Liposuction Article - Use of Reston Foam - American Plastic Surgery of Hawaii Hawaii

S. Larry Schlesinger, M.D.

Maui, Hawaii, USA

Abstract. Two new approaches in suction lipectomy of the buttocks region are described: liposuction of the "banana" and liposuction of the "sensuous triangle." The banana is the highest part of the posterior thigh just below the buttocks crease. It appears only in certain individuals and appears as a bulge under the buttocks crease. The preferred approach to liposuction of the banana is discussed as well as a theory as to its etiology. A common complication of liposuction of this area is ptosis of the buttocks crease. Methods of treatment of this complication are also discussed. The second topic addressed is liposuction of the sensuous triangle which is at the junction of the lateral thigh, and posterior thigh. The result of suctioning this area is a more athletic-appearing buttocks region.

Key words: Liposuction - Buttocks - Body contouring - Banana - Sensuous triangle

Liposuction of the "sensuous triangle" and the "banana" are adjunctive surgeries to other procedures such as liposuction of the lateral thigh, posterior thigh, or buttocks region. Suctioning of the sensuous triangle is accomplished at the same time as liposuction of the primary surgical site and is accomplished from the same infragluteal incision. Suctioning of the banana is accomplished from a lateral thigh incision.

The Sensuous Triangle

The sensuous triangle, which is at the junction of the lateral buttocks, the lateral thigh, and the posterior thigh, is converted by liposuction to an inverted pyramid. The base of this inverted pyramid is at the skin level and the nadir of the inverted pyramid is deep in the lateral thigh area (Fig. 1A,B).

The purpose in thinning the lateral aspect of the buttocks from the buttocks crease upward is to decrease the squareness of mature buttocks and to give this area a more youthful appearance. Taking a triangle or pyramid of fat out of this area gives a very athletic appearance to this region. The results look very much like the buttocks of an olympic swimmer. (Figs. 2,3).

Methods

First the mapping of the operative area is performed (Fig. 4). The apex of the mapped triangle on the skin surface is at the infragluteal incision and its two adjacent limbs fan out laterally. Suctioning the superior limb reduces the lateral buttocks area; suctioning the inferior limb reduces the outer half of the posterior thigh region. The nadir of this inverted pyramid ends deep in the lateral thigh tissue. No additional incisions are needed since suctioning is accomplished from the same infragluteal incision as used in both medial and lateral thigh suctioning.

Fig. 1. (A) The sensuous triangle, (B) descriptive terminology of the sensuous triangle

Fig. 2. Preoperative and postoperative views of the sensuous triangle

Liposuction is accomplished with cannulas that are 3.0 and 3.7 mm in internal diameter and 8.0 cm long. The usual volume removed during suctioning is approximately 10-25 cc. The suctioning, done with a Mercedes cannula, is performed very close to the subdermal layer of fat. It does not matter if the opening of the cannula is turned up or down.

Postoperatively, the area is covered with a triangular piece of Reston Foam. A Caromed girdle is also applied. The foam is left on for three days; this aids in an even distribution of fat with less lumping and bruising.

The Banana

The banana often looks like a second buttocks bulge or fold and appears in selected female patients. It is located at the highest part of the posterior thigh just below the buttocks crease. This elevation has never, to my knowledge, been reported in a male patient. I believe that this second fold is caused by the same osteocutaneous fibrous bands that create the buttocks fold. Some of these fibers insert into the skin as low as 1-3 in. below the buttocks crease. Fat infiltrates these fibrous bands causing a subgluteal bulge to be present. It has a very unaesthetic look when a bathing suit or shorts are worn. Patients frequently request reduction of the bulge in this area. (Figs. 5, 6).

Methods

The operative area is mapped (Fig. 7). An incision is made in the lateral thigh area with a #15 Bard Parker. I find that creating a lateral thigh incision is the best approach to treating the banana. Suctioning is accomplished with cannulas that are 3.0 and 2.4 mm in internal diameter and 17.0 cm long placed parallel to the banana and along its long axis. One should make a limited number of passes and suction superficially in this tisssue to decrease the chance of ptosing the buttocks secondary to injury of these essential fibrous bands. This technique causes the lease trauma to these osteocutaneous bands. The surgeon must continuously watch the buttocks crease while suctioning the banana because if the fibrous insertions are lysed, the buttocks crease will begin to migrate distally and will be noted as a relaxation of the crease. If this should occur, suctioning should be discontiued. One can do a delayed second procedure if additional liposuction is deemed necessary. To this end, the patient should be warned that suctioning the banana is often a staged procedure (Fig. 8).

Fig. 3. Prepoerative and postoperative views of the sensuous triangle

Fig. 4. Mapping and suctioning the sensuous triangle

Discussion

Sensuous Triangle

Liposuction of the sensuous triangle is an adjunctive procedure that may be accomplished along with most other suction lipectomy procedures of the buttocks and thigh area. Whenever I do liposuction of the lateral thigh, posterior thigh, or buttocks region, I will usually also do the senuous triangle. The suctioning can be done at the same time as the primary procedure and is accomplished from the same infragluteal incision. The resulting cosmetic depression from suctioning the sensuous triangle has a very aesthetic look, one that Patients appreciate. Patients report that the new shape of their buttocks area has a nice look and feel to it. They also report that their bathing suits fit better and they look much more attractive in that region. By removing the inverted pyramid of fat from this area, the result is a more youthful, athletic look. In addition, no complications have been noted in over 400 separate patient surgeries.

Fig. 5. The banana
Fig. 6. Theory: osteocutaneous fibrous bands forming the buttocks crease and ancillary bands with fatty infiltration forming the banana

Fig. 7. Mapping and suctioning the banana

Banana

The banana is a very tricky area to suction because of the proximity of osteocutaneous fibrous bands which create the buttocks crease. A known complication of excessive suctioning in the posterior thigh area is to disrupt or sever enough fibers that the buttocks crease falls from it normal location to a lower position. This has happened to many good plastic surgeons and there are a few treatments for this, but the best treatment is to avoid it (Fig. 9).

Fig. 8. Preoperative and postoperative views of the banana

Fig. 9. A common complication of overaggressive suctioning of the banana: ptosis of the buttocks crease

If ptosis of the buttocks crease occurs during surgery, the surgeon should make several passes with a 6.0-mm cannula, scarifying the dermis in the buttocks fold and creating a raw surface. Next, a foam tape sling should be created with 1-in. foam tape and Mastisol adhesive. This should be left on for seven days as acute treatment of iatrogenic buttocks ptosis. The foam tape should start in the medial thigh area, follow the buttocks fold, and be placed high on the lateral thigh or hip area. Better and longer adhesion is achieved with Mastisol adhesive. This treatment very often creates adhesions that effectively reestablish the buttocks crease.

If ptosis of the buttocks crease has already occurred, a delayed correction may be accomplished by the above-mentioned scarifying and taping technique. However, sometimes it may be necessary t perform a formal buttocks lift. For such a lift I use 2.0 Mersilene Vicryl suture material in anchoring the dermis to the deep fascia or periostium. The wound is then further closed with subcuticular 3.0 Vicryl and interrupted 4.0 nylon sutures in the skin. This will work to correct a dropped buttocks fold. However, it has the disadvantage of leaving a scar in the infragluteal region.

Summary

Patients may benefit from liposuction of the sensuous triangle and liposuction the banana as adjunctive procedures to suction lipectomy of the thigh or buttocks region. The sensuous triangle is an easily excavated inverted pyramid of fat the treatment of which adds little time to the surgical procedure but when removed adds much to the final appearance. The banana is a difficult area to suction because of its proximity to osteocutaneous fibrous bands that create the buttocks fold and the possibility of the complication of ptosis of the buttocks crease. Ptosis of this crease may be caused when these fibers are inadvertently severed. Ptosis may be surgically treated. Suctioning the sensuous triangle and the banana results in a younger, more athletic-appearing buttocks region.

*Presented at the 7th Annual Meeting of the Lipoplasty Society of North America, San Francisco, California, October 29, 1989
Address reprint requests to Larry Schlesinger, M.D., American Plastic Surgery of Hawaii Corporation, Kahului Bldg. Suite 300, 33 Lono Avenue, Kahului, Hawaii 96732, USA