COSMETIC

Separation, Aspiration, and Fat Equalization:

SAFE Liposuction Concepts for Comprehensive
Body Contouring
Simeon H. Wall, Jr., M.D. Background: Separation, aspiration, and fatty equilibration (SAFE) liposuction
Michael R. Lee, M.D. uses a process approach to body contouring and minimizes injury to surround-
Shreveport, La. ing structures. The multistep process allows for (1) fat separation, (2) lipoaspi-
ration, and (3) fat equalization. The purpose of this study was to review both
outcomes and complications of primary SAFE liposuction.
Methods: Retrospective chart review was completed of patients undergoing
SAFE liposuction from January of 2006 to January of 2011. Patient selection
was limited to those undergoing liposuction alone with no adjuvant excisional
procedures. Data were collected regarding demographics, body mass index,
operative details, and outcomes.
Results: Seven hundred thirty-four patients were identified as having under-
gone SAFE liposuction. One hundred twenty-nine patients were found to have
been treated with liposuction alone. Patient age ranged from 18 to 42 years
and body mass index ranged from 18 to 42 kg/m2 (mean, 26.3 kg/m2). Seven
patients (5.4 percent) underwent treatment of the face and neck, six patients
(4.7 percent) underwent treatment of upper extremities, 13 patients (10.1 per-
cent) underwent treatment of the chest, 20 patients (15.5 percent) underwent
treatment of lower extremities, 32 patients (24.8 percent) underwent treat-
ment of the circumferential trunk, and 51 patients (39.5 percent) underwent
treatment of circumferential trunk and additional area(s). No major complica-
tions occurred. Five of the 129 patients (3.87 percent) developed the minor
complication of seroma formation.
Conclusions: SAFE liposuction is a multistep process approach to body contour-
ing consisting of (1) fat separation, (2) lipoaspiration, and (3) fat equalization.
The results of this study show such technique to be safe and effective. (Plast.
Reconstr. Surg. 138: 1192, 2016.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

L
iposuction has classically been defined as have been proposed to minimize complications
surgical aspiration of fat in an effort to from liposuction.
improve body contour. From the time Illouz There exists a delicate balance between the
introduced and described blunt aspiration of amount of fat removed and the potential for com-
subcutaneous fat from the body,1 attempts have plications. A dose-response curve exists with regard
been made to improve safety, minimize complica- to liposuction volume and complications. As the
tions, and improve aesthetic results.2–4 The past amount of fat removed in an area (dose) increases,
three plus decades have witnessed different tech- the potential for skin irregularities and contour defor-
niques and technologies aimed at achieving such mities (response) also increases. Prevailing thought
improvements. Many of these have focused on is that surface irregularities and contour deformities
increasing the volume of fat removed, theoreti- are the result of uneven fat removal, with subsequent
cally delivering a more substantial result. Others adhesion formation between skin and the underlying

From The Wall Center for Plastic Surgery. Disclosure: The authors have no financial interest
Received for publication May 11, 2015; accepted July 28, to declare in relation to the content of this article. Dr.
2016. Wall receives royalties from Tulip Medical Products
Copyright © 2016 by the American Society of Plastic Surgeons and QMP video series.
DOI: 10.1097/PRS.0000000000002808

1192 www.PRSJournal.com
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 138, Number 6 • SAFE Liposuction

fascia. Essential to advancement of liposuction is the the process provides a basis for comprehensive
ability to reliably remove the desired fat volume while body contouring.
circumventing such deformities. Use of a process approach has been success-
Various technologies have been introduced over ful in improving outcomes and lowering compli-
the past three decades to facilitate fat removal and cation rates in other aesthetic operations such as
avoid the above-described dose-response curve in breast augmentation and augmentation masto-
liposuction. Many of these have used thermal injury. pexy.8–10 Application of this process approach in
The thermal energy introduced with techniques body contouring expands the realm of what can
such as ultrasound-assisted, laser-assisted, and radio- be accomplished with liposuction while adhering
frequency-assisted liposuction creates injury to fat to important surgical principles.
cells, therefore facilitating aspiration.5,6 The thermal
injury imparted to the tissues varies with the type, Principles of SAFE Liposuction
power, and level of energy used, with the commonal-
ity of inadvertent creation of a second dose-response • Optimize fat removal
curve with respect to contour deformity. This sec- • Provide comprehensive means of body
ond mechanism of creating contour deformities contouring
is dependent on the thermal load imparted to the • Preserve vascular integrity
tissues, with the creation of additional fibrosis, scar, • Maximize skin retraction
and their resultant sequelae. Furthermore, intrinsi- • Minimize potential for complications/
cally problematic to techniques that use nonspecific revisions
thermal injury is the acquired collateral damage to
stromal tissue and adjacent vasculature. Use of ther- The purpose of this study was to review out-
mal devices designed to eliminate complications comes in patients undergoing primary SAFE lipo-
from liposuction actually compound the problem. suction alone. Although the very principles of this
Advances in body contouring should focus technique make it useful when combined with
on preservation of anatomical structures rather excisional procedures and fat grafting, the pur-
than incrementally imposing larger sums of tissue pose of this study was to delineate outcomes in
injury and destruction. Methods that accomplish those treated solely with SAFE liposuction.
the goals of facilitating fat removal and body con-
touring and maximizing tissue preservation are SAFE Liposuction Technique
more likely to evade contour deformities. Opti- Several important technical considerations
mizing smooth, even fat removal while preventing should be mentioned. Basket-tip or other
the formation of adhesions or scar between the exploded-tip cannulas should never be used when
dermis and fascia is understandably of paramount suctioning (Fig. 1). Angled cannulas are used to
importance. Furthermore, creating a uniform (1) allow for the highest density of treatment area
interposed fat layer creates a barrier to adhesion and (2) provide the easiest manipulation from the
formation and should be a point of emphasis. point of entry.
SAFE Liposuction
SAFE liposuction7 is a nonthermal, multi-
step process of comprehensive fat management
that adheres to the aforementioned principles
of minimizing tissue injury and fulfilling aes-
thetic ideals. Steps of the process allow fat to be
separated from the adjacent stomal tissue and
vasculature by a mechanically generated pres-
sure gradient. Aspiration of this separated fat
can then be performed with minimal trauma to
surrounding structures. The process also allows
for smoothing of any irregular areas that persist,
thus providing a continuous layer of fat distribu-
tion to evade contour deformity. The treatment
area remains highly vascular, creating an opti-
mal environment for fat graft take. Collectively, Fig. 1. Photograph of exploded-tip (basket-tip) cannulas.

1193
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • December 2016

Wetting solution is typically used in a 1:1 or Aspiration

1.5:1 ratio of infiltration to aspiration in primary The next step of SAFE liposuction is to use less
cases. Introduction of the wetting solution is per- aggressive cannulas to aspirate this low-resistance,
formed with an exploded tip cannula that allows for separated fat. Again, size depends on the region
simultaneous fat separation. This technique, coined of treatment but, on average, ranges from 1 to
simultaneous separation and tumescence, was first 4 mm. As the perforators are spared during fat
described by Wall and Del Vecchio.11 The simulta- separation, and the low-resistance separated fat is
neous infiltration and separation of fat allows for preferentially aspirated, there is minimal vascular
quick vasoconstriction of the treated area and an disruption, resulting in little to no blood present
initial amount of fat separation, reducing opera- in the aspirated fat. There is also a more complete
tive time considerably. Once the desired infiltration or thorough aspiration of targeted fat, given that
is accomplished, fat separation continues and the there is minimal vascular disruption. Aspiration
multistep process of SAFE liposuction is completed. composes approximately 40 percent of the opera-
tive time per treatment area.
Separation
The initial step uses an exploded-tip cannula Fat Equalization
that separates or mechanically emulsifies the fat. Succeeding fat aspiration is the final step of the
With motion of the cannula, a relative pressure process, fat equalization. Fat equalization is per-
gradient is created between the baffles, or wings, formed without suction. The exploded-tip cannula
of the cannula head, much like the pressure gradi- is used to smooth out irregular areas during this
ent created across an airplane wing. The low-pres- step. The equalization of the treated areas is accom-
sure zones adjacent to the wings of the cannula plished by further emulsification of the remaining
allow the targeted fat globules to “escape” or sepa- fat bed, evening out the inevitable thicker and
rate from their attachments, creating mechani- thinner areas that exist. This fat equalization step
cally emulsified, or “separated” fat. This pressure creates more separated fat in the treated area,
gradient not only creates separation of the fat effectively resulting in a smooth bed of “local” fat
globules but does so without creating a suction grafts that prevent adhesion of the dermis down
avulsion injury to the surrounding vascular struc- to the deep fascia. This component of the SAFE
tures, thereby minimizing bleeding during this liposuction process typically composes 20 percent
process. Because this process is nonthermal, there of overall operative time but may be less or more
is no risk of a burn to either the skin or the under- depending on the efficiency of the preceding two
lying subcutaneous structures. steps and the specific goals of the surgeon.
Depending on the area being treated, cannula Repositioning, or shifting, of fat can also be
diameter ranges from 1 to 5 mm. Fat separation performed when appropriate. The cannula, in
composes approximately 40 percent of total opera- conjunction with external manual pressure, can
tive time per treatment area, thus emphasizing the be used to facilitate transposition of viable fat cells
importance of this initial step. During this step, to areas in need of augmentation or fill. Aggres-
both superficial and deep fat is separated through sive molding and equalization of the remaining
continuous passing of the cannula while no suc- fat provides a comprehensive means of improving
tioning is performed. A methodical approach is body contour. The surgical endpoint to this final
step is a smooth rolling pinch test of the treatment
used to ensure comprehensive treatment of the
area and smooth transition from the treatment
area. Areas being treated are treated widely and
area to adjacent areas. At the conclusion of this
often circumferentially to gain maximal skin
step, there should be a continuous blanket of fat
retraction. The surgical endpoint of fat separation
that spans the entire region treated, thus prevent-
is loss of resistance in all areas to be treated.
ing direct dermal adherence to underlying fascia.
Separation of the fat allows release from teth-
ering structures such as blood vessels and fibrous
septae. As there is no suction in this step, mini- PATIENTS AND METHODS
mal injury occurs to the dermis, vascular network, Retrospective chart review was completed of
nerves, and fascia while the fat is being separated. patients undergoing SAFE liposuction from Janu-
Fat separation does not equate to undermining. ary of 2006 to January of 2011. Patient selection
Undermining assumes truncation of perforating was limited to those undergoing primary liposuc-
vessels, whereas fat separation allows for vessel tion alone with no adjuvant excisional procedures
preservation and skin vascularity. or any other concomitant procedures.

1194
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 138, Number 6 • SAFE Liposuction

Data collected included age, sex, body mass There were no cases of contour deformity or inad-
index, and treatment sites. Furthermore, volumes equately treated areas identified. Five of the 129
of infiltration solution and lipoaspirate were patients (3.87 percent) developed the minor com-
recorded. Complications were classified as minor plication of seroma formation, all of which resolved
or major. Minor complications were those treated completely with one or more aspirations. Three sero-
with resolution in the clinic setting. Major com- mas were located in the trunk and two were located at
plications were considered any untoward result the knee. All seroma formations occurred in patients
requiring reoperation. that had undergone circumferential trunk treatment.
Results summarized in Table 1. Case examples are dis-
RESULTS played in Figures 2 through 6.
Seven hundred thirty-four patients were iden-
tified as having undergone SAFE liposuction. Of Face and Neck
these, 605 were excluded, as they underwent exci- A total of 10 patients underwent treatment of
sional procedures with liposuction or had addi- the face and neck with SAFE liposuction. All patients
tional concomitant procedures. One-hundred were treated with two small stab incisions, each
twenty-nine patients were found have been treated placed at the lateral border of the submental crease.
with primary SAFE liposuction alone and were All three steps of the process were applied with use
included for study. Patient age ranged from 18 to of 2.1-mm exploded-tip cannulas for separation
42 years (mean, 36 years), with a male-to-female and equalization, and 1.7-mm single-hole cannu-
ratio of 1:2.7. Body mass index ranged from 18 to las for aspiration. A wide treatment area was used
42 kg/m2 (mean, 26.3 kg/m2). to maximize skin retraction. Treatment boundaries
For those being treated in a single area, seven in all cases included the posterior sternocleidomas-
patients (5.4 percent) underwent treatment of the toid muscle followed distally to the sternal notch.
face and neck, six patients (4.7 percent) underwent Cephalically, treatment extended over the mandibu-
treatment of upper extremities (arms and axilla), lar border and into the bilateral jowl.
13 patients (10.1 percent) underwent treatment of
chest, and 20 patients (15.5 percent) underwent treat- Chest
ment of lower extremities (thighs, knees, and calves). A total of 24 patients underwent treatment of
Thirty-two patients (24.8 percent) underwent treat- the chest. All patients were male, with the majority
ment of the circumferential trunk and 51 patients being treated for gynecomastia. All patients were
(39.5 percent) underwent treatment of circumferen- treated through two small stab incisions, one at
tial trunk and additional area(s). The additional areas the inferior aspect of the areola and the other just
included face and neck (n = 3), upper extremities (n posterior to the anterior axillary line. None of the
= 9), chest (n = 11), and lower extremities (n = 51). included patients underwent joint excision of tis-
Wetting solution infiltration and volume of lipoaspi- sue. Again, wide treatment areas were addressed in
rate varied depending on treatment. No major all cases. Bordering regions included the posterior
complications occurred in any of the 129 patients. axillary line laterally, the lateral sternum medially,

Table 1. Summary of SAFE Liposuction Patient Operative Data

Site No. Infiltration Average Lipoaspirate Average Complications
Face/neck 10 None
 Average, ml 246 133
 Range, ml 140–320 50–175
Chest 24 None
 Average, liters 1.86 1.18
 Range, liters 0.8–3 0.35–2.5
Arms 15 None
 Average, liters 2.53 2.19
 Range, liters 1.6–4 0.95–4.35
Trunk 83 Seroma (3)
 Average, liters 4.51 3.64
 Range, liters 1–7 0.7–7.8
Legs 71 Seroma (2)
 Average, liters 4.19 3.44
 Range, liters 1.35–8 1–6.8

1195
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • December 2016

Fig. 2. Case example of the ideal female patient for SAFE liposuction treatment of the circumferential trunk and
medial thigh. Total lipoaspirate volume was 3.5 liters.

the clavicle cephalically, and the upper abdominal was of particular importance, as these patients were
wall distally. Use of the broad-based basket cannula not undergoing excision of skin laxity. A single stab
allows for optimal disruption and smoothing of the incision in the posterior-cephalic arm and two at
inframammary fold. The result is a more masculine the distal arm were sufficient to address the entire
transition from the chest to the abdomen. Fat equal- upper arm. Although the circumferential arm, axilla,
ization also allows for more global distribution of shoulder, and upper back were treated with separa-
centralized fat to create a more masculine shape. tion and equalization, only areas of fat excess were
Upper Extremity aspirated. This is a crucial component when treating
A total of 15 patients underwent treatment of the the upper arm, as suctioning in regions with minimal
upper extremity with SAFE liposuction. Circumfer- fat can lead to adhesion formation that is difficult to
ential treatment of the entire arm was found essen- correct even with fat equalization and redistribution.
tial to maximize retraction of the overlying skin. This Fundamental to avoiding contour deformities is the

1196
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 138, Number 6 • SAFE Liposuction

Fig. 3. Case example of large-volume liposuction using SAFE liposuction technique. A total of 5.3 liters was removed from the
circumferential trunk and thigh.

presence of fat separating the dermis and fascia. All Lower Extremity
patients exhibited improved definition of the upper Seventy total patients underwent treatment
extremity with a uniform decrease in fat volume of of the lower extremity with SAFE liposuction. All
treated areas. patients underwent circumferential liposuction
of the thigh, knee, and/or calf through a total of
Trunk four stab incisions on each lower extremity. Redis-
Eighty-three patients received treatment tribution of adipose tissue allowed for improved
of the circumferential trunk. All patients were contour and achievement of aesthetic ideals in
noted to have considerable volume of fat aspira- all patients. The zones of adherence11 are transi-
tion with SAFE liposuction. Approach varied per tioned through with fat separation and equaliza-
patient but, on average, six total stab incisions tion, but no aspiration is performed in these areas.
were used to address the circumferential trunk,
all within the bikini/underwear line. Position- DISCUSSION
ing during surgery included supine and lateral Popularization of liposuction by Illouz1 was
decubiti. Circumferential treatment was noted to based on four principles: (1) a fixed amount of
provide good skin retraction and improved body adult adipocytes, (2) hereditary patterns of fat
contour. distribution, (3) refractory localized collection of

1197
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • December 2016

Fig. 4. Case example of SAFE liposuction of the circumferential trunk and chest in a male patient.
Total lipoaspirate volume was 4.2 liters.

fat deposits, and (4) factors influencing fat distri- The process of SAFE liposuction allows for safe
bution such as genetics and morphologic types. removal of a large volume of fat as validated by
These principles provide the fundamental basis this study. Power-assisted liposuction has been
for operative removal of adipose tissue and serve shown to decrease operative times and the effort
as a premise for advancement. Evolution of body associated with liposuction, and the authors find
contouring should focus on the following princi- its use especially helpful in most liposuction cases.
ples: (1) optimizing fat removal and body contour Although power-assisted liposuction also provides
outcomes, (2) preserving remaining tissue and for more efficient fat separation and equalization
vascular integrity, (3) maximizing skin retraction in SAFE liposuction, it is not an essential compo-
in treatment area, and (4) minimizing complica- nent of SAFE liposuction. Sufficient fat separa-
tions and revision surgery (Table 2). tion and equalization can be generated by manual
motion of an exploded-tip cannula.
Optimizing Fat Removal
Evolution of liposuction techniques and tech- Comprehensive Body Contouring
nologies has largely centered on increasing the Although optimizing fat removal is an essen-
volume of lipoaspirate removed. Although the tial component of body contouring, it simply pro-
amount of fat to be removed should always be vides the foundation for improving body shape
individualized, technique that allows for even and contour. Sculpting the remaining fat to
and maximal reduction is of obvious benefit. create a more aesthetic shape is considered the

1198
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 138, Number 6 • SAFE Liposuction

Fig. 5. Case example where SAFE liposuction was used to improve size and shape of
the hips, thighs, knees, and calves. Total lipoaspirate volume was 3.6 liters.

focus of advanced technique. Such a principle Preservation of Vascular Integrity

has been influential in the recent popularization Original descriptions of closed fat removal
of fat grafting and repositioning in all realms of involved use of scissors to create subcutaneous
body contouring.12–14 SAFE liposuction is congru- tunnels while removing fat with curettes and suc-
ent with improving aesthetic shape, as the process tion. These methods were plagued with unpre-
allows for equalization and repositioning of the dictability related to collateral damage suffered by
viable fat that remains following aspiration. Fur- local blood vessels and adjacent anatomical struc-
thermore, the remaining fat interface that exists tures. The most significant modification made by
enjoys maximal vascularity, making it ideal to Illouz was the innovative introduction of a blunt
receive grafted fat. cannula.1 Use of a blunt tip cannula preserved

1199
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • December 2016

Fig. 6. Case example focusing on use of SAFE liposuction to improve truncal contour and
abdominal definition. Total lipoaspirate volume was 2.9 liters.

Table 2. Principles of Basic Liposuction and would improve the predictability of operative exe-
Advanced Liposuction cution. Although details of fat grafting are beyond
the scope of this article, the use of expansion vibra-
Principles of basic liposuction
 Fixed amount of adipocytes tion lipofilling deserves mention.11 Expansion
 Lipodystrophy is hereditary vibration lipofilling is performed with a power-
 Localized lipodystrophy is stable assisted exploded-tip cannula whereby fat is placed
 Lipodystrophy is influenced by multiple factors
Principles of advanced liposuction for the purpose of augmentation. Conceptually,
 Optimal fat removal and body contouring expansion vibration lipofilling allows for internal
 Preservation of tissue and vascular integrity expansion of the area targeted for grafting. Once
 Maximal skin retraction in treatment area
 Avoidance of complications and revisions expanded, the fat is introduced into the treatment
areas. Maximizing tissue vascularity also increases
the safety of concomitant excisional procedures.
blood and lymphatic vessels and provided aspira-
tion of fat. Maximizing Skin Retraction in the Treatment
SAFE liposuction follows and improves on this Area
paradigm of tissue preservation. Fat separation Use of liposuction for treatment of superficial fat
void of active suction detaches both superficial has long been a matter of controversy. Superficial fat
and deep fat from the adjacent tissue structures, in areas such as the trunk and thigh consists of small
maximizing their preservation. Use of suction lobules, tightly compartmentalized by thin, verti-
during this first step could jeopardize the integrity cally oriented fibrous septa. Deep fat is composed of
of perforators given that the targeted fat and the loosely arranged, larger lobules within more irregu-
blood vessels have similar resistance to the applied larly oriented septa. Although both superficial and
negative pressure (suction). It is for this reason deep fat may be mechanically removed by means of
that avulsive suction methods are avoided in SAFE aspiration, suction of deep fat alone fails to achieve
liposuction. Once the fat has been separated away the level of skin retraction and desired thickness
from the adjacent native tissue, it is simply and associated with superficial treatment.15–17
preferentially aspirated, given the now wide differ- Concerns surrounding superficial liposuc-
ential in resistance between the separated, liquid- tion are related directly to the aforementioned
state fat and the more solid blood vessels. adhesions and subsequent contour deformity.
Furthermore, the preservation of a robust local Superficial liposuction brings the cannula
blood supply facilitates fat grafting whether shifted opening in closer proximity to the underlying
or injected. Intuitively, increasing fat graft survival dermis. Consequently, the threshold for dermal

1200
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 138, Number 6 • SAFE Liposuction

injury is lowered, increasing the likelihood PATIENT CONSENT

of significant adhesion formation. Gasperoni Patients provided written consent for the use of their
et al.15,16 have long heralded the aesthetic results images.
granted by superficial liposuction. Enhanced
results were credited to removal of superfi-
cial adipose bulk and greater retraction of the REFERENCES
overlying skin. Gasperoni et al. suggested that 1. Illouz YG. Body contouring by lipolysis: A 5-year experience
removal of the subdermal fat layer allowed for with over 3000 cases. Plast Reconstr Surg. 1983;72:591–597.
cicatricial retraction of the cutaneous layer. Pro- 2. Rohrich RJ, Leedy JE, Swamy R, et al. Fluid resuscitation in
liposuction: A retrospective review of 89 consecutive patients.
ponents of superficial liposuction have stressed Plast Reconstr Surg. 2006;117:431–435.
the avoidance of an open cannula facing the 3. Pitman GH. Liposuction: Refinement in technique for
overlying dermis. The cannula is pointed away improved cosmetic results and increased safety. Aesthet Surg J.
from the dermis in an effort to minimize injury 1998;18:455–457.
and associated harms. 4. Wells JH, Hurvitz KA. An evidence-based approach to lipo-
suction. Plast Reconstr Surg. 2011;127:949–954.
SAFE liposuction allows separation of both
5. Scuderi N, Paolini G, Grippaudo FR, Tenna S. Comparative
superficial and deep from the adjacent dermis evaluation of traditional, ultrasonic, and pneumatic
and fibrous septae. This is accomplished with no assisted lipoplasty: Analysis of local and systemic effects,
suction, thus providing a gentler means of releas- efficacy, and costs of these methods. Aesthetic Plast Surg.
ing the fat to be removed. Finally, fat equalization 2000;24:395–400.
creates a partition between the dermis and deep 6. Cárdenas-Camarena L, Andino-Ulloa R, Mora RC, Fajardo-
Barajas D. Laboratory and histopathologic comparative study of
fascia, averting contour deformity. internal ultrasound-assisted lipoplasty and tumescent lipoplasty.
Plast Reconstr Surg. 2002;110:1158–1164; discussion 1165.
Minimizing Complications and Revision Surgery 7. Wall SH Jr. SAFE circumferential liposuction with abdomino-
Perhaps the most relevant discussion in pres- plasty. Clin Plast Surg. 2010;37:485–501.
ent-day body contouring is avoidance of untoward 8. Tebbetts JB, Adams WP. Five critical decisions in breast augmen-
tation using five measurements in 5 minutes: The high five deci-
and irreversible results. Use of a process approach sion support process. Plast Reconstr Surg. 2005;116:2005–2016.
has been shown to lower complication and revi- 9. Adams WP Jr. The process of breast augmentation: Four
sion rates in other plastic surgery operations.8–10 sequential steps for optimizing outcomes for patients. Plast
Such an approach is derived from a comprehen- Reconstr Surg. 2008;122:1892–1900.
sive understanding of tissue characteristics and 10. Lee MR, Unger JB, Adams WP. The tissue-based triad: A
process approach to augmentation mastopexy. Plast Reconstr
is instituted to improve surgical outcomes. SAFE Surg. 2014;134:215–225.
liposuction is a multistep process based on pres- 11. Wall SH Jr, Del Vecchio D. Liposuction and correction of
ent understanding of tissue characteristics and deformities. Paper presented at: Dallas Cosmetic Surgery
behavior. The findings of this study support the Symposium; March 5, 2014; Dallas, Texas.
use of this process approach for body contouring. 12. Eto H, Kato H, Suga H, et al. The fate of adipocytes after non-
vascularized fat grafting: Evidence of early death and replace-
ment of adipocytes. Plast Reconstr Surg. 2012;129:1081–1092.
CONCLUSIONS 13. Yoshimura K, Eto H, Kato H, Doi K, Aoi N. In vivo manipula-
tion of stem cells for adipose tissue repair/reconstruction.
SAFE liposuction uses a multistep process Regen Med. 2011;6(Suppl):33–41.
approach that fulfills the principles of advanced 14. Saylan Z. Liposhifting instead of lipofilling: Treatment of
body contouring. The results of this study reveal the postlipoplasty irregularities. Aesthet Surg J. 2001;21:137–141.
process to be a reliable means of delivering improved 15. Gasperoni C, Salgarello M, Emiliozzi P, Gargani G. Subdermal
aesthetic results and limiting complications. liposuction. Aesthetic Plast Surg. 1990;14:137–142.
16. Gasperoni C, Salgarello M. MALL liposuction: The natural
Simeon H. Wall, Jr., M.D. evolution of subdermal superficial liposuction. Aesthetic Plast
The Wall Center for Plastic Surgery Surg. 1994;18:253–257.
8600 Fern Avenue 17. Mentz HA III, Gilliland MD, Patronella CK. Abdominal etch-
Shreveport, La. 71105 ing: Differential liposuction to detail abdominal muscula-
swalljr@wallcenter.com ture. Aesthetic Plast Surg. 1993;17:287–290.

1201
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.