Liposuction for Body Contouring

Simeon Wall Jr.

Liposuction as a means of body contouring continues to grow in popularity and technologic sophistication. Surgeons performing liposuction have a better understanding of fat anatomy and fluid management, along with better instrumentation and technique to provide a more predictable, smoother result, with less disruption to vascular supply. Despite more than 35 years of progress, including the ability to maintain patient safety in larger-volume liposuction procedures, no techniques or technologies to date have been able to break the “dose-response curve” seen in liposuction in which the dose is the increasing amount of fat removed from an area and the response is the tendency toward skin irregularities or contour deformities 1–6 (Fig. 29.1).

Most well-trained and experienced surgeons are able to work well within the boundaries that this dose-response curve dictates; however, sometimes the cosmetic results achieved fall short of patient or surgeon expectations, requiring secondary or even multiple procedures, none of which are capable of matching or exceeding the result that could have been achieved in an optimal primary procedure.

Many technologies have been advocated that purport to eliminate the uneven, irregular, wavy, or otherwise unsmooth appearance of the treated area seen as “too much fat was removed,” even though this amount of fat and skin-pinch thickness was the desired amount by the patient and surgeon. Most of these proposed technologies use thermal energy, namely ultrasonic, laser, or radiofrequency.⁷ The most recent addition has been water jet–assisted liposuction.⁸ Not only have these technologies so far failed to reduce complications from liposuction, they have added an unintended, second dose-response curve of creating contour deformities based on the thermal load imparted to the tissues. Among other factors, such as the power, energy type, and how it is applied, the treatment time itself becomes the main contributor to creating contour deformities.

Fig. 29.1 Traditional dose-response curve in liposuction. (Reproduced from Aly A, Nahas F. The Art of Body Contouring: A Comprehensive Approach. New York: Thieme; 2017.)

Revision Liposuction Versus Secondary Liposuction

Revision liposuction and secondary liposuction procedures differ in a few important ways. Revision liposuction refers to a repeat operation usually done by the same surgeon to improve on the first result or to fix something left undone or not optimally done during the first procedure. Secondary liposuction procedures are often, but not always, done by a different surgeon than the one who did the first procedure and are more extensive in nature than a “revision” procedure. Another distinction between revision and secondary liposuction is temporal. Secondary procedures are usually not done sooner than a year after the initial procedure, even if performed by the same surgeon.

Reasons for a Repeat Procedure

Repeat procedures are done for a variety of reasons, including unsatisfactory results or the need for further improvement. Many times, a liposuction patient simply seeks further reduction to an area that was already treated, either because of weight gain or because they were dissatisfied with the amount or distribution of the liposuction. A typical scenario is a patient who underwent “spot” liposuction, usually of the upper or lower abdomen only.9 Because the entire abdominal or truncal unit was not contoured comprehensively, the patient is dissatisfied with the remaining area(s) of adiposity and therefore presents for a more comprehensive procedure secondarily (Figs. 29.2 and 29.3).

Fig. 29.2 Prior liposuction of the circumferential trunk. (Reproduced from Aly A, Nahas F. The Art of Body Contouring: A Comprehensive Approach. New York: Thieme; 2017.)

Fig. 29.3 Prior liposuction with abdominal etching. (Reproduced from Aly A, Nahas F. The Art of Body Contouring: A Comprehensive Approach. New York: Thieme; 2017.)

The most common presentation is a patient who is dissatisfied and seeks a secondary procedure because of one or many contour deformities that resulted from an initial liposuction procedure. These contour deformities can be represented by overall skin waviness, hills and valleys, strange contours, or outright divots and depressions. In association with these contour deformities, many patients also have skin damage in the form of hemosiderin deposition, pigmentary changes, and scarring from thermal or avulsive liposuction methods. Internal scarring is represented by an unnatural static and/or dynamic appearance of the area, with tethering, tightness, and worsening appearance with positional changes or skin tension. External scarring is usually only seen with thermal methods of liposuction where there were entry site burns, or even internal burns so severe that the overlying skin was burned and scarred.

Avoiding Unfavorable Results and Complications in Liposuction for Body Contouring

Summary Box

Complications and Unfavorable Results Associated with Liposuction for Body Contouring

Complications

• Edema

• Ecchymosis

• Seroma

• Hematoma

• Undercorrection

• Overcorrection

• Skin laxity

• Fat embolism

• Deep venous thrombosis

• Hyperpigmentation

• Irregular scar

• Skin necrosis

Unfavorable Results

• Skin waviness

• Hills and valleys

• Strange contours

• Divots and depressions

• Skin damage (e.g., hemosiderin deposition, pigmentary changes, scarring)

• Internal scarring resulting in skin tension

• External scarring (i.e., thermal injuries such as entry site burns)

Difficulties Inherent in Repeat (Revision or Secondary) Liposuction

The feasibility of liposuction itself is based on the premise that there is a relatively low-resistance, “harvestable” subcutaneous adipose tissue layer between the higher-resistance planes of the overlying superficial fat and dermis above, and the underlying musculoskeletal structures below. This differential in resistance between these planes is what allows a cannula to easily pass through and stay in the target fat layer. Put simply, liposuction works because fat is less dense and easier to traverse, disrupt, and remove than the tissues that surround it.

Once a liposuction procedure has been performed, this treatable tissue layer is scarred, adherent, or even obliterated, making navigation and fat extraction more difficult and potentially more dangerous even for experienced hands. For example, in a primary liposuction procedure, when significant resistance is encountered at the cannula tip, this is generally a sign that the cannula should be redirected. In a revision or secondary procedure, this is not necessarily the case, so the surgeon must be able to discern whether the resistance is coming from a vital structure or from fibrotic subcutaneous tissue left from an earlier procedure.

This loss of differential resistance seen in repeat liposuction procedures is the main reason these procedures so commonly result in problems, such as skin “end hits,” because of the natural tendency for the surgeon to redirect superficially, preferring to err here rather than into deeper structures. The loss of this low resistance plane can also result in potentially fatal (and likely underreported) abdominal perforation or damage to other deeper structures.

Many competent and experienced body contouring surgeons avoid performing repeat liposuction procedures altogether, perhaps wisely. Plastic surgeons typically strive for beautiful results that “do no harm” to the patient, but when considering repeat liposuction, they are faced with two nearly universal truths that distinguish these procedures from most other revision plastic surgery procedures:

1. The result will never be as good as the result that could have been obtained from an optimally performed primary liposuction procedure.

2. The risk of significant or serious injury is significantly higher and outside the usual scope of a primary liposuction procedure.

Despite these and other difficulties faced in repeat liposuction procedures, revision and secondary body contouring with liposuction can be very gratifying and successful for patients and their surgeons given the appropriate approach, care, techniques, and expectations.

Repeat procedures are also associated with complications different from those commonly seen after primary liposuction procedures. Repeat liposuction can be compared to operating in concrete (Box 29.1). In these procedures, the differential in resistance between the intended plane and the unintended planes is narrowed, and sometimes eliminated. As outlined previously, this difficulty in navigating through scarred, adherent subcutaneous tissues increases the risk of damage to skin and to deeper structures, potentially creating a life-threatening complication. In addition, these procedures also take more time, another factor that increases overall risk. Obviously, in such an environment, fat extraction is more challenging, and smoothness and uniformity are more difficult to achieve.

Box 29.1 Difficulties Inherent with Revision Liposuction

• Like operating in concrete—narrower differential in resistance between subcutaneous plane and unintended planes

• Takes much more time than primary liposuction—more difficult to thoroughly extract fat

• High risk of damaging skin or deeper structures

• More bleeding

• Greater tendency for contour deformities—more difficult to achieve smoothness and uniformity

• Contour deformities already present

• Common need to fat graft

Cannula “misadventures,” injury to skin and body structure, vascular disruption and major bleeding, nerve damage, musculoskeletal injury, and internal organ perforation have all been reported. Although these injuries are possible with any liposuction procedure, they are more likely to occur in repeat liposuction, where there is a high-resistance, scarred, and confluent tissue bed that requires more cannula passes and greater force to adequately perform the procedure.

In traditional liposuction, the dose-response curve refers to the propensity toward contour deformities with greater amounts of fat removal 1 (see Fig. 29.1). This has been an issue in liposuction since its advent. Thermal methods of liposuction (laser, ultrasonic, radiofrequency, and others) were developed as an attempt to thwart this phenomenon but have failed in this regard and instead initiate a damage–response slope that can ultimately lead to contour deformities related to thermal injury.

Thermal Injuries

The thermal injury imparted to the tissues varies with the type and power of the device and how much energy is used, setting up a second “dose-response” curve of simply using the device (the treatment time) that contributes to the creation of a contour deformity by way of the thermal load imparted to the treated areas. In addition, the thermal injury caused by these devices is not restricted to targeted fat, but may affect nontargeted fat as well as the supporting stromal network of tissues: blood vessels, nerves, stromal connective network, and dermis. In repeat cases, in which fibrotic areas have been created from previous procedures, the longer treatment times required lead to more thermal damage, and the process starts all over, ending in yet more contour deformities, when the explicit goal was fewer (Box 29.2).

Box 29.2 Progression of Deformities with Repeat Liposuction

Laser/ultrasound-assisted lipectomy/radiofrequency

↓

Fibrotic area from previous liposuction

↓

Requires longer treatment times

↓

More thermal damage

↓

More fibrosis and scar formation

↓

More contour deformities

For these reasons I have abandoned internal thermal technologies and use only fat-preserving techniques and technologies for both primary and repeat liposuction cases. In addition, fat grafting and fat equalization is an integral part of all of my contouring cases, necessitating a healthy recipient bed and healthy fat for maximum survival and regenerative potential.

Underextraction

Many patients request repeat procedures for further fat reduction either because of underextraction during the initial procedure or because of reaccumulation of adiposity from weight gain. In these patients, it is easy to think that simply removing additional fat from the target areas is all that is required, sometimes referred to as spot liposuction. In practice, however, even a straightforward repeat liposuction patient can be deceptively difficult to retreat with liposuction given the scar tissue and fibrosis encountered in nearly all of these cases. At best, these patients exhibit a denser, more fibrous area to reliposuction, making it more difficult to evenly extract more fat. More commonly, these patients have fibrotic deep fat compartments mostly devoid of suctionable fat, with only a relatively superficial zone of fat to be navigated, having a variable amount of fibrosis and tethering to the overlying dermis and underlying fascia. For this reason, no repeat liposuction patient should be approached as a simple case.

SAFELipo

An ideal body contouring procedure will seek to be comprehensive in nature, with applicability in most or all situations. For most patients, this requires not just the removal of fat tissue, but also fat grafting and fat redistribution. The SAFELipo technique (Separation, Aspiration, Fat Equalization) was developed specifically for repeat liposuction cases, in which fat grafting is often required, and the previously mentioned issues (scarring, existing contour irregularities, etc.) often exist (Box 29.3). It is a multistep approach of comprehensive fat management that not only reduces fat through liposuction, but can augment and redistribute fat. There are other techniques used in repeat procedures, but this chapter focuses on SAFELipo and its application in repeat procedures, the technique used by this author exclusively for both primary and secondary liposuction on all parts of the body and face. There will inevitably be a significant amount of overlap in how these techniques are used in primary versus secondary procedures, but this chapter specifically addresses how SAFELipo is used in repeat procedures.

Box 29.3 SAFELipo Process

1. Separate fat from its attachments without damaging the supporting structures by nonthermal mechanical emulsification and liquification of the fat.

2. Aspirate the separated fat preferentially without causing suction avulsion injury to the supporting structures, a bloodless process.

3. Equalize the fat in the remaining bed, leaving a smooth layer of local fat grafts to prevent scar and contour deformities.

Additional step for repeat SAFELipo:

4. Perform fat shifting, fat grafting, and release processes to improve the residual defects and volume deficiencies.

SAFELipo is different from other forms of advanced liposuction techniques in a few important ways that become apparent as the individual steps are explored. Of note, SAFELipo incorporates a process approach to fat contouring, with specific, repeatable delineated steps that standardize and simplify surgeries. A similar process approach has been applied to other cosmetic surgical procedures (e.g., breast augmentation) and has been shown beneficial. Furthermore, in contrast to thermal and avulsive forms of liposuction (standard suction-assisted liposuction), SAFELipo greatly reduces the risk of disrupting blood vessels and support structures, while at the same time maximizing the potential for an aesthetically pleasing outcome.

Another differentiator with SAFELipo is that avoiding the zones of adherence is unnecessary, because a contour deformity is not created using fat separation and fat equalization. Rather, during the fat separation stage, the zones can be nav igated, and the only time to be wary of these zones is when performing fat aspiration. Thus SAFELipo allows for much more comprehensive treatment without creating problems.

Indications and Contraindications

Good candidates for repeat liposuction, in general, have a body mass index of 30 or below, good diet and exercise habits, and reasonable expectations regarding outcomes. For patients who request a secondary liposuction procedure to address reaccumulation of fat, these factors become even more important. Patients who were not adherent to postoperative care after their first procedure or who quickly gained weight after a previous body contouring procedure might be considered suboptimal candidates for a repeat procedure.

Because a patient requesting a repeat procedure has already had a negative experience, carefully explaining what to expect from a repeat procedure is important. Obviously, if the surgeon is not able to completely fix the areas that are not aesthetically pleasing, this should be explained to the patient before he or she undergoes a second or third procedure. In addition, it is important to ensure the patient understands the limitations inherent in repeat procedures and the likelihood that the result will not be as optimal as might have been obtained with a better-performed first procedure. This is particularly true if the initial procedure involved the use of thermal liposuction because of the excessive amounts of scarring and fibrosis seen in these cases. In some cases, when patients have undergone one or more procedures using internal laser-assisted liposuction, no significant improvement can be gained; these patients should be advised not to undergo another procedure. If the patient’s expectations are not likely to be met by any available techniques, or if the amount of surgery required becomes excessive to gain only a modest improvement, these situations are good indicators that any operative plan will fail to ultimately please the patient.

Similar to revision rhinoplasty, I wait at least 1 year before performing a secondary procedure. That time is needed to ensure all swelling has resolved and that the tissues are as pliable, soft, and elastic as they can be. In addition, given the typical need to add, redistribute, and subtract from an area, a stable, unchanging tissue bed is required before planning reoperation. Most patients with moderate to severe contour deformities need 18 months to 2 years for the area to “settle” before attempting a significant repeat liposuction operation; the longer the time interval between the original surgery and the repeat operation, the higher the chances for long-term improvement and success.

Patient Evaluation

Some patients are left with so little subcutaneous fat after their initial procedure (and previous repeat procedures) that it is impossible to perform another procedure. Even with the SAFELipo process, there needs to be some amount of residual fat to create a smooth and natural-appearing contour. Cases that rely on pure fat grafting to create a smooth appearance are very difficult to execute and should be approached with extreme caution, if at all.

Fig. 29.4 Preventing contour deformities: markings to avoid the midbuttocks. (Reproduced from Aly A, Nahas F. The Art of Body Contouring: A Comprehensive Approach. New York: Thieme; 2017.)

Preoperative Planning and Preparation

As with primary liposuction, intermittent or sequential compression devices on the lower extremities are applied before induction of anesthesia and used throughout the surgery and for several days postoperatively, or until the patient is ambulating normally. Passive and active patient warming maneuvers are used from an hour before surgery until discharge from recovery to prevent hypothermia. Hypothermia, or a core temperature drop to below 36°C at any time during surgery, has been shown to increase bleeding, postoperative nausea and vomiting, and wound infection. Anecdotally, I have also seen more difficulty in postoperative pain management in patients who became hypothermic during surgery. Forced air units, heat-retaining stockinettes, circulating hot water mattresses, intravenous fluid warmers, warm infiltration fluids, warm prep solution, and a warm (74°F) room during the prep are used for significant primary or repeat body contouring procedures.

Fig. 29.5 Single whole body prep. (Reproduced from Aly A, Nahas F. The Art of Body Contouring: A Comprehensive Approach. New York: Thieme; 2017.)

Surgical Technique

The application of a process approach to liposuction, whether primary or repeat, simplifies the technique on many levels and allows for a much more complete treatment of the targeted areas, whether they require removal, redistribution, or addition of fat. As opposed to other methods of liposuction, any or all excess fat can be removed smoothly from the targeted areas without fear of causing skin injury or contour deformity.

Anesthesia

Repeat liposuction procedures are typically performed with general anesthesia. Except for minor touch-up procedures, repeat liposuction procedures do not lend themselves to being performed with local, tumescent, or conscious sedation anesthesia for the same reasons these methods are avoided for significant primary liposuction procedures. In addition, the dense scar tissue and unnavigable tissue planes that are commonly encountered limit the surgeon’s ability to easily, completely, and painlessly pass infiltration, separation, or liposuction instruments.

Markings

Repeat liposuction procedures usually require distinct topographic markings to clearly delineate the hills and valleys. It is wise to have a relatively detailed map of the areas to be reduced, redistributed, or augmented—usually represented by concentric black rings for reduction and cross-hatched markings in red for areas of redistribution or augmentation. It is also useful to make orientation marks on the treated areas to aid in symmetry while treating in various body positions (Fig. 29.4).

Patient Positioning

The positioning for repeat liposuction does not inherently differ from that of primary liposuction. That said, I avoid the prone position whenever possible. Adequate padding of all pressure points including at any positional changes is important, as is careful sterile prepping and draping. I prefer to do a single whole body prep with the sterile field extending from the neck down to the end of the bed so the patient can be moved into different positions during the procedure with no further prepping needed (Fig. 29.5).

Revision liposuction using the SAFELipo process is typically performed in three positions—supine and both the left and right lateral decubitus positions. Although evidence is currently lacking, turning the patient multiple times including into the lateral decubitus positions may reduce the risk of deep venous thrombosis and pulmonary embolism, because venous pressure is decreased on the elevated side, decreasing pooling and improving pelvic venous drainage.

Performing liposuction from these three positions can help prevent contour deformities, including “shark bites” in the midbuttocks and other common stigmata of liposuction (Fig. 29.6). Some surgeons perform the procedure with the patient mostly in the supine position. Contouring in this nonanatomic position of the lower extremities can lead to overcorrection or undercorrection, commonly seen as contour deformities of the midbuttock areas.