 |
|
|
|
| LIPOSCULPTURE: WHICH AREAS CAN WE TREAT? |
|
James M. Swinehart, M.D.
|
Liposuction previously performed under general anesthesia
is now a little-utilized approach. This method was responsible
not only for initially negative public attitude, but also
for considerable morbidity and mortality with pain, bleeding,
bruising, and prolonged recovery times.
|
| Now, however, the
only similarity of tumescent liposuction to the "old
method" is that fat is removed from the body through a tube. Several important
modifications of the operative technique have greatly refined liposculpture into
an art form. These developments include the use of tiny incisions (which disappear
without suturing), special post operative dressings and garments, efficient pumps
for local anesthesia infusion and liposuction, and precisely engineered microcannulas
designed for each body area and special situations. We will now examine treatment
of specific body areas in men and
women. |
|
44 year old white female with
good skin tone, but with excess abdominal, midriff, and
flank fat.
|
Note uniform, even contraction of skin with
undetectable result.
|
|
Obese 66 year old female patient with striae
(stretch marks), abdominal panniculus, and loose skin tone.
|
Result
3 ½ weeks later. Although striae
remain, skin has retracted well and patient was happy with
result.
|
| Some body areas and some patient types, are, of course, more
prone to asymmetry than others. A 22 year old athletic single
female with excellent skin tone will show little or no evidence
of surgery (other than a nicer contour) two weeks after the
procedure. On the other hand, a patient who is overweight,
flabby, who has not exercised in years, and has had children,
should never expect close to a perfect result. Abdominal asymmetry
is particularly likely in female patients, especially those
with surgical scars and the above-mentioned conditions, whereas,
male patients seem to show little or no irregularity. The midriff
and waist areas are more fibrous in nature. Asymmetry is uncommon
here, except where the flank liposuction is feathered onto
the back. |
|
"Angel wings" on
back causing unwanted bulges when patient's bra was fastened.
|
Flattening and disappearance after targeted
liposculpture.
|
| Many men are self-conscious
of the fat on their chest (male breast). Significant improvement
can be obtained via two crisscrossed
incisions — one in the inframammary area and one in the
axilla. |
|
Male patient in excellent physical condition
but with unwanted breast fat.
|
Flattening to nice athletic contour with
tumescent liposculpture.
|
| Tumescent liposuction of the buttocks can be a difficult
maneuver. Preexisting cellulite and uneven skin folds can
be a significant hindrance to an even outcome. The dermatologic
surgeon must be careful not to remove too much fat, and to
perform most of the fat removal in a superior direction from
an incision in the intergluteal crease in the prone position,
comparing both buttocks when finished. The soft, easily removed fat present on the inner thighs
makes over-correction a real risk. One must proceed slowly
and evenly, using very fine cannulas (12 gauge or smaller).
It is very important to crisscross the tunnels through anterior
and posterior incisions. Klein and Cook have each developed
foam pillows to elevate the opposite flexed knee, placing
the inner thigh on a horizontal plane accessible from a posterior
incision. One generally starts with a 12 and/or 14 gauge
cannula to set the tunnels, followed by a 3mm cannula, followed
by a 12 or 14 gauge cannula gauge for fine feathering. |
|
Prominent excess fat on inner thighs, as
well as abdomen and hips.
|
Remarkable improvement in all areas with
even, symmetrical results seen only three weeks later.
|
| Likewise, asymmetry is common in the saddlebag areas. This
may be due to the fact that the pinch technique is difficult
to employ here, or that variation or position can alter the
intraoperative appearance and direction of the tunnels. It
is common to leave too much fat in the posterior saddle bag
near the buttock, whereas one must be careful to avoid the
trochanteric depression. Feathering should be carried down
onto the lateral thigh. The results obtained, however, are
gratifying to many patients. |
|
Unwanted bulges on saddle bags (lateral thighs),
as well as hips, inner thighs, and knees.
|
Beautiful results seen in all areas treated.
Note also the improvement in patient's skin tone.
|
| Lipsuction of the knees often yields beautiful results, but
feathering must be skillfully blended into non-suctioned areas
of the middle third of the inner thigh. Liposuction of the
upper arms must be blended onto the infrascapular and infraclavicular
areas to avoid an uneven appearance. The skin nearly always
retracts in this location in relatively young patients with
good skin tone. |
|
Unwanted knee fat pads give the patient a
bow legged appearance. The dermatologic surgeon should avoid
treating the middle third of the thigh while removing fat
from the inner thigh and knee regions.
|
Uniform, even outcome after liposculpture.
Note that the objective of a straight line from the inner
thigh to the knee has been achieved giving the patient a
much thinner appearance.
|
|
Female patient with fat accumulation in chin
and neck.
|
Note complete retraction of skin following
this procedure.
|
| Many patients request
liposculpture of the face, neck, chin, and jowls. Indeed,
some patients wish body contouring to be
performed only in this region. Asymmetry is uncommon with neck
liposuction, where the surgeon strives to remove essentially
all of the fat. However, considerable surgical skill is needed
to
avoid a "hollow" appearance following liposuction of the cheeks. Although
the procedure is not a substitute for a facelift, a considerable amount of fat
can be removed, with significant correction, of the jowls and neck. Because of
the fact that hundreds of tiny tunnels are created (rather than one large cavity),
this skin nearly always completely retracts to a pleasing
contour. |
|
This 30 year old patient, although thin,
was often judged to be overweight because of his double chin.
|
After liposculpture, his neck contour matches
the rest of his thin body.
|
|
Same patient, lateral view, showing large
fat pads external to platysma muscle.
|
Note complete retraction of skin with smooth
aesthetic contour.
|
CORRECTION OF ASYMMETRY
Rather than having to correct asymmetry,
it is hoped that the dermatologic surgeon can prevent this
outcome by utilizing
the principles listed herein. However, in patients with
preexisting deformities, patients who have had previous
liposuction, or in patients with predisposing conditions
such as sun
damage
or poor skin tone, the physician must be able to address
this problem. |
|
Female patient before liposuction
|
After liposuction revealing depression in
thigh
|
|
Area to be treated with fat injection is
marked and anesthetized
|
Beautiful correction from fat transplantation
|
FAT TRANSPLANTATION
Fat transplantation is often quite successful for correction
of post liposuction depressions. The donor fat can, of course,
be removed from another area where too little fat was removed
initially. Should such an area not exist, the author prefers
the upper outer quadrant of the buttock as a donor source.
Many methods exist for lipoinjection, and controversy exists
presently over the role of washing and centrifugation. One
should, however, develop a personal technique whereby living
fat cells can be injected to achieve slight over-correction
soon as their removal from the donor area. Dermal grafting,
as described by Dr. Swinehart in the American Journal of
Cosmetic Surgery, may also show future promise for correction
of soft tissue defects. |
|
Cellulite release tool
|
"Cellulite" depressions
on lateral thigh
|
Improvement noted after cellulite release
technique
|
TREATMENT OF CELLULITE
We've
probably all seen, or experienced, those cottage-cheese
like dimples
or ripples on the hips or thighs known as "cellulite." Purported
treatments for these are likely as old as mankind — but
do they really work? First, a word about its origin. Cellulite may be present
at an early age. The author can visualize dimpling on his
six year old son's backside in the right light! Medically,
this condition seems to be like the tufting on a sofa; fibrous
bands pull certain areas of the skin downward into small
depressions, or pits. Another theory centers on decreased
circulation of the skin, leading to protein deposits and
irregular fat lobules. Weight gain, of course, contributes
to the problem. In
years past, salons and therapists have employed electric
current, as
well as vibrating massage belts, to reduce fat
and cellulite. Additionally, heat, herbal packs, and "exothermic
massage" have been tried. More recently, attention
has focused on the use of Xanthines (caffeine, theophylline,
aminophylline) for treatment of cellulite. The true effect of these therapies is unknown. Since thigh
diameter and water content varies not only with the time
of day but also with factors such as menstruation, small
changes in measurements should not be used to substantiate
these claims. Tumescent
liposuction, while effective in removing fat, may or may
not improve
this dimpled condition. Vigorous exercise,
by enlarging the underlying muscles, can often produce
improvement. Finally, the new "cellulite release" technique
also holds promise in some conditions. |
|
Athletic female patient who could not lose
fat from saddle bags, inner thighs, or knees even with vigorous
exercise and dieting.
|
One
photo says it all — this patient
has gone from an "8" to a "10" with tumescent
liposculpture by Dr. Swinehart.
|
ULTRASONIC LIPOSUCTION
An Italian surgeon,
Zocchi, has researched the use of ultrasound in fat transplantation
and liposuction for the past 10 years.
He has proposed a technique whereby ultrasound is first applied
to heat, liquefy and soften the targeted fat pads. Following
this maneuver, the liquid fat is removed by suction in the
usual fashion. The concept is, however, still under investigation
and possesses certain limitations. For one thing, the tumescent
technique, with its high pressure infusion pumps produces
sufficient tissue turgor to facilitate rapid dissolution
and removal of the tumesced fat. Also, the application of
hard to control heat induces the risk that thermal trauma
may damage fat tissues in an uneven fashion, thus inducing
surface irregularities and post inflammatory hyperpigmentation.
The use of ultrasound adds more time to a finesse procedure
that already takes two to three hours. Finally, as noted
by Jeff Klein, the California dermatologic surgeon who originated
tumescent liposuction — why add complexity to a procedure
that is refined, predictable, and nearly always produces
aesthetically pleasing results? This technique needs further
development and study before being released for widespread
public use.
In summary, tumescent liposculpture has revolutionized
the field of body contouring by providing a means of safe,
efficient, bloodless fat removal under local anesthesia.
Newer instrumentation has given the dermatologic surgeon
the tools to achieve outstanding results in selected instances.
Attention to the surgical maneuvers described above will,
hopefully, enable the liposculpture specialist to perfect,
with finesse, the anticipated surgical outcomes to an even
high degree.
Dr. Swinehart specializes in Tumescent Liposculpture
at 950 E. Harvard Avenue, #630, Denver, CO 80210 - Phone
(303) 744-1202. Copyright 1997 CDC. |
|
| |
|
