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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_577_Библиотеки_им_академика_М_И_Перельмана
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A. Di Giuseppe and F. Giovagnoli
Fig. 20.3 Pre-op photos, planning and 6-month post-op result. Only anterior and posterior view shown
anatomical and surgical adipose layers when performing body
contouring procedures. A combination of supercial subcutaneous undermining and deeper fat removal must be accomplished
to obtain a nice esthetic and proportioned result, depending on
the level of thighs where the surgeon is working (Fig.20.5).
Since year 2000, by using an ultrasound-assisted
device (VASER) for liposculpture, I have started treating
the anterolateral portion of the thighs, considering the
earlier difficulties in addressing that area. Since then,
also my pre-op photos and planning include the lateral
and the oblique views in order to have a full understanding of the body dimension and proportion. And I’m not
scared any more to fully treat, three- dimensionally, the
whole area [4].
1. Lateral Gluteal
2. Gluteal Crease
3. Distal Posterior Thigh
4. Mid Medial Thigh
5. Inferolateral Iliotibial
Tract
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Fig. 20.4 Zone of adherence
introduced by G.Illouz
Depression
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Fig. 20.5 Side-lateral view of thighs. This further projection introduces the concept of 3D contouring, in addition to anteroposterior view previously considered
20.2 Anatomy
Fat distribution in lower extremities and thigh is quite variable, depending on the area:
1. anterior surface: under the skin envelope, there is an areolar fat layer of variable thickness, then underlying fascia,
muscle layer, and then femur (bone);
2. external surface: under the skin envelope, the fat layer is
minimally represented. This is one of the forbidden areas
in correspondence with the deeper fascia lata (distal posterior thigh);
3. posterior surface: under the skin envelope, there is a distinct fat layer, with several myocutaneous brotic attachment to the overlying tissue, as in the infragluteal crease
(Fig.20.6).
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TM
Lower Extremities
Areolar layer
1) Skin
Lower Extremities
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A. Di Giuseppe and F. Giovagnoli
Fig. 20.6 Anatomy of fat layer distribution anterior, external and posterior surface of thigh
2) Subcutaneous tissue
3) Areolar layer
4) Fascia
5) Muscle
6) Bone
7) Lamellar layer
Fig. 20.7 Fat distribution in upper, medial, and lower third of thigh
A further distinction of the fat layers affects upper (A),
medial (B) and lower third (C) of thigh (Fig.20.7).
Fat distribution in antero-medial thigh presents few dif-
ferences on the thickness of the lamellar layer. This is
Thigh
A) UPPER THIRD
B) MEDIAL THIRD
1)
2)
3)
4)
5)
6)
C) LOWER THIRD
1)
2)
3)
4)
5)
6)
7)
Anterior Surface
1
2
Posterior Surface
3
External Surface
Skin
Fascia
Muscle
Femur
THIGH
C
1
1 Precision Fluid
Management System
2
®
2 VASER
Amplifier
3 VentX
Aspiration Console
3
A
Fig. 20.8 VASER System (Photo taken from VASER Solta Medical
User’s Guide [5]. Courtesy of Bausch, ©2022 Bausch Health Companies
4 Wireless Footswitch
System
4
Ultrasonic
®
Infiltration and
Inc., All Rights Reserved)
localized underneath the subcutaneous layer and is well rep-
B
resented in the upper third (A). The lamellar layer is nearly
absent in the medial third (B). And it appears again in the
lower third (C), but less represented.
Those anatomical variations must carefully be analyzed
by surgeon when planning and performing his thigh contouring liposuction. The medial third must be treated carefully,
due to the absence of the lamellar layer. Only supercial
undermining must be addressed in this layer to avoid
unpleasent complications as depressions and irregularities.
The upper third (A) presents a thicker lamellar layer that
must be addressed properly to reduce thickness. The subcutaneous layer could be quite thin by aging: here too, a cautious supercial undermining is the key to avoid secondary
irregularities and dimples.
In order to accomplish those needs, I believe surgeon
must use a delicate instruments which could exalt skin retraction capability.
And I did utilize VASER ultrasound device in order to
safely treat those areas and achieve good skin retraction. The
key to success is to nd a proper level of emulsication of
the fat layers in the different areas of thigh (Fig.20.8) [6].
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Fig. 20.9 Level of emulsication (Photo taken from VASER Solta Medical User’s Guide [5]. Courtesy of Bausch, ©2022 Bausch Health
Companies Inc., All Rights Reserved)
283
Fig. 20.10 Level of undermining (Photo taken from VASER Solta Medical User’s Guide [5]. Courtesy of Bausch, ©2022 Bausch Health
Companies Inc., All Rights Reserved)
I do use 3.7mm 2 or 3 rings VASER titanium probe with
The sequence of surgical plan must be as follow:
continous administration of energy, with power around
70–80% of total. In alternative, VASER mode could be utilized with energy setting still at 70–80% of total power.
VASER mode allows delivery of 50% of energy at the same
amount of time, thus reducing the total energy administrated
and thus potential complications. It is ideal for beginners, to
prevent mistakes and overemulsication of fat tissue
(Fig.20.9).
In order to achieve a better skin retraction, tissues must
be carefully undermined from the subcutaneous areolar
layer, by gently preserving the vascular network and the
connective structure which supports the overling tissues.
Ultrasound energy is ideal for this target, as it is selective
only for fat tissue. And it does spare all others structures
(a) Tumescent inltration of the deeper layer.
(b) Tumescent inltration of the supercial layer (until peau
d’orange (Fig.20.11) aspect is achieved).
(c) VASER ultrasound undermining of the supercial level
with minimal emulsication (VASER mode or continous mode depending on surgeon ability and
experience).
(d) VASER ultrasound deeper tissue emulsication (lamel-
lar layer essentially).
(e) VENTX aspiration or other system liposuction with
reduced power (15mhg).
(f) Tissue compression to favor tissue adhesion after clean-
ing of emulsied fat (Fig.20.12).
(vessels, nerves, elastic bers, and connective tissue), which
need to stay as essential for the stability of the tissue structure (Fig.20.10) [7].
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Fig. 20.11 Peau d’orange appearance
A. Di Giuseppe and F. Giovagnoli
20.3 Planning
The analysis of the photos in all direction allows to detect the
defects of contouring: fat excess, asymmetries, celulites, and
lipodystrophy. Drawings of the new lines and the fat excess
include the antero-medial and lateral aspect of the thigh. This
3D approach is the only one that could achieve new balanced
proportion of thighs in respect to the other body areas
(Fig.20.13).
Fig. 20.12 Tissue adhesion after cleaning of emulsied fat (Photo
taken from VASER Solta Medical User’s Guide [5]. Courtesy of
Bausch, ©2022 Bausch Health Companies Inc., All Rights Reserved)
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Fig. 20.13 Planning of 3D thigh contouring
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A. Di Giuseppe and F. Giovagnoli
20.4 Surgical Technique
Skin access incisions are planned at the inguinal crease and
at the suprapatella.
Tumescent inltration will be in 2:1 ratio appoximately.
VASER probe must be carefully chosen depending on
initial thickness of the fat tissue of patients. I do recommend 3.7 mm 2 rings VASER probe in all the areas,
exept the knees area and the inner-middle thigh, where
2.9 mm 2 rings probe should be electively selected
(Fig.20.14a, b).
After waiting 10min for proper functioning of adrenaline, an extensive subdermis undermining of all the areas is
performed. This process must be delicate by using continous
VASER mode, and it normally takes 3–4min to complete all
the target areas.
Once undermining is completed, emulsication of the fat
is performed in a uniform pattern with a 3.7mm probe.
Areas where more caution must be used are: the patella,
the inner-medial thigh, and the inner upper thigh. In all those
areas, a careful aspiration of emulsied fat with low pressure
must be performed using a 3.0mm VENTX cannula.
Over correction, depression, irregularities, and dimples,
all derive from a too aggressive aspiration. This is why the
aspiration phase is the most important one: must address the
nal result and contouring, must give proper shape and lines,
and reduce thickness of the fat layer where needed and
required.
Sense of artistry and proportion of surgeon are mandatory
requirments as well as a perfect planning, after analysis of
patient characteristics (skin texture, fat thickness, celulites,
dimples, irregularities, and asymmetries).
20.5 Step by Step
The patient has been inltrated anteriorly and posteriorly
with tumescent solution. Skin ports have been placed to prevent friction injuries by ultrasound probe (Fig.20.15).
VASER ultrasound administrated on the inner and
antero- medial thighs with a 3.7mm probe 2 grooves for the
supercial emulsication, using 70–80% of power in
VASER mode or continous mode depending on surgeon
experience. Deep layer emulsication by using same probe
always in continous mode. 60–120s ultrasound delivery for
100mL of TLA inltrate in each area is a proper guideline
(Fig.20.16).
In posterior thighs, extreme caution must be taken at the
subgluteal crease, where strong connective ligaments do
support the gluteal and must be respected to avoid drop of
the area (Fig.20.17).
Aspiration is performed with a 3.7mm VENTX cannula
on the deep layer and with a 3mm VENTX cannula on the
supercial layer (Fig.20.18).
The nal thickness and contouring of the reduced ap
must be veried with the same cannula without aspiration. It
will allow a nice redraping of the skin evenly, by using a
3mm cannula (Fig.20.19).
Fat layer thickness must be checked at the end of the procedure in each area performed. Pinch test with two ngers
will allows access to the precision of the surgery performed
(Fig.20.20).
The knees area requires ner instrumentation and less
energy: 2.9 mm probe, VASER mode, 3 mm cannula for
aspiration. Multiple directions must be followed to reach not
only the knees area but also the antero-medial and the anterior thigh as well with a single access at the patella
(Fig.20.21).
Fig. 20.14 (a) Surgical access through inguinal and patella incision,
(b) Full undermining of antero-medial lateral thighs and knees, using
2.9 or 3.7mm probe 2 rings Fig. 20.15 Tumescent inltration completed and skin ports on site
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Fig. 20.16 VASER antero-medial thighs
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Fig. 20.17 VASER in postero-medial thigh. In red caution area
Fig. 20.18 Aspiration 3.7mm cannula for deeper layer, 3.0mm VENTX for supercial
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Fig. 20.19 Redraping the skin evenly (3mm cannula)
A. Di Giuseppe and F. Giovagnoli
Fig. 20.20 Pinch test
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Fig. 20.21 Knees area: multiple area approach with single incision
20.6 Clinical Cases of3D Circumferential
Thigh Contouring withVASER
Those are clinical examples of pre op, planning and 6months
post-op appearance in body contouring reshaping, at abdomen anks, outer thigh, inner thigh, and anterior thigh (3D
circumferential thigh) (Figs.20.22 and 20.23).
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