Lipocontouring: Recipe for Esthetic Feminine Silhouette

Abstract

This chapter discusses the different types of procedures for augmenting body shape and size, including liposuction, lipoinjection, lipocontouring, and others. It presents a history and literature review of liposuction and details the author’s personal techniques with accompanying figures and photographs. The chapter also discusses safety and common complications of body contouring techniques.

1. Introduction

The influence of social media on how people view their bodies is undeniable. Increasingly, many people consider an hourglass body shape with a narrow waist and round buttocks to be “ideal.” This is true across many cultures and ethnic groups. Nowadays, there is a focus on buttock aesthetics, with many people wanting full, round buttocks free from cellulite and a small hip-to-waist ratio (Figure 1).

Figure 1.

a, b, c and d are images of patients who have undergone lipocontouring; from different ethnicity.

1.1 Liposuction, lipocontouring, and new concepts

Liposuction is one of the most frequently performed procedures in plastic surgery, accounting for 15–20% of all cosmetic procedures. In the last 5 years, it has been among the top three most requested procedures [1].

Contributions from researchers like Sterodimas, Coleman, Klein, Gasparotti, Zocchi, Apfelberg and others are the cornerstone for all current lipocontouring procedures performed [2, 3, 4, 5, 6, 7].

Alfredo Hoyos and Peter Prendergast’s book on high-definition liposculpture details advanced techniques in lipoplasty and autologous fat grafting [8]. The authors describe augmentation of muscular curves by lipoinjection over muscles and intramuscularly for an athletic body shape.

A meta-analysis by Hector Lázaro Cárdenas-Camarena et al [1] focused on safety and reducing fatal complications in liposuction. This study found that thromboembolic disease, fat embolism, pulmonary edema, lidocaine intoxication, and intraabdominal visceral lesion are the most serious complications when performing liposuction.

Danilla described the rectus abdominis fat transfer (RAFT) technique, which involves transfer of fat directly to the rectus abdominis muscle after flap elevation during lipoabdominoplasty [9]. Gonzalez et al. investigated incorporating the ultrasound-guided rectus abdominis fat transfer (UGRAFT) technique after high-definition liposuction in one patient [10].

1.2 Gluteal fat augmentation

Strong et al. contributed to the refinement of the fat grafting procedure with their review of harvesting, processing, and injection techniques [11].

Luiz Toledo invented the “Brazilian Buttock Technique” for transferring fat to the buttocks [12].

Mendieta [13] published his classification of the liposculpture of the gluteal units for better understanding of the area; gluteal fat augmentation became a three-dimensional body contouring technique more than just a simple buttock augmentation; Mendieta described a gluteal esthetic unit classification system involving 10 units (see Table 1 and Figure 2).

1.	Sacrum v-zone
2.	Flank
3.	Upper buttock
4.	Lower back
5.	Outer leg
6.	Gluteus
7.	Diamond zone: inner gluteal
8.	Mid-lateral buttock (point C)
9.	Inferior gluteal/posterior leg junction
10.	Upper back

Table 1.

Gluteal esthetic units.

Figure 2.

Gluteal esthetic units.

In Mendieta’s classification system, six esthetic zones contribute to the buttock frame/shape: zones 1–5 and 8. The mid-lateral buttock (zone 8) is unique in that it often requires fat transfer to improve contour. Additionally, this area does not contain muscle and thus requires special attention and precision when fat grafting. All approaches involve liposuction of zones 1–4 in all patients. It is important to note that excessive liposuction of zone 5 can also lead to an unnatural transition zone between the buttock proper and the lateral thigh [14].

Expansion vibration lipofilling (EVL), first described by Del Vecchio and Wall, is a more efficient alternative to syringe-based injection in large-volume fat transplantation to the breast and buttock, employing basket cannulae and vibration through recipient site tissue. By utilizing 4-mm large-bore tubing, the authors demonstrated that large-volume fat transplantation procedures such as Brazilian butt lift (BBL) can be performed more expeditiously, free the operating hand from fatigue, and allow for more focus on cannula tip location and anatomic cannula depth [15].

2. Aim of this work

This case series demonstrates the effect of lipocontouring in female patients. We describe liposuction combined with lipoinjection to promote better understanding of the implementation of new technologies to maximize esthetic results while prioritizing safety.

A combination of liposuction of the back, waist, and abdomen with lipo-augmentation and liposculpture of the buttocks with treatment of cellulite and buttock lifting by threads produced good esthetic results and high rates of patient satisfaction.

3. Patients

This case series includes a cohort of 243 female patients aged 18–50 years with a body mass index (BMI) in the range of 18–40 who underwent lipocontouring and waist liposuction (lipo 360 procedure) combined with other surgeries such as buttock lipofilling, tummy tuck, cellulite treatment, and thread lifting of the buttocks.

4. Surgical technique

4.1 Medical history

Patients were screened for history of previous operations, diabetes mellitus, hypertension, use of blood thinners, pregnancies, smoking, and cardiovascular diseases.

4.2 Examination

Body shape, buttock shape, fat distribution, skin laxity, adhesion lines, intra-abdominal fat, abdominal muscle weakness, hernias, cellulite condition, stretch marks, scars and umbilicus were all examined. Patient waists were measured at the smallest (maximal indentation) point and patient hips were measured at the widest part. The measurements were divided to obtain waist-to-hip ratio.

4.3 Photography

Patients were photographed from shoulders to knees at a distance of 2 meters and from different angles: anteriorly at 45 degrees to the right and left, laterally on both sides, and posteriorly at 45 degrees to the right and left. Cellulite condition of the buttock area was photographed in both a state of relaxation and during muscle clenching.

4.4 Marking

Permanent markers were used to mark areas for deep and superficial liposuction, adhesion lines, areas for lipoinjection, and areas of cellulite.

And dynamic muscle lines definition.

4.5 Anesthesia

Both general and epidural anesthesia were used.

4.6 Patient positioning

Patients were placed prone then supine.

4.7 Liposuction: Video 1,https://bit.ly/3QHTY6c

4.7.1 Tumescent infiltration

Tranexamic acid (50 mg for 500 cc of Ringer’s solution with maximum dose of 200 mg).

4.7.2 Suction-assisted liposuction (SAL)/traditional liposuction

No. 5 Mercedes cannula and no. 4 Basket cannula used for deep liposuction.

No. 4 Mercedes cannula used for superficial liposuction and dynamic lines.

4.7.3 Power-assisted liposuction (PAL)

No. 4 and no. 5 Mercedes cannulae.

4.7.4 Ultrasound-assisted liposuction (UAL)/VASER liposuction

VASER and LipoSound devices.

Used before liposuction.

4.7.5 Laser-assisted liposuction (LAL)

Fotona’s Nd: YAG laser machine.

Used before liposuction.

In a few cases, we used the laser both before and after liposuction (sandwich technique).

4.7.6 Syringe liposuction

Toomey tip syringes mounted on toomey tip ready no. 4 Mercedes cannulae.

4.8 Fat processing and preparation

Fat was aspirated into sterile 2000-cc containers or into toomey tipped syringes.

Decantation was performed only if fat was yellow in color.

Wash of aspirated fat with Ringer’s solution if bloody.

4.9 Lipoinjection: Video 1, https://bit.ly/3QHTY6c

No intramuscular injections were used in this series. Instead, only deep and superficial subcutaneous lipoinjections were used accordingly.

4.9.1 Syringe lipoinjection

Tommy tip syringes mounted on no. 4 Mercedes cannulae.

Three Luer lock syringes on no. 3 and no. 2 single-hole cannulae.

4.9.2 Expansion vibration Lipoinjection (EVL)

There is no propeller machine available in our practice and thus we used Toomey tipped syringes connected to a sterile single-use tube attached to a no. 4 Mercedes cannula.

Lipo-injection using power machine while vibration is on, another step of redistribution of fat after completion of lipoinjection by moving the cannula confirming homogenous redistribution of fat.

4.9.3 Cellulite release and C-point release: Video 2, https://bit.ly/3QHTY6c

Before lipoinjection the cellulite bands and adherent C-zone are prepared by injecting tumescent solution and cellulite bands and adhesions in c-point are released by no. 2 and/or no. 4 V-tip Toledo Cannula (Figure 3).

Figure 3.

V-tip/Toledo cannula.

4.9.4 Ultrasound guidance during lipoinjection

Multiple safety reports and task forces have banned gluteal intramuscular lipoinjection. Several papers reported accidental intramuscular injections despite the surgeon’s intentions to inject subcutaneously. Using ultrasound during injection increases precision and safety (Figure 4).

Figure 4.

Ultrasound-assisted lipoinjection of buttocks.

4.9.5 Thread lifting

Figure 5 shows the author’s personal thread lifting procedure using a no. 1 polydioxanone (PDS) loop suture, which is used in patients with skin laxity who refuse surgical lifting as purse string suture with 2 passages.

Figure 5.

Thread lifting of buttocks (author’s personal technique).

5. Results

5.1 Patient presentation: Video 3, https://bit.ly/3QHTY6c

Figure 6 shows the results of VASER liposuction (1000 cc) and syringe lipoinjection (700 cc of purified fat re-injected) in a 40-year-old patient weighing 55 kilograms.

Figure 6.

Preoperative marking and postoperative photos of lipocontouring in a 40-year-old patient weighing 55 kilograms.

5.2 Patient presentation

Figure 7 shows the results of VASER liposuction (4000 cc) and EVL lipofilling (2000 cc of purified fat re-injected) in a 40-year-old patient weighing 72 kilograms.

Figure 7.

Preoperative, marking and post operative photos of lipocontouring in 40 years 72 kilograms patient.

5.3 Patient presentation

Figure 8 shows the results of tummy tuck, traditional liposuction (5000 cc), and syringe lipoinjection (1000 cc of purified fat re-injected) in a 42-year-old patient weighing 75 kilograms.

Figure 8.

Preoperative marking and postoperative photos of lipocontouring in a 42-year-old patient weighing 75 kilograms.

6. Discussion

Technology and medical knowledge in all fields of plastic surgery, especially body contouring, have expanded tremendously in the last years. The number of patients, plastic surgeons, and procedures is increasing with market expansion.

This chapter discussed our contouring technique, which is easy to learn, simple, and reproducible. In addition, it has a high satisfaction rate and low complication rate.

Adding energy devices to the armamentarium of plastic surgeons, and using them with caution and within safety limits after sufficient training, leads to improved results with smoother curves and better skin re-draping.

Skin burns and vascular insults of the skin are the major complications reported in the literature. These may occur in small areas (e.g., loins) where straight cannulae hit directly into the skin. One patient in our series had bilateral burns after treatment with the LipoSound device (Figure 9).

Figure 9.

Bilateral burns in a patient after undergoing treatment with LipoSound device.

Larger burns and necrosis of larger areas of skin have also been reported in the literature [16]. No major burns occurred in this series.

Skin scarring and discoloration have also been reported, the latter being a more common occurrence. These complications can be largely avoided via cautious use of energy devices during liposuction (Figure 10).

Figure 10.

Pigmented scarring in a patient after undergoing treatment with LipoSound device.

Blood transfusions may be necessary when using liposuction to remove large amounts of fat or when there is excessive bleeding. Other complications may include skin irregularities and over and under corrections.

Teamwork among anesthesiologists, nursing staff, assisting surgeons, and residents is essential for safety and efficacy of body contouring procedures.

7. Conclusion

Lipocontouring procedures can help patients obtain their desired body shape and size. For some patients, this may mean a narrower waist, smaller waist-to-hip ratio, smooth transition from waist to hip, better skin tone, or less cellulite in the buttock area. The procedures used are based on patient factors such as bony frame, skin quality, age, health status, smoking condition, and amount of weight and fat resources. Differences in these factors among patients give different results. Although the best result is usually obtained with the initial surgery, some patients may opt for secondary and revisionary surgeries. For example, an additional round of fat grafting to the buttocks may produce a more esthetic result.

Acknowledgments

I am grateful for the opportunity to discuss ideas, ask questions, and receive input and guidance from Dr. Luiz Toledo, Dr. Hector Duran, and Dr. Carlos Oaxaca.

Ultrasound lipoinjections were guided by my anesthesia consultant Dr. Ahmed Shehab.

Conflict of interest

“I declare no conflict of interest.”

Notes/thanks/other declarations

I would like to thank my mom, dad, wife, and children for their support and sacrifice as I worked to complete this chapter. Special thanks to my team, especially my resident Dr. Hadeer el Shazly for her invaluable assistance.