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29 Critical Analysis andtheFuture ofLiposuction forBody Contouring
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Fig. 29.15 A patient before and 4 months after two sessions of cryotherapy of the abdomen and
anks, with a reduction of 13cm in the abdominal circumference
453
Pre- andPostoperative Treatments
In 1992, I understood that preoperative preparation and most importantly postoperative treatments helped to keep patients happy and involved in the process. I opened
an aesthetic clinic behind my ofce with beauty therapists and physiotherapists,
who would work with my patients pre- and postoperatively. One of the main treatments prescribed was the French massage therapy called manual lymphatic drainage (MLD), which was used before and after surgery (Fig.29.16). Patients were
advised to undergo ve to ten sessions of MLD and would feel less pain and less
swelling and bruising in the postoperative period. It was also a way of keeping an
eye on my patients postoperatively and addressing any issues they might have
immediately. Patients would also book skin treatments, advice on corsets, makeup,
and exercise. Corsets should be used for 3–4 weeks postoperatively.
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Fig. 29.16 Manual
lymphatic drainage of the
abdominal area post
liposuction
L. S. Toledo
Aesthetic Complications Treatment
Permanent color changes in the skin, uneven areas, and irregularities. Color changes
in the skin may improve with time but are sometimes permanent. Uneven aspiration
can be corrected with suction or injection of fat, fat shifting—dissection of the adjacent fat layers and redistribution of fat, mobilization of a fat graft, and subcision—
by using the V-tip cannula to cut the adherences and inject or aspirate fat. And
nally skin excess resection.
The Future ofLiposuction
It is difcult to predict the future, especially after so many modications have
already been made to the original technique. We can expect more precise techniques
to eliminate fat excess, new methods that allow for even skin retraction without tissue burns and irregularities, and techniques to improve skin quality. There is
research continuing to evaluate the improved skin quality of patients who over the
years have had facial fat injection for contour denition. We now have over 30 years
of this practice to study the long-term effects of this fat replacement technique. Fat
injection for breast augmentation, which was discouraged for many years, is now an
acceptable method to augment the breast naturally as some patients are not comfortable with having the implants. Research will continue on how to eliminate fat excess
without surgery. But while this does not happen, we can only rely on the good training of plastic surgeons in the available techniques. We have already witnessed one
miracle in our lifetime. Will there be enough time for a second?
29 Critical Analysis andtheFuture ofLiposuction forBody Contouring
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455
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Paulista de Medicina, 1983a.
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Plast Reconstr Surg 1993 Nov;92(6):1085–98; discussion 1099-100.
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Toledo LS: Equipment and Instrumentation. In Atlas of Suction Assisted Lipectomy in Body
Contouring. Ed Frederick Grazer. Churchill Livingstone, 1992b, 23–25.
Illouz YG.Body contouring by lipolysis: a 5-year experience with over 3000 cases. Plast Reconstr
Surg 1983b;72:591–7.
Fournier P.Microlipoextraction et Microlipoinjection. Rev. Chir. Esthet. 1985;10:40.
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IX Congress of the International Society of Aesthetic Plastic Surgery, Waldorf Astoria Hotel,
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Matsudo PK, Toledo LS: “Experience of Injected Fat Grafting”, Aesth Plast Surg 12:35–38, 1988.
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Fournier P. Body Sculpturing Through Syringe Liposuction and Autologous Fat Reinjection.
Samuel Rolf International. US: 1987.
Toledo LS: Syringe liposculpture: A two-year experience. Aesth Plast Surg 15:321–326, 1991a.
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Surgery, ASPER- The Beverly Hilton Hotel, Beverly Hills, CA, USA, 23–24 June 1990b.
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CA, USA, April 22–23, 1991b.
Toledo LS: “Supercial Syringe Liposculpture” Presented at the 59th Congress of the American
Society of Plastic Surgery– ASPRS * PSEF * ASMS, Boston, MA, USA, 21–25 Oct 1990c.
Toledo LS: “Fat Transplantation– Does it Work and Does it Last?” Panel at the Aesthetic Contouring
of the Body PSEF/ASAPS Course, January 11–13, 1990d, Santa Barbara CA, USA.
Toledo LS: “Supercial Syringe Liposculpture” presented at the VIII Annual Scientic Meeting
of the Lipoplasty Society of North America, LSNA, Boston, MA, USA, 20–21 October 1990e.
Gasparotti M: "Radical Liposuction”, presented at the International Symposium Recent Advances
in Plastic Surgery, Espaço Artefacto, São Paulo, SP, Brazil, 3–5 March, 1989.
Toledo LS: Supercial Syringe Liposculpture– A Personal Technique. In Annals of the International
Symposium Recent Advances in Plastic Surgery– RAPS92 – March 14-15, 1992c. Ed. Luiz
Sérgio Toledo, Estadão, 170–175.
Illouz YG, DeVillers YT (Eds). Body Sculpturing by Lipoplasty. Churchill Livingstone;
Edinburgh: 1989. P. 29.
“Supercial Liposculpture– Manual of Technique,” Luiz S Toledo, Carson M.Lewis, and Marco
Gasparotti. Springer Verlag, NewYork, USA.April 1993.
Kloehn R.Liposuction with “Sonic Sculpture”: six years’ experience with more than 600 patients.
Aesthet Surg J 1996;16:123–8.
Zocchi ML.Basic physics for ultrasound-assisted lipoplasty. Clin Plast Surg 1999;26:209–20.
Illouz YG: Liposuction– the evolution of the classical technique. pmfa news | APRIL/MAY 2014
| VOL 1 NO 4 | www.pmfanews.com
Fredericks S: Analysis and introduction of a technology: Ultrasound-assisted Lipoplasty Task
Force. Clin Plast Surg. 1999 Apr; 26(2):187–204; vii.
Silberg B N: The technique of external ultrasound-assisted lipoplasty. Plast Reconstr Surg. 1998
Feb;101(2):552.
Toledo LS, Heller N: Simpósio Internacional de Inclusões em Cirurgia Plástica e Lipoplastia,
Instituto Goethe, Porto Alegre– RS– Brasil– 07 e 08.12.2001
Neira R, Toledo LS et al: Low-Level Laser-Assisted Liposuction: The Neira 4 L Technique
February 2006. Clin Plast Surg 33(1):117–27, vii
Psillakis JM: Plastic surgery of the abdomen with improvement in the body contour. Physiopathology
and treatment of the aponeurotic musculature. Clin Plast Surg 1984 Jul;11(3):465–77.
Gasparotti, M: Three-Dimensional Supercial Liposculpture for Aged and Relaxed Skin. In
Liposuction: Principles and Practice. Ed Melvin A.Shiffman, Alberto Di Giuseppe. Springer,
2006, 198–205.
Toledo LS: The Abdomen. In Renements in Facial and Body Contouring. 1999 Lippincott-Raven,
Philadelphia, p178.
Toledo LS: “A New Fat Freezing Machine That Keeps the Ofce Busy” Presented at the– ASPS-
Aesthetica 2015 Super Symposium– April 30– May 2, 2015– Las Vegas, NV
L. S. Toledo
Chapter 30
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Liposuction
LuisFernandezde Córdova andRicardoCavalcantiRibeiro
Abstract Precision liposuction slims and reshapes specic areas of the body by
removing fat deposits, improving the body contours and proportion by removing
excess in overweight patients, and revealing structures in patients with desirable
weight. Back and gluteal regions are of difcult denition by diet and exercise only,
making lipoplasty a popular and safe option to enhance their aesthetics.
Patient selection is as important as the surgical technique to achieve satisfactory
results, and it is important to know the aesthetic considerations for male and women
to prevent feminization or masculinization.
Physical examination and laboratory and imaging tests should be performed
before liposuction, taking into consideration that best results are obtained in patients
with a body mass index of 24 and lower.
The sequence of a liposuction surgery is as follows: markings, anesthesia, asepsis and antisepsis, inltration of vasoconstricting solution, liposuction, and dressing.
Complications can be classied by the moment of presentation when they occur,
i.e., perioperative and postoperative, and by the area or system(s) affected, i.e., local
or systemic.
The accumulation of liquid in the lower back is the most common complication
in our practice and presents during the rst 7 days postop and is drained by needle
aspiration. The nal aesthetic result can be seen at 6 months, and as patients improve
their activity level and make lifestyle changes, further changes may be noticed.
L. F. de Córdova
Department of Plastic and Reconstructive Surgery, Hospital Universitário Gaffrée e Guinle,
Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
R. CavalcantiRibeiro (*)
Plastic and Reconstructive Surgery, Federal University of the State of Rio de Janeiro,
Rio de Janeiro, Brazil
e-mail: rribeiro@centroin.net.br
Switzerland AG 2023
J. M. Avelar, R. Cavalcanti Ribeiro (eds.), Body Contouring,
https://doi.org/10.1007/978-3-031-42802-9_30
457© The Author(s), under exclusive license to Springer Nature
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Keywords Liposuction · Body fat · Body contouring surgery · Brazilian butt lift
L. F. de Córdova and R. CavalcantiRibeiro
Introduction
Since rst described by Illouz during the 1980s, precision liposuction slims and
reshapes specic areas of the body by removing fat deposits, improving the body
contours and proportion by removing excess in overweight patients, and revealing
structures in patients with desirable weight [1–18]. Therefore, the surgeon is obliged
to acquire a precise knowledge of osteology and myology for a satisfactory sculpting of the human body where instead of bronze, marble, wood, or metal, the sculpting substrate is fat. Back and gluteal regions are of difcult denition by diet and
exercise only, making lipoplasty a popular and safe option to enhance their
aesthetics.
We must take into consideration cultural aspects that could alter the expectations
of the aesthetic patient, as it is the case of the Brazilian surgeons who popularized
the “Brazilian butt lift.”
It is helpful to classify patients on three types of lipodystrophy and skin
redundancy:
1. Localized lipodystrophy: Generally younger patients with good skin tone.
2. Generalized lipodystrophy: Often patients with slightly diminished skin tone,
some skin irregularities, and circumferential lipodystrophy throughout their
trunk and extremities.
3. Skin redundancy and lipodystrophy: Patients with signicant skin redundancy
would benet the most from excisional surgical techniques.
From William Sheldon [19], the American psychologist, we inherited the somatotypology system that describes three body types and is still widely used:
• Ectomorphs: they are typically thin and tall and have narrow shoulders, low body
fat percentage, and high metabolism.
• Mesomorphs: they have medium bone structure with a solid torso and are mus-
cular and lean with predisposition to gain weight if exercise is decient or caloric
intake is too high.
• Endomorphs: they gain weight easily requiring high-intensity exercise and diet-
ing to become lean and have large bone structure and wide waist.
Liposuction has been utilized throughout the past and current century as a surgical solution for unwanted convexities due to exercise- and diet-resistant fatty deposits as described by Dolsky in (1987) [1].
Body mass index, calculated by dividing the body weight in kilograms by the
height in meters squared, could be considered as an index of overall fat percentage
with studies revealing that a BMI of 20 is considered optimally attractive in women
and the goal of a “V”-shaped body with a low waist-to-chest ratio should be the aim
for men.
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When performing lipoplasty of the anks, it is important to know the aesthetic
considerations for male and women to prevent feminization or masculinization;
males tend to be atter inferiorly and posteriorly, while women exhibit fullness in
these areas, whereas men have superior and lateral fullness, while women have not.
459
Diagnosis/Patient Presentation
Liposuction patients often present themselves with a variety of concerns, complaints, and expectations. As a general rule, aesthetic surgery, including liposuction,
should be performed in healthy patients who maintain realistic goals. Patients committed to a positive lifestyle change involving a healthy diet and regular exercise or
those who were already following a healthy lifestyle preoperatively and continued
postoperatively experienced the best satisfaction scores.
During the initial evaluation, it is imperative for the plastic surgeon to translate
the expectations of the patient into realistic results. Besides explaining the method,
indications, and postoperative care, an informed consent should be signed, and photographs of the area to be treated must be taken. Problems can be avoided by taking
into consideration that not every patient presenting for a consultation must be treated.
A proper physical examination should be performed including recording of
height, weight, body mass index, circumferences of areas to be treated, asymmetries
and surface irregularities, scars, associated cellulite, skin tone and laxity, presence
of stretch marks, and muscle diastasis and/or hernias.
If the protrusion is due to subcutaneous fat and therefore theoretically easy to be
removed by liposuction, it can be ascertained by a simple “pinch” test. The fat that
the physician can pinch between two ngers is subcutaneous fat that can be removed
by aspiration.
Physical examination should be paired with a psychological evaluation recording
any symptoms of depression, anxiety disorders, or dysmorphophobia.
The following laboratory and imaging tests could be obtained before liposuction
is performed (depending on the country and legal specications for elective surgery):
• Coagulation (PTT, ProTime, INR)
• Complete blood count
• Creatinine, AST, ALT
• Glucose
• Lipid panel
• Electrolyte panel
• HIV
• Hep-C
• ECG
• Chest X-ray
• Abdominal wall ultrasound for hernia exclusion purposes
Taking clinical photographs requires the following simple rules (Fig.30.1):
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L. F. de Córdova and R. CavalcantiRibeiro
Fig. 30.1 Standardized preoperative pictures with frontal (a, b) and back (c, d) views. The suggested photographs in a clinical setting should include, besides anterior and posterior views, right
and left proles
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• Use an appropriate backdropand lightinglight to medium blue or medium gray)
• Remove distractions (jewelry and clothing)
• Use controlled lighting
• Reduce cast shadows
• Record settings (the same camera settings should be used for every patient)
• Use consistent framing for each aesthetic unit
Look specically for bleeding disorders, and it is imperative to know if the
patient is under antiplatelet, anticoagulant, and/or contraceptive therapy as well as
hormone replacement therapy.
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Patient Selection
The range of indications for liposuction, initially developed for aesthetic procedures, has been extended for pathological tissue increase disorders such as benign
symmetrical lipomatosis, adiposis dolorosa, gynecomastia, axillary hyperhidrosis,
and mobilization of skin aps, among others.
Ideal patients for liposuction are not obese, maintain a stable weight throughout
time, and have incorporated the three key elements mentioned above into their perioperative regimen. Regularly, they present with localized or generalized lipodystrophy with good skin tone, no scars, and no stretch marks. Pregnant patients or those
with morbid obesity, cardiopulmonary disease, body image perception issues, and
wound healing anomalies should be excluded from liposuction.
The consultation should occurin a comfortable environment and in no rush;
positive rapport and patient’s trust in the surgeon are just as important as the
qualications of the surgeon. A patient who distrusts the surgeon or entered the
operating room with doubts will be dissatised with the outcome regardless of the
results.
If the patient smokes, they must stop smoking at least 2 weeks before the surgery
and refrain from smoking at least 1 month postoperatively.
Nonessential medications should be excluded 3 weeks before surgery, including
herbal remedies and supplements, since they are not regulated by the Food and Drug
Administration and may add risk of complications, including bleeding or
hypercoagulability.
In front of a full-length mirror, to allow an open dialogue between the patient and
the physician, any areas of cellulite should be addressed as well as expected outcomes discussed in these areas.
Nowadays, anesthesia raises more concern on the patients than the surgery itself.
It is up to the surgeon to determine the optimal surgicalanaesthesiafor each patient,
as a general rule, to avoid epidural and spinal anesthesia in ofce-based procedures
to reduce the risk of potential hypotension and volume overload. Small-volume
liposuction can be performed with local anesthesia, with or without mild sedation,
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L. F. de Córdova and R. CavalcantiRibeiro
and large-volume liposuctionor liposuctioncombined with other surgical procedure should be performed under general anesthesia.
There are four different terms used to describe the types of wetting solutions
intended to reduce the blood loss during liposuction (Table30.1).
Most wetting solutions utilize lidocaine as a local anesthetic, which raised the
concern about toxicity. The traditional maximum dose of lidocaine with epinephrine is 7 mg/kg, but in a liposuction setting, various studies have reported safety of
lidocaine concentrations from 35 to 55 mg/kg in volume cases. The signs and symptoms of lidocaine toxicity include from tinnitus, lightheadedness, and circumoral
numbness to tremors, EKG alterations, seizures, and cardiopulmonary arrest.
Safety is a priority above cosmetic results. Many body contouring procedures
require complex positioning. Improper pressure to neurovascular structures may
lead to short- or long-term disability, and head positioning is extremely important in
the prone position. The neck must be in a neutral position and stable when changing
position intraoperatively to avoid carotid and/or vertebrobasilar arterial system dissection. Nerves across bony surfaces require appropriate angle and padding on the
table to avoid compression and stretch. Avoid arm abduction greater than 90°. Pedal
or calf compression devices should be applied. During the procedure, all areas not
being treated should be covered by a forced warm air blanket, and wetting solutions
should be warmed. In 2012, the consensus on liposuction in the Committee of Body
Contouring Surgery of the Brazilian Society of Plastic Surgery concluded that the
ideal volume to be aspirated safely goes from 5% to 7% of total body weight
(Table30.2).
Table 30.1 Techniques of lipoplasty may be divided into four types depending on the volume of
solution inltrated. The volume of inltration is related to the estimated blood loss as percentage
of volume aspirated being the superwet and tumescent techniques the safest [1-30]
Estimated blood loss as % of volume
Technique
Dry 20–45 No inltrate To treatment
Wet 4–30 200–300 ml/area To treatment
Superwet 1 1:1ml inltrate/
Tumescent 1 Inltrate to skin
aspirated Inltrate Volume aspirate
aspirate
turgor
endpoint
endpoint
1ml aspirate/
inltrate
2–3ml aspirate/ml
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