Liposuction in the Massive Weight Loss Patient


Fig. 12.1

Case 1 preoperative markings indicate the circumvertical mastopexy, limited abdominoplasty, and torso areas for VASERlipo. The magnitude of anticipated liposuction is indicated from 1+ to 3+. Lipoaugmentation is indicated in green minuses. The limited abdominoplasty is designed to maximize lateral skin tension at closure with the least pull between the umbilicus and mons pubis



The operation begins prone with a roller pump diffuse infiltration of 4200 cc of saline from 3 liter bags that have 60 mL of 1% Xylocaine, 5 amps of epinephrine, and 1 g of cephalosporin. Infusions were 800 mL for the right back, 700 ml in the left back, 600 mL in the right flank 1050 left flank, and 500 mL in the sacrum, later 700 cc in the abdomen. Through strategically placed 1 cm incisions, plastic skin protectors were inserted followed by two ring probes at 80% VASER power. VASER times on the back were 3–4 minutes in each area except for 7 minutes over the sacrum and later 9 minutes over the sacrum. Loss of resistance was our main guideline.


Through a 3.7 mm VentX cannula which has four openings near the tip, 2600 ml of fatty emulsion was collected in a sterile glass cylinder. Each side of the upper back has 300 mL aspirated and 400 ccs from right flank and 500 mL from the left flank and the sacrum and 700 ml from the abdomen. From a total of 2700 mL fatty emulsion, 700 ml of fluid was decanted. The remaining emulsion was poured through a kitchen colander and from this blood-free 600 ml of usable fat was isolated. That was then scooped into 10 cc syringes and then injected through 2 mm blunt-tipped Coleman side-hole cannulas for 260 mL on the left lateral buttocks and 160 cc on the right buttock. Later when she was turned supine, 140 mL of fat was injected into the superior pole of the right breast.


While the lipoaspirate was collected by my assistants, superior pedicle circumvertical mastopexy was performed. The superior pedicle includes the central inferior pole of breast. The distal end was sutured up under the breasts to the pectoralis muscle at the second rib, looking like a scorpion’s tail. This auto augmentation central pedicles were supported with 4 × 6 inch strips of GalaFlex slings, a monofilament mesh of Poly-4-hydroxybuterate. The sling was suture to the underlying pectoralis muscle and then curled around the rolled central pedicle to be sutured to the 3, 6, and 9 o’clock positions on the areola, thereby securing the position of the imbricated central flap and restricting areola stretch. Then the lateral pillars were sutured under the raise central pedicle and the circumvertical closure with 3-0 PDO Quill.


The abdominoplasty was simply a cutout of the preplanned lower abdominal incisions, followed by minimal direct undermining to the level of the umbilicus along with VASERlipo indirect undermining of the epigastrium and then closure with #1 PDO Quill and 3-0 intradermal Monoderm over laterally placed JP drains.


At 10 months the anticipated results were obtained (Fig. 12.2). The breasts remain raised, rounded, and nearly identical in size. The superior poles remain full and the areolas small and at the most projecting aspect of the breasts. Her left lateral view shows an ideal 40–60 ratios of upper to lower pole fullness. She prefers the slight redundancy of skin at the IMF over an excisional scar. All torso contours are improved with no skin laxity. She went from rectangular figure to nearly an hourglass with her waist narrower and the buttocks rounder. Her waist-to-hip ratio changing from .90 to a more desirable .74. Soon to be married, she is now pleased with her unclothed appearance.

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Fig. 12.2

Case 1 at 10 months, the breasts remain raised, rounded, and symmetrical. Her left lateral view shows an ideal 40–60 ratios of upper to lower pole fullness. All torso contours are improved with no skin laxity. She went from rectangular figure to nearly an hourglass with her waist narrower and the buttocks rounder. Her waist-to-hip ratio changing from .90 to .74


While the first case of VASERlipo dominated throughout the body contouring, this second case shows its impact on the upper body while the lower body undergoes extensive revision excisional surgery. This 35-year-old male was dissatisfied with his gynecomastia and his lower torso extended abdominoplasty with three flank liposuction sessions 14 years previously after losing 50 pounds (Figs. 12.3, upper, and 12.4, upper). An oblique flankplasty was combined with a lipoabdominoplasty to solve the lower body skin and adipose redundancy [10]. The gynecomastia and upper body laxity was treated by VASERlipo followed by application of bipolar radiofrequency energy (BodyTite by InMode, Tel Aviv, Israel). His markings plan VASERlipo followed by BodyTite for the anterolateral chest and a lipoabdominoplasty with posterolateral extensions of oblique flankplasty that includes most of his extended abdominoplasty scars.



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Figs. 12.3 and 12.4

Upper. Case 2. 35-year-old male was dissatisfied with his gynecomastia and his prior extended abdominoplasty with multiple flank liposuctions. An oblique flankplasty was combined with a lipoabdominoplasty to solve the lower body skin and adipose redundancy. The gynecomastia and upper body laxity was treated by VASERlipo followed by application of bipolar radiofrequency energy BodyTite. His markings plan VASERlipo followed by BodyTite for the anterolateral chest and a lipoabdominoplasty with posterolateral extensions of oblique flankplasty. Lower. Case 2. The result 14 months later shows smooth and tight-skin torso that reveals underlying muscularity and upper body dominance with minimal scars


The operation begins prone with 700 ml of saline with Xylocaine and epinephrine infiltrated into each lateral chest. Three minutes of continuous single ring probe VASER energy, followed by 150 ml of fatty emulsion. Then bipolar radiofrequency was applied for 10 kilojoules each side. While the physician assistant was performing those tedious treatments, the resident and I and my surgical tech performed the oblique flankplasties. He was then turned supine for simultaneous treatment of the chest with the lipoabdominoplasty. Through VASERlipo, midline undermining, and LaRoe dissection, the prior incomplete limited abdominoplasty could be converted to a complete abdominoplasty. Meanwhile I applied VASERlipo and then BodyTite to the gynecomastia and anterior chest. Infiltrated into each breast was 700 ml of saline with Xylocaine and epinephrine. After 3 minutes of VASER, 150 ml was extracted through 3.7 mm VentX cannulas from each chest. Then BodyTite was applied for 11 minutes to the chest (see RFAL video). An hour later the lipoabdominoplasty was completed.


The result 14 months later shows the completed surgical transformation followed by revitalized muscle building workout routine. He has a smooth and tight skin torso that reveals underlying muscularity and upper body dominance with minimal scars (Figs. 12.3 and 12.4 lower).


The third case demonstrates the interplay of VASERlipo throughout major excisional body contouring surgery. This 27-year-old woman lost 100 pounds but despite the best efforts of her nutritionist, she was stuck at 31 BMI. She accepts being full bodied but wants to get rid of loose skin and unaesthetic adipose bulges. She desires a narrow-waisted, sensuous figure, which includes enlargement of her previously reduced breasts and lateral buttocks. Her preoperative markings indicate the proximity of VASERlipo areas to excision sites (Figs. 12.5, 12.6, 12.7, 12.8, and 12.9, left). Since she desired lipoaugmentation, VASERlipo was on VASER mode and reduced power. The emulsion was collected in a sterile cannister and reconstituted as before.


Nov 4, 2020 | Posted by in Aesthetic plastic surgery | Comments Off on Liposuction in the Massive Weight Loss Patient
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