Chapter 42 Liposuction of the lower extremities and leg reshaping with fat
Lower extremity fat reduction and reshaping of the legs and buttocks is a common request from French women patients. There are specific techniques required to achieve excellent results on the lower extremities (Figs 42.1 and 42.2).
FIG. 42.1 Patient 1 year postoperative after circumferential liposuction of the upper legs.
FIG. 42.2 Circumferential liposuction of upper legs and buttocks.
Patient 1 year postoperative. (A, B) Side view; (C, D) front view; (E, F) back view.
Since the original description of the lipoaspiration technique by Illouz in 1977,1–3 many authors have applied the principles of vacuum liposuction with a smooth blunt cannula and introduced some modifications to achieve better shape and contours, better skin retraction, and more fat removal.
When it comes to leg reshaping, the preoperative consultation is fundamental, permitting a good selection of patients based on the local and general conditions found at the interview and clinical examination. It is important to keep in mind the condition of the legs, especially the importance of skin quality, color, texture, elasticity and the quality of the vessels (essentially the veins), which should be respected as much as possible to avoid complications and lead to a good result (Figs 42.3 and 42.4).
FIG. 42.3 Limitation of results due to skin quality. 1 year postoperative.
FIG. 42.4 Patient no. 4, 1 year after circumferential liposculpture of legs and buttocks, lipectomy of abdomen and inner leg lifting – back view (A, B).
I believe that liposuction technique must be adapted to the quantity of fat you need to remove, the quality of the skin, and the expectations of your patient. It is really important not to dissociate the buttocks from the legs, because when we talk about corporal harmony, women look at the upper part of their bodies, essentially breast, shoulders and arms, then the abdomen, and are finally interested in having a nicer shape and size of their buttocks and legs.
It requires a systematic approach to meet the expectations of the patient, in terms of skin quality and improvement of size and shape. Almost 100% of patients seeking lower extremity liposuction are women.
During the consultation, systematic questioning is important to pinpoint serious contraindications and define predictable results with the patient.
Ongoing medication is noted. All medication is discussed with the patient and usually all vitamins and medications interfering with coagulation are kept to a minimum and removed for 14 days pre- and postoperatively. This is to avoid extensive bruises or hematoma, which could be painful postoperatively and favor deep venous thrombosis (DVT).
The medical history is important, such as cardiac arrhythmia, DVT, pulmonary embolism, and serious blood coagulation abnormalities.
During patient examination body weight, body mass index (BMI), and distribution of the fat, deep and superficial, are all noted, as are pre-existing varicose veins, which need to be documented by Doppler ultrasonic examination. The patient’s skin quality is also evaluated and discussed.
Photos are taken without underwear and shown to the patient, who might not have noticed a tendency to slight hypertrophy, a real hemicorporal hypertrophy, or simply an asymmetry in shape and contour. Skin irregularities, as well as difficult regions to treat, are marked on the patient and new photos are taken, kept in the file and discussed with the patient, especially areas which will not be improved by liposuction or areas where the skin likely will not retract once the fat is removed. This is to avoid misunderstanding and will help the patient realize that her final result is satisfactory.
If it is planned to transfer some fat to reshape the buttocks, the calves or the breast, special consent for lipofilling will be signed, as well for inner leg and buttock lifting.
Many women are candidates for leg reshaping, and for buttocks and breast fat grafting at the same time;4,5 therefore it is important to properly inform the patient in order to benefit from both techniques. At that final point of the consultation the photos are helpful and in certain cases will be signed and approved by the patient. The patient is also asked to select photos of her ideal legs and buttocks in magazines and bring them. This helps me to understand the patient’s expectations, which sometimes can be unrealistic and a reason to decline the surgery.
It has been my experience that an obese patient with bad quality of skin, venous malformations, and cardiac arrhythmia will not be a suitable candidate for the procedure.
For other patients, who do not have an accumulation of major risk factors, the decision is always taken individually.
For this surgery, it is always important to balance the esthetic, functional, and psychological benefit given with the risk of complications. As a natural consequence, surgeons not familiar with the technique should be more cautious when evaluating the indications and adapt the estimated volume of fat removed as well as the number of treated areas to their experience, not to exceed 10% of the corporal surface. With experience, total leg reshaping becomes easier and patients are satisfied. Lower extremity liposuction and reshaping is not a procedure for inexperienced surgeons. Proficiency in being able to produce safe, satisfactory outcomes along with patient selection is essential.
Three days before surgery pubic hairs should be clipped and specific garments such as a corset and stockings are fitted.
The patient showers with Betadine the night before and on the morning of the day of surgery.
Sedative Before Surgery
Antibiotic prophylaxis is given 1 hour before surgery to provide maximum serum concentration during surgery. If surgery is longer than 3 hours, another dose is given. Normally, we use a cephalosporin-type antibiotic.