WANT THE CONFIDENCE THAT COMES WITH KNOWING YOU LOOK YOUR BEST? GET YOUR FREE CONSULTATION Liposuction CASE STUDIES SEE MORE PHOTOS SEE MORE PHOTOS SEE MORE PHOTOS SEE MORE PHOTOS SEE MORE PHOTOS SEE MORE PHOTOS SEE MORE PHOTOS SEE MORE PHOTOS SEE MORE PHOTOS SEE MORE PHOTOS SEE MORE PHOTOS SEE MORE PHOTOS SEE MORE PHOTOS SEE MORE PHOTOS SEE MORE PHOTOS SEE MORE PHOTOS SEE MORE PHOTOS SEE MORE PHOTOS SEE MORE PHOTOS SEE MORE PHOTOS Liposuction Liposuction is the surgical name assigned to the process of removing fat by using a suction system of hollow cannulas. The science of liposuction has dramatically evolved since it was pioneered over a century ago. Liposuction was made significantly safer after the introduction of a tumescent solution. Tumescent solution is a fluid that is injected into the layers of fat prior to suctioning and it contains: Lidocaine which is a numbing solution and thus provides pain control Epinephrine which is a vasoconstrictor that constricts the small blood vessels and thus decreases blood loss Bicarbonate solution which keeps the pH levels biological in order to preserve fat viability so that it can be used for fat grafting ARM CONTOURING ABDOMINAL ETCHING BACK CONTOURING BRAZILIAN BUTTOCKS WAISTLINE NARROWING LIPO REVISION Liposuction Just as important has been the addition of ultrasound assistance to the suctioning process which has allowed for superior liposculpture results. Today, expert liposuction surgeons are able to achieve near-perfect 9 or 10 contouring results, coined high definition liposuction. High definition liposuction allows surgeons to be sculptors and to convey their artistic insight to creating jaw-dropping results. Liposuction is no longer just a "debulking" procedure, but with the advent of high definition, liposuction surgeons are expected to create masterpieces, where patients' contour improvements are transformative. High definition liposuction has been shortened to eponym HD Liposuction by many in the liposculpture arena. In order to achieve HD liposuction results, expertise in ultrasound-assisted liposuction systems is required. Ultrasound-assisted liposuction was created by Solta Medical corporation through its proprietary Vaser Lipo technology. Vaser Lipo is the brand name of the technology that utilizes small gauged solid rods to deliver ultrasound energy to fat clusters in the body in order to release single-cell fat cells. Vaser lipo gently releases these fat cells, termed emulsification or melting of fat cells, into a liquid form. Once the fat clusters have been converted from a solid to a liquid state, the fat cells are then gently removed using Vaser liposuction. What makes Vaser liposuction so much more effective than traditional liposuction techniques requires some understanding of the anatomy of the fat layers underlying the skin. Fat cells are universally found in two layers: Superficial or near the surface Deep The deep fat is contained in a loose unobstructed layer that makes uniform removal of solid fat feasible when utilizing traditional piercing hollow cannulas. However, the superficial fat is contained in an obstructed layer is traversed by a web of fibrous chords, termed retaining ligaments. These ligaments act like a supportive structural network that provides stability to the skin. These ligaments prevent traditional liposuction cannulas from uniformly removing the superficial fat layer. As a result, traditional liposuction outcomes were limited to being a debulking surgery only. Enter Vaser liposuction. This type of lipo allows expert surgeons to melt both the superficial and deep layers of fat first. The liquefied fat can be now be collected using traditional suction cannulas. These cannulas can still only be positioned in the deep layer; however, as the deep layer fat is depleted, the liquefied superficial fat drain down into the deep layer and are then similarly. The benefits of Vaser Liposuction to body contouring are several and include: Comprehensive removal of both the deep and superficial fat resulting in transformative results Smooth contour void of divots or skin irregularity since the residual liquefied fat will evenly settle Less physical trauma to nerves and vessels Improved viability of fat cells that can then be transferred back to the body to reshape. For example the buttock, face or breasts In summary, Vaser liposuction allows for superior liposculpture outcomes that have raised the bar for liposculpture results. Today, liposuction has advanced from just a debulking surgery to a sculpting surgery in which patients' body contours are transformed. High definition liposuction has been coined to describe: Creation of beautiful curves, such as the "~" Tilde curve describing the waistline to buttocks curvature The appearance of muscle anatomy as the fat is comprehensively removed to make muscle shapes transparent Body highlights that are generated by selective removal of fat to create shading effects much like in a painting Circumferential sculpting that treats the entire body like a statue (3D) vs. one dimensional Surgeons or sculptors? HD liposuction has completely transformed the body liposuction community by challenging surgeons to operate like sculptors who can convey their artistic talents. Dr. Mowlavi is one of the top Vaser liposuction surgeons and is internationally renowned for his high definition liposuction results. Dr. Mowlavi has also served as an official Vaser trainer for surgeons throughout the world. Dr. Mowlavi has founded high definition liposuction centers throughout Southern California intended to provide comprehensive HD liposuction care to clients considering high-end liposuction. Success in liposuction requires: A thorough patient evaluation Strategically sound surgical design Implementation of surgical goals intraoperatively, and finally regiment Postoperative care to ensure superior liposuction outcomes Patient selection and evaluation are critical to achieving successful HD liposuction results. Patients must be healthy and possess excellent nutrition and maintain normal blood counts. If patient nutrition is not optimal, a protein intake of 150 grams per day is recommended preoperatively to maximize healing potential. If blood counts are suboptimal, patients are placed on iron supplements to optimize blood counts. Liposuction surgery at the level of high definition liposculpture requires meticulous planning and preoperative marking. Patients' surgical outcomes require not only planning for comprehensive removal of fat excess but also for managing any excess skin. When excess skin is observed a combination of minimally invasive skin tightening using Renuvion technology as well as removing excess skin such as a mini tuck. Finally, postoperative recovery has been optimized to ensure superior outcomes. First, customized compression garments with foam inlays are used to minimize postoperative swelling. In addition, regimented lymphatic messages are provided high-end body contoured patients to maintain all of the etched highlights and transformations. Specifically, patients are followed every day to every other day over the first 7 to 10 days. If you are considering high-end liposuction, then we encourage you to make a skype or FaceTime consultation or come meet with Dr. Mowlavi and our staff at Cosmetic Plastic Surgery Institute. If you do visit us in person, you will tour our state of the art operative theater and see the Vaser liposuction towers used to achieve high definition liposuction results. You will also have the opportunity to see HD liposuction patients in real life since we have a continuous line of patients who are completing their lymphatic messages. Finally, you will have the opportunity to meet all of our staff that will help you through your HD liposuction journey. Frequently Asked Questions: What is the history of liposuction? Liposuction was founded by Dr. Dujarrier in the 1800s in Europe. Unfortunately his fist attempt was devastating as his attempt at trying to thin out a ballerina’s legs resulted in him severing a major leg vessel leading to the amputation of her leg. It is of utmost importance for clients to recognize that liposuction is a surgical procedure requiring complete knowledge of human anatomy and thus should only be performed by a qualified surgeon. Is liposuction surgery safe? Advances in liposuction techniques over the last 5 to 10 years have allowed surgeons to provide liposuction procedure in a safe manner. One of the milestones was the development of tumescent fluid, which is infiltrated into the fat prior to initiating the actual suctioning. Injection of tumescent fluid has allowed surgeons to minimize blood loss significantly. In addition, research of the breakdown byproducts of the local anesthetic solution placed in the tumescent solution has allowed surgeons to better gauge the maximum volume of liposuction that can be safely removed in an outpatient setting. In general 5 L is the maximum volume of fat that should be removed in an outpatient setting without close overnight observation. Other important factors include: performance of liposuction by a trained plastic surgeon; the presence of an anesthesiologist who can manage shifts in body volume, and a facility that is accredited for surgery. How does fat accumulate? In your childhood, the fat volume increases by increased fat cell multiplication which results in more numbers of fat cells. Following adolescents, fat volumes increase by an increase in the size of the fat cells there. An exception to the rule is a client who is overly obese, termed morbid obesity, in which the fat cells begin to multiply as they did in childhood. When a client undergoes liposuction, the fat cells are literally stripped out leaving fewer fat cells in the body. However, if the client does not watch their diet and does not alter their lifestyle, they may regain their weight and undesired contour by virtue of the fat cells that are remaining growing in size. Are there any predilections for fat accumulation in males versus females? Observations have been made with respect to the difference in fat accumulation in males versus females. Males tend to accumulate fat around the belly and back and have been termed androids. Females tend to accumulate fat around the hips and thighs and have been termed gynoids. Are there different layers of fat and is this important for liposuction surgery? The fat underlying the skin is actually divided into two separate layers: the superficial deep layer. The superficial layer is more dense and has more septa (fibrous cables which span the fat and give it more rigidity). In contrast, the deep layer contains loose fat with less septal support. Areas that have more pronounced deep layer fat include around the belly button, in the buttocks, and in the medial thigh area. Universally, liposuction is performed in the deep layer only. By maintaining a uniform and undisturbed superficial layer, clients are ensured an aesthetic result without any contour abnormalities. What is cellulite and how can it be prevented? Cellulite refers to the pitting of the skin that is observed in the skin especially in the thigh area of women who have undergone weight gain and/or subsequent loss. Clients who have dense vertical septa (fibrous cables which extend from the skin to the deeper muscle) are more likely to show cellulite. When fat increases in volume, it pushes against the skin which may be tethered by these tight fibrous bands. Subsequently, if the client undergoes weight loss, the skin can loosen around these attachments can result in cellulite. The appearance of cellulite can be avoided by breaking up areas of fibrous attachment using a special cannula or by finger fracture technique by your surgeon. In addition, there are specific sites, referred to as zones of adherence, that are known to have a high density of these fibers in which liposuction should be avoided. Recent interest in lasers and heating elements have lead to supposed treatments of cellulite, such as endermologie, but none of these modalities is successful long-term. Is it true that fat cells can travel to another area following liposuction? No, fat cells can not travel to other sites. What has occurred that the client has not followed their postoperative lifestyle recommendation and started gaining weight. Since the areas liposuctioned have fewer fat cells, when the patient begins to gain weight, they are likely to gain it in other non-liposuctioned areas which have a full number of fat cells. What is ultrasonic liposuction? Ultrasonic liposuction uses hollow cannulas similar to standard liposuction surgery but also has an ultrasound probe at its tip which allows for heating and “cavitation” of the fat cells. “Cavitation” refers to melting of fat cells which presumably allows for easier evacuation of fat than the traditional mechanical suctioning using the hollow cannulas. Ultrasonic liposuction was developed to make the physical act of liposuctioning easier for the surgeon and to improve results for liposuction in more fibrous areas such as for the breasts and lower back. Overall, ultrasonic liposuctioning has not been universally accepted by the plastic surgeon community and has been noted to be associated with increased complications such as skin burns especially at the port sites. What is tumescent solution? In the evolution of liposuction, one of the obstacles was blood loss. When liposuction was performed without any infusion of fluids into the tissues, the liposuctioned fluid was noted to be 45 % blood in volume. Today, a solution, termed tumescent solution, has been developed which contains lidocaine and epinephrine, molecules that decrease the pain and constrict the blood vessels, respectively. When this solution is infiltrated prior to suctioning, the estimated blood loss is 1 % of the total suctioned volume. The only disadvantage to using tumescent fluid is monitoring body fluid shifts and avoidance of fluid overload. Subsequently, performance of liposuction surgery should only be undertaken in an accredited facility with professional staff, including an anesthesiologist, who will monitor total fluids entering and leaving the client during the case. Am I a good candidate for liposuction surgery? Over 50 % of the United States residents are overweight. As you become overweight you will first accumulate excess fat and then your skin will stretch to accommodate the increased weight of the fat pockets. You are considered a good candidate if you have gained localized fat deposits but your skin has not stretched out to the point of losing its elasticity. Clients younger than 50 years of age typically have preserved the elasticity of their skin and will observe tightening of their skin following liposuction as long as there is no looseness in the skin. What does liposuction surgery involve? On the day of surgery you will meet with the surgical staff and surgeon and you will be marked in a standing position. You will then be taken to the operating room where anesthesia will be provided and the surgeon will be meticulous about infiltrating predetermined tumescent solution volumes in and liposuctioning appropriate volumes out. The endpoint of liposuction is determined by the surgeon who gauges the aesthetic contour of the area liposuction visually and by feel. Several liposuction cannulas may be used in order to maximize amount of removed fat. The edges of the areas liposuctioned are feathered to allow for smooth contour lines. Finger fracture technique is used to break up any septal attachments(attachments from the skin to the muscle/bone) which will result in skin tethering appearance if not released. Finally, compression garments/girdles will be placed over the areas liposuctioned so that you can ensure a smooth and aesthetically pleasing contour. How do I plan for liposuction surgery? All clients should undergo a complete history and physical examination by a qualified surgeon. Clients should be considered healthy which requires having no medical illnesses or if having one or two medical problems that they be well controlled. In general, plan to be evaluated by your surgeon at least 2 weeks prior to surgery so that the surgeon has ample time to determined your health status and to check your blood work to ensure that you are a healthy and safe client for this procedure. How do I prepare for liposuction surgery? Since your surgery will require either twilight, epidural, or general anesthesia, you must take several precautions prior to surgery. First, you will have to avoid eating and drinking after midnight on the day before surgery. This precaution ensures that your stomach is clear of digested foods that could potentially be aspirated and contaminate your lungs during induction of general anesthesia. Since, you will have anesthetic medications administered throughout the case, you will remain groggy for some time and will require a ride to and from the surgery center if you elect not to commit to an overnight stay on the premises. You should choose a caretaker who is conscientious and who can spend the first night with you. What results can I expect after tummy tuck surgery? Following liposuction surgery, patients can expect an improved contour lines. Regions that are safely liposuctioned include: upper arm, arm pit, abdomen, flanks, back, lateral thighs, medial thighs, knees, jowls, and neck. As your swelling resolves and when you stop wearing your girdle, you will find yourself buying a whole new wardrobe to fit your trim figure Where will my tummy tuck surgery be performed? Since your surgery will require either twilight, epidural, or general anesthesia, it must be performed in an operating room that is part of a hospital institution or outpatient surgery center. Less frequently, patients may be operated on in an in-house office based operating room, but it is of utmost importance for patients to make sure that the office facility has been accredited by a surgical accreditation body such as AAAASF. What type of anesthesia will be used for my liposuction surgery? Several anesthesia options are available for clients interested in liposuction surgery. These include: Twilight sedation which involves a cocktail taken by mouth (an example would be a cocktail of: Valium, Vicodin, and Dramamine) and by IV fluids as needed for single and small areas such as the for the knees or arm pits. Epidural anesthesia which is delivered much in the same way for clients during childbirth. This anesthesia is excellent for liposuction of the legs such as the medial thighs and lateral thighs. General anesthesia is provided to clients seeking liposuction of multiple regions and/or large volumes of liposuction. What should I expect after liposuction surgery? Compressive postoperative garments/girdles are placed on clients over the areas treated at the end of surgery. These are worn to minimize postoperative swelling and to ensure a smooth and aesthetically pleasing contour. You may find the garments constricting but it is urged to wear the garments at all times for the first few weeks and up to 4 weeks if tolerable. You will feel soreness for the first 2 to 4 weeks following surgery but this discomfort is tolerable and after the 3rd or 4th day will not affect your daily activities. Expect to return to the office on day 7 to 10 to remove all port hole incision stitches. Expect to have bruising which will evolve over 2 to 4 weeks. When will I be able to return to work following liposuction surgery? Following a routine liposuction case involving treatment of 2 to 3 areas, patients can expect to return to work following 1 week if their occupation is sedentary or following 2 weeks if their occupation is more physical. Clients are encouraged to let the degree of soreness dictate how much they can do; the soreness will subside gradually over 2 to 4 weeks. Are there any side effects I can expect following liposuction surgery? Minor contour irregularities are not uncommon and have several causes. Patients who poses skin looseness or already demonstrate cellulite have a higher likelihood of developing contour irregularities. Release of septal attachments (tissue cables that stretch from the skin to the muscle) and feathering of the liposuctioned areas to allow for a smooth transition to non-liposuctioned areas are two means of avoiding contour irregularities. Finally, localized constricting clothes(such as a belt) may ruin an otherwise perfect liposuction surgery in the early postoperative period. Clients are recommended to wear their liposuction garments as a girdle for the first 4 weeks and to avoid any locally constricting clothes. When detected in the early postoperative period, manual message may correct minor contour irregularities. Finally, revision liposuction and fat grafting may be used to improve contour aesthetics. Prolonged swelling is infrequent in liposuction clients and may result from inadvertent disruption of a lymphatic vessel during surgery. Lymphatic vessels are responsible for drainage of all the extra fluid in the body. In general, liposuction surgery can not injure lymphatic vessels to the degree needed to get prolonged swelling. Patients should be encouraged to remain active which will stimulate the lymphatic vessels to work overtime. In addition, any client with prolonged swelling should consider getting their blood protein levels measured since they may not be absorbing extra fluid back into their blood stream due to low blood osmolarity. Prolonged swelling will eventually subside. Incisional scarring at liposuction port sites is a concern. In general, scarring at port sites can be eliminated by judicious attention to technique so that the cannulas are not being torqued against the skin edges. In addition, ultrasonic liposuction (which uses a heating element) is most often the cause of skin edge injury by thermal contact. When skin edges of the port sites have been traumatized, it is best to trim the skin edges prior to skin closure. Sensory changes are caused by trauma of the sensory nerves during the liposuction surgery. Universally, all sensation will return over 1 to 3 month period. This recovery period allows for traumatized nerves to heal themselves or for ingrowth of neighbor nerves in the event that a particular nerve was severed. Blistering of skin: Blistering of skin can occur from garment or tape irritation in the postoperative period. Clients should be aware of any localized skin irritation in the early postoperative period which when detected can allow for adjustment of garment/tape so that blistering is avoided. Blistering of the skin is merely a superficial injury to the skin and should heal without any difficulties with conservative care. Are there any risks associated with liposuction surgery? Significant blood loss is a concern when tumescent solution is not utilized during liposuction. Since tumescent fluid has been adopted universally by cosmetic surgeons, the risk of blood loss is negligible. Fluid shifts remain a problem especially when large volume liposuction is used. Large fluid shifts can have a detrimental effect on the heart even leading to heart failure and death. As a result patients who undergo large volume liposuction (greater than 5 L) are requested to spend their first postoperative night at the surgical facility or board and care facility under the direct care of a nursing professional. It is also critical to have all liposuction patients undergo a cardiac and health evaluation prior to surgery. When patients undergo liposuction surgery at a professional setting by a professional staff complications related to fluid shifts can be avoided. Major contour abnormalities may arise when an unqualified physician performs the liposuction surgery. Major contour abnormalities may arise if gross miscalculations are made in the volumes liposuctioned in a particular region usually due to overaggressive liposuction. Another cause of major contour abnormalities involves liposuction of “zones of adherence”. Zones of adherence are areas that have very strict attachments to the underlying muscle and bone, which when disrupted will lead to gross distortion of the overlying skin contour. An educated decision to pursue liposuction surgery by a qualified surgeon is going to avoid such complications. Deep vein thrombosis (DVT) may occur in the legs immediately following surgery. DVT refers to the clotting off of leg veins which may result in compromised blood flow return from the legs; a more critical consequence may develop from this clot if it is dislodged and travels to the lungs causing a pulmonary emboli. Although rare, pulmonary emboli are the leading cause of death following liposuction surgery. Although pulmonary emboli usually arise from blood clots, due to the nature of liposuction surgery, pulmonary emboli can also arise from fat particles, called fat emboli. DVT’s are avoided with routine use tumescent solution which constricts the blood vessels and avoids entry of fat particles into the vessels, wearing of pneumatic compression boots during surgery, and encouraging patients to walk as soon as possible following surgery. Patient-Specific Questions: How does the SMART Lipo compare to traditional suction assisted liposuction:? SMART liposuction results in inferior aesthetic results when compared to suction assisted liposuction. SMART liposuction utilizes minimally invasive technique utilizing laser technology combined with fat dissolving injections in an attempt to remove excess fat. Unfortunately, current technology of SMART liposuction does not allow for accurate and controlled removal of fat. As a result, patients often present to plastic surgeons complaining of contour abnormalities demonstrating areas of under and over correction, pitting, and cellulite appearance. In contrast, traditional suction assisted liposuction provides controlled removal of fat resulting in smooth contour lines. What happens to the fat during liposuction? Liposuction utilizes small caliber cannulas to remove excess fat from areas of disproportionately localized fat depots. When patients undergo liposuction, they will be reducing the number of fat cells that were present in the area being liposuctioned. This results in over all improvement of aesthetic contour as there will be fewer fat cells in the area of concern. In fact, if patients gain weight following liposuction, they will not gain the weight in the area liposuctioned when compared to areas not liposuctioned. In contrast, if they continue to lose weight, they will lose less fat from areas liposuctioned when compared to areas not liposuctioned. This is because as a patient continues to burn fat, the fat will be decreased proportionally from areas with increased fat cells when compared to areas with less fat cell density (areas that have been liposuctioned). Following liposuction does the fat go somewhere else? Patients may complain of areas of fat build up in areas previously unnoticed following weight gain after liposuction. This is because following liposuction, if patients gain weight, the fat cells are proportionetly increased in size. Since the areas of liposuction now have fewer fat cells, these areas will gain less prominence when compared to areas that have not been liposuctioned. Do wearing compression garments improve cosmetic results following liposuction? Wearing of compression garments is critical to attaining a smooth and even result following liposuction. Following liposuction a thin layer of fat cells are retained to provide a smooth and natural contour to areas of liposuctioned. These retained fat cells are free floating and not yet settled into their final resting position. Wearing of compression garments assures even distribution of these fat cells until they become fixed in their final resting position. Compression garments are ideally worn for 2 weeks following surgery. Is liposuction safe? Much research has been recently performed regarding the safety of liposuction surgery. The concern with liposuction surrounds two issues and these include volume shifts and Lidocaine toxicity. First, there is the potential to have large volume shifts in the body by virtue of the fact that a solution, referred to as tumescent solution, must be infused into your body prior to performing the liposuction. This fluid is intended to numb the areas being liposuctioned (by use of Lidocaine) and to constrict blood vessels in the area so there is minimal bleeding (by use of epinephrine). In order to avoid large volume shifts which can effect the hemodynamics of your system and your cardiac function, liposuction volumes must equal the tumescent solution infusion volumes. With meticulous monitoring of infusion and aspiration volumes, volume shift complications can be avoided. Finally, infusion volume of 3 L has been set by the American Society of Plastic Surgeons as the safe limit for outpatient liposuction cases. Second, Lidocaine toxicity and specifically its breakdown products (metabolites) have been identified as a second area of concern. Although lidocaine is broken down within a few hours, its byproducts which also can alter your cardiac function, peak in your blood at 12 hours following surgery. Unfortunately, 12 hours following surgery, patients are likely to be at home and sleeping. As such, infusion volume of less than 3 L has been determined to be a safe volume avoiding unsafe build up of Lidocaine biproducts within the blood stream. To ensure safety, patients are urged to have liposuction performed by board certified plastic surgeons who posses the training and experience to complete your liposuction surgery in a safe and effective manner. What is tumescent solution? Tumescent solution is the solution that is infused into areas being treated prior to liposuction. Tumescent solution includes: 1 L lactated ringers, 50 ml of 1 % Lidocaine with epinephrine, and 20ml of 8.4% Bicarbonate solution. The lactated ringers solution is merely the vehicle to deliver the medications and is a solution that mimics human physiological solution. The Lidocaine in the solution allows for numbing of the area prior to aspirating the fat with small caliber cannulas. The epinephrine in the solution allows the vessels in the area being liposuctioned to be constricted thus minimizing bleeding. The Bicarbonate solution allows for the Lidocaine to work almost instantaneously. What is micro-etching liposculpture? Micro-etching liposculpture refers to liposuction that is performed with small caliber cannulas as small as 3 mm in diameter which allow the surgeon to liposuction areas of concern with greater finesse. Micro-etching allows for accurate removal of fat in areas with minimal fattiness which may be bothering patients. Examples of areas that can be microsculptured include the neck, jowls, abdominal area in patients trying to get a six pack, revision of previous liposuctioned areas with contour abnormalities. What areas can be liposucitoned? Many areas may be liposuctioned in order to achieve aesthetically improved contour lines. These include: the neck, jowls, upper arms, arm pit/lateral breasts region, breasts, entire abdomen, flanks, entire back, lateral thighs, medial thighs, and medial knees. Are there any areas that should not be liposuctioned? Several areas should not be liposuctioned as aspiration of fat from these areas will result in dimpling of the overlying skin resulting in a cellulite look. These areas are prone to pitting since the skin is firmly attached to the underlying muscle and when the fat is removed, theses attachments result in the pulling in of the skin. Areas that are considered a contra-indication for liposuction include the area of the lateral buttocks between the flanks and lateral thighs, the anterior and posterior thighs, the inferior buttocks crease, and ankles.