Liposuction and Fat injection Liposuction Lipoplasty Lipolysis ...

ע" 

שת/ 

תבט/ 

ג" 

י 

1 

Liposuction and Fat injection 

Noam Hai M.D 

Sha’are Zedek Medical Center 

Liposuction 

Lipoplasty 

Lipolysis 

Adipoaspiration 

Blunt Suction Lipectomy (BSL) 

Suction Assisted Lipectomy (SAL) 

Liposculpture

ע" 

שת/ 

תבט/ 

ג" 

י 

2 

Prehistory 

Ancient and Modern concepts 

of feminine beauty 

• Rhythmic cultures 

• Men - Dominant 

• Sun is worshiped 

• Straight line prevailed 

over the curve 

• Melodic cultures 

• Women - Dominant 

• Moon is worshiped 

• Curve predominates

ע" 

שת/ 

תבט/ 

ג" 

י 

3 

Rhythmic cultures: Egypt 


Mikerinos

ע" 

שת/ 

תבט/ 

ג" 

י 

4 


Amenofis 

Rahotep 

Rhythmic cultures: Greece 

Ilio-Femoro-Rotulian Ilio-Femoro-Rotulian-Line Line 

(IFRL) 

3 Graces 100 B.C

ע" 

שת/ 

תבט/ 

ג" 

י 

5 

Rhythmic cultures: Rome 

1/8 

Venus de milo 

200 B.C 

Rhythmic cultures: Renaissance 

Botticelli

ע" 

שת/ 

תבט/ 

ג" 

י 

6 


Titian 


Velasquez

ע" 

שת/ 

תבט/ 

ג" 

י 

7 


Rubens 

Melodic cultures: Paleolithic age 

35,000 - 10,000 B.C 

• Willendorf Venus 

• Austria (1908) 

• 30,000 B.C 

• Most ancient 

Paleolithic statue

ע" 

שת/ 

תבט/ 

ג" 

י 

8 


35,000 - 10,000 B.C 

• Laussel Venus 

• Pyrenean (1908) 

• 22,000 B.C 


35,000 - 10,000 B.C 

• LespugneVenus 

• Italy (1922) 

• 20,000 B.C

ע" 

שת/ 

תבט/ 

ג" 

י 

9 

Melodic cultures 

Steatomelia 

Malta Dreamer 

Steatopygia 

Genetic Predisposition 

Ice age 

Fat = Energy store

ע" 

שת/ 

תבט/ 

ג" 

י 

10 

Clothing 

Hoop skirt 

Clothing 

The Bustle

ע" 

שת/ 

תבט/ 

ג" 

י 

11 

Today 

Lipodystrophy 

Surgical goal 

“...To achieve and maintain 

a slim and athletic figure…” 

Upper body / Lower body 

proportion

ע" 

שת/ 

תבט/ 

ג" 

י 

12 

Body contouring techniques 

1960-1970’s - Dermolipectomy 

• Abdominoplasty 

• Pitanguy‟s operation 

PRS 1964 

(Blair O. Rogers) 

Body contouring techniques 

Pitanguy’s operation - disadvantages 

• Long coarse scars 

• Delayed healing 

• Dehiscence 

• Recurrent deformities 

• New (Post-op) 

deformities 

• Taboo zones: Hips, 

knees, ankles

ע" 

שת/ 

תבט/ 

ג" 

י 

13 

“…You have to learn what 

others have done since you 

will not live long enough to 

make all the mistakes 

yourself…” 

Collapsing / Subcutaneous surgery 

• Closed blind lipectomy 

• Minimal (

ע" 

שת/ 

תבט/ 

ג" 

י 

14 

History 

“…The first malpractice suite 

for aesthetic surgery was 

against Dujarier 

after curette calf reduction 

(France 1929) …” 


Curette/Sharp technique 

• Schrudde Germany „64 - ‟72 

• The Fischers Italy „76 - ‟77 

• Kesselring Switzerland „78 

& Meyer 

• Teimourian „77 - ‟81 

& Fisher

ע" 

שת/ 

תבט/ 

ג" 

י 

15 


Cannula/Blunt technique 

• Y.G IllouzFrance „77 - „80 

• Fournier France „79 - „82 

• & Otteni 

Curette technique - Lipexheresis 

Schrudde - Germany 

• 2-3 cm incisions 

• Long scissors blind 

undermining 

• Uterine curette removal 

of adipose tissue 

• Outer thighs 

• Inner knees 

• Calves & ankles 

Severe complications: 

• Persistent 

lymphorrhea 

• Hematomas 

• Skin necrosis 

• Unreliable results in 

other surgeon‟s hands 

Abandoned

ע" 

שת/ 

תבט/ 

ג" 

י 

16 

Curette technique - Suction curette 

Arpard & George Fischer - Italy 1977 

• First to combine 

suction to curettage 

• Cellusuctiotome - their 

portable device 

• Plannotome - pocket 

creation 

• Crushing -> Suction 

• Manual (Pinching) & 

visual (vacuum jar) 

monitoring 

• Suction drainage - 15d 

• Bed rest 5-6 days 

Complications: 

• Continuous oozing 

• Seromas with fibrous 

encapsulation 

• Skin undulations 

• High complication rate 

Curette - Kesselring technique 

Ulrich Kesselring - Switzerland (1978) 

• Large scissors 

undermining 

• Sharp curette attached 

to vacuum machine 

• Tissue first cut then 

easily sucked out 

• Only trochanteric 

lipodystrophy 

• Young, good skin tone 

Good results

ע" 

שת/ 

תבט/ 

ג" 

י 

17 

Curette - Teimourian modification 

1977-1981 

• Sharp instruments: 

Scissors, modified Fascia 

Lata stripper 

• Uterine/Kesselring 

curette 

• More sites: Buttocks, 

knees,ankles,arms,flank 

• Combination procedures 

• 30% seroma - related to 

sharp dissection 

Curette technique - Conclusion 

• Cavity formation prior to suction 

• Destruction of most Fascio-cutaneous 

septa 

• Blood, nerves, lymph vessels disruption 

• Bleeding, Lymphorrhea 

• Persistent seroma -> prevention of skin 

retraction -> skin laxity & ptosis

ע" 

שת/ 

תבט/ 

ג" 

י 

18 

Curette technique - Conclusion 

Cannula/ Blunt technique 

Yves Gerard Illouz - France (1977-1980) 

• Blunt dissection 

• Sparing of the multiple 

septa containing 

neurovascular & lymphatic 

elements 

• Selective partial lipectomy 

• Sponge / Honeycomb / 

Spider-web pattern

ע" 

שת/ 

תבט/ 

ג" 

י 

19 

Cannula / Blunt technique 

Advantages over curette 

• Few taboo zones - practically any body part 

with excess fat 

• Several areas simultaneously 

• Multiple indications: Lipomas (Single/Multiple) 

Gynecomastia, Lipodystrophies 

• Adjunct to other procedures (Dermolipectomy) 

Abdominoplasty, Thigh lift, Breast reduction 

Rhytidectomy (esp. neck), flap defattening, 

Scar revision 


Old subdivision 

• The original wet technique of Illouz: 

Mildly hypotonic solution + Hyaluronidase 

• The dry technique of Fournier 

• The new wet technique of Hetter: 

Low dose epinephrine

ע" 

שת/ 

תבט/ 

ג" 

י 

20 


New subdivision 

Technique Infusate : Aspirate 

• Dry No infusate 

• Wet 1 : 2 

• Superwet 1-1.5: 1 

• Tumescent 3-6 : 1 

Adipose tissue in the past 

• Adipose tissue was long neglected by 

anatomists 

• Considered to be coverage of muscles, bones 

nerves and vessels 

• Inert / inactive reservoir

ע" 

שת/ 

תבט/ 

ג" 

י 

21 

Adipose tissue today 

• Fat tissue is vital for our life 

• Most energy rich fuel (9 Kcal/gr) 

• Dynamic and metabolically very active 

• Has physiological as well as pathophysiological 

role: NIDDM, Hypothyroidism, Hyperlipidemia 

• Daily turnover: 100-150 gr/day (70 kg adult) 

• X2 in stress, hunger, intense physical activity 

Adipose tissue - Main functions 

• Store and release FFA according to energy 

demands 

• Lipolysis: exerted by Lipoprotein Lipase (LPL) 

Triglycerides (TG) -> Glycerol + 3FFA 

• Lipogenesis: 

3FFA + Alfa Glycerol Phosphate -> TG 

• FFA Bind to Albumin, transported to peripheral 

tissue for oxidation

ע" 

שת/ 

תבט/ 

ג" 

י 

22 

FFA Outcomes 

Embryology 

• Adipose tissue evolves around subdermal 

capillary roots - 3 rd month 

• Adipoblasts - perivascular connective tissue 

• -> Preadipocytes -> TG production -> 

Mature adipocytes 

• Replicative burst of adipocytes - Puberty 

thereafter their number is relatively fixed

ע" 

שת/ 

תבט/ 

ג" 

י 

23 

Embryology 

Bjornthorp’s theory 

Embryology 

• In severe obesity when adipocytes reach 

maximal capacity -> postadipocytes 

• They regain replicative properties 

• Upper limit to fat cell size: 2-5 X normal 

• Clinically: BW > 150% Ideal BW (IBW) 

• Hypertrophic growth -> Hyperplastic

ע" 

שת/ 

תבט/ 

ג" 

י 

24 

Patterns of obesity 

Adipose cellularity 

• Hyperplastic obesity: Rare type, begins in 

early childhood, increased cell number 

• Resistant to diet, exercise etc. 

• Hypertrophic obesity: Most common, begins 

in adulthood, increased cell volume 

• Responds to diet, exercise etc. 

• Android obesity: Upper body accumulation, 

most frequent in males. 

• High risk for cardiovascular, atherosclerotic 

and metabolic complications (IHD, HTN, 

CVA, NIDDM) 

• Gynecoid obesity: Lower body accumulation, 

most frequent in females 

• Low risk 


Distribution pattern

ע" 

שת/ 

תבט/ 

ג" 

י 

25 

Android 


Distribution pattern 



Gynecoid

ע" 

שת/ 

תבט/ 

ג" 

י 

26 

Metabolism 

Active vs. “Reserve” fat 

• In animals many hormones regulate fat 

metabolism 

• In humans there are 2 hormones involved in 

acute regulation of fat metabolism: 

• Insulin & catecholamines 

• There are 2 receptors to catecholamines 

with antagonistic properties 

Metabolism 

Active vs. “Reserve” fat

ע" 

שת/ 

תבט/ 

ג" 

י 

27 

Metabolism 

Active vs. “Reserve” fat 

Metabolism 

“Reserve fat” was coined by Y.G Illouz 

Active fat cells 

• Beta 1 receptors 

• Lipolytic 

• Diet sensitive 

• Activated by: fasting, 

hunger, tobacco, 

caffeine 

• Upper body, Breast, 

Face 

Reserve fat cells 

• Alpha 2 receptors 

• Block lipolysis 

• Diet resistant 

• Resist amphetamines 

& derivatives 

• Lateral thighs, lower 

abdomen, buttocks

ע" 

שת/ 

תבט/ 

ג" 

י 

28 



Anatomy - some facts 

• Women have higher % of fat (Thicker adipose 

tissue throughout) 

• Weight is genetically determined (Twin studies) 

• Infants have 1/5 the fat concentration of adults 

• Extremities lose fat with age 

• Fat tends to accumulate intraabdominally 

• Blacks tend to accumulate fat in the buttocks, 

further magnified by their lumbar lordosis

ע" 

שת/ 

תבט/ 

ג" 

י 

29 

Anatomy 

Anatomy

ע" 

שת/ 

תבט/ 

ג" 

י 

30 

Adipose tissue sections 

in different sites 

SL - Superficial Layer 

DL - Deep Layer 

SQF - Subcutaneous 

(Superficial) Fascia 

Anatomy - SFS 

• The SFS & relation to muscle fascia 

determines individual contour. 

• Skin creases and plateaus: 

• Creases - where SFS is most adherent to 

muscle fascia or periostium (Ant. & Post. 

midline, inguinal, gluteal creases 

• Bulges - over fat deposits the SFS is least 

adherent (LFD‟s)

ע" 

שת/ 

תבט/ 

ג" 

י 

31 

Anatomy - SFS 

• Supf. Fascial System (SFS) - The human 

derivative of the Panniculus Carnosus (FODOR) 

• Abdominal SFS = Scarpa‟s fascia 

• Panniculus Carnosus: A thin sheet of striated 

muscle lying within or just beneath the supf. 

fascia serving to produce local skin 

movements 

• Well developed in lower mammals. In human 

primarily represented by the platysma 

Anatomy - Cellulite

ע" 

שת/ 

תבט/ 

ג" 

י 

32 

Anatomy - Cellulite 

Cellulite 

Chesterfield sofa phenomenon

ע" 

שת/ 

תבט/ 

ג" 

י 

33 

Two types of cellulite 

Lockwood 

• Primary (Illouz‟s): hypertrophied fat within 

anchored retinacula cutis 

• Secondary: related to skin laxity, women >35 

Associated with: aging, sun, massive weight 

loss or liposuction 

• Supf. fat - SFS - skin stretch -> ptosis -> 

pseudo LFD and cellulite 

• Corrected with surgical tightening of skin & 

SFS 

Nomenclature

ע" 

שת/ 

תבט/ 

ג" 

י 

34 

Anatomy - LFD’s 

(LFD) Localized Fat Deposit = Steatoma

ע" 

שת/ 

תבט/ 

ג" 

י 

35 

Well limited LFD 

Resembles lipoma 

1. Ileofemoral 

2. Middle femoral 

3. Ant. Femoral 

4. Post. extension 

Borders: 

Sup - supratrochanteric 

depression 

Ant - Fascia lata 

Trochanteric LFD 

Riding Breeches 

Trochanteric LFD 

Riding Breeches 

Inf - Middle 1/3 of thigh 

Post - Midpoint of gluteal 

crease

ע" 

שת/ 

תבט/ 

ג" 

י 

36 

In most cases: 

Supf. fat hypertrophy 

Except in: 

Blacks 

Brazilian mulattos 

Asians 

Buttocks 

Not a true LFD 

Buttocks 

Gluteal fold 

Ligament of Charpy = Ischiocutaneous 

ligament of Luschka: Triangular fibrous 

structure responsible for the fixed medial 

part of the gluteal crease (Hinge theory)

ע" 

שת/ 

תבט/ 

ג" 

י 

37 

Borders: 

Sup - 12 th ribs 

Ant - Abdominal mm. 

Inf - Iliac crest 

Post - Lumbar mm. + 

vertebral extension 

The hips 

Medial thigh 

Minimal amount of fat 

Must be preserved to protect vulva 

Hindrance - both sides rub when walking 

Poor redraping, natural depression

ע" 

שת/ 

תבט/ 

ג" 

י 

38 

Abdomen 

• LFD only in lower 1/2 

• Less than expected 

• Upper abdomen No LFD 

• Supf. fat hypertrophied 

• Dense/fibrous supf. Fat 

• Iliac crests 

• Umbilicus 

• Pubis 

Borders: 

Knees 

Well demarcated LFD - Medial aspect 

Maximal bulge at the level of condyle 

Anteromedial extension should also be treated

ע" 

שת/ 

תבט/ 

ג" 

י 

39 

Thin deep layer 

Thick supf. Fat 

(circumferential) 

Deltoid area 

pseudolipomatose 

Arms 

Face & Neck

ע" 

שת/ 

תבט/ 

ג" 

י 

40 

How to classify a roll ? 

LFD vs. supf. fat hypertrophy 

Diet responsiveness 

Early vs. late occurrence 

• Dorsal rolls 

• Iliac crest rolls 

Dorsal rolls

ע" 

שת/ 

תבט/ 

ג" 

י 

41 

“Special” deformities 

Violin deformity 


Double gluteal fold / “Banana” roll

ע" 

שת/ 

תבט/ 

ג" 

י 

42 


Marked gluteal depression 

LFD’s - Female

ע" 

שת/ 

תבט/ 

ג" 

י 

43 

LFD’s - Male

ע" 

שת/ 

תבט/ 

ג" 

י 

44 

Patient 

Evaluation 

Patients to avoid 

• Psychotics - Dysmorphophobia 

• “Dreamers” - Unrealistic expectations 

• Perfectionists - Minimal deformity raises 

substantial worry 

• Long history of: 

• Sun 

• Alcohol 

• Tobacco

ע" 

שת/ 

תבט/ 

ג" 

י 

45 

Obvious “poor” candidates 

• Marked obesity (Relatively minimal change) 

• Poor skin quality especially obvious 

redundancy 

• Repeated weight gain & loss (Yo-Yo dieting) 

destroys elasticity & redraping capability 

• Age in correlation to skin quality: same skin 

quality 20 vs. 60 y.o prefer the older patient 

Obvious “good” candidates 

• Young, slim, only a small bulge 

• Firm, smooth, tight skin 

BUT 

• Such patients are often extremely 

demanding and perfectionists 

• No defect, even an unnoticeable one will be 

forgiven

ע" 

שת/ 

תבט/ 

ג" 

י 

46 

“…a less demanding “poor” 

candidate is sometimes a 

better candidate than a 

“good” candidate…” 

Unsolvable problems 

• Cellulite / Peau d‟orange 

• Liposuction may worsen cellulite 

• Small skin excess may become more 

pronounced 

• Double gluteal (“banana”) roll may be 

exaggerated 

• Size reductions: “the entire lower body from 

waist down” 

• Difficult / Non forgiving areas

ע" 

שת/ 

תבט/ 

ג" 

י 

47 

Diagnostic clinical tests 

• Quantity - Is there sufficient fat to remove? 

• Quality - Will there be enough skin retraction? 

• Prognostic - How will the area appear after 

suction? 

Quantity tests 

• There are “false positive” LFD‟s 

• Bony skeleton - coxa vara 

• Prominent muscles 

• Accordionization of skin 

• Omental / Intra-abdominal fat 

• Megacolon 

• LFD‟s < 1.5 cm are not for suction

ע" 

שת/ 

תבט/ 

ג" 

י 

48 

• Fingers / caliper 

• Divide in 2 

• Static / dynamic 

• Tiptoeing 

• Buttock 

contraction 

• Less fat in pinch 

Static pinch test 

Dynamic pinch test

ע" 

שת/ 

תבט/ 

ג" 

י 

49 

Dynamic test for trochanteric 

lipodystrophy 

Dynamic test for trochanteric 

lipodystrophy

ע" 

שת/ 

תבט/ 

ג" 

י 

50 

• Discover this 

pseudodeformity 

• Lateral & inferior 

weight transfer of 

buttocks 

• suction directed 

towards buttocks 

& hips 

Accordionization 

Trimming test

ע" 

שת/ 

תבט/ 

ג" 

י 

51 

• Lifting thigh skin 

towards iliac crest 

• Deformity does not 

disappear -> no 

skin excess 

• Good candidate for 

suction 

• Xerogram 

• US 

• CT 

• MRI 

Lifting test 

Imaging

ע" 

שת/ 

תבט/ 

ג" 

י 

52 

• Appearance test 

• Percussion test 

Quality tests 

• Floating / Trembling test 

• Speed of retraction test (turgor) 

Reclining test

ע" 

שת/ 

תבט/ 

ג" 

י 

53 

If D

ע" 

שת/ 

תבט/ 

ג" 

י 

54 

• Manual compression 

reveals skin 

irregularities 

foretelling 

postoperative 

appearance 

Compression test 

The law of skin retraction 

If H

ע" 

שת/ 

תבט/ 

ג" 

י 

55 

Specific pitfalls 

• The fascia lata in trochanteric lipodystrophy 

• The double gluteal fold 

• The postoperative banana 

Planning the procedure 

• Which areas should be treated 

• How many areas should be treated in one 

session 

• What should be done in each area 

• When should the operation be scheduled

ע" 

שת/ 

תבט/ 

ג" 

י 

56 

Planning the procedure 

Preoperative markings

ע" 

שת/ 

תבט/ 

ג" 

י 

57 

Preoperative markings 

Preoperative markings

ע" 

שת/ 

תבט/ 

ג" 

י 

58 

Physics & 

Equipment 

Max vacuum = 

1 Atm

ע" 

שת/ 

תבט/ 

ג" 

י 

59 

1. Absolute vacuum 

(vaporization) 

2. Air “leak” 

The “ideal” Cannula

ע" 

שת/ 

תבט/ 

ג" 

י 

60 

Syringe pros: 

The “ideal” Cannula 

“Cobra” 

Syringe vs. pump 

• Less blood in aspirate 

• Less bruising & morbidity 

“Mercedes” 

In-line multihole 

• Reduced dead space (no vaporization) 

• faster healing shorter convalescence 

• Quiet O.R 

• No aerosol 

• Easy washing and storing fat 

• easy transportation to other facilities

ע" 

שת/ 

תבט/ 

ג" 

י 

61 

Syringe cons: 

• Time consuming 

• “Untidy” 

Syringe vs. pump 

In conclusion 

• Syringe is best suited for : 

• Small removals Size removals - pump 

• Touchup procedures 

• Fat graft harvesting 

• Superficial liposuction (?) 

Technique

ע" 

שת/ 

תבט/ 

ג" 

י 

62 

Pretunneling 

Criss-cross pattern

ע" 

שת/ 

תבט/ 

ג" 

י 

63 

Radiating tunnels 

Concealed incisions

ע" 

שת/ 

תבט/ 

ג" 

י 

64 

Concealed incisions 

Multiple entry stabs

ע" 

שת/ 

תבט/ 

ג" 

י 

65 

Positions - Supine 

1 2 

3 

Positions - Frog leg 

4

ע" 

שת/ 

תבט/ 

ג" 

י 

66 

Positions - Frog leg 

Positions - Prone

ע" 

שת/ 

תבט/ 

ג" 

י 

67 

Positions - Upright 

Intraoperative evaluation

ע" 

שת/ 

תבט/ 

ג" 

י 

68 

Fluids & Blood 

Wetting solutions 

Estimated hematocrit in aspirate 

• Dry (Fournier & Otteni) 5-54 (25%) 

30-46 (35%) 

• Original wet (Illouz) 20-25% 

100 NS + 20 Water + Wydase 1 unit/ml 

Overall 100-300 regardless of aspirated volume

ע" 

שת/ 

תבט/ 

ג" 

י 

69 

Wetting solutions 

Estimated hematocrit in aspirate 

• Wet (Hetter‟s solution) 8.7% -> 6.6% 

1 cc/cc 

0.25% Lidocaine + 1:400,000 Epinephrine 

• Tumescent (Klein 1990) @ 1% 

• 1-3 cc/cc or until turgid 

0.05-0.01% Lidocaine + 1:10 6 Epinephrine 

Superwet / Tumescence 

Pros Hunstad et al. 

• Eliminating the need for GA 

• Reduced blood loss 

• Reduced bruising -> Rapid recovery 

• Increased accuracy of removal (expansion 

of fat deposits) 

• Prolonged local analgesia 

• Better aesthetic result, less irregularities 

• High overall patient satisfaction

ע" 

שת/ 

תבט/ 

ג" 

י 

70 


Cons 1 Pitman et al. 

• Local anesthesia - not suited for all patients 

• Some may need sedation to fully relax 

• May require high -> toxic levels of lidocaine 

• Prolongs operative time 

• Although blood loss reduced, don‟t forget to 

prepare blood 

• May cause fluid overload -> cardiac / pulm. 

decompensation / Congestive failure 


Cons 2 Pitman et al. 

• May cause fluid overload -> cardiac/pulmonary 

decompensation -> Congestive heart failure 

• Aspirate contains more water -> Larger 

volumes should be removed (compensation) 

• Large clysis changes the feel & appearance of 

tissue -> altered tactile & visual cues to 

determine endpoints of liposuction

ע" 

שת/ 

תבט/ 

ג" 

י 

71 

Blood & fluid replacement 

“Internal burn” theory 


• Hetter estimated 1% drop in Hct for 150cc 

• Autologous blood recommended for 

removals > 1500cc 

• Pitman & Holzer: Autologous blood 

indicated if at the end of procedure: 

Hct25% 

• Removals of >15% BSA increase morbidity 

out of proportion 

• Autologous Blood increases safety

ע" 

שת/ 

תבט/ 

ג" 

י 

72 

“…Almost all lethal 

complications of liposuction 

stem from failure to maintain 

normal intravascular volume 

with resultant poor tissue 

perfusion…” 


Remember: 

• Fluid loss continues for >36 hours postop. 

(3rd space) 

• Clinical monitoring (Pulse, BP, Orthostatic 

BP, urine output) more accurate than Hct. 

• Maintain fluids to prevent tissue hypoxia, 

oliguria and renal failure, 

hemoconcentration and thromboembolism

ע" 

שת/ 

תבט/ 

ג" 

י 

73 

Dry 



3000cc 

IV 2:1 + 2 unit 

autologous blood 

Wet 

2500cc 

1:1 IV Intraop + 

1:1 IV Postop + 

1-2 units 

autologous blood 

for Hct

ע" 

שת/ 

תבט/ 

ג" 

י 

74 

Dressing / pressure garment 

Dressing / pressure garment

ע" 

שת/ 

תבט/ 

ג" 

י 

75 

5 Phases of convalescence 

Hetter 

1. Bandage phase (days 1-7) 

2. Fatigue phase (days 7-15) 

3. Disappointment phase (days 16-25) 

Massage is invaluable in this phase 

4. Relief phase (days 26-42) 

5. Satisfaction phase (>6 weeks) 

Complications

ע" 

שת/ 

תבט/ 

ג" 

י 

76 

Complications 

• Severe (Major, Mortal) complications 

• Minor complications 

• Sequelae / Transient conditions 

• Aesthetically unfavorable results 

Severe complications 

1. Fluid overload -> Pulmonary edema (CHF) 

2. Pulmonary embolus (PE) 

3. Fat Embolism Syndrome (FES) 

4. Myocardial infarction (MI) 

5. Renal failure (ARF) 

6. Massive (overwhelming) infection 

7. Viscus perforation: intestine, liver, spleen, 

lungs (pneumothorax) 

8. Lidocaine toxicity

ע" 

שת/ 

תבט/ 

ג" 

י 

77 


Survey among US & Canadian surgeons 

Pitman & Teimourian 1985 

Overall complication rate - 9.3% 

Unfavorable aesthetic results - 20.7% 


The commission an surgical suction lipectomy 

of the ASPRS 1987 

• Among 100,00 procedures in 5 years 

• 11 deaths 9 Major morbidity 

4 Suction alone 3 Pulmonary Emb. 

2 Nec. Fasciitis 3 Fat Embolus 

2 Hypovolemic shock or FES 2 Massive infection 

7 Combination 1 Perforation 

4 Pulmonary Embolus 

1 Infection & DIC 

1 FES + 1 Probable FES

ע" 

שת/ 

תבט/ 

ג" 

י 

78 


• “...The most frequent potential hazardous 

complication is hypovolemia from massive 

aspiration & 3rd space creation…” 

• Can be prevented by: 

• Intraoperative blood loss monitoring 

• Wet / tumescent technique 

• Maintain IV access for fluids & blood replacement 

• 24 hrs urine output monitoring 

Complications 

Dillerud PRS 1991 

• 2000 pts. 3511 procedures 

• Inclusion: Healthy (incl. stable diabetics, well 

controlled HTN) 

• Exclusion: BMI >35 

• Overall complication rate - 1.2% Excessive 

bleeding, Allergic reactions, dermatitis, anesthesia related 

complications, phlebitis, pneumonia, hypertrophic scars, 

persistent dysesthesia 

• Unfavorable results - 10.8% Asymmetry, underresection, 

skin irregularities. 

• Medial thigh, buttocks, ankles & calves - high % of 

complications & unfavorable results

ע" 

שת/ 

תבט/ 

ג" 

י 

79 

Long term patient satisfaction 

Dillerud PRS 1993 

• Overall satisfaction rate - 76% 

• 14% less satisfied 

• 6% dissatisfied 

• 4% unsure 

• Buttocks - highest dissatisfaction 

• Gynecomastia / submental area - highest 

satisfaction 

1. Anemia 

2. Seroma 

3. Hematoma 

Minor complications 

4. Surgical site infection 

5. Sensory N. damage - Persistent dysesthesia 

or hypesthesia 

6. Muscle or muscle fascia damage with 

persistent pain 

7. Pseudobursa formation (encapsulated 

seroma)

ע" 

שת/ 

תבט/ 

ג" 

י 

80 

Sequelae / Transient conditions 

1. Mild over / under resection 

2. Temporary hypesthesia 

3. Mild waviness 

4. Occasional minor dent or divot 

5. Faint hemosiderin deposits 

6. Transient pain 

7. Mild degree of asymmetry 

8. Transient fatigue 

Sequelae / Transient conditions 

• Almost inevitable 

• Vary substantially from patient to patient 

• Usually resolve within 3 months 

• Some areas take longer to recover 

Neck Knees Iliac-crests Thigh Abdomen Calves 

Fast Slow

ע" 

שת/ 

תבט/ 

ג" 

י 

81 

Aesthetically unfavorable results 

• Grey zone, thin line between anticipated 

sequelae and unfavorable results 

• Much related to skin redraping capabilities 

• Mentioned those that lead to law suites 


1. Grooving of the skin 

2. Multiple dents / divots 

3. Localized overresection “Dishing out” 

4. Generalized overresection - Flat thighs, 

buttocks, skinny appearance 

5. Skin necrosis 

6. Androgynous appearance 

7. Buttock ptosis 

8. Skin adhesions to muscle fascia

ע" 

שת/ 

תבט/ 

ג" 

י 

82 


Grooving 


Multiple dents & divots

ע" 

שת/ 

תבט/ 

ג" 

י 

83 


Skin necrosis 


Perforation through striae distensae

ע" 

שת/ 

תבט/ 

ג" 

י 

84 

Minimizing unfavorable results 

1. Careful patient selection 

2. Thorough preoperative evaluation & 

documentation 

3. Use small diameter cannulas 

4. Use multiple incisions 

5. Criss-cross 

6. Radial tunneling 

7. Peripheral mesh undermining 

8. Feathering the edges 

Minimizing unfavorable results 

“Touch-up”s and “redo”s not sooner than 6 

months 

Try deep massage to correct mild 

irregularities and waviness

ע" 

שת/ 

תבט/ 

ג" 

י 

85 

Minimizing infections 

• Totally sterile field (No discounts..) 

• Do not touch cannula barrel 

• Most likely site of infection treated last 

(Inner thighs) 

• Avoid perianal / perivaginal incisions 

• Perioperative Abx ??? 

Endermologie (LPG)

ע" 

שת/ 

תבט/ 

ג" 

י 

86 

Statistics 

Statistics - Females

ע" 

שת/ 

תבט/ 

ג" 

י 

87 

Statistics - Males 

Superficial liposuction 

Marco Gasparotti - 1992 

• After “traditional” deep liposuction supf. fat 

may still be thick -> gravitational ptosis 

• Small diameter cannulas, close tunnels, 

peripheral mesh undermining 

• Controlled subcutaneous scar contraction 

• Promotes effective skin retraction 

• Especially effective in: Lateral thigh, 

banana, redo

ע" 

שת/ 

תבט/ 

ג" 

י 

88 


Gasperoni - 1989-1994 

• MALL = Massive All Layer Liposuction 

• Combined deep adipoaspiration with 

subdermal defattening 

• Mercedes cannula, 2mm diameter 

• 404 procedures 293 pts. Excellent results 

• Goal: To reduce as much as possible the 

thickness of all adipose layers and to promote 

effective skin retraction 

• Flaccid skin 


Indications 

• Rippling irregularity 

• “Cottage cheese” deformity 

• Two types of skin (Matarasso): 

• Type A - Flaccid pseudoptotic skin Max benefit 

from supf. liposuction: Neck, dorsal rolls, 

outer thighs, banana 

• Type B - (Cellulite) Outer & Ant. thighs 

• Use pickle-fork cannula

ע" 

שת/ 

תבט/ 

ג" 

י 

89 

UAL 

PAL

ע" 

שת/ 

תבט/ 

ג" 

י 

90 

SAL / UAL / PAL 

Mega liposuctions

ע" 

שת/ 

תבט/ 

ג" 

י 

91 

Combination procedures

Liposuction and Fat injection Liposuction Lipoplasty Lipolysis ...

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?