**4. Operative technique**

Following preoperative photographs and markings, the patient is brought to the operating room and placed in the supine position. Sequential compression devices are placed and activated prior to induction of general anesthesia. A warming blanket is used throughout the procedure to maintain optimal body temperature. For moderate to large volume liposuction, 1 gram of tranexamic acid (TXA) is administered intravenously at the start of the procedure.

The areas to be liposuction are infiltrated with tumescent solution prior to formal prepping and draping. The liposuction entry sites are cleansed with Betadine prior to incision and the cannula is frequently wiped with Betadine. In moderate to large volume liposuction, lower concentrations of lidocaine are used and 1 gram of TXA is added to each 1 liter bag of tumescent solution. The tumescent formula typically utilized is 12.5 mL 1% lidocaine, 1 mL 1:1000 epinephrine, and 1 gram TXA in 1,000 mL of warm Lactated Ringer's solution. The total amount of tumescent solution used depends on the planned amount of aspirate. The ideal ratio of infiltration fluid to aspirate volume is 1:1 for moderate and large-volume liposuction. A higher ratio of tumescent solution is typically utilized for small volume liposuction.

Small Volume Liposuction: <2,000 mL. Moderate Volume Liposuction: 2,000 mL to 5,000 mL. Large Volume Liposuction: >5,000 mL.

#### *Enhanced Abdominal Contouring DOI: http://dx.doi.org/10.5772/intechopen.99398*

The patient is then fully prepped and draped. Skin protector ports are then placed at the access sites. Ultrasound-assisted liposuction (UAL) with VASER™ (Solta Medical, Hayward, CA, USA) is then performed to all areas of planned liposuction unless concomitant abdominoplasty is being performed. For these patients, VASER is only utilized posteriorly on the trunk. For the abdomen and posterior trunk, the VASER is set to 80% power. End hits of the cannula are avoided to prevent thermal injury to the dermis. Treatment is performed in both the deep and superficial fat layers until resistance is lost. Special attention is paid to zones of adherence to break up the dense fibrous attachments in these areas.

The typical treatment time is 5–10 minutes for the anterior trunk and 5–15 minutes for the posterior trunk.

The SAFE technique (Separation, Aspiration, Fat Equalization) described by Simeon Wall, Jr. [2, 3] is utilized for all trunk liposuction cases, but is avoided when performing liposuction to the anterior portion of the abdominoplasty flap.

Power-assisted liposuction (PAL) using MicroAire (Charlottesville, VA, USA) handpiece with 4 mm Mercedes tip and Basket tip cannulas is performed until even contour is achieved. The majority of the liposuction is focused on the deeper fat layers, leaving a thin, even blanket of fat in the superficial layer to prevent contour irregularities.

Fat equalization with a 4 mm basket tip cannula on the PAL handpiece is then performed. This equalization should be performed outside the areas of liposuction to blend and feather the liposuctioned area into the non-liposuctioned area.
