Table Of ContentSuperficial
I
Liposculpture
Marco Gasparotti Carson M. Lewis Luiz S. Toledo
Su perficial
Liposculpture
Manual of Technique
Foreword by Ricardo Baroudi
WITH 141 ILLUSTRATIONS IN 266 PIECES
INCLUDING 100 IN COLOR
Springer-Verlag
New York Berlin Heidelberg London Paris
Tokyo Hong Kong Barcelona Budapest
Marco Gasparotti, M.D.
Clinica Villa Salaria
Via Filippo Antonio Gualtlj!rio, n. 127
00139 Rome, Italy
Carson M. Lewis, M.D., F.A.C.S.
Plastic Surgery and Lipoplasty Center
of La Jolla
9900 Genesee Avenue Suite B
La Jolla, CA 92037-1271 USA
Luiz S. Toledo, M.D.
Clinica Toledo
Av. Rupublica do Libano 904
Sao Paulo, S.P. 04502-001, Brazil
Cover art by Howard Petlack
Library of Congress Cataloging-in-Publication Data
Gasparotti, Marco.
Superficial liposculpture : manual of technique 1 Marco
Gasparotti, Carson M. Lewis, Luiz S. Toledo.
p. em.
Includes bibliographical references and index.
ISBN 0-387-97917-4.-ISBN 3-540-97917-4
1. Liposculpture. I. Lewis, Carson M. II. Toledo, Luiz Sergio
III. Title.
[DNLM: 1. Lipectomy-methods. WO 600 G249sJ
RD119.5.L55G37 1993
617.9'5-dc20
DNLMIDLC
for Library of Congress 92-49210
Printed on acid-free paper.
© 1993 Springer-Verlag New York, Inc.
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ISBN-13: 978-1-4613-9304-7 e-ISBN-13: 978-1-4613-9302-3
DOl: 10.1007/978-1-4613-9302-3
Foreword
Ricardo Baroudi
During the 10 years since liposuction was intro followed by all plastic surgeons, as they were
duced to the world of plastic surgery, new hori considered safe practice.
zons have appeared with regard to the aesthetic Suddenly, however, no more than a year ago,
aspects of body contouring. Patients were en the International Plastic Surgery Society started
couraged by the absence of scars, the good re to hear from a young Roman plastic surgeon,
sults, the speed of recovery, and the safe condi Marco Gasparotti, regarding a procedure called
tions. superficial liposculpture that he had been per
As with any new procedure, the initial eu forming since 1982. Superficial liposculpture is
phoria subsided. It became apparent that lipo- , completely opposite to the traditional teachings
pIa sty could not be used in all cases, and it could of the plastic surgery community. Gasparotti had
!
not substitute for traditional surgery. Upon re- ' accumulated almost 10~rs of personal experi
view of the limitations and the possibilities, these ence before his discovery by the outside world.
two surgeries have come to be used in combina- , Although there were a small number of isolated
tion or alone depending on the surgical situation. personal communications in various countries,
The quality of care again improved. nothing evolved at a global level. Several friends
All publications ahd discussions have agreed and colleagues have since visited Gasparotti
with the basic principles that had originally been in Rome to observe and learn his technique
determined by Illouz. Although specific im of superficial liposculpture; and I was among
provements were made during the 1980s, the them.
consensus is now that lipoplasty should be per In 1981 I visited with Illouz after first hearing
formed as much as possible through and along from him at the Brazilian National Society annual
the subcutaneous tissues at the deep level just meeting in Fortaleza City, Brazil, where he pre
above the muscular aponeurosis. The dermis and sented his ideas about liposuction. These con
fat tissue above the superficial fascia should be cepts were controversial in this conservative sci
preserved to avoid dents, depressions, and skin' entific community. I confess that I thought Illouz
flabbiness. Until recently these rules were strictly held the so-called Columbus Egg. A few months
vi -:- FOREWORD
later I was with Illouz at Pierre Fournier's house gical technique, bandaging, and postoperative
discussing the positive and negative aspects of care.ln these chapters he demonstrates two dis
lipoplasty. On that memorable night Clyde Lit tinctive issues that were not considerations in
ton was a participant in the group. routine lipoplasty. The first is that liposuction
Ten years later I found myself with Gasparotti can be performed between the dermis and the
in Rome observing his surgery an~ reviewing his superficial fascia (at the areolar plane of the sub
research on superficial liposculpture. I invited cutaneous tissue). Few tunnels and suction are
him to my clinic in Brazil, where he demon done in the lamellar fat level, a region that re
strated his technique to a local 'group of sur mains virtually untouched. It is important to note
geons. It was not long before the aCtive Lipolysis that, as Gasparotti states, "where traditionalli
Society of North America discovered Gasparotti posuction ends, superficial liposuction begins."
and became intrigued with his results. A member The second issue is that of skin elasticity and its
of that society, Dr. Carson Lewis, invited shrinkage capacity. Surgeons have discussed
Gasparotti to his clinic in La Jolla, California, to this factor before but not in relation to liposuc
teach a handful of American plastic surgeons su tion. Gasparotti grasped these concepts and
perficial liposculpture. Gasparotti and Lewis began to utilize them in superficial liposuction in
soon joined forces with Luiz Toledo to write this 1981.
book. The effect of his work has led to another
While Gasparotti worked in Italy, Luiz Toledo change in traditional deep lipoplasty. Whereas
was busy working in Brazil. As Gasparotti was skin laxity combined with fat deposits were con
performing superficial liposuction, Toledo was traindications to liposuction, they are no longer
finding other ways to improve the metp.od he so with superficial liposculpture. The ability to
called superficialliposculpture. My perception of perform liposuction on patients 17-70 years of
their ultimate collaboration, this book, is that it age, regardless of skin flaccidity and amount of
is an invitation to other surgeons to observe and fat deposit, is an important contribution to body
then utilize their findings to improve the status contouring.
of lipoplasty in their practices. In Chapter 3 the reader can follow Toledo's
From the first to the last chapter, the reader experience with liposculpture using a syringe
can find meticulous information combined with ("superficial liposculpture"). Toledo combined
rich illustrations, making the book a good for these two techniques to treat localized fat depos
mula for superficialliposculpture. Beyond the its in patients with flaccid skin, skin irregulari
technical aspect, one can certainly enjoy the fla ties, depressions, and liposuction sequelae. He
vor of each individual writer. Each presents him-, has also been treating skin laxity in patients of all
self as though in conversation with you, the ages. The reader is introduced here to the Toledo
reader; and the three unique and distinctive per dissector, a speci~l,rorked-tip cannula used to re
sonalities shine through. Through the didactic sect skin septi/ln patients with cellulite. The
medium you will understand the concepts and chapters on cellulite and secondary liposuction
perhaps be entertained in the process. by Toledo demonstrate his vast knowledge and
The Preface by Carson M. Lewis is realistic re experience with fat injections to improve dents,
porting from an experienced and dynamic plastic irregularities, and skin turgor and t.o augment
surgeon. He is to be credited with introducing volume. •O nce again, the technical details and
Gasparotti to the United States and the scientific rich clinical illustrations with long-term follow
world. His contribution herein is a helpful dis up are well documented.
cussion of the evolution of lipoplasty and the var Lewis and Toledo join forces for discussing
ious players involved. contour augmentation. They each have had sig
Gasparotti authors the first two chapters, de nificant experience with the harvesting and rein
scribing in detail his concepts about liposculpt jection of fat, from minute amounts to 400 cc.
ing: patient selection, preoperative !outine, sur- The use of Lipogen versus bovine collagen (Zy-
FOREWORD -:- vii
mogen) as a filler in cases of contour deficiencies It was an honor to be asked to register my
is reviewed. thoughts al)d observations about this book. My
In the last chapter Lewis collates the ideas pre belief is that it will act as a stimulus to others,
sented in the book and summarizes the concepts. who can benefit from the experiences of those
The photographic documentation well supports who have traveled ahead.
the various findings.
Nothing is so powerful as an idea . .. who's time
has come. .
VICTOR HUGO
Preface
Is there a shortage of books and information on addressed nor corrected with this technique.
liposuction? Certainly not. Each year one or more These problems, unsolvable with conventional
new books on how to remove fat from the subcu liposuction, can now be successfully treated by:
taneous tissue via liposuction reach the market. the method called superficial liposculpture.
Our book goes beyond previous teaching, rais We now are advocating dissection in the su
ing the bench mark. With the information con perficial plane immediately underneath the skin.
tained herein the surgeon will be able to accom By working superficially, the surgeon can re
plish body and facial contouring not previously drape the skin, overcoming flaccidity, while
possible. treating difficult sites more effectively and surgi
Blunt suction lipectomy was originated by Il cally correcting cellulite.
louz. Starting in 1977 he adroitly assembled the Working in the superf}etal compartment can be
ingredients necessary to remove subcutaneous better accomplished wfth innovative equipment,
fat safely and effectively. Whenever possible he a syringe. Advantages of this syringe are numer
advocated working in the deep compartment of ous to both patient and surgeon: Compared to
fat. By staying deep the surgeon reduces the risk conventional liposuction techniques, the syringe
of contouring irregularities, including dents, is more precise and accurate; there is less blood
depressions, and ridges. This principle-staying loss; and convalescence is shortened. Another
deep-has been advocated for the more than 10 advantage is the ability to harvest fat (for reinjec
years that liposuction has been performed. tion) with little trauma to the adipose tissue.
Conventional liposuction has limitations: The Harvested fat can be used as a source for auto
patient with flaccid skin, for example, is rele logous grafts in many ways, e. g., for contour aug
gated to skin excision~ and certain sites treated mentation to build up areas deficient in tissue in
with conventional suction have only limited im both face and torso and for correcting contour
provement, with others being made worse. Fur- . irregularities that have resulted from previous
thermore, the phenomenon of cellulite is neither liposuction. The technique opens up new vistas
x -:- PREFACE
for transference and survival of fat. Previously, . had been using the syringe and going far beyond
in the hands of most surgeons fat transfer had the c;onventional methods of liposuction. My
been disappointing. first exposure to the superficial method was To
These major points combine to produce a ledo's 1990 lecture at the Lipoplasty Society of
method of body and facial contouring called su North America (LSNA) annual meeting in Bos
perficialliposculpture. The infon:pation offered ton. His· results were impressive-although
in this book allows surgeons to raise the level of some present were in disbelief.
excellence in their practice by helping them to Toledo then invited me to the RAPS meeting
perform more precise body scutpting and by in Brazil in March 1991. Gasparotti presented his
their learning procedures not previously pos technique at that meeting with results that were
sible. outstanding. His ability to treat large bulges of
fat in older women with flaccid skin was a revela
tion-a major breakthrough. I wanted to know
more about this technique; and Toledo, Gaspar
Evolution of the Book
otti, and I dined together. I invited each to be a
guest surgeon at a workshop in La Jolla in 1991,
Each of the authors of this book is trained in plas and each accepted. Toledo came in April and
tic surgery with an interest in aesthetics and September 1991, Gasparotti in July and Decem
body and facial contouring. Living and working ber. It was then that I had the unique opportu
on separate continents, our paths nevertheless nity to observe the technique and see the results,
came together; and the idea of combining our learning first hand from the masters themselves.
knowledge in a book became a reality. ~ In September 1991 in Seattle at the LSNA
Each of us has made original contributions to ASPRS meetings I was approached by Springer
this subject. As frequently occurs, individuals in Verlag publishers about new ideas for a book.
different parts of the world have made discover Gasparotti, Toledo, and I were aware that this
ies of a similar nature simultaneously without exciting new method had captured the interest
knowledge of the others' work. of surgeons, so to write the book was simply an
Marco Gasparotti, in Rome, was the first -to extension of what we believed and were already
work successfully in the superficial compart practicing. We thought the timing was impor
ment. His technique was not made known until tant, as we wanted to present the information to
1989 at a Recent Advances in Plastic Surgery our colleagues as quickly as possible. Our goal
(RAPS) meeting in Brazil hosted by Luiz Toledo. was to have the book available for the spring
Gasparotti had begun during the early 80s with meeting of LSNA-ASAPS in Boston in April
an approach contrary to what convention has 1993.
taught. Working simultaneously in Brazil was
Luiz Toledo, with ideas that were innovative and
different from the standard. The two physicians
Format of the Book
became acquainted when Gasparotti presented
his work in 1989 at the RAPS meeting in Brazil.
Each recognized the importance of the other's This book has peen written for the practicing aes
work. Ideas were exchanged, and a synergy de thetic surgeon. It is designed as a "how to" atlas
veloped producing a method better than before. complete with many photographs and illustra
As often happens, each learned from the other. tions of how to perform these techniques. Both
The operation colltinued to be refined by the two Mar.co Gasparotti and Luiz Toledo have made
surgeons, with numerous interchanges between significant contributions to body sculpting.
them. Toledo then visited Gasparotti in Italy and Gasparotti was the creator, the first to work so
Gasparotti returned the visit to Brazil. The super close to the skin successfully; and Toledo embel
ficial method was now out of its infancy stage lished the superficial method, expanding to
and into adolescence. Toledo, working in Brazil, other sites and developing the surgical treatment
PREFACE -:- xi
for cellulite. I have used the syringe for effecting with new concept, vocabulary develops. Terms
autologous fat grafts. such as G ppint, Lipogen, and Pizza Roller, to
Each author has contributed equally in terms mention a few, will become familiar to you.
of the amount of material presented. Gasparotti Principles you have held important for con
covers the origin of his technique and how it is ventional liposuction are herein violated. No
performed on the iliac crest areas, buttoc~s, and longer do we stay deep, we work superficially.
lateral femoral sites (the lateral portion ,of the In certain situations, sharper cannulas are used.
torso). Toledo addresses the use of superficial The opening of the cannula no longer remains
liposculpture at other sites, including the, abdo down but occasionally is turned upward. What
men, inner thighs, and knees. He has devoted sacrilege!. These changes are necessary, how
one chapter to the treatment of cellulite. I wrote ever, to perform the superficial method success
on the syringe as a choice of equipment. We will fully.
combine our efforts in chapters on contour aug Why the book? Because it goes beyond the
mentation (autologous fat grafting), secondary scope of previous books on body contour
liposculpture, and correction of contour irregu ing-demonstrating new techniques that pro
larities. In the final chapter I address the question vide a better way to treat difficult conditions and
of whether the results are reproducible using this to help patients. We want not only to demon
technique. I discuss my early problems and con strate these new techniques but to provide com
cerns and report early results. ' petent surgeons with a basis for using ,the new
You will note a certain amount of repetition in procedures.
the text. It was done purposefully. Although we The photograph of the three of us-Gaspar
three agree in principle, there is some variation otti, Lewis, and Toledo (left to right)-was taken
in our techniques. For you, the reader, one au September 1991 at the annual LSNA meeting in
thor's writing may be more meaningful than an Seattle when the book project was conceived.
other. Remember: for surgeons, repetition is the
mother of skill. Carson M. Lewis, M.D., F.A.C.S.
You will find new terms in this book. As any
Acknowledgments
I thank my parents Arnaldo and Laura for having book; to members of my staff and to my wife
taught me humility; my sister Alessandra for Helen for their encouragement and understand
having always believed in me; and my wife Fran ing; to Susan Money, my office manager, for help
cesca for her support during these years. I also in transforming the material from Marco Gaspar
want to thank Dr. Angiola Scioli and Dr. Marco ot~ into free-flowing English and her enthusiasm
Pagliari for. their continuous collaboration; Dr. for the project; and to Marco Gasparotti and Luiz
Karina Castrini for her efficient secretarial work; Toledo for taking time from their already busy
Ms. Fausta Pesarini for the book's translation; schedules to write this work.
....
and Susan Money for her important work of piefl:
ing together my scholastic English. CARSON M. LEWIS, M.D., F.A.C.S.
MARCO GASPAROTII, M.D.
I thank Esther Gumpert for her confidence; Dr.
I am indebted to our friends and colleagues Ri Adrien Aiache for inspiration; Dr. Jack Friedland
cardo Baroudi, M.D., for writing the Foreword, for encouragement; Dr. Tolbert (T) Wilkinson for
and Pierre Fournier, M.D., for designing the sy "guts"; Drs. Carson Lewis and Marco Gaspat
ringe and pointing out its advantages; to John otti; Dr. Gilberto de Almeida Jr., my assistant;
Johnson for his ideas and support; to John Panik, Lucimara Sanches Rodrigues, my nurse; Sonia
my surgical technician, for his innovative ideas Regina Moraes, Ply secretary; and my wife Kate
and help in the operating room; to Anne Grause for her dedication.
and Nancy Jenkins, my assistants, who under
took the typing and numerous rewrites of this LUIZ S. TOLEDO, M.D.
