Special Topic Liposuction of the Legs and Ankles: A Review of the Literature

Lipodystrophy of the legs and ankles presents a particularly challenging problem in aesthetic surgery. This is true both historically and presently. Anatomic peculiarities and technical challenges delayed the development of treatment for this condition. Today, attempts to overcome these same obstacles continue to rapidly change the face of liposuction in this anatomical area. Lipodystrophy of the legs and ankles is distressing to patients for several reasons. This condition, which is mostly limited to female patients and usually appears during the emotionally vulnerable time of adolescence,1,2 tends to make patients look heavier than they are. The problem is seen in all ethnic groups.3 The appearance of the leg may be so ill defined as to cause the patient severe psychological pain and loss of self-esteem. Legs and ankles are frequently not camouflaged by clothing and are therefore among the more conspicuous areas of lipodystrophy.3–5 These factors combine to make this an emotionally frustrating cosmetic deformity. Frustration is exacerbated by the fact that lipodystrophy in this area appears to be largely genetically predetermined and is especially resistant to exercise and diet.1,2,6 Despite a need for therapy, liposuction of the legs and ankles was slow to develop. The earliest attempt at treatment of these areas in the literature dates to the 1920s, when Dujarrier in France attempted to remove fat by curettage in the lower legs of a well-known ballerina. He transected a major artery, and this eventually resulted in amputation.7 Thus began the long-lived stigma surrounding lipectomy of the leg. In 1964, another surgeon, Schrudde of Cologne, attempted to remove such fat in his patients by curettage. Despite several good results, he reported skin necrosis in four of 15 patients in his series.4,1 In 1977, Fischer and Fischer presented the new lipectomy technique of suction curettage.8 This technique was attempted in the trochanteric areas but was abandoned because it left lymphorrhea, large cavities filled with lymph and serum, and terrible secondary sagging deformities over the affected areas.9 After disappointing experiences with closed curettage and closed suction curettage in the early 1970s, the modern era of lipectomy began in 1977 with Illouz in Europe.7,9,10 The first U.S. experience was in 1981, when American physicians of various specialties observed the new technique of suction lipectomy in France.2 Liposuction is now one of the most common cosmetic procedures,2 but the growth of this modality in the specific areas of the legs and ankles lagged behind. By the late 1980s, the legs and ankles were being treated more frequently, but large numbers of successful cases were not reported until 1989 and 1990.4 The ignition of the lipectomy wildfire by Illouz’s development of blunt liposuction techniques in 1978 resurrected the stigmata associated with circumferential lipectomy of the legs and ankles.7 The procedure had been portrayed as “fraught with complications and of limited benefit.”2 Others have said that lipoplasty of these areas frequently combines high expectations with, at best, modest results.4,11 Thus, early on, it became clear that liposuction