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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_511_Библиотеки_им_академика_М_И_Перельмана
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7 Back Rolls andTheir Treatment Options
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a
Fig. 7.8 (a) Pre-treatment photograph of a 35years old lady who wanted liposuction but got apprehensive and decided to undergo lipolysis
instead. (b) Shape after 4 sessions of lipolysis
7.9 Suction-Assisted Lipoplasty Withor
Without Skin Tightening Technology
b
the skin has stretched to an extent where even ultrasound
assisted liposuction (UAL) may not achieve signicant con-
traction of skin then the use of radiofrequency (RF)-assisted
Fat deposit on the back is in a supercial plane in tight compartments and hence traditional liposuction does not provide
much benet. Moreover, aggressively scraping the fat will
cause injury to the thin back muscles causing pain as well as
hematoma. The basic principle by which lipocontouring of
the back works is that once the skin ap has been thinned out
by removal of the excess fat, it will be repositioned on the
curved back and waist of the female form. Its attachment to
skin tightening with or without helium-activation (J- Plasma)
will be required [5]. Helium-activated RF improves skin tur-
gor not only by tightening and contracting the FSN bers but
also by stimulation of neocollagenesis and remodeling of the
dermal matrix [11].
The shapely outcome after this minimalistic procedure is
due to the concepts, some of them described by Gasparotti
[10] which include:
the underlying fascia and inherent ability of the skin to shrink
will produce further improvement in the skin bulges [9] It is
known that all types of skin even in very advanced stage has
the ability to contract signicantly when supercial liposuction is carried out using ne cannulas till the skin becomes
soft [10].
Ultrasound technology has the ability to emulsify the fat
by rupturing the lipocytes without mechanical disruption.
Use of this technology internally during liposuction will prevent injury to the supercial broseptal network (FSN) producing more skin retraction and at the same time helps in
partial release of the zones of adhesion thus achieving a
smooth transition. When the fat deposits are extensive and
1. After liposuction the thin cutaneous tissue drapes the
underlying curves.
2. Liposuction on the back should be done in a vertical
direction causing less damage to the lymphatic vessels.
3. Vertical liposuction also supports the skin envelope
against gravity by formation of vertical collagen tissue.
4. VASER energy to lyse the lipocytes and allow easy and
smooth removal of fat.
5. Radiofrequency with or without Helium activation to
improve the skin contraction.
6. 4weeks of customized support to allow the skin to contract and the edema to reduce.
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M. Thomas and J. D’silva
7.9.1 Procedure Steps
1. Marking is rst done in the standing position. All points
of elevation and depressions should be carefully marked
(Fig.7.9). The bra-line should also be marked so that the
access points are hidden.
2. Tumescent uid (Standard Klien’s solution) is inltrated
in the marked areas through one or two hidden access
points. After 15min VASER (Internal Ultrasound) was
used at 70% energy and a 3-ringed probe with a skin
guard. The end point of VASER use was when the tissue
became soft and fat started spilling out of the port as seen
in Fig.7.10.
3. Liposuction is then carried out by using Mercedes tip
straight cannulas and/ or the Aspirator III curved cannula
which has three triangular ports on its concave side. Three
millimeters cannulas are used so that there is no disruption of the broseptal network as seen in Fig.7.11.
4. Once the evacuation is complete, based on the preoperative plan, skin tightening procedure can be undertaken either by using radiofrequency-assisted skin
tightening device alone as seen in Fig. 7.12a, b or the
plasma therapy by Helium activation radio frequency as
seen in Fig.7.13. Care should be taken and injury to the
sub-dermal plexus should be prevented.
5. Once the skin tightening procedure has been completed,
the access point is sutured and patient is placed in a custom compression dressing. Lymphatic massage is started
after a week. Post procedure photographs as evaluated at
4 weeks after the treatment (Figs.7.14, 7.15, and 7.16).
Fig. 7.9 Marking the fat deposits with the patient standing
Fig. 7.10 VASER technology being used to lyse the lipocytes before
they are suctioned. Liqueed fat is seen as marked by the yellow ring
Fig. 7.11 The Aspirator III 3 mm cannula is being used to suck the
liqueed fat
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a
Fig. 7.12 (a) The bi-polar radiofrequency device with the internal and the external probes. (b) The increased temperature between the two probes
which causes collagen modulation and thus skin contraction
b
Fig. 7.13 Helium arc being displayed on the plasma therapy probe.
Used under the skin surface, it causes contraction of the bro septal
network
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Fig. 7.14 40-year-old tness
trainer (a, b) wanted her back
rolls to be reduced. She
underwent VASER-assisted
lipocontouring of the back
through a single midline
incision. (c, d) are postsurgery photographs taken at
4weeks
a
c
b
d
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a
c
b
d
Fig. 7.15 (a, b) 25-year-old working lady wanted her back and abdomen-shaped as she was suffering from PCOS. (c, d) are post-surgery pictures
taken 4weeks later after VASER lipo with radiofrequency-assisted skin tightening. Access point is on the midline back (yellow circle)
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M. Thomas and J. D’silva
a
b
c
d
Fig. 7.16 Pre-operative photographs (a, c) of a 35-year-old lady who underwent VASER-assisted liposuction of the back. (b, d) are post-operative
photographs taken 4weeks after the surgery
7.10 Lipectomy asPart ofUpper Body Lift
7.10.1 Indications forUpper Body Lift
Back rolls with loose skin in the upper back have the appearance of skin spilling over the bra line and thus compromising a smooth silhouette of the back. Large fat deposits on
the back who have undergone lipocontouring with not sufcient skin retraction may also lead to these cosmetic scenarios. This condition is predominantly visible in people
who have undergone massive weight loss secondary to diet
and exercise or bariatric surgery. Body contouring after
massive weight loss usually includes circumferential body
lift, thigh- lift, arm-lift, and breast procedures. Management
of back rolls through tissue excision has become more common as more and more people are going in for bariatric surgery. This procedure can be combined with surgery of the
breast and in the female the tissue to be excised can be deepithelized and used to create an autologous breast augmentation [12].
In men, gynecomastia surgery can be combined with
removal of excess tissue on the back as part of the upper
body lift procedure which will address the excess skin on the
upper torso circumferentially [13].
1. Back rolls with signicant skin laxity.
2. Grade 4 gynecomastia in a male with skin laxity extending to the back.
3. When tissue from the back can be used as a ap for autologous breast augmentation in a female.
4. In people who have residual back rolls after liposuction.
7.10.2 Procedure Steps
1. The rst step of any aesthetic procedure including the
back lift is marking in the standing position. The bra
outline is rst marked as seen in Fig.7.17a, b. The incision line is then marked extending from one inframammary crease to the other side if there is laxity of skin
across the spine too. In males it can be marked as two
separate incisions which are not continuous across the
midline. Tissue is then pinched on either side of the incision mark and the excision line is marked using a pinch
technique.
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a
Fig. 7.17 (a, b) Marking of the excess back roll being undertaken by using strong bimanual palpation on either side of the planned incision line
b
Fig. 7.18 Patient placed in prone position on a spinal frame (inset) and
all pressure points well supported and padded
2. After administration of general anesthesia, patient is carefully placed in a prone position on a spinal frame or chest
pillows. The neck and lower body should be well supported
and sequential compressive devices should be used to prevent deep vein thrombosis (DVT). The arms should be
placed on adjustable arm rests so that they can be easily
abducted and adducted during closure of incision (Fig.7.18).
3. Towel clip is now used to conrm the extent of skin excision so that there is no undermining required for closure
and at the same time the extent of tissue excision is adequate (Fig.7.19).
4. Tumescent uid is now inltrated in the tissue to be
excised for hemostasis. Incision is then made using a
Fig. 7.19 Towel clip being used to conrm the extent of skin and tissue
resection. The markings are now made using methylene blue
number 15 blade. Please note that the dermis on the back
is very thick but the back muscles are very thin (Fig.7.20).
5. Electrocautery is now used to cauterize all bleeding
points and the tissue is excised leaving behind the fascia
covering the muscle. The tissue should not be beveled or
undermined. This facilitates closure with an Ethibond
suture bite from the two supercial fascial system edges
and down the fascia over the muscle thus obliterating the
space (Fig.7.21).
6. Final closure is in two layers using Vicryl and Monocryl
subcuticular sutures. This is completed by preventing any
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M. Thomas and J. D’silva
Fig. 7.20 Incision has been made on one side of the chest and extended
to the fascia covering the muscle
a
Fig. 7.22 (a) Pre-operative photograph of a lady who had lost 35kg due to bariatric surgery and planned to undergo shaping of the breast at the
same time. (b) Post-operative result after 2weeks
Fig. 7.21 Tissue has been excised, hemostasis has been achieved and
deeper layer of closure has been done
b
“Dog ear” in the inframammary crease. Dressing is done
and left covered for a week. Range of motion and arm
abduction is increased gradually based on patient comfort
(Fig. 7.22). If abducting the arms is painful or creates
undo tension, they are advised to scale back their activity.
7.10.3 Possible Complications
1. Most common is scar widening, usually due to nonsuturing of the supercial fascial system. May need scar
revision.
2. Inadequate skin removal may require re-excision.
3. Dog ear may require correction.
4. Hypertrophy of scar is possible which may need local
Intra- lesional Triamcinolone injections with 5 FU as
well as application of silicone sheets (Fig. 7.23).
Pearls
1. Ultrasound-assisted liposuction is the mainstay of treatment for reduction of back rolls.
2. Moderate skin Laxity can be treated by using
radiofrequency- assisted skin tightening.
3. Alignment of midline and lateral tissues is very important
to achieve symmetry during back lift surgery.
4. Hypertrophy of scars is possible especially in a male
which may require further scar reduction treatment.
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a
Fig. 7.23 (a) Young male who had Grade 4 gynecomastia along with loose skin on the back. He underwent a “Boomerang technique” of breast
tissue excision along with excision of back tissue. (b) Post-operative result after 8weeks
Classication of back roll as proposed by us for its man-
agement [14].
GRADE I Back rolls which appear when the arms are kept
by the side and disappear when the arms are raised. Injection
lipolysis or Liposuction is the treatment option.
GRADE II Back rolls which have a single indentation (partial or complete) which reduces when the arm is raised.
VASER liposuction is the best treatment option.
GRADE III Back rolls with two or more skin indentations
with skin pinch of more than 2 cm. The skin fold should not
be lower than the inferior tethering point. Radio frequency
assisted liposuction and skin tightening is the best treatment
option.
GRADE IV Back rolls secondary to massive weight loss,
have multiple folds with skin pinch <2 cm and skin fold
lower than the tethering point or who have undergone prior
surgical treatment. Lipectomy is the best treatment option.
References
1. Rohrich RJ, Smith PD, Marcantonio DR, Kenkel JM.The zones of
adherence: role in minimizing and preventing contour deformities
in liposuction. Plast Reconstr Surg. 2001;107(6):1562–9. https://
doi.org/10.1097/00006534- 200105000- 00043. PMID: 11335837.
2. Apfelberg DB.The vast “waistland”: a rediscovered area in liposuction. Ann Plast Surg. 1994;33:237–40.
b
3. Klein JA. Tumescent technique: tumescent anesthesia and microcannular liposuction. ISBN 9780815152057. St. Louis: Mosby;
2000 https://books.google.co.in/books?id=pl5sAAAAMAAJ.
4. Hunstad J, Chen C, Abbed T.Bra-line back lift. Clin Plast Surg.
2018;46:77. https://doi.org/10.1016/j.cps.2018.08.010.
5. Mowlavi A, Talle A, Berri M, Rashid W.Successful back contouring with elimination of back rolls using ultrasound-assisted liposuction and helium-activated radiofrequency. Aesthet Surg J Open
Forum. 2020;2(4):ojaa036. https://doi.org/10.1093/asjof/ojaa036.
6. Rotunda A, Suzuki H, Moy RL, Kolodney MS.Detergent effects of
sodium deoxycholate are a major feature of an injectable phosphatidylcholine formulation used for localized fat dissolution. Dermatol
Surg. 2004;30:1001–8.
7. Thomas MK, D’Silva JA, Borole AJ.Injection lipolysis: a systematic review of literature and our experience with a combination of
phosphatidylcholine and deoxycholate over a period of 14 years
in 1269 patients of Indian and south east Asian origin. J Cutan
Aesthet Surg. 2018;11(4):222–8. https://doi.org/10.4103/JCAS.
JCAS_117_18.
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org/10.1097/GOX.0000000000000492. Published 2016 Sep 12.
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10. Gasparotti M.Supercial liposuction: a new application of the technique for aged and accid skin. Aesthet Plast Surg. 1992;16:141–
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11. Kim M, Kim KE, Jeong SW, et al. Effects of the ultra-highfrequency electrical eld radiofrequency device on mouse
skin: a histologic and molecular study. Plast Reconstr Surg.
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12. Hurwitz DJ, Agha-Mohammadi S. Postbariatric surgery breast
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13. Shermak MA. Management of back rolls. Aesthet Surg J.
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https://doi.org/10.1097/GOX.0000000000003827.
Back andButtocks
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MauroDalmiroSoriano
8
8.1 Introduction
Lipocontouring of back and buttocks is a surgical procedure
that has grown signicantly in the past few years, due to the
discerning eyes of their peers, tight garments, and, moreover,
because of social media and its unapproachable beauty standards. There are specic techniques that allow surgeons to
achieve great results in remodeling the back and buttocks, as
well as even better surgical skills by plastic surgeons in order
to perform more sophisticated and advanced procedures due
to scientic advancements to satisfy patient’s expectations
and increase the efcacy of the procedure.
Since the rst liposuction techniques were reported and
performed in France by Illouz and Fournier, and further
rened with incorporation of the Klein’s tumescent solution,
which has revolutionized the entire liposuction technique
and has renewed acceptance even by his detractors [1, 2],
the evolution has been constant and by contributions from
specialists and technology companies offering collaboration,
many systems and improved techniques have been developed so as to decrease timing and bleeding during the procedure and to allow skin retraction after liposuction. Needless
to say there is a better denition of the underlying muscular
structures with reduction in the percentage of complications.
8.2 Regional Anatomy
The posterior region of the body has a specic anatomy that
must be known in minute detail so that we can optimize our
results and decrease revisions (Fig.8.1). The preoperative
evaluation and documentation is extremely important in
order to plan correctly which areas we are going to lipoaspirate and graft (Figs.8.2 and 8.3). Additionally, we must be
aware of the body’s problematic areas including loose skin
and zones of adherence.
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 981- 19- 4997- 5_8].
M. D. Soriano (*)
Plastic Surgeon at Parque Sanatorium, Rosario,
Santa Fe, Argentina
© 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_8
139
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