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The calf and the ankles have not been considered good for liposuction because of significant postoperative pain and edema. A pneumatic tourniquet, as orthopedic surgeons have used for a long time, allows precise liposculpture without infiltration and minimal postoperative sequelae even in the case of very large extractions. Experience with over 150 cases over a period of more than 7 years, has enabled the authors to formulate some new notions concerning the physiopathology of the heavy legs syndrome and modifications of the surgical technique.
Liposculpture of the legs under tourniquet is the extraction of adipose tissue from the inferior extremity (ankle, calf, knee, and inferior third of the thigh) by use of a pneumatic tourniquet, i.e., the ankle, the calf, the knee, and the inferior third of the thigh. This aspiration is performed without tumescent infiltration and after interruption of the blood circulation by inflating the pneumatic tourniquet. The operation begins as soon as the leg is emptied of its blood. When terminated, it is mandatory to place an elastic bandage before removing the tourniquet.
In 1985, Temourian proposed (unpublished data) a liposuction technique under tourniquet but he infiltrated the tissues. In 1993, the authors devised the idea of using a pneumatic tourniquet in a case of adipose excess localized in the ankles, as practiced by orthopedic surgeons for the cure of hallux valgus. The postoperative course and results were surprisingly excellent. The procedure was repeated in other cases with similar encouraging results.
No precise description of the distribution of the adipose tissue in the human organism is found in classical anatomy articles. Feminine and masculine morphologies are different. The gynecoid distribution results in a particular feminine morphology with excess fat distribution in the hips and thighs. It is, however, necessary to distinguish anatomical varieties according to the degree of excess weight and the morphological type. The underlying conventional anatomy should be considered for both technical and esthetic reasons. For convenience, the leg is considered as the part of the lower limb situated beneath the pneumatic tourniquet. It comprises regions and spaces:
1. Regions: – Inferior third of the thigh included in the knee – Knee – Calf – Ankle – Foot
2. Spaces: – In reference to a surgical plan, one can consider that the adipose tissue is organized as extractable spaces. They are not partitioned anatomical entities with distinct limits and they are accessible by different surgical approaches. – The leg can be divided into four spaces by a sagittal and a frontal plane passing respectively by the tibial crest and the two malleoli. This permits an anatomical division.
(a) The ankle: This comprises the antero-external malleolar space that extends from the tibial crest at the front to the fibula at the back, with a round inferior limit forming an inferior convexity. The fibula superposes the antero-external muscular compartment. At this level, a cutaneous pinch of the top of the foot can reveal in some individuals a true lipoma in the antero-external compartment. Above this, the space is in continuity with the anterior surface of the leg. The postero-external space extends from the fibula at the front to Achilles’ tendon at the back. It continues below with the retro and external submalleolar compartment. Above, it continues with the internal adipose space of the knee and the subpopliteal space. The antero-internal space extends from the anterior tibialis tendon and the tibial crest at the front to the internal malleolus at the back. In some cases, the internal malleolus is surrounded by adipose tissue that effaces its normal contour. Here also, a cutaneous pinch can make a distinction between the zone of excess adiposis and the skin of the foot. The postero-internal space extends from the internal malleolus at the front to Achilles’ tendon at the back. It is prolonged below by the retro and submalleolar space, and above by the internal adipose space of the knee. The external submalleolar adipose lump at the ankle level is often a true lipoma situated above and slightly in front of the inferior edge of the external malleolus.
(b) Knee: The superior internal knee space is limited anteriorly by the prominence of the vastus internus of the quadriceps muscle, posteriorly by the grand adductor, superiorly by the tourniquet, and inferiorly by the articular interline. In muscular persons, a depression can be observed behind the vastus internus. The inferior internal knee space is limited anteriorly by the fibular tendon, the anterior tuberosity of the tibia, and the tibial crest. Posteriorly, it continues below with the adipose spaces of the calf. The supra-fibular space comprises the vastus internus and externus, which meet forming an inverted V, thus limiting the depression observed in muscular persons. The internal and external subfibular lumps are situated on each side of the fibular tendon and efface its normal contour. At stages IV or V, (see classification infra) the fibula forms a depression in connection with the surrounding zones. The superior external knee space extends from the vastus externus to the crural biceps tendon. The inferior external knee space extends from the tibial crest to the relief of the antero-external leg muscle.
(c) Calf: The muscular rounded contour can be covered by a thick panniculus adiposus (a large calf).
A classification can be established based on both the degree of weight excess and the morphological type:
1. Stage I: Quasi-total absence of adipose tissue. The skin directly covers the osteo-musculo-tendinous plan with no layer of fatty tissue. This is seen in lean subjects as well as in body builders who follow a protein diet.
2. Stage II: The adipose tissue is distributed harmoniously with an effacement of certain anatomical protrusions but with the presence of the bimalleolar and Achilles’ tendon contours. This is the case of the famous beautiful legs of actresses and models.
3. Stage III: This corresponds to a light excess of subcutaneous adipose tissue but to the point that in certain zones it can be pinched like a lipoma. The surcharge can predominate at the knee or the ankle or be distributed uniformly. The quantity of fat extracted at this stage ranges from 300 to 400 ml.
4. Stage IV: The adipose excess is quite important and is distributed over the whole leg. It leads to a fading out of the normal contours to the point that the malleoli form a depression. The foot is little or not concerned. The quantity of fatty tissue aspirated can reach 1,500 ml on each limb. Such a situation corresponds to true elephantiasis.
5. Stage V: This is the extreme stage, with veno-lymphatic complications. The lipoedema is permanent. Extractions exceed 1,500–ml. The doctors have artificially defined stages III, IV, and V as a function of the volume of fat extracted. A more precise classification could probably be established, based on the exact assessment of subcutaneous adiposis by an investigation such as magnetic resonance imaging.