Liposuction & Fat Transfer: Anatomic Considerations and Treatment Options

Since its initial presentation by Dr. Yves-Gerard Illouz in 1982, liposuction has evolved tremendously in all aspects, especially in terms of techniques and technology. These advances have significantly improved the overall safety and general results of liposuction and fat transfer procedures. While the notion of introducing and implementing new techniques and technology in practice can be exciting, a practitioner must never stray from the basic fundamentals of treatment that have been proven by solid scientific evidences.

Anatomic Considerations

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General Surgical Layers of Fat: Superficial, Intermediate, and Deep

For the purposes of liposuction and body contouring, subcutaneous fat is arbitrarily divided into three layers: superficial, intermediate, and deep. Anatomically, the properties of these layers allow a practitioner to know the safety layers of which can be suctioned and which would require more caution to prevent contour irregularities and any other possible injuries. As a rule of thumb, the deep and intermediate layers can be suctioned while the superficial layer should remain undisturbed as much as possible.

Liposuction & Fat Transfer: Popular Areas of Treatment

Upper Arms: The anatomy of the arm states that the fatty layer here is usually thin and mobile, with the ulnar nerve lying superficially just beneath the investing fascial layer, while superficial fat is compact, with a more areolar deeper layer. Access incisions should be incised at the elbow on the radial aspect, away from the ulnar nerve, and in the posterior axillary fold for more proximal suctioning. If more anterior suctioning is required, alternative access sites should be considered.

Back: The anatomy in this region is unique - it is made up of a very thick dermis with the underlying fats having a dense, fibrous characteristic. These qualities can make liposuction treatment in the back region significantly more difficult than in most other areas. Access incisions to this area can be incised medially or laterally, depending very much on the distribution of lipodystrophy. In females, it is also recommended for the access incision site be placed in the bra/bathing suit line for best cosmetic result. Due to various safety reasons, suctioning from areas off of the thoracic cage (hip region) to the posterior back should be avoided, as there is the potential possibility of intrathoracic penetration because of the dense skin and the fibrous tissues present in this area. If ignored, it may lead to dire outcomes.

Hips/Flanks: Suctioning of hips/flanks is usually accessible through the bilateral or single midline paraspinous region and/or incision in the lateral gluteal fold. Here, fat is usually loose, and in some cases, fibrous with thick overlying skin. Knowledge of the differing aesthetic consideration of the hips and flanks in males and females is crucial in preventing inappropriate masculinisation or feminisation. It is also essential for the practitioner to mark the lateral gluteal depression prior to liposuction, as violation of this important area can lead to irregular contour and deformity. Often, this adherent zone is a landmark to which both the hips and lateral thighs are reduced; creating a favourable silhouette. In others, it may represent an area of significant depression, in which case, autologous fat transfer is recommended.

Thighs: Thigh liposuction is another one of the more difficult procedures, where overly aggressive treatments may result in unsatisfactory contours. Particular attention should be paid to when marking the zones of adherence in this region, as the results of overzealous suctioning can lead to significant postoperative deformities. It is just as equally important to place the access incisions asymmetrically, to avoid an operated look.

Buttocks: When performing liposuction procedure for the buttocks, a practitioner should avoid deep, aggressive suctioning. The maintenance of length and position of the inferior gluteal crease are just as critically important. Special care should be taken when addressing the proximal posterior thigh as over-suctioning this area may result in skin rolls and redundancy. In females, this complication may elongate the gluteal fold, masculinising the female silhouette. As the buttocks is one area that can be very difficult to correct due to its anatomical structure, post-procedural autologous fat transfer or skin excision may sometimes be required.

Neck: Liposuction in the neck region is not uncommon as there is an increasing number of patients wanting to get rid of their double-chins. Access for treatment in this area is typically via a submental incision, just posterior to the lobule on either side. Suctioning should proceed in a controlled fashion, and the superficial dermis should be avoided. Continuous assessment of contour during procedure is important.

Abdomen: Liposuction treatment for the abdomen is popular in both men and women. Fat in the abdomen is amenable to all forms of liposuction with superficial liposuction to be approached with more care and caution. Often than not, access incisions for this area are made suprapubic and/or periumbilical. Performing superficial liposuction in this area requires more finesse in terms of skills and techniques - therefore, it is usually reserved for the linea alba or for the correction of secondary deformities. Due to the complexity of abdominal liposuction, especially superficial liposuction, it is recommended that the procedure be performed by, or under the supervision of, a well-experienced surgeon.

Treatment Options

There are many factors that influence and determine the type of treatment to be implemented and these include, but not limited to, the performing surgeon’s preference, body area to be suctioned, amount of expected aspirate, as well as the patient’s medical history.

Liposuction & Fat Transfer: One Problem, Three Solutions

While traditional/standard liposuction is referred to as suction-assisted liposuction (SAL), there are also other modalities of liposuction which include power-assistance, ultrasound as well as laser technology. Some of these modalities are: power-assisted liposuction (PAL), laser-assisted liposuction (LAL), ultrasound-assisted liposuction (UAL), and vaser-assisted liposuction (VAL).

Suction-Assisted Liposuction (SAL): SAL remains as the most common modality for liposuction, employing the use of variable-sized cannulas with an external source of suction for removal of aspirate. It allows the performing surgeon to manually loosen and suction unwanted fats. It is effective on many areas - from abdomen to under chin. However, post-surgery recovery may take longer than most other modalities.

Power-assisted Liposuction (PAL): Another popular modality for liposuction is PAL. This involves an external power source driving the cannula (which can vary in size and flexibility) at a 2-mm reciprocating motion at rates of 4000 cycles per minute. Advocates of PAL contend that it is best used for large volumes, fibrous areas, and revision liposuction as it allows the performing surgeon to have better control and precision of the device. Reportedly, recovery speed is faster than that of SAL and potential complications can be minimised.

Laser-Assisted Liposuction (LAL): LAL has been at the forefront of marketing hype in past recent years. This treatment involves inserting a laser fiber via a small skin incision. Depending on the product design, the fiber may either be housed within a cannula or as a stand alone. LAL is usually performed under a four-stage technique: infiltration, application of energy to the subcutaneous tissues, evacuation, and subdermal skin stimulation. The laser fiber acts to disrupt fat cell membranes and emulsify fat. Evacuation then commences via traditional liposuction cannulas. One of the current claims for the use of LAL is the purported skin-tightening effects. The belief is that the heating of the subdermal tissue can help tighten the skin, but on the other side of the same coin, it may also cause skin injuries if not correctly performed by a professional surgeon.

Ultrasound-Assisted Liposuction (UAL): UAL utilizes ultrasound energy to break down fat to allow removal. The mechanism of action is primarily mechanical in nature, but cavitation and even thermal effects may occur. With this technique, fat is emulsified, before allowing the removal of fat through traditional liposuction cannulas. The advantages of UAL is that it is able to produce improved results in fibrous and secondary procedures while at the same time be able to help reduce surgeon fatigue.

However, disadvantages such as the need for larger incisions, longer operative times, and the possibility of thermal injury have been reported. UAL also requires a super-wet environment and cannot be performed without any wetting solution. Lastly, it is very important for the performing surgeon to be able to appropriately manage the UAL probe so as to prevent thermal injury to the superficial dermis. Skin protectors should, and are strongly recommended to be used. Treatment to endpoints of UAL would also be different to those used for traditional SAL.

Vaser-Assisted Liposuction (VAL): In the case of VAL, it employs a newer generation of technology that incorporates less energy with more efficiency. Probes used in VAL are usually more solid and less flexible. These probes would often come in an array of sizes and grooving - catered to be used on the different tissues and layers of the site of operation. This advanced technology allows VAL procedures to use less energy, which in turn reduces its thermal component to the tissues. Furthermore, some studies have shown that VAL has limited advantages in managing blood loss and is therefore recommended for use in large-volume liposuction procedures including areas of fibrous fatty tissue where excess blood loss may be expected.

Advances in Liposuction & Fat Transfer: Staying Ahead

Liposuction, along with fat transfer procedures, have come a long way since their introduction to the medical arena; and with more than 3 decades of continuous progress, it is undoubtedly one of the most popular procedures performed around the world just as it would continue to be in the years to come. It is therefore, imperative for a practitioner to remain committed to the common goals of patient safety and improved aesthetic outcomes, by keeping abreast of trends through expanding knowledge, refining skills and mastering the latest and most advanced techniques in the field.

Hope you have enjoyed the article & video! Stay tuned for our future posts about more techniques and information related to our advanced aesthetic and cosmetic training courses!

Reference:

https://academic.oup.com/asj/article/30/1/83/199871

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