Female patients often seek contouring of the flank region in the upper back especially when bulges are produced secondary to compression by clothing. The back and upper flank areas are especially fibrous and generally require significant time to treat although ultimately only small amounts of fat may be removed. However, this is a satisfying area to treat for both the patient and cosmetic surgeon as shapely contouring can result. The flank area is usually treated in conjunction with the waist and hips. When treated as one unit, this is an area that can dramatically alter the shape of the female contour. It is best to approach this area initially with a 14- gauge Capistrano cannula to break through the fibrous tissue with ease. Later stages of the procedure can be performed with the 12-gauge Finesse or Capistrano cannulas. In general, the back has more potential for scarring so incision sites are minimized and placed as far laterally as possible. In this area, it is important to be conscious of avoiding symmetric placement of incision sites bilaterally. The patient is treated lying on her side but rotated slightly anteriorly.
In this position, the fat pockets can be lifted with the non-dominant hand and adequately aspirated. To effectively provide the patient with a harmonious female contour, the waist is also often simultaneously treated. This area is usually comprised of significant amounts of fat, which can be removed with 12-gauge cannulas. The female flanks and waist are usually treated in a single session, with the whole unilateral lower back area being treated one side at a time. Once both sides have been treated, the patient can be placed in the prone position for final blending of the whole back region. A 12-gauge Finesse cannula can be used to treat the mid back and cross the midline for optimal blending of both sides of the back.
Microcannula liposuction of the buttocks avoids many of the complications that heretofore prevented cosmetic surgeons from contouring this region. With larger cannulas, asymmetry and irregularities result not uncommonly. However, an entire buttocks region can be addressed with the microcannula technique, although a conservative approach is required. Buttocks fat is relatively devoid of significant vascular or neural structures and overall there is a general homogeneity to the fat. There are, however, fibrous septa within the fat known as ligaments of Jacque affording a supporting structure that in the youthful buttock maintains the normal visually pleasing configuration. The horizontal infragluteal crease is a confluence of multiple fibrous connective tissues connecting to the fascia distally and buttocks tissue superiorly. The various septa insert into the deep dermis of the crease defining the inferior boundary of the buttocks. This confluence is known as the ligaments of Lushka. The combination of the two sets of ligaments serves to elevate the buttocks from above and support the structure from below.
Over time the suspensory ligamental structure stretches, resulting in a drooping buttock. With obesity local additional accumulations of fat seems to occur, causing a bumpy quality to the surface. With microcannulas, all areas of the buttocks may be treated, including the “banana roll” inferiorly. This affords the opportunity to sculpt the buttocks region, which is often viewed as part of a complex involving the hips and lateral thighs. Microcannulas allow for careful sculpting and feathering of each of the important areas to avoid sharp cutoffs. With macrocannulas, some reduction in volume can occur, but areas such as the medial gluteal regions are typically left untreated and contouring the upper lateral buttock- flank border becomes problematic.
These areas are comfortably addressed with the microcannulas. The patient is positioned prone with the buttocks slightly elevated. The entire process proceeds with an emphasis on maintaining symmetry, uniformity, and smoothness. Superficial liposuction should be avoided in the buttocks region. The benefit of microcannulas is that fat is taken in all directions from multiple ports, reducing the problem in macrocannula liposuction of grooving or telltale irregularities. Gradual uniform reduction is the intent with fanning, intersecting, and interdigitating patterns of strokes, usually five to 25 from each port before proceeding to another port. The entire buttocks region is accessible, including the previously worrisome “Bermuda Triangle,” which is a triangle in the center of the buttocks extending from the infragluteal crease to the superior buttocks cleft. The only area that should be avoided is the infragluteal crease because of problems with asymmetry and irregularity. Even with microcannulas, dimpling can occur. To avoid this, the lipoaspiration must be deep, leaving a thick layer of fat undisturbed beneath the skin. The banana fold represents a problem area that must be addressed extremely conservatively to avoid causing a secondary buttocks crease. Liposuction of the banana fold should be considered as an effort to conservatively improve the area rather than to aggressively remove the fat in its entirety.
Clinically, to avoid a secondary crease, a residual but diminished banana fold should be present postoperatively. To avoid disruption of supporting structures, Klein advocates cannulas be directed at 45° from the horizontal. As stated already, the infragluteal crease should be avoided as asymmetry and irregularity can result and the benefits are small. The buttocks region must be treated conservatively overall. Excessive liposuction can cause a ptotic unsightly result. Klein states that a maximum of 30– 50% of the fat should be removed. The cosmetic surgeons prefer the more conservative 30% figure. Whereas size may matter, in actuality the intent should be a smooth, natural, well-proportioned end point.
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