22.1 Introduction

Flanks and hips are the most commonly treated areas for liposuction in men and women. They also have the distinction of being one of the areas with the highest satisfaction level when treated with liposuction. Treatment of these areas was popularized in the late 1970s by Teimourian and Fisher and the term “flank curettage” was coined. ¹ By the 1990s, Pitman reported that 45% of his patients had these areas treated with virtually all abdominoplasties as standard adjunctive therapy. ² The common term used now days are “love handles.”

22.2 Anatomy

The fat in these areas is divided into superficial and deep. The superficial fascial system (SFS) is responsible for encasing the superficial fat. ³ It consists of an intertwined fibro-septal network (FSN) consisting of fascial elements that provide structural support to the fat as well as to the overlying dermis. The superficial fat tends to be more structured in nature due to this fascial network, whereas the deeper fat contains less fascial elements.

The FSN’s role as a support pillar for the overlying dermis comes into play in cases requiring dermal tightening utilizing radiofrequency-assisted liposuction. ⁴ Elements of the Superficial Fascial System (SFS) condense down to the level of the muscle fascia and form Lockwood’s zones of adherence. This deep fat compartment is defined in men as cephalad to the iliac crest and has implications in the treatment of the flanks. In women, it tends to overly the iliac crest and hence lies more inferior (▶Fig. 22.1).

Lastly, the anatomical implication for treatment that needs to be taken into consideration is the underlying skeletal framework. Clinical conditions such as scoliosis, and the degree of pelvic tilt can have impact on the physical appearance of the fat distribution in the flanks. Patients will often mention their “bigger side” vs. “smaller side.” Therefore, it is of paramount importance that these asymmetries be pointed out to the patient on the preoperative photographs prior to surgery. What patients and physicians often surmise as a bigger vs. smaller side can simply be a manifestation of the underlying skeletal framework and not a quantitative judgment on fat amount. It’s important to explain to the patient in the preoperative consultation that while every effort will be made to attempt the correction of such asymmetry, it is typically not guaranteed (▶Fig. 22.1).