Back and flank liposuction: telling fat apart from skin folds

How does excess fat on the back and flanks differ by area?

The back and flanks may look like one continuous area, but the shape of the concern differs from place to place. A 2023 study stated that contour deformities of the back appear differently by area, such as back rolls, a fat deposit above the hip bone (iliac crest deposit), and a fat pad on the upper back just below the neck (buffalo hump), but that little literature has addressed their anatomical basis ^[1]. The flanks are the area that runs from the side of the waist to above the pelvis, and they are sometimes planned together with the abdomen or the back.

The same study dissected 12 fresh cadavers to examine the layers from the skin down to the deep fascia ^[1]. The fibrous membrane structure under the skin (superficial fascial system) acted as a bridge connecting all layers of the subcutaneous tissue; it was dense over the shoulder blade and in the triangular area of the lower back (lumbar triangle) and loose in the area below the shoulder blade ^[1]. The authors considered these regional differences to be consistent with the back contour deformities seen in Asian female patients, and they stated that dividing the back into zones based on anatomy is the foundation for improving the precision of liposuction and avoiding contour deformities ^[1].

However, this is a cadaver dissection study, not a clinical study comparing liposuction results in actual patients.

When liposuction is discussed, and when it falls short

If the skin has kept its elasticity and the thickness comes mainly from fat under the skin, liposuction is discussed. On the other hand, a 2014 article pointed out that changes in the upper back caused by aging or weight loss have received relatively little attention in the plastic surgery literature ^[2]. The upper back has areas where the skin is firmly attached to deeper tissue, which creates folds where the skin and the tissue beneath it overlap and sag, causing both functional and cosmetic discomfort ^[2].

Because of these attachment areas, the article stated that the upper back is difficult to refine with procedures such as abdominoplasty or a lower body lift, and the author presented the bra-line back lift, which removes excess skin and fat together along the bra line, as a reliable method ^[2]. This addresses cases in which sagging skin is the problem, and the research summaries used for this article contain no data on how much such folds are reduced by liposuction alone. If your skin overlaps and sags a lot, it is good to go into your consultation knowing that excisional surgery may be discussed as well.

High-definition liposuction and male patients

Traditionally, liposuction was performed in the deep fat layer, but in 1983 a method targeting the superficial fat layer was also introduced ^[3]. High-definition liposuction is described as an advanced method that aims to bring out the anatomical contours of an area while encouraging the skin to contract ^[3]. A 2022 review stated that liposuction has evolved from simply removing fat to sculpting tissue to reveal the outline of the muscles, and that its patient base has broadened, particularly among men ^[5].

A 2018 review stated that liposuction is the cosmetic surgery most commonly performed on men ^[6]. It stressed that men differ from women in fat distribution, goals, and emotional perspective, and that these must be taken into account to achieve satisfying results ^[6].

Complications and combined procedures

A 2023 systematic review of high-definition liposuction pooled 21 papers with 6964 patients, whose average age was 38 years and average body mass index was 25 kg/m² ^[3]. The overall complication rate was 14.4% and the major complication rate was 0.2%, and the most common complications were temporary skin darkening (hyperpigmentation, 3.8%), seroma (3.3%), and temporary hardening of the soft tissue (fibrosis, 2.7%) ^[3]. Satisfaction was reported at 92.6%, but reporting methods were not standardized, and the research summaries do not present separate results for the back and flanks alone ^[3].

A 2020 review stated that combining other procedures with abdominoplasty has become the rule rather than the exception, and that liposuction is the procedure most often added, followed by breast surgery, the lower back lift, and the thigh lift ^[7]. However, it stated that because the risk increases as surgery time grows longer, the scope of combined procedures is decided with the patient's health in mind ^[7].

A 2021 meta-analysis compared abdominoplasty alone with abdominoplasty combined with partial or circumferential liposuction, and necrosis-related complications occurred in 0.39% of the combined group and 1.01% of the abdominoplasty-only group ^[4]. Patients who also had liposuction did not have a higher risk of skin necrosis or repeat surgery, and overall rates were low, with partial loss of the skin flap at 0.24% and skin necrosis at 0.23% ^[4]. These results assume that abdominoplasty was performed, so they should be considered separately from back and flank liposuction alone.

Recovery and what to check during your consultation

After back and flank liposuction as well, swelling, bruising, and changes in sensation can occur, and the contours may be left uneven. The back is an area that is hard to see for yourself, so it helps to go over photos taken before surgery and the findings of your examination together to confirm which areas will be reduced and by how much. Results vary from person to person depending on skin elasticity, fat distribution, and weight changes, so it is best to make a plan with a specialist who has examined you in person.

• Whether the thickness is fat or folds of skin
• Which area is involved: the upper back, the bra line, the side of the waist, or above the hip bone
• Whether to have liposuction alone or combine it with excision or other procedures
• If procedures are combined, the added surgery time and risks
• Possible complications and the recovery period