Unsatisfactory Results of Liposuction

Panel Discussion

Unsatisfactory Results of Liposuction Editor’s note: My thanks to the moderator, Joseph P. Hunstad, MD (board-certified plastic surgeon and ASAPS member, Charlotte, NC), and to panelists Richard A. D’Amico, MD (board-certified plastic surgeon and ASAPS member, Englewood, NJ); Luiz S. Toledo, MD (boardcertified plastic surgeon and ASAPS member, São Paulo, Brazil); and Peter A. Vogt, MD (board-certified plastic surgeon and ASAPS member, Minneapolis, MN), for sharing their opinions and clinical experiences.

with a very slim neck that is disproportionate to her face, which seems to be the case here. Therefore, when performing a corrective sling procedure, I use an endoscope, which enables me to pass a Gore-Tex® strand from mastoid to mastoid, passing through the cervicomental angle. If there is excess skin, it should be managed with either superficial liposuction or skin removal. Dr. Hunstad: Dr. Vogt, how

would you treat a young person concerned about a full or fatty neck?

Dr. Hunstad: The first patient, a

young woman concerned with the fullness of her neck, was treated with liposuction. Photographs show platysma bands and an unnatural, overcorrected appearance of the neck (Figure 1). Dr. D’Amico, would you discuss isolated liposuction of the face and neck?

Dr. Vogt: I agree with Dr.

Joseph P. Hunstad, MD

Dr. D’Amico: Facial fat is a precious resource, and rarely would I remove it. The neck, however, presents a different situation. I believe that judicious and conservative fat removal in the neck can be appropriate. Unfortunately, the postoperative Luiz S. Toledo, MD defect seen in this patient is all too common. When performing liposuction, we need to be careful to leave some subcutaneous fat in the neck. If this patient is dissatisfied with the results, I would consider performing a platysma band plication. At a later time, if needed, I would consider a filler procedure—structural-type fat grafting would probably be my first choice. Dr. Hunstad: Dr. Toledo, does liposuction have a place

when treating a young patient who is primarily concerned with her neck?

Richard A. D’Amico, MD

D’Amico. As we age, we lose fatty tissue in the face and neck regions. Therefore, I am conservative when removing fatty tissue. It is also important to maintain symmetry between the neck and face region. To correct this patient’s problem, I would perform a neck lift, because I don’t believe I would be able to correct it with only a platysma band repair. Dr. Hunstad: Would you consider removing buccal fat in this patient?

Peter A. Vogt, MD

Dr. Vogt: In this case, I would perform judicious facial liposuction. In my opinion, the removal of buccal fat pads is a tertiary procedure, which I reserve for patients with extremely round, disproportionate faces. The more experienced I become, the more conservative I am in regard to removing buccal fat pads. Dr. Hunstad: Dr. Toledo, do you have any comments with respect to aspirating facial fat? Dr. Toledo: I rarely aspirate fat above the jaw line.

Dr. Toledo: If the patient also has a fat face and you

remove only the fat in the neck, the patient will end up

However, in some cases, I aspirate superficially from the jowls or above the nasolabial fold, or on rare occasions, from a cherubic face. Dr. Ulrich Kesselring from

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cause the deformity. Because the incision is generally made in the gluteal fold, as was the case with this patient, access is difficult, and you may end up suctioning distal to or around it rather than in the immediate area, which can result in undertreatment. To avoid this problem, I use a small end-cutting cannula, 2 to 3 mm in diameter, so I can carefully sculpt the subcutaneous fat. To aid skin retraction, I tape the area for approximately 1 week after surgery. Dr. Hunstad: Dr. Toledo, would you

comment on this patient? Dr. Toledo: I don’t believe that this

A

B

Figure 1. A and B, A 38-year-old woman concerned with the fullness of her neck underwent liposuction in the submental region. Postoperative photographs reveal platysma bands and an irregular contour in the submental area.

Switzerland performs an operation that involves the direct removal of fat and a Z-plasty to eliminate excess skin at the midline. I don’t perform the procedure, but many surgeons seem to be satisfied with the results.

resent, how is it caused, and how would you correct it? Dr. Vogt: The subgluteal fold, or

banana roll, that we see in this patient can occur for 2 reasons. First, in patients with unrecognized ptosis of the buttock, the banana roll tends to develop after surgery. You can recognize ptosis of the buttock before surgery by having the patient contract the buttock skin. If the skin does not elevate, the patient has buttock ptosis. Second, under-resection of fat in the immediate subgluteal fold can

Dr. Hunstad: The second patient is a

43-year-old woman who underwent circumferential liposuction of the thighs and inferior buttocks (Figure 2). After the operation she expressed concern about the residual fullness in the lower gluteal crease area. Dr. Vogt, what does this deformity rep-

Facial fat is a precious resource, and rarely would I remove it. –Richard A. D’Amico, MD

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is a banana fold deformity. The banana fold is formed below the subgluteal fold. This patient appears to have a dropped buttock. It is important to carefully evaluate the preoperative photographs because some patients are initially seen with normal double folds. I believe that in this case too much deep fat was removed from the buttock itself, because when fat is removed superficially, the result is retraction of the lower third of the buttock. The fibrous support that keeps the buttock round and in place was eliminated with the deep suctioning of the lower third of the buttock. That is why the buttock dropped. This is a very difficult situation to correct. I usually remove the wedge of skin. Dr. Hunstad: Dr. D’Amico, what is your assessment of this patient? Dr. D’Amico: I agree that too much fat was suctioned too deeply. Some patients will accept this outcome— the volume of their buttock has been reduced, and they feel better in their clothes. On the other hand, other patients are disappointed with the results and are willing to undergo

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Panel Discussion

ties in the buttock and trochanteric regions by using a V-tip dissector cannula, which creates tunnels into which I inject 3-mm threads of fat. I increase the number of threads until I have sufficiently filled the irregularities. Patients should understand that they may need to undergo a second and even third procedure to correct this problem.

removal of the skin even if that means being left with a scar. Dr. Hunstad: Dr. Vogt, how do you approach patients with skin laxity? Dr. Vogt: I examine the patient in a recumbent position. If I determine that the problem was over-resection rather than under-resection, I consider performing a belt lift. Patients are generally happy with the results. However, you have now performed a major operative procedure to correct a problem that could initially have been treated with a minor one.

A

Dr. Hunstad: Please describe your technique in more detail.

Dr. Toledo: Using a syringe, I harvest fat from wherever I can find it; no one site is better than another. If the fat B comes out with blood, I Dr. Hunstad: I have had gently wash it with Ringer’s good success in treating the Figure 2. A and B, A 43-year-old woman underwent circumferlactate—not saline—solution. ential liposuction of the thighs and inferior buttocks. After the banana fold by performing procedure, she was concerned with a residual fullness in the lower I pass the fat from one thorough, superficial sucgluteal crease area. Postoperative photographs reveal a double syringe to the other, decant it, roll in the gluteal crease. tioning. I have not had to and centrifuge it at 1500 rpm resort to excision. Let’s for 1 minute. I then decant move on to the third patient, fat resection. The dimples in the the excess fluid and slowly reinject who was concerned about bilateral trochanteric region appear to be secthe fat, using a cannula that is 3 mm depressions in the trochanter region, ondary and are due to the use of an wide. To avoid breaking the fat cells, where the entry site was located aspirator, which can potentially it is best to inject on withdrawal. (Figure 3). The patient also has remove too much fat around the deformities of the buttocks, which Dr. Hunstad: Do you inject into the incision. By using a syringe, you were suctioned. Dr. Toledo, what is underlying muscle to help fill the avoid this problem, because suctionyour assessment of this patient? depression and to possibly get a beting stops when the syringe is full. I ter take of your fat grafting? have had success treating irregulariDr. Toledo: Over- or under-resection

of fat are common problems of secondary liposuction. This patient has both. You can see that her flanks were underaspirated, so she has a good storage of fat for reinjection. I assume these irregularities in her buttocks are primary, and not the result of liposuction. The excess skin above the subgluteal fold may be due to excessive

Unsatisfactory Results of Liposuction

Dr. Toledo: I inject approximately 50 to 60 mL of fat to fill a trochanteric depression such as the one seen in this patient, and I would probably need to inject deep. Because the gluteus muscle begins at this site, not much fat can be injected there. I would inject fat mostly into the subcutaneous tissue but also into the gluteus muscle.

The more experienced I become, the more conservative I am in regard to removing buccal fat pads. –Peter A. Vogt, MD

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Dr. Hunstad: Dr. Vogt, would you share your technique?

muscle. Dr. D’Amico, would you discuss the severe problems seen in this patient?

Dr. Vogt: First let me say

Dr. D’Amico: This case high-

that oversuctioning is a common problem. Most surgeons don’t realize that the cannula continues to suction until it is removed, even if one takes his or her foot off the pedal. A lipo-filling technique is the only way to treat this problem. I believe that fat needs to be extracted with a syringe. I don’t believe that an aspirator, no matter where the pressure is set, will permit your fat graft to survive. Gentle handling of the lipo-filling material is critical. The smaller the needles that you use and the more tunnels you create, the better.

lights some of the critical issues surrounding large-volume liposuction. We must reassess the advantages of the true tumescent approach with a ratio of 2:1 and 3:1 A of infusate to aspirate, because of the potential for severe fluid overload and lidocaine toxicity. We should be promoting the super-wet approach with a 1:1 ratio. It is incumbent on surgeons who are using large lidocaine concentrations to monitor their patients for 12 to 14 hours, because of the B potential of lidocaine toxiciFigure 3. A and B, A 38-year-old woman complained of depresty during that time. It is of sions in the hip area after undergoing liposuction. Evaluation concern that in some states, revealed over-resection at the entry site and hip region and dimDr. Hunstad: Dr. D’Amico, patients are not allowed to pling in the gluteus, where suctioning had been performed. would you share with us stay overnight in officeyour experience in treating based facilities and are therepatients like this one? fore at home during that critical sions with undermining and manual Dr. D’Amico: First of all, to avoid period. manipulation of the surrounding creating false hopes, I tell patients fullness to fill the central depression? Dr. Vogt: First let me say that my up front that it’s unlikely that I am definition of large-volume liposucgoing to be able to completely Dr. Toledo: When I suction close to tion is removal of more than 4000 restore their contour. When the skin the skin and create a depression, I mL of total aspirate—not 5000 mL. is adherent to the deep tissues withcan free the surrounding fat with a I prefer to use a general anesthetic to out the presence of subcutaneous V-tip cannula. But this is only effecreduce the amount of lidocaine fat, as is the case with this patient, tive in mild cases. Fat grafting because I only use the super-wet correction is extremely difficult should probably be the first option technique and rarely exceed the because there is no plane in which to for more severe cases. 1:1 ratio. I use a formula that delivlayer the structural fat grafts. Dr. Hunstad: The fourth patient is a ers a very low concentration of Therefore, you may need to inject 39-year-old woman who underwent Xylocaine®, preferably far below into the muscle. This is one area in large-volume liposuction that includ35 mg/kg. To increase the safety and which ultrasound-assisted lipoplasty ed internal UAL (Figure 4). She avoid fluid overload, surgeons need (UAL) may be helpful, because if had postoperative complications to be in concert with the anesthesiolyou cannot completely fill in the including hematoma, infection, ogists. Often, we believe we are “valley,” you can at least improve and seromas, which left significant doing well when we are using a 1:1 the surrounding “hills”. depressions, particularly over her infusion to aspirate ratio, but if the left inner thigh, where the skin is amount of fluid being given exceeds Dr. Hunstad: Does anyone have now adherent to the underlying a safe volume, we can create overexperience treating similar depres-

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Volume 19, Number 4

Panel Discussion

load because more fluid is absorbed than we may realize. Dr. D’Amico: It is important to review drug interactions with the anesthesiologist. For example, midazolam can mask early signs of lidocaine toxicity. Because lidocaine and related drugs had been used in epidural anesthesia, I stopped using them. However, now that epidural anesthesia is performed with narcotics, many people are reconsidering its use. Dr. Toledo: I am against epidural

anesthesia, because when you reposition the patient, the anesthesia level changes, causing breathing problems. I use low-tumescent or super-wet anesthesia at a 1:1 ratio, and on rare occasions at a 1:1.5 ratio. I only use oral midazolam for sedation. For large-volume aspirations, we give midazolam along with fentanyl, and sometimes propofol. Although we do not intubate the patient, the anesthesiologist is ready should general anesthesia be needed. Rather than using absolute aspirate volume limits, my limit, for example, may be removal of 5000 mL of pure fat in a very heavy patient. I treat one side, turn the patient, and then infuse the other side. Dr. Hunstad: My definition of large-

volume liposuction is when more than 3 to 5 L of pure fat is aspirated. We use general anesthesia and limit the lidocaine dosage to 35 mg/kg. I agree with Dr. D’Amico that lidocaine toxicity occurs 12 to 14 hours after surgery—when the patient is at home—rather than in the immediate postoperative period. Patients therefore need to be carefully monitored during that period. In states that have curtailed overnight stays in an office setting, patients may be cared for at home by an informed family member

Unsatisfactory Results of Liposuction

A

B

Figure 4. A and B, A 39-year-old woman who underwent liposuction of the circumferential thighs experienced hematomas and other complications after the procedure, which caused severe depressions, irregularities, and deformity. On the left anterior thigh, the skin is literally adherent to the underlying fasciae with absolutely no fat present. Significant fullness remains in the right anterior and posterior thigh, the proximal inner thighs, the knees, and the infragluteal crease.

or trained personnel and must have easy access to the hospital in the event that complications arise. They must be made aware of the signs and symptoms of lidocaine toxicity.

instead of trying to accomplish a big result all at once. Dr. Hunstad: Could some of this patient’s complications have been caused by the use of UAL?

Dr. Toledo: It is important to

remember that you can always repeat the procedure. In some instances, it is much safer to perform the procedure in 2 or 3 stages,

Dr. D’Amico: Experience has shown that by reducing the energy application time, the exposure of tissue to ultrasound energy is reduced,

It is important to remember that you can always repeat the procedure. In some instances, it is much safer to perform the procedure in 2 or 3 stages, instead of trying to accomplish a big result all at once. –Luiz S. Toledo, MD

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evacuation phase. Feathering might have helped this patient.

decreasing the incidence of seroma and other UAL-related complications, such as burns and tissue damage. The risk of seroma and over-resection is reduced by adhering to defined end points. These end points are loss of resistance to cannula movement and change in the color of the aspirate from pale yellow to pink or tan. Treatment beyond these end points results in seroma and over-resections, as seen in this patient. Because ultrasound cannulas cannot be bent, they remain straight when treating a curved or cylindrical surface (eg, the leg or thigh) and therefore can hit the skin on the opposite side of the cylinder, causing skin burns. One can prevent this with appropriately placed incisions, which must be carefully planned when using UAL. One can also manipulate the tissues over a curved surface, bringing them to the cannula, to facilitate removal. In addition, I believe feathering is very important and should be done with UAL and not be left for the

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Dr. Hunstad: Dr. Vogt, you have begun to use the reciprocating cannula in deference to UAL. Would you share your experience? Dr. Vogt: About a year ago, because

of the problems that Dr. D’Amico just alluded to, I began using a reciprocating suction device that uses a cold cannula and reciprocates at 4000/min. This allows access to difficult areas, such as the flank and hip. I still use UAL in the upper extremity because I believe I get a bit more retraction of the skin, but my generator time is no more than 3 to 4 minutes per upper extremity. Dr. Hunstad: I share your experiences, as well as those of Dr. D’Amico. I have significantly reduced our UAL on-times and have seen a proportionate decrease in dysesthesias and seromas. Dr. Toledo, you performed UAL in Brazil long before it was available in

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the United States and have had a lot of experience with it. However, you no longer use UAL. Please share with us your experience and tell us why you now prefer the syringe technique. Dr. Toledo: For the past 11 years, I

have been using only the syringe. I have compared the results achieved by the use of UAL with those obtained through the use of syringe liposuction, which I presented at the 1996 ASAPS meeting. There was no significant aesthetic difference, and there was more delayed healing, itching, and pain, and no less bruising, on the side treated with UAL. So, I no longer use internal UAL. However, I still use external UAL. If it is difficult to aspirate with a syringe and a regular cannula, I use one of those new titanium-coated cannulas that slide easily and are very penetrating. ■ Reprint orders: Mosby, Inc, 11830 Westline Industrial Drive, St Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 70/1/100694

Volume 19, Number 4