Plastic Surgery Experience
Practical Ultrasound-Assisted Liposuction of the Thighs and Buttocks
by Samuel N. Pearl, MD – October 2008
In the early 1980s, liposuction (or suction-assisted lipectomy) was considered a new, controversial surgical procedure.
It has since revolutionized the world of aesthetic surgery—note that liposuction procedures have been applied to virtually every external part of the body.
One of the first clinical areas to be treated was the lateral thighs and buttocks, or “riding breeches.” Finally, a procedure was created that could successfully treat true body disproportion without involving lengthy incisions or recovery time.
Although the technique has become sophisticated, detailed, and more perfected, the basic premise remains unchanged: A surgeon removes unwanted fatty tissue through small incisions with a cannula attached to high vacuum suction.
Improving the appearance of the thighs, buttocks, and flanks remains a challenging task that will always be highly in demand.
Patients of normal weight, as well as those with true disproportion and good skin elasticity, are always ideal candidates. In reality, ideal candidates are in short supply.
As weight is gained (and lost) and aging occurs, laxity of the skin—associated with varying degrees of excessive fat—makes the patient-selection process more difficult.
Depending on the size of the patient, I limit my selection to within approximately 30 pounds of normal weight and limit my aspiration of fatty tissue to no more than 6 liters per outpatient session.
Talking to the patient and, in particular, listening to his or her desires and expectations ultimately determines their suitability as candidates for surgery.
Although there is no substitute for good judgment on your part, the more experienced and confident you are in your technical ability, the less you will be manipulated by your patient.
Although a thorough and complete workup for the patient’s chronic health issues, allergies, medications, bleeding history, surgical history, and psychological issues are a must, you must communicate realistic expectations to your patients in order to have successful outcomes.
Preparation and Surgery
Preparing my patients starts 2 weeks prior to surgery, and includes a discussion of and the cessation of all medications and supplements that are likely to interfere with clotting. Two days prior to surgery, the areas to be suctioned should be washed using chlorhexidine (Hibiclens).
All patients should obtain a hemogram and EKG evaluation; other tests can be ordered depending on their individual needs.
Arnica and bromelain by mouth are started the day before surgery—these are continued for 2 weeks after surgery, with the addition of arnica gel applied to all ecchymotic areas.
Call me old-fashioned, but I still use a topographical approach to marking with the patient in the standing position. It is helpful to mark areas that I do not want to suction in red and utilize purple to mark the areas that I plan to suction.
Special areas, such as the lateral posterior trochanteric depression, banana roll in the infragluteal area, and other unusual dimples and creases, are marked using a black pen—these are areas that I must suction with great caution and care.
If there are areas to fill with autologous fat, these are marked as well. All expected incisions are marked. Incisions in the infragluteal area are always made 5 to 10 millimeters above the fold.
Topographic markings are always helpful. Purple is used to mark the areas to be suctioned; red is used to mark areas that will not be suctioned; and black delineates incision sites and special areas that should be approached with caution.
Positioning the Patient
Although I occasionally suction the lateral thighs in the decubitus position, usually I begin in the prone position, suctioning the lateral, posterior, and medial thighs; the lateral buttocks, superior buttocks, flank areas, and midback; and—when necessary—the medial knees.
The incisions are closed with sterile dressings, and the patient is reprepped and draped in a sterile fashion in the supine position.
The inner thighs are predominantly suctioned in the frog-leg position through inguinal incisions. An additional incision is made in the midsuperior anterior thigh, which allows suctioning of the anterior, medial, and lateral thigh as well as suctioning of the anterolateral flank area.
Through a superior umbilical and one or two superior pubic incisions, the anterior flank—as well as the entire abdomen—can be reached for suctioning. Especially when the abdomen is being suctioned, the lateral and posterior flanks can also be treated in the left and right lateral decubitus positions. By using the prone, supine, and decubitus positions as necessary, I can get the best opportunity to obtain the desired contours.
Circumferential suctioning is common, but the location of the suctioning is based entirely on the desires of the patient, as well as his or her body shape, skin characteristics, weight, and (last but not least) my aesthetic judgment. It is unusual for me to suction the mid and lower lateral thigh. Judicious suctioning is performed in the space between the medial knee and the upper inner thigh.
I have not succeeded in significantly improving the area in the suprapatellar bursa area. As such, I openly discuss this with the patient.
Incisions made in the popliteal fossa and lower inner thigh are common, allowing access to the entire posterior leg. In addition to my standard incisions, I do not hesitate to add small incisions for final contouring, usually with 1.8-mm and 2.4-mm facial cannulae.
A final thought about positioning: It is critical to adequately pad and inspect areas that are prone to pressure, including an additional inspection of these areas during the procedure, especially on procedures that last for more than 2 hours.
All arm boards and other devices need to be functioning properly, with particular attention to positioning the neck, as well as protecting the eyes and brachial plexus areas on prone cases.
Prior to performing the procedure, the surgeon is responsible for ensuring that everything has been inspected. This should include a discussion with the anesthesiologist and circulating nurse regarding airway management, intravenous function, monitors, urinary catheter placement, heating blankets, and antiembolism devices.
A history of cervical spine, lower back, knee, hip, and shoulder problems are common and deserve the same attention as allergic history, cardiovascular disease, diabetes, and other chronic medical conditions.
The safety of our unconscious or sedated patients is our first priority, and that should never be overlooked. A postoperative problem due to improper positioning during the procedure is a potential nightmare that is almost always avoidable.
This 29-year-old woman—5 feet 3 inches tall and 110 pounds—at 1 year S/P received 2,000 cc ultrasound-assisted liposuction to thighs, buttocks, and flanks.
A 33-year-old, 5-foot-6-inch 180-pound woman at 9 months S/P 10,000 cc ultrasound-assisted liposuction to circumferential thighs, buttocks, flanks, midback, and abdomen, with associated skin abdominoplasty performed over two surgical procedures 2 months apart.
If the lateral thighs are included in the planned procedure, begin surgery with the patient in the prone position. General anesthesia is utilized in most cases. Anti-embolic leg or foot compression sleeves are placed over knee-high venous compression stockings. A urinary catheter is used, especially if the total volume suctioned is expected to be more than 2 liters. Silastic gel pads are used to reduce pressure problems, especially in the knee and foot/ankle areas.
It has always been my preference to use chlorhexidine (Icicles) as a prep. Draping consists of splitting a 3/4-sheet in half; my circulating nurse holds up the leg below the knee and places the sheet underneath the leg below the thigh, extending to the lateral chest wall.
After this is completed, sticky paper drapes are placed inferiorly and superiorly. After that, cover everything with a chest/breast sheet cut according to the areas to be suctioned.
Prior to draping, I use chest rolls consisting of rolled bath towels. Gel-padded arm boards are used to support the patient’s arms. Use additional bath towels as necessary to support the shoulders and avoid brachial plexus problems. Particular attention should be paid to the position and support of the neck, as well as the protection of the corneas, which are lubricated with Lacrilube (with tape holding them closed).
This portion of the procedure is critical. I do not proceed until all areas of the body are checked and rechecked by my circulating nurse, anesthesiologist, and myself.
Through infragluteal, superior buttock, and—if necessary—lateral back, popliteal, and medial lower thigh incisions, infusion is begun with a mixture of Ringer’s lactate, 1,000 cc; 25 cc of 2% plain lidocaine; and 1 cc of epinephrine, 1:1000.
If more than 6 liters of infusion is planned, then the lidocaine content per liter should be reduced to 25 cc of 1% Xylocaine plain with 1 cc of epinephrine, 1:1000.
The use of an accurate electric infuser pump with a digital readout has made infusion accurate and efficient, and is far better than any other infusion method I have used. I have been using the VASER laser-based system from Sound Surgical Technologies, Louisville, Colo.
I try to infuse approximately 1 to 1.5 times the expected fat volume to be suctioned. In very dense areas, such as the male breast, I infuse closer to two times the expected suction volume. My nurse keeps track of how much is infused and suctioned from each planned area, writing it on our bulletin board. At the completion of the case, all data is then transferred to the patient’s record.
I use the VASER system on virtually all of my patients, most often using a 3.7-mm two- or three-ring probe, with the VASER set at 80% continuous. A 2.9-mm probe is used for the inner thigh and knee areas at the same settings.
The skin-protection ports have been very helpful during the VASER and standard suctioning portions of the procedure, minimizing postoperative burns and abrasions. These are always held in place with a skin stapler, and the ports can be resterilized multiple times before they are spent.
As a reference, my experience using internal ultrasound began in 1996 with the LySonix system.
The VASER system emulsifies the fat, separating it from the surrounding fibrous soft tissue. This is particularly helpful in areas of dense tissue such as the midback, flanks, some lateral thighs, and upper abdomen.
Compared to other methods, ultrasound technology results in reduced trauma to the vessels and nerves—as well as less bruising and pain postoperatively—although trauma has by no means been eliminated.
The ultrasound system causes contraction of the skin secondary to heating the dermis and deeper tissues, resulting in skin tightening. This has been most apparent in the inner thighs, upper arms, neck, and periumbilical regions.
When suctioning in the prone position, it is important to have a 3D visualization of your desired result. When suctioning in the midback, flanks, and superior buttock areas, it is helpful to think of zones centered on the buttock tissue lying over the gluteus muscle. I do not usually suction this area (buttock augmentation, particularly with autologous fat, is performed primarily in this location).
Infiltration, the ultrasound-assisted work, and suctioning are always done in zones, usually in the order of infiltration.
I infiltrate the left flank and, if necessary, the midback and right side followed by the sacral zone. Next, I move to the left lateral, posterior, and medial thighs followed by the lateral and medial buttock, as necessary. Mendieta discusses an excellent, detailed description of the zones in a recent paper.1
Last, the medial knee zone and other “special” areas are infiltrated. The amount infused into each area is noted, and infiltration is performed deep to superficial. This is followed by an ultrasound treatment, but I do not always use the settings at 80% continuous.
Illustration of the Zones
Very dense areas may require 90% energy, and, when moving more superficially, sometimes I set the ultrasound system to the pulsatile mode to reduce the energy applied near the surface of the skin.
Routinely, I apply energy to within 1 cm of the skin, only allowing the skin that overlies the treated area to be warm to the touch. The more superficial areas are the last to receive ultrasound energy.
A 3.7 solid probe—usually 26 cm in length—is used for this procedure, although a shorter 2.9-mm probe is used frequently in the inner thigh and knee areas. Skin protectors and wet towels are always used to avoid burns and abrasions.
Loss of resistance is always said to be an end point to this portion of the procedure, but I am more aggressive in the areas that exhibit increased deformity, requiring more fatty removal, especially if the fat is dense and the skin elasticity is adequate.
The amount of time needed for ultrasound treatment is measured per area and is usually similar. However, every patient exhibits subtle to not-so-subtle differences when comparing their right and left sides.
- All medications and supplements that interfere with clotting are stopped 2 weeks prior to surgery.
- Patients receive 5 mg to 10 mg of Valium by mouth 1 hour prior to their procedure and the night before surgery.
- Most patients who have a history of significant motion sickness, or who have had previous postoperative nausea, receive a scopolamine patch placed behind the ear immediately prior to anesthetic induction.
- Unless there is an allergy, 1 gram of Kefzol and 8 grams of Decadron are given intravenously before starting the procedure.
- Zofran, 4 mg, is given prior to awakening, and, usually, 30 mg of Toradol is given intravenously after the garment has been placed or after the patient has been taken to the recovery room.
- Just prior to discharge and after removing the IV, second doses of Kefzo, 1 gram, and Decadron, 4 mg, are given to the patient.
- Previously filled prescriptions for oxycodone and acetaminophen x 40, Phenergan 25 mg suppositories x 6, and Keflex 250 mg x 12, are to be taken by the patient in the postoperative period.
- Other medications may include 10 mg of Ambien and, occasionally, a 4 mg Medrol dose pack.
- The combination of a preoperative scopolamine patch in concert with intraoperative Zofran (odansetron) and Decadron has been incredibly effective in minimizing postoperative nausea and emesis—even in patients who have a history of postanesthetic nausea.
Take care to minimize “end” hits by controlling the tip and palpating with the nonoperating hand. Be sure to exercise extreme caution in the superior, posterior “banana roll” portion of the thigh in order to minimize the appearance of a ptotic midlower buttock.
In addition, ultrasound energy must be carefully applied to the midbuttock posterior trochanteric area to avoid postoperative depressions.
After the ultrasound treatment is completed, suctioning is performed, most commonly using 3.7-mm and 3.0-mm cannulae and, if necessary, 2.4-mm and 1.8-mm facial cannulae for final contouring. A 4.6-mm cannula is used if significant debulking is necessary.
The cannula that I use most often is a 32-cm/3.7-mm with a Mercedes tip (from Grams Medical, Costa Mesa, Calif). High vacuum suctioning is performed from deep to superficial planes, with final contouring done using smaller cannulae.
During the suctioning process, a small depression or bulge of tissue may be difficult to correct with the 3.7-mm cannula via the standard incisions. Rather than create a greater deformity, I never hesitate to add additional small incisions, wherever necessary, to allow passage of a 2.4-mm or 1.8-mm cannula.
Suctioning is complete when, by visual and tactile examination, I have created the desired contours. All standard incisions are closed with 5-0 plain; smaller incisions are usually left open. Sterile 3×3 gauze dressings are placed, and the patient is reprepped and draped in a sterile fashion in the supine position.
Prior to transfer to a gurney, I turn the patient while he or she is still on the operating room table. This saves time and can easily be done in a safe, efficient fashion utilizing only the scrub nurse, circulating nurse, surgeon, and anesthesiologist.
Bilateral inguinal incisions are made just lateral to the adductor tendons, followed by incisions in the midupper anterior thighs, if necessary. Midpubic and superior umbilical incisions are utilized, especially when the abdomen is also to be suctioned.
Additional tumescent infiltration is performed, followed by ultrasound treatment using a 2.9-mm probe in the inner thighs. A 3.7-mm probe is used for the entire abdomen, anterolateral flanks, and, if necessary, the anterior thighs. Again, skin protectors and wet towels are used in order to avoid burns, and the ultrasound unit is set at 80% continuous.
The inner thighs are suctioned with the patient primarily in a frog-leg position; the remainder of the suctioning is performed in the supine position. If necessary, I will also place the patient in the lateral decubitus position to help clearly define the waist, posterior lateral flanks, and superior buttock areas.
In the OR
- All patients wear knee-high antiembolic supportive stockings into the operating room, with venous intermittent pressure sleeves used during the procedure and in the recovery room.
- Antiembolic stockings are worn for at least 3 days after surgery. Low-molecular-weight heparin (Lovenox) or other anti-embolic medication is not routinely used in order to avoid postoperative pulmonary embolus.
Incisions are closed. Dressings are applied, consisting of 3- x 3-inch gauze and a portion of an abdominal pad, followed by the placement of large Reston foam pads for additional compression and a lycra compression garment from mid-thigh to xiphoid or calf to xiphoid, depending on the areas suctioned.
For many years, I have successfully used Reston foam pieces that are rounded, beveled, and powdered on the adhesive side to minimize postoperative blisters and abrasions. Care is taken to avoid crumpled or overturned edges of the foam beneath the garment.
The patient is then awakened and recovered, with one to two pillows beneath the knees and the head of the bed, which is elevated to 30Ý.
As significant discharge is expected in the first 24 hours, the patient is sent home with disposable diapers to protect the car seat and the bed at home—as well as absorbent pads (Chux) and additional absorbent gauze and abdominal pads.
The patient is seen the day after surgery, at which time the dressings are changed. The Reston foam is removed, and the garment is reapplied. The patient receives additional foam, which should be placed on the abdominal and, sometimes, the flank areas, beneath the garment, for an additional 3 days in order to provide extra compression. Showering and washing of the garment is permitted 1 or 2 days after the procedure.
The patient’s instructions are to cool wash and dry the garment, and to use peroxide (with or without commercial stain remover) to remove bloodstains.
Pressure garments can still be damp when placed on the body and blow-dried into position. After showering, patients should blow dry all areas after towel drying. In addition, they are expected to be in the garment 24/7 for 2 weeks except for showering, washing the garment, and short rest periods.
The garments are worn for an additional 4 weeks as much as possible, to help shrink the skin and provide more attractive contours. Frequently, the patient will purchase a zipperless pressure garment for use after the initial 2 weeks.
To help decrease bruising and discomfort in the postoperative period, I instruct patients to take oral arnica and bromelain (from VitaMedica Corp, Manhattan Beach, Calif) starting prior to the operation. This regimen should be continued postoperatively for approximately 2 weeks. Arnica gel should be massaged into the bruised areas two to three times per day.
Gentle massage is begun when tolerated, usually within 1 week of surgery. Hand roller massage followed by vibratory massage (electric or battery-operated massagers) should start 1 to 2 weeks after surgery—this should be continued as necessary for up to 3 months or more from the surgery date.
This helps to smooth the areas of induration that are frequently encountered, especially in the areas of maximum suction.
Although the results vary, I usually tell patients that approximately 60% of the final result will be apparent at 6 weeks and 90% by 12 weeks after surgery.
Although the results vary, I usually tell patients that approximately 60% of the final result will be apparent at 6 weeks and 90% by 12 weeks after surgery.
Walking is started immediately, and athletic activity should commence 5 to 10 days after surgery. Endermologie or Velasmooth are recommended to selected patients to help with lymphatic drainage, skin contraction, and modest cellulite. Six to 10 sessions appear to be adequate for most patients.
Serious complications using ultrasound-assisted liposuction have been minimal. After more than 500 procedures, no infections have been reported.
One patient, after only modest liposuction of the abdomen (less than 2,000 cc’s total aspirate), required hospitalization and transfusion secondary to bleeding. She did not require immediate re-operation for hemorrhage and recovered uneventfully.
Although some ecchymosis was encountered in virtually every patient, no hematomas were present. Four seromas have been noted, all involving the lower abdomen or anterolateral flank. These resolved after one to three aspirations performed in my office. I have seen no pulmonary emboli, and I have had no deaths.
The most common complications following any liposuction procedure are some irregularities requiring secondary suctioning and, occasionally, structural fat grafting to depressed areas.
Every effort should be made to avoid depressions in the midlateral buttock posterior trochanteric area. It is always easier to suction a small amount later than to fill a depression. Only judicious, superficial suctioning in the banana roll area should be performed to avoid ptosis of the central lower buttock.
As I tell all patients preoperatively, it may be necessary to have a secondary procedure to achieve the desired result. Commonly, this involves performing ultrasound-assisted liposuction followed by secondary suctioning using local anesthetic with intravenous sedation. or local anesthetic alone.
Samuel N. Pearl, MD, completed his plastic surgery training at the University of Wisconsin after receiving additional general surgery training at Stanford University. He served as chief of emergency services in American Samoa, and he has worked in Africa, the South Pacific, and Central and South America. In his private practice, located near Los Altos and Palo Alto, Calif, he has been a specialized cosmetic plastic surgeon for more than 20 years. He can be reached at (650) 964-6600.
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