The liposuction technique has changed greatly over the years. In 1989, the authors presented subdermal superficial liposuction which treats the superficial fat layer and yields better skin retraction. With this technique the surgeon can treat thin adipose layers to obtain better results in more cases than the traditional liposuction technique. The technique can be used in cases with difficult skin adjustment and in secondary cases when "deep only" liposuction has been performed and there were residual adiposities. Subdermal superficial liposuction evolved so that one could obtain good skin retraction by performing massive liposuction of all the fat layers. The authors named this technique MALL (Massive All Layer Liposuction). The technique is applied in body areas where the fat layer is very thick and stretches the skin because of its volume and weight such as in the abdomen, posterior arms, and internal surface of the upper third of the thighs. MALL liposuction drastically reduces the indications for abdominoplasty and inner thigh and arm dermolipectomies. Knowledge of the anatomy of the subcutaneous fat and the superficial fascial system allows one to explain the subdermal superficial liposuction from an anatomical point of view, to perform a more rational and effective procedure, and to differentiate the technique depending on the area of the body.

Liposuction is a widely used technique today and indications are that it is becoming even more popular due to new technical refinements. The use of cannulae with a smaller diameter allows suction of the fat immediately under the dermis. The cannula we use to perform this new kind of fat suction is straight and has an external diameter of less than 2 mm. This cannula, the so-called Mercedes cannula, has a bullet tip and a three-hole head. Moreover, the holes are not round but are slit-shaped and oriented in the same plane at 120 degrees. This cannula is specifically designed to produce less trauma. The cannula with one downward-facing orifice is not suitable for suction of the subdermal layer and an upward-facing orifice would be too traumatic. The advantage of this new technique, apart from the possibility of treating patients with very slight adiposity, is to allow an effective skin retraction. When a large amount of fat has already been aspirated, residual deformities can occur. These skin irregularities represent the lack of an effective cutaneous retraction mostly due to the permanence of the subdermal fat. In fact, the presence of a thick subdermal adipose layer decreases the possibility of skin retraction. Therefore, indications for liposuction of the subdermal fat are mainly the slight adiposities and the remnant deformities of a previous liposuction operation. Moreover, this technique is applied to every lipoplasty whenever better skin retraction is needed.

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Subdermal superficial liposuction, first presented by the authors at the ISAPS Congress at Zurich in 1989, is performed with thin three-hole Mercedes cannulas (diameter ranges from 1.8 to 2 mm) to treat small and secondary adiposities and to allow better skin retraction. Suction of the subdermal layer of fat reduces the thickness and consistency of the superficial fat and enhances the possibility of skin retraction. In cases where there is a large adiposity of the abdomen, arms, or inner thighs, there is a conspicuous volume of fat whose weight tends to overstretch and to carry the overlying skin downward. In these cases we need to reduce the large fat volume to permit effective skin retraction. Therefore, we apply the principles of traditional liposuction with those of subdermal superficial liposuction to aspirate large amounts of fat from all the adipose layers. We call this technique Massive All Layer Liposuction (MALL). The amount of skin shrinkage after this "defatting" procedure is remarkable and the clinical results are very good. The MALL technique can be applied to other areas as well. In our experience this new liposuction technique has dramatically reduced the indications of abdominoplasties and dermolipectomies of inner thighs and arms.