The Tumescent Technique By Jeffrey A. Klein MD
Fat tends to accumulate preferentially on the female thigh. Despite vigorous exercise and physical conditioning, the lack of visible improvement in the shape or size can be discouraging. Disproportionately large thighs often necessitate clothing of two different sizes to accommodate both the upper and the lower body. For this and other reasons, women with this “two-body syndrome” may choose liposuction.
Opinions regarding the ideal proportions of the female figure have varied widely through time and across cultures. In the current era the aesthetic appeal of long legs seems to transcend culture. Artists portray long legs as attractive and refined. Many prospective liposuction patients want this “look” (Figure 32-1).
The English language lacks a word to designate the entire aesthetic unit of subcutaneous fat that includes the outer thigh, inferior lateral buttock, and proximal posterior thigh. For the purposes of liposuction, the usual designations of “outer thigh” and “trochanteric area” are not sufficiently inclusive.
The outer thigh, without the rest of its cosmetic unit, has an obovate (inverted-egg) shape. When liposuction is restricted to just the outer thigh, the result may be disproportionate and aesthetically displeasing. Liposuction that leaves excessive fat in the inferolateral buttock and banana-form fold of the proximal posterior thigh appears artless and amateurish.
Gross Anatomy of Subcutaneous Fat
The term lateral thigh aggregate describes a combined area of subcutaneous fat composed of the lateral trochanteric area, the inferolateral buttock, and the banana-form fold of the proximal posterior thigh. The approximate shape of the lateral thigh aggregate is somewhat cordiform or cordate (heart shaped). This grouping of smaller areas into a larger combined aesthetic unit has true-to-life artistic relevance (Figure 32-2).
The gross anatomy of the lateral thigh’s subcutaneous fat is notable for the lack of elasticity of the buttock ligaments. The inferolateral buttock tends to bulge and sag with advancing years. Slight liposuction of this area can give the patient a rounder, more proportionate appearance.
The shape of the buttock changes with age, probably because of increased gluteal weight and loss of tissue elasticity. The suspensory ligaments of Jacque are gluteal ligaments that traverse the fat of the buttock in a manner analogous to Cooper’s ligaments of the breast. As with the breasts, the effects of gravity eventually overcome the elasticity of the ligaments. With advancing age the suspensory ligaments of Jacque degenerate and the inferolateral buttock tends to sag.
Immediately subjacent to the subcutaneous fat pad of the lateral thigh is the tensor fascia lata and, more posteriorly, muscles of the buttocks and thigh. The sciatic nerve, located approximately 2 cm deep to the surface of gluteus muscle, is outside the surgical field, even during liposuction of the inferolateral buttock or the posterior thigh.
Malposition of the patient during liposuction increases the risk of significant aesthetic defects and patient dissatisfaction. For the lateral thighs, two aspects of surgical malposition are the topologic lipowarp and the trochanteric pseudobulge. The double infragluteal crease, the lipotrop, and the liponot are other undesirable consequences of artless liposuction.
Lipowarp. A lipowarp of the lateral thigh is a topologic distortion of the thigh’s subcutaneous fat compartments caused by a deviation of the body from the anatomic position. The supine or prone position compresses the subcutaneous fat of the lateral thigh in the anteroposterior direction while causing it to protrude laterally. Flexion, extension, or rotation of the hip changes the shape and proportions of this subcutaneous fat (Figure 32-3).
A clinically important form of a thigh lipowarp occurs with simple anterior flexion of the hip. The maneuver distorts the lateral thigh, stretching the posterolateral aspect and compressing its anterolateral aspect. When performing liposuction with the hip flexed, the surgeon tends to do too much liposuction posteriorly and not enough liposuction anteriorly. Although a skillful surgeon can compensate for this distortion, the deviation from the anatomic position poses an unnecessary risk of iatrogenic aesthetic defects (Figure 32-4).
Double Infragluteal Crease. A patient who has a prominent banana-form fold of the proximal posterior thigh will usually expect liposuction to remove this aesthetic “defect.” This is usually a difficult task, with a significant risk of doing too much liposuction and creating an extra horizontal infragluteal crease. Such a double infragluteal crease is both displeasing and distressing for the patient.
Trochanteric Pseudobulge. A special type of lipowarp is the trochanteric pseudobulge. Of all areas treated by liposuction, the lateral thigh is probably the most vulnerable to poor intraoperative positioning. Adduction of the thigh causes the greater trochanter to protrude outwardly, elevating and distorting the overlying fat and creating a pseudobulge. The greater the degree of thigh adduction, the greater is the size of the pseudobulge. The pseudobulge is maximal in the lateral decubitus “high-step” position (hip flexed forward and thigh adducted) (Figure 32-5).
By a simple self-examination, one can appreciate the relationship of femur and trochanteric position to pseudobulge size (Figure 32-6).
Lipotrop and Liponot. A lipotrop is an iatrogenic depression of the skin caused by localized excessive liposuction. This iatrogenic disfigurement can be avoided with an awareness of the dynamic nature of outer thigh surface anatomy, careful intraoperative positioning, and meticulous surgical technique (Figure 32-7).
Excessive liposuction of fat overlying the trochanteric tubercle on the lateral thigh typically produces a lipotrop. The surgeon tends to overcompensate and remove too much fat, thereby creating a trochanteric lipotrop, a discrete depression over the trochanter (Figures 32-8 and 32-9).
Appropriate patient positioning provides the confidence to do enough liposuction for cosmetic improvement while minimizing the risks of a lipotrop or a liponot. A liponot is a focal area of insufficient liposuction.
During the preoperative examination the surgeon should assist the patient to achieve a realist perspective. Photographs of both posterior and anterior views are helpful.
For example, although a woman may be certain that her only disproportionate area is the obovate lateral thigh, another observer might judge the hips to be a greater cosmetic problem. Such a patient may be unaware that her hips or buttocks are much more capacious and are more of an aesthetic problem than the lateral thighs. During the consultation a photograph often gives the prospective patient a more realistic understanding of the cosmetic contour problems.
It is important to evaluate and discuss the inferolateral buttocks and infragluteal banana-form fold. Ignoring these areas and only treating the large subcutaneous compartment of the thigh’s lateral obovate portion can result in a disappointed patient.
The optimal position for liposuction of the thighs is a version of the lateral decubitus position, modified so that the intraoperative position of the thighs approximates the anatomic position.
Liposuction of the lateral thighs using the supine or prone position presents both a warped target and an awkward access for the surgeon. The weight of the patient’s body compresses the targeted fat compartment in the anteroposterior direction and causes an accentuated bulge laterally. Whenever the patient is not properly positioned, achieving a smooth result is problematic.
The optimal surgical position during liposuction of the thighs recreates the anatomic position. The shape of an area of subcutaneous fat is influenced by the position of the subjacent musculoskeletal structures. The anatomic position minimizes the distortion of subcutaneous fat that occurs in other positions.
A patient’s preoperative shape is usually assessed with the patient standing in the anatomic position. With an intraoperative position that approximates the anatomic position, the nuances and subtleties of the preoperative shape will be more easily discerned during surgery. In addition, patients usually judge the results of their surgery while standing in front of a mirror in a manner that approximates the anatomic position. When surgery is done in the position used for postoperative assessment, smooth intraoperative results will more likely be appreciated as smooth postoperative results (see also Chapter 28).
Thigh Midine and Thigh Aside
The Thigh Midine and Thigh Aside are surgical pillows that do the following:
- Optimize the biomechanical positioning of the patient’s thighs during surgery
- Facilitate superior aesthetic results for liposuction of the lateral thigh
- Allow the surgeon to remove enough fat confidently to achieve significant improvement
- Reduce the risk of excessive fat extraction
The Thigh Midine is a wedge-shaped surgical positioning pillow that helps approximate the anatomic position with the patient in the lateral decubitus position. Normally the patient’s uppermost thigh is adducted in the lateral decubitus position. Adduction of the thigh accentuates the pseudobulge, whereas abduction minimizes the trochanteric protrusion.
The pseudobulge can be virtually eliminated with proper positioning of the femur. By rotating the femur anteriorly and medially and pointing the toes of that foot in a “pigeon-toed” manner, the trochanteric tubercle is displaced anteriorly. This significantly reduces the risk of a trochanteric lipotrop.
To position the Thigh Midine correctly, the patient should be in the lateral decubitus position with both legs straight. The uppermost part of the thigh is elevated and the Midine placed between the thighs. To minimize the risk of blood-borne pathogens, before each use the Midine should be placed within a previously sterilized zip-lock plastic bag. To prevent the Midine from sliding, it can be taped to the surgical table (Figure 32-10).
Liposuction of the lateral thighs requires preoperative topographic contour diagrams drawn directly on the patient’s skin (Figures 32-11 and 32-12).
Because the lateral thigh is adjacent to the hip, it is logistically convenient to treat these two areas on the same day. For the same reason the buttocks can be treated concomitantly. In an obese patient it might be excessive to treat the lateral thigh, hips, and buttock on a single day.
The number of incisions on the lateral thigh is determined by an effort to minimize scars and maximize the smoothness and completeness of results. Too few incisions will decrease the likelihood of optimally smooth results. Also, the fewer the number of incisions, the greater is the amount of trauma and friction on the existing incisions. For patients with darker pigmentation, extra care is required to minimize trauma to the skin surrounding the incisions and thus the risk of postinflammatory hyperpigmentation.
The deepest layer of fat should be the first to be liposuctioned in the lateral thigh. Analogous to the situation with infiltration, once a plane of liposuction has been created, it is difficult to judge the thickness of deeper layers of fat by palpation or to distinguish the interface between deep tumescent fat and muscle fascia.
For the initial stages of liposuction the cannula is inserted through several incisions located near the posterior border of the peripheral contour line of the lateral thigh. The cannula paths radiate anteriorly in a crisscross pattern toward the anterior margin of the lateral thigh (Figure 32-13).
With the cannula in one hand, the surgeon gently grasps and elevates the tumescent fat with the other hand while advancing the microcannula. This gentle grasping technique stretches the deepest fat away from the subjacent muscle. This allows the surgeon to accomplish liposuction within the deepest planes of subcutaneous fat while minimizing the risk that the microcannula might encounter muscle fascia.
Once the deepest plane is established in this way, the surgeon can more easily and accurately do liposuction in a proximal-to-distal direction, and vice versa, along the entire extent of the thigh’s long axis. The flexion of a microcannula increases with increasing length, and thus longer microcannulas cannot be directed as accurately or advanced with as much control as shorter cannulas. After multiple transverse tunnels have been established throughout the lateral thigh fat, longer cannulas can be directed longitudinally with more accuracy.
During liposuction the surgeon should intermittently check the amount of fat that has been removed from the area overlying the trochanter. This is accomplished by having the patient straighten the leg and medially rotate the toe, pointing it toward the floor. This maneuver displaces the trochanter anteriorly and flattens the area of the lateral thigh that is particularly susceptible to excessive liposuction. This area immediately overlying the trochanter should look flat but never concave (Figure 32-14).
It is important to place an adit (1.5-mm punch excision) at the most dependent or distal portion of the treated area of the lateral thigh. To permit maximal drainage of the blood-tinged anesthetic solution, this hole is not closed with suture. Encouraging rapid drainage of the residual bloody anesthetic solution results in a dramatic decrease in postoperative swelling, bruising, and tenderness.
All microincisions are allowed to remain open to maximize the postoperative drainage of the blood-tinged anesthetic solution. Sterile superabsorbent pads are placed over the incision to absorb the drainage and uniformly distribute the compression from postoperative garments (Figure 32-15).
Pitfalls and Special Considerations
Soon after completion of liposuction on a lateral thigh, an occasional patient will experience transient burning and aching in that area for about a half hour. This discomfort has no clinical consequence, its cause is obscure, and the situation resolves spontaneously. I am not aware of a similar syndrome affecting other areas of the body treated by liposuction. Patients under general anesthesia are not likely to experience this situation.
Circumferential Thigh Liposuction
Excessively prolonged healing and swelling are the predictable consequences of doing liposuction over the entire circumference of the thighs on a single day. The trauma of liposuction causes postoperative edema of the treated tissues.
Circumferential liposuction of the entire thigh produces circumferential inflammation, with consequent obstruction of the lymphatic and venous drainage from distal tissues. Impaired lymphatic flow leads to distal edema for the foot and leg. Edema and impaired venous drainage increase the risk of venostasis and venous thrombosis (see Chapter 34).
To minimize postoperative pain, swelling, and immobility, circumferential thigh liposuction should be done as a two-stage procedure and on two different days, preferably 1 or 2 months apart. A 4-week to 12-week interval between surgeries is usually sufficient to allow adequate decrease in swelling and soreness and partial recovery of lymphatic drainage. For example, with a staged procedure the surgeon might initially treat the hips and outer thigh, then complete the anterior and inner thigh a month or more later (see Figure 32-1, C and D).
By separating circumferential thigh liposuction into two surgeries, patients can return to normal activity almost immediately after each procedure, with minimal distal edema. The total duration of postoperative disability is significantly less than if all the liposuction were done on a single day (Figure 32-16).
Figure 32-1 Preoperative and postoperative photographs illustrating degree of cosmetic improvement that can be achieved with tumescent liposuction of outer thighs and hips. A and B, Focally bulging outer thighs. C and D, Large lateral thighs and hips yielded 4 L of supranatant fat with one session of liposuction. Inner thighs and knees were treated in separate procedure.
Figure 32-2 A, Topographic contour map of hip (H), lateral thigh (T), inferior lateral buttock (ILB), and buttock (B). Lateral thigh is ovate (egg-shaped) area; inferior lateral buttock is usually round or oval shaped. Banana-form fold of proximal posterior thigh is not conspicuous in this patient. B, Lateral thigh aggregate is cordate (heart-shaped) area consisting of lateral thigh and inferior lateral buttock. C, Same patient with additional contour drawings on hips and entire buttock. D, Orthogonal grid helps nurse infiltrate tumescent anesthetic solution.
Figure 32-3 A, Four adjacent 5 × 5–cm2 squares drawn with patient in anatomic position. B, When hip is flexed, 5 × 5–cm2 squares are distorted by lipowarp (in mathematic terms, squares are transformed by topologic isomorphism into trapezoids). Posterior pair of trapezoids have vertical sides 6 and 5 cm, whereas anterior pair of trapezoids have vertical sides 5 and 4 cm.
Figure 32-4 Lipowarps predispose to distorted liposuction results. A, Posterior (P) and anterior (A) halves of lateral thigh are approximately of equal area when patient is in anatomic position. B, With hip flexed, posterior thigh is expanded and anterior thigh compressed.
Figure 32-5 A, Thigh Midine is a surgical positioning pillow specifically designed to eliminate pseudobulge when patient is in lateral decubitus position. B, No trochanteric pseudobulge when patient stands upright in anatomic position. C, Adduction of thigh while lying in lateral decubitus position creates pseudobulge. D, Increasing degree of thigh adduction causes increased size of pseudobulge. E, Surgeon may cause lateral thigh lipotrop by removing too much fat when doing liposuction over pseudobulge. Such a lipotrop becomes visible when patient stands upright.
Figure 32-6 A, While standing upright, palpate trochanteric protuberances; then lean to one side, slightly raise opposite foot off ground, and adduct raised thigh toward midline; notice that pseudobulge becomes more prominent. B, Abduct raised thigh away from midline and medially rotate knee and ankle into exaggerated “pigeon-toed” position; notice that pseudobulge disappears as trochanter is displaced anteriorly and medially. C, Lateral view of trochanteric tubercle in upright position. D, Lateral view with hip rotated medially, showing anterior displacement of trochanteric tubercle. E, Anterior view of trochanteric tubercle in upright position. F, Anterior view with hip rotated medially, showing medial displacement of trochanteric tubercle.
Figure 32-7 Excessive liposuction can occur anywhere on thigh. A, Liposuction removed too much fat from localized area, resulting in lipotrop. B, Too much liposuction of entire lateral thigh. C, Excessive liposuction of right lateral thigh. Maximal fat removal is unsatisfactory. An appropriate amount of residual fat is necessary for optimal aesthetic results. The surgeons responsible for these cases were careless.
Figure 32-8 Trochanteric lipotrops in four patients resulted from too much liposuction of trochanteric pseudobulge. Poor intraoperative surgical positioning predisposes to this common iatrogenic cosmetic defect. A and B, Left thigh trochanteric lipotrops. C and D, Right thigh trochanteric lipotrops.
Figure 32-9 Lipotrop can result from suboptimal intraoperative positioning. A, Upright position shows results of excessive amount of liposuction overlying trochanter. Note cosmetically displeasing lipotrops (divots) of posterior thigh and lateral buttock areas. B, When same patient is placed in modified left lateral decubitus and high-step position, trochanteric tubercle protrudes and obscures lipotrop.
Figure 32-10 Thigh Midine positioning pillow helps maintain uppermost lateral thigh in an intraoperative posture that approximates anatomic position.
Figure 32-11 Tumescent liposuction of lateral thighs, hips, waist, and buttocks. Topographic contour diagrams delineate relevant surface anatomy: A, posterior; B, lateral. Preoperative views: C, posterior; D, lateral. Postoperative views 6 weeks after surgery: E, posterior; F, lateral.
Figure 32-12 Liposuction of lateral thighs, inferior lateral buttocks, hips, and posterior waist. A, Topographic contour diagram indicates relative depth of subjacent subcutaneous fat compartments. Preoperative views: B, posterior; C, anterior. Postoperative views: D, posterior; E, anterior. Note that anterior views reveal subtle evidence of idiopathic lipoatrophia semicircularis (semicircular lipoatrophy; see Figure 8-19).
Figure 32-13 Microincisions and microcannular paths that might be used for liposuction on a typical large lateral thigh, inferolateral buttock, and banana-form fold. These patterns are repeated multiple times sequentially to accomplish incremental liposuction. A, Approximate location of multiple adits or microincisions and orthogonal grid pattern that facilitates infiltration. B, Initial microcannular paths are directed transversely along deepest level. C, Liposuction through dependent adits to facilitate postoperative drainage. D, Crisscross pattern through inferolateral buttock and banana-form fold. E, Using longest microcannulas to do liposuction throughout targeted area. F, Slightly more liposuction might be needed in deepest portions of targeted fat.
Figure 32-14 Position of trochanteric tubercle relative to overlying skin varies as function of hip joint position. A, In anatomic position, with trochanteric tubercle indicated by cross. B, When hip is flexed 90 degrees, open circle indicates position of trochanteric tubercle. Solid diamond indicates position of trochanteric tubercle when patient is lying on Thigh Midine with hip maximally rotated anteriorly and medially. C, Patient in position for liposuction with sterile superabsorbent sheet placed over Thigh Midine and beneath patient’s thigh. Before placing it on surgical table, Thigh Midine is inserted, large end first, into sterilized, single-use, disposable zip-lock plastic bag. Thus, when in place between patient’s legs, zip-lock end of cover should be closest to patient. Long piece of 5-cm (2-inch)–wide paper tape is used to secure plastic cover table so that Thigh Midine does not slide toward end of table. D, Sterile surgical drape placed on top of patient.
Figure 32-15 Step-by-step instructions for using superabsorbent compression pads and bimodal compression garments for postliposuction care. A, Select appropriate length and size of elastic tube netting for outer thigh. Cut side hole in midportion of netting to accommodate opposite leg and thigh. B, Apply one or more superabsorbent pads over treated area. C, Layer pads so they overlap. D, Use 5-cm (2-inch)–wide paper tape to hold pads in place. E, Place tape along distal edge of pads to prevent leakage of drainage fluid. F, Pull elastic tube netting onto leg. G, Place foot of opposite leg through hole cut in elastic tube netting. H, Pull tubing onto both thighs. I, Pull netting over taped pads. J, Pull netting onto hips. K, Patient is ready to apply two compression garments for bimodal compression.
Figure 32-16 This patient first had liposuction of lateral thighs and hips. More than a month later, she had liposuction of inner thighs and knees. A, Preoperative view; B, postoperative view. After each procedure, she was able to return to work the following day. She had no pedal edema after either procedure.