New Special Topic Liposuction of the Legs and Ankles: A Review of … · 2020. 1. 10. · thetic surgery. This is true both historically and presently. Anatomic peculiarities and

Special Topic

Liposuction of the Legs and Ankles: A Reviewof the LiteratureFrederick G. Weniger, M.D., M.B.A., Jay W. Calvert, M.D., and E. Douglas Newton, M.D.Pittsburgh, Pa.; and Orange, Calif.

A TABOO PROCEDURE

Lipodystrophy of the legs and ankles pre-sents a particularly challenging problem in aes-thetic surgery. This is true both historically andpresently. Anatomic peculiarities and technicalchallenges delayed the development of treat-ment for this condition. Today, attempts toovercome these same obstacles continue torapidly change the face of liposuction in thisanatomical area.

Lipodystrophy of the legs and ankles is dis-tressing to patients for several reasons. Thiscondition, which is mostly limited to femalepatients and usually appears during the emo-tionally vulnerable time of adolescence,1,2

tends to make patients look heavier than theyare. The problem is seen in all ethnic groups.3The appearance of the leg may be so ill definedas to cause the patient severe psychologicalpain and loss of self-esteem. Legs and anklesare frequently not camouflaged by clothingand are therefore among the more conspicu-ous areas of lipodystrophy.3–5 These factorscombine to make this an emotionally frustrat-ing cosmetic deformity. Frustration is exacer-bated by the fact that lipodystrophy in this areaappears to be largely genetically predeter-mined and is especially resistant to exerciseand diet.1,2,6

Despite a need for therapy, liposuction ofthe legs and ankles was slow to develop. Theearliest attempt at treatment of these areas inthe literature dates to the 1920s, when Dujar-rier in France attempted to remove fat by cu-rettage in the lower legs of a well-known balle-rina. He transected a major artery, and thiseventually resulted in amputation.7 Thus be-

gan the long-lived stigma surrounding lipec-tomy of the leg. In 1964, another surgeon,Schrudde of Cologne, attempted to removesuch fat in his patients by curettage. Despiteseveral good results, he reported skin necrosisin four of 15 patients in his series.4,1 In 1977,Fischer and Fischer presented the new lipec-tomy technique of suction curettage.8 Thistechnique was attempted in the trochantericareas but was abandoned because it left lym-phorrhea, large cavities filled with lymph andserum, and terrible secondary sagging deformi-ties over the affected areas.9

After disappointing experiences with closedcurettage and closed suction curettage in theearly 1970s, the modern era of lipectomy be-gan in 1977 with Illouz in Europe.7,9,10 The firstU.S. experience was in 1981, when Americanphysicians of various specialties observed thenew technique of suction lipectomy in France.2Liposuction is now one of the most commoncosmetic procedures,2 but the growth of thismodality in the specific areas of the legs andankles lagged behind. By the late 1980s, thelegs and ankles were being treated more fre-quently, but large numbers of successful caseswere not reported until 1989 and 1990.4

The ignition of the lipectomy wildfire byIllouz’s development of blunt liposuction tech-niques in 1978 resurrected the stigmata associ-ated with circumferential lipectomy of the legsand ankles.7 The procedure had been por-trayed as “fraught with complications and oflimited benefit.”2 Others have said that lipo-plasty of these areas frequently combines highexpectations with, at best, modest results.4,11

Thus, early on, it became clear that liposuction

From the Division of Plastic Surgery, University of Pittsburgh School of Medicine; Aesthetic and Plastic Surgery Institute, University of CaliforniaIrvine; and Division of Plastic Surgery, The Western Pennsylvania Hospital. Received for publication July 12, 2002; revised August 4, 2003.

DOI: 10.1097/01.PRS.0000117299.55812.2E

1771

of the legs and ankles represented an entity fardifferent from liposuction in other anatomicareas, with unique anatomical and technicalchallenges to be overcome. Feared complica-tions then and now include poor patient satis-faction, persistent pigmentation, contour irreg-ularity, ulceration, and especially persistentedema.1,2,7 For these reasons, liposuction of thelegs and ankles was slow to develop.

As early as 1983, Illouz was finding much ofthis stigma of liposuction of the calves andankles to be well-founded. In his report of 3000cases of liposuction that year, he included 159patients who had liposuction of the ankles.12

Although he described good early results inthe ankle region, he recognized and warnedthat the postoperative edema in this area wasmuch greater than in any other anatomicalzone, lasting up to 6 months. As is discussed inmore detail, efforts to overcome this seeminglyinevitable edema have been a major front inthe battle to treat lipodystrophy in the legs andankles. Even cases of eventual good outcomesare tainted by the fact that the edema, whichpersists in the legs longer than in other bodyareas, often makes patients prematurely feelthat they had a poor result.13

Illouz also found other major complicationsto include long-term postoperative pigmenta-tion and contour irregularities.14 Such predis-position to hyperpigmentation is attributableto the dependent location.4 Irregularities,which have been claimed to be the most com-mon complication, are more common in thisarea because the fat is relatively thin. Theseirregularities are more commonly palpablethan visible.4

In 1990, Watanabe’s study of 166 cases ofliposuction of the legs and ankles showed thatpatient dissatisfaction was secondary to theseand multiple other factors. In addition to theaforementioned edema, irregularities, andprolonged postoperative pigmentation, thesecomplaints included legs that appeared lessslender than anticipated by the patient, asym-metries in shape, hypesthesia, and unexpect-edly severe postoperative pain.13 In fact, lipo-suction of these areas may be one of the mostpainful cosmetic procedures, and this discom-fort often remains for many weeks.7 When thelegs and ankles are treated with liposuction,the recovery will also be longer than for mostother areas because of factors such as edema.The reality of these complications in the con-text of a recovery period that can be challeng-

ing to both the patient and the physician ex-plains the continued hesitancy of manysurgeons to attempt this procedure.

Still, with advances in technique over the last15 years, complication rates seem to have dra-matically improved. Newer literature suggeststhat good results usually can be expected. De-spite prolonged postoperative edema, after 6months these patients are some of the mostgrateful.2 Watanabe showed 84 percent satisfac-tion in this patient population, although this iscompared with 98 percent satisfaction with li-posuction in other areas of the body.13 None-theless, cautious attitudes toward this proce-dure have been slow to change. As of 1997,there were still virtually no published articlesor textbooks emphasizing the significant ben-efit, high patient satisfaction, and progressivelylower complication rates of liposuction inthese areas.2 Recently, more investigators havediscussed new techniques that have contrib-uted to overcoming some of the aforemen-tioned obstacles. This review presents the ana-tomic basis for the challenges of liposuction ofthe legs and ankles and examines recent au-thors’ strategies for successful liposuction inthese difficult areas. It is intended to provideclinicians with an overview of the developingstate of the art, and to assist in sorting throughthe multiple techniques that have been pre-sented. Table I summarizes the individual au-thors’ differing strategies.

ANATOMIC CONSIDERATIONS OF THE LEGS AND

ANKLES

Illouz felt that the legs and ankles requiredspecial attention because of their unique ana-tomic features.7 He described this area as rela-tively taboo for liposuction because of thesecharacteristics.13–15 Understanding of theseunique anatomic considerations elucidates thebasis for most of the unique challenges of lipo-suction in the legs and ankles. First, many au-thors describe this area as having only onelayer of fat, with dense fibrous tissue and manylymphatics.7,13–15 This is thought to be largelyresponsible for easily caused postoperative skinirregularities.7 Also, because of this thin subcu-taneous fat layer, postoperative hematomas orecchymosis may result in pigmentation of theskin itself.13 In addition, the dependent natureof the lower legs, the fibrous nature of thefat,13–15 and possibly the disruption of thedense lymphatics from certain techniques16 en-gender a constant tendency toward postopera-

1772 PLASTIC AND RECONSTRUCTIVE SURGERY, May 2004

tive edema. A delay in the absorption of thisswelling may cause a tendency for more fibroustissue to form, thereby threatening permanent“woody” induration of the subcutaneouslayer.13

Anatomically, the larger, less sculptured legis rarely the result of undesirable fat distribu-tion alone, and usually is also the product ofbone and muscle configuration.11 This impor-tant anatomical consideration is addressedlater in the discussion of preoperative evalua-tion. The heterogeneic character of the fatthroughout the lower leg also presents a chal-lenge. For example, the subcutaneous fat inthe medial lower calf is softer and easier tosuction than that more laterally.13 This tends tolead to a greater reduction and resultant over-all concavity medially if this anatomic factor isnot taken into account.

Because of the neurovascular structures, li-posuction at the popliteal fossa should neverbe performed.6 Although the motor nerves anddeep vascular structures of the leg lie deep tothe investing fascia, the greater and lesser sa-phenous veins and the anatomically associatedsaphenous and sural nerves, respectively, livewithin the fat. Although one must take care notto injure these structures with stab wounds forcannulas, Grazer claimed no serious hemato-mas, superficial vein thromboses, or othercomplications from suctioning around the sa-phenous system.5

Within this anatomic setting, the pattern oflipodystrophy of the calves and ankles can beconsidered. Women tend to present with acommon pattern of lipodystrophy of the legsand ankles. Chamosa presents a thorough re-view of the aesthetic ideals in the legs, andexplains the typical adiposities that deviatefrom this form.17 In brief, the knee shouldnormally be bony, with some medial convexityand mild lateral concavity. More inferiorly, aconcavity should also occur between the kneeand the medial protrusion of the gastrocne-mius. This area is commonly deformed by ad-iposities that exaggerate the medial convexityof the knee and that fill in the aesthetic con-cavities of the lateral knee and the area be-tween the medial knee and the calf. In lipodys-trophy of the leg, there is also proportionallymore fat accumulation over the lower half ofthe leg than the upper areas.13 Again, theseaesthetic ideals and their common dystrophicdeviations are well presented graphically byChamosa.17

In 1997, Chamosa presented a uniquely dif-ferent conceptualization of the lipodystrophiesof this area by representing the cross-sectionalanatomy of the leg and ankle as a rhomboid,the points of which were the anterior edge ofthe tibia, the Achilles tendon, and the twomalleoli.18 In this model, fat tends to accumu-late along the lines between these points andthus obscures these prominences. He foundthe anterolateral and posterolateral aspects tobe the most frequent areas of lipodystrophy.Interestingly, Chamosa suggested using lipo-suction to visually camouflage malalignment ofthe knee, claiming that the aesthetic impact ofa varus or valgus knee can be decreased byconcentrating liposuction toward the lipodys-trophic areas on the convex side of the leg.18

Most patients’ concerns regard areas of ex-cessive fat distally over the medial and lateralmalleoli.1 In addition, excess fat often bluntsthe definition of the inferior bellies of thegastrocnemius muscles, especially medially.1,2

Such an obscure transition between the gas-trocnemius muscles and the more inferior legcontributes to a columnar appearance. Specialattention toward the contouring of this “tran-sition zone” is a focus of Mladick’s recentwork,19 and is further discussed.

Another localized excess of fat commonlyexists distally on either side of the Achillestendon, creating medial and lateral fullness atthe ankle.4 These normally concave areaspresent a unique technical challenge.

Despite these common foci of lipodystrophyin the legs and ankles, specific fat distributionsin this area of the body may be generally lesswell defined than in other commonly lipodys-trophic areas.14 Lipodystrophy of the legs andankles is often more circumferential than inother locations, which presents special techni-cal problems secondary to the unique andcomplex contours of these zones. There aretwo important exemptions to the commonlycircumferential nature of this lipodystrophy.First, excess fat rarely becomes confluent be-tween the perimalleolar regions across thepretibial region.1,5 This paucity of fat extendssuperiorly over the anterior tibia.4 Second, sig-nificant fat is never present over the Achillestendon distally.1,4,5 The consequence is that li-posuction rarely changes the anteroposteriordimension of the lower leg or ankle, which isinstead determined by the distance betweenthe anterior tibia and the posterior surface of

Vol. 113, No. 6 / LIPOSUCTION OF THE LEGS AND ANKLES 1773

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the Achilles tendon.4 This is an important pre-operative consideration.

Whether “circumferential” or more local-ized, lipodystrophy in the legs and ankles mustbe considered in the context of the wholelower extremity. As Chamosa stressed, “beautyis based on the different body regions being inproportion to one another. . .correcting a sin-gle area usually leads to an imbalance in thecontour of the lower limbs.”17 The aestheticgoal is the achievement of normal leg andankle contour, but this must be in proportionto neighboring body regions. Watanabe notedthat the medial knee should be addressed atthe same time as the leg, if needed, to give anoverall balanced shape.13 Although liposuctionof the knees is not further discussed here,much literature exists on this topic and suchtreatment should be considered when it ap-plies to the achievement of well-proportionedleg contour in a given patient.

PREOPERATIVE EVALUATION

Understanding the patterns of lipodystrophyand the unique relevant anatomy of the leg,one can assess individual candidates for surgi-cal treatment. When evaluating patients forliposuction of the legs and ankles, certain con-traindications should be respected. Because ofthe high risk of embolism from this procedure,patients with a history of deep venous throm-bosis, phlebitis, hypercoagulability, or any his-tory of a previous thrombotic event should beexcluded.7,11 In addition, the procedure shouldnot be performed on patients with circulatoryinsufficiency.1,2 The procedure should also beavoided in patients with chronic edema, tro-phic anomalies, and severe varicosities.14 Mildvaricosities do not preclude liposuction, andthese patients are not subject to increased post-operative morbidity.4 Active phlebitis, though,is an absolute contraindication to this proce-dure. If vein stripping is planned for severevaricosities, this should precede liposuction by3 months.4

The problem of skin laxity and draping afterliposuction of the legs and ankles is not asgreat a concern as in other areas.3 Originally, itwas felt that patients with good skin elasticity(younger patients) should be the best candi-dates, but experience has shown that the greatelasticity and the limited amount of skin in thisarea allows for very large volumes of fat to beremoved in almost all patients without concernfor postoperative skin laxity.1,3,10 Still, Te-

imourian claims his best results to be in pa-tients under the age of 40, although most pa-tients requesting this procedure are in their20s and 30s.20

Patients who may be candidates must be exam-ined to determine whether their complaints canin fact be addressed appropriately by this proce-dure. Visual inspection should not be consideredsufficient to assess fat deposits. In general, pa-tients with lipodystrophy of the calves and ankleswill show blunting of definition of the gastrocne-mius muscles and the ankles as previously de-scribed. If the legs have a large circumferencebut the gastrocnemius muscles are actually welldefined, the “problem” is likely that of increasedmuscle tissue, often in the soleus.1,2 Older litera-ture endorsed the use of xerograms to evaluatefat thickening.14 Most authors, though, use onlythe pinch test to determine whether the excesstissue is actually removable fat. Recommenda-tions for surgical treatment vary between authors,but pinch tests of 1.5 to 2 cm of fat at the calf and1 to 1.5 cm at the ankle are felt by many torepresent an indication for surgery.4,10,13 Despitethe fact that fat can usually be distinguished frommuscle in this way, at times patients with firmpinch tests suggestive of increased muscle tissueover both calf and ankle areas have had a surpris-ing amount of fat at surgery.1

Most authors perform the pinch test whilethe patients stand on a stool. Usually, it isperformed with the patient standing flat-footed, and then standing on the toes.1,3,4,10,11,14

The thought is that standing on the toes willflex and therefore help to define the edges ofthe gastrocnemius muscle bellies for marking.These authors perform the final preoperativeevaluation and marking in this manner. Re-cently, Mladick proposed the benefits of mark-ing the patient in the sitting position with thelegs dangling, claiming that “dangling legs aremore supple, which makes it easier to differen-tiate the thickness of the fat bulges from theunderlying muscles and tendons.”19 Klein sug-gests using the pinch test while the patient isresting her leg in the horizontal position on achair or stool with the ipsilateral knee bent atapproximately 90 degrees while standing onthe contralateral leg.6 Rohrich espoused a com-bination of dangling, standing, and sitting, cit-ing that the relaxed tone of the muscles allowsbetter differentiation of tissues in the sittingposition.21 We also feel that the combination ofall three positions is useful, with the benefit ofthe dangling position or Klein’s resting posi-


tion coming not so much from the decreasedtone of the muscles, but from the decreasedtension on all of the soft tissues—especiallyskin and subcutaneous tissue—as the foot isallowed to naturally plantar flex, thus facilitat-ing distinction between relaxed tissue typesduring the pinch test.

Klein recommends that contour lines shouldbe drawn in the preoperative evaluation posi-tion because distinct concentrations of fat canbe subtle and can be lost when tumid.6 Mostauthors mark areas of relatively greater orlesser fat deposits as would be done in otherareas of the body to intraoperatively demon-strate areas of fat requiring intensive resection.Mladick’s markings emphasize the contours ofthe transition zone, where the leg narrows pos-teriorly at the inferior edge of the gastrocne-mius muscles and then tapers down to theankle, approximately midway between the pop-liteal crease and the maleoli.19 Areas of fat areoften difficult to document with photographs,and this fact should be discussed with the pa-tient and the discussion documented in thechart, as it may be hard to show postoperativechanges in the photographs.6 Toledo notesthat results are usually subtle; therefore, someauthors recommend measuring preoperativeand postoperative leg circumferences for thisreason.5,22 He does mention, though, that pa-tients are often very pleased with even the mostsubtle objective changes, which may be imper-ceptible to others.22

As will be discussed further, many surgeonsput their patients in compressive garments forextended periods postoperatively. Some sur-geons require fitted garments. Authors suggest-ing the use of these garments recommend thatthe patient be fitted preoperatively for a prop-erly fitting garment.4,10,11 It is unclear what ef-fect the operative change in size has on theaccuracy of such planning.

The final preoperative concern after evalu-ating the patient is that of patient selection andcounseling. Because the outcome of this pro-cedure eventually relies heavily on postopera-tive management, this operation should be re-served for patients who are responsible enoughto follow postoperative instructions closely.1,2

TECHNIQUE

Positioning and Anesthesia

Over the past decade, the progression of theliterature concerning liposuction of the calves

and ankles has demonstrated changes in tech-niques, but there are still many disagreements.In 1990, Watanabe and others described lipo-suction in the prone position.3,13 Others havechampioned the idea of an awake patient ableto change positions between both sides andprone, to better visualize and assess the circum-ferential fat.1,2,23 In contrast, Mladick in 1994described the technique using a supine posi-tion, which he still recommends.10,19 Kleinplaces most patients in the lateral decubitusposition and turns the patient to the other sideduring the procedure.6

The literature has shown no real trend overtime among these alternatives toward a pre-ferred type of positioning. Most authors tendto endorse their technique on the basis of itsconvenient marriage with a certain type of an-esthesia, as some combinations tend to workbetter together.

Opinions also differ on the type of anesthe-sia used. In 1985, Teimourian described usingonly general anesthesia.24 Klein used straightlocal tumescent infiltration of anesthetic intothe tissue with a spinal needle.6 Watanabe usedepidurals in his patients and infiltrated 0.5%lidocaine and 1:200,000 epinephrine but didnot describe actual tumescing.13 Many othershave used sedation with “tumescent-type” infil-tration of a solution usually consisting of dilutelocal anesthetic (lidocaine), epinephrine, andsometimes bicarbonate in saline or lactatedRinger’s solution.1,7 Lillis described liposuc-tion, using only lidocaine as a tumescent fluid,on an awake patient who was therefore able tochange positions.2 This was also reported byMladick, who then used only local anestheticfor touchups.2,10 In 1996, Chamosa claimed toperform liposuction in a two-stage procedure.In the first stage, liposuction of only half of thecircumference on each leg and ankle was per-formed under general anesthesia. The secondstage was performed at 3 weeks, which involvedcompletion of the procedure under local anes-thesia.17 From these diverse possibilities, onecan understand that the best anesthetic maydepend on such factors as the extent of theprocedure and whether it is to be combinedwith other procedures.

The Role of Tumescence and Tourniquets

Most authors use some form of tumescentliposuction of the legs and ankles. There havebeen multiple techniques described that usetumescent infiltration of local anesthetic. The


various compositions of the actual tumescentfluids are presented in Table I. Here, some ofthe arguments that have been presented in theliterature for and against tumescent infiltrationwill be reviewed to provide the reader with acontext in which to balance these suggestionsand make his or her own decisions.

In 1995, Hunstad discussed the advantagesof the tumescent technique for liposuction ingeneral as described by Klein,25 adding thattumescence magnifies areas to be treated andthat it not only improves safety but decreasescost.26 Hunstad suggested the use of warm so-lutions to avoid shivering or heat loss in thepatient. He found that his tumescent tech-nique resulted in less ecchymosis and appar-ently less pain, citing a survey showing thatpatients felt overwhelmingly that general anes-thesia was unnecessary for their procedures.He also endorsed the use of lactated Ringer’ssolution over normal saline because lactatedRinger’s solution gave a lower acidity withoutrequiring the addition of bicarbonate. Finally,Hunstad suggested that lactated Ringer’s solu-tion, being more physiologic, may be less trau-matic to adipocytes. He recognized that thismay prove important in the context of graftingthe aspirated fat.26 In 1989, Illouz and de Vil-lers espoused many of these same advantagesof tumescence, claiming benefits of the “wettechnique” to be hydrodissection and magnifi-cation of the fat layer in which to work, thusfacilitating staying in the proper plane. Theystated that the dry technique is rougher, beingmerely “curettage.”14 In 1993, Klein showedthat the tumescent technique improved safetyin large-volume liposuction by eliminating theneed for general anesthesia, intravenous seda-tion, and narcotic analgesia, and by also virtu-ally eliminating surgical blood loss.25 Neitherof these authors discussed the application ofthese techniques specifically in the area of thelegs and ankles.

With these benefits in mind, Ersek and Salis-bury7 in 1995 described a superwet techniquein the legs and ankles. They too claimed thatthis helped to provide adequate analgesia andto reduce bleeding and subsequent bruising.Mladick also championed a superwet tech-nique in this anatomical area, claiming theadvantages of making the fat more turgid, mag-nifying fat accumulations, and decreasingblood loss through the use of tumescence flu-id.19 Lillis specified that the lower legs requirea reduced infiltration rate compared with

other anatomical locations, citing that the tis-sue is naturally more taut in this area andtherefore becomes more uncomfortable withdistention compared with other areas. There-fore, less volume should be used to maximallytumesce this area, which he notes causes severebut expected blanching and tautness of theskin.1,2 Mladick indeed clarifies that the volumeof fluid used for strictly defined tumescence(specifically, the infusion of twice the volumeof expected fat aspirate) is “unnecessary andexcessive and makes the leg excessively tight.”Instead, he uses approximately 1 cc of tumes-cent fluid per 1 cc of expected fat to be re-moved. In his technique, approximately 1000cc is injected per leg through multiholed fineinjecting needles.19

Lillis added another goal to tumescing, add-ing triamcinolone to his tumescent fluid.1

Chamosa also reported this technique andclaimed less edema since his addition of triam-cinolone to the tumescent solution.18

Although most authors champion some ver-sion of tumescing, there are those who havedescribed liposuction of the legs and ankleswithout the use of tumescent fluid infiltration.The dry technique was described by Fournierand Otteni in 1983 for use in general liposuc-tion.9 It was championed because it saved time,left the tissues less distorted for evaluation, andleft the aspirated tissue mostly unchanged his-tologically. Because of the lack of local anes-thetic, they used mostly general anesthesia withsome regional blocks. They admitted that thistechnique had the disadvantage of requiringvolume resuscitation, sometimes with colloiduse in large-volume cases.

The variation of dry liposuction of the lowerleg with a tourniquet inflated at the midthighwas first reported by Teimourian in 1985 andin 1987.20,24 Although he did not describe hiscases or technique in much detail, he claimedto have experienced no intraoperative bloodloss and minimal bleeding afterward, havingplaced drains overnight through the incisions.The legs were wrapped with Ace wrap beforethe tourniquet was released to minimizeedema formation.24 In 1990, Stallings sug-gested that a dry technique under tourniquetcould give very precise sculpting. He also ex-plained that the technique causes almost nobleeding and therefore no hemosiderin tissuestaining, and that this technique resulted inless postoperative swelling. The longevity ofthese benefits was ensured after the tourniquet


was released by placing a large bulky pressuredressing of Dacron fluffs and an Ace wrap be-fore the tourniquet was released. No drainswere used.27 In that same year, Watanabe ar-gued against such use of a tourniquet, reason-ing that although the lower leg is more subjectto persistent edema than other areas of thebody, it is also one of the least vascularizedareas.3 The basis for this argument, which wasnot explained in more detail, remains unclear.

In 1998, Karacalar and Ozcan described li-posuction of the kneecap area with a “super-dry” technique under tourniquet.28 Then, in2000, they reported the use of this techniquefor liposuction of the leg.29 They too felt thatthis technique should give the best intraoper-ative prediction of a final result because theend result on the table is not distorted byswelling from trauma or by injection of fluid.They reported first exsanguinating the leg withan Esmarch bandage from toes to upperthighs. Although they did not tumesce, theydid pretunnel with a 3-mm, single-hole, bluntrod. These authors also firmly wrapped the legsfrom the toes to above the knee with an elasticbandage before the tourniquet was let down, aswas done by Teimourian.24 They point out thatsuch dressing application under tourniquet is acommon, safe technique in hand surgery. Verylittle bruising was noted in these patients,which was conjectured to be secondary to hav-ing applied pressure to the tiny injured vesselsbefore the tourniquet was released. They notedthat the only patient in their series who devel-oped significant bruising was the single one inwhom the Esmarch bandage had been prema-turely released during the procedure.28 Thus, itappeared that liposuction and compressivedressing application under tourniquet controlmay be helpful in preventing both bruisingand edema from ever developing.

Of interest, Karacalar and Ozcan histologicallystudied the fat aspirated using this dry technique.Using as controls the contralateral legs with wettechnique and no tourniquet, they found the fatfrom the dry, tourniquet side to be almost blood-less and far more intact than the control tis-sue.28,29 This may have great significance as thepractice of lipoaugmentation becomes morecommonplace and the need for harvesting reli-able autograft material is realized.

Intraoperative Techniques

Authors differ slightly in their incision loca-tion, but fat removal always takes precedence

over attempts to limit the number of scars fromincisions.1,2,22 Ersek and Salisbury used only in-cisions in the posterior knee crease and in thecrease above the Achilles tendon both mediallyand laterally.7 Pitman4 and Lillis1,2 both de-scribed starting with three incisions both me-dially and laterally on each leg—one just belowthe knee, one midleg, and one just above theankle. Lillis stressed the point that additionalincisions are often required, especially on theposterior calf.2 Grazer described access to theankle and posterior calf through stab incisionson either side of the Achilles tendon.5 Mostauthors use one or a combination of thesegroups of incisions. Most importantly, the con-sensus stands that incisions should be added asneeded to achieve a good contour.

Watanabe claimed that, before beginningsuctioning, the use of a 5-mm feathering rod tocreate an artificial double layer of fat is neces-sary to prevent the suctioning of the most su-perficial fat.13 Mladick also endorsed pretun-neling without suction.10,19,30 Rohrich21

reported the use of internal ultrasound to assistsuctioning, whereas Klein6 felt that this is con-traindicated in the legs and ankles.

One of the most significant differences intechniques between liposuction in the legs andankles and liposuction in other areas of thebody is the small cannulas used in this area.This trend has developed among authors overthe past dozen years, and many authors discusshow they came to realize this necessity. Table Ishows the choices of various authors and theyear in which their work was published. Ingeneral, most authors currently use cannulasin the range of 2 to 5 mm, often using thesmallest for refinements around the ankles.

The type of cannula also differs betweenauthors, but with no consensus. Lillis, for ex-ample, favors smaller cannulas in the range of2 to 3 mm with openings recessed from the tipon the underside to avoid traumatizing theunderside of the dermis and to leave 2 to 3 mmof subdermal fat.1,2 In contrast, Mladick favorsthe use of triple-holed cannulas.10,19,30

Some authors endorse the use of bent andstraight cannulas to deal with the anatomiccomplexities of this area. In his earlier work,Mladick recognized that the delicate curves ofthe legs make liposuction with straight cannu-las difficult.13 Mladick described the use of 2-,3-, and 4-mm triple-holed cannulas, adding theuse of both convexly and concavely curved can-nulas.10,19,30 He claimed these curved cannulas


to be requisite to following the contours inthese tight areas. Chamosa also uses slightbends to the cannulas as needed to allow easiercontouring of the complex curves of the legand ankle.19

In 1995, Hunstad promoted the use of sy-ringes in liposuction in general. He cited thatthe use of syringes was quieter, less expensive,easier, faster, more lightweight, gave more con-trol and precision, avoided the awkward tub-ing, and caused less surgeon fatigue. It alsoallowed for multiple surgeons and made thesuction more immediately adjustable. In addi-tion, he claimed less trauma, bleeding, andbruising with this technique, and felt that sy-ringes allowed for better quantitative assess-ment of the fat removed.26

Toledo preferred syringes also, and used60-cc Toomey-tip syringes with 2- and 3-mmcannulas.22 Chamosa18 also preferred the use ofsyringes, whereas Mladick31 disagreed and usesmachine-generated suction because it is hardto maintain a seal around the cannulas whenworking in these small areas near the incisions.Most authors have not specified which type ofsuction they prefer.

Many surgeons differ on the endpoint ofliposuction in the calves and ankles. Most sur-geons believe that some thickness of fat shouldbe left behind. Authors such as Klein feel thatattempting to remove all the fat is a mistakebecause an incongruously muscular, masculineleg on a woman is generally undesirable. Inaddition, if skin is adherent to muscle in allareas except where small bits of fat were leftbehind, future weight gain will accentuatethese areas.6 Ersek and Salisbury felt that it wasvery important to ensure that some subcutane-ous fat be left to provide shape to the calvesand ankles.7

Aiche suggested thinning to a pinchable 1cm.3 In 1989, Illouz also suggested leaving 0.5cm of fat or a pinchable 1 cm.14 Watanabe firstpretunneled to artificially create a double layerof fat, and attempted to leave 3 to 5 mm of fatin this top layer, for a final postoperative pinchtest of 5 to 7 mm (except at the Achilles ar-ea).13 He felt that a thinner layer of fat wouldmake irregularities more noticeable. Lillis fa-vors small cannulas with openings recessedfrom the tip on the underside to avoid trauma-tizing the underside of the dermis and to leave2 to 3 mm of subdermal fat.1,2 Lillis alsopointed out that the aggressive use of the op-posite hand through downward pressure or

grasping of the cannula is contraindicated.Some mild downward pressure may sometimesbe necessary, and in fibrous pockets of fataround the malleoli, grasping and lifting fatand more aggressive cannula use is warranted.

Other authors strive to leave little or no fat.Mladick espoused very superficial work with 2-and 3-mm cannulas around the ankle, origi-nally specifying a single-holed cannula for thisarea,10 with no attempt to preserve any subder-mal fat in the ankles to approximately 5 cmabove the malleoli. He noted that the mostfrequent postoperative problem was, in fact,persistent ankle thickness in 10 percent of hispatients, which he attributed partly to persis-tent edema and partly to underresection.19 Henoted that “The degree of success is usuallydetermined by the improvement of the ankleregion.”10

Pioneers of liposuction of the calves and an-kles suggested that hypertrophy is often asym-metrical—often being more medial or later-al—and that isolated treatment was all that wasrequired.14 This preference for local treat-ments corresponded with an old belief thatthere are colliding zones in the dorsal calvesand ankles that should not be crossed to avoidirregularities.22 It was felt that the circumferen-tial technique should be avoided so that ve-nous and lymphatic return would not be se-verely altered.14 Mladick presented the conceptof circumferential liposuction in 1994.19 Overthe past several years, an understanding of theneed to blend the appearance of the entire leghas developed. Aiche stressed the importanceof feathering between the junctions of defattedand nondefatted portions of the leg with a4-mm cannula.3 Chamosa pointed out that onesingle area must never be done alone,17 andLillis encouraged an organized approach toavoid skipped areas.2 Klein felt that there aresome individuals who can benefit from circum-ferential work in all areas, but that other patientsshould have work limited to discrete areas.6 Mostrecent authors, though, have accepted Mladick’sconcept of circumferential liposuction. Still, To-ledo feels many if not most patients only needlocalized treatments.22

Although Mladick was one of the first toencourage circumferential liposuction, hemore recently stresses the importance ofsculpting the transition zone, previously de-scribed as the area where the leg narrows pos-teriorly at the inferior edge of the gastrocne-mius muscles and then tapers down to the


ankle, approximately midway between the pop-liteal crease and the malleoli. This transitionzone had already been alluded to by Reed in1989.11 Mladick claimed, “The importance ofthe Transition zone cannot be understated; itis a major aesthetic improvement.” He stressedmedial transition zone suctioning more aggres-sively than lateral on the posterior leg. Thisarea is suctioned transversely and obliquelythrough stab wounds placed posteriorly and 3cm medial and lateral to the posteriormidline.19

In contrast, Lillis claims that this concernover defining the inferior gastrocnemius mus-cle so that it can be sculpted is no longerwarranted. He claims that with his technique ofremoving all but a thin layer of subdermal fatcircumferentially in all areas, the shape of thegastrocnemius will naturally define itself.1,2

In addition to the transition zone conceptualmodification to the circumferential model ofliposuction of the leg and ankle, other varia-tions have been suggested. Chamosa feels thatreproducing the shape of the ankle by concen-trating on the reduction of fat in the four facetsof this aforementioned rhomboid produces abetter result than the circumferential liposuc-tion approach championed by Ersek, Mladick,and Watanabe.18 Earlier in the literature, be-cause of what he saw as a tendency to aspiratemore of the softer medial fat, Watanabe rec-ommended focusing on removing more fat lat-erally.5 This concept has not been revisited byother authors.

Recently, the optimal direction to suck withthe cannula has also come into question.Chamosa specified working in most areas longi-tudinally.17,18 In 1999, Frick studied the effect ofliposuction of the lower legs on epifascial lym-phatics.16 He examined the effect of dry liposuc-tion with 4-mm blunt cannulas both in paralleland perpendicular to the long axis of the leg. Hefound severe or moderate lymphatic injury inapproximately half of all transversely suctionedareas, whereas no severe injury and only a fewmoderate injuries were seen in areas suctionedparallel to the long axis. Importantly, Frickclaimed that “the flexibility and quality of thelymph vessels visualized and tested after lipec-tomy seem to be comparable to those of thelymph vessels harvested during lymph vesseltransplantation.”16,31

Klein works mostly in the longitudinal direc-tion for exactly this reason.6 Mladick recog-nized the value of this study but claimed to not

have seen an increase in postoperative edemafrom his transverse suctioning of the transitionzone. He suggests that this may be because ofhis use of 2- and 3-mm cannulas or becausethese lymphatics may regenerate in the normalleg.32 Lillis also felt that cross-tunneling isdesirable.2

The studies by Frick are difficult to interpretin the setting of tissue that has been infiltratedwith tumescent fluid, especially with the super-wet and tumescent techniques. The results ofprevious authors do not show any significantprolonged edema with aggressive transverse li-posuction at the transition zone from the gas-trocnemius and soleus muscle bellies to thetendon of Achilles. One must postulate thatthe increased volume of interstitial fluid pro-vides a protective effect on the lymphatics.Also, the cannula size used by the majority ofauthors is less than 4 mm. Of course, there isalso the unknown importance of injury re-sponse of live tissue versus cadaveric tissue. Inaddition, it is difficult to provide any data re-garding the strength, mobility, and elasticity oflive versus cadaveric tissue in these operativesituations. These factors, which have not beenstudied, and the clearly documented favorableresults of authors that do use transverse strokesduring liposuction make it difficult to draw anyconclusions from Frick’s study.

One of the more recent techniques de-scribed is the use of ultrasound assistance withliposuction of the leg and ankle. Mladick feelsthat the use of external ultrasonic assisted lipo-suction may help to disperse the tumescencefluid, soften the fat, and possibly increase post-operative skin contracture.19 Rohrich com-mented that although he does not find exter-nal ultrasonic assisted liposuction helpful, hehas begun using internal ultrasound to im-prove results, especially in the transitionzone.21

No consensus has developed in the literatureregarding the management of the stab woundsfor the cannulas. Many authors mention clos-ing the wounds with nonabsorbable sutures,whereas some authors leave the wounds opento drain.

DRESSINGS AND POSTOPERATIVE CARE

As postoperative edema is one of the mostdaunting hurdles of liposuction of the legs andankles, postoperative care to prevent this prob-lem has proven to be fundamental to improve-ments in this treatment modality. The specific


modalities used by the authors is presented inTable I. Most authors use some form of com-pressive therapy and attention to postoperativeleg elevation. Despite agreement on the needfor attention to postoperative care, no clearpreferred regimen has developed, and the sug-gested postoperative treatments continue tovary from the simple to the most complex pro-tocols. The various interventions described atprogressive stages of the procedure to combatedema are presented.

Aiche3 felt that the fluid and blood fromsurgery would collect in dependent areas, lead-ing to continued tender swelling. He thoughtthat this could be addressed in two ways. First,one can flush the wounds with saline to removedebris that could produce an oncotic load andleave pigments. Second, drains can be placeddependently for 2 days, after which the woundscan be closed with delayed sutures. Te-imourian placed one Jackson-Pratt and threePenrose drains in each leg for 24 hours.20,24

Mladick described milking excess fluid outthrough incisions after suctioning each leg.10

Another concept described to battle the for-mation of edema is the prevention of its for-mation even before the patient leaves the op-erating room. Chamosa wraps the first leg in anEsmarch strap elastic tourniquet while workingon the second leg. This is not removed untilthe definitive postoperative dressing is applied,a strategy that he feels also prevents postoper-ative hematomas.18 Similarly, after finishing thefirst leg, Mladick tightly wrapped it with a6-inch Ace wrap to above the knee while thecontralateral leg was contoured and likewisebandaged. When both legs were done, the firstwas unwrapped and the incisions closed, fol-lowed by the second leg. Mladick claimed thatthis “maintains continuous firm compressionon the legs to avoid accumulation of blood.The compression has also been successful inminimizing bruising.”19

Techniques involving pneumatic tourniquetuse focus specifically on this goal of minimiz-ing edema formation in the operative and im-mediate postoperative periods. Application ofa compressive dressing before the release ofthe tourniquet prevents edema and bleedingbefore it has the chance to develop because thetraumatized tissues are never exposed to bloodflow without a compressive dressing in place.After placing his drains, Teimourian appliedstockinette and then an elastic bandage frommidfoot to above the knee before the tourni-

quet was released. The procedure was thenperformed on the other leg.20 Karacalar andOzcan described a similar technique.28,29

Even without the use of a tourniquet, thecornerstone of postoperative care is compres-sive therapy. The simplest form of compressivetherapy is the use of criss-crossed elastic tapeplaced posteriorly on the legs.14 More com-monly, postoperative care includes compres-sive stockings, and some authors feel the use ofmedical grade graduated compression stock-ings in the range of 35 to 40 mmHg to beimperative. Such proponents suggest that thesesupport hose be fitted and purchased preoper-atively.4,11 Other authors use an Ace wrap in-stead of, or in addition to, compressivestockings.5,7,10,19,20,24,27,31

Foam padding has been placed beneath theelastic dressing to provide more compression.Watanabe13 placed a 1-cm-thick urethanesponge on the fossa created lateral to the Achil-les tendon to prevent blood accumulation.Over this, he wrapped the leg with an elasticbandage. Postoperatively, tight stockings wereinitiated during the first week after the pres-sure bandages were removed. Grazer describedplacing a Reston sponge more circumferen-tially under thromboembolic disease stockingsand occasionally applying an Ace bandage overtop in addition. Reexamination after removingthe foam at 24 hours showed reduction in ec-chymosis where the Reston foam was.5 Mladickapplies tight surgical hose to above the knee,and then circumferentially covers the areasfrom the ankles to the calves with soft nonad-hesive foam wrapped with a 6-inch Ace wrapover top.10,19,31 These authors suggest leavingcompressive dressings in place for varyinglengths of time, as shown in Table I.

Several authors endorse the use of massagein the postoperative period to decrease edemawhile the body repairs its ability to remove thisexcess fluid. Chamosa considered the “use ofbody support therapy wear and massage forlymph drainage to be fundamental.”17

Mladick modernized the concept of postop-erative massage to reduce edema through theapplication of sequential compression devicesin the postoperative period. He claimed thatthe use of sequential compression devicesmarkedly decreased the period of postopera-tive edema compared with his early experi-ence, with most patients using sequential com-pression devices being almost edema-free by 2months.19 He begins the use of sequential com-


pression devices in the recovery room, and theoriginal dressings are not changed until thefourth postoperative day. Mladick requires thathis patients use the sequential compression de-vices as much as possible, at least at night, withfirm stockings during the day for 2 months.

Varying authors differ in their opinions onthe need for postoperative leg elevation andrest. Lillis felt strongly that “strict attention toleg elevation especially in the first three dayswill greatly decrease the amount and durationof peripheral edema.” Although he admits toone patient who went mountain climbing 1week postoperatively and still had an excellentresult, he enumerates complications that canbe expected with noncompliance, such as hugerecurrent bilateral seromas.2 Other authorssuggest widely varying activity restrictions,which are listed in Table I.

Several other modalities have been used tocombat postoperative edema. Chamosa addedtriamcinolone to his tumescent fluid,18 as didLillis.1 Watanabe claimed that local injection of1 to 2 cc of double-diluted dexamethasoneacetate every 2 weeks was very effective in com-bating edema.13 Rohrich reported the use ofexternal ultrasound two to three times perweek for 3 or 4 weeks combined with manualmassage in the office to facilitate edemaresolution.21

Despite this shift toward aggressive means ofedema prophylaxis, some surgeons remainminimalists. Klein wraps the legs with the inci-sions left open with absorbent pads and thenelastic bandages that are kept on until thedrainage stops. He considers further compres-sion to be optional, and feels that bed rest andelevation are unnecessary. His patients are en-couraged to ambulate as of the first postoper-ative day.6

OUR PREFERRED TECHNIQUE

We prefer a combination of the aforemen-tioned techniques to achieve the best possibleresult with the fastest recovery and the leastpostoperative edema. The use of a tourniquetand compression dressings is thought to beessential to the success of this technique. Ag-gressive manual massage and thromboembolicdisease hose are also emphasized.

Preoperative Evaluation and Markings

The patient is marked in a seated position.The transition zone from calf to ankle ismarked for aggressive suctioning and easy

identification intraoperatively. Other areasthat will be reduced by suctioning are alsomarked, and care is taken to identify the areaoverlying the tibia, as this will not be violatedby suction cannulas.

Operative Technique

The patient is placed in the supine positionand either general anesthesia or spinal anes-thesia with sedation is used. Prophylactic anti-biotics are given 1 hour before coming to theoperating room. The lower extremities are pre-pared and draped in the usual sterile fashion,and sterile tourniquets are applied to thethighs. One of the legs is elevated for 5 minutesand the tourniquet is inflated to 300 mmHg.The areas to be suctioned are infiltrated with asolution containing 1 mg of epinephrine and20 cc of 0.25% bupivacaine per liter of lactatedRinger’s solution. This will provide pain reduc-tion long after the operative anesthetic hasworn off. A wet technique is used.

Incisions are made laterally and medially toaddress the lower leg fat along the Achillestendon and up to the transition zone. Incisionsare made medial and lateral to the palpabletibia at the middle third of the lower leg toaddress the transition zone. At the proximalthird of the leg, less liposuction is performed,to create the appearance of a muscular calftransitioning to a thinner ankle. A combina-tion of 2- and 3-mm suction cannulas are used,and the tip configuration is generally variedaccording to the thickness of the fat layer beingsuctioned. After completion of the first legliposuction, attention is turned to the otherleg, where the same procedure is performed.The tourniquet is not deflated on either limbuntil the conclusion of the procedure.

Postoperative Dressings

With the tourniquets still inflated bilaterally,the dressings are applied. Wounds are dressedwith 2 � 2-inch gauze pads, and the legs arewrapped with Reston foam and 6-inch Ace ban-dages over the foam. Care is taken to make thefoam circumferential in nature up to the levelof the knees. The adhesive side is placed defin-itively away from the patient’s skin. The tour-niquets are then deflated and the patient takento recovery.

Postoperative Care and Management

The patient is to minimize the activity ofstanding and walking for 1 week. Preferably,


they should take 1 week off from work or traveland remain supine with their legs elevated themajority of the first week postoperatively. Fullbed rest is not recommended. The dressingsare removed at 1 week and the patient is placedin thromboembolic disease hose for the next 3to 6 months. Leg elevation is strongly empha-sized, with two pillows every evening, and man-ual massage is started as soon as the patient isable to tolerate this maneuver. The patient isable to remove the thromboembolic diseasehose completely when all residual edema iseradicated from the lower extremities (Fig. 1).

CONCLUSIONS

Liposuction of the calves and ankles is cer-tainly an important operation to offer the ap-propriate patients. Many authors have ap-proached the problem in many different ways,which indicates that there is no one best way tohandle the problem of lipodystrophy of thisdifficult region. The most important point is todevelop a technique that is safe and reliableand produces excellent results. The extensivereview presented here will help one formulatean approach that is customized to the surgeonand to the patient. When the “best” technique

FIG. 1. Preoperative views (left), preoperative markings (center), and postoperative views (right) of a patient with lipodystrophy.Notice the poor definition of the gastrocnemius muscles and the thickness around the malleoli preoperatively. The transitionzone is marked and a total of six incisions are planned: one medial and one lateral at the knees, one medial and lateral at thecentral portion of the transition zone, and one medial and one lateral just above the malleoli. Anterior and posterior views ofpostoperative result at 1 year show definition retention and no edema.


is not immediately obvious, it is important tokeep in mind the principles of excellent surgi-cal patient care and synthesize the best ap-proach that generates the best results in yourhands.33

Frederick G. Weniger, M.D., M.B.A.Division of Plastic Surgery6B Scaife Hall3550 Terrace StreetPittsburgh, Pa. [email protected]

REFERENCES

1. Lillis, P. J. Liposuction of the knees, calves, and ankles.Dermatol. Clin. 17: 865, 1999.

2. Lillis, P. J. Liposuction of the arms, calves, and ankles.Dermatol. Surg. 23: 1161, 1997.

3. Aiche, A. E. Lipoplasty of the calves and ankles. In G. P.Hetter (Ed.), Lipoplasty: The Theory and Practice of BluntSuction Lipectomy, 2nd Ed. Boston: Little, Brown, 1990.Pp. 347-353.

4. Pitman, G. H. Liposuction & Aesthetic Surgery. St. Louis:Quality Medical Publishing, 1993. Pp. 413-444.

5. Grazer, F. M. Knees, calves, and ankles. In F. M. Grazer(Ed.), Atlas of Suction Assisted Lipectomy. New York:Churchill Livingstone, 1992. Pp. 297-300.

6. Klein, J. A. Tumescent Technique: Tumescent Anesthesia andMicrocannular Liposuction. Philadelphia: Mosby, 2000.Pp. 440-443.

7. Ersek, R. A., and Salisbury, A. V. Circumferential lipo-suction of knees, calves, and ankles. Plast. Reconstr.Surg. 98: 880, 1996.

8. Fischer, A., and Fischer, G. M. Revised technique forcellulitic fat reduction in riding breeches deformity.Bull. Int. Acad. Cosmet. Surg. 2: 40, 1977.

9. Fournier, P. F., and Otteni, F. M. Lipodissection in bodysculpting: The dry procedure. Plast. Reconstr. Surg. 72:598, 1983.

10. Mladick, R. A. Circumferential “intermediate” lipo-plasty of the legs. Aesthetic Plast. Surg. 18: 165, 1994.

11. Reed, L. S. Lipoplasty of the calves and ankles. Clin.Plast. Surg. 16: 365, 1989.

12. Illouz, Y.-G. Body contouring by lipolysis: A 5-year ex-perience with over 3000 cases. Plast. Reconstr. Surg. 72:591, 1983.

13. Watanabe, K. Circumferential liposuction of calves andankles. Aesthetic Plast. Surg. 14: 259, 1990.

14. Illouz, Y.-G., and de Villers, Y. T. Body Sculpturing byLipoplasty. New York: Churchill Livingstone, 1989. Pp.124-126, 275-280.

15. Illouz, Y.-G. Surgical remodeling of the silhouette byaspiration lipolysis or selective lipectomy. AestheticPlast. Surg. 9: 7, 1985.

16. Frick, A., Hoffmann, J. N., Baumeister, R. G. H., and Putz,R. Liposuction technique and lymphatic lesions inlower legs: Anatomic study to reduce risks. Plast. Re-constr. Surg. 103: 1868, 1999.

17. Chamosa, M. Comprehensive liposuction of lowerlimbs: Basic concepts. Aesthetic Plast. Surg. 20: 49, 1996.

18. Chamosa, M. Suction lipectomy of the ankle area. Plast.Reconstr. Surg. 100: 1047, 1997.

19. Mladick, R. A. Advances in liposuction contouring ofcalves and ankles. Plast. Reconstr. Surg. 104: 823, 1999.

20. Teimourian, B. Suction Lipectomy & Body Sculpting. St.Louis: Mosby, 1987. Pp. 495-510.

21. Rohrich, R. J. Advances in liposuction contouring ofcalves and ankles (Discussion). Plast. Reconstr. Surg.104: 832, 1999.

22. Toledo, L. S. Refinements in Facial and Body Contouring.Philadelphia: Lippincott-Raven, 1999. Pp. 165-167.

23. Gasparotti, M. Superficial liposuction: A new applica-tion for the technique for aged and flaccid skin. Aes-thetic Plast. Surg. 16: 141, 1992.

24. Teimourian, B. Tourniquet after suction lipectomy ofthe lower extremity. Plast. Reconstr. Surg. 75: 442, 1985.

25. Klein, J. A. Tumescent technique for local anesthesiaimproves safety in large-volume liposuction. Plast. Re-constr. Surg. 92: 1085, 1993.

26. Hunstad, J. P. Tumescent and syringe liposculpture: Alogical partnership. Aesthetic Plast. Surg. 19: 321, 1995.

27. Stallings, J. O. The use of the pneumatic tourniquet. InG. P. Hetter (Ed.), Lipoplasty: The Theory and Practice ofBlunt Suction Lipectomy, 2nd Ed. Boston: Little, Brown,1990. P. 354.

28. Karacalar, A., and Ozcan, M. Liposuction of the knee-cap area under tourniquet: A superdry procedure.Aesthetic Plast. Surg. 22: 408, 1998.

29. Karacalar, A., and Ozcan, M. The superdry techniquefor lipoplasty of the leg and the no-touch techniquefor autologous fat transplantation. Plast. Reconstr. Surg.106: 738, 2000.

30. Mladick, R. A. Lipoplasty of the calves and ankles. Plast.Reconstr. Surg. 86: 84, 1990.

31. Mladick, R. A. Suction lipectomy of the ankle area (Dis-cussion). Plast. Reconstr. Surg. 100: 1053, 1997.

32. Mladick R. A. Liposuction techniques and lymphaticlesions on lower legs: Anatomic study to reducerisks (Discussion). Plast. Reconstr. Surg. 103: 1874,1999.

33. Asken, S. Liposuction Surgery and Autologous Fat Trans-plantation. Norwalk, Conn.: Appleton & Lange, 1988.Pp. 106-107.


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