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30 Liposuction
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473
Funding The authors received no nancial support for the research, authorship,
and/or publication of this chapter.
Level of Evidence V.
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L. F. de Córdova and R. CavalcantiRibeiro
Chapter 31
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High-Denition Liposculpture: Critical
Vision andFuture Perspective
FelipeMassignan andFilipeFuzinatto
Abstract The text objectively and simply talks about the technical foundations of
high- precision three-dimensional surgeries. Scientic paradigms based on evidence
and secular artistic concepts are explained. In addition, in a pleasant and summarized way, the preoperative marking is described, as well as the use of the technology adopted by the pioneers of the approach, associating with key points of the
surgical sequence. It ends with a critical view, based on and experienced by the
authors, adding to that the exercises of imagination compatible with the speed of
technical advances in the area of aesthetic and reparative plastic surgery.
Keywords High-denition liposculpture · Three-dimensional anatomical relief ·
Ultrasonic technology
Introduction
Firstly, it is important to dene the meaning of terms like high-denition, hd lipo,
and muscle marking, in order to avoid inadequate meanings in surgical approach.
Those are related to athletic humans exclusively. However, with that particularity,
supercial anatomical relief is vast in detail in genres; and what expresses this abundance is the three-dimensionality concept.
As a denition, three-dimensional space is the one which has height, depth, and
width and—in practice—indicates what is known as surface relief. The human body
reects light homogeneously (Schider 1957). When spotting the topography with
predominance of shadows, one is faced with a slender fabric with null or concave
F. Massignan (*) · F. Fuzinatto
São Paulo, Brazil
Switzerland AG 2023
J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_31
475© The Author(s), under exclusive license to Springer Nature
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projection (Schider 1957). However, when viewing a light-reecting area, it can be
considered that the surface has projection and volume. The tonal progression
extending from the shaded to the illuminated surface can be understood by the gradual increase in thickness and projection tissue, using the dark area as a starting point
(Schider 1957; Massignan 2018).
Contemporary schools of plastic surgery adopt, as a safety rule, lamellar extraction for liposuction procedure (Avelar 1989; Pereira and Radwansky 1996).
However, the three-dimensional body contour seeks to be reliable with the anatomical surfaces using multiple surgical strategies, as manipulating the lamellar layer,
areolar layer, or both of them strategically, maintaining the current paradigm in safe
(Avelar 1989; Hoyos and Millard 2007). As we can see, the challenge for the plastic
surgeon is enormous, considering that he is trained from the beginning to follow
evidence-based medicine practice. Thus, being humble to improve concepts such as
the three dimensions from technical art becomes a promising starting point
(Avelar 1989).
F. Massignan and F. Fuzinatto
Liposuction asSculpture
A large number of tools were inserted in procedures involving body contour surgeries but few proved their efciency (Schider 1957; Jewell 2020). It is important to
mention the third-generation ultrasound, produced since 2001, for example, and
that 1 year after its launch with a pilot study of Jewell (Jewell etal. 2002) reached
2021 with Ali Juma (Juma etal. 2021), proving in dozens of articles its variability
of positive statistics (Jewell 2020), among which decreased blood depletion by 36%
(Nagy and Vanek Jr 2012), increased skin retraction by 53% compared to usual
tools (Nagy and Vanek Jr 2012), the numerical increase of viable adipocytes after
aspiration (Ince etal. 2019; Stosich and Mao 2007), and, in an unprecedented way,
safety in surgical handling of the areolar layer (Massignan 2018; Hoyos and Millard
2007; Juma etal. 2021).
It can be inferred, therefore, that it is a device studied in several perspectives, for
a long period, showing to be safe and, mainly, compatible with the technique
(Massignan 2018; Jewell 2020; Rohrich et al. 1998). The negative points of this
device shown by the guidelines are related to the long learning curve and the high
cost of the equipment (Jewell 2020; Rohrich etal. 1998; Klein 1990).
Liposculpture, in those days, therefore, is based not only on a simple removal of
fat but rather approaches which vary in strategies to respect the characteristics of the
anatomical unit to be manipulated (Massignan 2018). Anatomical relief is vast in
detail (Avelar 1989); therefore, the variations should be predened with aspiration
of the lamellar layer only or adipose collect with partial thicknesses of supercial
31 High-Denition Liposculpture: Critical Vision andFuture Perspective
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and deep tissue or, still, aspiration of both following the histological characteristic
of the topography to be carved (Avelar 1989; Cimino and Bond 1996; Berkenstein
and Grotting 2000).
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Surgical Technique
In order to achieve an aesthetically harmonic result, one must approach human
anatomy with the “look of a sculptor.” Although fat removal is part of the threedimensional technique, this is not the main objective, as the focus is on revealing
the musculoskeletal structures below the surface. The perception of static and
dynamic anatomical alternation is essential (Massignan 2018; Hoyos and
Millard 2007).
The skin is opaque for patterns of reection and absorption of light in adult
humans due to the gradual decrease in tissue thickness (Schider 1957; Jewell 2020).
From the brightest point to the darkest, there is a tonal progression. The brightest
region contains higher volume and projection, and the darkest is slender and deeper
(Schider 1957).
Considering men, surgical reasoning is based on the premise that the musculature of the anterior thorax and upper limbs (pectoral upper, deltoid, and biceps) have
higher volumes when compared to the anatomical units located caudally to these.
That concept is fundamental for technical planning, as uniform volumetric propor-
for that reason, is often performed in the pectoral and deltoid muscles (Hoyos and
Millard 2007).
Considering women, the planning should be started from the cylindrical forms of
the buttocks and breasts, as they are the angular anatomical centers with the other
areas (Schider 1957; Massignan 2018; Hoyos and Millard 2007). Smaller muscles,
obviously, have slender volumes, but they are adhering to harmonic balance. The
rectus abdominal muscles are outlined by creating shadows in their contours. In
those circumstances, the shape is related to the transitions and precise limits, being
unnecessary volumetric increase (Hoyos and Millard 2007; Nagy and Vanek Jr
2012), since the perceptions of their edges are delicate and, in rare exceptions,
hypertrophic.
The main anatomical landmarks of the human body, where the shadow areas are
the sharpest, used as a “frame” to be carved (Fig.31.1). The negative spaces neighboring them have two characteristics, which are as follows: its shaded color is less
intense than the one mentioned above and the fabrics are thicker than those of the
landmarks and slender than those of the adjacent topographies, which are characterized as positive spaces, because they have projection and reect the light (Schider
1957; Massignan 2018; Hoyos and Millard 2007).
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Fig. 31.1 Negative sapaces in men follow the numerical order above (Hoyos and Millard 2007)
F. Massignan and F. Fuzinatto
Essential Surgical Approach, Inltration, Emulsication,
andSupercial andDeep Liposuction
1. Preoperative marking. In the preoperative marking, the areas of deep adipose
tissue extraction are delimited in blue (Hoyos and Millard 2007) (Fig.31.2).
Next, the framework is made (Massignan 2018; Hoyos and Millard 2007), that
is, the delimitation of anatomical landmarks (Fig.31.3). After that, the delimitations of the negative spaces are made by interconnecting the entire areas.
2. Inltration. Start with the deep layers, and after, approach the surface layers,
with standard tumescent solution, with uniform distribution (Klein 1990). This
movement will facilitate the correct handling of the lamellar and areolar layers.
Ropivacaine solution 7.5% is used in a volume of 5ml (appropriate to the body
weight of each patient) in every 1000ml of heated saline solution, associated
with 1 ampoule of adrenaline and 250mg of tranexamic acid (Massignan 2018).
3. Emulsication. Start emulsifying by the areolar layer, and then migrate toward
the lamellar layer (Schider 1957; Rohrich etal. 1998). The sequence is important
due to the gravitational characteristic of water protection. Succinctly the frequency of the ultrasonic device is on average 60–70% in the trunk and 50% in
members in continuous mode (C) in the lamllar environment and 50% dispersion
in VASER® (mode pulsatile V) in the areolar compartment (Massignan 2018;
Hoyos and Millard 2007).
31 High-Denition Liposculpture: Critical Vision andFuture Perspective
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Fig. 31.2 Delimitation of
deep fat tissue extraction
areas
Fig. 31.3 Framing of the
main anatomical lines
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4. Deep extraction. The liposuction of emulsied tissue starts from the lamellar
layer ( deep) (Klein 1990). Follows from distal to proximal, with homogeneous
fan-shaped movements. The surgeon’s non-dominant hand remains at and open
by performing pressure movement perpendicular to the extraction point
(Massignan 2018; Illouz 1992). The choice of the diameter of the cannulas and
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F. Massignan and F. Fuzinatto
their curvatures are selected according to the anatomical unit. During the
approach of the lamellar layer, the extraction must be homogeneous (Juma etal.
2021; Rohrich etal. 1998; Illouz 1992).
5. Surface extraction. The liposuction in the emulsied compartment in the super-
cial planes of the subcutaneous cellular tissue (areolar) should be cautious and
restricted in the marking areas for three-dimensional liposculpture (negative
spaces) (Massignan 2018; Hoyos and Millard 2007). This care is very important
to maintain the expected three-dimensional relief.
The control of the cannula by the surgeon requires attention and precision in
order to maintain parallel movement in relation to the skin plane; this prevents
damage to supercial fascial planes, vascular interconnections (Camper, Scarpa),
and subdermal plexus (Berkenstein and Grotting 2000). Cannulas should be
selected according to their thickness (number 3) and curvatures respecting the
anatomical unit to be carved.
6. Aspiration of negative spaces. Just as the artist sculpts and cuts the relief on an
object of interest, strategically removing structural content to create threedimensional shapes, the surgeon faithfully addresses subcutaneous cellular tissue in areas of transitions between the underlying muscle groups (Schider 1957).
Negative spaces are the areas that both lamellar and areolar layers are handled in
order to generate from them a deep relief effect (Massignan 2018; Hoyos and
Millard 2007). And from them, a gradual tonal skin progression effect occurs in
the negative spaces. This phenomenon can be understood with a gradual increase
of tissue thickness begin in the shaded area until the topografy reect light
(Stosich and Mao 2007). This surgical maneuver is performed treating the region
of interest from three skin accesses (Massignan 2018) (Fig.31.4).
Fig. 31.4 Delimitation of negative spaces
31 High-Denition Liposculpture: Critical Vision andFuture Perspective
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481
Critical Vision
The learning curve seems to extend further and further as plastic surgeons delight in
three-dimensional precision liposuction (Jewell etal. 2002; Rohrich etal. 1998).
This point deserves special attention, because technical education must be improved
at the same speed.
There is a growing progress in the surgical eld and, consequently, its translation
into results. Simultaneously, new obstacles arise, sometimes in search of even more
rened standards, sometimes in the difculty of keeping clear the foundations that
shape this surgical variable to young professionals. Factors such as age, gender,
surface tissue quality, and patient expectations will always be included in the context (Hoyos and Millard 2007).
Currently, the reliable anatomical relief is being reproduced in topographic
extensions that extend from the posterior cervical region to the distal region of the
lower limbs (Cimino and Bond 1996). Some topographies—due to their design—
are still challenging to be sculpted, for example, the intersections of the with external oblique muscle, the geometric shapes formed in the movement of the scapulae,
and the asymmetries of the deltoid muscle in mesomorphic patients.
The insertion of an artistic anatomy in the routines of plastic surgery (Massignan
2018), such as preoperative markings following precepts from centuries-old sculp-
ture schools, and the procient increase in surgical complexity and—consequently—the quality of the result offered to patients are considered enriching points
in this eld. Remember that the line between “beautiful” and “distorted” is tenuous
(Massignan 2018). Therefore, the probability of inadequacies is predictable in
young surgeons (Ince etal. 2019). Standardized algorithms would be a smart maturing formula for professionals and, in the same way, of protection in safety and quality of this new surgical line (Ince etal. 2019).
Future Perspectives
Body contour surgery is an area of plastic surgery that allows harmonic angulation
between topographic units. Technological evolution is inserted to assist both in the
aesthetic result and in patient safety.
The recent introduction of technologies such as radiofrequency devices (RF)
(e.g., Renuvion®, BodyTite®, etc.) helps to improve the results of the procedure
making pathologies such as brosis, cellulite, and “cutis marmorata” less complex
in its treatment. Moreover, they decrease the rate of some complications (seroma,
burns, bleeding, etc.). However, there is still insufcient research data for a denitive conclusion.
It is believed that the evolution will provide new horizons in the plastic surgery
area. Art, technology, security, and tissue manipulation will be topics in development to the conceptual limit. In a futurology exercise, microinvasive surgery will be
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F. Massignan and F. Fuzinatto
the next foundation of the set mentioned above, making possible the moment when
fat removal will be performed in multiple sessions with minimal injury and morbidity to the patient, resulting in a gradual decrease in adipose deposits. Similarly,
progressive body contour modeling will be millimeter, as well as sculptors carve
marble or painters paint their canvases (Figs.31.5, 31.6, 31.7, 31.8, 31.9, 31.10,
and 31.11).
a
b
c
Fig. 31.5 A 43-year-old male patient, preoperative (a) and 1 year later in the postoperative period
(b) with the muscle relaxed (static) and (c) with the muscle contracted (dynamic)
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