using lateral inframammary port and then from pubic tubercle from bottom up
(2nd)
External oblique Must be debulked minimally and be more prominent than its adjacent neighbors (superiorly the serratus
anterior), medially the semilunaris line, inferiorly the V to the P (below the iliac crest) and posteriorly
the back
Lower lateral
abdomen
Back Lower lateral back debulk completely (no transition zone)
Buttocks Buttocks shelf desirable (no transition zone)—Your pants need to hang on this shelf!
Referred to as a V to P
Area below the iliac crest
Negative space concavity just under the iliac crest/lip
Must core out both negative zone (waistline) and transition zone
Must create a buttocks shelf (in comparison to smooth and gentle tilde curve in females)
Latissimus bulk left over the middle and upper back
Central diamond must be minimally debulked only to allow for drainage (versus in females cored out)
Remember buttocks shape more square
Dene central vertical line (along the spine)
Dene the lateral paravertebral muscle lines (extend from ports over the venous dimples)—This is
much more important for males in comparison to the females
Upper aspect more square; mid buttocks at (not rounded)
Central lateral inferior buttocks fat grafted to create a linear and square contour
Buttocks proper more square—May even have to square off the central inferior buttocks with fat
grafting
Create a buttery appearance with grafting only over the gluteus medius muscle
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13.5 Mastery inUltrasound-Assisted
Liposuction (UAL)
After proper patient selection, the creation of a sound customized surgical plan, and accurate preoperative markings,
follows the real test of your abilities to achieve HDL results.
Mastery in ultrasound-assisted liposuction (UAL) delivery is
a true art form that requires training and experience. Much
like an artisan, you will have to possess the desire and will to
master delivery of UAL that is required to achieve HDL
results.
Ultrasound-assisted liposuction utilizes a solid rod to
deliver ultrasound energy from its tip to the fat cells located
in the fatty layers. This ultrasound energy creates small air
bubbles within the tumescent solution which literally pop fat
cells from a semisolid state of cell clusters into liquid state of
single fat cells. This concept, termed cavitation, allows fat
cells to be readily siphoned into hollow bore cannulas. This
is truly an advancement over traditional liposuction that
removes cells by piercing them out of their semi-solid cluster
state. Additionally, the ultrasound energy can be delivered to
both the deep layer as well as the supercial fatty layer. This
nuance unique to ultrasound-assisted liposuction is not trivial and is the differentiating factor that makes it superior to
traditional liposuction. This is because traditional liposuction is limited to removing fat from the deep layer only. This
means at best, patients can expect to be debulked. Instead,
ultrasound-assisted liposuction rst provides for the com-
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Fig. 13.4 Ultrasound-assisted liposuction helps in complete and uniform removal of liquid fat from the deeper layer
plete and uniform removal of liquid fat from the deep layer
rather than traditional liposuction that can at best remove
tunnels of fat (Fig.13.4). Although cross hatching of tunnels
has been advocated to attempt uniform fat removal, it can
never achieve the smooth, comprehensive, and uniform
removal of liquid fat. More importantly, the ability to selectively remove the supercial layer is what sets UAL above all
other liposuction modalities and allows the surgeon to literally sculpt highlights of the muscles.
Traditional liposuction is limited by suction cannulas
being able to traverse and remove fat from the deep fat layer
only [2].
The ability to remove both the deep fat comprehensively
and supercial fat selectively is what allows for creation of
high-denition liposuction results. It is this higher standard
of sculpting ability that requires you to be an artisan. Highdenition liposuction outcomes can only be obtained when
fat is removed comprehensively in order create maximal
waistline narrowing with exaggerated curves in females.
Uniform fat removal also allows for optimal skin contours
such as in the creation of smooth thighs. Finally, ability to
comprehensively remove fat from areas that are more brous,
such as the back, allows for elimination of skin rolls and love
handles [3].
Comprehensive fat removal is probably most critical to
correcting botched liposuction outcomes. This is because
unfavorable liposuction outcomes result from uneven
removal of the fat. As such, the ability to remove fat comprehensively is what allows for correction of such deformities.
The goal is to remove any and all residual fat to bring the
G. Hamlet and A. Mowlavi
skin down to a single uniform playing eld. Another advantage of ultrasound-assisted liposuction is that is able to
remove fat and surrounding scar tissue. Scar tissue is an
unfortunate consequence of any type of liposuction. Scar tissue results from injury and arrival of proinammatory cells
resulting from the back-and-forth friction created from the
suction cannulas traversing the tissue planes. Ability to
remove scar tissue is probably most notable in patients who
have developed paradoxical adipose hyperplasia (PAH) that
describes overgrowth of deep fat cells with surrounding scar
tissue that occurs when the supercial fat is removed with
cryotherapy. PAH is localized to areas treated with cryotherapy and seems to occur in patients following weight gain [5].
Creation of 4D liposuction with unveiling of the muscles
is what makes high-denition liposuction so revered.
Creation of a four pack in females and a six pack in males
has not been feasible with traditional liposuction.
This level of sculpting requires the ability to selectively
remove the supercial fat thus creating differential in muscle
bellies by being able to empty out gulleys located around the
junctions of muscle bellies. In the abdomen the gulleys
include the midline vertical linea alba, the lateral vertical
semilunaris line, and the horizontal inscriptions. This highest
level of controlled fat removal is what makes high-denition
liposuction an art form in addition to a medical surgery.
Compression coupling is the maneuver that describes controlling fat removal especially from the supercial fat layers.
This maneuver involves using your non-dominant hand to
compress the fat cells into the tip of your ultrasound probe as
well as your suction cannula. Thus, compression coupling is
employed not only during administration of ultrasound
energy but also during the siphoning of the fat using suction
cannulas. Specic hand postures have been developed to
describe various compression coupling positions and these
include:
(a) The ninja thumb (Fig.13.5a–c),
(b) The karate chop (Fig.13.6),
(c) The thumb-index nger arc (Fig.13.7); and
(d) The nger push (Fig.13.8).
(a) Ninja thumb
(b) Karate chop
(c) Thumb-index nger arc
(d) Finger push
Finally, high-denition liposuction requires harvesting,
processing, and replacement of fat into areas needing volume
replacement. Routine areas requiring augmentation include
the chest in males and the breast and buttock in females.
Infrequently, fat replacement is required in replacing fat into
divots or concavities created by botched liposuction surger-
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