The Tumescent Technique By Jeffrey A. Klein MD
Female Legs and Ankles
Liposuction of the legs is requested much less frequently than liposuction of areas on the thighs and torso. The disproportionate and displeasing distribution of fat on the female ankles and legs is most often genetically predetermined. Exercise and diet usually do not improve this disproportionality.
The leg is defined as the portion of the lower extremity between the knee and the ankle. The fat on the legs and the ankles primarily is mantle fat. Typically, there is a negligible amount of deep fat that is distinct and separate from the subcutaneous mantle fat. Nevertheless, focal areas exist where the fat on the legs is more prominent.
The areas of bulging subcutaneous fat can be subtle or obvious. In some patients the entire leg, except for the pretibial area, can benefit from liposuction. In others, liposuction should be limited to discrete areas.
Areas of fat may be easily seen but difficult to document with photographs. Consequently, before-and-after photographs might not demonstrate the degree of improvement that is seen clinically. Patients should be informed of this before surgery, with the discussion documented in the patient’s chart.
It is often difficult to appreciate the degree of fat in the legs when the patient is standing upright with equal weight on both feet. In the vertical standing position the cutaneous envelope is pressed outward and made more taut by the bulging action of the calf muscles.
The quantity of fat in the leg is more easily appreciated when the knee is bent and the leg is held in a horizontal position, resting on a stool or chair. In this position the skin and subcutaneous fat are more easily grasped, and the “pinch test” provides a more accurate assessment of the amount of fat (Figure 40-1).
Prominent focal areas of fat on the leg are relatively subtle compared with other parts of the body. Because tumescent infiltration can easily obscure the subtleties of fullness in the ankles and lateral calf, it is important to draw the topographic contour lines accurately on the areas to be reduced by liposuction (Figures 40-2 to 40-4).
A modified lateral decubitus position, using a Thigh Aside pillow to elevate the uppermost leg, is comfortable for the patient and allows easy surgical access for liposuction of the legs and ankles. After surgically preparing and scrubbing the legs, ankles, and feet, placing them on a sterilized superabsorbent sheet is more convenient than using a nonabsorbent sterile drape.
From this position the surgeon can do liposuction on both the lateral and the posterior aspects of the uppermost leg and the medial and posterior aspects of the dependent leg. The patient then rotates onto her other side, and the process is repeated (Figure 40-5).
The prone position can also be used occasionally.
Infiltration with a spinal needle requires care and attention to avoid inadvertent infiltration into subjacent calf muscles. A gentle technique with spinal needles is usually well tolerated but takes time and patience to be accomplished painlessly and without ancillary analgesia. Infiltration with a larger cannula is more uncomfortable and probably requires parenteral narcotic analgesia and sedation.
Achieving optimal tumescence as an end point of infiltration increases the likelihood of complete anesthesia and optimal vasoconstriction. Once complete local anesthesia has been achieved, however, complete tumescence is not necessary when initiating liposuction. In fact, with the decreased tumescence that occurs approximately 30 minutes after infiltration is complete, liposuction becomes easier. After the infiltrated tissue has become tumescent, the surgeon can more easily grasp the tissues and more accurately direct the microcannula to the deepest layers.
The microcannulas are principally directed parallel to the leg’s long axis. Some crisscrossing is necessary to ensure smooth, uniform results. Because the subcutaneous blood vessels and lymphatics are oriented parallel to the long axis, directing a cannula transversely is more likely to injure these vessels.
It is not clear how liposuction-induced injury to dermal vasculature of the ankles or lower leg might affect the risk of venous insufficiency many years later. The ankles are especially susceptible to long-term effects of vascular injury. Clinical experience has shown that a history of cellulitis or phlebitis of the leg predisposes to late onset of postphlebitis syndrome. This condition is associated with chronic venous insufficiency, stasis dermatitis, and increased risk of cutaneous ulcerations. Because of this concern, I believe that superficial liposuction and internal ultrasonic-assisted liposuction are contraindicated in the leg and ankle.
Excessive superficial liposuction that risks injury of the subdermal vascular plexus is unnecessary. The popliteal fossa contains important neurovascular structures that are vulnerable to injury by a liposuction cannula. The surgeon should never attempt liposuction within the popliteal fossa.
Postoperative care is simple. The legs are wrapped in absorbent pads, which are temporarily secured with elastic tube netting and then wrapped with elastic bandages. Compression bandages are necessary until all drainage has ceased, after which compression is optional.
The multiple adits almost guarantee that drainage of residual blood-tinged anesthetic solution will be achieved with minimal compression. With multiple adits and open drainage, prolonged or extreme compression is unnecessary.
Residual edema is minimal and largely resolves within a few days. Patients are encouraged to ambulate during the first few postoperative days to encourage drainage and decrease edema. Bed rest and leg elevation are unnecessary.
Pitfalls and Special Considerations
Attempting to remove all leg fat is generally a mistake. Maximum liposuction of the legs results in an incongruously muscular appearance. A masculine, muscular leg on a female figure is usually undesirable.
More importantly, future weight gain will accentuate irregularities. Slight variations always occur from area to area in the amount of fat removed. In later years, when the patient gains weight, the skin will remain adherent to muscle in areas with no fat. Areas with residual fat will be the sites of additional fat accumulation. The ultimate result is a cobblestone appearance that is difficult to repair without significant risk of dermal injury and scarring.
Figure 40-1 Recommended position for assessing subcutaneous fat of leg.
Figure 40-2 A and B, Preoperative lateral and posterior views with contour drawings on legs. C and D, Lateral and posterior views 1 day after liposuction with open drainage and bimodal compression.
Figure 40-3 Contour drawings on ankles. Relatively small areas of cosmetically displeasing deposits of fat can be accurately delineated before tumescent infiltration for liposuction totally by local anesthesia.
Figure 40-4 With liposuction of large legs, surgeon should not remove too much fat. Conservative reduction of legs with results proportionate to thighs is better than dramatic liposuction that removes so much fat that legs and thighs appear incongruous. This patient was satisfied with improvement after liposuction of 400 ml of supranatant fat from each leg. A and B, Anterior and posterior views with preoperative contour drawings. C and D, Postoperative anterior and posterior views.
Figure 40-5 Positioning legs and ankles during infiltration and liposuction. Thigh Aside positioning pillow is covered with single-use, clear plastic bag. Legs rest on sterile, superabsorbent, operating room table sheet.