WHAT IS BACK LIPOSUCTION

Back liposuction applies to individuals with localized fat in the upper and lower back. Liposuction of the back can decrease fullness in the upper back by reducing subcutaneous fat and can result in skin retraction, particularly with power-assisted ultrasound liposuction (U-PAL).

Upper back liposuction is an excellent complement to the arm breast lifts, while Liposuction of the lower back will complement the abdomen, buttocks, and thigh lifts. The upper and lower back liposuction secondarily unmasks and enhances the buttock region.

Back liposuction is not a procedure frequently applied to massive weight loss patients who have achieved a body mass index of less than 30. Their issue is more skin redundancy and lax tissue than subcutaneous fat. The sacrum often has a fatty deposit that responds well to Liposuction and helps contour the buttock.

Basic science and Anatomic Considerations of Back Liposuction

Subcutaneous fat is arbitrarily divided into superficial, intermediate, and deep layers. These separate layers have relative consistency, and thickness varies for different anatomic areas. Liposuction is done in the intermediate and deep layers. The superficial layer contains the vascular structure, and when it is treated, it increases the risk for contour irregularities.

Patient Types Presented for Back Liposuction

It is helpful to classify patients based on the three types of fatty tissue deposits and skin redundancy in the Back:

1. Type I: localized fatty tissue deposits. Often younger patients with good skin tone and minimal skin irregularities.
2. Type II: generalized fatty tissue deposits. These patients tend to have slightly diminished skin tone with some skin irregularities and circumferential fatty tissue deposits throughout their trunk and extremities.
3. Type III: skin redundancy and fatty tissue deposits. Patients display significant skin redundancy that would be more amenable to excisional surgical techniques to improve shape and contour. Liposuction may be a valuable adjunct to achieve an optimal result if necessary.

Back Liposuction Vary according to Gender Fat Distribution (male vs. female)

The male or android distribution is characterized by fatty tissue deposition in the upper body and central visceral (internal) fat deposits. An adult man has disproportionate fatty deposits under the skin in the abdomen, the waist, the shoulders, and the nape. These deposits are associated with androgen receptors on adipocytes. Android deposits are more metabolically active; they are changed with dietary habits and correlate with disease risk.  

The female or gynecoid distribution refers to fat accumulation in peripheral stores, specifically those below the waist, like the thigh and gluteal areas. These deposits are associated with estrogen receptors on adipocytes. Gynecoid fat deposits in obese and non-obese women are not significantly affected by diet restriction.

The back’s subcutaneous fat and skin anatomy are unique from the extremities. It has a very thick dermis and a dense, fibrous attached to the underlying superficial fat. There are many fibrous connections between the superficial fat of the back and the underlying fascia that often form into rolls. Beneath the superficial fat, a loose, areolar fat is present deep on the deep top fascia. Both men and women present with fullness in the back present with fatty tissue collection in the waist and the hip/flank region.

 A Female’s back has a lateral contour that widens at the level of the lower ribs and hips. The center portion is narrow. From the lateral view, the midline shows a superior kyphosis and lumbar lordosis accentuating the shape of the buttocks.

In males, this is different, with narrower hips translating into a V shape type of contour due to the difference in the fat deposits and muscular structure.

Indications for Back Liposuction (small vs. large volume)

Small volume Back Liposuction

Liposuction of the back patients often presents with a variety of expec­tations, concerns, and complaints. As a rule, back liposuction is performed in healthy patients who maintain realistic goals and expecta­tions. Studies have shown that patients who undergo proper long-term lifestyle changes will achieve the highest postoperative satisfaction from their liposuction-assisted body contouring procedure.

A successful body contouring patient must satisfy four key elements to achieve and maintain optimal results:

1. Lifestyle change
2. Regular exercise
3. Well-balanced diet
4. Body contouring.

Back liposuction-appropriate candidates are not morbidly obese, are of stable weight, and have incorporated the above lifestyle changes into their preoperative regimen. Preoperative consultation with a dietician may prove benefi­cial for long-term patient satisfaction.

Ideal candidates for back liposuction present with excess subcutaneous fat in the back, flank, hips, and lateral thigh, often creating “rolls.” Women will often complain of fat rolls along the bra line. This area responds exceptionally well to PAL, allowing the fold to be broken up and excess fat removed.

As they age or lose significant weight, men and women tend to lose volume and contour in the buttock. Some complain that they have pain sitting or physical activities such as horseback riding. Many are interested in increasing the fullness of the gluteal region for aesthetics and functionality. By combining liposuction with fat grafting techniques, we broaden the possibilities of improvement in addressing the back and the surrounding areas, thus providing optimal patient results.

Large Volume Back Liposuction

As the prevalence of obesity continues to increase, so do the accompanying risks to health and lifespan from hypertension, diabetes, coronary artery disease, and increased surgical morbidity and mortality. Large-volume lipo-sculpture can be performed safely on healthy overweight patients.

It improves body contour and body image and reduces cardiovascular risk factors such as obesity, systolic blood pressure, and plasma insulin. Therefore, the resultant morbidity and mortality decrease.

 It may even prevent or delay the development of diabetes or impaired glucose tolerance if the previously mentioned beneficial effects are long-lasting.  

Back liposuction is a cosmetic procedure in the right hand and is a safe and efficient method to improve body contour. The impact on self-esteem is vital that we summarize this saying to our patients: “We will operate on your body, but the most important is that you will feel the effect on your mind.”

It is worth emphasizing that liposuction is only one of the weapons to fight against being overweight after surgery; patients are better motivated to start a program including a dietary regimen and physical exercise, or in other words, a complete change in their lifestyle.

Back liposuction is contra­indicated in patients who are pregnant or in poor general medical health. Patients with morbid obesity, cardiopulmo­nary disease, body image perception issues, unrealistic expectations, wound healing difficulties, or who have exten­sive or poorly located scars should be excluded from consid­eration for liposuction.

Preoperative assessment of Back Liposuction

During this initial interaction, the cosmetic surgeon must assess the patient’s goals of surgery and be able to determine if the patient has realistic expectations regarding the outcome and postoperative body image.

• It may be helpful to have the patient prioritize the body regions they are most concerned with while focusing on specific com­plaints within these areas.
• A detailed medical history should be obtained, including any medications, allergies, and tobacco use. Critical are notations in the medical history of diabetes, massive weight loss, previous surgery, previous liposuction, and a complete detailed list of medications and supple­ments.
• Any concerns about a patient’s medical suitability to undergo anesthesia and an operative procedure should result in a referral for preoperative clearance with either an internist or cardiologist.
• The patients need to be asked specifi­cally about herbal and over-the-counter medications because these are frequently omitted. You should discontinue non-essential medications at least three weeks before surgery.
• A preoperative evaluation by a primary care doctor, internist, or cardiologist may be warranted in selected patients. This typi­cally includes anyone with a significant medical history or patients older than 50 years of age.

Prof. Moawad prefers to work only with patients classified as ASA I and II. Irrespective of age, all patients after 60 are sent to the cardiologist for a complete cardiac and vascular checkup and hematological studies, including fast blood sugar, hepatitis, and HIV tests.

Massive weight loss patients should undergo the same preoperative evaluation and clearance for liposuction and any excisional-type body contouring procedure (including nutrition, hemoglobin, iron, vitamin B₁₂, etc.). It is safest to refrain from operations until these lab results are normalized.

Diabetes is not a contraindication for liposuction. These patients do well with careful blood sugar control using insulin/oral antidiabetic agents. With careful control of the blood pressure, hypertension is also not a contraindication for medium to large liposuction. Both parameters improve with liposuction. Careful assessment and written agreement by the endocrinologist/cardiologist is needed.

Herbal remedies and supplements, including bleeding or hypercoagulability, should be avoided in the perioperative period. Avoiding aspirin, NSAIDs, and hormonal therapy can help prevent such com­plications as well. We strongly recommend that oral contraceptives and estrogen these medications be discontin­ued a month before the operative procedure.

Unnecessary medications are expressly prohibited, primarily; aspirin, beta-blockers, estrogens, vitamins, and the so-called herbal drug ten days before surgery.

Of course, suppose there is a medical indication and necessity for these drugs. In that case, I should complete a consultation with the primary physician or appropriate specialist before discontinuation of the medical therapy.

Physical Examination Before Back Liposuction

A detailed physical exam is performed at the first visit and consultation. During the initial and subsequent visits, height, and weight with calculating body mass index (BMI) is paramount for safety and observation of long-term trends during follow-up. For back lipo­suction candidates, six key elements are documented.

1. Evaluation of areas of fatty tissue deposits and contour deformities
2. Skin tone and quality
3. Asymmetries
4. Dimpling and cellulite
5. Myofascial support
6. Zones of adherence.

The physical exam is best performed before a full-length mirror, allowing an open dialogue between patient and physician. The patient should confirm precisely what will be addressed during the procedure.

The back liposuction patient must be marked in the standing position. Afterward, the patient may be asked to lie down, adjusting other markings. Specific attention to pre-existing asymmetry or contour irregularity should be discussed and noted in the chart. The body is not symmetric, and the markings will be slightly different on the two sides.

We divided the back region into three major groups: upper, central, and lower, followed by the patient’s topographical fatty tissue collection and skin folding. Each should be marked and aggressively treated to give the patient a smooth posterior appearance and a concave waist.

For the Back, liposuction I use a topographic type of marking with concentric circles. The smallest inner circle is the highest. It denotes the area of most fat collection. It needs more liposuction in a deep plane. As I move more peripherally, the expected fat suctioned is less and lies more superficial. This is important to blend nicely with the surrounding areas.

Professional medical photography can be helpful for accurate and consistent pre-and postoperative documentation. High-quality medical images should be obtained with anterior, posterior, lateral, and oblique views, documenting the results and objective evaluation of outcomes for both patient and physician. Find­ings may be challenging to interpret in males.

After back liposuction, a follow-up visit is typically scheduled 2–3 weeks after the initial consultation. During this visit, computer images are reviewed, which allows the patient to establish realistic expectations. The second visit allows further dialogue between the patient and physician so that all questions may be answered, and issues addressed. The patient and physician should discuss the procedure, alternative treatments, financial obligations (including further surgeries if required), and complications and risks.

Informed consent of Back Liposuction

The patient has sufficient information about the back liposuction proce­dure, postoperative course, and long-term results to make a truly informed decision. The operative surgeon should perform this vital process (not a nurse or staff) and be documented in the medical record. Three days before surgery, the patient uses an antiseptic soap containing povidone-iodine or chlorhexidine. One day before Augmentin, 1g twice daily is initiated and continues for six days.

Perioperative Notes of Back Liposuction.

Before back liposuction, the patient is placed in a warming blanket 30–60 min before the procedure. Local anesthesia should be warmed and not administered to cold unless IV sedation is used. Additionally, calf compression is applied to the lower legs as preoperative precautions to assist in DVT prophylaxis and prevent the patient from becoming cold during the procedure.

During back liposuction patient is carefully monitored (non-invasive pulse oximetry, blood pressure, pulse rate, temperature, and EKG in three derivations). Regardless of the volume to be aspirated, all cases are handled as an outpatient. Parenteral fluid replacement is hardly necessary.

Anesthesia and Location of Back Liposuction

It is up to the surgeon to determine the optimal surgical setting for each patient undergoing back liposuction. Factors that influence this decision are the expected lipoaspi­rate, length and extent of the procedure, patient positioning, operating surgeon preference, anesthesiologist preference, and overall patient health.

Awake back liposuction is performed in MSI- an office-based setting with a tumescent technique. Small-volume back liposuction cases can be performed with local anesthesia, with or without mild seda­tion. Complex, large-volume back liposuction and combined cases should be performed under general anesthesia. At MSI prefer IV anesthesia for most cases.

Prof. Moawad considers back liposuction to be “large” when over 4,000 ml. In general, we try not to extract over 10,000 mL per session. Although it is still very safe for patients over this limit (with minimum blood loss and typical normal signs), the duration of the procedure is prolonged, which involves fatigue for both the patient and the surgeon.

Four different terms describe infiltration of local anesthesia (wetting techniques): dry, wet, superwet, and tumescent. These terms are based on the volume of infiltrating as a ratio of the volume suctioned. The dry technique uses no wetting solution and has few indications of liposuction.

The wet technique involves pre-infiltrating two hundred–300 mL of solution per region to be treated, regardless of the anticipated amount to be aspirated.

The superwet tech­nique employs an infiltration of 1 mL of solution per estimated 1 mL of expected aspirate.

Finally, the tumescent infiltra­tion, popularized by Klein et al., involves extensive infiltration of solution that infiltration significant tissue turgor and results in total infiltration of ~3 mL of wetting solution per 1 mL aspirated.

The local anesthesia is injected in 1:1 volume and aspirated depending on fatty tissue deposits and their location. If aspiration of 3, 6, or 8 L of fat is planned, the injection should be 3, 6, or 8 L of Klein’s solution.

Prof Moawad preferred two injectors to infiltrate tumescent anesthesia at a lower rate in large volume back liposuction. I believe that tumescent infiltration should be carried out in this area until the tissue has firmness and a slight “orange peel” appearance, which will help stabilize the tissue during the liposuction phase. Patience is required, but I can achieve satisfactory results.

Regardless of the technique used, the infiltrate should be allowed for 30 – 60 min before suctioning because the anesthetic’s estimated onset of action and the solution’s vasoconstrictor effect reach maximum.

Using the accurate tumescent method, blood loss is less than 1 % of the total extracted volume. Major aspirations of 8–10 L imply a blood loss of no more than 80–100 mL, which in no way compromises the patient’s safety.

The strict application of the current technology allows us to carry out extensive back liposuction procedures at ambulatory facilities with no risk. Following a 30–60 min permeation of local anesthesia will result in the homogenization of the adipose tissue. This effect is essential to facilitate the suction process and get regular postoperative results.

While waiting for the real action of tumescent anesthesia, we use external ultrasound energy to liquefy fatty deposits. This will help in superficial liposuction and final contouring of the back. This is important in male patients or secondary procedures. External ultrasound with no suction is the non-invasive treatment of localized fat deposits of volume smaller than 300 ml by increasing the intracellular volume and rupturing the cellular membrane.

For volumes more significant than 300 mL, we can combine external Ultrasound with either syringe liposculpture in small cases or power-assisted in large ones. External ultrasound produced significant physician and patient benefits both operatively and postoperatively.

Now the anesthesia has reached its peak. The skin looks blanched and firm. The preferred position to treat these patients is the prone position. A unique pillow may gently flex the patient at the midline to address the lower back region more efficiently.

Back Liposuction Techniques  

Factors that influence selecting a particular type of back liposuction technique include surgeon preference, target area, expected aspirate, and history of the previous liposuc­tion. The traditional SAL remains the most common and popular modality for liposuction among plastic surgeons. The author prefers syringe reduction techniques in localized fatty tissue deposits of small volume or when fat grafting is required later.

To achieve satisfactory results for back liposuction Multiple access points are utilized using a crisscross technique to cover the sizeable back surface, including paraspinal, bra line, infra-scapular, flanks, and lumbar regions. Four incisions are utilized to perform suitable liposuction of the back most of the time.

Incisions are small, no more than 2 mm, and do not need suturing at the end. It is good to remember the saying, “In liposuction cases, entry points are small, but the wound is large.” The approach is essential to get more admirable results with receptible or no scars

Reduction Syringe Liposculpture Technique for Back Liposuction

Four steps are required:

• Removal of excess fatty tissue in a crisscross fashion.
• Remodeling of the remaining crisscrossed adipose tissue.
• Redistribution of the skin after a wide peripheral mesh undermining the neighboring normal adipose tissue has been done with a cannula with no extraction (like subcision).
• Adequate immobilization of the treated area until shrinkage and healing proceed satisfactorily.
• The left hand is the “brain hand” with liposculpture, and the right is a mere piston.

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. Then the deep phase of liposculpture is accomplished.

The surgeon must remember that closed liposculpture is an artistic, three-dimensional, architectural body contouring technique. It is a tactile operation with the surgeon working blindly. The results are different from those of traditional liposuction.

There are two types of fat removal with aspiration. One is liposuction, which removes fat at a deep plane to remove fat deposits. The other is liposculpture, which removes fat mainly at the superficial plane. Removing fat from the superficial fat lay will result in skin draping and tightening, resulting in a more aesthetic result. Twenty-five years of experience performing liposuction has convinced me that I need to be able to work superficially and in the deeper plane if I am to obtain optimum results.

Suction-assisted liposuction uses a two-stage technique. The site is infiltrated with a predetermined wetting solution and then evacuated after allowing time for the solu­tion to set and take effect. Advantages of this technique include ease of use, mal­leable cannulas, a wide variety of cannulas, and decades of experience and results.

When suctioning the back, forceful excursion of the cannula should be avoided, as fibrous areas may redirect the cannula to an unsafe location. Suctioning from areas of the thoracic cage (hip region) towards the posterior back should not be performed cautiously to prevent intra-abdominal and intra-thoracic penetration of the cannula.

Back Liposuction begins using the syringe for harvesting fat (lower back) for later grafting. Once much fat is needed to be obtained, back liposuction is performed on the deeper fat in a routine manner using the SAL. In the deeper planes, I use 3.0–3.7-mm cannulas.  

Most of the time, the skin in this area is quite thick, and it contrasts nicely. I might require superficial liposuction for patients with lax skin and excessive fat in this area. The surgeon needs to make a smooth transition between the hips, flanks, buttocks, the lateral thigh, the back, and the waist. When performing liposuction of the hips and flanks, knowledge of the differing aesthetic consideration of the hips and flanks in males and females is crucial.

Power-assisted liposuction uses an externally powered cannula, variable in size and flex, and oscillates in a 2–3-mm reciprocating motion at four thousand–six thousand cycles/ min. Advocates of PAL contend that it is best used for large volumes, fibrous areas such as the back, and revision liposuction. Because the PAL cannula breaks up fibrous fat much more readily, the procedure is significantly faster and less labor-intensive for the surgeon than traditional SAL.

In back liposuction, we always combine power-assisted, suction-assisted, and syringe-reduction liposuction. A 3 mm spatula or multi-hole reciprocating cannula without suction (pre-tunneling) at first applied. 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. Refinement is carried out in the superficial plane using small 2.0-mm or smaller cannulas. In our hands, using more soft cannulas and changing to larger cannulas makes back liposuction easier.

The quantity of fat removed can be moderate, but improved results are often observed with the release of folds and attachments to deeper tissue. In our series of patients treated with this modality, we routinely improve the contour of the back, flanks, lumbar, and gluteal area. Assistants use roller towels to gently remove the remaining saline solution and break down fat cells from the entry points in the end. Autologous fat grafting and liposhifting may be required to obtain optimum results.

In large volume back liposuction, two surgeons operate together; Both acts to debulk fat, while one surgeon only finishes the superficial final contouring on both sides. If extraction over 10 L is considered, it is preferred to do back liposuction in two sessions. Since the blood loss is minimal, the surgical trauma is low, and the drugs used as sedatives and analgesics are quickly metabolized, the second procedure can be done 1–2 weeks later.

Surgical Endpoints of Back Liposuction

Longstanding endpoints have been established for traditional liposuction, such as skin pinch, final contour, and volume of aspirate. Measured volume aspirated is a good indicator for bilateral procedures to judge symmetry and contour, comparing each side to the opposite. Other indicators such as treatment time, blood in aspirate, and amount of aspiration are essential factors to consider.

Back Liposuction Post Operative Notes

Sutures are not applied to the entry points. This allows for easy dripping of the fluids. When all tumescent solution is drained from the surgery site postoperatively, gradual adherence and shrinking of the subcutaneous wound are initiated, resulting in a global three-dimensional wound contraction and a horizontal subcutaneous scar.

Maximum shrinking is usually seen after four months; the total wound healing time continues for 18 months. In the same process, the shrinking of the connective tissue fibers leads to the retraction of the skin. This must always be considered when judging the outcome.

After back liposuction, patients are placed in a compression garment, customized based on surgeon preference, and performed the procedure. The sterile padded dressing is applied with Micropore tape. On top of this, an elastic bandage is applied, followed by pressure garments when finishing. It helps diminish bruising and edema in our hands.

At the end of the surgery, the patients remain 1–2 h more before returning home by their means. Prof. Moawad always insists the patients must be accompanied by another person (friend or relative).

She will wear the garment 24 h per day, removing it only to shower for the first week. The French tape and gauzes are removed on the second postoperative day. This makes lymphatic drainage easier and a quicker reduction of inflammation.

Pressure garments are worn for the coming month for at least 12 hr./day, especially when the patient is active.

Moderate physical activity begins on the second day, and heavy physical activity (including gym, jogging, and extreme physical exercise) is strongly recommended after one month.

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.

External ultrasound is used starting the following week after the surgery to improve the body contour further and provoke a quicker reduction of inflammation. Ultrasonic therapy will be continued as needed for irregularity and ecchymosis.

Patients are asked to ambulate on the day of the surgery. Patients are allowed to shower as early as 1 or 2 days postoperatively. Walking is encouraged immediately, and light activity is allowed two weeks after surgery. Initial postoperative visits are sched­uled for 5–7 days postoperatively; return to activity/work can occur as early as 3–4 days or at two weeks, depending on the procedure.

Patients should expect to initially gain weight after back liposuction due to volume shifts and postopera­tive swelling. Bruising should be minimal and dissipate by 7–10 days after surgery. Edema tends to peak from 3 to 5 days after surgery.

As patients’ activity levels improve and necessary lifestyle changes proceed, I may notice further changes. Patients should begin to see contour changes in their waist by two weeks, and at six weeks should be able to appreciate significant changes in their shape. Depending on the patient, the final aesthetic result can be seen 3–6 months after surgery.

Complications of Back Liposuction

In our experience, liposuction complications in the back are rare when performed by experienced surgeons. The back and flanks are very “forgiving” areas for liposuction, making deformities due to excessive liposuction extremely rare. The most common complication is under-correction of the deformities and the need for a secondary “revision” procedure.

Hyperpigmentation at the incision site is common, especially in Hispanic and black patients. This pigmentation is often post-inflammatory hyperpigmentation and resolves over four to six months.

Postop­erative complications occur in three different windows. These are the perioperative period (0–48 h), early postoperative period (days 1–7), and late postoperative period (1 week to 3 months).

Perioperative complica­tions can include anesthesia and cardiac complications, cannula trauma to the skin and internal organs, and volume loss/overload from bleeding or excess fluid administration. Cannula injury to blood vessels, bowel, and other solid intra-abdominal organs has been reported.

Liposuction surgery, especially when it involves multiple areas, places the patient at risk for hypothermia. Preventative measures include warming the wetting solutions and prep, increasing the ambient room temperature, and use of preoperative and intraoperative warming.

Pre-warming the patient for one h has also significantly reduced hypothermia incidence. It should be considered, particularly for longer body contouring cases and those involving multiple areas.

In the perioperative period, fluid shifts occur, which, if improperly managed, can lead to hypovolemia or volume overload. As a rule, we require our patients to obtain preoperative medical clearance over 50 years of age or have any concomitant risk factors, such as cardio­pulmonary disease.

Careful management of intraoperative and postoperative fluids and an intraoperative datasheet helps prevent volume-related complications from liposuction.

Other early postoperative complications include venous thromboembolism, infection, and skin necrosis. The incidence of DVT in liposuction has been reported at <1%, but a marked increase in this percentage is demonstrated when liposuction is combined with other surgery.

Wound infections, including necrotizing fasciitis, are serious complications known to occur in liposuction. Fortu­nately, these types of complications are rare. Complaints of persistent postoperative fevers or cellulitis should be closely monitored and aggressively treated.

As a preventative measure, first-generation cephalosporins are administered perioperatively within 30 min of the incision. There is no indication for routine postoperative antibiotics after the perioperative dose in stan­dard liposuction.

Late liposuction complications include delayed seroma formation, edema and ecchymosis, paresthesia, hyperpig­mentation, and contour irregularities. A loose closure of cannula sites, postoperative compression garments, and expression of residual fluid over liposuction areas at the end of the procedure can potentially reduce the incidence of seroma formation.

 Postoperative edema and ecchymosis occur to a varying extent in all patients. Significant ecchymoses may result in hemosiderin deposition and hyperpigmentation. This can be challenging to eliminate. Prolonged edema can occur up to 3 months post-surgery and is best treated with supportive care and lymphatic massage.

Postoperative paresthesia/dysesthesia can occur in all forms of liposuction. The sensory changes are usually reversible and can take up to 10 weeks to recover.

Other Techniques that Can be Use in Back Liposuction

Ultrasound-assisted liposuction utilizes ultrasonic energy to break down fat and facilitate suction-assisted removal. With this technique, fat is emulsified, which allows removal through traditional liposuction cannulas. Its mechanism of action is also primarily mechanical, but cavitation and some thermal effects are alleged to occur.

UAL com­prises three stages: (1) infiltration, (2) emulsification, and (3) evacuation and contouring may utilize skin protection to help protect the skin from thermal injury.

Advantages of UAL include less surgeon fatigue. By utilizing ultrasound-assisted liposuction, advocates report a more uniform treatment of fat layers and improved contour with minor revision. Disadvantages include increased equipment cost, slightly more extensive incisions, longer operative times, and thermal injury.4

VASER-assisted liposuction employs a newer generation ultrasound-assisted liposuction device that incorporates less energy with more efficient, solid probes. The system uses less energy, decreasing its thermal component to the tissues. After either continuous or pulsed energy treatment, the fat broken down is then evacuated with a traditional liposuction cannula.

Laser-assisted liposuction has been at the forefront of marketing hype. Companies and physicians utilizing these devices employ a four-stage technique: infiltration, application of energy to the subcutaneous tissues, evacuation, and finally, subdermal skin stimulation. t. Most companies and physicians utilizing these devices employ a four-stage technique: infiltration, application of energy to the subcutaneous tissues, evacuation, and finally, subdermal skin stimulation. The treatment involves the insertion of a laser fiber via a small skin incision. The most common available wave­lengths in the United States are 924/975 nm, 1064 nm, 1319/1320 nm, and 1450

The laser fiber acts to disrupt fat cell membranes and emulsify fat. Evacuation then commences via traditional liposuction cannulas. The belief is that the heating of the subdermal tissue may provide a skin-tightening effect. Prof Moawad is not convinced it yields clinical differences.

Water-Assisted Liposuction (WAL)

WAL burst onto the scene in 2007 for conscious liposuction, allowing improved contouring facilitated by an awake patient. First, the standard wetting solution is injected in the form of a fan-shaped spray by a waterjet approximating the force of a strong shower.

As anesthesia takes effect, a more dilute solution is substituted. This constant fluid flow increases adipose cell detachment and reduces the risk of adverse volume-related fluid-electrolyte shifts, circulatory overload, and postoperative edema. It also shortens the procedural time in large volume liposuction and has been shown to promote blood-sparing fat removal in lipedema.

Radiofrequency-Assisted Liposuction (RFAL)

Radiofrequency-assisted liposuction (RFAL) utilizes diathermy-like bipolar radiofrequency energy to disrupt fatty cell membranes and encourage lipolysis. A beneficial secondary effect on skin contraction is also claimed, and much like LAL, it causes a thermal injury at the subdermal surface.

The uncontrolled and focally concentrated injury that besets LAL has been addressed using two electrodes. The internal one in the subcutaneous adipose tissue forms numerous tunnels similarly to SAL, but without the force required as RF energy itself produces lipolysis. Additionally, an external electrode channels the energy so that the effect is within the fat and focused on the subdermal surface.

IMPORTANT NOTES FOR THOSE WHO ADVOCATE THE USAGE OF THERMAL INJURY TO REMOVE FAT

Various technologies have facilitated fat removal over the past three decades. Many of these have been used thermal injury. The thermal energy introduced with ultrasound-assisted, laser-assisted, and radiofrequency-assisted liposuction creates injury to fat cells, therefore facilitating aspiration. However, the thermal load imparted the creation of additional fibrosis, scarring, and contour irregularities. Therefore, using thermal devices designed to eliminate fat increases liposuction complications.

Conclusion

Liposuction approaches will vary since each patient has different anatomy, emotions, and expectations. Superficial liposuction combined with liposuction in the deep or traditional planes is necessary if one is to create a sculpture rather than remove fat.

Back liposuction is based on scientifically sound principles, but the optimal results depend on the eye to visualize and the skill to create the desired symmetry and contour artistically. Combining several techniques with fat grafting allows simultaneous improvement of many body areas, resulting in a significant overall body contour enhancement.

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High-Definition Back Liposuction Results (before & after)

HD Liposuction Results (before and after)