The high hip or iliac crest area is forgiving but one must avoid overresection. In most cases deep liposuction will be sufficient in these areas unless a patient has flaccid skin. The fat here is normally easy to remove because it is not very fibrous and comes off quite easily. The skin is fairly dense with a rather thick dermis. It is rare that superficial liposuction is needed here. In patients with significant flaccidity of the skin and large flanks, superficial liposuction may be required, with the results always being controlled with digital manipulation and palpation to avoid irregularities. The cosmetic surgeon needs to make a smooth transition between the hip, the buttocks, the lateral thigh, the back and the waist. One must remember the high hips have a concavity that blends into the convexity of the lateral thigh. The incisions used are trochanteric and sacral and, since small incisions are performed with a no. 11 blade or the very smallest 1.5–2.0-mm skin punch wherever access is needed. It is important to be able to create the desired contour and for that reason incisions are placed wherever needed. The deeper fat will need to be removed in a slightly superior medial plane. The cannulas that I use here are the multiple-holed, ventral three-holed and the one- and two-holed spatula of 3.0–3.7 mm. If superficial liposuction is required then the smaller 2.0–3.0-mm cannulas are used.
One of the areas most requested for liposuction is the lateral thigh. Unfortunately, the lateral thighs are one of the most unforgiving areas of the body. The lateral thighs are very susceptible to irregularity especially if there is a significant amount of skin flaccidity. The superficial technique has significantly improved results that can be obtained in the lateral and posterior thigh. The use of autologous fat grafting and liposhifting may be required to obtain optimum results. Sculpturing of the lateral thighs needs to be blended into the hips, buttocks and waist to resculpture the lateral figure from the waistline to the knee . At least two incisions are required. Usually one is made over the greater trochanteric area and another below the distal margin of the proposed reduction. I, however, do not hesitate to make small stab wounds with a no. 11 blade or puncture wounds with a small 1.5–2.0-mm skin punch if needed to obtain better access. If the procedure is done with the patient in the prone position, one must be very careful to avoid the commonest complication of lateral thigh liposuction, which is depression that occurs because too much superficial fat is removed from the lateral femoral skin. The subcutaneous infiltration of the tumescent fluid is then carried out. Overinfiltration is indicated in this area especially if there is flaccidity. I try to determine the amount of fat that will be removed during the preoperative marking period.
This will help indicate the amount of tumescent fluid to be injected. In this area, it is my opinion the tumescent infiltration should be carried out until there is a firmness and slight “orange peel” appearance to the tissue. This will help stabilize the tissue during the liposuction phase. After 12–15 minutes one can normally began the procedure. Prior to liposuction surgery, determination is made of the amount of fat, if necessary, that will be needed for later augmentation or filling of depressions to yield the round attractive feminine shape. Fournier often teaches his students to use syringes to determine the amount of fat needed to fill defects. He will take a 60- ml syringe and lay it in the defect to determine the amount of fat needed to fill that area. In some manner one needs to determine the amount of fat that will be needed for corrections of the depressions. Either the 10-ml or the 60-ml Luer-lock syringe with a small amount of saline and Coleman needles are used to harvest the fat for later use. I attempt to obtain at least 2–3 times the amount of fat I believe will be required.
The deep phase of liposculpture is accomplished first. At the present time I use the oscillating mechanically assisted device. The cannulas presently used are the multiple-holed, ventral threeholed and the one- or two-holed spatula. The tunnels are made in a crisscross fashion but always in the vertical plane. Vertical tunnels tend to contract in the horizontal plane, whereas horizontal tunnels will contract vertically and leave waviness and irregularity. It is important to remember that you are creating round planes so be careful not to flatten the thighs. The marks that were made earlier serve to show depressions and elevations. As these elevations are reduced sculpturing must be continued very evenly, constantly using your hand in a flat position, and your eye to identify where there are irregularities. Moving to the superficial plane, refinement is carried out using small 2.0-mm or smaller cannulas. The Gasparotti area is sculptured as a part of this unit in such a manner to create a very slight depression. The suction in this area is made around the lateral thigh–buttocks junction in such a way to create roundness and not a flattening. Superficial liposuction in this area helps with contracture of the skin in such a way to elevate the buttocks to hold the resection. For the “banana roll,” the area just below the inferior gluteal crease, one must be extremely careful.
The liposuction below the gluteal fold can yield a dropping of the buttocks and create a worse or even a double banana roll. One needs to work deeper laterally until the desired reduction has been achieved and then work around cautiously underneath the buttocks in the superficial plane. Fine cannulas are used and slow conservative resection is accomplished by constantly palpating and molding with the non-operative hands. This will usually give the desired result and reduce the size of the inferior gluteal crease. In the lateral thigh and posterior thigh, fine irregularities are handled with the Toledo “pickle fork” cannula. The postoperative care includes foam padding and a compression girdle. The foam padding presently used is either Reston foam or similar padding that you can buy at the local upholstery store and sterilize in your office. Topifoam can also be used. The foam is cut in a manner to provide supporting compression to hold your sculptured results and the girdle is then placed. The garment and the padding are left in place until the fourth postoperative day. Following removal of the garment and the padding the patient is placed back in the garment only. She will wear the garment 24 h per day removing it only to shower for the first week. At the end of the first week she will return to the office for external ultrasonic therapy if it is necessary. The garment will then be worn for the second week 18 h per day and for the third week 12 h per day. Ultrasonic therapy will be continued as needed for irregularity and ecchymosis.
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1. Natural Remedies for Soft Supple and Glowing Skin
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