Introduction
Liposuction techniques, technologies, publications, and scientific events evolve continuously,
seeking increasingly better and more predictable outcomes with maximum potential safety.
Searching for better outcomes, there are references[1 ]
[2 ]
[3 ]
[4 ]
[5 ]
[6 ]
[7 ]
[8 ]
[9 ]
[10 ]
[11 ]
[12 ]
[13 ]
[14 ] about abdominal and body definition techniques and new technologies with laser,
ultrasound, and radiofrequency devices for higher contraction of the fibrous septa
and dermis, in addition to fat grafting techniques as great allies for improving outcomes
with new preparation techniques and better integration. On the other hand, there are
no references to objective volume controls for more precise and predictable liposuction
outcomes, which would reduce the need for retouching or refinements by combining aesthetic
sensitivity and surgical experience with objective parameters to control infiltrated
and aspirated volumes of each body region treated.
Regarding safety, scientific articles[15 ]
[16 ]
[17 ]
[18 ]
[19 ]
[20 ] highlighted several points to minimize major and minor complications, emphasizing
the significance of selecting a specialist with adequate training in plastic surgery
and liposuction. The authors emphasized preoperative measures, including a thorough
clinical evaluation, healthy and non-inflammatory nutritional status, avoiding obese
patients and combined surgeries, and, especially, limiting surgical times to up to
5 hours.
A review revealed many articles highlighting these safety points to avoid complications,
the importance of the aspirated volume for prognosis, and the greater risk of longer
surgeries. However, there were few references[21 ]
[22 ]
[23 ]
[24 ] regarding a more effective control of infiltrated and aspirated volumes to minimize
potential major and minor complications.
The present study aimed to describe a methodology called Lipocodes to measure the
infiltrated and aspirated volume, time, and surgical speed in liposuction and fat
grafting procedures.
Materials and Methods
The current descriptive theoretical study presents the LipoCodes methodology.
The author developed the LipoCodes methodology in 2010 due to the difficulty in knowing
exactly what was being infiltrated and aspirated in each body region during liposuction.
This information would allow greater control of volumes and more precise outcomes,
minimizing reinterventions and increasing the safety level in liposuction.
The lack of a previously described or properly presented model for controlling volumes
in liposuction inspired the development of a methodology for volume control in liposuction.
Initially, it consisted of notes on printed paper of the volumes aspirated in the
main liposuction regions for greater control. It evolved to control the infiltrated,
aspirated, and grafted volumes in liposuction, in addition to the start and end time
of infiltration and aspiration.
More recently, in 2021, this information was transferred to a Microsoft Excel (Microsoft
Corp, Redmond, WA, USA) spreadsheet using volume automatic calculation tools, prior
definition of the liposuctioned and fat-grafted regions, definition of access portals
for liposuction/fat grafting, and calculation of the time for infiltration and liposuction.
The LipoCodes methodology has been registered at the Brazilian National Institute
of Industrial Property (Instituto Nacional da Propriedade Industrial – INPI, in Portuguese)
since 2021, under number 920441726.
The LipoCodes methodology consists of four main parameters:
FAT DEPOSITION REGIONS AND GRAFT REGIONS;
LIPOSUCTION DEPTH LEVELS;
ACCESS PORTALS (INCISIONS); AND
INFILTRATED AND ASPIRATED VOLUME CONTROL.
1. FAT DEPOSIT AND GRAFT REGIONS:
The methodology defines 11 main fat deposit regions and 8 fat graft regions. Their
limits (anatomical references) are described below ([Figs. 1 ]
[2 ]
[3 ]
[4 ]):
Fig. 1 Female model, frontal view. Predefined fat deposition regions: arms (1), upper back
(3), lower back (4), upper abdomen (5), lower abdomen (6), inner thighs (7), trochanteric
region (8), knees (9), medial legs (10), and lateral legs (11). The figure also shows
the predefined regions for fat grafting in the abdomen (Ab).
Fig. 2 Female model, back view. Predefined fat deposition regions: upper back (3), lower
Back (4), inner thighs (7), trochanteric region (8), knees (9), medial legs (10),
and lateral legs (11). The figure also shows the predefined regions for fat grafting
in the gluteus (Gl).
Fig. 3 Male model, frontal view. Predefined fat deposition regions: pectoral (2), upper
back (3), lower back (4), upper abdomen (5), lower abdomen (6), and inner thighs (7).
The figure also shows the predefined regions for fat grafting in the abdomen (Ab),
deltoids (De), biceps (Bi), chest (Ch), and thighs (Th).
Fig. 4 Male model, back view. Predefined fat deposition regions: upper back (3), lower back
(4), and inner thighs (7). The figure also shows the predefined regions for fat grafting
in the deltoids (De), triceps (Tr), and gluteus (Gl).
1A. FAT DEPOSITION REGIONS:
ARMS ([Figs. 1 ]
[2 ])
Surface of the deltoid muscles (posterior or spinal portion) and triceps.
CHEST ([Fig. 3 ])
Surface of the pectoralis major muscle (portions with a sternal origin, sixth and
seventh ribs, rectus abdominis).
UPPER BACK ([Figs. 1 ]
[2 ]
[3 ]
[4 ])
Surface of the serratus anterior muscle (anterior limit), teres major and teres minor
muscles (upper limit), and the upper third of the latissimus dorsi muscle (inferior
and posterior limit).
LOWER BACK ([Figs. 1 ]
[2 ]
[3 ]
[4 ])
Surface of the lower third of the latissimus dorsi muscle (upper limit), thoracolumbar
fascia (posterior limit), external oblique muscle (anterior limit), and Lockwood's
ligament (inferior limit).
UPPER ABDOMEN ([Figs. 1 ]
[3 ])
The medial limit is the linea alba, from the umbilicus to the xiphoid process; the
superior limit is the costal margin; the lateral limit is the anterior borders of
the serratus and external oblique muscles; and the inferior limit is the horizontal
line from the linea semilunaris to the umbilicus.
LOWER ABDOMEN ([Figs. 1 ]
[3 ])
The medial limit is the linea alba, from the umbilicus to the pubic symphysis; the
superior limit is the horizontal line from the linea semilunaris to the umbilicus;
the lateral limit is the anterior border of the external oblique muscle; and the inferior
limit goes from the inguinal ligament to the pubic symphysis.
INNER THIGHS ([Figs. 1 ]
[2 ]
[3 ]
[4 ]
Triangle between the inguinal ligament (upper limit), sartorius muscle (lateral limit),
posterior border of the adductor magnus muscle (posterior limit).
TROCHANTERAL REGION ([Figs. 1 ]
[2 ])
Tensor fasciae latae muscle (anterior limit), gluteus maximus muscle (posterior limit),
vastus lateralis muscle (inferior limit), and Lockwood's ligament (upper limit).
KNEES ([Figs. 1 ]
[2 ])
Inner knees and pes anserinus region (tendons of the gracilis, sartorius, and semitendinosus
muscles).
INNER LEGS ([Figs. 1 ]
[2 ])
Lower border of the medial gastrocnemius muscle belly (upper limit), calcaneal tendon
(posterior limit), tibia (anterior limit), medial malleolus of the tibia (inferior
limit).
LATERAL LEGS ([Figs. 1 ]
[2 ])
Lower border of the lateral gastrocnemius muscle belly (upper limit), calcaneal tendon
(posterior limit), tibialis anterior muscle (anterior limit), lateral malleolus of
the fibula (inferior limit).
1B. FAT GRAFTING REGIONS:
ABDOMEN (Ab) ([Figs. 1 ]
[3 ])
Surface of the rectus abdominis muscles.
DELTOID (De) ([Figs. 3 ]
[4 ])
Surface of the deltoid muscle (lateral portion).
TRICEPS (Tr) ([Fig. 4 ])
Surface of the triceps muscle (long and lateral portions).
BICEPS (Bi) ([Fig. 3 ])
Surface of the biceps muscle (long and short portions).
CHEST (Ch) ([Fig. 3 ])
Surface of the pectoralis major muscle.
GLUTEUS (Gl) ([Figs. 2 ]
[4 ])
Surface of the gluteus maximus muscle (upper 3/4).
THIGHS (Th) ([Fig. 3 ])
Surface of the vastus lateralis and vastus medialis muscles.
LEGS (Le) ([Figs. 3 ]
[4 ])
Surface of the lateral and medial bellies of the gastrocnemius muscle.
2. LIPOSUCTION DEPTH LEVELS ([Fig. 5 ]):
- LEVEL I;
- LEVEL II; AND
- LEVEL III.
Fig. 5 Liposuction depth levels. Level I. (A ) Abdominal flap removed at abdominoplasty, with the liposuction cannula at level
I, below the superficial fascia and above the muscular fascia. (B ) Liposuction cannula under the superficial fascia and above the muscular fascia (Level
I) in the abdominal region.
LEVEL I ([Fig. 5 ]): Liposuction of fat from the deepest plane of the subcutaneous cellular tissue
(SCCT) below the superficial fascia and above the muscular fascia.
LEVEL II ([Fig. 6 ]): Liposuction of fat from the SCCT above the superficial fascia and below the dermis.
Fig. 6 Liposuction depth levels. Level II. (A ) Abdominal flap removed at abdominoplasty, with liposuction cannula at level II,
above the superficial fascia and below the dermis. (B ) Liposuction cannula below the dermis and above the superficial fascia (level II)
in the abdominal region.
LEVEL III ([Fig. 7 ]): Liposuction of fat from the SCCT above the superficial fascia and below the dermis.
Its difference from level II is its proximity to the dermis (juxtadermal) and positioning
of the cannula holes facing downwards. Level III aims to promote the formation of
depressions and grooves to highlight planned anatomical elements (definition liposuction).
Fig. 7 Liposuction depth levels. Level III. (A ) Abdominal flap removed at abdominoplasty, with liposuction cannula at level III,
just below the dermis, with the cannula holes facing downwards. (B ) Juxtadermal liposuction cannula (level III) in the abdominal region.
3. ACCESS PORTALS (INCISIONS) ([Figs. 8 ]
[9 ]
[10 ]
[11 ]):
Fig. 8 Female model, frontal view. Access portals and cannula extension (in yellow) for
preferred liposuction in prone decubitus: E (elbow), U (umbilicus), P (pubis), K (knees),
and L (legs).
Fig. 9 Female model, back view. Access portals and cannula extension (yellow) for preferred
liposuction in prone decubitus: E (elbow), T (thoracic back), S (sacral), G (gluteal
fold), and L (legs).
Fig. 10 Male model, frontal view. Access portals and cannula extension (yellow) for preferred
liposuction in side decubitus: E (elbow), M (mammary groove), U (umbilicus), I (iliac
crest), P (pubis), K (knees), and L (legs).
Fig. 11 Male model, back view. Access portals and cannula extension (yellow) for preferred
liposuction in side decubitus: E (elbow), I (iliac crest), and L (legs).
These portals were designed for the two most commonly used decubitus positions in
liposuction surgeries:
3A. VENTRAL DECUBITUS (VP) ([Figs. 8 ]
[9 ])
E (elbow)
P (pubis)
K (knees)
L (legs)
T (thoracic back)
S (sacrum)
G (gluteal groove)
U (umbilicus)
3B. SIDE DECUBITUS (SD) ([Figs. 10 ]
[11 ])
E (elbow)
M (mammary groove)
I (iliac crest)
P (pubis)
K (knees)
L (legs)
U (umbilicus)
4. INFILTRATED AND ASPIRATED VOLUME CONTROL
Infiltrated volume control
Infiltration of the prepared solution with a 50-mL graduated syringe to control each
milliliter of infiltrated volume in each previously defined region. The infiltrated
volume is recorded in a specific Excel spreadsheet, the LipoCodes spreadsheet, which
has a model for female ([Fig. 12 ]) and another for male patients ([Fig. 13 ]). The two spreadsheets have an automatic sum feature to control the regional and
total infiltrated volumes.
Fig. 12 Spreadsheet for female patients. The first page has columns for each predefined aspiration
and grafting region. The first line in each column, in gray, records the infiltrated
volume in each region. Other lines (in white) record the aspirated and grafted volumes
obtained with the intermediate device. The yellow line below each column is the total
liposuction or grafting volume for each predefined region. Below and to the right,
the total infiltrated, liposuctioned, and grafted volumes are calculated automatically.
Below and to the left, the surgical times are recorded, including the start and end
times of infiltration, aspiration, and definition liposuction. On the second page,
developed to facilitate patient understanding, two female models, in front and back
views, highlight the predefined aspiration and grafting regions and, next to them,
the total volumes of each region at the corresponding levels. The total volumes (infiltration,
aspiration, and grafting) are also at the bottom of this page.
Fig. 13 Spreadsheet for male patients. The first page has columns for each predefined aspiration
and grafting region. The first line in each column, in gray, records the infiltrated
volume in each region. Other lines (in white) record the aspirated and grafted volumes
obtained with the intermediate device. The yellow line below each column is the total
liposuction or grafting volume for each predefined region. Below and to the right,
the total infiltrated, liposuctioned, and grafted volumes are calculated automatically.
Below and to the left, the surgical times are recorded, including the start and end
times of infiltration, aspiration, and definition liposuction. On the second page,
developed to facilitate patient understanding, two female models, in front and back
views, highlight the predefined aspiration and grafting regions and, next to them,
the total volumes of each region at the corresponding levels. The total volumes (infiltration,
aspiration, and grafting) are also at the bottom of this page.
Each column of the spreadsheet corresponds to the previously described regions. The
columns for the most commonly treated regions in liposuction are defined, and the
blank columns are for less common regions. The infiltration volume from sequential
50-mL syringes is recorded in the first line of each column, highlighted in gray.
Aspirated volume control
This control uses an intermediate system ([Figs. 14 ]
[15 ]) developed by the author to count aspirated volumes positioned between the liposuction
hoses, called the LipoCodes system.
Fig. 14 System for accurate counting of aspirated volumes, with three parts: (A ) catheter tip obtained from a urine collector, with its opening and closing valve;
50mL syringe with catheter tip, graduated in milliliters, without the plunger (discarded);
stainless-steel part with two outlets to connect liposuction hoses: one for liposuction
and the other for exhaust. (B ) Connected parts ready for use. (C ) System in use, with fat in the syringe, before disposal.
Fig. 15 (A ) Top view of the stainless-steel part with two outlets for connecting liposuction
hoses. (B ) Bottom view of the part. C. Catheter tip obtained from a urine collector and its
opening and closing valve.
The LipoCodes system consists of a 50-mL syringe with a catheter tip, graduated in
milliliters, without the plunger (which is removed) ([Fig. 14 ]).
The upper part of the 50-mL syringe, at the plunger inlet, has a stainless-steel piece
developed by the author with 2 outlets for liposuction hose connection: one hose for
liposuction and the other for exhaust ([Fig. 15 ]).
In the lower part of the 50-mL syringe, the catheter tip is connected to an outlet
connector from a urine collector, and its opening and closing valve controls the volume
aspirated in the 50-mL syringe ([Fig. 15 ]).
In this system, the liposuction fat enters the upper part and fills the 50-mL syringe.
When the syringe is full ([Fig. 14 ]), the volume in milliliters is recorded on the spreadsheet ([Figs. 12 ]
[13 ]) in the column corresponding to each region, and the total aspirated volume is automatically
recorded. Next, the valve at the bottom is opened to empty the syringe and then closed.
This sequence is repeated until the liposuction outcome and volume for each region
are achieved.
Grafted volume control
Fat grafting aspiration uses negative pressure and a 50-mL graduated syringe for exact
control, per milliliter, of the grafted volumes in each previously defined region.
The grafted volumes by region are recorded in the space provided for fat grafting
in the LipoCodes spreadsheet ([Figs. 12 ]
[13 ]), allowing their visualization at any time during surgery or later.
Surgical time control
The LipoCodes spreadsheet records the start and end times for infiltration, liposuction,
and its definition ([Figs. 10 ]
[11 ]).
The spreadsheet automatically calculates the liposuction speed in mL/min and mL/h
([Figs. 12 ]
[13 ]).
Discussion
New techniques, technologies, and scientific publications on liposuction continue
to evolve significantly, increasingly seeking better and more predictable outcomes[1 ]
[2 ]
[3 ]
[4 ]
[5 ]
[6 ]
[7 ]
[8 ]
[9 ]
[10 ]
[11 ]
[12 ]
[13 ]
[14 ] with maximum potential safety.[15 ]
[16 ]
[17 ]
[18 ]
[19 ]
[20 ]
The Lipocodes methodology allows precise control of infiltrated and aspirated volumes
per milliliter with specific and well-defined anatomical regions, coinciding with
the usual locations of fat deposits, well known by plastic surgeons, with higher anatomical
definitions for better understanding and education purposes.
The methodology defines three levels of suction depth, which, combined with the above-mentioned
anatomical regions, provide a three-dimensional view of liposuction.
This objective information on the volume in milliliters from each region increases
the expectation of the aesthetic outcome to control symmetry and treat any potential
asymmetries, in addition to controlling the grafted fat volume when indicated. Currently,
the endpoint in most liposuctions has been based on coarser volume information (deciliter
or centiliter) and the subjective observation and personal experience of each plastic
surgeon. In this methodology, the volume information is inserted into the Lipocodes
spreadsheet, which is monitored by the surgeon and the medical team during the procedure,
to achieve greater precision in liposuction by using objective parameters that help
the surgeon forecast the volumes for infiltration and aspiration in each region, guiding
the correction of any asymmetries. It also contributes to better team monitoring,
making liposuction more educational, controlled, and objective for younger and more
experienced surgeons.
In addition, objective information about infiltrated and aspirated volumes is significant
for safety by aiding intra and postoperative fluid replacement.
The author developed the LipoCodes intermediate system ([Figs. 14 ]
[15 ]) for counting aspirated volumes with a 50-mL syringe without a plunger and a stainless-steel
part positioned between the liposuction hoses in an artisanal manner to control each
milliliter. Current commercial systems count in 50-mL increments, which prevents more
rigorous volume control. The author is negotiating to develop the intermediate system
with specialized companies for large-scale production and commercialization.
Another significant piece of information provided by LipoCodes is the surgical speed
in mL/min and mL/h. This information provides the plastic surgeon and the team with
knowledge on the pace of the surgery, the liposuctioned fat removal time, and the
procedural duration. The importance of surgical time to minimize complications is
well cited in the literature.[11 ]
[14 ]
[17 ]
[18 ]
[20 ]
[25 ] Since there is growing concern regarding surgical time, the Lipocodes methodology
encourages a better intraoperative flow and improves the understanding of the entire
team through standardization, reducing anesthesia time, surgical time, materials,
and stress.
The defined portals or incisions lie at the two most commonly used decubitus positions
for posterior region liposuction. These are suggestions to minimize the number of
portals, and the surgeon can modify them according to personal preference.
Regarding liposuction depth, level I is below the superficial fascia, allowing increased
volumetric reduction and lower contour remodeling; this is why we begin liposuction
in this deeper plane. Level II is above the superficial fascia for better contour
remodeling, requiring more care to avoid irregularities. Level III is closer to the
dermis, and it requires leaving the cannula holes facing downwards to avoid greater
trauma to the deep dermis, which could cause exaggerated retractions, dyschromia,
pain, and other complications. This liposuction for definition purposes was originally
described by Mentz[26 ] and improved by Hoyos,[27 ] being widely used by several plastic surgeons and challenged by others.
By controlling the well-defined regions, the infiltrated and aspirated volumes, and
the aspiration depth levels, the three-dimensional liposuction has a more precise
control for better outcomes, asymmetry correction, and fewer touch-ups and refinements.
The LipoCodes methodology systematizes liposuction regardless of the equipment and
technique preferred by each plastic surgeon. The goal is to make liposuction more
controlled, objective, didactic, and educational, with higher predictability.
The LipoCodes methodology can use any liposuction equipment: syringe, aspirator, vibration
system, ultrasound, and laser. The plastic surgeon does not need to change their preferred
technique or equipment for infiltration and liposuction, only add the intermediate
system and the LipoCodes spreadsheet to transfer the information obtained during the
liposuction surgery with or without grafting.
Our review found six articles using volume and region control measurements. Araújo[28 ] measured the skin fold with an adipometer before and six months after the procedure,
showing the outcomes with no numbers, only photos. Cohen et al.[10 ] compared three-dimensional magnetic resonance images and total fat aspirated for
the entire abdomen, before and six months after surgery. Marongiu et al.[21 ] cited a method to control and accelerate infiltration. Bukret and Alonso[22 ] developed geometric models for liposuction marking to improve efficacy and safety
in laser liposuction. Harutyunyan et al.[23 ] used ultrasound to calculate the fat volume for liposuction and developed specific
software. Lastly, Gu et al.[24 ] developed a method for circumferential liposuction in several locations in the arm,
quantifying clinical efficacy. We did not find references presenting a clear control
of infiltrated and aspirated volumes, defining regions and aspiration planes, describing
access portals, or controlling surgical speed.
In summary, the main objectives of the LipoCodes methodology are to:
Obtain objective parameters of liposuction volumes by areas, depth, and volumes to
be aspirated.
Develop an intraoperative flow (sequence).
Improve the understanding of the entire team through standardization.
Reduce losses (anesthesia, materials, surgical time, stress).
Increase the surgical procedure flow.
Reduce surgical time.
Improve predictability.
Obtain more consistent outcomes.
Improve asymmetry treatment.
Minimize the potential for refinements or adjustments.
Assist in the artistic thinking of the plastic surgeon.
Use with any liposuction equipment preferred by each plastic surgeon.
