Thigh and Knee Liposuction Treatment & Management

Assuming that the patient meets the criteria for consideration for liposuction surgery, medical therapy such as diet and exercise are not indicated.

Liposuction

Preoperative preparations

• Discontinue the following:

  • Smoking

  • Aspirin, aspirin-containing medications

  • Ibuprofen

  • Vitamin E

  • Garlic preparations and other herbal remedies

  • Diet medications for 2 weeks before surgery

  • Alcohol for 2 weeks before surgery

  • Medications in appendix I for 2 weeks before surgery

• Wash areas to be liposuctioned with antibacterial soap or cleanser beginning 2 days prior to surgery.

• Make transportation and aftercare arrangements.

• Decide on location, either hospital operating room, hospital-attached or free-standing ambulatory surgery center, or office surgical facility.

  • Whether liposuction should be an inpatient or outpatient surgery has become controversial because of complications and the reported mortality rate. In several states it has led to attempts at legislative intervention to define how, when, and where liposuction is to be performed, as well as volume guidelines.

  • The general consensus, still leaving the final decision up to individual physician, is that an otherwise well patient having liposuction of less than 1500 mL volume can undergo the procedure as an outpatient.

  • Instructions for observation at home must be clear, and an at-home caregiver should be present at all times for the first 24 hours. For more than 1500 mL volume, patients should remain overnight in an extended care facility that allows for monitoring of vital signs, intake and output fluid management, and observation by professionals.

  • Safety issues aside, many, if not most, patients are more comfortable spending their first night after surgery in a facility with professional care and access to management of pain and nausea.

  • The growth of ambulatory surgery has paralleled the growth of cosmetic plastic surgery. With it has come the creation of the office-based surgical facility. When such a facility is constructed and staffed in accordance with standards set by various licensing and certifying organizations (Accreditation Association for Ambulatory Health Care [AAAHC], American Association for the Accreditation of Ambulatory Plastic Surgery Facilities [AAAAPSF], Medicare), it is a safe, appropriate location for liposuction.

  • However, there are many examples of poorly equipped and staffed facilities functioning as ambulatory surgical centers but limiting expenses to be competitive at the peril of patient and physician. Competition is good and healthy, especially when it benefits the public by offering options, alternatives, and lower prices; however, when competition spurs cutting corners and increasing risk, no one benefits.

Patient marking

Prior to sedation or induction of anesthesia, make accurate and precise skin markings with patient in a standing position. If possible, use a full-length 3-way mirror to make these topographical maps, as it will give the patient the opportunity to view all of the areas to undergo liposuction and to point out areas of individual concern. Use either a sterile surgical marker or clean indelible marker (Sharpie).

Especially for the inexperienced liposurgeon, for thigh and knee liposuction it is useful to mark in a consistent fashion. Begin by delineating the entire region, including superior and inferior limits of the thigh and knee, medial and lateral lines, and anterior and posterior. Mark landmarks such as the gluteal crease and popliteal line. Next, outline natural indentations, dents, and depressions. Finally, outline bulges to be reshaped with concentric circles that, like a topographical map, delineate the maximum to minimal projections, thus the relative amount of liposuction for the area. If the surgeon plans to liposuction the entire thigh circumferentially, then markings should demonstrate this plan as well.

While one cannot always be sure of the exact number and location of incisions, for liposuction of the thighs and knees, the standard incisions (of approximately 3-mm length) are buttocks crease, lateral buttock or hip, medial groin, and medial popliteal line. As long as the incisions are kept short, skin is protected with lubrication from abrasive cannula trauma, and closed with subcuticular sutures only, incisions can be placed almost anywhere they are needed to perform the liposuction and remain inconspicuous.

Anesthesia

General, spinal, and epidural with tumescent or superwet infiltration: General, spinal, and epidural anesthetics require an anesthesiologist or nurse anesthetist and provide the greatest level of control and patient comfort. The author prefers general anesthesia for all but the most localized and limited areas of liposuction. The presence of an anesthesiologist maintains patient comfort and manages and monitors fluids; this is crucial for patient safety and the surgeon's peace of mind. There is no question that this increases costs.

• Tumescent only: The tumescent technique, with or without sedation, is another option with many proponents. In the tumescent technique, tumescent solution is injected under pressure (either with a pressurized fluid bag or using a compressed gas-pressurized infusion apparatus, as shown below) until the endpoint is reached of tissues being firmly uniformly distended. Tumescent fluid infusate is the primary mode of anesthesia.

  Cabot high-pressure infusion pump for infusing tumescent fluid.

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• Local: Except for limited areas, pure local anesthesia, usually defined as a field block using 0.5-2% lidocaine with adrenaline, is not possible because of the load of anesthetic agent required. Therefore, local anesthesia in liposuction refers to the "tumescent technique" as described by Klein. ^[12] As described above, the dilute lidocaine and adrenaline solution serves to provide both anesthesia and hemostasis. For many liposuctionists, no other forms of analgesia or anesthesia are used.

• Local with sedation: Another option is to combine the tumescent method with oral and/or parenteral sedative agents. This may include a preoperative sedative cocktail as well as intravenous opiates, sedative agents such as Valium or Versed, and Propofol by drip or bolus. Where sedation is used, the author strongly recommends that these be administered and the patient monitored either by an anesthesiologist or certified registered nurse anesthetist (CRNA), not the surgeon and circulating nurse.

Intraoperative fluid management

Intraoperative fluid management is critical. As a significant portion of the tumescent/superwet solution is absorbed, consider it in the calculations of intravenous intraoperative and postoperative fluid needs. In addition to the usual intraoperative monitoring devices, the patient undergoing liposuction needs to have a secure intravenous line capable of delivering large fluid volumes if necessary. An indwelling Foley catheter to monitor hydration may be necessary as well. Also monitor core body temperature, as these patients can and do have major reductions in body temperature during the surgery.

Positioning

This is a matter of surgeon preference. The author prefers the patient in a prone position for liposuction of the posterior thigh, saddlebag, hip roll, banana roll, upper and lower medial thigh, and medial knee, followed by the supine and frog-leg position for the remainder of the inner thigh and knee, as well as the anterior thigh and anterior knee.

Procedure

Sequential pneumatic compression devices are used in all patients. Every effort is made to maintain core body temperature through use of warmed intravenous fluids, warmed wetting solutions, and warming devices, since the degree of skin area exposed and the use of fluids rapidly encourages loss of body heat.

Following induction of anesthesia, if the prone position is desired first, turn the patient or leave him or her in the supine position. Make multiple stab incisions in the desired locations with a No11 scalpel blade (shown below). As the author performs virtually all liposuction procedures under general endotracheal anesthesia, incision sites are not anesthetized. Infusion incisions should be the same as those planned for use in the liposuction procedure. If a small area is performed under a local infiltration anesthesia, the stab incision site(s) is infiltrated with 0.5% lidocaine with 1:200,000 epinephrine via syringe and a 25-27–gauge, 1.5-inch needle. These incisions serve both for infiltration of the wetting solution as well as for liposuction access.

Next, in the routine liposuction case, the surgeon injects tumescent or superwet solution under pressure, as shown below, either to the point of tissue turgidity, if the tumescent method is used, or to a predetermined volume if the superwet method is applied. Instill infusate at all 3 anatomic levels of fat: prefascial, intermediate, and superficial. The volume injected depends on whether the surgeon is a proponent of the tumescent or superwet method. For the former, the volume of fluid injected is approximately 3 mL or greater for each milliliter of aspirate that the surgeon expects to extract from the area to be injected. For the latter (superwet), approximately 1-1.5 mL/mL of aspirate is injected.

Before infiltration, the author paints the area with Betadine (povidone iodine) solution, dons sterile gloves, and drapes the operative field for injection. Following injection, surgically prep the patient with Betadine soap and paint and drape appropriately. Blanching of the tissues occurs over the succeeding 10-20 min. The surgical procedure should not commence until blanching is present.

Technique

Liposuction cannulas come in an almost unlimited number of designs, sizes, and shapes. Selection is a matter of personal preference. Experienced liposurgeons rarely use cannulas wider than 4.6-5 mm as they are overly aggressive and can produce dents and divots rapidly. The author prefers both the triple-hole accelerator tip cannulas and the Mercedes Tip cannulas of various sizes from 2-4 mm internal diameter, as shown below. Both long and short versions are used. They are attached by sterile hose to the liposuction machine, shown below. A multitude of such nonultrasonic machines are available.

With the patient in the appropriate position, using the existing incisions and adding incisions where necessary, introduce the cannula, as depicted in the image below. The author usually begins with the larger diameter accelerator cannulas (3 and 4 mm) for both pretunneling and suctioning in the deep compartment first and then in the intermediate level to approximately 0.5 cm beneath the skin. Intermediate layer liposuction generally results in significant skin contraction without the risks (bleeding, dents, irregularities, visible postoperative "tracks," lines of the cannulae) of superficial liposuction. Where significant skin laxity exists or is anticipated and additional skin contraction desired, the author liposuctions with 2-mm cannulas in the superficial layer (1-2 mm beneath skin).

The endpoint is both visual and palpable. The visual endpoint is when the desired contour has been reached. This is confirmed by a combination of pinch test (comparing preoperative with postoperative thickness), palpation of smoothness, and amount of fat removed.

Close wounds with an intradermal monofilament absorbable suture (4-0 Monocryl [poliglecaprone 25]) and cover with a clear adherent sterile dressing (Op-Site or Bioclusive dressing). No drains are used. Treated areas are occasionally covered with a nonadherent foam material (TopiFoam silicone-gel adhesive foam pad) for somewhat greater direct compression in certain areas. Do not use taping or Reston foam. Apply a compressive garment.

Under some circumstances, when the volume of fat to remove is large or if the area is extremely fibrous, use UAL for the initial softening and liquefaction of the deep fatty layer. The author prefers the Mentor Contour machine, although the LySonix ultrasonic liposuction device has been used previously. The author's preference is based on the Mentor device's protective sleeve and continuous irrigating system that allows ultrasonic liposuction with a small (3-4 mm) incision rather than the somewhat larger incisions necessitated by the size of the skin protectors used with the LySonix device.

Following surgery, patients spend an average of 1-1.5 hours in recovery (postanesthesia care unit) before discharge to their overnight room or home. Normally, monitoring for the first 12-24 hours consists of vital signs and intake-and-output. With tumescent or superwet techniques, fluid management with intravenous replacement is reduced. Studies indicate that approximately 20% of wetting solution is not absorbed. Absorption is approximately 1 mL of injected wetting solution per milliliter of fat aspirated. Remaining fluid needs are delivered with intravenous replacement both intraoperatively and postoperatively and by mouth during the postoperative period. In addition to stable pulse and blood pressure, urinary output of 1-2 mL/kg/h is the goal. Blood transfusion is rarely necessary and, if indicated, is usually anticipated; autologous blood previously has been set aside for transfusion as packed red blood cells.

Bloody drainage

For approximately 48 hours after surgery, especially during the first 24 hours, there is a significant amount of bloody drainage from the incision sites. This occurs even though these wounds are sutured closed and covered with a presumably watertight dressing. While some liposurgeons advocate a conscious active evacuation of fluid from the wounds at the completion of surgery or even insertion of drains, the author has not found this either necessary or advantageous. Warn patients and their caregivers to expect this or they will be understandably frightened and assume that something has gone awry.

Avoid heat and hot water

Encourage early ambulation and activity postoperatively. Patients may shower beginning the day following surgery, but baths are not allowed. Shower water should be lukewarm to avoid possible burns in the liposuction regions. Liposuctioned areas will be numb or at least have much reduced sensibility. Therefore, they are liable to burn injuries. Advise patients to avoid heat packs, heating pads and hot water bottles, hot tubs or even hot baths, and sun tanning, naturally or with tanning beds. Avoid these various activities for several months or until skin sensation has returned to normal.

Compression garments

Patients should have multiple (at least two) compressive garments to allow one to be washed while having a clean one at all times. Compressive garments are used continuously for a minimum of 3-6 weeks (surgeon's preference) and are followed by a garment of lesser compression (and better fashion) such as snug-fitting bike shorts (for patients who have had upper thigh liposuction only) or leotards for those who have had more complete thigh and knee procedures.

Massage

Additionally, when areas are comfortable to the touch, prescribe a combination of lymphatic massage, occasional ultrasound treatments, and self-compression using a standard rolling pin. This process continues for up to about 3 months as tissues progress through the normal phases of healing, deep scar tissue formation, and remodeling of scar tissue.

Return to activity

Return to full normal activity is individually based and depends on a variety of factors including pain tolerance, motivation, and need to return to work. On average, patients are able to resume most normal activities within 1-2 weeks. Some patients are quite active within a matter of days.

Patients who spend the night in the surgery center are examined the morning after surgery and then discharged if doing well. Day patients, discharged home from the recovery room, are seen the following day in the office for an initial follow-up visit. Thereafter, patients are seen at 1-week intervals for the next 3 weeks. After that, follow-up office visits are at 3, 6, and 12 months after surgery.

Photographs and measurements are taken at the 1-, 3-, 6-, and 12-month visits.

The process of deep scar tissue development and resolution takes as long as 6 months.

Risks and complications of liposuction may be divided into the risks generally associated with surgical procedures and those that are more specific to liposuction. ^{[13, 14]}

General risks of surgery

See the list below:

• Bleeding: Significant bleeding is not really considered a risk of liposuction; however, large or megavolume liposuction can encompass the loss of a sizable amount of blood, requiring transfusion.

• Seroma is infrequent in the thighs and knees and usually self-limited, thus these require no treatment.

• Infection is uncommon but fat has poor resistance to infection. The physician needs to be cognizant of and able to recognize necrotizing infection.

• Scarring: Incisions usually heal uneventfully; however, the patient can develop hypertrophic scarring. Additionally, inadvertent injury to overlying skin through superficial liposuction or UAL can produce hypertrophic scarring. ^[15]

• Anesthetic risks vary, of course, with the type of anesthesia selected by the surgeon.

  • Probably most plastic surgeons use general anesthesia administered by either a physician anesthesiologist or a CRNA, together with tumescent infiltration, for all except limited areas of liposuction. For an in-depth discussion of general anesthetic risks, refer to a textbook of anesthesia.

  • In broad terms, beyond the "chipped tooth, corneal abrasion" sorts of risks, the major risks include fluid overload with congestive heart failure and pulmonary edema, toxic effects of anesthetic agents, lidocaine toxicity (where a tumescent fluid is also used) including seizures and cardiac arrhythmia, cardiac arrest, and death.

  • When tumescent infiltration with or without sedation is the chosen form of anesthesia, the risks are similar to those of general anesthesia in terms of fluid overload, lidocaine toxicity, and excessive sedation with respiratory and/or cardiac arrest.

  • Finally, on those occasions when spinal or epidural anesthesia is used, additional risks include spinal headache, persistent spinal fluid leak, infection, "high spinal anesthesia" with respiratory depression, and cord injury.

• Phlebitis and pulmonary embolus: Despite using preventive measures including sequential compression devices, phlebitis and deep vein thrombosis (DVT) occur, as do subsequent pulmonary emboli.

Specific liposuction risks

See the list below:

• Skin necrosis: As mentioned earlier, superficial liposuction, overzealous subdermal fat thinning, liposuction in areas of prior incision scars, and UAL as well as idiopathic causes can result in partial-thickness and full-thickness skin necrosis following liposuction. These usually are best treated conservatively where possible. Larger areas of necrosis may require excision and grafting.

• Burns: Particularly in the use of older and high-power UAL devices, burns can occur. Treatment is the standard care for such a depth injury.

• Hypertrophic scarring: This can occur as mentioned above.

• Fat emboli: These are less common than imagined although there have been reports in the literature. Some liposurgeons use prophylactic alcohol therapy.

• Fluid overload/pulmonary edema: This is a significant risk requiring appropriate fluid management and monitoring. When fluid overload occurs, it requires immediate appropriate management.

• Drug toxicity: The patient can react to lidocaine, bupivacaine, or epinephrine.

• Unfavorable esthetic results: The patient may experience asymmetry, divots and dimpling, lumpiness and waviness, and skin laxity.

Results of liposuction of the thighs and knees, particularly the outer thigh and knee, usually are very favorable. With reasonable patient selection and conservative treatment, even inexperienced liposurgeons can expect a good result. The desired result in the outer thigh is a smooth contour less the "saddlebag" bulge, without divots, indentations, or skin laxity. Posteriorly, at the thigh-buttock junction, ideally a defined break should be apparent between upper thigh and buttock, without a roll (banana roll) at that junction.

Less forgiving are the medial and anterior thigh. In the medial thigh, where skin is quite thin and the subcutaneous fatty layer frequently not large, conservatism is key. More aggressive liposuctioning can easily result in excessive skin laxity, an appearance of skeletonization and concavity, and skin discoloration. The desired result is a smooth line from the upper border of the inner knee to the groin, with slight concavity above the knee transitioning to slightly greater fullness of the upper inner thigh, but without a bulging roll in the final 6-8 cm before the groin crease. With the heels together, the upper inner thighs should either barely graze each other or have a slight separation.

However, a study by Armijo et al indicated that liposuction-assisted medial thighplasty can be an effective means of medial thigh contouring in patients with lipodystrophy related to aging or a large weight loss. The procedure described, performed on 45 patients in the study, involves the following ^{[16, 17]} :

• L-shaped anterior markings

• Superwet infiltration

• Circumferential combined superficial ultrasound-assisted/suction-assisted liposuction

• Predesigned and patterned skin excision and layered closure

Advantages to the procedure, according to the investigators, include nerve and lymphatic preservation, blood loss reduction, and, through maintenance of the saphenous vein system, aversion of wound breakdown and skin loss. ^[16]

Especially for the inexperienced surgeon, it is best to avoid the anterior thigh. When it is necessary to liposuction the anterior thigh, perform this as part of a circumferential thigh liposuction. Be conservative; undercorrection and leaving fat behind is better than having even the slightest concavity along the thigh's anterior curvature.

Long-term results are mixed. While the fat removed from individual locations does not return, patients do have a tendency to gain weight following liposuction in greater than ideal percentages. Where large-volume liposuction has been part of total body recontouring, weight gain is common. However, where liposuction has been used for its intended purpose of shaping isolated fat collections, results and long-term prognosis are excellent.

As surgeons gain greater understanding of fat metabolism and means of controlling weight gain, liposuction to contour the results of heredity, with chemical management of weight fluctuations, may become a routine task for the cosmetic physician.

Lifestyle cosmetic procedures such as liposuction may become part of the comprehensive area of medicine termed "cosmetic medicine and age management." Looking good, feeling good, and living longer and more productively may become a reality.

For excellent patient education resources, see eMedicineHealth's patient education article Liposuction.