Liposuction of the Kneecap Area by Miguel Chamosa, M.D.
With the popularity of shorter skirts and shorts in women's fashion and in keeping with an athletic lifestyle in general, knees and lower thighs are more frequently exposed, and liposuction of these areas has become a commonly performed procedure. While complications are rare and the patient satisfaction rate is quite high, or perhaps for these very reasons, little has been published on this topic to date. Dr. Chamosa delineates in clear terms all the basic principles to keep in mind for this procedure. Obviously, as is the case with any surgical procedure, patient evaluation based on cogent and generally applicable criteria is always the prudent approach.
I recommended some time ago the conceptual division of the knee region into six areas for the purposes of liposuction.1 Using a virtually identical division, Dr. Chamosa describes his experience with 108 patients, all of whom had liposuction of the medial knee, 52 percent also having had liposuction of the area the author designates as area 6. This coincides with my experience in terms of the frequency of inclusion of these areas. Similarly, I also have found it necessary to treat the lateral and infrapatellar areas in approximately one-fourth of the patients undergoing liposuction of the knee region.
I note with interest, however, that Dr. Chamosa suctions the suprapatellar area quite commonly (in about half his patients), an area I very seldom subject to suction. In fact, I recommend a great deal of caution in approaching this area. To accommodate flexion of the knee joint, this region is endowed with significant “surplus” of skin, even in young individuals. Ultimately, the surgeon's decision should not be driven by patient demand, which may focus attention on this area. Indeed, even patients who never had liposuction (albeit, they tend to be in the older age group) often inquire about the possibility of skin excision from the suprapatellar area. My concern, however, beyond the obvious considerations, also stems from the experience of a number of patients presenting with postsuction deformities in this region. Upon close scrutiny of the 20-year-old patient's photographs shown by Dr. Chamosa, a left medial knee suprapatellar skin fold is apparent preoperatively. This same fold looks deeper on the postoperative photograph.
The author appropriately points out the importance of a thorough knowledge of anatomy in performing a liposuction. In this regard, it is worth noting that a number of anatomic studies2-5 confirmed Gardner and Gray's original description6 of a deep (lamellar) and a superficial (areolar) subcutaneous adipose layer being present in most body regions. A fascial layer that is more discrete in some anatomic areas, such as the neck (platysma) and the lower abdomen (Scarpa's fascia), distinctly separates these two layers. In other body regions, however, this fascia is less well defined, as noted by Avelar,2,3 resembling a honeycomb structure that extends throughout the span of the subcutaneous fat. The term superficial fascia system was proposed to describe this anatomic structure.7 Whether well or poorly defined, this structure is most likely a rudimentary counter-part of the panniculus carnosus widely present in other mammals.8 I am not aware of any detailed description of this fascia anywhere in the literature, and the Nomina Anatomica does not clearly define it either.9 An elegant cadaver dissection and computed tomographic study carried out by Markman and Barton4 showed that distal to the midthigh two discrete (deep and superficial) subcutaneous adipose layers could not be distinguished. Consequently, in the region of the knee, where a fascial layer is not present to help guide the tip of the cannula in the proper plane during liposuction, the surgeon's margin of error is reduced, and the cannula can easily penetrate into a superficial level, too close to the undersurface of the dermis, resulting in postoperative surface irregularities. Therefore, I have been recommending careful pretunneling as a maneuver to help obviate such a mishap. Localized excessive removal of fat, if recognized intraoperatively, usually can be treated successfully with reinjection of autologous fat.
Further, the author lists several reasons why penetration of the knee joint with the cannula is anatomically “impossible.” Indeed, I am not aware of any reports of such occurrence, although smaller-diameter cannulas are currently in common use. On the other hand, the prepatellar and infrapatellar bursae are, in my opinion, at more immediate risk, which is why the surgeon should be thoroughly familiar with their anatomic location.
The author makes a few other generally helpful suggestions for liposuction of the knee area, such as the recommendation to use large enough access incisions to minimize friction burns. In this respect, I would add that I also have found coating the tip of the cannula with antibiotic ointment and/or the use of plastic guards to be beneficial.
In conclusion, although this article adds nothing substantively new to previously described concepts for liposuction of the knees, it serves to refocus our attention in a systematic and organized fashion to this commonly performed procedure.
Peter Bela Fodor, M.D.
Suite 814; 9201 Sunset Blvd.; Los Angeles, Calif. 90069
1. Fodor, P. B. Lipoplasty of the knees and anterior thighs. Clin. Plast. Surg.
16: 361, 1989.
2. Avelar, J. M. Study of the Anatomy of the Subcutaneous Adipose Tissue Applied for Fat-Suction Technique. In R. J. Maneksha (Ed.). Transactions of the IXth International Congress of Plastic and Reconstructive Surgery
, New Delhi, India, March 1-6, 1987. Pp. 377-379.
3. Avelar, J. Regional distribution and behavior of the subcutaneous tissue concerning selection and indication for liposuction. Aesthetic Plast. Surg.
13: 155, 1989.
4. Markman, B., and Barton, F. E., Jr. Anatomy of the subcutaneous tissue of the trunk and lower extremity. Plast. Reconstr. Surg.
80: 248, 1987.
5. Batuira, A. T., Callia, W., Villano, J. B., et al. Compartamento do Tegumento Dermo-Adiposo pos Lipoaspiracao. XXI Congr. Brasil Cir. Plastic.,
6. Goss, C. M. (Ed.). Gray's Anatomy
. 30th Ed. Philadelphia: Lea & Febiger, 1985.
7. Lockwood, T. E. Superficial fascial system (SFS) of the trunk and extremities: A new concept. Plast. Reconstr. Surg.
87: 1009, 1991.
8. Fodor, P. B. From the panniculus carnosus (PC) to the superficial fascia system (Editorial). Aesthetic Plast. Surg.
17: 179, 1993.
9. Johnson, D., Cormack, G. C., Abrahams, P. H., and Dixon, A. K. Computed tomographic observations on subcutaneous fat: Implications for liposuction. Plast. Reconstr. Surg.
97: 387, 1996.