Many patients will come for consultation stating that their “butt” is too large. Most of the time the enlargement is in the posterior high hips and lateral thighs that give the impression of a larger buttocks. This can be reduced with attention to the lateral thighs with the contouring described earlier in this article. A triangle with its apex at a top of the inner gluteal crease and each base point at the midpoint of the inferior gluteal crease on either side is considered “no man’s land.” Suction in this area can lead to a flattening of the derriere and masculinize the female figure. Lateral to this area one can mold the buttocks with fine cannulas in the deep area only. Superficial liposuction should not be done to this area. Small irregularities that are present preoperatively can be corrected with fat grafting.
The area just below the brassiere line or the area just below the scapula often has a transverse roll of fat that is disconcerting to many of our patients. For purpose of practicality this can be considered as a single subcutaneous layer of fat with no area of deep fat. This fat is fibrous, making penetration difficult in this area. For that reason the mechanically assisted cannula works well. One needs to be very aggressive to remove most of the fat to get good contraction. This is one area in which ultrasonic liposuction works well. Generous tumescent infiltration helps to elevate the tissue for a more complete reduction. In our hands using finer cannulas and graduating to larger cannulas makes resection easier. Patience is required but good results can be achieved. There may be multiple rolls below the scapula down to the waist-line. Each should be marked and aggressively treated to give the patient a smooth posterior appearance and a concave waist. Since the skin is quite thick in this area, superficial liposuction should be done.
The loose areolar fat and the very thin skin of the inner thigh makes this one of the very difficult areas to treat without leaving “divots.” It is easy to overresect because this fat does not contain much fibrous tissue. The markings are important, delineating the highest point of fat and the margins to be reduced. After the tumescent fluid has been introduced the technique I presently use is to begin working superficially and gradually working to deeper areas. Only small up to 2.0-mm cannulas with ventral holes should be used by those unaccustomed to working in this area. I presently use a multiple-holed cannula that I had custom- made. The maneuver used is to move in the superficial plan initially and as the cannula is removed to press the tip angle slightly deeper. In this manner the fat can gently be reduced in a smooth fashion. The incisions used for this are just below the distal marks and in the suprapubic area. When reducing the inner thighs from the posterior approach, most of the posterior fat can be reduced through an incision in the inner thigh at the mid-portion below the marking. Positioning is important and one must be very careful if suctioning with the legs in a “frog leg” position. It is very easy to overresect if one is not careful.
For this reason most of the resection should be done with the assistant holding the leg straight and slightly adducted. The cosmetic surgeon can then work from the inside of the leg, constantly feeling for any depressions or irregularity. Do not overresect in the mid thigh area or one will leave a bow-legged appearance. Blend the upper medial thigh into the mid thigh. The fit of the garment is important in order to mold the inner thigh. The garment must come all the way to the inguinal crease. The skin of the inner thigh is extremely thin and the garment could cause a depression. I use foam padding under the garment. This seems to help considerably in preventing these depressions. External ultrasound postoperatively helps smooth minor irregularities.
The skin is very thick in the knee area and superficial liposuction is not really required to obtain good results. I recommend a straight leg position. Phase the resection of the knee into the mid thigh without a “step-off.” Most patients have a small area that will need to be reduced on the medial side just below the knee to obtain the nicest result. The amount of fat removed is minimal but the results are often quite impressive.
Basically there is one layer of fat in the lower leg and it is mainly concentrated in the medial and posterior portion of the leg. Incisions just below the posterior popliteal crease give access and are well hidden. I address the inner calf first and then move to the posterior area. By using incisions at either end of the popliteal crease crisscrossing can be accomplished and vertical suctioning carried out. A roundness or fullness of the mid calf is the desired look; therefore, rarely is liposuction required in this area. In some cases lipoaugmentation may be indicated for a fuller mid calf. The distal calf and ankle can be done with small incisions made laterally and medially slightly above and behind the lateral and medial malleolus. Suction can be done superiorly and inferiorly from these incisions. Liberal use of tumescent fluid will be needed and suctioning should be fairly superficial. During the postoperative period the patient may have a significant amount of swelling. I use foam pads and stockings with 30–40-mmHg pressure on the ankles and calves when both are sculptured. Foam pads are cut and positioned to mold the ankles. If only the ankles are sculptured the elastic ankle supports purchased at a pharmacy work quite well.
One of the disconcerting aspects of aging in women is the so-called pendulous or sagging arm. Many women owing to genetics, age and weight gain accumulate fat in a disproportionate manner over the posterior dependent area of the arm. The fat is usually distributed in the lateral, medial and posterior portion of the upper arm. Exercise will not remove or reduce the volume of fat in this area. Rarely is liposuction required in the anterior or volar aspect. The goal of the liposuction surgeon is to reduce the bulk of fat in this area without creating a masculine appearance. Uniformly decreasing the subcutaneous fat over the lateral, medial and posterior surfaces yields a thinner arm. Decreasing the weight of the fat from the skin of the arm allows for contraction. The thicker “sagging” upper arm gives the appearance of obesity; therefore, most women desire a thinner, more youthful arm. Liposculpture can yield excellent consistent results.
One must be careful to sculpture the arms in a manner to complement the rest of the female figure. Extremely thin arms in some women will be disproportionate. Liposuction of the arm can be easily approached with the arm bent with two small 1.5-mm punches just above the posterior elbow medially and laterally; and a third incision in the posterior and axillary crease. If the anterior axillary fat pad needs to be reduced as well, another punch incision can be made in the anterior axillary crease. During the tumescent phase pretunneling can be accomplished. This will help prevent overresection during the liposculpture portion of the operation. For the arm I use mainly two very small cannulas up to 2.0 and 2.5 mm. The direction of the suction is a crisscrossing pattern parallel to the long axis of the arm. Multiple tunnels with small cannulas will uniformly decrease the volume without over resection. After the deeper fat has been removed I switch to a very small 2.0-mm one-holed flat spatula-type cannula to free the fibrous septa and allow smooth contraction of the skin. With experience the tumescent infiltration very closely equates the aspirate. As one area of caution, there is frequently a small 15–35 ml distal fat pad near the elbow close to the area of the surgical access punch wounds.
If this is not removed, there will remain a sagging look at the elbow. Many patients will also have prominent axillary fat pads. Occasionally they are found in patients who are thin. Fat pads seem to worsen with age. By elevating the patient’s arm at a right angle with the elbow bent one can easily palpate the fat and delineate it from the underlying muscle. Tumescent infiltration and liposuction with small cannulas and liposculpturing in a uniform manner can reduce this area and yield a smooth blending into the axillary upper arm that is aesthetically pleasing. I have found the arm and axillary area to be one of the most satisfying liposculpturing procedures for both myself and my patients. Postoperative care for the arms is mainly elastic sleeves with compression pads posterior and over the axillary area. These are worn for 24 h per day for the first week and then 12 h per day for the second week.
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