Conventional liposuction is based on deep removal of localized fat pads. In 1981 the cosmetic surgeon modified this technique by shifting the level of aspiration to the superficial areolar layer of fat, to better reshape a body profile, allowing this method to be used also in older patients with very relaxed skin.The technique was an obvious and logical solution to the limitation presented with traditional liposuction (deep fat removal). The simple deep removal of fat gives us only a reduction of the volume of an anatomical section but not its reshaping, which should be performed taking particular care of the superficial layer of fat. In addition, we can “fix in place” our job with the aid of the skin, that once made lighter, can shrink on new surfaces we have carved.
Therefore, the skin becomes the cosmetic surgeon’s best friend and not a liposculptor’s enemy, as in a conventional liposuction, where, emptying in depth, we used to leave a thick and heavy adipose cutaneous flap sagging because of gravity and postoperative edema. The thinner the skin, the more it draws back. The more flaccid the skin, the more it must be thinned to stimulate the skin retraction properties to the maximum, and profit from its ability to readapt, driven by proper elastic compressive bandages and garments. The thin adipose skin flap will therefore act as a support and dynamic container for the properly molded content (the fat). For the first time in liposuction, the skin is an active structural and dynamic element, and not only a passive element of the operation. Through contraction, the skin becomes firmer, the orange skin appearance (“cellulite”) is improved, and the skin become smoother because, working in the superficial compartment of fat, most of the fibrous attachments can be released from the subcutaneous fat to the dermis. This also allows the skin to move freely and relocate. The subdermal fat is reached only if there is a need to maximally tighten the cutaneous adipose flap in very flaccid skin patients. Superficial liposculpture must always respect the subdermal vascular plexus, and leave 3–4 mm of subdermal fat intact to avoid irregularities.
From January 1981 to May 2003 liposuction was performed by the cosmetic surgeon on 5,103 patients between 16 and 74 years of age. Most of the adipose tissue was located in the outer thighs and hips (87%), and most of the patients had liposuction in multiple areas, including the inner thighs (41%), abdomen (18%), knees (74%), calves (9%), ankles (36%), and arms (1%). The age of the patients was between 16 and 74, and the maximum volume of pure fat removed was 5 l without any blood transfusion. Patients from which more than 3 l of fat was aspirated spent 12 h in the clinic.
One hour before liposuction surgery, a series of photographs are taken in the office documenting the deformities to be corrected. Polaroid pictures are taken of the patient with markings of the operative sites for reference in the operating room. These pictures are very important, especially in patients with very flaccid skin, because the deformity almost disappears when they are placed in position on the operating table. Patients are prepared for liposuction surgery with coagulating therapy consisting of tranexamic acid, vitamin K, and ceftriaxone for 5 days preoperatively. An antibiotic is given intravenously 2 hours before liposuction surgery, and is continued orally for 72 h.
General anesthesia is used in 63% of the cases, especially in older patients, secondary cases with a lot of scar tissue, and in patients where multiple areas have to be treated.
The drawing must be very accurate and done in sequence from the right thigh, right hip, left thigh, left hip, gluteus, torso, inner thigh, abdomen, knees, calves and, finally, the ankles and arms. Keep the patient standing, in front of a large mirror:
1. Draw the whole area to be treated with a continuous line up to the furthest point in which the deformity meets the neighboring region, and mark the point of maximum projection of the deformity.
2. Mark with a plus or a minus the points where more or less fat should be removed to obtain ideal curves. The liposuction surgery must rigidly follow this drawing, attempting always to follow the outline to the maximum. The areas to be treated will more often than not be different in the two sides; therefore, the drawings will rarely be the same.
3. Mark the areas that will need to be filled (lipofilling) to create the optimal curve.
4. Evaluate, by pinching the adiposities to be removed, the approximate quantity of fat to be removed, and write this amount down adjacent to the site.
5. Mark the eventual depressions or actual dermal irregularities so that we can recognize them during the liposuction surgery and not attribute them to technical mistakes (make the patient well aware of these deformities before liposuction surgery).
6. Evaluate how much to remove and when to stop aspirating by performing a simple maneuver that consists of pushing the lateral femoral deformity inward to evaluate visually the new shape desired and then marking a line exactly below our hand in this new position. This plane will be the new level we want to take the lateral femoral profile. During the operation aspiration is stopped when this plane is reached. Each type of deformity must be treated according to precise artistic concepts, always trying to include the whole defects within the treatment, to achieve a complete three-dimensional harmony.
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