Lifts, implants, liposuction
The popularity of bariatric surgery is gaining momentum, and more and more patients are learning that body contouring with lifts, implants, and liposuction is required to restore their bodies and enhance the results of their substantial weight loss.
Aging, nutritional deficiencies, and considerable weight loss often lead to tissue laxity and droopy or sunken contours. After the return of a positive nitrogen balance and correction of anemia and vitamin and mineral deficiencies, various types of body lifts may be performed. These lifts may also be combined with molded soft-solid silicone implants to restore youthful fullness. The remaining bulges are eliminated by liposuction.
According to the American Society of Plastic Surgeons, 60,000 body contouring procedures were performed in the United States in 2004, representing a 7% increase over 2003. Lifting and tailoring fallen and excess skin began with the face in about 1900, and neck lifts followed. Various breast reductions and lifts—Thorek, Biesenberger, Skoog, Strömbeck, McKissock, and Dufourmentel—were developed. By mid-century, abdominoplasty and buttock lifts were popularized by Blair Rogers, MD, and Ivo Pitanguy, MD. More recently, techniques developed by Claude Lassus, MD, Madeleine Lejour, MD, Elizabeth Hall-Findley, MD, Dennis Hamond, MD, Louis Benelli, MD, and Sampaio Göes, MD, for vertical and periareolar breast lifts with less scarring have gained popularity. Belt lipectomy developed by Ricardo Baroudi, MD, improved the ability to contour the midsection, and the medial thigh tuck of John Ransom Lewis, MD, and others helped contour the leg.
It remained for Ted Lockwood, MD, to combine several of these advances to form the lower body lift that has been so successful following bariatric surgery. This lift contours the back, flanks, abdomen (from the sides), and medial thighs and lifts the lateral thighs and buttocks from above. Deep, nonabsorbable sutures into the fascial system support the lift, and liposuction fine-tunes the contours.
There is often skin rippling in the lower thigh. The residual fat and heaviness about the knees and lower thigh can be moderated by liposuction, but neither liposuction nor the standard thigh lift can completely resolve the ripples of loose skin in this area. Direct excision is possible, but the scars may not be acceptable. The smallest of these is a crescentic excision above the knee. The larger and less acceptable scar is vertical and placed at the inside of the thigh (like an arm lift, or brachioplasty). These residual ripples can be helped by massage, particularly suction-roller treatments. Applying good skin nutrients is helpful, as are moisturizers; both soften the ripples and improve stretch marks.
In areas where there is insufficient bulk to achieve pleasing contours, the use of solid silicone implants, fat or dermafat grafts, or both can make the difference. Marked weight loss, congenital underdevelopment, wasting diseases, trauma, and neuromuscular disorders can result in areas of deficiency. Techniques for safely placing standard and custom moulage implants have been developed.1
Calf augmentation has been performed for 25 years. It is a relatively straightforward procedure that can be done under local, dissociative (deep twilight), or general anesthesia. Each of the two heads of the gastroenemius muscle is augmented by placing a teardrop-shaped soft-solid silicone implant (spacer) under the fascial covering of the muscle. The entry is through a short incision in the popliteal crease behind the knees. This surgery has helped greatly to provide definition to the underdeveloped calf. However, when the entire lower leg is thin, there has been no satisfactory answer until recently.
Eight years ago, I began studies into augmenting this part of the anatomy. For the past 6 years, I have used a patented combined calf–leg silicone implant that fills out the leg from the knee to the ankle. Cases of spindly legs, atrophy from trauma or nerve injury, polio, and clubfoot have all responded well with significant cosmetic improvement and no loss of function. Patients who previously would not have considered wearing shorts or skirts are now thrilled to be able to do so. The approach is the same as for the standard calf augmentation with the addition of a 1-inch incision placed vertically above the inside of the anklebone.2
Recently, I have also augmented the thin outer thigh with custom-molded implants and, of course, submuscular buttock augmentation is rapidly gaining in popularity. (I use a soft anatomical silicone implant of my own design.) If necessary, a bit of liposuction is added inside the knee or high inner thigh, and the entire lower half is now amenable to reshaping.
Breast implants, when indicated, enhance the lifting procedures, and are generally placed in the submuscular or biplanar position. Biceps and triceps augmentations are being developed because requests for augmentation of the arms have been increasing. Biceps may be enlarged by a special submuscular technique, whereas triceps are enlarged by direct subfascial placement. The development of softer solid silicone implants has been very helpful. Tailoring flabby arms (brachioplasty) is routine.
Facial implants—malar, submalar, chin, angle of the jaw, and nasal dorsum—complete the possibilities of a fuller look, and fat grafting and injectable fillers are useful adjuncts in the quest for more youthful curves in the face and body. Breasts that sag and have lost volume may be repositioned and some of the volume made up by using the deeper layers of excess skin. Adding a saline- or silicone-filled implant at the same time enhances this effect.
Even after considerable weight loss, there may still be areas of fullness. Typically, deep fat deposits reside in these areas. Caucasian women are generally affected in the hips and at the trochanters or saddlebags; Hispanic women in the central area, abdomen, flanks, and hips. In these areas, the fat may be whiter and is less metabolically active. Judicious liposuction can smooth these contours. The type of liposuction used (e.g., standard wet technique or ultrasound) is less important than the skill and experience of the operator.
Some personal notes regarding the early days of liposuction may be appropriate here. In the mid- and late 1970s, I treated some cases of trochanteric lipodystrophy with the Schrude–Kesselring type of open fat curettage using uterine curettes and Yankower suction.2,3 When I relocated to southern California and opened a practice in Agoura Hills, I met a barber who told me about a remarkable new fat removal technique she’d heard about from Norman Martin, MD. Martin had recently returned from Paris, where he spent time with Gerard Illouz, MD.
Illouz had advanced the Kesselring procedure by combining the curette and suction in one instrument. The hollow tube with a side opening near the tip still had a sharp lower lip, but most importantly, the tip itself was blunt. Martin was modifying the cannulae to make them smoother and thinner. Because he was an ENT-trained surgeon and had encountered derision and disbelief from plastic surgeons, he was interested in having a plastic surgeon bring his work to wider groups. We did six cases together, and in February 1982 I presented them with statistics from Martin’s several hundred cases at the Rocky Mountain Association of Plastic Surgeons annual meeting. To my knowledge, this was the first presentation to a medical society on the subject by an American surgeon.
Greg Hetter, MD, and Frank Herhan, MD, were in the audience. At the conclusion they came up and related that they had been at a presentation by Pierre Fournier, MD (an associate of Illouz), the week before but still had doubts. However, after seeing what I had presented, they resolved on the spot to go to Paris. Upon their return, they set up the Lipolysis Society (lipolysis was the original term for the procedure), which was later changed to the Lipoplasty Society.
On his second trip to France, Martin brought back two Medical X suction machines and two sets of inscribed Illouz cannulae—one set for each of us. (Although my machine is now in the garage, I continue to use a somewhat improved U.S.-made version as well as a Unitech® machine on a daily basis). I have taught Yves Devilliers, MD (who later coauthored a book with Illouz), and other surgeons the technique and have performed over 7000 procedures.
Simon Fredricks, MD, credits Martin with bringing liposuction to the United States.4 Fredricks was skeptical at first when he headed the ASPRS blue ribbon panel that went to France to debunk the “overblown” reports of this technology, but he returned with a ringing endorsement.
Bahman Temorian, MD, in Maryland should also be credited as a pioneer in the field. He stressed using a grid technique, breaking up the fat by approaching it from at least two directions. I had come to the same conclusion independently and called it “the overlapping fan pattern.”
When lipolysis started, the French patients were large and the cannulae were large—10 mm and 8 mm were standard. The techniques had to be refined for adaptation to more moderate body types, The cannulae were progressively reduced to where we now use nothing larger than 5 mm—usually 3 or 4 mm, with 2 mm for the face.
Whereas Illouz routinely used saline for his wet technique and Martin added hyaluronidase, I started adding Xylocaine® with epinephrine: 50 mL of 1% solution to each liter of saline, a 1:200,000 dilution. The installation method then in use introduced the saline via multiple punctures with an 18-gauge needle. However, without general anesthesia, this was not easily tolerated. I used a 25-gauge spinal needle to numb the skin, then installed the fat-anesthetizing saline with 20-gauge needle punctures.5 Jeffrey Klein, MD, has done a great service by quantitating the use of Xylocaine with epinephrine and in applying the term “tumescent” to the procedure.6
I asked a manufacturer (Byron) to make a long, blunt-tipped needle with many tiny holes in the sides so that I could “pretunnel” and instill the saline mixture at the same time. The company obliged, fixing these needles onto 20-gauge Luer-Lok® hubs, and the spray needle was born. Joseph Hunstead, MD, later added a spiral pattern to the holes. In the early 1990s, Eugene Courtiss, MD, demonstrated that circumferential liposuction could be done in one procedure.7 In 1997, I reported on the safety of large-volume resections when done without general anesthesia.8 All of these surgical advances and the use of external modalities, (e.g., ultrasound, radiofrequency, Endermologie®, the ion magnetic inductor, and perhaps mesotherapy–lipodissolve treatments) and improved skin care and nutrition have enhanced our ability to shape and reshape the human body. n
Robert Gutstein, MD, FACS, is a board-certified plastic surgeon who practices in Beverly Hills and Agoura Hills, Calif. He can be reached at (310) 277-0910 or [email protected].
1. Gutstein R. Body sculpting. Plastic Surgery Products. 2001;11(11): 34-38.
2. Schrude J. Lipectomy and lipexheresis in the lower extremities. Langenbecks Archive Surg. 1977; 345:127.
3. Kesselring UK, Meyer RA. Suction curette for removal of excess local deposits of subcutaneous fat. Plast Reconstr Surg. 1987;62:305-306.
4. Fredricks S. In reply. Lipoplasty Society Newsletter 2000;17(1):6.
5. Gutstein R. Paper presented at: Annual Meeting of the Rocky Mountain Association of Plastic Surgeons. 1982.
6. Klein J. The tumescent technique for liposuction surgery. Am J Cosmetic Surg. 1987;4:263-267.
7. Courtiss EH. Reduction mammmaplasty by suction alone. Plast Reconstr Surg. 1993;92:1276-1284.
8. Gutstein R. Paper presented at: Annual Meeting of the Rocky Mountain Association of Plastic Surgeons. 1997.