The Tumescent Technique By Jeffrey A. Klein MD
Female Hips and Back and Male Flanks
The surface anatomy of the female hips and back is the visible manifestation of the local fat compartments. For the purposes of liposuction, surface anatomy of the back can be subdivided into the following clinically important subsets (Figure 33-1):
- Cervicodorsal (neck/back) hump
- Posterior axillary back
- Subscapular back (or flank)
- Lumbar pad
- Sacral pad
In defining areas targeted for liposuction, the waist is regarded as the bilateral portion of the torso between the costal margin and the iliac crest. Patients often consider the waist as the entire circumference of the midtorso, including the abdomen. In slender persons the waist is typically the smallest circumference of the torso. As a degree of obesity increases, the waist and abdominal girth expand, and the greatest circumference of the torso becomes the waist.
The hips typically extend over the posterolateral torso, bounded above by the waist and anteriorly by the anterior iliac crest. The proximal extent of the hip fat pad is the costal margin. The distal margin is typically defined by the lateral gluteofemoral dell, located between the hip and the lateral thigh at approximately the level of the maximum concavity of the lateral gluteus muscle (Figure 33-2).
The fat of the hips has relatively little fibrous tissue content. In contrast, proximal to the hips, fat pads of the waist and subscapular back are increasingly fibrous.
The fatty content of the female hips increases with advancing age. When viewing a woman from her backside, it is not difficult to assess her approximate age; hip size provides a good estimate. Photographs of the backsides of women ages 20, 30, 40, 50, and 60 can often be ranked according to age based on size and shape of the hips. Liposuction of the hips usually helps a woman’s body look younger, at least from the perspective of the backside.
Some women might not appreciate the aesthetic necessity of a liposuction of the hips and waist. A woman with large hips and outer thighs is often more concerned about the thighs and pays little heed to her hips. She may simply not understand her aesthetic problem and thus not see the necessity of hip liposuction. Her thighs may have always been a problem, whereas her hips may have become a problem only recently.
At the initial consultation, if the size of the hips cannot be ignored, it is proper for the surgeon to discuss the relative merits of doing liposuction of the hips. In a woman with disproportionately large hips, aggressive liposuction of the outer thighs but not treating the hips will yield a suboptimal result and a dissatisfied patient. Although it might be inappropriate to insist that the hips be treated, the surgeon has an obligation not to ignore the situation. The patient should be made aware that treating the thighs while not treating the hips may yield disproportionate aesthetic results.
If, despite having large hips, a patient elects to have only the thighs treated, the liposuction of the outer thighs cannot be done as completely. Ignoring the hips while aggressively doing liposuction of the outer thighs risks producing a disproportionate result. By including the hips, the surgeon can also be more aggressive in reducing the size of the outer thighs.
A woman who has both a large abdomen and large hips may believe that the abdomen alone is responsible for her inability to look good in clothes. If the abdomen alone is treated, the patient will be dissatisfied when she realizes the effect of not treating her disproportionately large hips.
The hips contain deep fat deposits. When drawing the topographic contour mapping on the patient’s skin, the goal is to depict accurately the areas of deepest fat deposits (Figure 33-3). The orientation of the deepest fat deposits of the female hips, however, is deceptive.
Hip fat has a different orientation than the fat of the outer thighs. The perpendicular line to the deepest plane of fat on the outer thigh is oriented horizontally. In contrast, because of the shape of the female bony pelvis, the perpendicular line to the deepest plane of fat on the hip is oriented approximately 30 to 45 degrees superiorly from the horizontal (Figure 33-4).
Accurate tumescent liposuction requires precise topographic contour lines drawn on the patient before infiltration and surgery. If the surgeon draws the concentric circles on the hip so that the perpendicular line to the central circle is horizontal, the deepest fat on the hip will usually escape liposuction.
To indicate the intended area for deepest liposuction, this basic anatomic fact must be taken into account when planning and executing the drawing on the patient. If the central concentric circles are placed too distally, liposuction will inadequately treat the proximal extent of the hips.
The entire hip usually is easily accessible when the patient is in the lateral decubitus position.
Occasionally, part of the waist may be obscured by inordinately large hips because of the lateral flexion of the spine and the cephalad rotation of the iliac crest toward the lateral costal margin. For this patient it is often helpful to place a folded towel or flat pillow under the dependent waist. This maneuver straightens the spine and exposes the sulcus between the rib and the hip. Placing a pillow between the patient’s leg and providing an armrest might improve patient comfort (Figure 33-5).
The hip is one of the easiest areas to treat by liposuction. Because the degree of fibrousness of the fat is usually minimal, the hip fat comes out with minimal effort. Smooth, natural-appearing results require careful attention to achieving a subtle zone of transition between the hip and the adjacent areas of the buttock, lateral thigh, abdomen, and waist.
Incisions placed on the lateral aspect of the torso have less of a tendency to become hyperpigmented and therefore are less likely to remain visible than incisions on or near the back. This should be taken into account when deciding where to place incisions or adits.
If the hips/waist and abdomen are to be treated on separate days, the surgeon must be certain not to ignore or overlook the transitional area between the lateral abdomen and the anterior waist.
The posterior margin of the hip typically trails off into the waist, with a wedge-shaped bulge or tail of fat tapering as it extends posteriorly and superiorly below the inferior costal margin. When this tail of fat is prominent, it should not be ignored during liposuction of the hips. The surgeon may regard it as a “time capsule”; if untreated initially, it will often “return” and require treatment at a later date to placate a dissatisfied patient (Figure 33-6).
The inferior margin of the hip is often delineated by a transverse dell that courses distal to the iliac crest and proximal to the trochanteric tubercle. This dell accounts for the violin-like appearance of the female posterior perspective. Some women have little or no dell between their hips and outer thighs.
In a moderately obese woman, lack of a dell usually indicates a relatively deep deposit of fat in the zone between the hip and lateral thigh. This deposit demands careful attention during liposuction. The smoothest results are often achieved when the hip and outer thigh are treated at the same time (Figure 33-7).
Postoperative care of the hips is relatively simple, with the use of absorptive pads and two garments to provide bimodal compression.
Pitfalls and Special Considerations
Liposuction of the hips, waist, and entire abdomen on the same day produces significant circumferential swelling and tenderness. This restricts the patient’s ability to perform such routine tasks as bending over to tie shoes and getting in and out of a car. The unanticipated postoperative pain, impaired flexibility, and frustration limit patient satisfaction.
Preoperatively the determined patient wants to “do it all at one time and get it over with” and is willing to endure the resulting soreness and immobility. Postoperatively the overambitious surgeon soon learns the realities of patients’ ability to tolerate circumferential liposuction of the waist and abdomen. Virtually every patient will complain of the unanticipated pain and difficulty of the recovery.
By dividing one complex surgery into two simpler surgeries, the surgeon can pay greater attention to the art and finesse of liposuction and often achieve better cosmetic results. An easier recovery and superior results will increase patient satisfaction.
An unusual type of fibrosis of the hips can make liposuction of this area somewhat challenging. An occasional patient might have had drugs injected into the hips. Multiple deep subcutaneous injections of the hips can eventually produce a nodular fibrosis as a result of an inflammatory sclerotic reaction induced by the vehicle of the injection. The surgeon may not anticipate this unusual situation but with extra effort will achieve a satisfactory result.
The gross anatomy of the subcutaneous fat of the back, including the area distal to the scapula, the cervicothoracic dorsal hump, sacral fat pad, and posterior axillary fold, is not particularly distinctive. Only the dorsal hump and the sacral fat pad seem to have discrete localized compartments of fat. From the liposuction surgeon’s perspective, the subcutaneous fat on the back is a rather uniform layer, partitioned in only a few areas by fibrous reticulations that force excessive fat to bunch up in cordilleras (hills) or parallel rolls (Figure 33-8).
Infrascapular Back. The infrascapular back is the area just caudal to the scapula. The fat overlying the midposterior back is more fibrous than in most other areas. The liposuction surgeon can regard the fat distal to the scapula as a single subcutaneous layer, devoid of any well-defined deep compartment of fat. In some obese persons, with fat caudal to the scapula, the surgeon sees two or three transverse rolls of fat parallel to the underlying ribs.
Discrete linear condensations of fibrous tissue seem to subdivide the back into a cordillera of rolling hills or a mullion of folded parallel rolls of fat. Microcannular tumescent liposuction can provide significant cosmetic improvement to the female back as well as the hips (Figure 33-9).
Ultrasonic Liposuction. Because of the difficulty in penetrating a densely fibrous area of fat with liposuction cannulas with an outside diameter greater than 2.0 mm, some surgeons have resorted to ultrasonic-assisted liposuction (UAL) for the back. I believe that most surgeons who advocate UAL have had little experience with using 16-gauge microcannulas to initiate liposuction in fibrous areas.
UAL uses larger cannulas, necessitates larger incisions and scars, takes longer to complete, and is associated with an increased risk of seromas and dermal necrosis. Ultimately, aesthetic results are not better than results achieved with microcannular liposuction.
Fibrous Content. The greater the fibrous content of a fat compartment, the more resistance to penetration by a cannula, and the more difficult it is to achieve a satisfactory degree of liposuction. The use of smallest diameter cannulas (16 gauge) greatly facilitates liposuction in areas that are especially fibrous, such as the midlateral back. Furthermore, the initial use of small cannulas, followed by larger microcannulas, permits more thorough liposuction and is more comfortable for the patient.
The highly fibrous nature of fat in the subscapular area makes liposuction a challenge. This densely fibrous tissue is nearly impossible to penetrate with large cannulas. With the use of microcannulas and tumescent infiltration, however, this area can be successfully treated.
The 16-gauge Capistrano cannulas are particularly helpful in initiating liposuction. Once the deeper plane of liposuction tunnels has been established using 16-gauge microcannulas, the surgeon can then use 14-gauge cannulas. With artistic patience and persistence the surgeon can achieve gratifying results totally by local anesthesia.
Incision sites on the back tend to cause hyperpigmentation considerably more than incisions located more laterally. Incision sites for back liposuction should be placed as far laterally as practical.
Postoperative care after liposuction of the back merely requires adequate coverage with superabsorbent pads, held in place with an appropriate torso compression garment. A high degree of external compression is not necessary. The motion of the torso during respiration and other normal daily activities are sufficient to expel the residual blood-tinged anesthetic solution completely from treated areas overlying the rib cage (Figure 33-10).
Absorptive compression sponges are applied in a manner similar to that used for the abdomen and breasts. First, an appropriate length of the proper-size elastic tube netting is selected for the torso. For the hips and waist a simple cylinder-shaped segment of netting is sufficient; it is often not necessary to cut side holes for the arms (see Figure 31-20). If the pads are to be placed over the back or flanks, however, the tube netting should be cut similar to the netting used for the breast, with two lateral arm holes (see Figure 38-12). The absorptive compression sponges are then applied, with 5-cm (2-inch)–wide paper tape used to hold them in place. After pulling the elastic tube netting into place, appropriate elastic compression garments are applied.
Pitfalls and Special Considerations
The skin on the back is especially susceptible to hyperpigmentation of scars from incisions for liposuction. The number of scars should be minimized and care taken to avoid unnecessary trauma to the epidermis near incision sites on the back. Trauma to the dermal-epidermal junction predisposes to postinflammatory hyperpigmentation.
Because there is no deep compartment of fat on the back but merely a thick layer of subdermal fat, the surgeon may tend to do too much superficial liposuction. The result of excessive liposuction that attacks the subdermal surface is disfiguring erythema ab liporaspiration (Figure 33-11). Similarly, the tendency to perform excessive liposuction on the back risks penetrating too deeply and injuring striated muscle.
When treating patients with dorsal cordilleras or rolls of fat, liposuction is easier if the patient is about her maximum weight. For patients who have rolls of fat distal to the scapula and who have lost considerable weight, liposuction is relatively more difficult. For mildly obese patients who have no obvious fatty cordilleras, liposuction can provide great improvement. Particularly with liposuction of the back, significant weight gain after liposuction may negate much of the surgical improvement.
Lumbosacral Fat Pads. The relatively small areas at the lower back are easily treated. Removal of a prominent sacral fat pad minimizes the appearance of obesity.
The surgeon should use caution during the preoperative physical examination of this area. A focal lipoma or hairy nevus may indicate occult spina bifida. If in doubt, a consultation with a knowledgeable radiologist may be appropriate.
Cervicothoracic Dorsal Hump. An increasing degree of obesity is often associated with a prominent localized accumulation of fatty tissue on the middle part of the upper back, overlying the proximal thoracic vertebrae. In younger patients this dorsal hump can be rather fibrous. In middle-age and older female patients this hump becomes less fibrous and more easily suctioned.
Because of generalized obesity, patients with a fatty dorsal hump are unlikely to be good candidates for extensive liposuction. Nevertheless, liposuction of the dorsal hump is easily accomplished, with great patient satisfaction (Figure 33-12).
Examination. Preoperative physical examination should readily distinguish between a soft fatty dorsal hump and a more rigid kyphosis. A radiologic examination rarely is necessary to confirm the diagnosis of excessive localized subcutaneous fat.
Surgery. Before tumescent anesthetic infiltration, concentric topographic contour drawings should accurately delineate the breadth and depth of the targeted fatty deposit.
Liposuction is accomplished through several small, transversely oriented incisions or through adits; their precise location is not critical but should appear random.
The skin in this area is thicker than anywhere else on the body; therefore incisions need to be slightly larger than in thinner skin. The liposuction is easily done using 16-, 14-, and 12-gauge microcannulas.
Drainage. Postoperative drainage is facilitated by normal movement of the shoulders and neck, so no need exists for extra compression. Drainage, which usually ceases within 24 to 36 hours, is accommodated by taping a superabsorbent pad over the treated area.
The term flanks is generally understood by the average patient and is more appropriate than the vernacular “love handles.” The subcutaneous fat of male flanks tends to be rather fibrous. Nevertheless, by using microcannulas, especially Capistrano microcannulas, virtually every male flank can be satisfactorily aspirated with relative ease (Figure 33-13).
Gross Anatomy of Subcutaneous Fat. With increasing age, males tend to accumulate subcutaneous fat overlying the lateral oblique muscles, although not every bulge in this area is caused by fat. Even when no fat exists in this area, a muscular individual will have some fullness attributable to the muscles.
The normal degree of skin laxity that appears in this area with increasing age is accentuated by the waist band of a tight pair of pants. Liposuction will not eliminate this exaggerated appearance of redundant skin.
Surface Anatomy. In the female the anatomic area identical to the male flanks is called the “waist.” One of the most characteristic features that distinguish the male and female silhouette is the location of the “belt line.” In men the belt line is below (caudal to) the flanks and iliac rim, whereas in women the belt line is above the hips and iliac rim and just below the costal margin.
The male flanks extend between the iliac rim and the costal margin, approximately from the anterior to the posterior iliac crest. Typically the deepest and thickest deposit of fat on the male flank is located posterior to the most lateral extent of the flank. Thus, when viewed anteriorly, male flanks do not appear as prominent as when viewed posteriorly.
In the female the area below the bra strap (infrascapular back) is often designated the “female flank.” Although a common target for liposuction in women, this same infrascapular area on men rarely undergoes liposuction.
In contrast to the female, the typical male has little fat immediately caudal to the iliac rim. Therefore attempting liposuction below the iliac rim on a male is unlikely to provide significant cosmetic improvement.
The fat of the flanks is most accurately delineated by nested or roughly concentric topographic contour rings that correlate with the relative depth of the fat; the central rings correspond to the deepest deposits. These topographic markings are most effectively drawn with the patient standing erect, approximately in the anatomic position (Figures 33-14 and 33-15).
The lateral decubitus position facilitates accurate and thorough liposuction of the male flanks. The patient’s back, hips, and knees should be slightly flexed to provide comfort.
Liposuction of the male flanks with the patient in the supine position does not allow sufficient access to the posterior extent of the fat compartment, and this area may be insufficiently treated. When the surgery is accomplished under general anesthesia, the patient is in the supine position for endotracheal intubation. Changing positions when the trachea is intubated risks displacing the patient’s endotracheal tube and causing hypoventilation or hypoxemia. Thus, when using general anesthesia, the surgeon tends to treat the posterior male flank inadequately. Also, it is difficult to move a patient who is unconscious and unable to cooperate. When liposuction is accomplished totally by local anesthesia, the surgeon merely asks the patient to roll over on his side.
Infiltration into the fibrous fat of a male is easier with a spinal needle than a blunt-tipped, multiholed infiltrating cannula with a larger diameter. Infiltration with the spinal needle encounters little resistance from the fibrous fat and therefore causes less patient discomfort. With spinal needles, infiltration is more uniform and complete and local anesthesia and vasoconstriction are more profound than with a larger cannula. Therefore liposuction can be more easily accomplished totally by local anesthesia when a spinal needle is used for infiltration.
After placing the anesthetic blebs in the dermis with a 30-gauge needle, the infiltration spinal needle is passed through the anesthetized bleb without requiring an incision. The spinal needle does not cause scarring or hyperpigmentation, and thus it can be inserted through as many sites as deemed convenient and advantageous.
Infiltration is initiated in the deepest plane of the fat deposit and then directed more superficially. From its insertion site the infiltration spinal needle is directed radially in many directions and depths, overlapping the paths of other needles from adjacent insertion sites.
To ensure patient comfort during liposuction along the margins of the flank area, the infiltration is extended at least 1 cm beyond the boundaries of the intended area of liposuction.
Microcannular access into the subcutaneous fat is provided by microincisions or surgical adits. A conscious effort must be made to minimize incisions, which might eventually be visible as small scars.
I prefer to use surgical adits, consisting of 1.5-mm and 2.0-mm punch excisions. The 2.0-mm adits are placed just below the belt line to minimize the appearance of incision sites when the patient is shirtless. Because a 1.5-mm punch excision leaves a minimal scar, a limited number of 1.5-mm adits can be located anywhere within the treated area. Because incisions on the back are more likely to result in hyperpigmentation or a visible scar, incisions are placed laterally rather than posteriorly, when feasible.
The liposuction sequence is analogous to the infiltration process in that liposuction is initiated in the deepest layer of fat and then carried out more superficially. The initial stages of liposuction in this fibrous area employ 16-gauge cannulas; 14-gauge and occasionally 12-gauge Capistrano cannulas are used to complete the liposuction procedure.
Microcannulas allow excellent liposuction results for the fibrous male flanks. UAL is not necessary for successful liposuction of the male flank.
Early in my liposuction experience, I discovered that male patients routinely ignored my instructions to wear a postoperative compression garment for at least a week. Almost every male patient simply discontinued compression binders as soon as the drainage had ceased.
Realizing that no adverse effects occurred with such brief compression, I modified instructions for postoperative care. With open drainage, prolonged postliposuction compression is no longer required. Bimodal compression minimizes duration of compression and accelerates rapid resolution of postliposuction edema, soreness, and bruising.
After liposuction of the male flanks, patients are instructed to wear superabsorbent compression pads to accommodate the open drainage. Obese patients and those with liposuction of both the abdomen and the flanks usually do best with a breast and torso garment and one or two elastic torso binders. Nonobese patients may require only a single torso binder to secure the absorptive pads and provide compression for 2 to 3 days. Elastic torso binders may be 15 cm (6 inches) or 22.5 cm (9 inches) wide.
Pitfalls and Special Considerations
The most lateral extent of the male flank is not the most visible part of the fatty deposit. In most patients the deepest area of fat is deposited more posteriorly. If this posterior flank fat is not included in the area treated by liposuction, most male patients will be disappointed in the results. For example, liposuction of the male abdomen and flanks during a single procedure under general anesthesia with the patient remaining in the supine position will invariably result in undertreatment of the posterior extent of the male flanks.
An overaggressive approach to liposuction of the flanks can injure the subdermal vascular plexus and produce erythema ab liporaspiration, a chronic reticulated erythema that resembles erythema ab igne. Avoiding this complication requires caution not to rasp the skin’s undersurface and injure the delicate subdermal capillary vasculature (see Chapter 8).
Figure 33-1 Surface anatomy of back includes regularly identifiable areas: PAB, posterior axillary back; F, flanks (or subscapular back); W, waist; L, lumbar pad; S, sacral pad. Hip H is often liposuctioned concomitantly with back.
Figure 33-2 Lateral gluteofemoral dell is transverse saddleback concavity between lateral iliac crest and trochanter. This dell is not apparent in every female.
Figure 33-3 Typical contour drawings on hips. A, Hip is contiguous with buttock and lateral thigh. In patients who are not too obese, all three of these areas may be liposuctioned on same day. B, Combination of hip, lateral thigh, and inferior lateral buttock is one of the most common areas treated on same day. C, Occasionally, lumbosacral areas are treated at same time as hips.
Figure 33-4 Point on hip that corresponds to greatest depth of fat (D1) is located proximal to and different from point of maximum lateral protrusion (D2). Being aware of this visual illusion, surgeon should carefully palpate and gently squeeze hip before marking concentric circles that will dictate area where liposuction will be most thorough.
Figure 33-5 Position for liposuction of hip. When lying on one side in lateral decubitus position, patient is more comfortable when pillows support uppermost contralateral arm and leg.
Figure 33-6 A, Relatively thin medial tail of hip. B, Thicker lateral portion of proximal hip.
Figure 33-7 Posterior perspectives of four patients before and after liposuction of hips. A and B, Typical voluminous hips and result of liposuction. Additional liposuction could be done on outer thighs. C and D, Hip liposuction in darkly pigmented patient showing temporary but slowly resolving hyperpigmentation at incision sites. E and F, Liposuction of hips, outer thighs, inner thighs, and inner knees was accomplished with two separate surgical procedures. Left posterior medial thigh shows subtle horizontal double gluteal crease consistent with excess liposuction in this area. G and H, This patient previously weighed 20 kg (45 pounds) more than her weight at surgery. After great weight loss, total number of fat cells does not decrease significantly; thus adipose tissue is relatively high in collagen content and relatively low in lipid content. Liposuction results are less dramatic for patients who previously had great weight loss.
Figure 33-8 Contour drawings on hips, waist, and back demonstrated on two patients. A and B, First patient before liposuction of hips, waist, flanks, and posterior axillary back. C and D, Second patient before liposuction of hips, waist, and flanks.
Figure 33-9 Microcannulas facilitate liposuction of fibrous areas on back. A and B, Microcannular tumescent liposuction provided this patient with a narrow waist for first time in her life. C and D, Cordilleras (hills) of dorsal fat respond well to microcannular liposuction. E and F, Results of microcannular liposuction were impressive even before this patient lost weight by dieting.
Figure 33-10 Liposuction from back to lateral thigh requires two types of garments worn simultaneously to hold absorptive pads in place and to provide postliposuction compression. Torso garment provides compression for back and hips while Overall garment provides compression for hips and thighs.
Figure 33-11 Erythema ab liporaspiration showing reticulate pattern of erythema resulting from aggressive superficial liposuction on undersurface of skin.
Figure 33-12 Cervical dorsal hump before (A) and after (B) microcannular tumescent liposuction. C, Contour drawing of hump. D, Supranatant fat (about 550 ml) removed by liposuction.
Figure 33-13 Male flanks of all types and sizes respond well to microcannular tumescent liposuction. A and B, Flanks of thin male, preoperative and long-term postoperative views. C and D, Flanks of male of average weight before and two months after surgery. E and F, Flanks of relatively obese male before surgery and 1 day after microcannular tumescent liposuction.
Figure 33-14 Flanks of obese male. A and B, Preoperative topographic contour drawings show posterodorsal extent of fat compartment. C and D, Preoperative views. E and F, Two months after tumescent liposuction totally by local anesthesia.
Figure 33-15 Because of proximal skin laxity, some males have pleat in skin between flanks and lateral back. A, Lateral view with contour drawings. B, Posterior view before tumescent liposuction. C, Postoperative view reveals that liposuction cannot consistently eliminate pleat above male flank.