Lipomyosculpture

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Chapter 20 Lipomyosculpture

Ewaldo Bolivar Souza Pinto Sr., Pablo Silva Frizzera Delboni, Matheus Monseff Vieira Borela

Key Points

• Morphological and histological analysis demonstrates differences in the superficial layer, regarding the layout of lobes, the shape disposition of interlobular septa tissue (collagen), and thickness of the different body parts.

• Marking before surgery is considered a key step for successful surgery. This should always be performed with the patient standing in front of the mirror. This ensures three-dimensional mobility and the patient can monitor all the surgeon’s movements and tracings.

• Ultrasonic energy (UAL) and vibroliposuction (VL) are useful as aids to conventional liposuction, but not for skin retraction.

• Liposuction must respect the histological peculiarities of the superficial layer of fat in order to stimulate skin retraction, and follow the muscle fibers’ direction; this makes it possible to carve the fat on the muscle, avoiding criss crossing.

Introduction

Since the first half of the twentieth century, many surgeons have been trying to change body contours in accordance with changing concepts of beauty. Since its introduction by Illouz, liposuction has become the best option for body contouring surgery. Improvements in conventional surgery became possible with the development of new liposuction equipments and methods.

In this chapter we describe a new body contouring technique, based on the direction of muscle fibers and collagen, rather than the more traditional crossing tunnels. Excellent results have been achieved, with less trauma and better skin retraction.

Preoperative Preparation

The clinical evaluation should be as thorough as possible, based on detailed history and physical examination.

It is important to have data on: age, sex, comorbidities, medications, allergies, gastroesophageal reflux, any history of tranfusions and their reactions, abuse of legal and illegal drugs, anesthesia complications, the possibility of pregnancy, and functional capacity.

A complete physical examination should be performed, with emphasis on cardiovascular disorders and volume status.

Supplementary examinations should not be carried out randomly and indiscrimately, but in accordance with the clinical evaluation in order to recommend and implement pre- and postoperative care aimed at reducing the surgical risk.

Morpho-Histology of Subcutaneous Adipose Tissue

The subcutaneous tissue is divided into two layers. Its morphological and histological analysis demonstrates differences in the superficial layer, regarding the layout of lobes, shape, disposition of interlobular septa tissue (collagen), and thickness of different body parts (Fig. 20.1).

• Upper abdomen: irregular (50%), elliptical (40%) and rounded (10%) lobes with a parallel arrangement to the epidermis, thick (50%) and thin (50%) septa with a parallel arrangement in relation to the lobes (Fig. 20.2).

• Lower abdomen: irregular (50%), elliptical (30%) and rounded (20%) lobes with a parallel arrangement to the epidermis, thick (70%) and thin (30%) septa with a parallel arrangement in relation to the lobes (Fig. 20.3).

• Lateral thigh: irregular (80%), elliptical (10%) and rounded (10%) lobes with a parallel arrangement to the epidermis, thick (70%) and thin (30%) septa surrounding the lobes (Fig. 20.4).

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FIG. 20.1 Layout of fat cells in different areas of the body. Topography of the areas studied.

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FIG. 20.2 Upper abdomen: thick and parallel septa tissue.

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FIG. 20.3 Lower abdomen: thick and surrounding septa tissue, irregular lobes of adipose tissue.

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FIG. 20.4 Lateral thigh: thick and perforating septa tissue.

• Anterior thigh: irregular (60%), elliptical (30%) and rounded (10%) lobes with a parallel arrangement to the epidermis, thick (50%) and thin (50%) septa surrounding and penetrating the lobes (Fig. 20.5).

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FIG. 20.5 Anterior thigh: thick and surrounding septa tissue, irregular lobes of adipose tissue.

• Medial thigh: irregular (90%) and elliptical (10%) lobes with a parallel and perpendicular arrangement to the epidermis, thick (30%) and thin (70%) septa surrounding and perforating the lobes (Fig. 20.6).

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FIG. 20.6 Medial thigh: thin and surrounding septa tissue, irregular lobes.

• Dorsal region: irregular (80%), elliptical (10%) and rounded (10%) lobes with a parallel arrangement to the epidermis, thick (80%) and thin (20%) septa (Fig. 20.7).

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FIG. 20.7 Back: thick and perforating septa tissue.

• Flank: irregular (70%), elliptical (20%) and rounded (10%) lobes with a perpendicular arrangement to the epidermis, thick (50%) and thin (50%) septa surrounding and perforating the lobes (Fig. 20.8).

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FIG. 20.8 Flank: surrounding septa tissue, irregular lobes of adipose tissue.

• Gluteal region: irregular (80%), elliptical (10%) and rounded (10%) lobes with a parallel arrangement to the epidermis, thick (90%) and thin (10%) septa surrounding and perforating the lobes (Fig. 20.9).

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FIG. 20.9 Gluteal region: thick and perforating septa tissue, irregular lobes of adipose tissue.

• Sacral promontory: irregular (80%), elliptical (10%) and rounded (10%) lobes with a parallel arrangement to the epidermis, thick (90%) and thin (10%) septa perpendicular to the lobes (Fig. 20.10).

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FIG. 20.10 Sacral promontory: thick and perforating septa tissue, elliptical lobe of adipose tissue.

• Submental region: irregular (90%) and elliptical (10%) lobes with a perpendicular arrangement to the epidermis, thick (40%) and thin (60%) septa surrounding the lobes (Fig. 20.11).

FIG 20.4–20.11 Appears imageONLINE ONLY

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FIG. 20.11 Submental region: thin and surrounding septa tissue.

Comparing this analysis to results from clinical observations after liposuction there is an increased skin retraction in those topographies, in which the septa, consisting mostly of collagen, are thicker. Recently, we have been studying a new concept in liposuction – noncrossing tunnels – during the procedure. This new technique follows the muscle fiber directions in each aspirated region, preserving the integrity of the collagen fibers, which are responsible for greater skin retraction in the postoperative period.

Surgical Technique

Marking

Marking before surgery is considered a key step for successful surgery. Marking is always performed with the patient standing, without the administration of preanesthetic and in front of the mirror. While ensuring three-dimensional mobility, the patient can monitor all the surgeon’s movements and tracings, and is able to give his/her opinion and indicate the areas that bother most and that may go unnoticed. Thus, patient and surgeon can match expectations and actual surgical possibilities. After defining the areas to be sucked, the direction of the muscle fibers is drawn to help in following the technique of lipomyosculpture (Figs 20.12–20.14).

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FIG. 20.12 Marking following the muscle fibers – front.

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FIG. 20.13 Marking following the muscle fibers – profile.

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FIG. 20.14 Marking following the muscle fibers – back.

Patient Position

It is essential to provide comfort and safety to patients. The position, depending on the region to be treated, should favor the tubes’ orientation, allowing a wide approach to the area to facilitate the liposuction.

The patient can be positioned on the operating table in the prone, supine, or right and left lateral positions.

Liposuction

The incisions are 5 mm thick, usually perpendicular to the power lines and located in the peripheral area of the region to be treated, allowing the cannula to be correctly aligned. Subcutaneous fat layers with variable thickness should always be left, depending on the treated area, to avoid excess sagging skin and to maintain a correct body anatomy, particularly in women, who need this fat to maintain estrogen homeostasis.

In all areas, regardless of the tube thickness or the use of ultrasound-assisted liposuction (UAL) or vibroliposuction (VL), liposuction is performed following the anatomical direction of the muscle fibers, as an essential part of the lipomyosculpture technique.

Liposuction begins at the deep layer of subcutaneous tissue. This layer, because of the lack of histological differences in the different body areas studied, is treated in the same way with UAL and VL. This aids conventional liposuction, which is performed later (except in regions such as the buttocks, submental, arm, anterior thigh, and medial thigh, where superficial dermal lesions may be caused). The superficial layer is treated according to the peculiarities of each region.

Submental

In this region of loose collagen and irregular cells, we use a 3 mm cannula in the superficial layer, through a submental incision. This follows the fibers of the platysma muscle, just to standardize it without removing excessive fat, which prevents sagging.

Arm

In this area, the liposuction is performed in the superficial layer with a 3 mm cannula, following the direction of the triceps brachii muscle. The incision may be proximal or distal.

Upper Abdomen

This region has more irregular globules and looser collagen than the lower abdomen, creating an area more susceptible to irregularities. In this region we use a 3 mm cannula with conventional liposuction for the refinement of this layer, after aspiration of the deeper layer with UAL and VL through an incision at the level of the xiphoid process, following the fibers of the rectus abdominis muscle.

Lower Abdomen

By having a greater amount of collagen, the superficial layer becomes more compact and thicker than in the upper abdomen. So, we use UAL and VL in both layers, superficial and deep, and a posterior refinement is performed with a 3 mm cannula. When treating the lateral region of this area we use two incisions at the level of the pubis, equidistant from the midline, directing the cannula based on the rectus abdominis muscle and external oblique muscle.

Back

In an area of irregular globules and dense collagen, we use UAL and VL to facilitate the removal of this resistant tissue, and then a 3 mm cannula for the refinement. We follow the direction of the trapezius muscle and the latissimus dorsi muscle, by incisions in the superior or inferior area of the tracing, or both. We insert a silicon drain in the dorsal region, which is removed after 24 hours.

Flank, Sacral Promontory, and Lateral Thigh

The irregular globules with dense collagen give these regions a stronger consistency. So we use UAL and VL in these layers, as we do in the deep layer, facilitating its removal. Finally, we perform the refinement of the superficial layer with a 3 mm cannula. We follow the fibers of the external oblique muscle and latissimus dorsi muscle, and the fibers of the tensor fascia lata muscle and vastus lateralis muscle on the lateral thigh, and latissimus dorsi muscle on the promontory. An incision in the intergluteal groove gives access to both promontory and flank, and other incisions can be made as needed, in order to facilitate access. In the flank, the incision is made in the tracing proximal or distal periphery, or both.

Buttocks

The subcutaneous tissue in the projection of the gluteal muscles is respected, and only the superior insertion outlines are aspirated.

Anterior Thigh

We treat only the irregular globules of the superficial layer, using a 3 mm cannula to harmonize the surface, and a ring cannula to rearrange the fat between the collagen fibers, preventing imperfections. The incision is also made in the tracing proximal or distal periphery, following the fibers of the rectus femoris muscle and vastus medialis muscle.

Medial Thigh

Irregular lobes of fat, interspersed with collagen, form a fragile structure with the thin skin that overlaps. The treatment of our choice is liposuction only in the superficial layer, with a 3 mm cannula, or up to a 4 mm cannula in cases where the patient has a greater subdermal layer, and maintain the deep layer to support the region. This prevents postoperative sagging. We follow the fibers of the gracilis, adductor longus and adductor magnus muscles, through an incision near the groin.

Knee

The inner side of the knee should be aspirated cautiously with a 3 mm cannula, due to a high risk of irregularities, with direction based on the distal region of the sartorius and gracilis muscle fibers, through an incision in the medial popliteal groove.

Postoperative Care

After the surgery, the treated areas are protected with compression bandages and a medium compression mesh, for a minimum of 30 days. Later precautions involve lymphatic drainage, the goal of which is the dissolution of residual nodules and global stimulation of this system.

Complications

Complications of lipomyosculpture are almost the same as those in conventional liposuction. They can be local or systemic. However, we observed that lipomyosculpture has fewer local complications such as bruises, seroma and irregularities.

Conclusion

The superficial body anatomy is formed mainly by its muscles, so the perfect body would be the one with visible muscle structures, giving the desired shape. Based on subcutaneous tissue histology and muscle fiber arrangement, the technique of lipomyosculpture was developed. This consists of performing liposuction, while respecting the histological peculiarities of the superficial layer of fat in order to stimulate skin retraction, and following the muscle fibers’ direction, thereby seeking to carve the fat onto the muscle.

Through this technique we can also minimize some common complications in conventional liposuction, such as intraoperative bleeding and muscle damage. This happens because the location of the subcutaneous neurovascular bundle follows the same direction as the muscle fibers, so there is less chance of bleeding (Fig. 20.15). Muscular trauma and its consequences are diminished when fibers are divided, instead of breaking them incidentally with the cannula.

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FIG. 20.15 Fat resulting from lipomyosculpture.

The technique achieves both layers, superficial and deep subcutaneous tissue, in order to obtain a good skin retraction and a smooth removal of fat tissue. This requires a careful surgical sequence to obtain the desired results. See case studies shown in Figs 20.16–20.21.

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FIG. 20.16 (A–D) 33-year-old patient – 15 days postoperative.

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FIG. 20.17 (A–C) 23-year-old patient – 30 days postoperative.

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FIG. 20.18 (A–C) 31-year-old patient – 6 months postoperative.

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FIG. 20.19 (A–C) 20-year-old patient – 30 days postoperative.

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FIG. 20.20 (A–C) 33-year-old patient – 60 days postoperative.

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FIG. 20.21 (a) Patient aged 54, 2 years postoperative of primary conventional liposuction (left); 3 months postoperative of secondary liposuction (lipomyosculpture) (right). (b) Patient aged 54 showing skin retraction after lipomyosculpture.

image Bonus images for this chapter can be found online at http://www.expertconsult.com

Figs 20.4–20.11 can be found online.

Further Reading

da Rocha RP. Atlas de cirurgia estética para o residente. Revinter Ltda. 2005;1:29.

Ferner H, Staubes J, Sobotta J. – Atlas de anatomia humana, 18th ed. Editora: Guanabara Koogan SA; 1984.

Souza Pinto EB. Nossa experiência em lipoaspiração. Brasília/Brazil: Anais do Congresso Brasileiro de Cirurgia Plástica; 1983.

Souza Pinto EB. Lipoaspiração superficial. Revinter: Rio de Janeiro; 1999.

Souza Pinto EB. Morphohistologic analysis of fat tissue in áreas treated with lipoplasty. Aesth Plast Surg J. 2002:513–518.

Souza Pinto EB, Federico R, Pessoa de Melo SP, et al. Lipomioplasty with Vaser: A new approach to body contouring. Innovations in Plastic and Aesthetic Surgery. 2008;54:433–442.

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