Liposuction: Principles and Practice 9783662489017, 9783662489031, 3662489015

Table of contents :
Foreword to the Second Edition......Page 8
Preface to the Second Edition......Page 10
Contents......Page 12
Contributors......Page 22
Part I: Anesthesia......Page 33
1: Anesthesia for Liposuction......Page 34
1.2 The Surgical Facility......Page 35
1.2.1 Personnel......Page 36
1.3 Preoperative Evaluation......Page 37
1.3.1 Preoperative Risk Assessment......Page 38
1.4.1 Cardiac Disease......Page 39
1.4.2 Obesity......Page 40
1.4.3 Hypertension......Page 41
1.4.5 Pulmonary Disease......Page 42
1.4.6 Sleep Apnea Syndrome......Page 43
1.5 Anesthesia for Liposuction......Page 44
1.5.1 Local Anesthesia......Page 45
1.5.2 Sedative–Analgesic Medications (SAM)......Page 48
1.5.3 General Anesthesia......Page 54
1.5.4 Preoperative Preparation......Page 57
1.5.5 Airway Management......Page 62
1.5.6 Perioperative Monitoring......Page 63
1.5.7 Perioperative Fluid Management......Page 64
1.6 Recovery and Discharge......Page 67
References......Page 69
Additional Recommended Reading......Page 80
2.1 Introduction......Page 81
2.3 Tumescent Technique......Page 82
References......Page 83
3.1 Background and History......Page 85
3.2.2 Pharmacology of Tumescent Anesthesia......Page 86
3.2.3 Tumescent Anesthesia Formulation......Page 87
3.3 Lidocaine Metabolism and Toxicity......Page 88
3.5 Ancillary Pharmacology......Page 90
3.6.1 Tumescent Fluid Infiltration......Page 91
3.6.2 Microcannulas and Lipoaspiration......Page 93
3.8 Complications......Page 94
3.9 Safety of Tumescent Liposuction......Page 96
3.10 Guidelines for Maximum Volumes of Lipoaspiration......Page 97
References......Page 98
4.1 Introduction......Page 100
4.3 Articaine Study......Page 101
References......Page 103
5.1 Introduction......Page 104
5.2 Background......Page 105
5.3.1.2 Lidocaine Dosing and Toxicity......Page 106
5.3.1.3 Epinephrine Dosing and Toxicity......Page 107
5.3.1.5 Effect of Sodium Bicarbonate in Tumescent Lidocaine Anesthesia......Page 108
5.3.2.2 Pharmacokinetics......Page 109
5.3.2.4 Relative Potency, Tolerability, and Toxicity......Page 110
Efficacy of Combined Caine Formula......Page 111
Safety of Combined Caine Formula......Page 112
References......Page 113
6.1 Introduction......Page 116
6.3 Surgical Technique......Page 117
6.4.1 Efficacy......Page 118
6.5 Discussion......Page 119
References......Page 122
Part II: Histology, Pathology, Biochemistry, and Physiology......Page 124
7.1 Introduction......Page 125
7.2 Experimental and Preclinical Background......Page 126
7.3 Clinical Studies......Page 127
References......Page 129
Part III: Preoperative......Page 131
8.2 Physical Examination......Page 132
8.5 Preoperative Instructions......Page 133
9.2.1 Introduction......Page 136
9.2.2 Discussion......Page 137
9.4 Dangers of Herbals in Surgery......Page 138
9.5 Toradol for Postoperative Analgesia......Page 139
9.6.3.1 Effects (Pharmacology)......Page 141
9.6.3.5 Food and Drug Administration Warnings......Page 142
References......Page 143
Part IV: Cannulas, Equipment......Page 146
10.2 Cannula Types......Page 147
10.3 Decontamination and Sterilization Techniques......Page 148
10.4 Infections Secondary to Surgery......Page 151
References......Page 152
11.1 Introduction......Page 154
11.2 Technique......Page 155
11.3 Discussion......Page 156
References......Page 157
12.1 Introduction......Page 158
12.3 Discussion......Page 159
References......Page 161
13.1 Introduction......Page 163
13.3 Discussion......Page 164
References......Page 165
Part V: Techniques......Page 166
14.2 New Principles of Liposuction......Page 167
References......Page 169
15.1 Introduction......Page 170
15.3 History......Page 171
15.4.1 Adipose Anatomy-Physiology......Page 173
15.5.2 Ultrasound-Assisted Liposuction (UAL)......Page 174
15.5.4 Power-Assisted Liposuction......Page 175
15.5.6 Radiofrequency-Assisted Liposuction (RFAL)......Page 176
15.7 Subdermal Liposuction......Page 177
Conclusions......Page 178
References......Page 179
16: Nonaesthetic or Functional Indications of Liposuction......Page 182
16.2.1 Knees......Page 183
16.2.2 Legs......Page 184
16.2.3 Thighs......Page 185
16.2.4 Hips......Page 187
16.2.5 Upper Extremities......Page 188
16.2.7 Abdomen......Page 189
16.3.1 Multiple Symmetric Lipomatosis (MSL) (Madelung or Launois-Bensaude Disease)......Page 190
Conclusions......Page 191
References......Page 192
17.1 Introduction......Page 195
17.2.2 Volume......Page 196
Conclusions......Page 197
References......Page 198
18.1 Dry Liposuction Procedure......Page 199
18.3 Anatomy of Lymphatics in the Lower Limb......Page 200
18.4 Lymphatics of the Upper Limb......Page 201
18.6 Lymph Liposuction......Page 202
References......Page 203
19.1 Introduction......Page 204
19.2 Standards of Liposuction Today......Page 205
19.3 The Role of Tissue Stabilization......Page 206
19.4 Side Comparison Study to Demonstrate the Effects of the MASST......Page 207
References......Page 208
20.1 History of Syringe Liposculpturing......Page 209
20.2.1.2 Syringes......Page 212
20.2.2 Cautions......Page 213
20.3.2 Pre-estimation of the Quantity to Be Resected......Page 214
20.3.5 Anesthesia......Page 215
20.3.8 Positioning the Patient......Page 216
20.3.9 Surgical Technique......Page 217
20.3.10 Dressing......Page 218
20.3.12 Technical Considerations......Page 219
20.6 Results......Page 220
References......Page 222
21.1 Introduction......Page 223
21.2 Modifications in Syringe-­Assisted Liposuction......Page 224
21.3 Modifications in the Tumescent Solution Infiltration......Page 225
21.4 Modifications in the Cannula Port Side......Page 226
References......Page 227
22.1 Introduction......Page 229
22.4 Material......Page 230
22.6 Discussion......Page 231
References......Page 235
23.1 Introduction......Page 236
23.2 Technique......Page 237
23.3 Discussion......Page 238
References......Page 240
24.1 Introduction and General Concepts......Page 241
24.3.1 Development and Structure......Page 242
24.3.2 Fat Biochemistry and Adipose Tissue Metabolism......Page 243
24.4.1 Regional Fat Distribution by Gender and Race......Page 244
24.5 Impact of Liposuction on General Health Risks......Page 245
24.6.1 Preoperative Preparation......Page 246
24.6.3 Total Injected Volume......Page 247
24.6.4 Transoperative and Postoperative Facts......Page 250
24.8 Final Considerations......Page 251
References......Page 252
25.1 Introduction......Page 254
25.3 Indications......Page 255
25.4.2 Technique of Subcutaneous Infiltration......Page 256
25.4.3 Operative Technique......Page 257
25.4.3.1 Follow-Up and Postoperative Care (Figs. 25.4 and 25.5)......Page 259
25.5 Results......Page 260
25.6.1 Local complications......Page 279
25.6.2 General Complications......Page 280
25.7 Discussion......Page 283
References......Page 284
26.1 Introduction......Page 285
26.2 Technique......Page 289
References......Page 302
27.1 Introduction......Page 303
27.2.2 Case 2 (Fig. 27.2)......Page 306
27.3 Discussion......Page 312
References......Page 316
28.2.1 Patient Selection......Page 317
28.4 Preoperative Planning......Page 318
28.5.2 Skin Incisions......Page 319
28.5.3 Probes......Page 320
28.5.4.1 Fat Emulsification......Page 321
28.6 Clinical Results......Page 323
28.7 Mastopexy......Page 324
28.9 The Passot Technique......Page 326
28.9.2 Procedure......Page 329
28.11 Selectivity and Specificity of Ultrasound......Page 338
28.12 Calcifications......Page 339
Conclusions......Page 340
References......Page 341
29: The Clinical Applications of Multifrequency Ultrasound Technology in Body Reshaping......Page 342
29.1 Introduction......Page 343
29.3 US and Adipose Tissue Interaction......Page 344
29.4 What about Multifrequency Technology......Page 346
29.6 Surgical Application......Page 347
29.8.2 Cavitation Effect and Infiltration......Page 348
29.8.3 Surgical Time......Page 349
29.13 Transcutaneous Ultrasound Treatment......Page 350
29.13.2 Preoperative Planning and Choice of Probe......Page 354
29.13.5 Posttreatment Advice and Session Scheduling......Page 355
29.17 Combined Treatments......Page 356
Conclusions......Page 357
References......Page 359
30.1 Introduction......Page 360
30.2 Study Results......Page 361
30.3 Discussion......Page 362
References......Page 364
31.1 Introduction......Page 366
31.3 Current Instrumentation......Page 367
31.4 Advantages and Disadvantages of Powered Instruments......Page 369
References......Page 370
32.2 Material and Methods......Page 371
32.3 Technique......Page 372
32.3.2 Nutational Infrasonic Liposculpture......Page 373
32.4 Results......Page 374
References......Page 376
33.1 Introduction......Page 377
33.3 Consultation and Patient Selection......Page 378
33.4 Operative Techniques......Page 379
33.6 Results......Page 380
33.7 Discussion......Page 382
References......Page 386
34.2 Nd:YAG Laser......Page 388
34.3 Histological Studies......Page 389
34.4 Surgical Technique......Page 390
34.5 Results......Page 392
Conclusions......Page 393
References......Page 394
35: Combination Laser-Assisted Liposuction and Minimally Invasive Skin Tightening with Temperature Feedback for Treatment of the Submentum and Neck......Page 395
35.1 Introduction......Page 396
35.2.3 LAL Step......Page 397
35.2.5 ST Step......Page 398
35.3.4 Safety and Recovery......Page 399
35.4 Discussion......Page 400
References......Page 403
36.1 Introduction......Page 405
36.2 Review of Treatment Series......Page 406
36.3.1 Case 1......Page 407
36.3.3 Case 3......Page 408
36.3.5 Case 5......Page 409
36.4 Technique Evolution......Page 410
36.6 Discussion......Page 411
References......Page 413
37.1 Introduction......Page 415
37.2.3 Case 3......Page 416
37.3 Discussion......Page 418
References......Page 421
38.1 Introduction......Page 422
38.2 Patient Selection......Page 424
38.2.1 The Ideal Patient......Page 425
38.2.2 Common Pitfalls......Page 426
38.4.2 Anesthesia......Page 427
38.4.3 Surgery......Page 428
38.5 Recovery Phase......Page 431
38.6 Complications......Page 432
References......Page 433
39.1 Introduction......Page 434
39.2 Asian Anatomy and Aesthetics......Page 435
39.3 Adipose Anatomy, Histology, and Physiology......Page 436
39.4.1 Facial Liposuction......Page 437
39.4.2 Autologous Facial Fat Transplantation......Page 438
Reference......Page 440
40.1 Introduction......Page 441
40.1.1 Patient Selection......Page 442
40.2 Technique......Page 443
40.4 Complications......Page 446
References......Page 448
41.1 Introduction......Page 449
41.3 Results......Page 450
41.4 Discussion......Page 451
References......Page 454
42.1 Introduction......Page 456
42.2 Surgical Technique......Page 457
42.3 Discussion......Page 458
References......Page 459
43.1 Introduction......Page 460
43.3.3 Submental Neck Skin......Page 461
43.4 Evaluation......Page 462
43.5 Patient Selection Process......Page 463
References......Page 465
44.1 Patient Consultation......Page 466
44.2 Technique......Page 467
44.3 Postoperative Care......Page 468
44.4 Discussion......Page 469
References......Page 470
45.1 Introduction......Page 471
45.3 Principles of Operation......Page 472
45.4 Operative Technique......Page 473
45.6 Discussion......Page 474
References......Page 478
46.2 Classification......Page 479
46.4 Mechanisms of Axillary Odor......Page 480
46.5.3 Botulinum Toxin......Page 481
46.5.5 Surgical Treatments......Page 482
46.6.2 Technique......Page 483
Conclusions......Page 484
References......Page 485
47: Liposuction for Axillary Hyperhidrosis: Reconciling Trial Results and Expert Opinion......Page 487
47.3 Discussion......Page 488
Conclusions......Page 490
References......Page 491
48.1 Introduction......Page 492
48.3 Method......Page 493
48.5 Laser Treatment and Suction or Laser Treatment Alone? Which Approach Is Superior?......Page 495
48.6 Safety Measures......Page 497
48.7 Ectopic Sweat Glands......Page 498
48.8 Epilation......Page 499
48.11 Observed Side Effects and Complications......Page 500
48.12 Safety Guidelines......Page 504
49.2 Upward Rotation of the Breast......Page 505
49.3 Subdermal Skin Stimulation......Page 506
49.4 Subcutaneous UAL Undermining......Page 507
49.5 Discussion......Page 509
References......Page 514
50.1 Introduction......Page 515
50.2.2 Conventional Liposuction or Suction-Assisted Lipectomy (SAL)......Page 517
50.2.3 Ultrasound-Assisted Liposuction (UAL)......Page 518
50.2.4 Open Excision ± Skin Reduction......Page 519
50.4 Discussion......Page 520
References......Page 525
51.1 Introduction......Page 528
51.3 Clinical Features......Page 529
51.5.1 Anesthesia......Page 530
51.5.2 Technique......Page 531
References......Page 532
52.1 Introduction......Page 534
52.2.1 Instruments......Page 535
52.2.2 Anesthesia......Page 536
52.2.3 Regularity......Page 537
52.2.5 Internal Ultrasound......Page 538
52.2.6 External Ultrasound......Page 539
52.3 Discussion......Page 541
Conclusions......Page 542
References......Page 543
53.2 Complications of Silicone Injections......Page 545
53.4.1 Stage I......Page 546
53.4.4 Stage III......Page 547
53.5.1 History......Page 548
53.6.3 Fat Preparation......Page 549
53.6.6 Postoperative Care......Page 550
53.7.1 Case Example......Page 551
References......Page 552
54.3 History......Page 553
54.4 Anatomy......Page 554
54.6 Physiopathology of the Heavy Legs Syndrome and Lipoedema......Page 555
54.7 Surgical Technique......Page 556
54.7.2 Operation Tactics......Page 557
54.8 Postoperative Period......Page 558
54.9 Complications......Page 559
54.10 Discussion......Page 560
References......Page 562
55.1 Introduction......Page 563
55.2 Case Presentation......Page 564
55.3 Discussion......Page 565
References......Page 568
56.1 Introduction......Page 569
56.2.2 Blood Supply......Page 571
56.3.3 Technique......Page 572
56.6.1 Case 1: Right Foot Dorsum Degloving Injury with Groin Flap Coverage......Page 574
56.6.3 Case 3: Left Ankle Crush Injury with ALT Flap Coverage......Page 575
References......Page 577
57.2 Technique......Page 578
57.2.2 Liposuction......Page 579
57.2.3.1 Trochanteric Dermolipectomy for Correction of Drooping Buttocks and Interfemoral Flaccidity......Page 581
57.2.3.2 The Upper Limbs......Page 582
57.2.3.3 The Abdomen......Page 583
References......Page 586
58.1 Introduction......Page 588
58.6 Proposed Surgery and Its Objectives......Page 589
58.7 Technical Sequence......Page 590
58.8 Postoperative Care......Page 592
58.9 Clinical Cases......Page 594
Conclusions......Page 616
References......Page 617
59.2 History......Page 618
59.3 Clinical Anatomy......Page 619
59.4 Patient Evaluation......Page 620
59.5.1 Preoperative Treatment......Page 621
59.5.2 Suction Lipectomy......Page 622
59.5.3 Dermolipectomy......Page 623
59.6 Postoperative Care......Page 624
References......Page 625
60.1 Introduction......Page 627
60.4 Differential Diagnosis......Page 628
60.6 Diagnosis......Page 629
Conclusion......Page 630
References......Page 631
61.1 Introduction......Page 632
61.6 Assessing Body Composition......Page 633
61.8 Materials and Methods......Page 634
61.9 Operative Technique......Page 635
61.10 Clinical Results......Page 637
61.11 Surgical Risk......Page 639
References......Page 643
62.1 Introduction......Page 644
62.2 Case Reports......Page 645
References......Page 647
63.1 Introduction......Page 649
63.2.1 Case 1......Page 651
63.3 Summary......Page 652
References......Page 653
64.1 Introduction......Page 655
64.2 Diagnosis......Page 656
64.5 Results......Page 657
References......Page 658
65.1 Introduction......Page 659
65.2.2 Technique......Page 660
65.3 Postsurgical Hematomas......Page 661
References......Page 662
66.1 Fox–Fordyce Disease......Page 664
66.2 Therapies......Page 665
66.3 Description of Procedure: Axillary Liposuction-Assisted Curettage......Page 666
References......Page 667
67.1 Introduction......Page 668
67.2 Technique......Page 669
Conclusions......Page 672
References......Page 673
68.1 Introduction......Page 674
68.2 Technique......Page 675
68.3 Results......Page 676
References......Page 678
69: Reverse Tissue Expansion by Liposuction Deflation Adopted for Harvest of Large Sheet of Full-­Thickness Skin Graft......Page 680
69.3 Discussion......Page 681
References......Page 682
70.2 Cellulite......Page 683
70.4 Lymphedema......Page 684
References......Page 685
71.1 Introduction......Page 687
71.3 Discussion......Page 688
References......Page 690
72.1 Neurofibromatosis Type 1 and Plexiform Neurofibromas......Page 691
72.3 Use of Liposuction for Treatment of Plexiform Neurofibromas......Page 692
72.4 Risks of Procedure......Page 693
Conclusions......Page 694
References......Page 695
73.1 Introduction......Page 696
73.2.1 Technical Aspects......Page 697
73.3 Discussion......Page 698
73.4 Timing of Liposuction......Page 699
73.7 SAL in Irradiated Flaps......Page 700
References......Page 701
74.2 Side Effects Associated with Filler Materials......Page 703
74.3 Liposuction Technique for Extraction of Permanent Fillers......Page 705
References......Page 706
Part VI: Lipedema (Lipoedema) and Lymphedema......Page 707
75.2 Anatomy and Pathophysiology......Page 708
75.3 Clinical Categories of Lipedema......Page 711
75.8 Surgical Therapy......Page 712
References......Page 713
76.1 Introduction......Page 714
76.2 Diagnosis......Page 716
76.4 Technique......Page 719
76.5.1 Controlled Compression Therapy (CCT)......Page 721
76.7 Patient Selection......Page 722
References......Page 724
77.2.1 Clinical Aspects......Page 727
77.2.5.1 Conservative Treatment......Page 728
77.3.1 Patients and Methods......Page 730
77.4 Discussion......Page 731
References......Page 735
78.3 Lipolymphosuction......Page 736
78.5 Endermologie® and LPG Technique......Page 737
78.8 Results......Page 738
78.9 Discussion......Page 739
References......Page 742
79.1 Introduction......Page 743
79.2 Clinical Picture......Page 744
79.4 Extragenital Impact of Sex Hormones......Page 746
79.6 Lymphological Liposculpture......Page 747
79.7 Cologne Lipoedema Study 2012......Page 748
References......Page 752
Part VII: Complications......Page 754
80.1 Introduction......Page 755
80.3.1.1 Fat Embolism Syndrome (FES)......Page 756
80.3.1.4 Hypovolemia/Anemia......Page 757
80.3.1.5 Lidocaine Toxicity......Page 758
80.4.1 Contour Irregularities......Page 759
80.4.2 Skin Necrosis......Page 760
80.4.4 Hyperpigmentation......Page 761
Conclusion......Page 762
References......Page 763
81.2.1 Asymmetry......Page 764
81.2.4 Depressions (Grooves, Waviness)......Page 765
81.2.7 Fibrosis......Page 766
81.2.9 Hyperpigmentation......Page 767
81.2.12 Lidocaine Toxicity......Page 768
81.2.16 Neurologic Problems......Page 769
81.2.19 Scars......Page 770
81.2.21 Thromboembolism......Page 771
81.2.22 Toxic Shock Syndrome......Page 772
References......Page 773
82.2 Local Anesthetic Toxicities......Page 775
82.3.1 Animal Research......Page 776
82.3.2 Local Anesthetic System Toxicity (LAST)......Page 777
82.5.1 Animal Studies Showing Drug Toxicity Response to Lipid Rescue......Page 778
82.5.2 Specific Toxic Effects of a Variety of Drugs Were Treated in Humans Successfully......Page 779
82.6 Guidelines and Advisories......Page 780
82.7 Proposed Mechanisms by Which Lipid Rescue Works......Page 781
References......Page 783
83: Correction of Liposuction Sequelae by Autologous Fat Transplantation......Page 787
83.2 Patients and Methods......Page 788
83.4 Results......Page 789
83.4.1 Case 1......Page 790
83.5 Discussion......Page 792
References......Page 797
84.2 Technique......Page 800
84.4 Discussion......Page 803
References......Page 805
85.2 Risks of Mortality with General Anesthesia......Page 806
85.5 Cosmetic Surgical Procedures and Mortality......Page 807
References......Page 808
86.1 Introduction......Page 809
86.2 Causes of Death after Liposuction and Risk Factors Related to Fatal Complications......Page 810
86.3 Medicolegal Consequences, Autopsy, and Analysis of Physician Technique......Page 812
References......Page 814
87: Harmful Effects of Liposuction and Lipolysis Procedures Questionable Safety and Scientific Validity: A Medico-Legal Perspective and Advantages of “Light” Hypo-osmolar Liposuction......Page 817
87.2.1.1 Case 1......Page 818
87.2.1.2 Case 2......Page 820
87.2.2.2 Case 4......Page 821
87.2.2.3 Case 5......Page 823
87.3 Lipolysis and Lipotomy......Page 824
87.3.2 Physical Mechanism of Lipotomy......Page 825
87.4 Merits of Light Hypo-­osmolar Liposuction......Page 829
Conclusion......Page 830
References......Page 831
88.1 Introduction......Page 832
88.2 Technique......Page 833
88.3 Discussion......Page 834
References......Page 836
89.2 Necrotizing Fasciitis (NF)......Page 838
89.3 Visual Loss and Blindness......Page 841
Conclusions......Page 844
References......Page 845
90.1 Introduction......Page 846
90.4.1 Timing of Onset and Symptoms......Page 847
Conclusions......Page 848
References......Page 849
91.1 Introduction......Page 850
91.3 Operative Technique......Page 851
91.4 Postoperative Course......Page 852
91.5 Discussion......Page 853
References......Page 855
92.1 Introduction......Page 857
References......Page 858
Part VIII: Postoperative......Page 860
93.1 Introduction......Page 861
93.2.1 Cholesterol......Page 862
93.2.3 Subcutaneous to Visceral Fat Ratio, Waist Circumference......Page 863
93.2.4 Blood Glucose Levels and Insulin Resistance......Page 864
93.4 Inflammatory Markers......Page 865
References......Page 866
94: Liposuction and Visfatin......Page 868
94.2 Visfatin......Page 869
References......Page 870
Part IX: Outcomes and Patient Satisfaction......Page 872
95.1 Introduction......Page 873
95.3 Diagnosis and Classification......Page 874
95.5 Technique......Page 876
95.6.1 Effect on Pain......Page 877
95.7 Complications......Page 878
95.8 Selection of Patients......Page 879
References......Page 882
96.1 Introduction......Page 884
96.3 Sociodemographic and Quality of Life Aspects......Page 885
96.4 Body Dysmorphia......Page 886
References......Page 887
Part X: Medical Legal, Commentary......Page 888
97.1 Introduction......Page 889
97.4 Other Dangers......Page 890
97.6 Medical Board of California vs. Matory, Tustin District, CA; Medical Board of California vs. Hoo, Tustin District, CA......Page 891
97.8 Herron vs. Stewart, Forsyth County (NC), Superior Court. In Medical Malpractice Verdicts, Settlements & Experts 1995;11(10)47......Page 892
97.11 Medical Board of California vs. O’Neill......Page 893
97.13 Medical Board of California vs. Chavis, Los Angeles District, CA......Page 894
97.15 Estate of Caswell vs. Daniel, Commonwealth of Kentucky Fayette Circuit Court (Eighth Division), Case No. 99-CI-1947......Page 895
97.17 Donnell-Behringer vs. McCann, Los Angeles County (CA) Superior Court, Case No. VC26507. In Medical Malpractice Verdicts, Settlements & Experts 2000;16(8):50......Page 896
97.20.2 Legal Definition......Page 897
97.20.3 Suggestions for Office......Page 898
97.21 Discussion......Page 899
References......Page 900
98.2 Terminology......Page 902
98.5 New Technologies......Page 903
98.8 Ultrasound-Assisted Liposuction......Page 904
References......Page 905
Index......Page 906

Citation preview

Melvin A. Shiffman Alberto Di Giuseppe Editors

Liposuction Principles and Practice Second Edition

123

Liposuction

Melvin A. Shiffman • Alberto Di Giuseppe Editors

Liposuction Principles and Practice Second Edition

Editors Melvin A. Shiffman Tustin CA USA

Alberto Di Giuseppe Department of Plastic Surgery Regional Hospital-Ancona Ancona Italy

ISBN 978-3-662-48901-7 ISBN 978-3-662-48903-1 DOI 10.1007/978-3-662-48903-1

(eBook)

Library of Congress Control Number: 2016934047 © Springer-Verlag Berlin Heidelberg 2016 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. Printed on acid-free paper This Springer imprint is published by Springer Nature The registered company is Springer-Verlag GmbH Berlin Heidelberg

I would like to dedicate this book in memory of Irving Rappaport. He was my mentor and friend, and he was dedicated to perform surgery in the best possible manner, no matter how difficult. Irving had degrees in Dentistry and Medicine and was Board Certified in Surgery and Plastic Surgery. He was a Master of Head and Neck Surgery and a talented surgeon who was innovative and delicate. I started knowing Irving in my first year of residency at the long Beach Veterans Hospital when I was placed on the Head and Neck Service as my first rotation. When we started a surgery, he would ask me how I would approach the case, and after I explained the steps of the procedure I would do, he would begin the surgery with a totally different approach. In 3 years of residency, he would ask me to help in many cases despite my not being assigned to the Head and Neck Service. He would allow me to do many of the difficult cases and finally we began working as a team, each of us doing some part of the surgery. He taught me how to do a facelift incision and raise flaps in order to remove parotid tumors. He taught me how to reconstruct the head and neck, do rotation flaps and tubed pedicle flaps, as well as find the best cosmetic incision for each case. After 3 years at the VA Hospital, Irving left to become Chief of Surgery at the Orange County Medical Center and I was a Senior Resident and placed in charge of the 40-bed Head and Neck Service as well as 80 beds of general surgery and 40 beds of thoracic surgery. When I finished residency and went into private practice, Irving used my office for his private patients. From then on I assisted him in all of his surgeries in head and neck cancer cases and plastic and aesthetic surgery. I also helped him with his head

and neck clinic as well as the radiation oncology clinic at the Medical Center after it became the University of California, Irvine. After about 13 years together, our practices had grown too large for even the new office of 2500 square feet and we each took on an associate. The associates did not last for more than a year, but Irving and I would meet at the hospital frequently and talk over old times as well as new political problems that he was so intensely pursuing. Irving was an inspiration to me and I think constantly about how much he taught me in surgery.

Foreword to the Second Edition

Enriched with 46 excellent presentations written by experienced liposuction surgeons, this second edition will continue to deserve the envied title of reference book in liposuction, this new art and science recently created to improve or maintain the health or external beauty of the human body at all ages in safe conditions! In this very complete book, beginners as well as trained liposuction surgeons will have many information, maneuvers, or safe procedures in local anesthesia, complications, procedures, results, innovations, and sometimes pearls about all they need to know or on all they want to improve or on what they have been taught but that they want to refresh or to study again to accomplish their daily very delicate, precise, and responsible art and science. At all ages a pleasant appearance without flaw is strongly desired! All ages have their own beauty, which can be prolonged or improved when desired thanks to liposuction surgery or other procedures of aesthetic surgery! Some philosophers teach that human beauty is health visible! It is certainly true and this very wise sentence should always be remembered and thought by our patients! Paris, France

Pierre F. Fournier, M.D.

vii

Preface to the Second Edition

This Second Edition of Liposuction: Principles and Practice is an attempt to combine older techniques and ideas with newer techniques, modifications of techniques, and updated ideas about liposuction. The book is expanded to 136 chapters from a variety of international and innovative experts. There have been slow but steady changes in liposuction techniques and methods that include monitoring of fluid infiltration in multiple sites and large volume liposuction, modification to improve the efficacy of liposuction, changes in megaliposuction, application of multi-frequency ultrasound technology, nutational infrasonic liposculpture liposuction/liposculpture assisted by compressed air, managing components of the aging neck, limited-incision surgical debulking of lymphatic malformations, superficialization of arteriovenous fistulae, reverse tissue expansion by liposuction deflation adopted for harvest of large sheet of full-thickness skin graft, and lipid rescue for anesthetic toxicity. Other original chapters have been modified and updated. This book is intended for doctors interested in learning liposuction as well as those slightly or extensively experienced in liposuction. This updated version is again to be published by Springer-Verlag. The editors wish to thank the staff of Springer for their dedication to produce the very best in books with excellent color and sharp images to the photos and a magnificent book cover. The format makes reading easy although the book may be a little on the heavy side with so many pages. Tustin, CA, USA

Melvin A. Shiffman, M.D., J.D.

ix

Contents

Part I

Anesthesia

1

Anesthesia for Liposuction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Gary Dean Bennett

3

2

Tumescent Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Melvin A. Shiffman

51

3

Liposuction with Local Tumescent Anesthesia and Microcannula Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . Shilesh Iyer and Bernard I. Raskin

4

Tumescent Local Anesthesia with Articaine . . . . . . . . . . . . . . . Afschin Fatemi

5

A Combined Lidocaine/Ropivacaine Formula for Tumescent Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Julio Cesar Novoa

6

Efficacy of Tumescent Local Anesthesia with Variable Lidocaine Concentration in 3430 Consecutive Cases of Liposuction. . . . . . . . . . . . . . . . . . . . . . . . Louis Habbema

Part II 7

71

75

87

Histology, Pathology, Biochemistry, and Physiology

Metabolic and Clinical Studies of Liposuction in Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Beniamino Palmieri

Part III

55

97

Preoperative

8

Preoperative Consultation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Melvin A. Shiffman

9

Drugs to Limit Use of or Avoid When Performing Liposuction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Melvin A. Shiffman

105

109

xi

Contents

xii

Part IV 10

11

12

13

Cannulas, Equipment

Inadequate Sterilization of Liposuction Cannulas: Problems and Prevention . . . . . . . . . . . . . . . . . . . . . Brenda C. Edmonson and Allan E. Wulc An Inexpensive Method of Liposuction Cannula Port-Site Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . Lee Seng Khoo, Henrique N. Radwanski, and Ivo Pitanguy Negative Pressures Generated by Different Caliber Syringes Used for Liposuction . . . . . . . . . . . . . . . . . . . Ricardo Luis Rodriguez and Alexandra Condé-Green Negative Aspiration Pressure of Manual Liposuction with Coleman Technique Is Highly Depending on the Position of Plunger of the Syringe . . . . . . . . Christian Herold and Hans-Oliver Rennekampff

Part V

121

129

133

139

Techniques

14

Principles of Liposuction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Melvin A. Shiffman

145

15

The Principles and Techniques of Liposuction . . . . . . . . . . . . . Miles G. Berry

149

16

Nonaesthetic or Functional Indications of Liposuction . . . . . . Michel Costagliola, Bishara Atiyeh, Florence Rampillon, and Saad Dibo

161

17

Accurately Monitoring Fluid Infiltration During Multiple-Site or Large-Volume Liposuction . . . . . . . . . . . . . . . Nigel Yong Boon Ng, Marc-James Hallam, and Charles Nduka

175

18

Liposuction Technique and Lymphatics in Liposuction. . . . . . Andreas Frick, Rüdiger G.H. Baumeister, and Johannes N. Hoffmann

179

19

Tissue Stabilization in Liposuction Surgery . . . . . . . . . . . . . . . Gerhard Sattler and Dorothee Bergfeld

185

20

Reduction Syringe Liposculpturing . . . . . . . . . . . . . . . . . . . . . . Pierre F. Fournier

191

21

Minor (Smart) Modifications for Increasing the Efficacy of Liposuction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Karaca Basaran and Idris Ersin

205

Contents

xiii

22

23

Histological Study of the Aspirate from Breast Liposuction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Louis Habbema and Josephine J.M. Alons

211

Large-Volume Liposuction for the Treatment of the Metabolic Problems of Obesity . . . . . . . . . . . . . . . . . . . . Beniamino Palmieri

219

24

Large-Volume Liposuction for Obesity . . . . . . . . . . . . . . . . . . . Enrique Hernández-Pérez, Jose A. Seijo-Cortes, and Hassan Abbas Khawaja

25

Megaliposculpture and Therapeutic Megaliposculpture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pierre F. Fournier

26

Ultrasound-Assisted Lipoplasty for Face Contouring with Vaser. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Alberto Di Giuseppe, George Commons, and Luca Grassetti

225

239

271

27

Excisional Body Contouring Surgery and Vaser . . . . . . . . . . . Dennis J. Hurwitz

289

28

Vaser-Assisted Breast Reduction . . . . . . . . . . . . . . . . . . . . . . . . Alberto Di Giuseppe

303

29

The Clinical Applications of Multifrequency Ultrasound Technology in Body Reshaping. . . . . . . . . . . . . . . . Giovanni Zoccali, Benedetta Cinque, Gino Orsini, Paolo Palumbo, Salvatore Scandura, Gianfranca Miconi, Cristina La Torre, Maria Grazia Cifone, and Maurizio Giuliani

30

Histologic Changes with Breast Ultrasound-Assisted Liposuction . . . . . . . . . . . . . . . . . . . . . . . . Joseph T. Chun, James W. Taylor, and Stuart E. VanMeter

31

Powered Liposuction Equipment . . . . . . . . . . . . . . . . . . . . . . . . Timothy Corcoran Flynn

32

Nutational Infrasonic Liposculpture (NIL) Liposuction/Liposculpture Assisted by Compressed Air. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ângelo Rebelo

33

34

Breast Reduction by Liposuction Using Tumescent Local Anesthesia and Powered Cannulas. . . . . . . . Louis Habbema Laserlipolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diego E. Schavelzon, Guillermo Blugerman, and Anastasia Chomyszyn

329

347

353

359

365 377

Contents

xiv

35

36

37

Combination Laser-Assisted Liposuction and Minimally Invasive Skin Tightening with Temperature Feedback for Treatment of the Submentum and Neck. . . . . . . . . . . . . . . . . . . . . . . . . . . . Macrene Alexiades

385

Radiofrequency-Assisted Liposuction of the Upper Arms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Diane Irvine Duncan

395

Abdominal Liposuction: Optimizing Outcome by Adding Radiofrequency Heating. . . . . . . . . . . . . . . . . . . . . . Diane Irvine Duncan

405

38

Facial Recontouring with Liposuction . . . . . . . . . . . . . . . . . . . . Edward H. Farrior, Raymond D. Cook, and Stephan S. Park

39

Liposuction and Lipotransfer for Facial Rejuvenation in the Asian Patient . . . . . . . . . . . . . . . . . . . . . . . Tetsuo Shu and Samuel M. Lam

425

Managing the Components of the Aging Neck: From Liposuction to Submentalplasty, to Neck Lift. . . . . . . . . Alan Matarasso, Hamid Abdollahi, and William Lao

433

Liposuction and Suspension of the Orbicularis Oculi for the Correction of Persistent Malar Bags . . . . . . . . . . Ioannis E. Liapakis and Eleftherios I. Paschalis

441

Tumescent Liposuction in the Treatment of Hemifacial Hypertrophy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Onder Tan

449

Submental Liposuction Versus Formal Cervicoplasty: Which One to Choose? . . . . . . . . . . . . . . . . . . . Tirbod Fattahi

453

40

41

42

43

44

Liposuction of the Upper Extremities . . . . . . . . . . . . . . . . . . . . Melvin A. Shiffman and Sid Mirrafati

45

Three-Dimensional Circumferential Liposuction of the Overweight or Obese Upper Arm . . . . . . . . . . . . . . . . . . Yoon Gi Hong

46

47

Treatment of Excessive Axillary Sweat Syndromes (Hyperhidrosis and Osmidrosis or Bromhidrosis) with Liposuction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ren-Yeu Tsai Liposuction for Axillary Hyperhidrosis: Reconciling Trial Results and Expert Opinion . . . . . . . . . . . . . Omer Ibrahim and Murad Alam

413

459

465

473

481

Contents

xv

48

49

50

Laser-Assisted Suction of Axillary Sweat Glands and Axillary Epilation . . . . . . . . . . . . . . . . . . . . . . . . . . Martin Klöpper, Gosta Fischer, and Guillermo Blugerman

487

Mastopexy (Breast Lift) with Vaser Ultrasound-Assisted Liposuction . . . . . . . . . . . . . . . . . . . . . . . . Alberto Di Giuseppe and Mario Russo

501

A Comparison of Conventional with Ultrasonic Liposuction in Gynaecomastia Surgery . . . . . . . . . . . . . . . . . . . Charles M. Malata and Kai Yuen Wong

511

51

Aspiration of Breast Cysts with Liposuction. . . . . . . . . . . . . . . Shridhar Ganpathi Iyer, Thiam Chye Lim, and Jane Lim

52

Refinements in Liposculpture of the Buttocks and Thighs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Luiz S. Toledo

531

Liposuction and Lipofilling for Treatment of Symptomatic Silicone Toxicosis of the Gluteal Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Rebecca C. Novo, Leela S. Mundra, Nicole Miller, and Christopher J. Salgado

543

53

54

55

56

Liposculpture of the Lower Extremities Using a Tourniquet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Kamal Cherif-Zahar and Soraya Bensenane-Hasbelaoui

525

551

The Transverse Upper Gracilis Flap for Breast Reconstruction Following Liposuction of the Thigh. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anita T. Mohan, Corrine Wong, and Michel Saint-Cyr

561

The Combined Use of Liposuction and Arthroscopic Shaver in Contouring Lower Limb Fasciocutaneous Flaps . . . . . . . . . Adrian SH Ooi and Yee Siang Ong

567

57

Liposuction and Dermolipectomy . . . . . . . . . . . . . . . . . . . . . . . Ivo Pitanguy, Henrique N. Radwanski, and Bárbara H.B. Machado

58

Deformation of Dermal-Adipose Tissue: Resolution of Cases Rejected by Traditional Medicine . . . . . . . . . . . . . . . . Néstor L. Asurey

577

587

59

The Modern Lipoabdominoplasty . . . . . . . . . . . . . . . . . . . . . . . Jorge I. de la Torre and Luis O. Vásconez

617

60

Lipomas Treated with Liposuction. . . . . . . . . . . . . . . . . . . . . . . John Stuart Mancoll

627

Contents

xvi

61

62

63

HIV Lipodystrophy Treatment (Buffalo Hump) with VASER Ultrasound-Assisted Lipoplasty . . . . . . . . . . . . . . Alberto Di Giuseppe, Marianne Wolters, Herman Lampe, and Guido Zanetti Palliative Treatment of Madelung’s Disease: Ultrasound-Assisted Liposuction and Intralipotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Angela Faga Syringe Liposuction for Residual Fat in Involuted Hemangioma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Beatriz Berenguer, Javier Enríquez de Salamanca, Beatriz González, Pilar Rodríguez, Antonio Zambrano, and Antonio Pérez Higueras

633

645

651

64

Liposuction in Dercum’s Disease . . . . . . . . . . . . . . . . . . . . . . . . Erik Berntorp, Kerstin Berntorp, and Håkan Brorson

657

65

Treatment of Hematomas with Liposuction . . . . . . . . . . . . . . . Antonio Ascari-Raccagni

661

66

Treatment of Fox–Fordyce Disease with Liposuction-Assisted Curettage . . . . . . . . . . . . . . . . . . . . . Stephanie Marschall, Michael Marschall, and K. Mireille Chae

67

68

69

667

Liposuction Superficialization of Brachiocephalic Fistulae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Marlin Wayne Causey and Niten Singh

671

Liposuction for Superficialization of Deep Veins After Creation of Arteriovenous Fistulas . . . . . . . . . . . . . . . . . Eric D. Ladenheim

677

Reverse Tissue Expansion by Liposuction Deflation Adopted for Harvest of Large Sheet of Full-Thickness Skin Graft. . . . . . . . . . . . . . . . . . . . . . . . . . . . Amir E. Ibrahim, Hamed Janom, and Mohamad Raad

683

70

Cellulite Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pier Antonio Bacci

687

71

Liposuction Treatment of Cellulite. . . . . . . . . . . . . . . . . . . . . . . Clara Lieberman, Jose A. Cohen, and Rashi Rosenstock

691

72

Liposuction in the Treatment of Plexiform Neurofibromas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Srdan Babovic and Dusica Babovic-Vuksanovic

695

Contents

xvii

73

74

Liposuction Contouring After Head and Neck Free Flap Reconstruction . . . . . . . . . . . . . . . . . . . . . . Amir E. Ibrahim, Hamed Janom, and Mohamad Raad Liposuction Technique for Extraction of Bio-Alcamid and Other Permanent Fillers . . . . . . . . . . . . . . Kamal Bisarya, Kayvan Shokrollahi, and Max Murison

Part VI

701

709

Lipedema (Lipoedema) and Lymphedema

75

Lipedema and Lymphatic Edema. . . . . . . . . . . . . . . . . . . . . . . . Manuel E. Cornely

715

76

Liposuction of Lymphedema of the Extremities . . . . . . . . . . . . Emma Hansson and Håkan Brorson

721

77

Tumescent Liposuction in Lipoedema . . . . . . . . . . . . . . . . . . . . Wilfried Schmeller, Axel Baumgartner, and Yvonne Frambach

735

78

Vibro-Assisted Liposuction and Endermologie for Lipolymphedema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pier Antonio Bacci and Serena Leonardi

745

Update Lipoedema 2014: Cologne Lipoedema Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Manuel E. Cornely and Matthias Gensior

753

79

Part VII 80

81

82

83

84

Complications

Analysis of Postoperative Complications of Superficial Liposuction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sang Wha Kim and Youn Hwan Kim

767

Prevention and Treatment of Liposuction Complications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Melvin A. Shiffman

777

Lipid Rescue for Local Anesthetic and Nonlocal Anesthetic Drug Toxicity . . . . . . . . . . . . . . . . . . . Melvin A. Shiffman

789

Correction of Liposuction Sequelae by Autologous Fat Transplantation . . . . . . . . . . . . . . . . . . . . . . Luiz Haroldo Pereira, Beatriz Nicaretta, and Aris Sterodimas Fat Shifting for the Treatment of Skin Indentations . . . . . . . . Melvin A. Shiffman and Guillermo Blugerman

801

815

Contents

xviii

85

Liposuction Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Melvin A. Shiffman

821

86

Death After Liposuction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Claudio Terranova

825

87

Harmful Effects of Liposuction and Lipolysis Procedures Questionable Safety and Scientific Validity: A Medico-Legal Perspective and Advantages of “Light” Hypo-osmolar Liposuction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Michel Costagliola, Bishara Atiyeh, Florence Rampillon, and Benoit Chaput

88

89

90

91

92

Correction of Gluteal Contour Deformities After Overaggressive Liposuction Utilizing the Deepithelialized Fasciocutaneous Infragluteal (FCI) Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Dominik Duscher, Michael Pollhammer, and Georg M. Huemer Blindness and Necrotizing Fasciitis After Liposuction and Fat Transfer . . . . . . . . . . . . . . . . . . . . . . . . . . . Briar L. Dent and John E. Sherman Complications of Liposuction Beyond the Surgical Site: Focus on the Optic Nerve Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Tommaso Agostini and Mario Dini

94

849

855

863

Fat Embolism After Liposuction in Klippel-Trenaunay Syndrome . . . . . . . . . . . . . . . . . . . . . . . . Gaby Doumit and Mihiran Karunanayake

867

Massive Pulmonary Thromboembolism After Abdominoplasty and Liposuction. . . . . . . . . . . . . . . . . . . Cenk Conkbayir

875

Part VIII 93

833

Postoperative

Changes in Metabolic Syndrome Parameters After Liposuction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Juraj Payer Jr. and Kristína Brázdilová Liposuction and Visfatin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jose Antonio Robles-Cervantes, Oscar F. Fernández-Diaz, Lázaro Cárdenas-Camarena, and María de Lourdes Sánchez-Aldana Robles

881 889

Contents

xix

Part IX 95

96

Outcomes and Patient Satisfaction

Quality of Life in Patients with Dercum’s Disease: Before and After Liposuction. . . . . . . . . . . . . . . . . . . . Emma Hansson and Håkan Brorson Psychology and Quality of Life of Patients Undergoing Liposuction Surgery . . . . . . . . . . . . . . . . . . . . . . . . Gerhard Sattler, Dorothee Bergfeld, Boris Sommer, and Matthias Augustin

Part X

895

907

Medical Legal, Commentary

97

Medical Legal Problems in Liposuction . . . . . . . . . . . . . . . . . . Melvin A. Shiffman

913

98

Editor’s Commentary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Melvin A. Shiffman

927

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 931

Contributors

Hamid Abdollahi, M.D. Department of Plastic Surgery, Manhattan, Eye, Ear and Throat Hospital, New York, NY, USA Tommaso Agostini, M.D. Department of Plastic Surgery, Azienda Ospedaliero Universitaria Careggi, Florence, Italy Murad Alam, M.D. Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA Department of Otolaryngology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA Department of Surgery, Feinberg School of Medicine, Chicago, IL, USA Macrene Alexiades, M.D., Ph.D. Dr. Macrene Skin Results 37 Actives, New York, NY, USA Dermatology and Laser Surgery Center of New York, New York, NY, USA Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA Josephine J.M. Alons, M.D. Pathologisch-Anatomisch Laboratorium Amsterdam, Amsterdam, The Netherlands Antonio Ascari-Raccagni, M.D. Department of Dermatology, G.B. Morgagni-L.Pierantoni General Hospital, Forli, Italy Nestor L. Asurey, M.D. Private Practice, Valencia, España Bishara Atiyeh, M.D. Plastic and Reconstructive Surgery, American University of Beirut Medical Center, Beirut, Lebanon Matthias Augustin, M.D. Private Practice, Institute and German Center for Health Services Research in Dermatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany Srdan Babovic, M.D. Department of Plastic Surgery, Olmsted Medical Center, Rochester, MN, USA Dusica Babovic-Vuksanovic, M.D. Department of Medical Genetics, Mayo College of Medicine, Rochester, MN, USA

xxi

xxii

Pier Antonio Bacci, M.D. Private Practice, Arezzo, Italy Karaca Basaran, M.D. Department of Plastic, Reconstructive and Aesthetic Surgery, Bagcilar Research Hospital, Bagcilar, Istanbul, Turkey Rüdiger G.H. Baumeister, M.D. Plastische, Hand-, Mikrochirurgie, ChirurgischeKlinik und Poliklinik -Grosshadern, Klinikum der Universität, München, Germany Axel Baumgartner, M.D. Hanse-Klinik, Lübeck, Germany Gary Dean Bennett, M.D. Department of Anesthesiology, Chapman Medical Center, Orange, CA, USA Soraya Bensenane-Hasbelaoui, M.D. Private Practice, Paris, France Beatriz Berenguer, M.D. Private Practice, Madrid, Spain Division of Plastic Surgery, Universidad Autonoma of Madrid, Hospital “Niño Jesus”, Madrid, Spain Dorothee Bergfeld, M.D. Rosenparkklinik, Center for Cosmetic Dermatologic Surgery, Rosenparkklinik, Darmstadt, Germany Erik Berntorp, M.D. Department of Clinical Coagulation Research, Skåne University Hospital, Malmö, Sweden Lund University, Malmö Centre for Thrombosis and Haemostasis, Skane University Hospital Malmö, Malmö, Sweden Kerstin Berntorp, M.D. Department of Endocrinology, Skåne University Hospital, Malmö, Sweden Miles G. Berry, B.Sc., M.B.B.S., M.S. The Institute of Cosmetic and Reconstructive Surgery, London, UK London Welbeck Hospital, London, UK Kamal Bisarya, BSc MBBS MRCS (ENG) MSc MEd DIC Burns, Plastic and Reconstructive Surgery, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK Guillermo Blugerman, M.D. Centro B & S Excelencia en Cirugía Plástica, Buenos Aires, Argentina Private Practice, Buenos Aires, Argentina Kristína Brázdilová, M.D., Ph. D. 5th Department of Internal Medicine, Medical Faculty of Comenius University and University Hospital Bratislava, Bratislava, Slovakia Håkan Brorson, M.D., Ph. D. Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden Lázaro Cárdenas-Camarena, M.D. Department of Plastic Surgery, Hospital Innovãre, Zapopan, Jalisco, Mexico

Contributors

Contributors

xxiii

Department of Plastic Surgery, Jalisco Reconstructive Surgery Institute “José Guerrerosantos”, Guadalajara, México Marlin Wayne Causey, M.D. San Antonio Military Medical Center, San Antonio, TX, USA K. Mireille Chae, M.D. Private Practice, Mill Creek, WA, USA Benoit Chaput, M.D. Department of Plastic and Reconstructive Surgery, CHU Toulouse University, Toulouse, France Anastasia Chomyszyn, M.D. Centro B & S Excelenciaen Cirugía Plástica, Buenos Aires, Argentina Joseph T. Chun, M.D. Division of Plastic Surgery, University of Tennessee Medical Center at Knoxville, Knoxville, TN, USA Maria Grazia Cifone, M.D. Department of Life, Health and Environmental Sciences, Laboratory of General Pathology, Immunology and Immunopathology, L’Aquila University, L’Aquila, Italy Benedetta Cinque, M.D. Department of Life, Health and Environmental Sciences, Laboratory of General Pathology, Immunology and Immunopathology, L’Aquila University, L’Aquila, Italy Jose A. Cohen, M.D. Private Practice, San Jose, Costa Rica George Commons, M.D. Private Practice, Palo Alto, CA, USA Alexandra Condé-Green, M.D. Division of Plastic Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA Cenk Conkbayir, M.D. Private Practice, Lefkoşa/Kıbrıs, Cyprus Cardiology Department, Near East University, Nicosia, Turkey Raymond D. Cook, M.D. Department of Otolaryngology – Head and Neck Surgery, University of North Carolina and Wake Medical Center, Raleigh, NC, USA Manuel E. Cornely, M.D. CG Lympha, Köln, Germany Private Practice, Düsseldorf, Germany Michel Costagliola, M.D. Department of Chirurgie Réparatriceet Esthétique, Faculté de Médecine Toulouse-Ranguei, Toulouse, France Dijon University, Dijon, France Department of Plastic, Reconstructive and Aesthetic Surgery, Toulouse University, Toulouse, France Javier Enriquez De Salamanca, M.D. Department of Plastic Surgery, Universidad Autonoma of Madrid, Hospital “Niño Jesus”, Madrid, Spain

xxiv

Jorge I. de la Torre, M.D. Mountain Brook Plastic Surgery & Laser Center, Birmingham, AL, USA Department of Plastic Surgery, School of Medicine, University of Alabama, Birmingham, AL, USA Briar L. Dent, M.D. Division of Plastic Surgery, Department of Surgery, New York- Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA Alberto Di Giuseppe, M.D. The Hospital Group, London, UK Department of Plastic and Reconstructive Surgery, University of Ancona, Ancona, Italy Private Practice, Ancona, Italy Saad Dibo, M.D. Department of Plastic and Reconstructive Surgery, American University of Beirut Medical Center, Beirut, Lebanon Mario Dini, M.D. Department of Plastic Surgery, University of Florence, Centro Bufalini, Florence, Italy Gaby Doumit, M.D., M.Sc. Department of Plastic Surgery, Centre Hospitalier Universitaire (CHU) Sainte Justine, Montreal, Quebec, Canada Dermatology and Plastic Surgery Institute, Cleveland Clinic, Cleveland, OH, USA Diane Irvine Duncan, M.D. Plastic Surgical Associates of Fort Collins, Fort Collins, CO, USA Dominik Duscher, M.D. Department of Plastic, Aesthetic and Reconstructive Surgery, Kepler University Hospital, Linz, Austria Brenda C. Edmonson, M.D. Private Practice, Huntsville, AL, USA Idris Ersin, M.D. Department of Plastic, Reconstructive and Aesthetic Surgery, Bagcilar Research Hospital, Bagcilar, Istanbul, Turkey Angela Faga, M.D., F.I.C.S. Plastic and Reconstructive Surgery, University of Pavia, Pavia, PV, Italy Edward H. Farrior, M.D. Private Practice, Tampa, FL, USA Afschin Fatemi, M.D. S-thetic Clinic, Duesseldorf, Germany Tirbod Fattahi, M.D., D.D.S. Department of Oral and Maxillofacial Surgery, University of Florida Health Science Center, Jacksonville, FL, USA Oscar F. Fernández-Diaz, M.D. Department of Plastic Surgery, Jalisco Reconstructive Surgery Institute “José Guerrerosantos”, Guadalajara, México

Contributors

Contributors

xxv

Gosta Fischer, M.D. Department of Pathology, Institute for Pathology, Reinhard-Nieter Hospital, Wilhelmshaven, Germany Timothy Corcoran Flynn, M.D. Tulane Dermatology Department, Tulane University, New Orleans, LA, USA Cary Skin Center, Cary, NC, USA Pierre F. Fournier, M.D. Private Practice of Aesthetic Surgery, Paris, France Yvonne Frambach, M.D. Hanse-Klinik, Lübeck, Germany Andreas Frick, M.D. Chirurgische Klinik und Poliklinik der Universitaet Klinikum Groshadern, München, Germany Shridhar Ganpathi Iyer, M.D. Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yong Loo Lin School of Medicine, National University Cancer Institute, Singapore, Singapore, Singapore Matthias Gensior, M.D. Department of Plastic and Esthetic surgery, CG Lympha GmbH, Köln, Germany Maurizio Giuliani, M.D. Department of Life, Health and Environmental Sciences, Plastic and Reconstructive Surgery Section, L’Aquila University, L’Aquila, Italy Beatriz Gonzalez, M.D. Department of Plastic Surgery, Universidad Autonoma of Madrid, Hospital “Niño Jesus”, Madrid, Spain Luca Grassetti, M.D. Department of Plastic and Reconstructive Surgery, University of Ancona, Ancona, Italy Louis Habbema, M.D. Medisch Centrum ’t Gooi, Bussum, The Netherlands Marc-James Hallam, M.D. Surrey, UK Aberdeen Royal Infirmary, Aberdeen, UK Emma Hansson, M.D., Ph.D., M.A. Department of Clinical Sciences Malmö, Lund University, Lund, Sweden Plastic and Reconstructive Surgery, Skåne University Hospital, Malmö, Sweden Department of Plastic Surgery, Haukeland University Hospital, Clinical Medicine I, Bergen University, Bergen, Norway Enrique Hernández-Pérez, M.D. Private Practice, Miami, FL, USA Christian Herold, M.D. Department of Aesthetic and Plastic Surgery, Sana Klinikum Hameln-Pyrmont, Hameln, Germany Klinik für Plastische und Ästhetische Chirurgie – Handchirurgie, Hameln, Germany

xxvi

Antonio Pérez Higueras, M.D. Division of Plastic Surgery, Universidad Autonoma of Madrid, Hospital “Niño Jesus”, Madrid, Spain Johannes N. Hoffmann, M.D. Chirurgische Klinik und Poliklinik der Universitaet Klinikum Groshadern, München, Germany Yoon Gi Hong, M.D. Department of Aesthetic Plastic Surgery, YESTAR Aesthetic Plastic Hospital, Dalian City, China Georg M. Huemer, M.D., M.Sc., M.B.A. Section of Plastic, Aesthetic and Reconstructive Surgery, Department of General Surgery, Kepler University Hospital, Linz, Austria Dennis J. Hurwitz, M.D. Hurwitz Center for Plastic Surgery, Pittsburgh, PA, USA Department of Plastic Surgery, University of Pittsburgh Medical School, Pittsburgh, USA Amir E. Ibrahim, M.D. Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon Department of Plastic Surgery, University of Texas, M.D. Anderson Cancer Center, Houston, TX, USA Division of Plastic Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon Omer Ibrahim, M.D. Department of Dermatology, Cleveland Clinic Foundation, Cleveland, OH, USA Shilesh Iyer, M.D. Private Practice, Santa Clarita, CA, USA Hamed Janom, M.D. Division of Plastic Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon Mihiran Karunanayake, M.D. Service de chirurgie plastique, Centre Hospitalier Universitaire Saint-Justine, Université de Montréal, Montreal, Quebec, Canada Hassan Abbas Khawaja, M.D. Cosmetic Surgery and Skin Center, Lahore, Pakistan Lee Seng Khoo, M.D., MB ChB BAO, MRCS Ed. Instituto Ivo Pitanguy, Botafogo, Rio de Janeiro, Brazil Sang Wha Kim, M.D. Department of Plastic and Reconstructive Surgery, College of Medicine, Seoul National University, Seoul National University Hospital, Jongno-gu, Seoul, Republic of Korea Youn Hwan Kim, M.D., Ph.D. Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, Seongdong-Gu, Seoul, Korea

Contributors

Contributors

xxvii

Martin Klöpper, M.D. Private Practice, Northeim, Germany Cristina La Torre, Ph.D. Department of Life, Health and Environmental Sciences, Laboratory of General Pathology, Immunology and Immunopathology, L’Aquila University, L’Aquila, Italy Eric D. Ladenheim, M.D. LDAC Vascular Centers, Fresno, CA, USA Samuel M. Lam, M.D. Willow Bend Wellness Center, Lam Facial Plastic Surgery Center and Hair Restoration Institute, Plano, TX, USA Herman Lampe, M.D. Private Practice, Frankfurt, Germany William Lao, M.D. Department of Plastic Surgery, Manhattan, Eye, Ear and Throat Hospital, New York, NY, USA Serena Leonardi, M.D. Private Practice, Arezzo, Italy Ioannis E. Liapakis, M.D. Opsis Clinical, Plastic and Reconstructive Surgery, Heraklion, Crete, Greece Clara Lieberman, M.D. Private Practice, San Jose, Costa Rica Jane Lim, M.D. Division of Plastic, Reconstruction and Aesthetic Surgery, National University Hospital (Singapore), Singapore, Singapore Thiam Chye Lim, M.D. Division of Plastic, Reconstruction and Aesthetic Surgery, National University Hospital (Singapore), Singapore, Singapore National University of Singapore, Singapore, Singapore Barbara H.B. Machado, M.D. Private Practice, Rio de Janeiro, Brazil Charles M. Malata, B.Sc. (H.B.), LRCP, MRCS, M.D. Department of Plastic and Reconstructive Surgery, Cambridge Breast Unit at Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK Academic Plastic Surgery, Faculty of Health Sciences, Postgraduate Medical Institute, Anglia Ruskin University, Cambridge and Chelmsford, UK John Stuart Mancoll, M.D. Private Practice, Virginia Beach, VA, USA Michael Marschall, M.D. Private Practice, Wheaton, IL, USA Stephanie Marschall, M.D. Plastic Surgery Consultants of DuPage, Wheaton, IL, USA Alan Matarasso, M.D., FACS Plastic Surgery, Manhattan Eye, Ear and Throat Hospital, Lenox Hill Hospital, North Shore-Long Island Jewish Health System, New York, NY, USA

xxviii

Gianfranca Miconi, M.D. Department of Life, Health and Environmental Sciences, Laboratory of General Pathology, Immunology and Immunopathology, L’Aquila University, L’Aquila, Italy Nicole Miller, B.S. Division of Plastic, Aesthetic and Reconstructive Surgery, Miami, FL, USA Sid Mirrafati, M.D. Mira Aesthetics, Costa Mesa, CA, USA Anita T. Mohan, MRCS Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA Leela S. Mundra, B.S. Division of Plastic, Aesthetic and Reconstructive Surgery, Miami, FL, USA Max Murison, MB BCh, FRCS, FRCS (Plast) Burns, Plastic and Reconstructive Surgery, Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Heol Maes Eglwys, Morriston, Swansea, UK Charles Nduka, M.B., B.S., M.A. (Oxon) Queen Victoria Hospital, East Grinstead, UK Nigel Yong Boon Ng, M.D., MBChB Aberdeen Royal Infirmary, Aberdeen, UK Beatriz Nicaretta, M.D. M.Sc. Department of Plastic and Reconstructive Surgery, IASO General Hospital, Athens, Greece Rebecca C. Novo, M.D. Division of Plastic, Aesthetic and Reconstructive Surgery, University of Miami, Miami, FL, USA Julio Cesar Novoa, M.D. Private Practice, El Paso, TX, USA Yee Siang Ong, MBBChir, FAMS (Plastic Surgery) Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore, Singapore Adrian SH Ooi, MBBS, MRCS (Ed), MMed(Surg) Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Singapore, Singapore Gino Orsini, M.D. Department of Life, Health and Environmental Sciences, Plastic and Reconstructive Surgery Section, L’Aquila University, L’Aquila, Italy Beniamino Palmieri, M.D. Department of Surgery, University of Modena and Reggio Emilia, Modena, Italy Paolo Palumbo, Ph.D. Department of Life, Health and Environmental Sciences, Laboratory of General Pathology, Immunology and Immunopathology, L’Aquila University, L’Aquila, Italy Private Practice, Birmingham, AL, USA Stephan S. Park, M.D. Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology – Head and Neck Surgery, University of Virginia Health Systems, Charlottesville, VA, USA

Contributors

Contributors

xxix

Eleftherios I. Paschalis, M.D. Harvard University Massachusetts Eye and Ear Infirmary, Boston, MA, USA Juraj Payer Jr., M.D. Department of Plastic Surgery, Medical Faculty of Comenius University and University Hospital Bratislava, Bratislava, Slovakia Brandeis Clinic, Prague, Czech republic Luiz Haroldo Pereira, M.D. Department of Plastic Surgery, LH Clinic, Rio de Janeiro, Brazil Ivo Pitanguy, M.D. Ivo Pitanguy Institute, Rio de Janeiro, Brazil Michael Pollhammer, M.D. Section of Plastic, Aesthetic and Reconstructive Surgery Department of General Surgery, Kepler University Hospital, Linz, Austria Mohamad Raad Division of Plastic Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon Henrique N. Radwanski, M.D. Private Practice, Ivo Pitanguy Institute, Rio de Janeiro, Brazil Florence Rampillon, M.D. Clinique du Parc, Toulouse, France Bernard I. Raskin, M.D. Private Practice, Santa Clarita, CA, USA Angelo Rebelo, M.D. Clinica Milenio, Lisboa, Portugal Hans-Oliver Rennekampff, M.D. Department of Plastic Surgery, Hand Surgery, Burn Center University Hospital, RWTH Aachen, Germany, Aachen, Germany Jose Antonio Robles-Cervantes, M.D., M.Sc., Ph.D. Reconstructive Surgery Institute, Health Ministry, Guadalajara, Mexico Department of Internal Medicine, Jalisco Reconstructive Surgery Institute “José Guerrerosantos”, Guadalajara, Mexico INNOVARE, Cirugía Plástica Especializada, Guadalajara, Mexico Ricardo Luis Rodriguez, M.D. Cosmeticsurg, Plastic Surgery Clinic, Lutherville, MD, USA Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Medical School, Baltimore, MD, USA Pilar Rodriguez, M.D. Division of Plastic Surgery, Universidad Autonoma of Madrid, Hospital “Niño Jesus”, Madrid, Spain Rashi Rosenstock, M.D. Private Practice, San Jose, Costa Rica Mario Russo, M.D. Clinica Ruesch, Napoli, Italy Michel Saint-Cyr, M.D. Division of Plastic Surgery, Mayo Clinic, Rochester, MN, USA

xxx

Christopher J. Salgado, M.D. Division of Plastic, Aesthetic and Reconstructive Surgery, Miami, FL, USA María de Lourdes Sánchez-Aldana Robles, M.D. Department of Endocrinology, University of Guadalajara, Guadalajara, Mexico Gerhard Sattler, M.D. Rosenparkklinik, Center for Cosmetic Dermatologic Surgery, Rosenparkklinik, Darmstadt, Germany Salvatore Scandura, M.D., CAM Day Surgery Clinic, Monza, Italy Lecco, Italy Diego E. Schavelzon, M.D. B&S Centro de ExcelenciaenCirugiaPlastica, Bs. As., Argentina Wilfried Schmeller, M.D. Private Practice, Hanse-Klinik, Lübeck, Germany Jose A. Seijo-Cortes, M.D. Private Practice, Miami, FL, USA John E. Sherman, M.D. Division of Plastic Surgery, St. Barnabas Hospital, Bronx, NY, USA Division of Plastic Surgery, Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA Melvin A. Shiffman, M.D., J.D. Private Practice, Tustin, CA, USA Kayvan Shokrollahi, B.Sc., MBChB, M.Sc., LLM, MRCS Burns, Plastic and Reconstructive Surgery, Mersey Regional Burns and Plastic Surgery Unit, Liverpool, UK Tetsuo Shu, M.D. Private Practice, Tokyo, Japan Niten Singh, M.D. University of Washington, Seattle, WA, USA Boris Sommer, M.D. Rosenparkklinik, Center for Cosmetic Dermatologic Surgery, Darmstadt, Germany Aris Sterodimas, M.D., M.Sc., Ph.D., ARCS Plastic and Reconstructive Surgery Department, Regenerative Plastic Surgery Institute, IASO General Hospital, Athens, Greece Onder Tan, M.D. Department of Plastic Reconstructive and Aesthetic Surgery, Ataturk University, Erzurum, Turkey Ataturk Universitesi Tip Fakultesi, Plastik Rekonstruktif ve Estetik Cerrahi a.d, Yakutıye Arastırma Hastanesı, Erzurum, Turkey James W. Taylor, M.D. Department of Surgery, Division of Plastic Surgery, The University of Tennessee Medical Center, Knoxville, TN, USA Claudio Terranova, M.D. Section of Legal Medicine and Toxicology, Department of Legal Medicine, Occupational Medicine, Toxicology and Public Health, Hospital University of Padova, Padova, Italy

Contributors

Contributors

xxxi

Luiz S. Toledo, M.D. ISAPS National Secretary – UAE, Dubai, UAE Ren-Yeu Tsai, M.D. Department of Dermatology, Taipei Medical University, Taipei Municipal Wan-Fang Hospital, Taipei, Taiwan Stuart E. VanMeter, M.D. Department of Pathology, The University of Tennessee Medical Center, Knoxville, TN, USA Luis O. Vásconez, M.D. Division of Plastic Surgery, School of Medicine, University of Alabama, Birmingham, AL, USA Mountain Brook Plastic Surgery and Laser Center, Birmingham, AL, USA Marianne Wolters, M.D. Private Practice, Frankfurt, Germany Corrine Wong, MRCS. Division of Plastic Surgery, UT Southwestern, Dallas, TX, USA Kai Yuen Wong, M.A., M.B., BChir, MRCS Department of Plastic and Reconstructive Surgery, Cambridge Breast Unit at Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK Allan E. Wulc, M.D. Private Practice, Bryn Mawr, PA, USA Kamal Cherif-Zahar, M.D. Private Practice, Paris, France Antonio Zambrano, M.D. Division of Plastic Surgery, Universidad Autonoma of Madrid, Hospital “Niño Jesus”, Madrid, Spain Guido Zanetti, M.D. Department of Plastic Surgery, Sant’ Orsola Hospital, Bologna, Italy Giovanni Zoccali, M.D. Department of Health Sciences, Plastic Reconstructive and Aesthetic Surgery Section, University of L’Aquila, L’Aquila, Italy Department of Life, Health and Environmental Sciences, Plastic and Reconstructive Surgery Section, L’Aquila University, L’Aquila, Italy

Part I Anesthesia

1

Anesthesia for Liposuction Gary Dean Bennett

Abstract

As a result of advances in surgical technique and anesthesia practices, the safety and popularity of liposuction has continued to increase. With the assumption of a more critical role in the selection of the facility as well as the delivery of the anesthesia, the surgeon must also accept the responsibility to understand the requirements of safe anesthesia practices. At the same time, anesthesia providers must recognize the unique characteristics of the surgical techniques involved with liposuction. Although considered an extremely safe procedure, liposuction still has the potential for lifethreatening complications related to both surgery and anesthesia such as infection, hemorrhage, respiratory failure, congestive heart failure, and pulmonary embolism. Because of the unique population of patients who seek liposuction, there is a greater risk of comorbidities such as morbid obesity, diabetes mellitus, hypertension, sleep apnea, and airway abnormalities that may increase the risk of anesthesia and surgery. In light of these potential risks, each patient must be critically assessed preoperatively to determine if comorbidities exist that may increase the risk to the patient. In some cases, office-based procedure may not be the appropriate setting for the surgical procedure. Options for anesthesia techniques include local, local with sedation, regional, and general. The determination of the most appropriate anesthesia technique must be based on the type and extent of the liposuction and the patient’s individual preferences and risk factors. In cases involving large-volume liposuction, large

Dedication To my mother, Mary Ellen Bennett (1917–2009), whose enduring love, support, and encouragement know no boundaries. G.D. Bennett, M.D. Department of Anesthesiology, Chapman Medical Center, 2601 E Chapman Avenue, Orange, CA 92869, USA e-mail: [email protected] © Springer-Verlag Berlin Heidelberg 2016 M.A. Shiffman, A. Di Giuseppe (eds.), Liposuction: Principles and Practice, DOI 10.1007/978-3-662-48903-1_1

3

G.D. Bennett

4

volumes of infusate, potential hemodilution, occult blood loss, and unpredictable amounts of aspirate, perioperative fluid management presents a unique challenge to the anesthesia provider. Postoperative complications may be minimized with recovery and discharge criteria that meet strict nationally accepted standards.

1.1

Introduction

Nearly 75 % of all elective surgery is performed in an outpatient setting [1]. As much as 25 % of all outpatient surgeries are performed in physicians’ offices [2]. More than 50 % of aesthetic plastic surgeons perform most of their procedures in an office setting [3]. Clearly, economic considerations play a major role in the shift to ambulatory surgery. Because of greater efficiency, these outpatient surgical units have greater costeffectiveness [4]. Also, these outpatient settings allow more convenient access to medical treatment for the patient and provide a greater degree of privacy to the patient, particularly when aesthetic procedures are performed. Advances of monitoring capabilities and the adoption of monitoring standards of the American Society of Anesthesiologists (ASA) are credited for a reduction of perioperative morbidity and mortality [5]. Advances in pharmacology have resulted in a greater diversity of anesthetic agents with rapid onset, shorter duration of action, and reduced morbidity [6]. The advent of minimally invasive procedures has further reduced the need for hospital-based surgeries. Regulatory agencies such as American Association for Accreditation of Ambulatory Surgery (AAAASF) and Accreditation Association for Ambulatory Health Care (AAAHC) have helped establish minimum standards of care for surgical locations where anesthesia is administered. Ambulatory anesthesia has even become a formal subspecialty of anesthesia with the establishment of the Society for Ambulatory Anesthesia (SAMBA) in 1984. An evaluation of 1.1 million outpatients revealed that the mortality rate after ambulatory anesthesia was 1.5 per 100,000 cases [7]. No deaths occurred in 319,000 patients who were monitored in accordance with ASA standards [8, 9].

As a consequence of the shift away from hospital-based surgery, the surgeon has adopted a more important role in the medical decision making with respect to anesthesia. Frequently, the surgeon decides on the location of surgery, the extent of the preoperative evaluation, the type of anesthesia to be administered, the personnel to be involved in the care and monitoring of the patient, the postoperative pain management, and the discharge criteria used. Therefore, it is incumbent upon the surgeon to understand current standards of anesthesia practice. If the surgeon chooses to assume the role of the anesthesiologist, then he or she must adhere to the same standards that are applied to the anesthesiologist. While the morbidity and mortality of anesthesia have decreased [10, 11], risk awareness of anesthesia and surgery must not be relaxed.

1.2

The Surgical Facility

The surgeon is largely responsible for deciding which facility the procedure is to be performed. Surgical facilities may be divided into five main categories: 1. Hospital-based inpatient 2. Hospital-associated ambulatory surgical units 3. Freestanding surgical center with short-stay accommodations 4. Freestanding surgical centers without shortstay accommodations 5. Office-based operating rooms Each of these choices has distinct advantages and disadvantages. While convenient, economical, and private, office-based surgery is associated with up to four times the mortality as surgeries performed at certified freestanding ambulatory

1

Anesthesia for Liposuction

surgical centers [12]. Moreover, the types of complications that occur with surgeries in office-based settings are more severe than those that occur in the certified ambulatory surgical centers. Domino [13] reported that 21 % of the complications that occurred as a result of procedures performed in certified ambulatory surgical centers were fatal, whereas 64 % of the adverse outcomes that resulted from procedures performed in officebased settings were fatal. Forty-six percent of the complications that occurred in the office-based settings were considered to be avoidable, while only 13 % of the complications were considered avoidable in the certified ambulatory surgical centers. Grazer and de Jong [14] evaluated data of a survey of 1,200 aesthetic surgeons pertaining to liposuctions performed between 1994 and 1998. Of 496,245 procedures, 95 deaths were documented. Forty-six percent of these deaths followed procedures performed in office-based settings, while 26 % followed hospital-based procedures. Sedation of pediatric patients performed in the office results in a greater incidence of permanent neurological injury and death compared to when sedation is administered in the hospital [15]. Patients with a risk of ASA III undergoing major surgical procedures such as large volume should preferentially be treated at hospital-based or hospital-associated surgical units rather than an office-based operating room [16–18]. Ultimately, patient safety should be the paramount factor in the final decision. If the intended surgical procedure requires general anesthesia or enough sedative–analgesic medication to increase the probability of loss of the patient’s lifepreserving protective reflexes (LPPRs), then, according to the law in some states of the USA, the surgical facility must be accredited by one of the regulatory agencies (AAAASF, AAAHC, or the JCAHO) [19, 20]. However, many states in the USA currently do not have regulations pertaining to office-based procedures. Regardless of which type of facility is selected or the type of anesthesia planned, the standard of care should be equivalent to the standards set for hospitals [21]. Practice guidelines that specifically pertain to office-based procedures have been developed

5

by the ASA and the American Society of Plastic Surgeons [22–24]. The American Society for Aesthetic Plastic Surgery has decreed that its members only operate in office-based settings that have been accredited by any one of the three accrediting agencies. The operating room must be equipped with the type of monitors required to fulfill monitoring standards established by the ASA [25], as well as proper resuscitative equipment and resuscitative medications [26, 27]. The facility must be staffed by individuals with the training and expertise required to assist in the care of the patient [27, 28]. Emergency protocols must be established and rehearsed [29]. Optimally, the surgical facility must have ready access to a laboratory in the event a stat laboratory analysis is required. Finally, a transfer agreement with a hospital must be established in the event that an unplanned admission is required [26, 27].

1.2.1

Personnel

One of the most critical elements of a successful surgical outcome is the personnel assisting the surgeon. Qualified and experienced assistants may serve as valuable resources, potentially reducing morbidity and improving efficiency of the operating room [30, 31]. With an office-based operating room, the surgeon is responsible for selecting the operating room personnel. An anesthesiologist or a certified nurse anesthetist (CRNA) may administer anesthesia. The surgeon may prefer to perform the surgery using exclusively local anesthesia without parenteral sedation, especially in limited procedures such as liposuctions with the tumescent technique [32]. However, many surgeons add parenteral sedative or analgesic medications with the local anesthetic. If the surgeon chooses to administer parenteral sedative–analgesic medications, then another designated, licensed, preferably experienced individual should monitor the patient throughout the perioperative period [33]. The use of unlicensed, untrained personnel to administer parenteral sedative–analgesic medications and monitor patients may increase the risks to the

G.D. Bennett

6

patients. It is also not acceptable for the nurse monitoring the patients to double as a circulating nurse [34]. Evidence suggests that anesthesiarelated deaths more than double if the surgeon also administers the anesthesia [35]. Regardless of who delivers the anesthesia, the surgeon should preferably maintain current advanced cardiac life support (ACLS) certification, and all personnel assisting in the operating room and recovery areas must maintain basic life support certification [36]. At least one ACLS-certified health provider must remain in the facility until the patient has been discharged [37].

1.3

Preoperative Evaluation

The time and energy devoted to the preoperative preparation of the surgical procedure should be commensurate with the efforts expended on the evaluation and preparation for anesthesia. The temptation to leave preoperative anesthesia preparation of the patient as an afterthought must be resisted. Even if an anesthesiologist or CRNA is to be involved later, the surgeon bears responsibility for the initial evaluation and preparation of the patient. Thorough preoperative evaluation and preparation by the surgeon increase the patient’s confidence, reduce costly and inconvenient last-minute delays, and reduce overall perioperative risk to the patient [38]. If possible, the preoperative evaluation should be performed with the assistance of a spouse, parent, or significant other so that elements of the health history or recent symptoms may be more readily recalled. A comprehensive preoperative evaluation form is a useful tool to begin the initial assessment. Information contained in the history alone may determine the diagnosis of the medical condition in nearly 90 % of patients [39]. While a variety of forms are available in the literature, a checklist format to facilitate the patient’s recall is probably the most effective [40]. Regardless of which format is selected, information regarding all prior medical conditions, prior surgeries and types of anesthetics, current and prior medications, adverse outcomes to previous anesthetics or other medications, eating disorders, prior use

Table 1.1 Guidelines for preoperative testing in healthy patients (ASA 1–11) Age 12–40a 4–60 Greater than 60

Test CBC CBC, EKG CBC, BUN, glucose, ECG, CXR

Adapted from Roizen et al. [52] Pregnancy testing for potentially childbearing females is recommended a

of antiobesity medication, and use of dietary supplements which could contain ephedra should be disclosed by the patient. A family history of unexpected or early health conditions, such as heart disease, or unexpected reactions, such as malignant hyperthermia, to anesthetics or other medications should not be overlooked. Finally, a complete review of systems is vital to identifying undiagnosed, untreated, or unstable medical conditions that could increase the risk of surgery or anesthesia. Last-minute revelations of previously undisclosed symptoms, such as chest pain, should be avoided. Indiscriminately, ordered or routinely obtained preoperative laboratory testing is now considered to have limited value in the perioperative prediction of morbidity and mortality [41–45]. In fact, one study showed no difference in morbidity in healthy patients without preoperative screening tests versus a control group with the standard preoperative tests [46]. Multiple investigations have confirmed that the preoperative history and physical examination is superior to laboratory analysis in determining the clinical course of surgery and anesthesia [47–51]. Guidelines for the judicious use of laboratory screening, particularly in healthy patients, are now widely accepted (Table 1.1) [52]. Additional preoperative tests may be indicated for patients with prior medical conditions or risk factors for anesthesia and surgery (Table 1.2) [53]. Consultation from other medical specialists should be obtained for patients with complicated or unstable medical conditions. Patients with ASA III or VI risk designations should be referred to the appropriate medical specialist prior to elective surgery [33]. The consultant’s role is to determine if the patient has received optimal

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Anesthesia for Liposuction

Table 1.2 Common indications for additional riskspecific testing Electrocardiogram History: coronary artery disease, congestive heart failure, prior myocardial infarction, hypertension, hyperthyroidism, hypothyroidism, obesity, compulsive eating disorders, deep venous thrombosis, pulmonary embolism, smoking, chemotherapeutic agents, chemical dependency, chronic liver disease Symptoms: chest pain, shortness of breath, dizziness Signs: abnormal heart rate or rhythm, hypertension, cyanosis, peripheral edema, wheezing, rales, rhonchi Chest X-ray History: bronchial asthma, congestive heart failure, chronic obstructive pulmonary disease, and pulmonary embolism Symptoms: chest pain, shortness of breath, wheezing, unexplained weight loss, and hemoptysis Signs: cyanosis, wheezes, rales, rhonchi, decreased breath sounds, peripheral edema, abnormal heart rate or rhythm Electrolytes, glucose, liver function tests, BUN, creatinine History: diabetes mellitus, chronic renal failure, chronic liver disease, adrenal insufficiency, hypothyroidism, hyperthyroidism, diuretic use, compulsive eating disorders, diarrhea Symptoms: dizziness, generalized fatigue or weakness Signs: abnormal heart rate or rhythm, peripheral edema, abnormal breath sounds, jaundice Urinalysis History: diabetes mellitus, chronic renal disease, and recent urinary tract infection Symptoms: dysuria, urgency, frequency, and bloody urination Adapted from Roizen et al. [53]. Reproduced with permission from Bennett [346]

treatment and if the medical condition is stable. Additional preoperative testing may be considered necessary by the consultant. The medical consultant should also assist with stabilization of the medical conditions in the perioperative period if indicated. A complete written report from the medical consultant regarding the patient’s medical status should be given to the surgeon prior to scheduling the surgery. A hastily scribbled note from the medical consultant stating “cleared for surgery” is entirely inadequate and could potentially delay the surgery or result in perioperative complications. If the surgeon has concerns about a patient’s ability to tolerate anesthesia, a

7 Table 1.3 The American Society of Anesthesiologists’ physical status classification ASA class I: a healthy patient without systemic medical or psychiatric illness ASA class II: a patient with mild, treated, and stable systemic medical or psychiatric illness ASA class III: a patient with severe systemic disease that is not considered incapacitating ASA class IV: a patient with severe systemic, incapacitating and life-threatening disease not necessarily correctable by medication or surgery ASA class V: a patient considered moribund and not expected to live more than 24 h

telephone discussion with an anesthesiologist or even a formal preoperative anesthesia consultation may be indicated. Certain risk factors such as previously undiagnosed hypertension, cardiac arrhythmias, and bronchial asthma may be identified by a careful physical examination. Preliminary assessment of head and neck anatomy to predict possible challenges in the event endotracheal intubation is required may serve as an early warning to the anesthesiologist or CRNA even if a general anesthetic is not planned. For most ambulatory surgeries, the anesthesiologist or CRNA evaluates the patient on the morning of surgery.

1.3.1

Preoperative Risk Assessment

The ultimate goals of establishing a patient’s level of risk are to reduce the probability of perioperative morbidity and mortality. As previously discussed, the preoperative evaluation is the crucial component of determining the patient’s preoperative risk level. There is compelling evidence to suggest that the more coexisting medical conditions a patient has, the greater the risk for perioperative morbidity and mortality [33, 54]. Identification of preoperative medical conditions helps reduce perioperative mortality. A variety of indexing systems have been proposed to help stratify patients according to risk factors. One such classification, first proposed in 1941 [55], later modified in 1961 by Dripps et al. [56], and finally adopted by the ASA in 1984 (Table 1.3) [57], has emerged as the most widely

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accepted method of preoperative risk assessment. Numerous studies have confirmed the value of the ASA system in predicting which patients are at a higher risk for morbidity [58] and mortality [59–61]. Goldman and Caldera [62] established a multifactorial index based on cardiac risk factors. This index has repeatedly demonstrated its usefulness in predicting perioperative mortality [63, 64]. Physicians should incorporate one of the acceptable risk classification systems as an integral part of the preoperative evaluation. Multiple authors have documented the association between morbidity and mortality and the type of surgery [65–68]. The consensus of these studies confirms the increased risks of perioperative complications for more invasive surgeries, surgeries with multiple combined procedures, surgeries with prolonged duration, and surgeries with significant blood loss [69]. After reviewing 1,200 office-based facial plastic surgeries, 86 % of which exceeded 240 min, Gordon and Koch concluded that increased morbidity or mortality was not associated with the duration of surgery [70]. Nevertheless, the American Society of Plastic Surgeons has recommended that procedures not exceed 6 h and that procedures should be completed by 3:00 P.M. [23]. While studies correlating the amount of fat aspirate during liposuction with perioperative morbidity and mortality have not been performed, it would not be unreasonable to extrapolate conclusions from the previous studies and apply them to liposuction. Liposuction surgeries with less than 1,500-mL fat aspirate are generally considered less invasive procedures, while liposuctions aspirating more than 3,000 mL are considered major surgical procedures [27]. As blood loss exceeds 500 mL [69] or the duration of surgery exceeds 2 h, morbidity and mortality increase [58, 71]. Guidelines presented by the American Society for Dermatologic Surgery, the American Academy of Dermatology, the American Society of Plastic Surgeons, and the American Academy of Cosmetic Surgery have concluded that for office-based liposuction, the total supernatant fat and fluid should be limited to less than 5,000 mL [13].

1.4

Anesthesia in Patients with Preexisting Disease

Over the past 30 years, the morbidity and mortality of surgery have steadily declined [11]. One hypothesis to explain this decline has been the greater recognition of preoperative risk factors and the improved perioperative medical management of patients with coexisting diseases. Surgeons who perform outpatient surgery, especially office-based surgery, and particularly those surgeons who chose to administer sedative or analgesic medication, must appreciate how these medical conditions may increase the risk of anesthesia in the surgical patient. Furthermore, the surgeon should maintain a current working understanding of the evaluation and treatment of these medical conditions.

1.4.1

Cardiac Disease

Cardiac-related complications, including myocardial infarction and congestive heart failure, are the leading causes of perioperative mortality [72, 73]. Most patients with heart disease can be identified with a careful preoperative history and physical examination [51]. Since 80 % of all episodes of myocardial ischemia are silent [74, 75], a high index of suspicion for silent ischemia must be maintained when assessing asymptomatic patients with risk factors for heart disease, such as smoking, hypertension, diabetes mellitus, obesity, hyperlipidemia, or family history of severe heart disease. Patients with known cardiac disease must be evaluated by the internist or cardiologist to ensure the medical condition is optimally managed. When anesthesia is planned, patients with significant heart disease should preferentially undergo surgery at a hospital-based surgical unit rather than a physician’s office. Most studies have consistently demonstrated that patients who have suffered previous myocardial infarctions have a dramatically greater risk of reinfarction and death if surgery is performed less than 6 months after the cardiac event [76–78]. Subsequent studies suggesting a lower rate of reinfarction [79, 80] involved patients

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who were hospitalized in the intensive care unit with invasive hemodynamic monitoring. These studies may not have relevance to patients undergoing elective ambulatory surgery. At this time, the prudent choice remains to postpone elective surgeries for at least 6 months after myocardial infarction. Goldman et al. [62] established a cardiac risk index which has been useful in identifying patients with intermediate risk for cardiac complications in the perioperative period [63]. Patients with a score greater than 13 should be referred to a cardiologist for preoperative evaluation. Dipyridamole thallium scanning and dobutamine stress echocardiography have proven useful in predicting adverse perioperative cardiac events [81]. One reliable and simple screening method to evaluate cardiac status is exercise tolerance. The ability to increase the heart rate to 85 % of the age-adjusted maximal heart rate is a reliable predictor of perioperative cardiac morbidity [82]. Cardiac conditions that warrant further evaluation include recent myocardial infarction, new onset or uncompensated heart failure, severe, unstable angina, symptomatic dysrhythmias, Mobitz II or third degree heart block, and severe valvular disease. Otherwise, extensive cardiac testing may have limited usefulness in the asymptomatic patient [83]. Despite years of investigation, no one anesthetic technique or medication has emerged as the preferential method to reduce the incidence of perioperative complications in patients with cardiac disease [84, 85]. Regardless of which anesthesia technique is selected, scrupulous monitoring should serve as the framework for safe anesthetic management. Wide hemodynamic fluctuations and tachycardia must be avoided to prevent ischemic episodes in the perioperative period.

1.4.2

Obesity

The prevalence of obesity (body mass index or BMI >30) in the USA is estimated to be 34 % of the population, while the prevalence of overweight and obesity combined (BMI >25) is

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estimated to be 68 % [86]. It is reasonable to assume that patients undergoing certain aesthetic surgical procedures such as large-volume liposuction have a greater incidence of obesity. The most widely accepted method of quantifying the level of obesity is the body mass index (BMI), which is determined by weight (kg)/height (M) [2]. Patients with a BMI over 25 are considered overweight; those with a BMI over 30 are considered obese, while a BMI over 35 indicates morbid obesity [87]. The risk factors associated with obesity such as diabetes mellitus, hypertension, heart disease, sleep apnea, and occult liver disease [88] should concern clinicians administering anesthesia to patients with obesity. A thorough preoperative evaluation must rule out these occult risk factors prior to elective surgery. Anatomical abnormalities make airway control challenging [89] and endotracheal intubation hazardous [90]. The combination of a higher gastric volume and lower pH with a higher frequency of esophageal reflux results in a higher risk of pulmonary aspiration [91] in the obese patient; pulmonary function can be severely restricted even in an upright position [92]. In the supine position, pulmonary function is even further reduced [93]. Pulmonary function is further compromised in the anesthetized patient. Because of these cardiopulmonary abnormalities, obese patients develop hypoxemia more quickly [94]. This respiratory impairment may persist up to 4 days after surgery [95]. Even distribution and metabolism of medications vary significantly and often unpredictably in the obese patient [96]. Given the increased risk of perioperative morbidity and mortality of anesthesia, morbidly obese patients (BMI >35) undergoing major surgery and anesthesia of any type should preferentially be restricted to a hospital-based surgical facility. In general, these patients should not be considered candidates for ambulatory surgery. Anesthesia delivered in the office setting should be restricted to patients with BMI less than 30. While premedication with metoclopramide (Reglan®, Wyeth Pharmaceuticals), a dopaminereceptor antagonist, increases gastric motility and lowers esophageal sphincter tone [97, 98], a

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troubling association between single-dose metoclopramide and tardive dyskinesia [99] has limited the routine use of this medication in preoperative preparation of the patient. A histamine receptor blocking agent such as ranitidine (Zantac®, Glaxo) used with metoclopramide the evening before and the morning of surgery reduces the risk of pulmonary aspiration [100]. Because of the increased risks of deep venous thrombosis (DVT) [101] and pulmonary embolism (PE) in the obese patient [102], prophylactic measures such as lower extremity pneumatic compression devices and early ambulation should be used. An undetermined number of patients selfadminister herbal dietary supplements. Many of these supplements contain ephedra alkaloids which may predispose the patient to perioperative hypertension and cardiac arrhythmias [103]. Some of these herbal products may result in the increased incidence of bleeding as a result of intrinsic anticoagulant properties of these herbal supplements similar to warfarin. Antiobesity medications such as aminorex fumarate, dexfenfluramine (Redux®, Wyeth-Ayerst), fenfluramine (Pondimin®, AH Robins), and phentermine (Ionamin®, Adipex-P®, Fastin®, Oby-Cap®, Obenix®, Oby-trim®, and Zantryl®, various manufacturers) are associated with pulmonary hypertension and valvular heart disease, even with as little as 2 months of use. While most patients develop symptoms such as palpitations, dyspnea, chest pain, irregular heart rate, murmur, and edema, some patients remain asymptomatic [104]. Patients who have developed pulmonary hypertension and valvular heart disease as a result of these medications are predisposed to fatal cardiac arrhythmias, congestive heart failure, and intractable hypotension. Some authors advocate a cardiac evaluation with echocardiogram and continuous wave Doppler imaging with color-flow examination for any patient who has taken these antiobesity medications prior to surgery. Sustained hypotension may not respond to ephedrine, a popular vasopressor. Phenylephrine is the treatment of choice for hypotension occurring in these patients [104].

1.4.3

Hypertension

Early studies revealed a significantly increased risk of perioperative mortality in patients with untreated hypertension [105, 106]. The reduction in mortality from cardiovascular and cerebrovascular disease resulting from proper treatment of hypertension has been widely accepted [107– 109]. Although still somewhat controversial, most authors concur that preoperative stabilization of hypertension reduces perioperative cardiovascular complications such as ischemia [110–112]. Patients with undiagnosed or poorly controlled hypertension should be identified early in the preoperative preparation process and referred to the family physician or internist for evaluation and treatment. Physicians should not mistakenly attribute severe hypertension to the patient’s preoperative anxiety. Because of the risk of rebound hypertension, antihypertension medications should be continued up to and including the morning of surgery [113], except for angiotensin-converting (ACE) inhibitors, which have been associated with hypotension during induction of general anesthesia [114]. Mild to moderate perioperative hypertension may be a response to inadequate general or local anesthesia or pain control. In these cases, pain is usually accompanied by other signs, such as the patient’s complaints, tachycardia, and tachypnea. If hypertension persists despite additional local anesthetic or analgesic medication, then treatment of the blood pressure is indicated. Moderate to severe blood pressure elevations occurring during the surgery or during recovery should be treated using one or more of the antihypertensive agents available. Perioperative hypertension, especially if the hypertension is accompanied by tachycardia, may be treated with a beta-adrenergic blocking agent such propranolol in judiciously administered, intravenous doses of 0.5 mg iv at 10–15min intervals. Even small doses of a beta-adrenergic blocking agent have been shown to reduce the incidence of cardiac ischemia [111]. Labetalol (Normodyne®, Trandate®), an antihypertensive agent with combined alpha-adrenergic

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and beta-adrenergic blocking properties, administered in 5–10-mg doses iv every 10 min, is also a safe and effective alternative to treat both hypertension and tachycardia [115]. Nifedipine (Procardia®, Pfizer), 10 mg sl, a potent systemic and coronary arteriolar dilator, effectively reduces blood pressure and may be administered in a conscious patient. The effect of nifedipine may be additive if given with narcotics or inhalational anesthetic agents. Because nifedipine and lidocaine are both highly protein bound, caution must be exercised when administering nifedipine after high-dose lidocaine tumescent anesthesia has been administered to avoid possible toxic effects of the lidocaine [116]. For severe hypertension, hydralazine (Apresoline®, Novartis), a potent vasodilator, may be useful in 2.5–5-mg doses iv at 10–15-min intervals. The effects of hydralazine may be delayed up to 20 min and its effects prolonged. Hydralazine may cause tachycardia or hypotension, especially if the patient is hypovolemic [117].

1.4.4

Diabetes Mellitus

Although patients with diabetes mellitus have a substantially increased surgical mortality rate than nondiabetic patients [118], these complications are more likely to be a consequence of the end-organ disease such as cardiovascular disease, renal disease, and altered wound healing [54, 119, 120]. While evidence suggests that tight control of blood sugar in insulin-dependent diabetics slows the progression of end-organ disease [121], tight control is associated with additional risks such as hypoglycemia and even death [122]. The preoperative evaluation should identify diabetic patients with poor control as well as medical conditions associated with diabetes such as cardiovascular disease and renal insufficiency. Diabetic patients have a greater incidence of silent myocardial ischemia [123]. Minimum preoperative analysis includes fasting blood sugar, glycosylated hemoglobin, electrolytes, BUN, creatinine, and EKG. If any doubt exists regarding the patient’s medical stability, consultation should be obtained from the diabetologist,

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cardiologist, or nephrologist. Patients with brittle diabetes or with other coexisting medical conditions should be referred to a hospital-based surgical unit, especially if general anesthesia is contemplated. The goal of perioperative management of stable type I or type II diabetic patients is primarily to avoid hypoglycemia. Although patients are generally NPO after midnight prior to surgery, a glass of clear juice may be taken up to 2 h prior to surgery to avoid hypoglycemia. Patients with type I diabetes should not administer insulin, and patients with type II diabetes should not take the oral hypoglycemia agents the morning of surgery. Diabetic patients should be scheduled the first case in the morning to minimize the risk of hypoglycemia during the NPO period. After the patient arrives, a preoperative fasting glucose should be checked, and then an infusion of 5 % dextrose is generally initiated at 1–2 mL/kg/h and continued until oral fluids are tolerated in the recovery period. Usually, one half of the patient’s scheduled dose of insulin is administered after the intravenous dextrose is begun [124]. For surgeries longer than 2 h, at least one peripheral blood glucose should be measured, especially if the patient is receiving general anesthesia. Blood glucose above 200 mg/dL may be effectively managed with a sliding scale of insulin [125]. Treatment regimens directed toward tighter control of the blood sugar, such as continuous insulin infusions, do not necessarily improve the perioperative outcome [126, 127]. Current consensus for patients with type 1 diabetes mellitus recommends maintaining intraoperative blood glucose at or slightly above the patient’s usually maintained levels [128]. It is imperative that prior to discharge, patients be able to tolerate oral intake without nausea and vomiting. A final glucose level should be checked prior to discharge.

1.4.5

Pulmonary Disease

Bronchial asthma, chronic bronchitis, chronic obstructive pulmonary disease, obesity, history of smoking, and recent upper respiratory infection

G.D. Bennett

12 Table 1.4 Grade of dyspnea while walking Level 0 1 2 3 4

Clinical response No dyspnea Dyspnea with fast walking only Dyspnea with one or two blocks walking Dyspnea with mild exertion (walking around the house) Dyspnea at rest

Adapted from Boushy et al. [130]. Reproduced with permission from Bennett [346]

are the most common medical conditions which may influence pulmonary function in the perioperative period. An estimated 4.5 % of the population may suffer some form of reactive airway disease [129]. If these medical conditions are identified in the preoperative history, a thorough evaluation of the patient’s pulmonary function should ensure. As with other medical conditions, a careful history may help separate patients with these medical conditions into low- and high-risk groups, especially since the degree of preoperative respiratory dyspnea closely correlates with postoperative mortality [130]. Using a simple grading scale, the patients’ preoperative pulmonary function can be estimated (Table 1.4). Patients with level 2 dyspnea or greater should be referred to a pulmonologist for more complete evaluation and possibly further medical stabilization. The benefits of elective surgery in patients with level 3 and 4 dyspnea should be carefully weighed against the increased risks. Certainly, this group of patients would not be considered good candidates for outpatient surgery. Since upper respiratory infection (URI) may alter pulmonary function for up to 5 weeks [131], major surgery requiring general endotracheal anesthesia should be postponed, especially if the patient suffers residual systems, such as fevers, chills, coughing, and sputum production, until the patient is completely asymptomatic. While many studies confirm that patients who smoke more than one to two packs of cigarettes daily have a higher risk of perioperative respiratory complications than nonsmokers, cessation of smoking in the immediate preoperative period may not improve patients’ outcome. In fact, patients’ risk of perioperative complications may

actually increase if smoking is stopped immediately prior to surgery. A full 8 weeks may be required to successfully reduce perioperative pulmonary risk [132]. If the physical examination of asthmatic patients reveals expiratory wheezing, conventional wisdom dictates that potentially reversible bronchospasm should be optimally treated prior to surgery. Therapeutic agents include inhaled or systemic, selective beta-adrenergic receptor type 2 agonists such as albuterol (Ventolin®, Glaxo, Proventil®, Proair®, Teva) as a sole agent or in combination with anticholinergic such as ipratropium (Atrovent®, Boehringer Ingelheim) and locally active corticosteroid such as beclomethasone dipropionate (Beclovent®, Vanceril®) medications [133]. Continuing the asthmatic medications up to the time of surgery [134] and postoperative use of incentive spirometry [135] have been shown to reduce postoperative pulmonary complications. With regard to treated stable pulmonary disease, there are no conclusive, prospective, randomized studies to indicate which anesthesia technique or medications would improve patient outcome.

1.4.6

Sleep Apnea Syndrome

Sleep apnea syndrome (SAS) may be a result of an abnormality of the respiratory control center of the brain in central sleep apnea or obstruction of the upper airway in obstructive sleep apnea (OSA) which is the most common cause of SAS. Many patients present with a combination of central sleep apnea and OSA, also referred to as mixed sleep apnea. According to the National Commission on Sleep Disorders Research, nearly 20 million Americans suffer with SAS. Unfortunately, the majority of patients with SAS remain undiagnosed [136]. The incidence of sleep apnea increases among obese patients [136, 137]. Since the target population for many aesthetic surgical procedures such as large-volume liposuction includes patients with morbid obesity, SAS becomes a more relevant concern.

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OSA is a result of a combination of excessive pharyngeal adipose tissue and inadequate pharyngeal soft tissue support [138]. During episodes of sleep apnea, patients may suffer significant and sustained hypoxemia. As a result of the pathophysiology of OSA, patients develop left and right ventricular hypertrophy [139]. Consequently, patients have a higher risk of ventricular dysrhythmias and myocardial infarction [140]. Most medications used during anesthesia, including sedatives such as diazepam and midazolam, hypnotics such as propofol, and analgesics such as fentanyl, meperidine, and morphine, increase the risk for airway obstruction and respiratory depression in patients with SAS [141]. Death may occur suddenly and silently in patients with inadequate monitoring [142]. A combination of anatomical abnormalities makes airway management, including mask ventilation and endotracheal intubation, especially challenging in obese patients with OSA [143]. Perioperative monitoring, including visual observation, must be especially vigilant to avoid perioperative respiratory arrest in patients with SAS. For patients with severe SAS, particularly those with additional coexisting medical conditions such as cardiac or pulmonary disease, surgery performed on an outpatient basis is not appropriate. For these high-risk patients, monitoring should continue in the intensive care unit until the patients no longer require parenteral analgesics. If technically feasible, regional anesthesia may be preferable in patients with severe SAS. During the preoperative evaluation of the obese patient, a presumptive diagnosis of OSA may be made if the patient has a history of loud snoring, long pauses of breathing during sleep (more than 10 s), as reported by the spouse, or daytime somnolence [144]. If SAS is suspected, patients should be referred for a sleep study to evaluate the severity of the condition. For severe OSA preoperative continuous positive airway pressure (CPAP) should be initiated 2 weeks prior to the scheduled surgery. For these patients CPAP should be continued in the postoperative recovery preferably with the patient’s own CPAP equipment [145]. Postoperatively, patients with

13

any history of SAS should not be discharged if they appear lethargic or somnolent [146]. These patients should not be discharged until oxygen saturation is maintained on room air. Patients with severe OSA should not be discharged to an unmonitored setting for the first 24 h [145].

1.4.7

Malignant Hyperthermia Susceptibility

Patients with susceptibility to malignant hyperthermia (MH) can be successfully managed on an outpatient basis after 4 h of postoperative monitoring [147]. Triggering agents include volatile inhalation agents such as halothane, enflurane, desflurane, isoflurane, and sevoflurane. Even trace amounts of these agents lingering in an anesthesia machine or breathing circuit may precipitate an MH crisis. Succinylcholine and chlorpromazine are other commonly used medications which are known triggers of MH. However, many non-triggering medications may be safely used for local anesthesia, sedation–analgesia, postoperative pain control, and even general anesthesia [148]. Nevertheless, anesthesia for patients suspected to have MH susceptibility should not be performed at an office-based setting. Standardized protocol to manage MH (available from the Malignant Hyperthermia Association of the United States, MHAUS), supplies of dantrolene (Dantrium®, Procter and Gamble Pharmaceuticals), and cold intravenous fluids should be at the surgical facility for all patients. Preferably, patients with MH susceptibility should be referred to an anesthesiologist for prior consultation. Intravenous dantrolene [149] and iced intravenous fluids are still the preferred treatment for MH. MHAUS may be contacted at 800–98MHAUS, and the MH hotline is 800-MH HYPER.

1.5

Anesthesia for Liposuction

Anesthesia may be divided into four broad categories: local anesthesia, local anesthesia combined with sedation, regional anesthesia, and general anesthesia. The ultimate decision to

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Table 1.5 Clinical pharmacology of commonly used local anesthetics for infiltrative anesthesia in adults (70 kg) Concentration Agent (%) Lidocaine 1.0 Chloroprocaine 1.0 Mepivacaine 1.0 Prilocaine 1.0 Etidocaine 0.5 Bupivacaine 0.25 Ropivacaine 0.2 Levobupivacaine 0.25

Duration of action (min) 30–90 20–30 45–90 30–90 120–180 120–240 120–240 120–240

Maximum dose (without epinephrine) mg/kg Total mg Total ml 4 300 30 10 700 70 4 300 30 5 350 35 4 300 60 2.5 175 70 2.7 200 80 2.5 185 75

Duration of action (min) 60–120 30–60 60–120 60–120 180–240 180–240 180–240 180–240

Maximum dose (with epinephrine) mg/kg Total mg 7 500 14 1,000 7 500 8 550 5.5 400 3 225 2.7 250 3 225

mg/kg 50 100 50 55 80 90 100 90

Adapted from Covino and Wildsmith [150] and Berde and Strichartz [151] Reproduced with permission from Bennett [346] Individual doses may vary depending on ethnic background, individual sensitivities, body habitus, or coexisting medical conditions

select the type of anesthesia depends on the type and extent of the surgery planned, the patient’s underlying health condition, and the psychological disposition of the patient.

1.5.1

Local Anesthesia

A variety of local anesthetics are available for infiltrative anesthesia. The selection of the local anesthetic depends on the duration of anesthesia required and the volume of anesthetic needed. The traditionally accepted, pharmacological profiles of common anesthetics used for infiltrative anesthesia for adults are summarized in Table 1.5 [150, 151]. The maximum doses may vary widely depending on the type of tissue injected [152], the rate of administration [153], the age, underlying health, and body habitus of the patient [154], the degree of competitive protein binding [155], and possible cytochrome inhibition of concomitantly administered medications [156]. The maximum tolerable limits of lidocaine (Xylocaine®) have been redefined with the development of the tumescent anesthetic technique [157]. Lidocaine doses up to 35 mg/kg were found to be safe if administered in conjunction with dilute epinephrine during liposuction [158]. With the tumescent technique, peak plasma levels occur 6–24 h after administration [158, 159]. Doses up to 55 mg/kg have been found to be within the therapeutic

Table 1.6 Medications inhibiting cytochrome oxidase P450 3A4 Amiodarone Atenolol Carbamazepine Cimetidine Clarithromycin Chloramphenicol Cyclosporin Danazol Dexamethasone Diltiazam Erythromycin Fluconazole Flurazepam

Fluoxetine Itraconazole Isoniazid Labetolol Ketoconazole Methadone Methylprednisolone Metoprolol Miconazole Midazolam Nadolol Nefazodone Nicardipine

Nifedipine Paroxetine Pentoxifylline Pindolol Propofol Propranolol Quinidine Sertraline Tetracycline Terfenadine Thyroxine Timolol Triazolam Verapamil

Adapted from Shiffman [156] Reproduced with permission from Bennett [346]

safety margin [160]. However, guidelines by the American Academy of Cosmetic Surgery recommend a maximum dose of 45–50 mg/kg [37]. Using a segmental infiltration technique and moderate sedation, Wang et al. [161] effectively reduced the concentration of lidocaine in tumescent fluid to 0.0252 % in high-volume liposuction. Since lidocaine is predominantly eliminated by hepatic metabolism, specifically cytochrome oxidase P450 34A, drugs that inhibit this microsomal enzyme may increase the potential of lidocaine toxicity [156, 162]. Table 1.6 [156] lists

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some of the more common medications, which inhibit the cytochrome oxidase system. Propofol and Versed, commonly used medications for sedation and hypnosis during liposuction, are also known to be cytochrome P450 inhibitors. However, since the duration of action of these drugs is only 1–4 h, the potential inhibition should not interfere with lidocaine at the peak serum level 6–12 h later. Lorazepam is a sedative which does not interfere with cytochrome oxidase and is preferred by some authors [163]. Certainly, significant toxicity has been associated with high doses of lidocaine as a result of tumescent anesthesia during liposuction [158]. The systemic toxicity of local anesthetic has been directly related to the serum concentration by many authors [32, 155, 158–160, 163, 164]. Early signs of toxicity, usually occurring at serum levels of about 3–4 mg mL for lidocaine, include circumoral numbness, lightheadedness, and tinnitus. As the serum concentration increases toward 8 mg/mL, tachycardia, tachypnea, confusion, disorientation, visual disturbance, muscular twitching, and cardiac depression may occur. At still higher serum levels above 8 mg/mL, unconsciousness and seizures may ensue. Complete cardiorespiratory arrest may occur between 10 and 20 mg/mL [155, 163, 164]. However, the toxicity of lidocaine may not always correlate exactly with the plasma level of lidocaine presumably because of the variable extent of protein binding in each patient and the presence of active metabolites [155] and other factors already discussed including the age, ethnicity, health, and body habitus of the patient and additional medications. Ropivacaine (Naropin®, AstraZeneca) and levobupivacaine are long-lasting local anesthetics with less cardiovascular toxicity than bupivacaine and may be a safer alternative to bupivacaine if a local anesthetic of longer duration is required [151, 165]. The cardiovascular toxicity of bupivacaine and etidocaine is much greater than lidocaine [151, 165, 166]. While bupivacaine (Marcaine®, Sensorcaine®) toxicity has been associated with sustained ventricular tachycardia and sudden profound cardiovascular collapse [167, 168], the incidence of ventricular dysrhythmias has not been

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as widely acknowledged with lidocaine or mepivacaine (Carbocaine®) toxicity. In fact, ventricular tachycardia or fibrillation was not observed despite the use of supraconvulsant doses of intravenous doses of lidocaine, etidocaine, or mepivacaine in the animal model [165]. Levobupivacaine (Chirocaine®, AstraZeneca), an S(−) isomer of the racemic bupivacaine, has emerged as another alternative local anesthetic with a prolonged duration of action for infiltrative anesthesia, peripheral nerve blocks, and central anesthesia, including epidural and intrathecal anesthesia. Except for a somewhat longer duration of the sensory block in central anesthesia, the pharmacokinetics of levobupivacaine is virtually indistinguishable from bupivacaine. However, levobupivacaine has a wider therapeutic safety margin with less cardiotoxic potential and less CNS and cardiac depressant effects compared to bupivacaine [169, 170]. Indeed, during administration of infiltrative lidocaine anesthesia, rapid anesthetic injection into a highly vascular area or accidental intravascular injection leading to sudden toxic levels of anesthetics resulting in sudden onset of seizures or even cardiac arrest or cardiovascular collapse has been documented [171, 172]. One particularly disconcerting case presented by Christie [173] confirms the fatal consequence of a lidocaine injection of 200 mg in a healthy patient. Seizure and death occurred following a relatively low dose of lidocaine and a serum level of only 0.4 mg/100 mL or 4 mg/mL. A second patient suffered cardiac arrest with a blood level of 0.58 mg/100 mL or 5 mg/mL [174]. Although continued postmortem metabolism may artificially reduce serum lidocaine levels, the reported serum levels associated with mortality in these patients were well below the 8–20 mg/mL considered necessary to cause seizures, myocardial depression, and cardiorespiratory arrest. The 4 mg/mL level reported by Christie [173] is uncomfortably close to the maximum serum levels reported by Ostad et al. [160] of 3.4 and 3.6 mg/mL following tumescent lidocaine doses of 51.3 and 76.7 mg/kg, respectively. Similar near toxic levels were reported in individual patients receiving about 35 mg/kg of lidocaine by

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Samdal et al. [174]. Pitman and Klein [175] reported that toxic manifestations occurred 8 h postoperatively after a total dose of 48.8 mg/kg which resulted from a 12-h plasma lidocaine level of 3.7 mg/kg. Ostad et al. [160] conclude that because of the poor correlation of lidocaine doses with the plasma lidocaine levels, an extrapolation of the maximum safe dose of lidocaine for liposuction cannot be determined. Given the devastating consequences of lidocaine toxicity, physicians must exercise extreme caution while attempting to push the acceptable safe limits to ever-higher levels of tumescent anesthesia. Physicians must consider the important variables affecting susceptibility of individual patients to lidocaine toxicity before “boldly going where no surgeon has gone before,” especially since plasma lidocaine levels typically peak after the patient is at home. Topical anesthetics in a phospholipid base have become more popular as a technique for administering local anesthetics. Application of these topical agents may provide limited anesthesia over specific areas such as the face for minor procedures including limited laser resurfacing. EMLA (eutectic mixture of local anesthetics), a combination of lidocaine and prilocaine, was the first commercially available preparation. This topical anesthetic preparation must be applied under an occlusive dressing at least 60 min prior to the procedure to develop adequate local anesthesia [176]. Even after 60 min, the anesthesia may not be complete and the patient may still experience significant discomfort. Many physicians prefer to use their own customized formula, which they obtain from a compounding pharmacy. Frequently, the patient is given the topical anesthetic to be applied at home prior to arrival to the office or surgical center. However, these compounded formulas are not monitored by the FDA, and compounding pharmacies may vary in the quality control standards. Some of the formulas may contain up to 40 % local anesthetics in various combinations. This type of preparation could deliver up to 400 mg per gram of ointment to the patient. The application of 30 g of a compounded formula containing a total of 40 % local anesthetic over a

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wide area with subsequent occlusive dressing could expose the patient to 12,000 mg of local anesthetic. Studies have demonstrated that systemic absorption of local anesthetic after application of topical local anesthetic is limited to less than 5 % [177, 178]. Even with limited systemic absorption, the development of toxic blood levels of local anesthetic, with the ensuing catastrophic results, would not be hard to envision if a large quantity of a concentrated compounded anesthetic ointment were applied under an occlusive dressing. There has been at least one case report of death after application of a compounded local anesthetic ointment while preparing for aesthetic surgery [179]. Physicians who prescribe compounded topical local anesthetics to patients prior to surgery should reevaluate the concentration of these medications as well as the total dose of medication that may be delivered to the patient. Patients who report previous allergies to anesthetics may present a challenge to surgeons performing liposuction. Although local anesthetics of the amino ester class such as procaine, chloroprocaine, tetracaine, or cocaine are associated with allergic reactions, true allergic phenomena to local anesthetics of the aminoamide class, such as lidocaine, bupivacaine, ropivacaine, and mepivacaine, are extremely rare [175, 180]. Allergic reactions may occur to the preservative in the multidose vials. Tachycardia and generalized flushing may occur with rapid absorption of the epinephrine contained in some standard local anesthetic preparations. The development of vasovagal reactions after injections of any kind may cause hypotension, bradycardia, diaphoresis, pallor, nausea, and loss of consciousness. These adverse reactions may be misinterpreted by the patient and even the physician as allergic reactions [180]. A careful history from the patient describing the apparent reaction usually clarifies the cause. If there is still concern about the possibility of true allergy to local anesthetic, then the patient should be referred to an allergist for skin testing [181]. In the event of a seizure following a toxic dose of local anesthetic, proper airway management and oxygenation maintenance are critical. Seizure

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activity may be aborted with intravenous diazepam, 10–20 mg intravenously (iv); midazolam, 5–10 mg iv; or thiopental, 100–200 mg iv. Although the ventricular arrhythmias associated with bupivacaine toxicity are notoriously intractable [167, 168], treatment is still possible using large doses of atropine, epinephrine, and bretylium [182, 183]. Some studies indicate that lidocaine or amiodarone should not be used during resuscitation of local anesthetic-induced arrhythmias [151, 184]. Numerous case reports have emerged describing successful resuscitation of intractable ventricular arrhythmias and asystole which were induced by acute bupivacaine, lidocaine, and ropivacaine toxicity using intravenous infusions of 20 % lipid emulsions (Intralipid®, Baxter, Liposyn®, Hospira) [185–190]. Research in animals has confirmed the rescue effects of intravenous lipid emulsions for local anesthetic toxicity [191]. The recommended dosage of 20 % lipid emulsion is 1.5 mL/kg iv over 1 min, repeated every 5 min until adequate circulation is restored [192]. Marwick et al. [190] reported recurrence of ventricular tachycardia 40 min after successful resuscitation with lipid infusion. For surgical centers where local anesthetics are routinely used for large cases or regional anesthesia, having at least 1,000 mL of a 20 % lipid emulsion in reserve for emergency resuscitation of local anestheticinduced cardiac arrhythmias has been suggested as a reasonable precaution [190]. Pain associated with local anesthetic administration is due to pH of the solution and may be reduced by the addition of 1 mEq of sodium bicarbonate to 10 mL of anesthetic [193].

1.5.2

Sedative–Analgesic Medications (SAM)

Many aesthetic surgical procedures are performed with a combination of local anesthesia and supplemental sedative–analgesic medications (SAM) administered orally (po), intramuscularly (im), or intravenously (iv). Procedures performed under local or regional anesthesia generally are accompanied with SAM. The goals

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of administering supplemental medications are to reduce anxiety (anxiolysis), the level of consciousness (sedation), and unanticipated pain (analgesia) and, in some cases, to eliminate recall of the surgery (amnesia). Sedation may be defined as the reduction of the level of consciousness, usually resulting from pharmacological intervention. The level of sedation may be further divided into four broad categories: minimal sedation (anxiolysis), moderate sedation/analgesia (formerly referred to as “conscious sedation”), deep sedation/analgesia, and general anesthesia (Table 1.7) [194]. Conscious sedation, an outdated term, is occasionally still used to distinguish a lighter state of anesthesia with a higher level of mental functioning whereby the life-preserving protective reflexes (LPPRs) are independently and continuously maintained. Furthermore, the patient is able to respond appropriately to physical and verbal stimulation [195]. Life-preserving protective reflexes (LPPRs) may be defined as the involuntary physical and physiological responses that maintain the patient’s life which, if interrupted, result in inevitable and catastrophic physiological consequences. The most obvious examples of LPPRs are the ability to maintain an open airway, swallowing, coughing, gagging, and spontaneous breathing. Some involuntary physical movements such as head turning or attempts to assume an erect posture may be considered LPPRs if these reflex actions occur in an attempt to improve airway patency such as expelling oropharyngeal contents. The myriad of homeostatic mechanisms to maintain blood pressure, heart function, and body temperature may even be considered LPPRs. As the level of consciousness is further depressed to the point that the patient is not able to respond purposefully to verbal commands or physical stimulation, the patient enters into a state referred to as deep sedation. In this state, there is a significant probability of loss of LPPRs. Ultimately, as total loss of consciousness occurs and the patient no longer responds to verbal command or painful stimuli, the patient enters a state of general anesthesia [191, 192, 194, 195]. During general anesthesia, the patient most likely

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Table 1.7 Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia Minimal sedation (anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes and ventilatory and cardiovascular functions are unaffected Moderate sedation/analgesia (“conscious sedation”) is a drug-induced depression of consciousness during which patients respond purposefullya to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained Deep sedation/analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefullya following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to produce a given level of sedation should be able to rescueb patients whose level of sedation becomes deeper than initially intended. Individuals administering moderate sedation/analgesia (“conscious sedation”) should be able to rescueb patients who enter a state of deep sedation/analgesia, while those administering deep sedation/analgesia should be able to rescueb patients who enter a state of general anesthesia Reproduced with permission from Wolters Kluwer [194] Monitored anesthesia care does not describe the continuum of depth of sedation; rather, it describes “a specific anesthesia service in which an anesthesiologist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure” a Reflex withdrawal from a painful stimulus is NOT considered a purposeful response b Rescue of a patient from a deeper level of sedation than intended is an intervention by a practitioner proficient in airway management and advanced life support. The qualified practitioner must correct adverse physiological consequences of the deeper-than-intended level of sedation (such as hypoventilation, hypoxia and hypotension) and returns the patient to the originally intended level of sedation. It is not appropriate to continue the procedure at an unintended level of sedation

loses the LPPRs and cardiovascular function may be impaired. Table 1.8 [194] summarizes the changes that occur during the four stages of sedation analgesia. In actual practice, the delineation between the levels of sedation becomes challenging at best. The loss of consciousness occurs as a continuum. With each incremental change in the level of consciousness, the likelihood of loss of LPPRs increases. Since the definition of conscious sedation is vague, current ASA Guidelines consider the term sedation–analgesia a more relevant term [33]. Monitored anesthesia care (MAC) has been generally defined as the medical management by a qualified physician or certified registered nurse anesthetist (CRNA) of a patient receiving local anesthesia during a diagnostic or therapeutic procedure with or without the use of supplemental medications to support the life of and provide

comfort and safety to the patient [196]. MAC usually refers to services provided by the anesthesiologist or the CRNA. The term “local standby” is no longer used because it mischaracterizes the purpose and activity of the anesthesiologist or CRNA. Surgical procedures performed using a combination of local anesthetic and SAM usually have a shorter recovery time than similar procedures performed under regional or general anesthesia [197]. Using local anesthesia alone, without the benefit of supplemental medication, is associated with a greater risk of cardiovascular and hemodynamic perturbations such as tachycardia, arrhythmias, and hypertension particularly in patients with preexisting cardiac disease or hypertension [198]. Patients usually prefer sedation while undergoing surgery with local anesthetics [199]. While the addition of sedatives and analgesics

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Table 1.8 Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia Committee of origin: quality management and departmental administration (Approved by the ASA House of Delegates on October 27, 2004, and amended on October 21, 2009) Moderate sedation/ Minimal sedation analgesia (“conscious Deep sedation/ anxiolysis sedation”) analgesia General anesthesia Responsiveness Normal response Purposeful response to Purposeful response Unarousable even to verbal verbal or tactile following repeated or with painful stimulation stimulation painful stimulation stimulus Airway Unaffected No intervention Intervention may be Intervention often required required required Spontaneous Unaffected Adequate May be inadequate Frequently ventilation inadequate Cardiovascular Unaffected Usually maintained Usually maintained May be impaired function Reproduced with permission from Wolters Kluwer [190] 2/23/10

during surgery under local anesthesia seems to have some advantages, the use of SAM during local anesthesia is certainly not free of risk. A study by the Federated Ambulatory Surgical Association concluded that local anesthesia with supplemental medications was associated with more than twice the number of complications than with local anesthesia alone. Furthermore, local anesthesia with SAM was associated with greater risks than general anesthesia [71]. Significant respiratory depression as determined by the development of hypoxemia, hypercarbia, and respiratory acidosis often occurs in patients after receiving minimal doses of medications. This respiratory depression persists even in the recovery period [200, 201]. Houseman [202] determined that during liposuction, the risk of serious complications is greater when the procedures are performed with sedation than when the procedures are performed under local anesthesia without sedation. One explanation for the frequency of these complications is the wide variability of patients’ responses to these medications. Up to 20-fold differences in the dose requirements for some medications such as diazepam and up to fivefold variations for some narcotics such as fentanyl have been documented in some patients [203, 204]. Even small doses of fentanyl as low as 2 mcg/kg, considered by many physicians as subclinical, produce respiratory depression for more than 1 h in some patients [205]. Combinations of

even small doses of sedatives, such as midazolam, and narcotics, such as fentanyl, may act synergistically (effects greater than an additive effect) in producing adverse side effects such as respiratory depression and hemodynamic instability [206]. The clearance of many medications may vary depending on the amount and duration of administration, a phenomenon known as contextsensitive half-life. The net result is increased sensitivity and duration of action to medication for longer surgical cases [207]. Because of these variations and interactions, predicting any given patient’s dose–response is a daunting task. Patients appearing awake and responsive may, in an instant, slip into unintended levels of deep sedation with greater potential of loss of LPPRs. Careful titration of these medications to the desired effect combined with vigilant monitoring is the critical element in avoiding complications associated with the use of SAM. Supplemental medication may be administered via multiple routes including oral, nasal, transmucosal, transcutaneous, intravenous, intramuscular, and rectal. While intermittent bolus has been the traditional method to administer medication, continuous infusion and patientcontrolled delivery result in comparable safety and patient satisfaction [208, 209]. Benzodiazepines such as diazepam (Valium®, Hoffmann-La Roche Inc.), midazolam (Versed®, Hoffmann-La Roche Inc.), and lorazepam (Ativan®, Biovail and Baxter) remain popular

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for sedation and anxiolysis. Patients and physicians especially appreciate the potent amnestic effects of this class of medications, especially midazolam. The disadvantages of diazepam include the higher incidence of pain on intravenous administration, the possibility of phlebitis [210], and the prolonged half-life of up to 20–50 h. Moreover, diazepam has active metabolites which may prolong the effects of the medication long after the immediate postoperative recovery period [211, 212]. Midazolam, however, is more rapidly metabolized, allowing for a quicker and more complete recovery for outpatient surgery [211]. Because the sedative, anxiolytic, and amnestic effects of midazolam are more profound than other benzodiazepines and the recovery is more rapid, patient acceptance is usually higher [213]. Midazolam is an excellent choice as a supplement to sedation and regional or general anesthesia to relieve concerns about potential recall after anesthesia. However, the amnestic effect of midazolam or other benzodiazepines may be an undesirable effect if the patient actually chooses to have recall of the procedure or if the patient cannot recall important instructions issued by the physician. Since lorazepam is less affected by medications altering cytochrome P459 metabolism [214], it has been recommended as the sedative of choice for liposuctions which require a largedose lidocaine tumescent anesthesia [163]. The disadvantage of lorazepam is the slower onset of action and the 11- to 22-h elimination half-life, making titration cumbersome and postoperative recovery prolonged [211, 214]. All benzodiazepines are reversed by flumazenil (Romazicon®, Roche) [211]. Generally, physicians who use SAM titrate a combination of medications from different classes to tailor the medications to the desired level of sedation and analgesia for each patient. Typically, sedatives such as the benzodiazepines are combined with narcotic analgesics such as fentanyl (Sublimaze®, Janssen), meperidine (Demerol®, Sanofi Winthrop), or morphine during local anesthesia to decrease pain associated with local anesthetic injection or unanticipated breakthrough pain. Fentanyl has the advantage of rapid onset

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and duration of action of less than 60 min. However, because of synergistic action with sedative agents, even doses of 25–50 mg can result to respiratory depression [206, 215]. Other medications with sedative and hypnotic effects such as a barbiturate, ketamine, or propofol are often added. Adjunctive analgesics such as ketorolac may be administered for additional analgesic activity. As long as the patient is carefully monitored, several medications may be titrated together to achieve the effects required for the patient characteristics and the complexity of the surgery. The use of prepackaged combinations of medications defeats the purpose of the selective control of each medication and is not advised [33]. More potent narcotic analgesics with faster onset of action and even shorter duration of action than fentanyl include sufentanil (Sufenta®, Janssen), alfentanil (Alfenta®, Akorn), and remifentanil (Ultiva®, GlaxoSmithKline and Abbott). These narcotic analgesics may be administered using intermittent boluses or continuous infusions in combination with other sedative or hypnotic agents. However, extreme caution and scrupulous monitoring are required when these potent narcotics are used because of the risk of respiratory arrest, particularly when used in combination with other sedative or analgesic medications [216, 217]. The use of these medications should be restricted to the anesthesiologist or the CRNA. A major disadvantage of narcotic medication is the perioperative nausea and vomiting [218]. All narcotic medications are reversed by naloxone (Narcan®, DuPont). Many surgeons feel comfortable administering SAM to patients. Others prefer to use the services of an anesthesiologist or CNRA. Prudence dictates that for prolonged or complicated surgeries or for patients with significant risk factors, the participation of the anesthesiologist or CRNA during procedures requiring sedative–analgesia is preferable. Regardless of who administers the anesthetic medications, the monitoring must have the same level of vigilance. Propofol (Diprivan®, AstraZeneca), a member of the alkylphenol family, has demonstrated its versatility as a supplemental sedative– hypnotic agent for local anesthesia and regional

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anesthesia. Propofol may be used alone or in combination with a variety of other medications. The rapid metabolism and clearance of propofol result in faster and more complete recovery with less postoperative hangover than other sedative– hypnotic medications such as midazolam and methohexital [197, 219]. The documented antiemetic properties of propofol yield added benefits of this medication [220]. The disadvantages of propofol include pain on intravenous injection and the lack of amnestic effect [221]. However, the addition of 3 mL of 2 % lidocaine to 20 mL of propofol reduces the pain on injection with no added risk. If an amnestic response is desired, a small dose of a benzodiazepine, such as midazolam, 2–5 mg iv, given in combination with propofol, provides the adequate amnesia. Rapid administration of propofol may be associated with significant hypotension, decreased cardiac output [222], and respiratory depression [223]. Continuous infusion with propofol results in a more rapid recovery than similar infusions with midazolam [224]. Patient-controlled sedation with propofol has also been shown to be safe and effective [225]. Propofol has no known pharmacological antagonist. Initially, the use of propofol was limited to anesthesiologists and nurse anesthetists primarily because of the rapid and often unanticipated transition from minimal to deep sedation. The frequent complication of sudden apnea and hypotension associated with the use of propofol requires airway management and resuscitative skills. Because of its overall efficacy during moderate sedation, propofol became attractive to physicians of other specialties such as gastroenterology, pulmonology, and emergency medicine for outpatient procedures [226]. However, the FDA required the package labeling of propofol to include the statement, “should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure” [227]. Contending that propofol can be safely administered by a registered nurse under physician supervision, these physician groups have advocated that the FDA change the labeling

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requirements so that the use of propofol for moderate sedation could be expanded to include other medical specialties. However, the American Society of Anesthesiologists and the American Association of Nurse Anesthetists issued a joint statement urging adherence to the packaging recommendations because of concerns of potential complications which could occur during moderate and deep anesthesia with the administration of propofol by individuals not trained in the management of patients under anesthesia [228]. Any physician who intends to use propofol sedation must be proficient in the management of potential complications associated with propofol, particularly the management of apnea and airway obstruction [229–233]. Fospropofol disodium (Lusedra®, Eisai), a water-based, phosphorylated prodrug of propofol, was approved by the FDA in May of 2008 for use during MAC by physicians trained in the administration of general anesthesia. Fospropofol is rapidly metabolized by alkaline phosphatases into propofol, formaldehyde, and phosphate. Fospropofol shares the hypnotic, anxiolytic, sedative, and antiemetic properties of propofol. However, because fospropofol is water based, intravenous administration is not associated with pain, a significant advantage over propofol. The time to loss of consciousness, time to peak effect, and duration of action of fospropofol are longer compared to those of propofol. Fospropofol shares the similar decreases of mean arterial pressure, tachycardia, and respiratory depression with propofol, although fospropofol resulted in less apnea than propofol. The optimal dose to induce moderate sedation during colonoscopies and bronchoscopies was 6.5 mg/kg, while the dose to induce deep sedation was 8 mg/kg. Subsequently, one quarter of the original dose was administered every 4 min to maintain the level of sedation. The time to discharge for patients who received either propofol or fospropofol was significantly faster than for those patients who received a midazolam and meperidine combination. Most subjects who received fospropofol experienced varying degrees of mild to moderate perineal itching, burning, or paresthesias that were resolved after a few minutes

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without treatment. Transient myoclonus was also reported in some of the participants. Like propofol, fospropofol has no known pharmacological antagonist [234]. Barbiturate sedative–hypnotic agents such as thiopental (Pentothal®) and methohexital (Brevital®), while older, still play a role in some clinical settings. In particular, methohexital, with controlled boluses, 10–20 mg iv, or limited infusions, remains a safe and effective sedative–hypnotic alternative with rapid recovery. However, with prolonged administration, recovery from methohexital may be delayed compared to propofol [235]. Barbiturate medications have no known pharmacological reversing agent. Ketamine (Ketalar®, Pfizer), a phencyclidine derivative, is a unique agent because of its combined sedative and analgesic effects and the absence of cardiovascular depression in healthy patients [236]. Because the CNS effects of ketamine result in a state similar to catatonia, the resulting anesthesia is often described as dissociative anesthesia. Although gag and cough reflexes are more predictably maintained with ketamine, emesis and pulmonary aspiration of gastric contents are still possible [237]. Unfortunately, a significant number of patients suffer distressing postoperative psychomimetic reactions [238]. While concomitant administration of benzodiazepines attenuates these reactions, the postoperative psychological sequelae limit the usefulness of ketamine for most elective outpatient surgeries. Droperidol (Inapsine®, Janssen), a butyrophenone and a derivative of haloperidol, an antipsychotic, acts as a sedative, hypnotic, and antiemetic medication. Rather than causing global CNS depression like barbiturates, droperidol results in more specific CNS changes similar to phenothiazines. For this reason, the cataleptic state caused by droperidol is referred to as neuroleptic anesthesia [239]. Droperidol has been used effectively in combination with various narcotic medications. Innovar is a combination of droperidol and fentanyl. While droperidol has minimal effect on respiratory function if used as a single agent, when combined with narcotic medication, a

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predictable dose-dependent respiratory depression may be anticipated [240]. Psychomimetic reactions such as dysphoria or hallucinations are frequent, unpleasant side effects of droperidol. Benzodiazepines or narcotics reduce the incidence of these unpleasant side effects when used in combination with droperidol [241]. Extrapyramidal reactions such as dyskinesias, torticollis, or oculogyric spasms may also occur, even with small doses of droperidol. Diphenhydramine usually reverses these complications [242]. Hypotension may occur as consequence of droperidol’s alphaadrenergic blocking characteristics. One rare complication of droperidol is the neuroleptic malignant syndrome (NMS) [243], a condition very similar to malignant hyperthermia (MH), characterized by extreme temperature elevations and rhabdomyolysis. The treatment of NMS and MH is essentially the same. While droperidol has been used for years without appreciable myocardial depression [241], a surprising announcement from the Federal Drug Administration warned of sudden cardiac death resulting after the administration of standard, clinically useful doses [244]. Unfortunately, despite studies which refute the FDA’ s conclusions [245] and an expert panel’s opinion supporting the use of droperidol [246], this potential complication makes the routine use of this once very useful, cost-effective medication difficult to justify given the presence of other alternative medications. Butorphanol, buprenorphine (Buprenex®, Reckitt Benckiser), and nalbuphine (Nubain®, Endo) are three synthetically derived opiates which share the properties of being mixed agonist–antagonist at the opiate receptors. These medications are sometimes preferred as supplemental analgesics during local, regional, or general anesthesia because they partially reverse the analgesic and respiratory depressant effects of other narcotics. While these medications result in respiratory depression at lower doses, a ceiling effect occurs at higher dose, thereby limiting the respiratory depression. Still, respiratory arrest is possible, especially if these medications are combined with other medications with respiratory

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depressant properties [247]. While the duration of action of butorphanol is 2–3 h, nalbuphine has a duration of action of about 3–6 h and buprenorphine up to 10 h with a peak effect occurring after 3 h, making these medications less suitable for surgeries of shorter duration. Finally, if a patient has been taking narcotic analgesics for the treatment of a chronic pain condition, the addition of an agonist–antagonist medication for the procedure could precipitate withdrawal symptoms. Dexmedetomidine (Precedex®, Abbott), an alpha2-adrenoreceptor agonist, with eight times the affinity of clonidine, and anxiolytic, sedative, and analgesic properties, is another recent addition to the available medications for sedation– analgesia [248]. Dexmedetomidine has also been shown to reduce the sympathetic response to anesthesia and surgery. Several studies have demonstrated the safety and effectiveness of this medication for outpatient procedures [249–251]. Although dexmedetomidine has less respiratory depression when compared to other medications, the delayed recovery time compared with other alternatives, the relative expense of the medication, and the potential adverse effects of hypotension and bradycardia have led some authors to conclude that the potential usefulness of this medication for outpatient procedures requiring sedation–analgesia may be limited [252]. Chloral hydrate, the first and oldest of the medications developed for sedation, was first synthesized in 1832. Chloral hydrate and nitrous oxide combinations have been used for sedation, particularly in the pediatric population for officebased procedures, including dental work and diagnostic procedures, for many years primarily because of the convenience of the oral chloral hydrate dosing (70 mg/kg). Many of these procedures have been performed in non-accredited offices without the monitoring recommended by the ASA Guidelines. As a result, this combination of medications has resulted in complications in a significant number of patients primarily due to hypoxemia [253]. Many of these complications may have been avoided with proper patient monitoring. Table 1.9 summarizes the recommended doses for SAM [254–256].

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1.5.3

General Anesthesia

While some authors attribute the majority of complications occurring during and after aesthetic procedures to the administration of systemic anesthesia [32, 257], others consider sedation and general anesthesia safe and appropriate alternatives in indicated cases [27, 175, 258, 259]. In fact, Klein correctly acknowledges that most of the complications attributed to midazolam and narcotic combinations occurred as a result of inadequate monitoring [32]. Although significant advances have been made in the administration of local anesthetics and supplemental medications, the use of general anesthesia may still be the anesthesia technique of choice for many patients undergoing selected aesthetic surgical procedures such as large-volume liposuction. General anesthesia may be appropriate when working with patients suffering extreme anxiety and high tolerance to narcotic or sedative medications or if the surgery is particularly complex. The goals of a general anesthetic are a smooth induction, a prompt recovery, and minimal side effects, such as nausea, vomiting, or sore throat. Older volatile inhalation anesthetic agents, halothane, enflurane (Ethrane®, Baxter), and isoflurane (Forane®, Baxter) [260], are still in use because of the cost-effectiveness and the longestablished safety, reliability, and convenience of use in selected patient populations. Because of the risk of halothane hepatitis and MH, halothane should not be used in adults unless there is a specific indication. Any halogenated volatile inhalation anesthetic may cross-react and precipitate hepatitis in patients who have previously suffered halothane hepatitis [261]. Inhalation anesthetics should not be used in patients who have experienced any postoperative hepatotoxicity. The newer inhalation agents, sevoflurane (Ultane®, Baxter) and desflurane (Suprane®, Anaquest), share the added benefit of rapid onset of action and emergence [260, 262, 263]. However, these newer agents are associated with higher costs, especially desflurane due to the high total anesthetic consumption during normal surgical

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24 Table 1.9 Common medications and dosages used for sedative analgesia Medication Bolus dose Average adult dose Opioid analgesics – rapid onset, short duration of action (sedative, analgesic) Alfentanil 5–7 μg/kg 30–50 μg Fentanyl 0.3–0.7 μg/kg 5–50 μg Remifentanil 0.25–0.5 μg/kg 10–30 μg Sufentanil 0.05–0.15 μg/kg 2.5–7.5 μg Opioid analgesics – slower onset, long duration of action (sedative, analgesic) Meperidine 0.2 mg/kg 10–20 mg iv, 50–100 mg im Morphine 0.02 mg/kg 1–2 mg iv, 5–10 mg im Opiate agonist–antagonist analgesics – long duration of action (sedative, analgesic) Buprenorphine 2–5 μg/kg 0.1–0.3 mg Butorphanol 2–7 μg/kg 0.1–0.5 mg Nalbuphine 0.07–0.1 mg/kg 4–7.5 mg Benzodiazepines (sedative, anxiolytic, hypnotic, amnestic) Diazepam 0.05–0.1 mg/kg 5–7.5 mg Lorazepam 0.01–0.02 mg/kg 1–2 mg Midazolam 0.030–0.075 mg/kg 2.5–5.0 α2-adrenergic agonists (sedative, hypnotic, analgesic) Dexmedetomidine 1 μg/kg 20–70 μg Alkylphenols (sedative, antiemetic) Fospropofol 6.5 mg/kg 120–400 mg Propofol 0.2–0.5 mg/kg 10–50 mg Barbiturate (sedative, hypnotic) Methohexital 0.2–0.5 mg/kg 10–20 mg Thiopental 0.5–1.0 mg/kg 25–50 mg Phencyclidine (dissociative hypnotic, sedative, analgesic) Ketamine 0.2–0.5 mg/kg 10–20 mg 5–10 μg/kg/ min

Continuous infusion rate 0.2–0.5 μg/kg/min 0.01–0.02 μg/kg/min 0.025–0.1 μg/kg/min 0.1–0.5 μg/kg/h NA NA NA NA NA NA NA 0.50–1.0 μg/kg/min 0.2–0.7 μg/kg/min NA 10–75 μg/kg/min 10–20 μg/kg/min 20–50 μg/kg/min

Adapted from Philip [254], SaRego et al. [255], and Fragen [256] Reproduced with permission from Bennett [346] Based on an average weight of 70 kg. These doses may vary depending on age, gender, underlying health status, and other concomitantly administered medications

procedures [263] and the requirement of a heated vaporizer. Nitrous oxide, a long-time favorite anesthetic inhalation agent, although popular because of its shorter duration of action and low cost, is associated with postoperative nausea and vomiting [264] and perioperative hypoxemia. With the advent of the shorter-acting inhalation agents, sevoflurane and desflurane, the necessity of nitrous oxide is much less compelling. Table 1.10 [260–263, 265, 266] summarizes the available inhalation anesthetics and some of the significant clinical characteristics. The development of potent, short-acting sedatives, opioid analgesics (Table 1.11) [254–256,

266–271], and neuromuscular blocking agents (NMBAs) (Table 1.12) [272–274] has resulted in medication regimens that permit the use of intravenous agents exclusively for surgical procedures requiring general anesthesia. Most of these medications can also be used during general anesthesia in combination with other sedative (Table 1.9) and inhalation agents (Table 1.10) using modified doses for each type of combination [267]. Sugammadex (Bridion®, ScheringPlough), a novel synthetic cyclodextrin neuromuscular relaxant reversal agent, which acts by selectively binding the steroidal neuromuscular blocking agents (rocuronium, vecuronium, and pancuronium), may allow for faster and more

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25

Table 1.10 Inhalation anesthetics Agent Rapid onset and recovery Desflurane

MACa(%)

Significant clinical considerations

6.0

Nitrous oxide

105

Sevoflurane

1.71

Fastest rate of recovery of all inhaled agents. Only volatile agent that does not reduce pulmonary resistance Induction by inhalation poorly tolerated Requires heated vaporizer Most expensive inhalation agent Increased risk of MH in susceptible patients Nonhalogenated May cause diffusion hypoxia and increase PONV Megaloblastic bone marrow depression may occur after 12 h of exposure Induction by inhalation well tolerated in adults and children Potentially nephrotoxic only after prolonged exposure No cases of renal failure have been reported Increased risk of MH in susceptible patients

Slower onset and recovery Enflurane

1.68

Halothane

0.76

Isoflurane

1.12

Rarely used in the USA Increased risk of MH in susceptible patients Induction by inhalation in children well tolerated Hepatitis occurs in 1:10,000 adults Should not be used in adults Increased risk of MH in susceptible patients Induction by inhalation in children well tolerated Induction by inhalation poorly tolerated Increased risk of MH in susceptible patients

Minimum alveolar concentration required for immobility in 50 % of subjects exposed to a noxious stimulus Reproduced with permission from Bennett [346] Table 1.11 Common intravenous medications and dosages used for general anesthesia Medication Bolus dose Opioids Alfentanil 25–100 μg/kg Fentanyl 3–15 μg/kg Remifentanil 1–2 μg/kg Sufentanil 0.25–2 μg/kg Alkylphenols (sedative, antiemetic) Fospropofol 6.5 mg/kg Propofol 1–3 mg/kg Barbiturates Methohexital 1–2 mg/kg Thiopental 3–4 mg/kg Imidazoles Etomidate 0.2–0.6 mg/kg Phencyclidines Ketamine 0.5–2.0 mg/kg

Average adult dose

Continuous infusion rate

1–7 mg 200–1,000 μg 70–140 μg 20–160 μg

0.5–2 μg/kg/min 2–10 μg/kg/h 0.1–1.0 μg/kg/min 0.5–1.5 μg/kg/h

200–450 mg 75–200 mg

NA 50–150 μg/kg/min

75–150 mg 200–300 mg

50–100 μg/kg/min 70–100 μg/kg/min

10–40 mg

NA

35–150 mg

15–100 μg/kg/min

Based on an average weight of 70 kg. These doses are for sole use of the agent listed and may vary depending on age, gender, underlying health status, and other concomitantly administered medications. Doses may change if additional medications are added Reproduced with permission from Bennett [346]

G.D. Bennett

26 Table 1.12 Neuromuscular blocking agents for general anesthesia Medication Intubating dosea Longer duration of action and slower onset of action D-tubocurarine 0.5 mg/kg Pancuronium (Pavulon®)

Significant clinical characteristics Oldest agent. Causes hypotension through ganglionic blockade and histamine release Causes tachycardia and hypertension through vagal blockade

0.1 mg/kg

Intermediate duration of action with faster onset of action Atracurium (Nimbex®) 0.5 mg/kg

Cisatracurium (Nimbex®)

0.2 mg/kg

Rocuronium (Zemuron®)

1.0 mg/kg

Metabolized by ester hydrolysis and Hoffman degeneration Can be used in patients with kidney failure Causes histamine release and hypotension and tachycardia Metabolized by Hoffman degeneration Can be used in patients with kidney failure Less histamine release than atracurium The fastest onset of action of all nondepolarizing NMBAs Not stable in solution. Requires mixing

Vecuronium (Norcuron®) 0.1 mg/kg Shorter duration of action with faster onset of action Gantacurium 0.4 mg/kg

Metabolized by ester hydrolysis and cysteine adduction Cysteine may be used for reversal Causes histamine release and hypotension and tachycardia only at higher doses, less than atracurium Not yet available in the USA Succinylcholine 1.0 mg/kg The only depolarizing agent available The fastest most reliable onset of action of all NMBAs The shortest duration of action of all NMBAs Most popular NMBA for rapid-sequence induction Causes skeletal muscle fasciculations and masseter rigidity May result in severe postoperative myalgias Causes hyperkalemia in some patients Increases intracranial and intraocular pressure May induce MH in susceptible patients May result in prolonged block in patients with pseudocholinesterase deficiency Reproduced with permission from Bennett [346] a Pertains to adults only. Doses may vary in patients depending on weight, body habitus, or medical conditions or additional medications added

predictable recovery from neuromuscular blockade [275]. The anesthesiologist or CRNA should preferentially be responsible for the administration and monitoring of a general anesthesia when these medication regimens are being used.

1.5.4

Preoperative Preparation

Generally, medications which may have been required to stabilize the patient’s medical conditions should be continued up to the time of surgery.

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Notable exceptions include anticoagulant medications, monoamine oxidase inhibitors (MAO) [276, 277], and possibly the angiotensin-converting enzyme (ACE) inhibitor medications [114, 278]. It is generally accepted that MAO inhibitors, isocarboxazid (Marplan®, Oxford Pharmaceuticals Services), pargyline (Eutonyl®, Abbott), phenelzine (Nardil®, Pfizer), selegiline (Emsam Transdermal Patch®, Bristol-Meyers Squibb, Eldepryl®, Deprenyl®, Somerset Pharmaceuticals), and tranylcypromine (Parnate®, Glaxo SmithKline), be discontinued 2–3 weeks prior to surgery, especially for elective cases, because of the interactions with narcotic medications, specifically hyperpyrexia, and certain vasopressor agents, specifically ephedrine [276, 277]. Patients taking ACE inhibitors, captopril (Capoten®, Bristol-Myers Squibb), enalapril (Vasotec®, Merck), and lisinopril (Prinivil®, Merck, Zestril®, Zeneca), may have a greater risk for hypotension during general anesthesia [114]. Diabetics may require a reduction in dosage of their medication. However, if the risks of discontinuing any of these medications outweigh the benefits of the proposed elective surgery, the patient and physician may decide to modify the preoperative medication regimen or to postpone, modify, or even cancel the proposed surgery. Previous requirements of complete preoperative fasting for 10–16 h are considered unnecessary by many anesthesiologists [279, 280]. More recent investigations have demonstrated that gastric volume may be less 2 h after oral intake of 8 oz of clear liquid than after more prolonged fasting [281]. Furthermore, prolonged fasting may increase the risk of hypoglycemia [282]. Many patients appreciate an 8-oz feeding of their favorite caffeinated elixir 2 h prior to surgery. Preoperative sedative medications may also be taken with a small amount of water or juice. Abstinence from solid food ingestion for 10–12 h prior to surgery is still recommended. Liquids taken prior to surgery must be clear [283], e.g., coffee without cream or juice without pulp. Healthy outpatients are no longer considered at risk for gastric acid aspiration, and therefore, routine use of oral antacids, histamine type 2 (H2) antagonists, or gastrokinetic medications is not

27

indicated. However, patients with marked obesity, hiatal hernia, or diabetes mellitus have higher risks for aspiration. These patients may benefit from selected prophylactic treatment [284]. Sodium citrate, an orally administered, non-particulate antacid, rapidly increases gastric pH. However, its unpleasant taste and short duration of action limit its usefulness in elective surgery [97]. Gastric volume and pH may be effectively reduced by H2-receptor antagonists. Cimetidine (Tagamet®, Glaxo), 300 mg po 1–2 h prior to surgery, reduces gastric volume and pH. However, cimetidine is also a potent cytochrome oxidase inhibitor and may increase the risk of reactions to lidocaine during tumescent anesthesia [285]. Ranitidine (Zantac®, Glaxo), 150–300 mg po 90–120 min prior to surgery [286], and famotidine (Pepcid®, Merck), 20 mg po 60 min prior to surgery, are equally effective but have a better safety profile than cimetidine [287]. Omeprazole (Prilosec®, Astra Zeneca), 20 mg po, which decreases gastric acid secretion by inhibiting the proton-pump mechanism of the gastric mucosa, is a safe and effective alternative to the H2-receptor antagonists [287]. Metoclopramide (Reglan®, Baxter and Schwarz Pharma),10–20 mg po or iv, a gastrokinetic agent, which increases gastric motility and lowers esophageal sphincter tone, may be effective in patients with reduced gastric motility, such as diabetics or patients receiving opiates [97, 214]. However, extrapyramidal side effects, such as permanent dystonic reactions, which have been reported to occur with just one dose, limit the routine use of the medication [98, 99, 218]. Postoperative nausea and vomiting (PONV) remains one of the more vexing complications of anesthesia and surgery [288]. In fact, patients dread PONV more than any other complication, even postoperative pain [289]. PONV is the most common postoperative complication [290], the most important factor in determining length of stay after ambulatory anesthesia [291], and the most common cause of postoperative patient dissatisfaction [292]. The use of prophylactic antiemetic medication has been shown to reduce the incidence of PONV [293]. Even though many

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patients do not suffer PONV in the recovery period after ambulatory anesthesia, greater than 35 % of patients develop PONV after discharge [294]. A recent Cochrane review of all medications to control PONV, prepared by Carlisle and Stevenson, is the most comprehensive evaluation of the safety and efficacy to date [295]. Droperidol (Inapsine®, Akorn), 0.625– 1.25 mg iv, an extremely cost-effective antiemetic [296], has been a popular treatment for perioperative nausea and vomiting for many years. However, troublesome side effects such as sedation, dysphoria, and extrapyramidal reactions have been described [297]. In 2001, the FDA issued a black box warning concerning a fatal cardiac arrhythmia, torsades de pointes, due to prolongation of the QT interval after low doses of droperidol [244]. These complications seemed to preclude the widespread use of droperidol altogether. However, after a closer analysis of the reported cases of cardiac complications following droperidol, one study refuted the FDA’s determination that doses of droperidol, in doses less than 1.25 mg, caused the reported cardiac complications [245]. The FDA’s conclusion has been further challenged following a review of all the pertinent data by an expert panel from Duke University Medical Center in 2003 [246]. Ondansetron (Zofran®, Pfizer), a serotonin antagonist, 4–8 mg iv, one of the most effective antiemetic medications available, is generally not associated with sedative, dysphoric, or extrapyramidal sequelae [298, 299]. The antiemetic effects of ondansetron may reduce PONV for up to 24 h postoperatively [300]. The effects of ondansetron may be augmented by the addition of dexamethasone, 4–8 mg iv [301], or droperidol, 0.625– 1.25 mg iv [302]. Ondansetron is available in a parenteral preparation and as orally disintegrating tablets and oral solution. Other effective serotonin antagonists, granisetron (Kytril®, Roche), 1 mg iv, and dolasetron mesylate (Anzemet®, Aventis Pharmaceuticals), 12.5–25 mg iv, share the efficacy of ondansetron but have half-lives twice that of ondansetron [303, 304]. Granisetron is also available in a transdermal preparation. Promethazine (Phenergan®, Baxter), 12.5– 25 mg po, pr, or im, a phenothiazine, one of the

G.D. Bennett

first H1 receptor antagonists available for the treatment of nausea and vomiting, is still in use today by many physicians for prophylaxis of PONV, especially in combination with narcotic analgesics. In 2009, the FDA issued a warning regarding severe tissue damage and gangrene following the use of intravenous or subcutaneous promethazine administration. Because of the anticholinergic properties, promethazine use in patients with prostatic hypertrophy may result in urinary retention. Prochlorperazine (Compazine®, Glaxo SmithKline), 5–10 mg po or im and 25 mg pr, is another older antiemetic phenothiazine that is still in use for PONV. Once again, sedation and extrapyramidal effects may complicate the routine prophylactic use of these medications [99, 218]. Dexamethasone is another safe, cost-effective alternative for the prevention and treatment of perioperative nausea and vomiting with an efficacy equal to droperidol and ondansetron [287, 305]. A single iv dose of 10-mg dexamethasone has rare reported side effects and may be combined with other antinauseant and antiemetic medications [305, 306]. Because of its delayed onset of action, dexamethasone should be administered early in the perioperative period [305]. Preoperative atropine, 0.4 mg im; glycopyrrolate, 0.2 mg im; and scopolamine, 0.2 mg im, anticholinergic agents once considered standard preoperative medications because of their vagolytic and antisialagogic effects, are no longer popular because of side effects such as dry mouth, dizziness, tachycardia, and disorientation [306]. Transdermal scopolamine (Scopoderm TTS®, Novartis Pharma) applied 90 min prior to surgery effectively reduces PONV. However, the incidence of dry mouth and drowsiness is high [307], and toxic psychosis is a rare complication [308]. Urinary retention may result from anticholinergic in patients with prostatic hypertrophy. Antihistamines, such as diphenhydramine (Benadryl®, McNeil), 25–50 mg po, im, or iv; dimenhydrinate (Dramamine®, Pfizer), 25–50 mg po, im, or iv; and hydroxyzine (Atarax® or Vistaril®, Pfizer), 50 mg po or im [309, 310], may also be used to treat and prevent PONV with few side effects except for possible rare hypotension and postoperative sedation [310].

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Table 1.13 Antiemetic medications Antiemetics Aprepitant Dexamethasone Dimenhydrinate Diphenhydramine Dolasetron Droperidol

Fosaprepitant Granisetron Hydroxyzine Metoclopramide

Dose (mg) 40–80 4–10 25–50 25–50 12.5–25 0.625–2.5

Route po iv, im po, iv, im po, iv, im iv iv

115 1 25–50 10–20

iv iv po, iv, im po, iv

Ondansetron Prochlorperazine Promethazine

Scopolamine

4–8 5–10/25 12.5–25

0.2

iv, im, sl po, im, pr po, im, pr

im, iv, tc

Significant adverse effects Headache Slow onset, fluid retention Sedation, hypotension Sedation, hypotension Headache, possible arrhythmia Sedation, dysphoria, extrapyramidal, cardiac arrhythmias Injection site pain Headache, tachycardia Sedation, hypotension Tardive dyskinesia, dystonic reactions Headache, tachycardia Dysphoria, extrapyramidal, oculogyric crisis Sedation, extrapyramidal, dystonic reactions, vascular necrosis Sedation, disorientation, dry mouth, blurred vision, tachycardia, psychosis

Reproduced with permission from Bennett [346]

A very simple, effective, and often overlooked method of nausea control in the perioperative period is the use of inhaled isopropyl alcohol, the type contained in widely available single-use alcohol prep pads [311]. While this method has developed as a popular folk remedy for nausea, recent studies have confirmed its safety and efficacy. This treatment seems to be most effective for nausea associated with vasovagal reactions. Recent advances in the control of nausea and vomiting have focused on the neurokinin type 1 (NK1) receptor antagonists such as aprepitant, 40 mg po, for oral dosing and fosaprepitant, 115 mg iv, the lyophilized prodrug of aprepitant, for intravenous dosing (Emend®, Merck). NK1 receptors are highly concentrated in the chemoreceptor trigger zone (CTZ) of the emetic center of the brain stem. Substance P, a pain-mediating neurotransmitter, is a member of the family of NK peptides [312]. A recent study concluded that 40 mg of aprepitant resulted in a significant reduction of nausea and vomiting in the first 24 h after balanced anesthesia compared to ondansetron [313]. Table 1.13 summarizes these antiemetic medications.

The selection of anesthetic agents may also play a major role in PONV. The direct antiemetic actions of propofol have been clearly demonstrated [314]. Anesthetic regimen utilizing propofol alone or in combination with other medications is associated with significantly less PONV [268]. Although still controversial, nitrous oxide is considered by many authors a prime suspect among possible causes of PONV [264, 315, 316]. The use of opiates is also considered a culprit in the development of PONV and the delay of discharge after outpatient surgery [218, 317–319]. Adequate fluid hydration has been shown to reduce PONV [320]. One goal of preoperative preparation is to reduce patients’ anxiety. Many simple, nonpharmacological techniques may be extremely effective in reassuring both patients and families starting with a relaxed, friendly atmosphere and a professional, caring, and attentive office staff. With proper preoperative preparation, pharmacological interventions may not even be necessary. However, a variety of oral and parenteral anxiolytic–sedative medications are frequently called

30

upon to provide a smooth transition to the operative room. Diazepam, 5–10 mg po, given 1–2 h preoperatively, is a very effective medication, which usually does not prolong recovery time [321]. Parenteral diazepam, 5–10 mg iv or im, may also be given preoperatively. However, because of a long elimination half-life of 24–48 h and active metabolites with elimination half-life of 50–120 h, caution must be exercised when using diazepam, especially in shorter cases, so that recovery is not delayed [212]. Pain and phlebitis with iv or im administration also reduces the popularity of diazepam [210]. Lorazepam, 1–2 mg po or sl, 1–2 h preoperatively, is also an effective choice for sedation or anxiolysis. However, the prolonged duration of action may prolong recovery time after shorter cases [322]. Midazolam, 5–10 mg im 30 min preoperatively or 2–5 mg iv minutes prior to surgery, is a more potent anxiolytic–sedative medication with more rapid onset and shorter elimination half-life compared to diazepam [323]. While midazolam is available in an oral syrup preparation for children because of unpredictable results, it is not considered a useful alternative for preoperative medication in adults [324]. Oral narcotics, such as oxycodone, 5–10 mg po, may help relieve the patient’s intraoperative breakthrough pain during cases under sedative–analgesic anesthesia with minimal potential perioperative sequelae. Parenteral opioids, such as morphine, 5–10 mg im or 1–2 mg iv; meperidine, 50–100 mg im or 10–20 mg iv; fentanyl, 10–20 mg iv; or sufentanil, 1–2 mg iv, may produce sedation and euphoria and may decrease the requirements for other sedative medication. The level of anxiolysis and sedation is still greater with the benzodiazepines than with the opioids. Premedication with narcotics has been shown to have minimal effects on postoperative recovery time. However, opioid premedication may increase PONV [325, 326]. Antihistamine medications, such as hydroxyzine, 50–100 mg im or 50–100 mg po, and diphenhydramine, 50 mg po/im or 25 mg iv, are still used safely in combination with other premedications, especially the opioids, to add sedation and to reduce nausea and pruritus. However, the anxiolytic and amnestic effects of these

G.D. Bennett

antihistamines are not as potent as the benzodiazepines [309]. Barbiturates, such as secobarbital and pentobarbital, once standard premedications, have largely been replaced by the benzodiazepines and other agents. Postoperative PE is an unpredictable and devastating complication with an estimated incidence of 0.1–5 %, depending on the type of surgical cases, and a mortality rate of about 15 % [327]. Risk factors for thromboembolism include prior history or family history of DVT or PE, obesity, smoking, hypertension, use of oral contraceptives or hormone replacement therapy, and patients over 60 year of age [328]. Estimates for the incidence of postoperative DVT vary from 0.8 % for outpatients undergoing herniorrhaphies [329] to as high as 80 % for patients undergoing total hip replacement [327]. Estimates of fatal PE also vary from 0.1 % for patients undergoing general surgeries to up to 1–5 % of patients undergoing major joint replacement [327]. While a recent national survey of physicians performing tumescent liposuction in a total of 15,336 patients indicated that no patient suffered DVT or PE [330], only 66 physicians who perform liposuction responded out of 1,778 questionnaires sent, which is a mere 3.7 % response rate. A review of 26,591 abdominoplasties revealed nine cases of fatal PE, or 0.03 %, but gave no information regarding the incidence of nonfatal PE [331]. Other reports suggest that the incidence of pulmonary embolism after tumescent liposuction and abdominoplasty may be more common than reported [332–336]. One study revealed that unsuspected PE may actually occur in up to 40 % of patients with who develop DVT [336]. Prevention of DVT and PE should be considered an essential component of the perioperative management. Although unfractionated heparin reduces the rate of fatal PE [337], many surgeons are reluctant to use this prophylaxis because of concerns of perioperative hemorrhage. The low-molecular-weight heparins, enoxaparin (Lovenox® or Clexane®, Sanofi-Aventis), dalteparin (Fragmin®, Pfizer), and ardeparin (Normiflo®, Wyeth-Ayerst), are available for prophylactic indications. Graduated compression stockings and intermittent pneumatic lower

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extremity compression devices applied throughout the perioperative period until the patient has become ambulatory are considered very effective and safe alternatives in the prevention of postoperative DVT and PE [338, 339]. Even with prophylactic therapy, PE may still occur up to 30 days after surgery [340]. Physicians should be suspicious of PE if patients present postoperatively with dyspnea, chest pain, cough, hemoptysis, pleuritic pain, dizziness, syncope, tachycardia, cyanosis, shortness of breath, or wheezing [328].

1.5.5

Airway Management

Maintaining a patent airway, ensuring adequate ventilation, and prevention of aspiration of gastric contents are the goals of successful airway management. Because the consequences of complications related to airway management misadventures are so potentially devastating, this important topic warrants special focus. Indeed, an analysis of closed claims confirms that complications due to airway mismanagement generate one of the highest numbers of legal claims [341]. Because of the inherent pathology associated with many patients undergoing liposuction, particularly large-volume liposuction, such as morbid obesity, many should be classified as higher risk due to airway abnormalities. Physicians administering anesthesia to these patients should study the difficult airway algorithm published by the American Society of Anesthesiologists (ASA) [342]. Surgeons who perform procedures without the assistance of an anesthesiologist are obligated to understand these critical airway issues as well. In the majority of cases, simple airway obstruction during moderate or deep sedation may be easily relieved by gently elevating the anterior mandible with one finger, a maneuver aptly described as the “finger of life.” A critical element of airway management is the preoperative airway assessment. Proper crisis preparation is critical to the avoidance of airway management disasters. One consideration often acknowledged by experienced anesthesiologists is that the presence of full facial hair often conceals potential facial anomalies that could make

31 Table 1.14 Anatomical characteristics that identify a potentially difficult airway 1. Prodigious upper incisors 2. Prominent overbite 3. Space between incisors with maximum oral opening less than 3 cm (less than 2 finger widths) 4. Inability to completely visualize uvula (Mallampati class III or IV) 5. Thyromental mental distance less than 3 finger widths 6. Short or thick neck anatomy (circumference great than 60 cm (17 in for males 16 in for females)) 7. Reduce cervical range of motion (i.e., due to degenerative joint disease or trauma). Patient is unable to touch chin to chest wall or extend neck 8. Inability to voluntarily prognanth mandible or push lower incisors inform of upper incisors 9. Limited temporal mandibular joint compliance 10. Narrow or highly arched palate 11. BMI greater than 35 kg/m2 12. Large amount of facial hair

Table 1.15 Critical decisions during the management of a difficult airway Prepare difficult intubation equipment including video-assisted fiber-optic laryngoscope Awake intubation (with or without fiber-optic devises) versus intubation after induction of general anesthesia Maintenance or suppression of spontaneous ventilation (i.e., with muscular paralysis) Use of ventilation aids (e.g., nasal or oral airway, LMA or Combitube® esophageal/tracheal airway) Call for help from another physician qualified in airway management Invasive intubation (e.g., retrograde wire-intubation, cricothyrotomy, tracheostomy) Abandon intubation attempts and awaken the patient Adapted from Bennett [346]

intubation more challenging. Table 1.14 summarizes important anatomical characteristics that identify a potentially difficult airway during the preoperative airway assessment modified from the ASA Task Force on Management of the Difficult Airway [342]. These abnormalities could legitimately be referred to as “the dirty dozen traits.” Table 1.15 summarizes critical decisions during the management of a difficult airway modified from the ASA Difficult Airway Algorithm [343, 346].

G.D. Bennett

32

The availability of video-assisted fiber-optic laryngoscopes (Glidescope®, Storz C-Mac®, McGrath® and Levitan Optical Stylet®) has provided an indispensable advantage to the physician when faced with a challenging airway. In general, for airways that could potentially present a serious challenge to the physician, the awake, fiber-optic-assisted approach with sedation is the initial preferential course of action. Maintenance of spontaneous ventilation is usually a safer alternative than suppression of spontaneous ventilation with very difficult airways. When airway trauma is evident due to multiple unsuccessful attempts at direct laryngoscopy or intubation, or there is an inability to ventilate the patient with an occlusive mask or ventilatory assist devices (LMA: LMA North America, Inc. San Diego, California or Combitube® Esophageal/Tracheal Airway: TycoKendall, Mansfield, MA), it is always advisable to awaken the patient and proceed on another day. Invasive airway management such as cricothyrotomy should be reserved for emergency situations that may otherwise result in significant morbidity or mortality. The anesthesiologist should have a pre-prepared difficult intubation tray or cart available for every case [346]. It would not be an exaggeration to state that the laryngeal mask airway (LMA) has transformed airway management for elective and emergency airway control. The LMA can be a life-saving alternative to maintain an open airway during difficult intubations. The LMA may also serve as airway support for cases that may not require full endotracheal intubation during both adult [344] and pediatric procedures [345]. LMAs of various sizes should be available within easy reach during any surgical procedure regardless of the type of anesthesia used [346].

1.5.6

Perioperative Monitoring

The adoption of standardized perioperative monitoring protocol has resulted in a quantum leap in perioperative patient safety. The standards for basic perioperative monitoring were approved by the ASA in 1986 and amended in 1995 [25].

These monitoring standards are now considered applicable to all types of anesthetics, including local with or without sedation, regional, or general anesthesia, regardless of the duration or complexity of the surgical procedure, regardless of whether the procedures are performed in the office or the hospital setting, and regardless of whether the surgeon or anesthesiologist is responsible for the anesthesia. Vigilant, continuous monitoring and compulsive documentation facilitates early recognition of deleterious physiological events and trends, which, if not recognized promptly, could lead to irreversible pathological spirals, ultimately endangering a patient’s life. During the course of any anesthetic, the patient’s oxygenation, ventilation, circulation, and temperature should be continuously evaluated. The concentration of the inspired oxygen must be measured by an oxygen analyzer. Assessment of the perioperative oxygenation of the patient using pulse oximetry, now considered mandatory in every case, has been a significant advancement in monitoring. This monitor is so critical to the safety of the patient that it has earned the nickname “the monitor of life.” Evaluation of adequate ventilation includes observation of skin color, chest wall motion, and frequent auscultation of breath sounds. During general anesthesia with or without mechanical ventilation, a disconnect alarm on the anesthesia circuit is crucial. Capnography, a measurement of respiratory end-tidal CO2, is required not only when the patient is under moderate sedation, deep sedation, or general anesthesia but also during the postoperative recovery period. Capnography provides the first alert in the event of airway obstruction, hypoventilation, or accidental anesthesia circuit disconnect, even before the oxygen saturation has begun to fall. The use of capnography should also be applied to patients recovering from sedation–analgesia or general anesthesia because of the potential for respiratory arrest during recovery. All patients must have continuous monitoring of the electrocardiogram (ECG) and intermittent determination of blood pressure (BP) and heart rate (HR) at a minimum of 5-min intervals. Superficial or core body temperature should

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be monitored. Of course, all electronic monitors must have preset alarm limits to alert physicians prior to the development of critical changes. While the availability of electronic monitoring equipment has improved perioperative safety, there is no substitute for visual monitoring by a qualified, experienced practitioner, usually a CRNA or an anesthesiologist. During surgeries using local with SAM, if a surgeon elects not to use a CRNA or an anesthesiologist, a separate, designated, certified individual must perform these monitoring functions [33]. Visual observation of the patient’s position is also important in order to avoid untoward outcomes such as peripheral nerve or ocular injuries. Documentation of perioperative events, interventions, and observations must be contemporaneously performed and should include BP and HR every 5 min and oximetry, capnography, ECG pattern, and temperature at 15-min intervals. Intravenous fluids, medication dosages in mg, patient position, and other intraoperative events must also be recorded. Proper documentation may alert the physician to unrecognized physiological trends that may require treatment. Preparation for subsequent anesthetics may require information contained in the patient’s prior records, especially if the patient suffered an unsatisfactory outcome due to a previous anesthetic regimen. Treatment of subsequent complications by other physicians may require information contained in the records, such as the types of medications used, blood loss, or fluid totals. Finally, compulsive documentation may help exonerate a physician in many medical– legal challenges. When local anesthesia with SAM is used, monitoring must include an assessment of the patient’s level of consciousness as previously described. For patients under general anesthesia, the level of consciousness may be determined using the bispectral index (BIS), a measurement derived from computerized analysis of the electroencephalogram. When used with patients receiving general anesthesia, BIS improves control of the level of consciousness, rate of emergence and recovery, and cost control of medication usage [347].

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Given that 18 % of malpractice claims against anesthesiologists are related to peripheral nerve injuries occurring in the perioperative period [348], scrupulous attention to patient positioning during anesthesia is critical, especially for prolonged cases under general anesthesia. Elbows, knees, and feet should be carefully padded and the extremities should be placed in a neutral position avoiding extreme abduction, extension, or flexion to prevent traction on peripheral nerves. A pillow under the knees in the supine position may reduce the pressure on the low back and avoid postoperative back pain. Prolonged immobilization of the head may result in localized alopecia from follicular pressure necrosis. Maintaining neutral head position particularly during laryngoscopy may reduce postoperative neck pain. Documentation of proper positioning and frequent checks of positioning may be helpful in the defense in the event of a legal claim due to an unanticipated perioperative nerve injury. Patient’s eyes should be protected from inadvertent contact to avoid ocular injuries such as corneal abrasions. Hypothermia should be avoided during extended surgical procedures using FDAapproved warming devices such as the Bair Hugger®, Arizant Healthcare Inc. Makeshift warming devices such as heated IV bags, heated water bottles, electric blankets, warming lights, or forced heated air are absolutely contraindicated due to the high likelihood of severe burn injuries [349, 350].

1.5.7

Perioperative Fluid Management

One of the most critical and controversial aspects of liposuction, particularly large-volume liposuction, is perioperative fluid management. Determining appropriate fluid replacement during large-volume liposuction can be extremely challenging. For maintenance the typical healthy 60-kg male generally requires 1–2 mL/kg/h or about 100–200 mL per hour to replace metabolic, sensible, and insensible water losses [365]. After a 10–12-h period of fasting, a 60-kg patient may be expected to have an approximately 1-L volume

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deficit on the morning of surgery. This deficit should be replaced iv over the first few hours of surgery. In addition to the fluid deficit, induction of general anesthesia is usually accompanied by vasodilatation which requires compensatory iv fluid administration of approximately 0.5 mL/kg or 300 mL. The patient’s usual maintenance fluid needs may be met during surgery with an iv crystalloid solution such as lactated Ringer’s solution. Replacement fluids may be divided into crystalloid solutions, such as normal saline (0.9 % NaCl) or balance salt solution (lactated Ringer’s solution); colloids, such as fresh frozen plasma, 5 % albumin, plasma protein fraction, or hetastarch; and blood products containing red blood cells, such as packed red blood cells. Generally, balanced salt solutions may be used to replace small amounts of blood loss. For every mL of blood loss, 3 mL of fluid replacement is usually required [351]. However, as larger volumes of blood are lost, attempts to replace these losses with crystalloid reduces the serum oncotic pressure, one of the main forces supporting intravascular volume. Subsequently, crystalloid rapidly moves into the extracellular space. Intravascular volume cannot be adequately sustained with further crystalloid infusion [352]. At this point, many authors suggest that a colloid solution may be more effective in maintaining intravascular volume and hemodynamic stability [353, 354]. Given the ongoing crystalloid–colloid controversy in the literature, the most practical approach to fluid management is a compromise. Crystalloid replacement should be used for estimated blood losses (EBL) less than 500 mL, while colloids, such as hetastarch, may be used for EBLs greater than 500 mL. One milliliter of colloid should be used to replace 1 mL of EBL [351]. However, not all authors agree on the benefits of colloid resuscitation. Moss and Gould [355] concluded that isotonic crystalloid replacement, even for large EBLs, restores plasma volume as well as colloid replacement. For patients undergoing liposuction with less than 1,500 mL of fat extraction using the tumescent technique, studies have determined that postoperative serum hemoglobin remains essentially unchanged [356]. Therefore, intravenous fluids

G.D. Bennett

beyond the deficit replacement and the usual maintenance amounts are generally not required [27, 175, 356, 357]. As the volume of fat removed approaches or exceeds 3,000 mL, judicious iv fluid replacement, including colloid, may be considered depending on the patient’s hemodynamic status [27]. Fluid overload with the possibility of pulmonary edema and congestive heart failure following aggressive administration of infusate and intravenous crystalloid solutions has become a significant concern [18, 175, 357–360]. Using the tumescent technique during which subcutaneous infusion ratio of 2–3 mL for 1 mL of fat is aspirated, significant intravascular hemodilution has been observed [358]. A 5-L tumescent infusion may result in a hemodilution of 10 %. Plasma lidocaine near toxic levels, combined with an increased intravascular volume, may increase the risk of cardiogenic pulmonary edema, even in healthy patients [155, 358, 360]. Several authors have recommended various perioperative crystalloid replacement regimens. For large-volume liposuction, Klein advocates that no additional iv fluids be given. Pitman et al. [359] proposed limiting iv replacement to the difference between twice the volume of total aspirate and the sum of iv fluid already administered intravenously and as tumescent infusate. This replacement formula presumes a ratio of infusate to aspirate of greater than 2–1. If the ratio is less than one, more generous replacement fluids may be required since hypovolemia may occur [18]. More recently, Rohrich et al. [361] proposed using the intraoperative fluid ratio as a guide to fluid replacement. The intraoperative fluid ratio was defined as the volume of super-wet solution and intraoperative intravenous fluid divided by the aspiration volume. In their series of 89 patients, these authors concluded that for liposuctions less than 5,000 mL using the ratio 2.1 and for large-volume liposuction greater than 5,000 mL using the ratio 1.2 resulted in satisfactory fluid management without any adverse cardiopulmonary sequelae. They further concluded that for large-volume liposuction, no additional replacement iv fluids should be given at all. The determination of fluid replacement is still not an exact science, by any means. Because of

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the unpredictable fluid requirements in patients, careful monitoring is required, including possible laboratory analysis such as CBC and BUN [18]. To avoid hypothermia, particularly during longer or more extensive surgical procedures, all intravenous or tumescent fluids should be pre-warmed to 38 °C (100 °F). During prolonged surgical procedures or large-volume liposuction under sedation–analgesia, care must be taken not to administer too much fluid to avoid patient discomfort due to a distended urinary bladder. The estimation of perioperative blood and fluid loss during surgical procedures is not a trivial task. Observers in the same room frequently have wide discrepancies in the estimated blood loss. In some surgical procedures, unrecognized blood loss may occur. Substantial amounts of blood can seep around and under the patient, unnoticed by the surgeon, only to be discovered later as the nurses apply the dressing. Because of subcutaneous hematoma formation and the difficulty of measuring the blood content in the aspirate during large-volume liposuction, estimating the EBL during liposuction may be a particularly daunting task. Fortunately, the development of tumescent technique has dramatically reduced perioperative blood loss during liposuction surgeries [32, 352]. The blood content in the aspirate after tumescent liposuction has varied between less than 1 % [358, 362] and 8 % [359]. To underscore the difficulty of estimating the EBL, the range of the determined blood loss in one study was 0–1,002 mL or 0–41.5 % of the aspirate for liposuctions removing 1,000–5,500 mL of fat [359]. Samdal et al. [362] admitted that the mean fall of postoperative hemoglobin of 5.2 % (±4.9 %) was higher than anticipated. The authors suggested that previous estimates of continued postoperative blood extravasation into the surgical dead space may be too low and may be greater than the EBL identified in the aspirate. Mandel [363] concluded that unappreciated blood loss continues for several days after surgery, presumably due to soft tissue extravasation and that serial postoperative hematocrit determinations should be used, especially for large-volume liposuctions. Centrifuging a mixed sample of the aspirate to

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determining the red blood cell volume is one method to better estimate the amount of blood in the aspirate. Recent developments of pulse oximeters that can accurately determine hemodilution may be very useful in guiding fluid replacement. The decision to transfuse a patient involves multiple considerations. Certainly, the EBL, health, age, estimated preoperative blood volume of the patient, and the hemodynamic stability of the patient are the primary concerns. The potential risks of transfusions, such as infection, allergic reaction, errors in cross matching, and blood contamination, should be considered. Finally, the patient’s personal or religious preferences may play a pivotal role in the decision to transfuse. Cell-saving devices and autologous blood transfusions may alleviate many of these concerns. Healthy, normovolemic patients, with hemodynamic and physiological stability, should tolerate hemoglobin levels down to 7.5 g/dL [364]. Even for major surgical procedures or large-volume liposuction using the tumescent technique, transfusions are rarely necessary [27]. Once the decision to transfuse is made, 1 mL of RBCs should be used to replace every 2 mL of EBL along with replacement colloid or crystalloid [351]. Serial hematocrit determination, although sometimes misleading in cases of fluid overload and hemodilution, is still considered an important diagnostic tool in the perioperative period to assist with decisions regarding transfusion. An estimate of the patient’s volume status and possibly hemoglobin content of the blood may be routinely determined by newer, noninvasive pulse oxygenation-type monitors in the future. During longer, extensive surgical procedures and large-volume liposuction monitoring, the urine output using an indwelling urinary catheter is a useful guide to the patient’s volume status. Urinary output should be maintained at greater than 0.5 mL/kg/h. However, urinary output is not a precise method of determining the patient’s volume status since other factors, including surgical stress, hypothermia, and the medications used during anesthesia, are known to alter urinary output [365]. Therapeutic determinations based on a decreased urinary output become even more challenging since oliguria may be a result of

G.D. Bennett

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either hypovolemia or fluid overload and congestive heart failure. Determining fluid requirement solely on urinary output may result in inaccurate or unnecessary replacement. In general, the use of loop diuretics, such as furosemide, to accelerate urinary output makes everyone in the operating room feel better but does little to elucidate the cause of the reduced urinary output and, in cases of hypovolemia, may worsen the patient’s clinical situation. However, a diuretic may be indicated if oliguria develops in the course of large-volume liposuction where the total infusate and intravenous fluids are several liters more than the amount of aspirate [360] or in cases with minimal blood loss with adequate hydration.

1.6

Recovery and Discharge

The same intensive monitoring and treatment which occurs in the operating room must be continued in the recovery room under the care of a designated, licensed, and experienced person for as long as is necessary to ensure the stability and safety of the patient, regardless of whether the facility is a hospital, an outpatient surgical center, or a physician’s office. During the initial stages of recovery, the patient should not be left alone while hospital or office personnel attend to other duties. Vigilant monitoring including visual observation, continuous oximetry, continuous ECG, and intermittent BP and temperature determinations must be continued. Because the patient is still vulnerable to airway obstruction and respiratory arrest in the recovery period, continuous visual observation is still the best method of monitoring for this complication. Supplemental oxygenation should be continued during the initial stages of recovery and continued until the patient is able to maintain an oxygen saturation above 90 % on room air. The most common postoperative complication is nausea and vomiting. The antiemetic medications previously discussed, with the same consideration of potential risks, may be used in the postoperative period. Because of potential cardiac complications, droperidol, one of the most commonly used antiemetic, is now

considered by the FDA unsafe unless the patient has no cardiac risk factors and a recent 12-lead ECG was normal without prolongation of the QT interval [244]. Ondansetron, 4–8 mg iv or sl, is one of the most effective and safe antiemetics [298–302]. Postoperative surgical pain may be managed with judiciously titrated iv narcotic medication such as meperidine, 10–20 mg iv every 5–10 min; morphine, 1–2 mg iv every 5–10 min; butorphanol, 0.1–0.2 mg iv every 10 min; or hydromorphone, 0.1–0.2 mg iv every 5–10 min. However, when using narcotic medications to control postoperative pain, scrupulous monitoring in accordance with the ASA Guidelines [25] must be maintained because of the risk of delayed respiratory depression which could result in respiratory or cardiac arrest. Following large-volume liposuction, extracellular fluid extravasation or third spacing may continue for hours postoperatively leading to the risk of hypotension, particularly if the ratio of tumescent infusate to aspirate is less than one [360]. For large-volume liposuction, blood loss may continue for 3–4 days [363]. Crystalloid or colloid replacement may be required in the event of hemodynamic instability. The number of complications that occur after discharge may be more than twice the complications occurring intraoperatively and during the immediate recovery period combined [366]. Accredited ambulatory surgical center must have established discharge criteria. While these criteria may vary, the common goal is to ensure the patient’s level of consciousness and physiological stability. It is usually not necessary to urinate prior to discharge for most patients. The following is one example of discharge criteria that may be used (Table 1.16). The use of medications intended to reverse the effects of anesthesia should be used only in the event of suspected overdose of medications. Naloxone, 0.1–0.2 mg iv, a pure opiate-receptor antagonist, with a therapeutic half-life of less than 2 h, may be used to reverse the respiratory depressant effects of narcotic medications, such as morphine, demerol, fentanyl, and butorphanol. Because potential adverse effects of rapid opiate reversal of narcotics include severe pain, seizures,

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Table 1.16 Ambulatory discharge criteria All life-preserving protective reflexes, i.e., airway, cough, and gag, must be returned to normal The vital signs must be stable without orthostatic changes There must be no evidence of hypoxemia 20 min after the discontinuation of supplemental oxygen Patients must be oriented to person, place, time, and situation (times 4) Nausea and vomiting must be controlled and patients should tolerate po fluids There must be no evidence of postoperative hemorrhage or expanding ecchymosis Incisional pain should be reasonably controlled The patient should be able to sit up without support and walk with assistance Patients should be discharged in the care of a responsible adult Patients should not drive for at least 24 h if sedatives or analgesics were used Modified from Mecca [367] Reproduced with permission from Bennett [346]

pulmonary edema, hypertension, congestive heart failure, and cardiac arrest [368], naloxone must be administered by careful titration. The effective half-lives of many narcotics exceed the half-life of naloxone. Naloxone has no effect on the actions of medications, such as the benzodiazepines, the barbiturates, propofol, dexmedetomidine, or ketamine. Flumazenil, 0.1–0.2 mg iv, a specific competitive antagonist of the benzodiazepines, such as diazepam, midazolam, and lorazepam, may be used to reverse excessive or prolonged sedation and respiratory depression resulting from these medications [369]. The effective half-life of flumazenil is 1 h or less [370]. The half-lives of the benzodiazepines exceed the half-life of flumazenil. The benzodiazepines have effective half-lives greater than 2 h and, in the case of diazepam, up to 50 h. Many active metabolites unpredictably extend the putative effects of the narcotics and benzodiazepines. Because the effective half-lives of most of the benzodiazepines and many of the narcotics exceed that of flumazenil and naloxone, a major risk associated with the use of flumazenil and naloxone is the recurrence of the effects of the benzodiazepine or narcotic after 1–2 h. If the

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patient has already been discharged to home after these effects recur, the patient may be at risk for oversedation or respiratory arrest [368, 371]. Therefore, routine use of reversal agents, without specific indication, prior to discharge is ill advised. Patients should be monitored for at least 2 h prior to discharge if these reversal agents are administered [33]. Physostigmine (Antilirium®, Forest), 1.25 mg iv, a centrally acting anticholinesterase inhibitor, functions as a nonspecific reversal agent which may be used to counteract the agitation, sedation, and psychomotor effects in the central nervous system caused by a variety of sedative, analgesic, and inhalation anesthetic agents [372, 373]. Neuromuscular blocking drugs, if required during general anesthesia, are usually reversed by the anesthesiologist or CRNA prior to emergence in the operating room with anticholinesterase inhibitors such as neostigmine (Prostigmin®, ICN) or edrophonium (Enlon®, Bioniche Pharma, Tensilon®, Valeant Pharmaceuticals, or Reversol®, Organon) [274]. Occasionally, a second dose may be required when the patient is in the recovery room. If these neuromuscular blocking agents are not fully reversed, the patient could suffer a catastrophic respiratory arrest in the recovery room. In the event patients fail to regain consciousness during recovery, reversal agents should be administered. If no response occurs, the patient should be evaluated for other possible causes of unconsciousness, including hypoglycemia, hyperglycemia, hyponatremia, cerebral vascular accidents, or cerebral hypoxia. If hemodynamic instability occurs in the recovery period, causes such as occult hemorrhage, hypovolemia, pulmonary edema, congestive heart failure, or myocardial infarction must be considered. Access to laboratory analysis to assist with the evaluation of the patient is crucial. Unfortunately, stat laboratory analysis is usually not available if the surgery is performed in an office-based setting. The above text is meant to serve as an overview of the extremely complex subject of anesthesia. It is the intent of this chapter to serve as an introduction to the physician highlighting salient considerations in the perioperative management of

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patients and should not be considered a comprehensive presentation. The physician is encouraged to seek additional information on this broad topic through the other suggested readings. At least one authoritative text on anesthesia should be considered a mandatory addition to the physician’s office references.

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48 340. Bergqvst D, Lindblad B. A 30-year survey of pulmonary embolism verified at autopsy: an analysis of 1274 surgical patients. Br J Surg. 1985;72(2):105–8. 341. Miller C. Management of the difficult intubation in closed malpractice claims. ASA Newsl. 2000;64(6): 13–9. 342. Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, Hagberg CA, Caplan RA, Benumof JL, Berry FA, Blitt CD, Bode RH, Cheney FW, Connis RT, Guidry OF, Nickinovich DG, Ovassapian A, American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118(2):251–70. 343. Wilson WC. Trauma: airway management ASA difficult airway algorithm modified for trauma-and five common trauma intubation scenarios. ASA Newsl. 2005;69(11):9–16. 344. Verghese C, Brimacombe JR. Survey of laryngeal mask airway usage in 11,910 patients: safety and efficacy for conventional usage. Anesth Anal. 1996;82(1):129–33. 345. Lopez-Gil M, Brimacombe J, Alvarez M. Safety and efficacy of the laryngeal mask airway. A prospective survey of 1400 children. Anaesthesia. 1996;51(10): 969–72. 346. Bennett GD. Anesthesia for aesthetic surgery. In: Shiffman MA, Di Giuseppe AD, editors. Cosmetic surgery art and techniques. Berlin: Springer; 2013. 347. Gan TJ, Glass PS, Windsor AN, Payne F, Rosow C, Sebel P, Manberg P. Bispectral index monitoring allows faster emergence and improved recovery from propofol, fentanyl and nitrous oxide anesthesia. BIS Utility Study Group. Anesthesiology. 1997;87(4):808–15. 348. Cheney FW, Domino KB, Caplan R, Posner KL. Nerve injury associated with anesthesia. A closed claim analysis. Anesthesiology. 1999;90(4):1062–9. 349. Kressin KA. Burn injury in the operating room: a closed claims analysis. ASA Newsl. 2004;68(6):9–11. 350. Cheney FW, Posner KL, Caplan RA, Gild WM. Burns from warming devices in anesthesia: a closed claims analysis. Anesthesiology. 1994;80(4):806–10. 351. Tonnesen AS. Crystalloids and colloids. In: Miller R, editor. Anesthesia. 4th ed. New York: Churchill Livingstone; 1994. p. 1595–618. 352. Linko K, Malelaine A. Cardiorespiratory function after replacement of blood loss with hydroxyethyl starch 120, Dextran-70, and Ringer’s lactate in pigs. Crit Care Med. 1989;17(10):1031–5. 353. Hankeln K, Radel C, Beez M, Laniewski P, Bohmert F. Comparison of hydroxyethyl starch and lactated Ringer’s solution in hemodynamics and oxygen transport of critically ill patients in prospective cross over studies. Crit Care Med. 1989;17(2):133–5.

G.D. Bennett 354. Dawidson I. Fluid resuscitation of shock: current controversies. Crit Care Med. 1989;17(10): 1078–80. 355. Moss GS, Gould SA. Plasma expanders: an update. Am J Surg. 1988;155(3):425–34. 356. Jaen C. Study on the possible hydroelectric disorders induced by lipoaspiration with the tumescent technique and syringe aspiration. Int J Aesthet Reconstr Surg. 1997;5:67–75. 357. Parish TD. A review: the pros and cons of tumescent anesthesia in cosmetic and reconstructive surgery. Am J Cosmet Surg. 2001;18:83–93. 358. Klein JA. Superwet liposuction and pulmonary edema. In: Klein JA, editor. Tumescent technique: tumescent anesthesia and microcannular liposuction. St. Louis: Mosby; 2000. p. 61–6. 359. Pitman GH, Aker JS, Tripp ZD. Tumescent liposuction a surgeon’s perspective. Clin Plast Surg. 1996;23(4):633–41. 360. Gilliland MD, Coates N. Tumescent liposuction complicated by pulmonary edema. Plast Reconstr Surg. 1997;99(1):215–9. 361. Rohrich RJ, Leedy JE, Swamy R, Brown SA, Coleman J. Fluid resuscitation in liposuction: a retrospective review of 89 consecutive patients. Plast Reconstr Surg. 2006;117(2):431–5. 362. Samdal F, Amland PF, Bugge JF. Blood loss during liposuction using the tumescent technique. Aesthetic Plast Surg. 1994;18(2):157–60. 363. Mandel MA. Blood and fluid replacement in major liposuction procedures. Aesthetic Plast Surg. 1990; 14(3):187–91. 364. Leone BJ, Spahn DR. Anemia, hemodilution, and oxygen delivery. Anesth Analg. 1992;75(5):651–3. 365. Kaye AD, Grogono AW. Fluid and electrolyte physiology. In: Miller RD, editor. Anesthesia. 5th ed. Philadelphia: Churchill Livingstone; 2000. p. 1601. 366. Natof HE, Gold B, Kitz DS. Complications. In: Wetcher BV, editor. Anesthesia of ambulatory surgery. 2nd ed. Philadelphia: Lippincott; 1991. p. 374–474. 367. Mecca RS. In: Borash PG, Cullen BF, Stoelting RK, editors. Postoperative recovery. Philadelphia: J.B. Lippincott; 1992. p. 1517–8. 368. Bailey PL, Egar TD, Stanley TH. Intravenous opioid anesthetics. In: Miller RD, editor. Anesthesia. 5th ed. Philadelphia: Churchill Livingstone; 2000. p. 273–376. 369. Jensen S, Knudsen L, Kirkegaard L, Kruse A, Knudsen EB. Flumazenil used for antagonizing the central effects of midazolam and diazepam in outpatients. Acta Anaesthesiol Scand. 1989;33(1):26–8. 370. Klotz U. Drug interactions and clinical pharmacokinetics of flumazenil. Eur J Anaesthesiol. 1988; 2(Suppl):103–8. 371. McCloy RF. Reversal of conscious sedation by flumazenil: current status and future prospects. Acta Anaesthesiol Scand Suppl. 1995;108:35–42.

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Anesthesia for Liposuction

372. Bourke DL, Rosenberg M, Allen PD. Physostigmine: effectiveness as an antagonist of respiratory depression and psychomotor effects caused by morphine or diazepam. Anesthesiology. 1984;61(5):523–8. 373. Hill GE, Stanley TH, Sleutker CR. Physostigmine reversal of postoperative somnolence. Can Anaesth Soc J. 1977;24(6):707–11.

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Additional Recommended Reading Miller RD MS, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Cohen NH, Young WL. Miller’s anesthesia. 8th ed. Philadelphia: Elsevier; 2014.

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Tumescent Technique Melvin A. Shiffman

Abstract

The tumescent technique has improved the problem of blood loss during liposuction. A larger amount of lidocaine can be used up to 55 mg/kg depending on the patient’s weight. Klein introduced local tumescent anesthesia and showed that at least 35 mg/kg of lidocaine can be used in diluted solution. Klein proposed a number of solutions with different medication and strength of medication in the diluted solution. It is difficult to state exactly what Klein’s solution contains when the term is used in the literature. The tumescent technique is the use of a diluted formula of medications to expand the tissues in which it is injected and result in anesthesia and decreased blood loss during liposuction.

2.1

Introduction

In the early days of liposuction, the dry technique was used with general anesthesia. The technique used had no fluids injected into the tissues and resulted in 20–45 % blood loss [1–6]. Liposuction was limited to 2,000–3,000 mL because of the blood loss, and patients were frequently given transfusions [2]. The wet technique relies on infusions of 100– 300 mL of normal saline into each site but has blood

loss of 15–30 % [7–11]. With epinephrine added to the fluid, the blood loss is reduced to 20–25 %. The tumescent technique has improved the problem of blood loss reducing it to 1–7.8 % [12, 13]. The term “superwet anesthesia” has been used to describe the same fluid injection as with the tumescent technique [14]. This technique consists of an infusion of saline with epinephrine and an aspirate removal of approximately 1:1. Local tumescent anesthesia usually has a fluid infusion to aspirate ratio of 2:1 or 3:1.

M.A. Shiffman, M.D., J.D. Private Practice, 17501 Chatham Drive, Tustin, CA 92780, USA e-mail: [email protected] © Springer-Verlag Berlin Heidelberg 2016 M.A. Shiffman, A. Di Giuseppe (eds.), Liposuction: Principles and Practice, DOI 10.1007/978-3-662-48903-1_2

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M.A. Shiffman

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2.2

Local Tumescent Anesthesia

Klein reported the use of local tumescent anesthesia in 1987 [15]. The report described solutions used that consisted of: 1. For general anesthesia: (a) Normal saline: 1,000 mL (b) Epinephrine: 1 mg 2. For local tumescent anesthesia: (a) Normal saline: 1,000 mL (b) Epinephrine: 1 mg (c) Lidocaine: 1,000 mg The ratio of the amount of tumescent solution compared to the amount of aspirate removed was 1:1. Klein, in 1990 [16], showed that 35 mg/kg was a safe amount of lidocaine to use for local tumescent anesthesia. The solution utilized at that time consisted of: 1. 2. 3. 4.

Normal saline: 1,000 mL Epinephrine: 1 mg Lidocaine: 500 mg Sodium bicarbonate: 12.5 mEq

Klein, in 1993 [12], changed the local tumescent anesthesia solution to: 1. 2. 3. 4. 5.

Normal saline: 1,000 mL Epinephrine: 0.5–0.75 mg Lidocaine: 500–1,000 mg Sodium bicarbonate: 10 mEq Triamcinolone: 10 mg (optional)

The amount of mean tumescent solution compared to the total aspirate was 4,609 mL: 2,657 mL or almost 2:1. By 1995, Klein [17] had changed the tumescent formula to: 1. 2. 3. 4. 5.

Normal saline: 1,000 mL Epinephrine: 0.5–0.65 mg Lidocaine: 500–1,000 mg Sodium bicarbonate: 10 mEq Triamcinolone: 10 mg

In 2000, Klein [18] described a variation of drugs in the local tumescent solution according to the area being liposuctioned. The basic solution to be changed after checking for completeness of anesthesia was: 1. 2. 3. 4.

Normal saline: 1,000 mL Lidocaine: 500 mg Epinephrine: 0.5 mg Sodium bicarbonate: 19 mEq

If the anesthesia was not adequate, then a variety of formulations were proposed for each area of the body and ranged from 750 to 1,500 mg lidocaine, 0.5–1.5 mg epinephrine [12, 14–25], and 10 mEq sodium bicarbonate. Local tumescent anesthesia is used as the anesthetic for performing liposuction, especially with small cannulas (microcannulas). The same fluid can be used with conscious sedation to provide the necessary local anesthesia.

2.3

Tumescent Technique

Compared with local tumescent anesthesia, the tumescent technique is used to diminish blood loss and bruising, provide fluid replacement, and act as a local anesthetic after surgery. The tumescent technique is used with deep sedation or general anesthesia. The solution utilized is a variation on local tumescent anesthesia with the main elements being the fluid, either normal saline or lactated Ringer’s solution (1,000 mL), and 1 mg epinephrine for vasoconstriction. There is some use for the inclusion of lidocaine but not at the levels necessary for local tumescent anesthesia. The expected tumescent fluid to total aspirate ratio is usually 1:1. The author’s formula for the tumescent technique with general anesthesia and deep sedation consists of: 1. Lactated Ringer’s solution: 1,000 mL 2. Epinephrine: 1 mg 3. Lidocaine: 250 mg

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Tumescent Technique

Sodium bicarbonate, 12.5 mEq, the lidocaine is increased to 350 mg if local tumescent anesthesia, with or without conscious sedation, is utilized. The total aspiration, except for rare cases, does not exceed 4,500 mL. Tumescent fluid, with 250 mg lidocaine in 1,000 mL, with a total of 4,500 mL administered gives a total of 1,125 mg lidocaine, which is 16 mg/kg in a 70 kg patient. This allows 4,500 mL total aspirate (1:1). In a 70 kg (150 lb) patient using 350 mg lidocaine per liter and infusing 4,500 mL, the lidocaine infused is 1,575 mg/kg and therefore 22.5 mg/kg. In contrast, local tumescent anesthesia using 500 mg lidocaine per liter in a 70 kg patient requires 7,000 mL tumescent fluid to obtain 3,500 mL total aspirate (2:1), and the total lidocaine is 3,500 mg or 50 mg/kg. Cardenas-Camarena [26] reported the use of the tumescent technique with the fluid consisting of 1,000 mL normal saline and 1 mg epinephrine in patients having general anesthesia or peridural regional block (with lidocaine). The ratio of the volume of tumescent fluid to that of extracted fluid was 1:1. In the facial area, the total lidocaine should probably not exceed 7 mg/kg early in the injection since absorption of the lidocaine with epinephrine peaks within 15 min (because of the high vascularity of the face and epinephrine takes 15 min to cause adequate vasoconstriction) and then a second peak occurs in 8–14 h. Lidocaine in facial tumescence can exceed a total of 490 mg in a 70 kg patient if infused slowly. The more rapid the infusion, the lower the blood level of lidocaine needed to result in toxicity.

2.4

Discussion

Most patients in the author’s practice prefer not to be awake during the liposuction procedure. They are frightened and anxious and have heard things from friends or over the internet about the “gross” methods used in liposuction. Watching or hearing the sounds (machines and talking) with the liposuction procedure is abhorrent to some patients. Just the thought of

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the slightest discomfort during the procedure is enough for some patients to prefer general anesthesia or deep sedation. There have been instances of surgeons performing liposuction with local tumescent anesthesia where the patient has complained about pain and the surgeon would not reinject tumescent fluid or avoid the painful area since the procedure “is almost done.” The use of the tumescent technique combined with low vacuum [27, 28] has resulted in minimal blood loss, better patient satisfaction with the results of liposuction, and less bruising. The idea is to fill the areas to be liposuctioned with enough fluid to swell the tissues but not cause blanching. Injection of fluid begins with tunnels in the deep subcutaneous tissues and ends in tunnels in the superficial fat. Total aspirate usually approximates the amount of infusate without consciously attempting to get them equal. Liposuctioning is stopped in any tunnel that produces blood. It is possible to infuse more tumescent fluid if the preliminary results are not satisfactory to the surgeon, blood is beginning to appear in some of the tunnels, and more liposuctioning is required.

References 1. Dillerud E. Suction lipoplasty: a report on complications, undesired results, and patient satisfaction based on 3511 procedures. Plast Reconstr Surg. 1991;88(2): 239–46. 2. Courtiss EH, Choucair RJ, Donelan MB. Largevolume suction lipectomy: an analysis of 108 patients. Plast Reconstr Surg. 1992;89(6):1068–79. 3. Ersek RA. Severe and mortal complications. In: Hetter GP, editor. Lipoplasty: the theory and practice of blunt suction lipectomy. 2nd ed. Boston: Little, Brown; 1990. p. 223–5. 4. Drake LA, Ceilley RI, Cornelison RL, Dobes WL, Dorner W, Goltz RW, Lewis CW, Salasche SJ, Chanco Turner ML, Alt TH, et al. Guidelines of care for liposuction. Committee on Guidelines of Care. J Am Acad Dermatol. 1991;24(3):489–94. 5. Hetter GP. Blood and fluid replacement for lipoplasty procedures. Clin Plast Surg. 1989;16(2):245–8. 6. Courtiss EH, Kanter MA, Kanter WR, Ransil BJ. The effect of epinephrine on blood loss during suction lipectomy. Plast Reconstr Surg. 1991;88(5):801–3.

54 7. Goodpasture JC, Bunkis J. Quantitative analysis of blood and fat in suction lipectomy aspirates. Plast Reconstr Surg. 1986;78(6):765–72. 8. Gargan TJ, Courtiss EH. The risks of suction lipectomy: their prevention and treatment. Clin Plast Surg. 1984;11(3):457–63. 9. Clayton DN, Clayton JN, Lindley TS, Clayton JL. Large volume lipoplasty. Clin Plast Surg. 1989;16(2):305–12. 10. Dolsky RL. Blood loss during liposuction. Dermatol Clin. 1990;8(3):463–8. 11. Hetter GP. Blood and fluid replacement. In: Hetter GP, editor. Lipoplasty: the theory and practice of blunt suction lipectomy. 2nd ed. Boston: Little, Brown; 1990. p. 191–5. 12. Klein JA. Tumescent technique for local anesthesia improves safety in large-volume liposuction. Plast Reconstr Surg. 1993;92(6):1085–98. 13. Pitman GH. Tumescent liposuction: operative technique. Oper Tech Plast Reconstr Surg. 1996;3(2): 88–93. 14. Matarasso A. Superwet anesthesia defines largevolume liposuction. Aesthet Surg J. 1997;17(6): 358–64. 15. Klein JA. The tumescent technique for lipo-suction. Am J Cosmet Surg. 1987;4(4):263–7. 16. Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol. 1990;16(3):248–63. 17. Klein JA. Tumescent technique chronicles: local anesthesia, liposuction, and beyond. Dermatol Surg. 1995;21(5):449–557. 18. Klein JA. Tumescent formulation. In: Klein JA, editor. Tumescent technique: tumescent anesthesia & microcannular liposuction. St. Louis: Mosby; 2000. p. 187–95.

M.A. Shiffman 19. Greco RJ. Massive liposuction in the moderately obese patient: a preliminary study. Aesthet Surg J. 1997;17(2):87–90. 20. Hanke CW, Bernstein G, Bullock S. Safety of tumescent liposuction in 15,336 patients. Dermatol Surg. 1995;21(5):459–62. 21. Kaplan B, Moy RL. Comparison of room temperature and warmed local anesthetic solution for tumescent liposuction: a randomized double-blind study. Dermatol Surg. 1996;22(8):707–9. 22. Lillis PJ. Tumescent technique for liposuction surgery. Dermatol Clin. 1990;8(3):439–49. 23. Narins RS, Coleman WP. Minimizing pain for liposuction anesthesia. Dermatol Surg. 1997;23(12): 1137–40. 24. Ostad A, Kageyama N, Moy RL. Tumescent anesthesia with a lidocaine dose of 55 mg/kg is safe for liposuction. Dermatol Surg. 1996;22(11):921–7. 25. Samdal F, Amland PF, Bugge JF. Plasma lidocaine levels during suction-assisted lipectomy using large doses of dilute lidocaine with epinephrine. Plast Reconstr Surg. 1994;93(6):1217–23. 26. Toledo LS. Syringe liposculpture: a two-year experience. Aesth Plast Surg. 1991;15(4):321–6. 27. Cardenas-Camarena L, Tobar-Losada A, Lacouture AM. Large-volume circumferential liposuction with tumescent technique: a sure and viable procedure. Plast Reconstr Surg. 1999;104(6):1887–99. 28. Elam MV, Packer D, Schwab J. Reduced negative pressure liposuction (RNPL): could less be more? Int J Aesthet Restor Surg. 1997;3(2):101–4.

3

Liposuction with Local Tumescent Anesthesia and Microcannula Technique Shilesh Iyer and Bernard I. Raskin

Abstract

In conjunction with the innovation of tumescent anesthesia, small microcannulas were developed to more gently and precisely remove layers of adipose tissue to achieve a sculpting effect. These cannulas have a diameter of 20–10 gauge (0.58–2.7-mm inner diameter) compared with the larger cannulas having a diameter from 3 to 6 mm or greater. The authors discuss tumescent anesthesia, tumescent fluid infiltration, and tumescent liposuction technique with microcannulas.

3.1

Background and History

Tumescent liposuction refers to the process of suction-assisted aspiration of subcutaneous fat after infiltration with a dilute crystalloid solution containing lidocaine and epinephrine. By definition, pure tumescent liposuction is performed entirely under local anesthesia and excludes the use of general anesthesia or intravenous sedation [1]. The concept of liposuction utilizing local tumescent anesthesia and microcannulas was reported by Klein [2] in 1987. Prior to this innovation, liposuction techniques employed largerdiameter cannulas under general anesthesia. The field of modern liposuction was first described by

S. Iyer, M.D. (*) • B.I. Raskin, M.D. Private Practice, 28212 Kelly Johnson Parkway #245, Santa Clarita, CA 91355, USA e-mail: [email protected]; [email protected]

Fischer [3] in 1976 and further expanded by liposuction pioneers Pierre Fournier and YvesGerard Ilouz. Initially, the procedure was performed with larger-diameter cannulas under a dry technique until Ilouz of France introduced the wet technique utilizing an infiltrated hypotonic saline and hyaluronidase solution to facilitate the fat removal. While these early techniques were effective, they were associated with more trauma and potential complications including hemorrhage, fluid loss, and pain [4–6]. The invention of tumescent anesthesia by Klein revolutionized the field of liposuction. Klein described a technique for aspirating adipose tissue entirely under local anesthesia with a dilute solution of lidocaine and epinephrine. The technique provided excellent hemostasis, maintained fluid balance, and eliminated the need for general anesthesia and associated complications. In conjunction with the innovation of tumescent anesthesia, small microcannulas were developed

© Springer-Verlag Berlin Heidelberg 2016 M.A. Shiffman, A. Di Giuseppe (eds.), Liposuction: Principles and Practice, DOI 10.1007/978-3-662-48903-1_3

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S. Iyer and B.I. Raskin

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to more gently and precisely remove layers of adipose tissue to achieve a sculpting effect. These cannulas have a diameter of 20–10 gauge (0.58– 2.7-mm inner diameter) compared with the larger cannulas having a diameter from 3 to 6 mm or greater. With proper technique, liposuction utilizing microcannulas under local tumescent anesthesia is an exceedingly safe and effective procedure with a relatively comfortable postoperative recovery period for the patient [7].

3.2

Tumescent Anesthesia

3.2.1

Advantages of Tumescent Anesthesia

The concept of tumescent anesthesia relies on infiltrating a dilute solution of normal saline with lidocaine and epinephrine that is partially removed in the lipoaspirate (10–30 %) but largely removed from the subcutaneous tissue over several hours after the procedure has been completed. This slow absorption allows for gradual intravascular volume replacement and elimination of the lidocaine over several hours without achieving toxic plasma lidocaine levels (over 5 μg/mL) [8]. This technique provides excellent anesthesia, obviating the need for general anesthesia and its associated complications, and provides excellent hemostasis provided by the vasoconstrictive effects of the epinephrine. The procedure can be done safely on an outpatient basis with rapid postoperative healing. Furthermore, owing to delayed lidocaine absorption, prolonged anesthesia can last up to 18 h, mitigating the need for postoperative analgesic medications [7]. In addition to its local anesthetic effects, an added benefit of tumescent solution with lidocaine appears to be an antibacterial effect. The antibacterial properties of lidocaine are known and have previously been reported [9, 10]. Contradictory studies, however, have questioned the antibacterial properties of lidocaine when very low concentrations are used as in tumescent fluid [11]. Nevertheless, although studies on this issue are not definitive, physicians experienced in

the tumescent technique have noted a low rate of significant clinical infections, which may be attributed in part to the antibacterial properties of lidocaine [5, 12, 13]. Addition of bicarbonate to lidocaine appears to enhance the in vivo antibacterial effect [14].

3.2.2

Pharmacology of Tumescent Anesthesia

Tumescent anesthesia relies on the effects of lidocaine, which acts by blocking the sodium ion flux across nerve membranes and slowing the rate of depolarization such that threshold potentials are not reached and impulses are not propagated [15]. The tumescent concept works because lidocaine’s aromatic structure renders it lipophilic in nature. Lidocaine is therefore highly soluble in fat and has a high affinity for the subcutaneous compartment. When skin is excised after infiltrating tumescent anesthesia, there is a marbled appearance and puddles of anesthetic solution are loculated within and between connective tissue septa. These lakes act as physical reservoirs of lidocaine. The lipophilic property of lidocaine is harnessed in the tumescent technique to delay the absorption of lidocaine into the systemic circulation. The lidocaine is slowly removed from the subcutaneous compartment over several hours owing to its affinity for the subcutaneous tissues, the relative hypovascular nature of the subcutaneous tissues, and the vasoconstrictive effects epinephrine, all of which minimize intravascular absorption of the lidocaine [15]. Compression of the vasculature by the infused fluid may also contribute to the slow absorption [8]. After infiltration, clinical observation has determined that optimal anesthesia and hemostasis occur after 15–30 min. Greater duration of time may allow additional anesthetic effect. Elimination of the lidocaine from the fat occurs over 48 h, with peak plasma concentrations occurring around 12 h. When utilizing a maximum dose of 35 mg/kg, lidocaine concentrations have been shown to peak 12–14 h after infiltration and were in the range 0.8–2.7 μg/mL [7].

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Liposuction with Local Tumescent Anesthesia and Microcannula Technique

With the tumescent anesthesia formulation, significantly higher doses of lidocaine can be used compared with the traditional upper limit of 7 mg/kg lidocaine with epinephrine. Early work by Klein and Lillis [16] dramatically altered the manner in which local anesthesia metabolism and safe dose determinations were viewed. Now it is firmly established that 35 mg/ kg lidocaine as performed in liposuction is a safe level, and studies indicate that levels up to 55 mg/kg may be tolerated safely, presuming there are no contraindications such as potential drug interactions or underlying hepatic insufficiency [7, 8]. Caution must be exercised when using higher doses of lidocaine in the range 50–55 mg/kg as cases of mild nausea and vomiting have been reported, although the plasma lidocaine levels were below 3.5 μg/mL [17]. Doses exceeding 55 mg/kg were shown to be associated with a 2 % incidence of mild toxicity of nausea and vomiting, and the incidence is 10 % or greater if dosages above 60 mg/mL are used. The cited threshold for lidocaine toxicity is 5 μg/mL, although deaths have been reported in the literature at lower levels. Those patients, however, did not have solely tumescent liposuction under local anesthesia [15]. Tumescent anesthesia is highly effective and has an extraordinary safety profile when appropriate dosing is used and strict guidelines are maintained. According to the textbook Tumescent Technique by Klein [15], “tens of thousands of tumescent liposuction patients have received 35–50 mg/kg of lidocaine with no known reports of deleterious effect, which has proved the safety of tumescent local anesthesia for liposuction.”

3.2.3

Tumescent Anesthesia Formulation

The tumescent fluid formulated for microcannula liposuction most often consists of a concentration of 0.05–0.1 % lidocaine. A typical standard 0.1 % solution contains a total of 1,000 mg lidocaine, 10 mEq sodium bicarbonate, and a concentration of 1:1,000,000–1:2,000,000 epinephrine in 1 l of normal saline solution [15].

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The full-strength 0.1 % solution is useful when treating smaller areas (neck, jowls) or when treating those areas which tend to be more fibrous and tender (abdomen, back, breasts, female flanks). However, tumescent formulations vary depending on the clinical circumstance. Different concentrations of lidocaine are chosen depending on the area and volume required. For instance, a 0.05 % lidocaine formulation may be used when treating more extensive areas where larger amounts of fluid are required but the maximum safe dosing is to be maintained. Alternatively, extremely sensitive areas such as the periumbilical region are often resistant to 0.05 and 0.1 % solutions and a 0.15 % mixture may be required. When infusing just a neck, higher lidocaine concentrations can be used since only smaller volumes of total fluid are required. This contrasts with the abdomen and flanks, where significantly larger volumes are required, making use of higher concentrations potentially problematic. Keeping in mind the 35–55-mg/kg upper limit and the volumes of infiltration needed, varying concentration levels can be utilized. Epinephrine is a potent adrenergic agent that acts as a vasoconstrictor that enhances hemostasis and prevents rapid systemic absorption of lidocaine from the subcutaneous tissues. Epinephrine dosing was empirically derived, with experience showing that doses of 0.5–1 mg/L (which yields a final epinephrine concentration of 1:2,000,000–1:1,000,000) provided consistent vasoconstriction with a low incidence of tachycardia. The addition of epinephrine to the mixture results in prolonged local anesthetic effect and permits higher lidocaine doses by slowing its absorption. Furthermore, the epinephrine provides a dramatic hemostasis that substantially reduces blood loss. Although higher concentrations of epinephrine provide more effective hemostasis, patients should be monitored for tachycardia and hypertension. Thorough preoperative evaluations should be performed and lower concentrations of epinephrine should be considered in patients with underlying medical conditions such as thyroid or cardiovascular disease. Smaller areas over multiple sessions can be performed if required. Premedication with

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58 Table 3.1 Standard tumescent anesthesia formulation 0.15 % lidocaine 0.1 % lidocaine 0.075 % lidocaine 0.05 % lidocaine

Lidocaine (mg) 1,500 1,000 750 500

Epinephrine (mg) 0.5–1 0.5–1 0.5–1 0.5–1

clonidine may also be helpful (see later) in patients who may be sensitive to epinephrine effects [15]. The solubility of lidocaine is enhanced in acidic solutions but these are often more painful to inject. Buffering of lidocaine solution with sodium bicarbonate has been shown to decrease pain [18]. Because non-acidic solutions cause the spontaneous degradation of epinephrine, it is recommended that anesthetic solutions be freshly mixed on the day of surgery (Table 3.1) [15].

3.2.4

Calculating the Maximum Lidocaine Dose

The maximum lidocaine dose must be calculated for each patient individually on the basis of the patient’s weight, which should be obtained on the day of surgery. A dose of 35–55 mg/kg should not be exceeded. For a 160-lb man, the maximum lidocaine dose is calculated as follows: 160 lb/2.2 = 72.3 kg. The total dose range is from (35 × 72.3) to (55 × 72.3), i.e., from 2,530.5 to 3,976.5 mg. The absolute upper limit of lidocaine is 3,976.5 mg in this example. Various concentrations and volumes of tumescent fluid can be used depending on the areas being treated, but the total dose of lidocaine should not exceed 3,976.5 mg. Thus, with a 0.1 % lidocaine solution, the total volume of fluid used should be less than 4 l.

3.3

Lidocaine Metabolism and Toxicity

Metabolism of lidocaine occurs through the hepatic cytochrome enzymes, which convert the lipophilic lidocaine to a hydrophilic molecule

Sodium bicarbonate (mEq) 10 10 10 10

Normal saline (1) 1 1 1 1

that can be more readily eliminated. Lidocaine is metabolized rapidly with 70 % elimination with first pass through the liver, where the molecule undergoes oxidative N-dealkylation. Lidocaine is largely metabolized by the cytochrome P450 3A4 (CYP3A4) enzyme. Reduction in the cytochrome enzymes, either through downregulation or competitive inhibition by other medications, can reduce the clearance of lidocaine and augment the potential for lidocaine toxicity. Alternatively, parenchymal liver disease or decreased hepatic blood flow can also reduce the rate of lidocaine clearance [7, 19, 20]. Medications such as ketoconazole and erythromycin can impair lidocaine metabolism by inhibiting its cytochrome P450-mediated metabolism. A thorough understanding of lidocaine metabolism and drug interactions is essential prior to performing tumescent liposuction to avoid possible lidocaine toxicity. A report of medication-related lidocaine toxicity after tumescent liposuction was attributed to concomitant use of sertraline or flurazepam via their inhibitory effects on the cytochrome P450 enzymes [20]. Table 3.2 includes a list of some CYP3A4 inhibitors that are clinically relevant when evaluating a patient preoperatively for liposuction. It should be emphasized that many medications are metabolized by the CYP3A4 enzyme system and the table shown is only a partial list. Furthermore, some food ingredients such as naringenin and quercetin in grapefruit juice can also have inhibitory effects on the cytochrome system [19]; therefore, careful preoperative evaluation for all possible CYP3A4 interactions must be diligently performed. It is advised that each and every medication that the patient is taking be closely reviewed for possible cytochrome P450 interactions. In patients on medications that affect the cytochrome enzyme system, the dose of lidocaine

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Table 3.2 Drugs with potential cytochrome P450 interactions Acebutolol Acetazolamide Alprazolam (Xanax) Amiodarone (Cordarone) Anastrozole (Arimidex) Atenolol Cannabinoids Carbamazepine (Tegretol) Cimetidine (Tagamet) Chloramphenicol Clarithromycin (Biaxin) Cyclosporine (Neoral) Danazol (Danocrine) Dexamethasone Diazepam (Valium) Diltiazem (Cardizem) Erythromycin Esmobolol Felodipine (Plendil) Fluconazole (Diflucan) Flurazepam (Dalmane) Fluoxetine (Prozac) Fluvoxamine (Luvox) Indinavir (Crixivan) Isoniazid Itraconazole (Sporanox) Ketoconazole (Nizoral) Labetalol Methadone Metoprolol Metronidazole (Flagyl) Mibefradil (Posicor) Miconazole (Monistat)

Midazolam (Versed) Nadolol Naringenin (grapefruit juice) Nefazodone (Serzone) Nelfinavir (Viracept) Nevirapine (Viramune) Nicardipine (Cardene) Nifedipine (Procardia) Norfloxacin (Noroxin) Norfluoxetine Omeprazole (Prilosec) Paroxetine (Paxil) Pentoxyfylline Pindolol Propranolol Propofol Quinidine (Quinaglute) Remacemide Ritanavir (Norvir) Saquinavir (Invirase) Sertinadole Sertraline (Zoloft) Stiripentol Terfenadine (Seldane) Thyroxine Timolol Triazolam (Halcion) Troglitazone (Rezulin) Troleandomycin (TAO) Valprolic acid Verapamil (Calan) Zafirlukast (Accolate) Zileuton (Zyflo)

used during tumescent liposuction should be maintained below 35 mg/kg. If possible, medications with cytochrome P450 interactions should be discontinued prior to surgery. Because some medications which are cytochrome inhibitors have a prolonged half-life and are tightly bound to plasma proteins, at least 7 days should elapse between the time that the medication is discontinued and the surgery is performed. Patients with a history of liver disease or hepatic insufficiency should also be treated conservatively. Generally, these patients should be treated only if hepatic

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Table 3.3 Signs of lidocaine toxicity Lidocaine level (μg/ml) Signs of toxicity 3–5 Nausea, vomiting, drowsiness, lightheadedness tingling 5–8 Tinnitus, paresthesias, CNS changes, cardiovascular toxicity >8 Coma, seizures, and severe cardiac and respiratory depression

transaminases and liver enzymes are in the normal range and the total dose of lidocaine should be kept below 35 mg/kg. The same is true for those patients with decreased hepatic perfusion due to medications or cardiovascular disease that can lead to possible impaired lidocaine metabolism and toxicity [7, 15]. The issue of medication interactions is especially important when considering the choice of ancillary medications that are to be used. A discussion of these ancillary medications can be found in the following. Careful attention must be paid to possible cytochrome P450 interactions when choosing prophylactic antibiotics, analgesics, and anxiolytics. For example, benzodiazepams are frequently administered orally prior to tumescent liposuction. While most benzodiazepams are metabolized by CYP3A4, lorazepam is not and can be safely used without altering lidocaine metabolism [15]. In addition to concomitant medication use and underlying medical disease, there are several factors that should be considered in determining the maximum safe dose of lidocaine. Both male patients and thinner patients tend to have a lower volume of distribution for lidocaine in the subcutaneous compartment and may not tolerate extreme doses of lidocaine. Elderly patients as well may not tolerate higher doses owing to diminished liver perfusion that occurs with age [20]. When lidocaine is employed properly, the risk of lidocaine toxicity is very low with the pure tumescent liposuction technique. However, all surgeons practicing tumescent liposuction should be familiar with the signs of lidocaine toxicity that occur when serum levels exceed 5 μg/mL (Table 3.3). Treatment of lidocaine toxicity, which is beyond the purview of this text, includes

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supportive measures and seizure treatment. It is recommended that all liposuction surgeons be certified in advanced cardiac life support.

3.4

Alternative Anesthetic Agents

Various alternative tumescent formulations have been utilized, including infusion of dilute epinephrine without local anesthesia with supplemental bupivacaine after surgery [22]. However, owing to bupivacaine’s effect on myocardium, the potential for cardiotoxicity is greater and its use is not advocated [23]. Use of prilocaine at 35 mg/kg was reported in the European literature at and it was found to be safe. Methemoglobinemia is a potential side effect of prilocaine, however, and there is a paucity of data in the literature to date on this anesthetic agent’s use in liposuction [24]. At this time, the use of alternative anesthetic agents is not well studied and their safety profiles remain unclear. Lidocaine is well documented to be safe and effective in tumescent liposuction and remains the standard in the USA.

3.5

Ancillary Pharmacology

The material in this section is presented as a general discussion only and not as a complete reference on alternative and additional drugs. The reader should be well conversant with the medications before prescribing for any particular patient. The decision for prophylactic and perioperative antibiotics has no current standard. As discussed earlier, infection rates are extremely low with the tumescent technique. This may be related to lidocaine acting as an antibacterial agent as discussed earlier in this chapter [5, 9, 10]. Clinically the decision for antibiotics at this time is determined by the surgeon. We routinely prescribe prophylactic broad-spectrum antibiotics initiated the day prior to surgery. It is essential that the antibiotic of choice is not metabolized by the CYP3A4 system so as to avoid interaction with lidocaine metabolism.

Lorazepam by mouth (usually 1–2 mg) should be considered as the recommended sedative preoperatively because it is not metabolized by the cytochrome P450 system. Other benzodiazepams, including diazepam, may have interactions with lidocaine through the CYP3A4 system and are generally avoided. Orally administered lorazepam can be used to produce the same sedative, anxiolytic, and anterograde amnesic effects as 10–20 mg diazepam. Nausea may occur with 2 mg and often only 1 mg is needed. The drug has a half-life of 10 h or longer and frequently a dose taken the night before might be all that is needed. Alternatively, a dose of 1 mg lorazepam may be administered 1 h prior to surgery [1]. Clonidine has been popularized as an effective analgesic with mild sedative and antianxiolytic properties at a single dose of 0.1 mg orally and can be safely used unless patients have low blood pressure or slow pulse. It is also especially useful in patients who may be borderline with regard to tachycardia and hypertension to maintain a lower heart rate and blood pressure during surgery. Clinical effects begin 20–40 min after ingestion. Repeated doses should not be given. Clonidine is a drug underappreciated by liposuction surgeons and should be recognized as an effective supplement for analgesia, which can help minimize the need for narcotics. Furthermore, clonidine may potentiate the anesthetic effects of lidocaine and enhance the effects of opiates [15]. Klein also advocates the use of 0.3–0.4 mg of intravenous atropine given in a dilute mixture after intravenous access has been established to prevent vasovagal events when clinically needed [15]. Midazolam is widely used by surgeons and anesthesiologists in cosmetic surgery both before surgery and as part of intravenous sedation. According to Klein, 3 % of patients require intravenous midazolam at a dose of 1 mg during infiltration to supplement oral clonidine and lorazepam. Midazolam has a short duration of effect after a single dose. Problems with disinhibition may occur with this drug, but the amnestic effect is significant and often beneficial during the infiltration phase where discomfort may be present in select patients [15]. While respiratory

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depression is possible, the drug may be immediately reversed with intravenous flumazenil [25]. There is a theoretical problem with concomitant use of beta-blockers in conjunction with epinephrine as unopposed alpha stimulation could result. However, this appears to be primarily a theoretical issue. In clinical practice it appears that the absorption of epinephrine from the tissue is too slow to result in a significant problem. This problem has not surfaced in any of the major studies on morbidity and mortality. As a result, patients on beta-blockers generally continue their usual doses [17]. However, if a modified tumescent technique is used and general anesthesia is employed, the anesthesiologist should be advised to avoid the use of propranolol owing to the potential for unopposed adrenergic stimulation [21]. Narcotics are utilized by many liposuction surgeons [26]. They may be provided as part of intravenous sedation and anesthesia or as supplemental analgesia for surgeons utilizing the local anesthetic liposuction approach. The combination of meperidine and antihistamine has a long and established usage for all types of pain management and may be provided by intravenous or intramuscular routes. Sometimes doses as low as 10 mg can be effective in the author’s experience, although dosing of 50 mg may be necessary. Naloxone should always be available when administering narcotics. Butorphanol in low doses is a safe alternative [27]. Fentanyl in a 25–50-μg dose may be substituted for meperidine, although caution must be exercised as it is metabolized by the cytochrome 3A4. In general, with intravenous dosing, fentanyl has a relatively short duration of action and causes less nausea and orthostatic hypotension [15].

3.6

Tumescent Liposuction Technique

3.6.1

Tumescent Fluid Infiltration

Various techniques for fluid infiltration have been described and individual variations among surgeons are extremely common. Routinely, a warmed solution of the tumescent formula is

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prepared. An ideal temperature of 37–40 °C has been reported to be ideal to maximize patient comfort upon infiltration [28]. The use of bicarbonate buffer also helps to minimize discomfort. The tumescent fluid is infiltrated first using a 25-gauge spinal needle to sprinkle the fluid diffusely. Once a small amount of fluid has been distributed over the area to be treated, a 20-gauge needle is subsequently used to infiltrate more fluid. Finally, small incisions with a no. 11 blade or a 2-mm punch are made in the skin, and a 14-gauge multihole infiltration cannula is inserted into the subcutaneous plane to achieve complete tumescence. Most surgeons utilize the same incision ports for infiltration that are used for fat aspiration. When performed in this stepwise fashion, patient comfort is maximized. Although spinal needles may help with patient comfort, some surgeons opt to avoid these needles and use only the blunt infiltration cannulas, as they are potentially less traumatic. During the infiltration process, attention must be paid to maintaining the needle at approximately a 30–45° angle with respect to the horizontal plane. A fanlike pattern is utilized to ensure wide distribution of the fluid (Fig. 3.1). The surgeon at all times should be aware of where the end of the needle resides to avoid injury to thoracic and intra-abdominal structures. When the infiltration cannula is used in the final stages, it is passed in a plane that is parallel to the horizontal plane. Fluid must be delivered to all levels of fat. Infiltrating only the more superficial fat may clinically give a tumesced feel to the skin but the deeper fat has not been anesthetized; therefore, it is recommended that the deeper fat be infiltrated first. The subcutaneous tissue can be gently grasped and lifted during the infiltration process to ensure that the deeper fat is anesthetized and to prevent inadvertent injury to deeper structures (Fig. 3.2). The tumescent fluid is infiltrated under pressure. Most physicians utilize pumps where the rate can be preset and a foot pedal allows on/off control. The amount of time required for infiltration can be reduced by increasing the rate of lidocaine infusion but this is often accompanied by increased patient discomfort and may require

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Fig. 3.1 Fanlike pattern from multiple sites for infiltration and liposuction

more premedication depending on patient tolerance [29]. Additionally, rapid infusion may result in patchy or uneven distribution and incomplete anesthesia and hemostasis. Meticulous infiltration with tumescence throughout the fat results in less than 1 % blood loss per liter of aspirate, whereas rapid infiltration results in 7 % blood loss per liter aspirated (Fig. 3.3) [15]. It has been shown that serum levels of lidocaine are not affected by the pressure or the rate of infusion [30, 31]. Alternative methods include hanging an intravenous bag with a pressure cuff. The surgeon must monitor both the total volume infiltrated and the total lidocaine dose carefully during the infiltration process.

Fig. 3.2 Fat being grasped and lifted to infiltrate deep layers without injuring deeper structures

Infiltration is continued until the tissue has become fully tumesced. The infiltrated areas have a firm, edematous quality to palpation. The skin is characterized by pallor and is slightly cool owing to the vasoconstrictive effects of the tumescence. A peau d’orange appearance is undesirable and should be avoided. Hydrodissection secondary to tumescent fluid helps maintain patient comfort in that the infiltration cannula is not pushed through the tissue so much as the fluid is utilized to open the tissue beyond the cannula tip. Properly performed, infiltration is slow and steady, allowing the cannula to slip between fibrous septa smoothly rather

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Fig. 3.3 Fat aspiration in multiple planes with a fanlike pattern. Arrows are the direction of insertion of cannulas

than imposing excessive traction as it is pushed through resistant tissue. The volume infiltrated is the minimal amount to achieve complete local anesthesia. Empirically it is usually on the order of 2:1 or 3:1 (fluid infiltrated to aspirated fat) [15]. Maximum tumescence is not required for complete anesthesia or vascular stabilization and excess volumes should be avoided as it results in a more difficult liposuction.

3.6.2

Microcannulas and Lipoaspiration

The tumescent liposuction technique is nicely complemented by the use of microcannulas. These cannulas are designed to have a narrow diameter and may have multiple apertures or only one or two holes. They vary in length, so both large and small areas can be effectively treated and proximal and distal areas can be reached from a single incision site. Microcannulas offer a number of advantages. First, owing to the small diameter, they are generally less painful as they penetrate through the subcutaneous tissue. Additionally, the smaller-diameter cannulas often pass more easily through fibrous tissue, which is especially advantageous in specific areas such as

the upper abdomen, back, and breasts. Generally, the microcannulas remove small amounts of fat with each stroke. This allows for gradual and precise removal of fat to prevent textural irregularities and depressions. Although slower than larger cannulas, microcannulas can ultimately be just as aggressive in removing large volumes of adipose tissue. Cannula size and type is a matter of each surgeon’s individual preference and a variety of cannulas can be used effectively, depending on the surgeon’s experience and skill. Before beginning infiltration, the areas to be treated should be marked in a topographical fashion while the patient is standing. These markings should indicate those areas of denser fat accumulations where more fat is to be removed as well as those areas where less fat is present. The markings should also designate the edges of the region being treated where feathering will occur for optimal blending and cosmetic outcome [15]. After infiltration of the tumescent fluid, the surgeon should wait approximately 15–30 min to allow the tumescent fluid to reach maximum effect. As patients generally are awake during the tumescent liposuction procedure, they can be positioned precisely to allow for optimal liposuction. Initially, smaller-diameter cannulas can be used to penetrate the subcutaneous tissue and

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create tunnels through which larger cannulas can be passed. Through this method, intraoperative comfort will be maximized [26]. The cannula is generally passed through the same incisions used for infiltration of the tumescent fluid. These entry points are strategically placed to be minimally visible after the patient has fully recovered. Multiple entry points are required to access the entire area to be treated. Entry sites should be randomly placed without symmetry within any given area that is being treated. This will ultimately produce the most inconspicuous results. The fat is removed in layers, starting first with the deepest layers. The skin is lifted with the nondominant hand to create a tunnel of tissue through which the cannula is passed. A fanning pattern is used to remove an entire plane of fat. This fanning pattern can be repeated in different planes, starting in the deep subcutaneous fat and moving more superficially (Fig. 3.3) [15]. The end point with tumescent liposuction is somewhat different from that of non-tumescent techniques in that there is still fluid in the tissue after the appropriate amount of fat has been aspirated. Determining the end point is a matter of surgical experience and depends on tissue palpation and visual configuration.

3.7

Postoperative Care: Open Drainage and Compression

The postoperative course following tumescent liposuction is generally rapid and comfortable; however, patients must be well informed as significant edema, purpura, and fluid drainage can occur. Furthermore, the drainage may be blood tinged and alarming to the unprepared patient. The entry sites through which the liposuction is performed are not closed. Rather, they remain open and serve as drainage points through which the tumescent fluid can flow resulting from a combination of compression and gravitational forces. Open drainage can continue for up to 3–4 days and appropriate absorbent dressings are required [15]. Immediately after the procedure is completed, highly absorbent pads are applied. The pads are

applied under compressive elastic garments and left in place for 24 h. They can be replaced every 24 h if they become soaked and should be utilized until drainage ceases. After the drainage has discontinued, the dressing should be changed to a mildly compressive support garment. This dressing provides support and can help to contour the skin as it retracts during the weeks following liposuction. Heavy compression during this period is unnecessary and may be counterproductive by impeding lymphatic drainage. Klein [32] has described this two-phased postoperative compression system as “bimodal compression.” Rapid return to normal function with tumescent liposuction can be dramatic. In general, for abdomen and flanks, most patients prefer a few days of rest and typically return to work 5 or 5 days after surgery. However, with tumescent liposuction, many patients rebound quickly and we have had patients leave on vacation the next day or return to work within a day or two. This is because of the less traumatic nature of tumescent liposuction under local anesthesia, owing to techniques of infiltration and use of microcannulas. Skin retraction during the postoperative period occurs over several weeks (Fig. 3.4). Some postoperative edema in the treated fields may persist for a few weeks. Patients need to be reassured that the final cosmetic outcome will not be apparent for at least 2 months after the procedure. Occasionally, touch-up procedures can be performed if needed but waiting at least 2–3 months or longer after the initial procedure is prudent.

3.8

Complications

As with any surgical procedure, inherent risks and potential complications exist with tumescent liposuction. A detailed discussion on liposuction complications can be found elsewhere in this book. The advantage of the tumescent microcannula liposuction technique is that the potential risks of liposuction are minimized. Given the excellent hemostasis provided by the epinephrine in the tumescent fluid, the risk of postoperative bleeding is very low. Thorough knowledge of the underlying anatomy is essential, however, to

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a

b

Fig. 3.4 Liposuction of lateral thighs and hips: (a) preoperative; (b) postoperative

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make sure that larger vessels are not transected by the smaller-diameter cannulas, which are potentially more traumatic than larger-diameter cannulas [15]. As discussed earlier, there is a low rate of postoperative infection possibly owing to antibacterial properties of lidocaine [9, 10]. Perioperative prophylactic antibiotic use may also help to minimize infection rates. Scarring is generally minimal if microcannulas and small entry points are used. Reduced scarring is a major advantage of the microcannula technique but patients must still be warned of possible pigmentary alteration and even hypertrophic scarring in prone individuals. Patients should also be advised that persistent numbness or dysesthesia may occur in treated areas, although this is usually not permanent [15, 33]. Textural irregularities, rippling, and dimpling are complications associated with liposuction that are greatly minimized with the tumescent microcannula technique. Because small volumes of fat are removed with each stroke, the fat can be removed in thin layers to achieve a gradual and uniform reduction in the subcutaneous layer. This allows for sculpting the tissue with uniformity, giving a smooth, even result. Some complications unique to or more pronounced with the tumescent technique relate to the large volumes of lidocaine-containing fluid that are infiltrated. Significant ecchymoses and edema can occur especially in the scrotal/labial areas or the distal upper and lower extremities. When performing liposuction of the abdomen, thighs, arms, or distal lower extremities, patients should be forewarned that this is normal for the postoperative course. Gradual resolution of the purpura and edema occurs over several days following the procedure [15, 32–34]. In some patients, seromas may form and larger patients with a pannus where fluid can collect are at an increased risk for this complication. Small seromas generally spontaneously resolve but larger seromas may require aspiration of the fluid with a 20-gauge needle [15, 34]. Skin ulceration secondary to necrosis is a rare complication and can occur from excessive injury to the dermis. Care must be taken to avoid superficial liposuction in the dermis,

which can compromise the dermal and epidermal vascular supply. With proper liposuction technique, a superficial layer of fat should be left intact and the dermis should be free from injury, thereby avoiding the risk of skin ulceration and necrosis [15].

3.9

Safety of Tumescent Liposuction

A 1999 article detailing five deaths involved patients with systemic anesthesia, either intravenous sedation or general anesthesia [35]. None of the patients had evidence of lidocaine toxicity. One developed an abrupt EKG and physiologic changes within 30 s of being rotated from the prone to the supine position, which may have been related to severe hypotension that can develop with combinations of droperidol and fentanyl [36]. None of these patients had true tumescent liposuction in that the tumescent fluid was not used as the main source of pain control. Three patients succumbed to intraoperative hypotension of unknown cause, one from pulmonary thromboembolism, and one from fluid overload. Only one patient had an elevated lidocaine level of 5.2 but this was after resuscitative efforts. The author concluded that two of the cases may have been caused by lidocaine toxicity, but this does not appear to be supported by the data [13]. In 2000, Coldiron [37, 38] reviewed reports of deaths in Florida and concluded that specific details were lacking but that the complications were not specific to an office setting or involved tumescent liposuction. The association with systemic anesthesia was seen in a study of 95 liposuction deaths in a study of plastic surgeons [39]. The survey of 1,200 plastic surgeons performing a total of 496,245 procedures demonstrated a mortality of 1 in 5,224 procedures, which was computed to a rate of 19.1 per 100,000; 47.7 % occurred after office-based surgery and 16.9 % after hospital-based surgery. The primary cause of death was thromboembolism in 23.4 % of cases. None of the patients succumbed to lidocaine toxicity.

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A survey of dermatologists was performed looking at complications occurring from 1994 to 2000. Data were obtained on a total of 66,570 liposuction procedures. No deaths occurred, and the serious adverse event rate was 0.68 % [13]. In this review, procedures had been performed in non-accredited office settings, ambulatory surgical centers, and hospitals. Adverse event rates were higher for tumescent technique liposuction combined with intravenous or intramuscular sedation than for tumescent technique liposuction combined with oral or no sedation. Of the 45 adverse events recorded, only one is listed as lidocaine toxicity. The conclusion was that tumescent liposuction performed by dermatologic surgeons is safe in an office setting [13]. Other studies have found that tumescent liposuction as performed per American Society of Dermatologic Surgery (ASDS) guidelines is considered very safe and should be differentiated from more aggressive liposuction methods [1, 40–42]. The ASDS data base of over 300,000 procedures from 1995 to 2000 performed according to ASDS guidelines demonstrates no deaths [1]. Similarly, a 1988 survey encompassing 9,478 tumescent liposuction procedures performed by dermatologists without intravenous sedation documented no fatalities [43]. A 1995 survey of 15,336 tumescent procedures as performed by dermatologists showed no fatalities [12]. A 1999 analysis of malpractice claims from 1995 to 1997 showed that dermatologists performing liposuction in the office had fewer malpractice claims than plastic surgeons performing liposuction in the hospital. The conclusion was attributed to the use of the tumescent liposuction technique and the smaller volumes of fat removed by dermatologic surgeons [44]. Fatality factors with liposuction may include general or intravenous sedation, multiple surgeries performed concurrently, removal of large volumes of fat during one procedure, inpatient setting, administration of toxic doses of lidocaine combined with general/intravenous anesthesia, and intravenous fluid overload [45]. Dermatologists commonly rely on tumescent anesthesia as the primary pain management method during liposuction. When intravenous or

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general anesthesia is added, a variety of drugs that are metabolized by the same cytochrome enzymes or reduce hepatic blood flow may be utilized, resulting in diminished lidocaine metabolism. Further, the subcutaneous tissue may be underinfused, which means the tissue may not be fully tumesced. It is thought that full tumescence protects blood vessels in the fibrous septae by compression, making liposuction less traumatic. Intravenous sedation and general anesthesia are commoner when larger-volume liposuction is planned or in conjunction with other cosmetic procedures. The combination of multiple forms of anesthesia and the combination of drug effects and large-volume liposuction may be the cause of the mortalities [39]. One issue of concern is deep venous thrombosis leading to pulmonary embolism subsequent to liposuction and its relationship to hormonal therapy. Butterwick [46] indicates that the incidence of deep venous thrombosis with true tumescent liposuction without general anesthesia or deep intravenous sedation appears no greater than the general incidence in women on oral contraceptive or hormone replacement. The conclusion is that these medications need not be discontinued prior to surgery unless additional risk factors are present, such as estrogen content greater than 35 mg/day. One additional recommendation is proper fitting of postoperative garments to avoid constricting venous return and making sure women ambulate postoperatively. Graduated support hoses were recommended for women with increased risk factors of deep venous thrombosis [46].

3.10

Guidelines for Maximum Volumes of Lipoaspiration

Guidelines for safety establishing the maximum volume of aspirate have been set by the American Academy of Dermatology as 4,500 mL of fat and by the ASDS as 5,000 mL of total fluid/fat [1, 34]. We remove no more than 4–5 L of fat during each session. If patients have several areas requiring treatment, multiple sessions must be planned. Safety of the tumescent liposuction technique is

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maximized when it is performed in compliance with these guidelines.

14.

Conclusion

Tumescent liposuction under local anesthesia with the microcannula technique allows for very safe and effective body sculpting and fat reduction entirely under local anesthesia. Thorough understanding of the pharmacology of lidocaine and implementation of the infiltration and aspiration guidelines and techniques associated with tumescent microcannula liposuction are essential to achieve optimal outcomes.

15. 16.

17. 18.

19.

20.

References 21. 1. Coleman 3rd WP, Glogau RG, Klein JA, Moy RL, Narins RS, Chuang TY, Farmer ER, Lewis CW, Lowery BJ. Guidelines of care for liposuction. J Am Acad Dermatol. 2001;45(3):438–47. 2. Klein JA. The tumescent technique for liposuction surgery. Am J Cosmet Surg. 1987;4(4):263–7. 3. Fischer G. First surgical treatment for modeling body’s cellulite with three 5mm incisions. Bull Int Acad Cosmet Surg. 1976;2:35–7. 4. Flynn TC, Coleman WP, Field L, Klein JA, Hanke CW. History of liposuction. Dermatol Surg. 2000; 26(6):515–20. 5. Klein JA. Tumescent technique for local anesthesia improves safety in large-volume liposuction. Plast Reconstr Surg. 1993;92(6):1085–95. 6. Ilouz YG. History and current concepts of lipoplasty. Clin Plast Surg. 1996;23(4):721–30. 7. Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol. 1990;16(3):248–63. 8. Ostad A, Kageyama N, Moy RL. Tumescent anesthesia with a lidocaine dose of 55 mg/kg is safe for liposuction. Dermatol Surg. 1996;22(11):921–7. 9. Parr AM, Zoutman DE, Davidson JSD. Antimicrobial activity of lidocaine against bacteria associated with nosocomial wound infection. Ann Plast Surg. 1999; 43(3):239–45. 10. Miller MA, Shelley WB. Antibacterial properties of lidocaine on bacteria isolated from dermal lesions. Arch Dermatol. 1985;121(9):1157–9. 11. Craig SB, Concannon MJ, McDonald GA, Puckett CL. The antibacterial effects of tumescent liposuction fluid. Plast Reconstr Surg. 1999;103(2): 666–70. 12. Hanke C, Bernstein G, Bullock S. Safety of tumescent liposuction in 15,336 patients: national survey results. Dermatol Surg. 1995;21(5):459–62. 13. Housman TS, Lawrence N, Mellen BG, George MN, Filippo JS, Cerveny KA, DeMarco M, Feldman SR,

22.

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25. 26. 27.

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Fleischer AB. The safety of liposuction: results of a national survey. Dermatol Surg. 2002;28(11):971–8. Thompson KD, Welykyj S, Massa MC. Antibacterial activity of lidocaine in combination with a bicarbonate buffer. J Dermatol Surg Oncol. 1993;19(3):216–20. Klein JA. Tumescent technique: tumescent anesthesia & microcannular liposuction. St Louis: Mosby; 2000. Lillis PJ. Liposuction surgery under local anesthesia: limited blood loss and minimal lidocaine absorption. J Dermatol Surg Oncol. 1988;14(10):1145–8. Klein JA. Anesthetic formulations of tumescent solutions. Dermatol Clin. 1999;17(4):751–9. Colaric KB, Overton DT, Moore K. Pain reduction in lidocaine administration through buffering and warming. Am J Emerg Med. 1998;16(4):353–6. Singer M, Shapiro LE, Shear NH. Cytochrome p450 3A: interactions with dermatologic therapies. J Am Acad Dermatol. 1997;37(5 Pt 1):765–71. Klein JA, Kassarjdian N. Lidocaine toxicity with tumescent liposuction. Dermatol Surg. 1997;23(12): 1169–74. Shiffman MA. Medications potentially causing lidocaine toxicity. Am J Cosmet Surg. 1998;15:227–8. Rohrich RJ, Beran SJ, Fodor FB. The role of subcutaneous infiltration in suction assisted lipoplasty: a review. Plast Reconstr Surg. 1997;99(2):514–9. Klein JA. Intravenous fluids and bupivacaine are contraindicated in tumescent liposuction. Plast Reconstr Surg. 1998;102(7):2516–7. Lindenblatt N, Belusa L, Teifenbach B, Schareck W, Olbrisch RR. Prilocaine plasma levels and methemoglobinemia in patients undergoing tumescent liposuction involving less than 2000 ml. Aesthetic Plast Surg. 2004;28(6):435–40. Physicians’ desk reference. Montvale: Medical Economics; 2004. Narins RS. Minimizing pain for liposuction anesthesia. Dermatol Surg. 1997;23(12):1137–40. Raskin BI. Intramuscular Stadol for analgesia during tumescent liposuction. Am J Cosmet Surg. 1999; 16:4. Kaplan B, Moy RL. Comparison of room temperature and warmed local anesthetic solution for tumescent liposuction. Dermatol Surg. 1996;22(8):707–9. Hanke CW, Coleman 3rd WP, Lillis PJ, Narins RS, Buening JA, Rosemark J, Guillotte R, Lusk K, Jacobs R, Coleman 4th WP. Infusion rates and levels of premedication in tumescent liposuction. Dermatol Surg. 1997;23(12):1131–4. Butterwick K, Goldman MP, Sriprachya-Anunt S. Lidocaine levels during the first two hours of infiltration of dilute anesthetic solution for tumescent liposuction: rapid versus slow delivery. Dermatol Surg. 1999;25(9):681–5. Rubin JP, Bierman C, Rosow CE. The tumescent technique: the effect of high tissue pressure and dilute epinephrine on absorption of lidocaine. Plast Reconstr Surg. 1999;103(3):990–6. Klein JA. Post-tumescent liposuction care: open drainage and bimodal compression. Dermatol Clin. 1999;17(4):881–9.

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33. Rostan EF, Madani S, Clark RE. Tumescent liposuction: fat removal for medical and cosmetic purposes. N C Med J. 1998;59(4):244–7. 34. Lawrence N, Clark RE, Flynn TC, Coleman WP. American society for dermatologic surgery guidelines of care for liposuction. Dermatol Surg. 2000;26(3):265–9. 35. Rao RB, Ely SF, Hoffman RS. Deaths related to liposuction. N Engl J Med. 1999;340(19):1471–5. 36. Marshall BE. General anesthetics. In: Gilman AG, Goodman LS, Gilman A, editors. Goodman and Gilman’s the pharmacological basis of therapeutics. 6th ed. New York: Macmillan; 1980. 37. Coldiron B. Patient injuries from surgical procedures performed in medical offices. J Am Med Assoc. 2001;285(20):2582. 38. Coldiron B. Office based surgery: what the evidence shows. Cosmet Dermatol. 2001;14:29–32. 39. Grazer FM, de Jong RH. Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast Reconstr Surg. 2000;105(1):436–46.

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40. Kaminer MS. Tumescent liposuction council bulletin, November 2000. Dermatol Surg. 2001;27(6):605–7. 41. Coleman WP, Hanke CW, Glogau RG. Does the specialty of the physician affect fatality rates in liposuction? A comparison of specialty specific data. Dermatol Surg. 2000;26(7):611–5. 42. Scarborough D, Bisaccia E. Patient safety in the outpatient surgical setting. Cosmet Dermatol. 2001;14:10. 43. Bernstein G, Hanke CS. Safety of liposuction: a review of 9478 cases performed by dermatologists. Dermatol Surg Oncol. 1988;14(10):1112–4. 44. Coleman III WP, Hanke CW, Lillis P, Bernstein G, Narins R. Does the location of the surgery or the specialty of the physician affect malpractice claims in liposuction? Dermatol Surg. 1999;25(5):343–7. 45. Hanke CW, Coleman 3rd WP. Morbidity and mortality related to liposuction. Questions and answers. Dermatol Clin. 1999;17(4):899–902. 46. Butterwick KJ. Should dermatologic surgeons discontinue hormonal therapy prior to tumescent liposuction? Dermatol Surg. 2002;28(12):1184–7.

4

Tumescent Local Anesthesia with Articaine Afschin Fatemi

Abstract

The author studied the safety and efficacy of articaine in tumescent local anesthesia even with use of high quantities. He found that articaine exerts high anesthetic potency and low toxicity. There were no neurotoxic or cardiac side effects due to articaine that were observed during or after the treatment. Articaine may be the choice local anesthetic to use in liposuction.

4.1

Introduction

The introduction of tumescent local anesthesia (TLA) has been a tremendous advance in outpatient surgery, particularly for minimally invasive surgery applications in dermatologic surgery, phlebology, and aesthetic and plastic surgery. Liposuction is the primary indication in which TLA is used in large amounts, as described by Klein [1]. Anesthetic components of TLA include mostly lidocaine (Klein’s solution) or prilocaine (Sattler’s solution [2]). The development of Sattler’s solution has been a notable landmark for decreasing the risks of lidocaine and its main metabolite xylidine. Toxic reactions due to the high cardiotoxicity of lidocaine and its metabolites have been A. Fatemi, M.D Private practice, S-thetic Clinic, KaiserswertherMarkt 25-27, 40489 Duesseldorf, Germany e-mail: [email protected]

described with implications of death after liposuction [3]. The less toxic prilocaine causes clinically significant methemoglobinemia in doses higher than 7 mg/kg. Methemoglobinemia, possibly up to 25 %, is caused by the metabolite ortho-toluidine. ortho-Toluidine, like xylidine, is proven to be a genotoxin and is in addition strongly suspected to be a human carcinogen [4]. Potency, pKa, and elimination half time of lidocaine and prilocaine are similar. The slow resorption into the blood circulation and the long time that the local anesthetics remain in the fatty tissue cause a regional anesthetic effect of up to 18 h [5]. The amide-type local anesthetics like lidocaine or prilocaine and also the main metabolites are primarily metabolized in the microsomes of the liver via cytochrome P450. Saturation kinetics of this enzyme and the high concentrations of the reactants cause accumulation of prilocaine or lidocaine and especially their metabolites, raising the probability of toxic events. Elimination of the local anesthetics and metabolites is prolonged

© Springer-Verlag Berlin Heidelberg 2016 M.A. Shiffman, A. Di Giuseppe (eds.), Liposuction: Principles and Practice, DOI 10.1007/978-3-662-48903-1_4

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A. Fatemi

72

and peak plasma levels occur between 6 and 10 h after infiltration because of the slow systemic resorption and the accumulation of the substances in the serum [6]. Peak plasma levels of methemoglobin occur between 14 and 18 h after infiltration of prilocaine TLA. The prolonged high plasma levels of these local anesthetic drugs and their metabolites become even more dangerous through drug interaction. The drugs mentioned may inhibit cytochrome P450 or compete with plasma protein binding and therefore further slow down elimination of local anesthetics and raise their toxicity [7]. Some physicians have tried to reduce lidocainerelated toxicity or prilocaine-related methemoglobinemia in TLA by mixing them or one of them with ropivacaine or bupivacaine. The use of ropivacaine or bupivacaine in higher doses, as needed for liposuction, however, is contraindicated because of their very high toxicity [8]. Also the toxicity of two mixed amide-type local anesthetics is not independent or reduced but additive [9] and therefore such a mixture is not recommended.

4.2

Articaine

The author has used articaine as the local anesthetic of choice for TLA. In contrast to the agents mentioned, articaine is an acid–amide-type local anesthetic. There is a thiophene ring in the structure instead of a phenylene ring like in other local anesthetics (Fig. 4.1). Articaine was described for the first time in 1976 and is preferentially used in dental surgery. Articaine exerts high anesthetic potency

CH3

O

NHC

H

CH2

N

COOCH3

Fig. 4.1 Articaine chemical structure

Local anesthetic Procaine Lidocaine Mepivacaine Prilocaine Articaine Bupivacaine Ropivacaine

C3H7

Relative potency 1 4 4 4 5 16 16

Duration >The well-established concept of overcorrection when fat grafting is not accomplished in one stage in volume anymore, nor is it done using an open and unreliable technique. Rather, the procedure is done in stages over period of time, using a simple, easy procedure with repeated injections, a method that is readily accepted by the patient and the surgeon. For the past 17 years, this author has used only plastic syringes on which common cannulas are mounted in all cases of reduction liposculpturing. Cannulas and syringes are selected according to the volume of the adiposity.

Syringe Not high No problem since precise estimate of resected volume by each operator on paired adiposities. Desirable to treat large, medium, multiple, or paired adiposities Operative and anesthesia time decreased. Hospitalization and convalescence time shorter. Less fatigue for operators No tissue vaporization. Transport in liquid environment. Buffering if impact. Syringe allows reuse of fat Using an old instrument like a syringe simplifies the operation too much

20.2.1 Equipment

blunt tip, which is round or bullet shaped. Those of average external diameter (minicannulas) measure 3, 3.5, or 4 mm. Their useful length is 14–24 cm, and they also have a round or bulletshaped tip and one blunt opening. Others have a diameter equal to 5 mm (macrocannulas). They have a useful length of 15–24 cm. The cannulas are mounted on the syringe either externally (Tulip) or passing through the syringe (French model). Special cannulas can be easily mounted on 50- or 60-mL syringes with a long hub, as used by urologists. Two to four small holes may be added on the tip of some annuals (accelerators), and the speed and ease of extraction are increased. When cannulas are reused, metal cleaners should be used before sterilization. Future cannulas will be made of hard plastic. They will be sterile and disposable and of all lengths and of all diameters. It would be ideal to have a sterile, disposable cannula and syringe made in one piece: such a model is under study.

20.2.1.1 Cannulas Cannulas are classified according to their outside diameter. They are made of metal. Those of very small external diameter (microcannulas) measure 2 or 2.5 mm. Their useful length is 7 or 12 or 24 cm. They have a blunt opening and a

20.2.1.2 Syringes Syringes of average size (10 or 20 mL) are made of plastic and are sterile and disposable. They are used with microcannulas or minicannulas. Small syringes do not need a lock. The plunger is locked with a plastic needle cap.

20.2

Reduction Syringe Liposculpturing

20

Reduction Syringe Liposculpturing

a

195

b

Fig. 20.1 (a) All the equipment needed: a Toomey syringe, a Tulip cannula, a lock. It takes 12 s to fill a 60-mL syringe after infiltration. (b) The makeshift lock

Large-volume syringes are used with macrocannulas (50 and 60 mL). These syringes are plastic, sterile, and disposable. They should have a large opening of 5 mm or more of outside diameter. The implantation of a cone on the syringe has an 8–10-mm external diameter (Toomey tip). A lock (snapper) is necessary to immobilize the plunger (Fig. 20.1). It is best to fill the syringe with a few milliliters of normal saline before the extraction to avoid any dead space.

20.2.1.3 The Lock A lock is necessary when using 60-mL syringes. Different models exist. We recommend the “Johny lock” (Johnson). We use only the makeshift one, which is excellent. The lightness of our equipment decreases possible bleeding. 20.2.1.4 The Awl or Ice Pick To avoid incision scars, punctures are made through the skin with an awl. This opening can be dilated with a hemostat to allow entry of the cannula. The puncture of the skin made by the awl heals better than an incision with a scalpel and is almost invisible. This puncture needs to be dilated with an artery forceps to avoid friction with the skin, which may give a pigmented spot at the place of the puncture.

20.2.2 Cautions The larger the diameter and capacity of a syringe, the less its suitability for transportation of the fat.

This is why it is much better to use a syringe adapted to the volume of the adiposity and to the volume of fat to be extracted. The outside diameter of the syringe should be as small as possible. This is why a 2-mL syringe for insulin injections is superior to the standard 2-mL syringe, which is much shorter. The cannulas should also be chosen according to the volume of the adiposity. If specially made cannulas are not available for mounting on plastic syringes, it is a simple task to use the standard machine Karman cannulas. The machine mounting is first sawed off, and then the cannula is passed through the barrel of the plastic syringe and pushed with long scissors in a screw-type motion through the plastic cone after the opening has been appropriately cut. It may be necessary to use an ice pick or hemostat to dilate the plastic cone still further. The cannulas have to be adapted perfectly to the cone and syringe. This equipment is as useful as any specially manufactured cannula for syringe-assisted liposculpturing. The equipment is tight, waterproof, and airproof. Surgeons who choose to make their own equipment can obtain the syringes in medical, dental, or veterinary supply stores. Cannulas of 2, 2.5, and 3 mm can be mounted externally, as their inside diameter corresponds to the inside diameter of the small syringes (Luer lock). In all systems described, suction is as fast as with the machine, is less shocking, provokes less bleeding, and is less tiring.

P.F. Fournier

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20.3

Reduction Syringe Liposculpturing Technique

The goal of the procedure is to perform a partial lipectomy in the localized adiposity. Four steps are required: 1. Removal of the excess adipose tissue in a crisscross dissection/extraction (lesional lipectomy or mesh lipoextraction). 2. Remodeling of the remaining crisscrossed adipose tissue. 3. Redistribution of the skin after a wide peripheral mesh undermining of the neighboring normal adipose tissue has been done with a cannula (perilesional mesh lipoplasty). No removal of adipose tissue during the peripheral undermining has to be done. 4. Adequate immobilization of the treated area until shrinkage and healing proceed satisfactorily. In some cases, after performing reduction liposculpturing on one or several adipose regions, it is worth using part of the harvested fat (60 mL usually) to fill in the neighboring depressions. The final result will be improved. The surgeon must keep in mind that closed liposculpturing is an artistic, three-dimensional, architectural technique of body contouring. It is essentially a tactile operation with the surgeon working almost blindly. We are dealing with a volume of space-covering tissue, the skin. Fat is highly vascularized; consequently, a lipectomy has to be performed using a blunt cannula to create crisscrossed dissection/extraction channels. It is imperative to avoid excessive bleeding through the use of vasoconstrictors. It is also crucial to reposition the skin and underlying fat using the shrinking properties of the skin and the technique of peripheral mesh undermining. Finally, adequate immobilization is vital to liposculpturing.

20.3.1 Basic Principles The following are some of the basic principles in reduction syringe liposculpturing:

1. A crisscrossed lipectomy (tunnels, columns of fat, lattice, and mesh lipectomy) has to be performed. Several approaches have to be made. No more than three strokes in the same direction (Fischer) [2]. 2. A peripheral mesh undermining technique is usually part of the operation (without fat extraction). This is mostly important when the skin is of average quality with mature patients. 3. Dissecting hydrotomy with vasoconstrictors (chilled normal saline at 2 °C and 1 mL/L adrenalin) is necessary. 4. The required instruments include a small blunt-tip cannula with one blunt opening, an ice pick, and syringes. 5. The shrinking properties of the skin should be utilized after repositioning and immobilizing the tissues.

20.3.2 Pre-estimation of the Quantity to Be Resected The amount of adipose tissue to be resected during liposculpturing must be calculated during the patient’s various preoperative examinations. This is a matter of experience and judgment and can be acquired only with time after assisting the operations performed by other surgeons. Only then can an accurate estimate be made. During the operation, this estimate can be more or less modified, but overall the surgeon has a relatively good idea of the amount of tissue to be resected. It is not a “suck as you go procedure.” Pre-estimation requires the same kind of judgment that is necessary for other aesthetic operations. The eye will examine the state of the skin (thick, with or without stretch marks); the fingers will test the tonicity of the areas to be treated by using the pinch test with the patient in a standing position, lying down, while the underlying muscles are contracted, and while walking. The pre-estimation of a region such as the saddlebag area can be done only after a careful study of the neighboring adipose areas that can play a role in the origin of the saddlebags: hips,

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Reduction Syringe Liposculpturing

buttocks, and the lower buttocks fold. One must therefore differentiate between true saddlebags, false saddlebags, and mixed cases. Squeezing of the buttocks is requested to differentiate false saddlebags from true ones and mixed cases. Xerographies, echographies, scanner, or other complementary examinations can be useful but are never demanded because the pre-estimation is above all clinical. The pre-estimation is noted on the patient’s card, on special diagrams, or on the Polaroid photographs made during the course of the first visit. Computer study may also be used.

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from the second marking. This corresponds to the extent of the peripheral mesh undermining. Finally, the openings (or incisions) should be marked by a circle to avoid any permanent or transient tattooing from the ink of the marking pen. All the adipose regions are marked before the operation, as is the site of the intended incisions or openings. The approximate amount of resection will be marked in the middle of the adiposity.

20.3.5 Anesthesia 20.3.3 Notes We once more insist that the surgeon needs to know the approximate amount of adipose tissue to be resected before the operation. The following items depend on the quantity to be resected: 1. Whether the operation can be done all at once or over several procedures 2. Whether conventional, tumescent, local, general, or epidural anesthesia is to be utilized (the dose of local anesthesia also needs to be estimated) 3. The amount of fluids and electrolytes needed 4. The length of the hospitalization (whether or not the patient is ambulatory) 5. Whether a blood transfusion needs to be considered even if today this is not frequent 6. The approximate length of the operation and of the convalescence

Reduction liposculpturing can be done according to the type of anesthesia that the patient desires whether general, twilight, epidural, local, or cryoanesthesia. Local anesthesia is the preferred method. For many years, we have used the tumescent technique as Klein [3] described it; chilled saline at 2 °C is used instead of saline at room temperature. We consider chilling as very

20.3.4 Marking the Patient Marking the patient (Fig. 20.2) is done with the patient in the standing position, just before the operation. A green Pentel pen is used; the skin marker must be of good quality to resist the preparations. We mark (1) the adiposity by encircling it (2) 1–1.5 cm around the previous circle (the tip of the cannula will be pushed until the second marking, so there will be no stair-step deformity) and (3) beyond the adiposity between 2 and 8 cm

Fig. 20.2 Marking the patient

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P.F. Fournier

important with tumescent anesthesia. The cold increases the anesthesia, decreases the bleeding, and prevents shock. A thorough study of tumescent anesthesia is a must before practicing liposculpturing. External cryoanesthesia can be used in addition to local anesthesia. Ice packs will improve the anesthesia and decrease the bleeding. If refrigerated bags are used, one should watch the patient carefully because the bags can cause skin burns or pigmentation. This does not occur with ice cubes.

better than incising it. In all of the approaches used for the past few years, we have used an awl or an ice pick to make the opening. Should the awl or ice pick puncture be too small to allow the passage of the cannula, the hole can be dilated by passing first one branch and then the second branch of a hemostat, which are separated very gently. As there is no incision of the skin, the healing of the wound is far superior to a standard incision and is almost invisible. The wound needs to be closed in most of the cases by a fine nylon 5-0 suture or by an inverted stitch of absorbable material.

20.3.6 Preparation of the Area

20.3.8 Positioning the Patient

In all cases of reduction liposculpturing, the area should be injected to decrease bleeding as well as to enhance the procedure. A 60-ml syringe or a pump is used for this preparation. During general or epidural anesthesia, we use the following solution: 1 L of chilled normal saline at 2 °C and 1-mg epinephrine. The amount injected is roughly half of the estimated fat to be removed. This solution is injected deep into the fatty layer to obtain a spasm of the vessels at this level. After 5 min, another injection of chilled saline at 2 °C, with epinephrine, is administered in the upper layer before starting the procedure. There are no special recommendations as the area is prepared with the local anesthesia when using tumescent anesthesia as described by Klein [3]. The tumescent solution is always chilled at 2 °C. Between 1 and 4 L is injected in the average case.

The position of the patient should, of course, be the most adequate and convenient for the surgeon. Choices include the supine position, the prone position, and the lateral position. With all of these positions, arms or legs to be moved during the operation should be prepared according to the needs of the surgeon. Under local anesthesia, there is no problem, as the patient can move or be moved if necessary. This also holds true if epidural anesthesia is used. However, during general anesthesia, the patient is supine, and it is necessary to elevate a side of the patient to permit the surgeon to work on the waist, the hip, or the lateral chest roll. Other localizations are within easy reach, e.g., thighs, knees, and double chin. It is also possible if the patient is in the supine position to work on the buttock or to create an infragluteal fold, although this is not as easily done as in the prone position. By moving the patient who has been specially prepared, it is possible to work on almost all localized adiposities of the pelvis in the supine position. When using general anesthesia, turning the patient from the prone to the supine position or vice versa during a liposculpturing procedure should be avoided whenever possible. Nevertheless, it is sometimes necessary to do this, and special precautions should be observed by the surgeon and anesthesiologist. For safety reasons, it is much better to do the requested procedures in two stages instead of taking risks with the patient when a change of position is needed.

20.3.7 Approaches in Liposculpturing The planned approach has to allow for easy, efficient work in the adiposity to obtain the best possible result. Approaches used long ago at the beginning of the procedure which are concealed far from the adiposity must be avoided if they interfere with proper working conditions. As many approaches as are necessary will be performed for the crisscross work; there will be a minimum of two. Puncturing the skin in the right tension line is

20

Reduction Syringe Liposculpturing

A word of caution: positioning the patient is important, as the surgeon should not be working in unfavorable conditions. The surgeon should always have easy access to the different approaches needed during the procedure in order to do the best work possible. Tumescent anesthesia allows the surgeon to work in the best conditions as the position of the patient is easily modified.

20.3.9 Surgical Technique In describing surgical technique, the work on a hip with a 3- or 4-mm cannula and a 60-mL syringe will be used as an example. At the previously marked sites, incisions or openings are made (we prefer the puncture) and are dilated with a hemostat. Pretunneling is not absolutely necessary but is recommended if the fat is hard. The cannula is directed in the area before liposculpturing is begun. Before it starts, one should fill the syringe with 5 ml of chilled saline; this will then act as a buffer. The cannula is then passed through the opening, while the left hand folds temporarily the skin. a

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The plunger is withdrawn and kept withdrawn by the surgeon’s right hand. The maneuver is not difficult and can be made easier by the use of a stop. The cannula will be moved in a fan-shaped motion, approximately three times in the same direction (we do not recommend that it stay in the same tunnel). The strength of the surgeon is exerted when pushing the cannula into the adipose tissue, not when pulling it. The opening of the cannula will face down during this maneuver. After 60 mL of fat has been collected in the barrel, the syringe is emptied into a basin on the operating table. The same procedure will follow using another approach and so on to perform even crisscrossed work. When the adiposity is conical (saddle bags or abdomen), the surgeon has to work in the middle of the adiposity, below the conical portion, giving small strokes to “decapitate” this adiposity, and he or she has to give long strokes to “level” the adiposity, using different approaches to obtain crisscrossed work (Fig. 20.3). Three approaches are used when treating in a clockwise direction and so on saddlebags. Three for an abdomen. Even crisscrossed work is achieved when using a different approach to fill

b

Fig. 20.3 (a) Approaches in saddlebag liposculpture include a central crisscrossed lipoextraction zone and peripheral mesh undermining. (b) Saddlebag liposculpture. Small strokes are given in the center to “decapitate” the adiposity

P.F. Fournier

200 Table 20.2 Summary of the work of the hands The left hand Stabilizes Lifts Grasps Hardens Guides Localizes Palpates

The right hand Pushes Pulls Dissects Fills the syringe Empties the syringe Pulls on the plunger Measures the amount of fat extracted

Monitors Carries out the pinch tests

a syringe. The left hand still guides and follows the work of the right hand. Liposculpturing is a tactile operation. The work of the hands is summarized in Table 20.2. The division of labor between the two hands is opposite to that for standard surgery, in which the right hand is the one that dominates. With liposculpturing, the left hand is the “brain hand,” and the right one is a mere piston. One may in some circumstances use a smaller cannula (no. 2) to do the crisscrossing at a different level. At intervals, the left hand will pinch the skin (pinch test) between the index finger and the thumb to evaluate the thickness of the fold. The surgeon will usually monitor the modification of the contour of the area treated to avoid an overcorrection and will also check the volume of fat removed against the pre-estimate. A 1-cm uniform thickness of fat covering the area should be left, and this result is checked by a pinch test made with the left hand. Should the fat in the syringe show too much blood, the surgeon must stop suctioning the area and work on another part of the adiposity. Should the patient complain under local anesthesia, the surgeon should inject more of the anesthetic solution. It should be noted that the skin has to be grasped in order to place the cannula in the right place. The left hand should be flat during the whole operation to stabilize the tissues and should exert some pressure on the tissues.

When the lipectomy has been completed and the expected amount of fat removed, the surgeon will perform a peripheral mesh undermining using the same openings and the same instruments. No suction is done during this procedure. The cannula is pushed in a fan-shaped motion until it reaches the marked line of the mesh undermining. This mesh is also done in a crisscross fashion through the area already lipectomized. The peripheral mesh undermining allows the excess skin that is covering the crisscross lipectomized adiposity to fit better in its new bed; less resistance will be encountered in the neighboring tissues because many retinacula cutis will have been severed. The peripheral mesh undermining must be proportional to the amount of fat removed and also to the quality of the skin. When a small amount of fat is removed in a young patient, it is unnecessary. When one area is completely treated, the surgeon will work on the opposite paired adiposity unless another well-trained lipoplasty surgeon has already done the second side. When a neighboring depressed area has to be grafted, part of the fat that has been harvested will be washed with normal saline and reinjected in a crisscross manner. This area will be remodeled with the surgeon’s left hand and immobilized together with the other treated areas. Remodeling of the adipose area is done with the surgeon’s left hand. We never drain. When some patients have heavy legs, we use Cherif-Zahar’s [4] technique under general anesthesia: a tourniquet is applied on the thigh after emptying the leg of its blood using an elastic bandage. No infiltration is necessary. There is no bleeding during the operation, and the results are excellent.

20.3.10 Dressing Unless a special garment is used, the surgeon will do the dressing using Elastoplast. Several layers have to be used because the dressing acts as an external splint.

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Reduction Syringe Liposculpturing

20.3.11 Fluid and Electrolyte Balance When using general or epidural anesthesia, the anesthesiologist will take care of the problem of fluid and electrolyte balance. Roughly double the amount of fat removed has to be given to the patient in fluids. When using tumescent anesthesia, no fluid should be given intravenously as recommended by Klein [5].

20.3.12 Technical Considerations The quantity of fat to be removed is the visible resection. One has to think that during the procedure, the to-and-fro movements of the cannula devitalize a certain amount of adipose tissue, which later will be resorbed by the body. This is the invisible or biologic resection. During the procedure, there is adipose tissue destruction. The volume of fat reduction is obtained in two different ways: mechanical disruption and suction friction scraping. The visible resection is the one obtained by the scraping motion of the cannula, which also removes a part of the fat that has been mechanically disrupted. The invisible resection is made up of most of the devitalized fat obtained by the friction of the cannula and of some of the mechanically disrupted fat. After a certain period of time, the procedure will create scar tissue, which will be followed by contractions, as is true for any operation on or below the skin. This consideration enhances the prognosis for a thorough and even lipectomy. The peripheral mesh undermining in the whole area treated is to obtain a homogeneous contraction of the scar tissue. The skin will be affected by the primary contraction of the muscular fibers (immediate, active process). The adipose tissue will be modified by the contraction of the fibrous tissue (passive contraction, delayed). After a liposculpturing procedure, there is an immediate improvement in contour owing to the biologic

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resection. The skin will also be modified immediately by the primary contraction of elastic fibers and later by the contraction of the underlying fibrous scar tissue. Surgeons performing liposculpturing should remember that the most important consideration is “not what is removed, but what is left and how it is left” (as in a rhinoplasty). If too much blood is in the aspirate, one should stop working in the area and work on another part of the adiposity or on another adiposity. Under no circumstance should windshield-wiper movements be made, as they will cut the adipose columns that harbor vessels, nerves, and lymph vessels. When lumps are felt under the skin, one should work on them with a smaller cannula (decreasing work). The following points are to be remembered: 1. Small cannulas with one opening should be used. Cannulas with accelerator are also widely used. 2. Blunt tip and blunt openings should face downward (opposite to the scale on the syringe). 3. The syringe should be used for extraction and hydro-cryodissection. 4. An atraumatic technique with no windshieldwiper movements should always be used. 5. Tunnels should be fan shaped, starting from the puncture wound. 6. Dissection should be blunt and deep, using the direct approach and puncturing with an ice pick. Superficial liposculpturing with thin cannulas may be used in selected cases. 7. Crisscrossing (tunnels and fat columns, lattice work) should be done. Two or more approaches can be used. 8. The left hand should direct the operation. 9. Peripheral mesh undermining should be performed when necessary. 10. Remodeling and immobilizing should be done. 11. Grafting the neighboring depressed areas has to be considered sometimes.

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20.4

Cautions in Liposculpturing

The following cautions should be kept in mind: (1) never use sharp cannulas; (2) the opening should always look down opposite to the scale of the syringe; (3) never make windshield-wiper movements; and (4) decreasing work may be useful in certain circumstances; i.e., the use of a smaller cannula after a larger one has been used. Asepsis is very important: the incision is minor, but the wound is major. Pushing the cannula below the skin and waiting, without moving it, do not remove fat; when using a suction machine or a syringe, it is necessary to move the syringe in the fat to see the fat flow in the syringe or in the tube. This is why liposuction is not a good term for the procedure. Lipoextraction is a more accurate word. Lipoextraction carried out artistically is liposculpturing. Liposuction makes one think of a passive act without possible complications, whereas liposculpturing makes one think of an active act with possible complications. Larger-diameter cannulas produce more damage to the fat. A large contour defect can be created very rapidly and is difficult to treat. Smaller cannulas (3 or 4 mm external diameter) are advised. Because 1 cm of fat has to be left below the skin, all contour defects, such as cottage cheese deformity, can be treated later in a separate procedure (e.g., cutting the subcutaneous connections with a 14-gauge needle and grafting a few milliliters of autologous fat) or superficial liposculpturing. Superficial liposculpturing with a small cannula (2 mm) can be performed during the main procedure, if necessary.

20.5

Complications

It has been said that there are few complications but many errors in liposculpture. When using the syringe cannula technique, many complications are complications of “beginners.” All “unpleasant events” of anesthesia (general, epidural, or local) can be seen but are rare. It is the same with surgical complications (hemorrhage, infection, etc.) in trained hands. There is less bleeding edema and shock with the syringe during major cases. The complications that we have encountered with the syringe are mostly aesthetic complications (insufficient resection, a resection that is too large or irregular, cutaneous waves due to a bad skin tonicity and post-lipoplasty irregularities). A good selection of candidates and a rigorous technique following a lengthy practical and theoretic training will help avoid most complications. When treating post-lipoplasty irregularities, the syringe fat grafting or the liposhifting technique as described by Saylan [6] can be used (loosening the fat subcutaneously, shifting the fat externally, and fixation of the fat). As Fischer says, “Lipoextraction is easy, liposculpture is difficult.”

20.6

Results

As the results obtained with the syringe cannula are as good as those with others instruments (machine, ultrasonic, powered) and the technique is safer and simpler, we recommend the syringe cannula technique (Figs. 20.4, 20.5, and 20.6). It

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a

b

Fig. 20.4 Saddlebags in a mature patient: (a) preoperatively; (b) postoperatively

a

b

Fig. 20.5 Liposculpture of the abdomen: (a) preoperatively; (b) postoperatively

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a

b

Fig. 20.6 Neck and face liposculpturing: (a) preoperatively; (b) postoperatively

should be remembered that what matters is not what is in our hand, but what is in our head. It is not the instrument that is doing the operation, it is the liposuction surgeon. No instrument can replace talent and experience. Conclusions

The use of the syringe has been an advance in reduction and incremental liposculpturing. A real democratization in the medico-surgical group has been possible owing to the simplification of the equipment. The shock-absorbing action of the syringe makes the operation safer. Excellent results are obtained because one does perfectly symmetrical work. The syringe is a unit of measurement in this surgery of volume.

References 1. Grazer FM. Suction-assisted lipectomy, suction lipectomy, lipolysis, and lipexeresis. Plast Reconstr Surg. 1983;72(5):620–3. 2. Fischer G. History of my procedure, the harpstring technique and the sterile fat safety box. In: Fournier P, editor. Liposculpture: the syringe technique. Paris: Arnette; 1991. p. 9–17. 3. Klein JA. The tumescent technique for liposuction surgery. Am J Cosmet Surg. 1987;4:263–7. 4. Cherif-Zahar K. La liposuccion des chevilles sous gorrot pneumatique. Serie personelle de 25 cas. Rev Chir Esthet Lang Franc. 1995;22(79):51–4. 5. Klein J. Tumescent technique: tumescent anesthesia and microcannular liposuction. St. Louis: Mosby; 2000. 6. Saylan Z. Liposhifting: treatment of postliposuction irregularities. Int J Cosmet Surg. 1999;7(1):71–3.

Minor (Smart) Modifications for Increasing the Efficacy of Liposuction

21

Karaca Basaran and Idris Ersin

Abstract

Since the description of the modern liposuction methods, many new devices and equipments have been introduced, together with the development of different technologies. Upon the fat transfer and stem cell treatments becoming widespread, atraumatic and effective liposuction and lipotransfer methods have also become commonly employed. There is a wide range of commercial equipments from conventional syringe-assisted liposuction sets to high-tech devices, all designed for different purposes. When these equipments are not accessible or in case of deficiencies of the current systems, the surgeons may find smart and low-cost solutions using the described technical modifications.

21.1

Introduction

Today, liposuction is among the most commonly performed cosmetic surgical procedures. Various liposuction equipments and techniques have been developed to date since the introduction of the modern lipoplasty methods by Illouz more than 20 years ago [1]. Together with the widespread use of fat transfer and stem cell treatments, atraumatic and effective liposuction methods have become

K. Basaran, M.D. (*) • I. Ersin, M.D. Department of Plastic, Reconstructive and Aesthetic Surgery, Bagcilar Research Hospital, Mimar Sinan cad. No:6, Bagcilar, Istanbul 34200, Turkey e-mail: [email protected]; [email protected]

widespread. Current liposuction equipments include various cannulas intended for different purposes, aspiration hoses, syringes, remote control devices, and cables [2]. In addition, many surgeons perform the liposuction surgery together with a second surgeon, using a combination of different techniques. All these factors create a chaotic and cumbersome setting, where many devices are used simultaneously at the operating rooms. Even the potential minor mechanical issues can reduce the efficacy of the liposuction and result in unfavorable outcomes such as violation of sterility and loss of time. Also, different equipments may not always be available at all surgical centers, which can cause a reduction of cost-effectiveness. Thus, many surgeons create smart and simple solutions in response to various problems they encounter in

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their own surgical practice and publish them. In this chapter, various solutions developed related to liposuction will be summarized as presented in literature.

21.2

Modifications in SyringeAssisted Liposuction

It is not always possible to have access to machine-assisted liposuction devices in the office setting. In such cases, syringe-assisted techniques are preferred due to its ability to ensure fat removal with a higher level of control and less trauma. Also the aspirated fat can be obtained in a sterile manner to be used again as autologous fat grafting [3]. This method was developed by Pierre Fournier in 1985 and is based on adaptation of the liposuction cannula to a syringe, where negative pressure is created via withdrawal of the piston [4]. Despite all advantages, the syringe-assisted liposuction method also bears certain disadvantages. For example, the surgeon should hold the whole system consisting of the cannula, syringe, and the piston lock during the fat aspiration. Also, the syringe volume of 50–60 mL is rapidly achieved, thereby necessitating frequent interruption of the procedure for a change of the syringe [3]. In addition, a stable connection can hardly be ensured by using specific cannula for every different type of syringe. Otherwise, an appropriate negative pressure cannot be obtained due to air leaks. There are commercially available syringes, piston locks, and various connector apparatuses, specifically designed for this purpose. However, similar syringe-assisted liposuction systems can be established by using the standard materials that are available at each hospital in case of nonavailability of them. For example, Fournier [5] created a notch at the back of the protruding side of piston using a lancet and ensured locking of the piston withdrawn by creating a chamber on the syringe so that the protrusion fits in it. Koldas et al. [6] recommended the use of a towel clamp for this process. After the piston is withdrawn, it is fixed by a clamp by

pinching, thereby avoiding return of the piston to its former position (Fig. 21.1). Similarly, Narayanan et al. [7] reported that the piston could be fixed by using a hemostat device. Nisi et al. [4] reported that a 10-ml standard syringe piston could be inserted in the 60-ml syringe chamber and used as a piston lock. Kerstein et al. [8] and Ahmed et al. [9] eliminated the locking problem using the same method and smaller syringes in a less costly and simpler way. Instead of using standard injectors, Kahveci et al. [10] adapted the manual vacuum aspiration (MVA) injector kit normally used for curettage and endometrial biopsy procedures in the daily gynecology practice, together with the Karman cannula to the suction cannula. Another problem is the potential for the snapper type devices designed as syringe locks, to dislodge, fall on the ground, and become non-sterile. Moss [11] reported that the snapper could be fixed to the piston with a sterile rubber band to avoid a fall in an attempt to overcome this issue (Fig. 21.2). Other drawbacks of syringe-assisted cannula include potential discordance between the syringe and the cannula connections plus the air leakage problems. This may result from the differences in the junction points of different types of syringes and long-term repeated use of the same cannula. As a result, an effective negative pressure cannot be achieved and the procedure needs to be interrupted frequently. Basaran et al. [12] recom-

Fig. 21.1 The towel clamp is applied to the piston, thereby avoiding return of the piston to its former position (This technique was described by Koldaş et al. [6])

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Minor (Smart) Modifications for Increasing the Efficacy of Liposuction

Fig. 21.2 The modification described by Moss: the snapper fixed to the piston with a sterile rubber band [11]

Fig. 21.3 A modification described by Basaran et al. to avoid an air leak between the syringe head and the cannula. Notice the placement of a sterile latex glove at the connection [12]

mended a quite simple and inexpensive solution to the issue of air leakage between the syringe and the cannula. A tight connection is ensured between the syringe head and the cannula via placement of a piece cut from the sterile latex surgery glove, thereby avoiding the air leakage (Fig. 21.3). Natividade da Silva et al. [3] described a new liposuction assembly consisting of a 100 mL feeding syringe, standard Foley CH22 catheter, towel clamp, machine-assisted liposuction system, and a cannula. While the Foley catheter is adapted to the feeding syringe through cutting of the Foley catheter balloon site, the other tip is connected to the liposuction cannula. As previously described, the syringe is locked with a towel clamp to ensure persistent negative pressure. Thus, a constant connection is ensured between the cannula and the syringe. Also, the

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Fig. 21.4 A Foley catheter is adapted to the feeding injector through cutting of the Foley catheter balloon site. The other tip is connected to the liposuction cannula (This technique was first described in 2007 by Da Silva et al. [3])

need for the surgeon to hold the injector during the procedure is eliminated. The Foley catheter, thanks to its elastic structure, can comply with different cannula. The requirement for less syringes and thus the lesser interruption of the procedure are also among the advantages of this method (Fig. 21.4). A similar modification was recommended by Gherardini and Rauso [13]. The authors ensure connection between the cannula and the syringe by using a sterile silicon suction connection tube.

21.3

Modifications in the Tumescent Solution Infiltration

Tumescent liposuction has become widely used due to its efficacy and safety in liposhaping proven by a large number of surgeons. Infiltration of high levels of fluid into all surgical sites may be difficult and time consuming particularly in large-volume liposuction cases [14]. Motor infusion pumps have been used for this purpose. However they are not very common, and due to their high cost, they may not be suitable for use in office setting. Modifications have been reported by using various systems such as the wound irrigation system, Jet Lavage system, arthroscopy set, and micromotor irrigation system [14–17]. However these systems may not be readily available everywhere and may be of high cost.

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Aydın et al. reported a practical and a low-cost solution for infiltration of high levels of tumescent fluid, which can be applied with the materials, available at all healthcare centers. The infusion bag is connected to the system infusion set by a threeway stopcock. By rotating the handle of three-way stopcock, the syringe can be filled and thus the location of the handle is re-changed and infiltration performed, thereby ensuring infiltration in a controlled manner (Fig. 21.5) [18]. Infusion pumps with mechanical pressure for blood infusion in the hospital setting can also be used for tumescent infiltration. The solution, prepared in a flexible serum bag, is placed in a pressurized infusion pump. Serum hose is transferred to the operation table in a sterile manner and adapted to the infiltration cannula. When the infusion pump is inflated in a way to ensure high pressure, a rapid tumescent solution infiltration is achieved (Fig. 21.6).

Fig. 21.5 This simple system is ensuring high-volume infiltration in a controlled manner and avoiding loss of time due to syringe change (This technique was first described in 2009 by Aydın et al. [18])

21.4

Modifications in the Cannula Port Side

Injury to the skin site at the port entry sites may occur due to repetitive trauma and friction during liposuction. While port sites usually recover without complications, traumatic incisions may also occur with intense scars. In addition, as a result of the long-term exposure of ultrasoundassisted liposuction cannula to the skin, an increase in heat may occur, which may result in burns and even skin necrosis. Certain apparatuses have been developed to be placed at the skin entry of the cannula to avoid direct exposure of the skin to the cannula. However these apparatuses are not always available and may be of high cost. To avoid these complications, Lasso [19]

Fig. 21.6 A modification to ensure rapid tumescent infusion. The blood infusion pump is inflated to increase the pressure

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Minor (Smart) Modifications for Increasing the Efficacy of Liposuction

a

209

b

Fig. 21.7 (a) Skin protective apparatus, prepared by cutting from a 1 mL injector. (b) Protector in place. This technique was first described in 2013 by Bank and Song [20]

used a silicone tube around an ultrasonic liposuction cannula to prevent the contact of the cannula with the skin, and the occurrence of burns was avoided. In the absence of skin protective apparatus, protections similar to these apparatuses may be produced by using syringe pieces. Bank et al. [20] and Khoo et al. [21] demonstrated the benefits of skin protective apparatuses, prepared by cutting from a 1 mL injector (Fig. 21.7). A cannula of thickness up to 4 mm can easily pass through these apparatuses. If needed, this cannula may be fixed to the skin via sutures passed through the holes opened at sites. Man reported the cross-incision technique he developed to avoid injury to the skin by the cannula. Thanks to the incision in the form of a cross sign, the cannula can more easily pass through the incision site and create a smaller surface of contact, thereby ensuring a procedure with better recovery and scar tissue [22].

21.5

Other Technical Modifications

Weber et al. [2] reported that the devices and equipment, cables, and hoses used for liposuction operations could have contact with the non-sterile sites such as the surgeon’s leg and easily get contaminated. They reported a suspension system based on keeping the extensions of the devices together using a system hang from the ceiling.

Zhanqiang et al. [23] described a more effective cannula design, which ensured a sharp dissection during liposuction and caused less tissue injury relative to blunt dissection. This paddle-like, U-shaped design, made of stainless steel, is placed in parallel to the tip of the conventional cannula, thereby achieving more effective results in liposuction.

References 1. Illouz YG. Body contouring by lipolysis: a 5-year experience with over 3000 cases. Plast Reconstr Surg. 1983;72(5):591–7. 2. Weber P, Dryden RM, Foster JA. The liposuction apparatus “suspension device”: hi-plane liposculpture. Dermatol Surg. 2000;26(6):602–4. 3. Natividade da Silva PE, Ferreira P, Silva A, Malheiro E, Reis J, Amarante J. A new device for syringeassisted liposuction. Plast Reconstr Surg. 2007;119(2):763–4. 4. Nisi G, Silvestri A, Castello MF, D’Aniello C. A smart and simple idea for blocking the plunger during syringe liposuction. Aesthet Plast Surg. 2006;30(4):500. 5. Fournier PF. A simplified procedure for locking the plunger during syringe-assisted liposculpturing. Plast Reconstr Surg. 1996;98(3):569–70. 6. Koldaş T, Onel D, Ozden BC. The use of a towel clamp as a complementary instrument for manual fat harvest. Ann Plast Surg. 2004;52(6):626–7. 7. Narayanan V, Khanna A. A simple method of locking the plunger during syringe liposuction. Plast Reconstr Surg. 2004;114(7):1973. 8. Kerstein RL, Siddiqui A, Erdmann M. Use of the dual plunger for creating negative pressure in 10 ml syringe

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9.

10.

11.

12.

13.

14.

15.

for fat aspiration in Coleman fat transfer procedure. J Plast Reconstr Aesthet Surg. 2011;64(1):e29–30. Ahmed F1, Nehme J, Turner M, Bennett N. Fat harvesting: spare your thumb, don’t spoil the fat. Plast Reconstr Surg. 2012;129(6):1023e–5. Kahveci R, Rehimli M, Esmer A, Rehimli S, Kanturk R, Menderes V. A useful technique to obtain adequate negative pressure for liposuction. J Plast Reconstr Aesthet Surg. 2009;62(12):e604–5. Moss R. A simple method of preventing snapper fallout during syringe liposuction. Plast Reconstr Surg. 2007;119(5):1627–8. Basaran K, Ersin I, Pilanci O. A practical solution for preventing an air leak during syringe-assisted liposuction. Aesthet Plast Surg. 2013;37(2):472–3. Gherardini G, Rauso R. Improving efficacy of liposculpture revisions using a short plastic tube as syringe connector. Dermatol Surg. 2012;38(6):967–8. Horch RE. Modified device for easy infiltration of tumescent solution in liposuction. Aesthet Plast Surg. 2007;31(1):85–7. Galla TJ1, Walgenbach KJ, Bach AD, Voigt M, Stark GB. Infiltration of tumescent anesthetic solution by a modified wound irrigation system. Aesthet Plast Surg. 1999;23(6):386–7.

16. Gündeşlioğlu AO, Akin S, Maral T. A simple handmade device for easy, quick, and efficient tumescent infiltration in liposuction. Plast Reconstr Surg. 2004;114(1):269–70. 17. Ozyazgan I. Use of available micromotor irrigation system for liposuction tumescent fluid infiltration. Plast Reconstr Surg. 2004;113(1):449. 18. Aydin HU, Yiğit B, Serin DA, Güven E. A simple setup for easy infiltration of large volumes. Aesthet Plast Surg. 2009;33(1):129–30. 19. Lasso JM, Arenas D, Valiente A. A cheap device to perform ultrasound-assisted lipoplasty. Plast Reconstr Surg. 2003;111(7):2483–4. 20. Bank J, Song DH. Inexpensive method of liposuction cannula port-site protection. Aesthet Plast Surg. 2013;37(4):843. 21. Khoo LS, Corona GG, Radwanski H, Fernandes VS, Pitanguy IH. Inexpensive method of liposuction cannula port-site protection. Aesthet Plast Surg. 2014;38(1):256–7. 22. Man D. The cross-incision for lipoplasty: minimizing lipoplasty scars. Plast Reconstr Surg. 2005;116(3):930–1. 23. Zhanqiang L, Yongxue X, Qinjian P, Meiheng W, Hong G. Fat planer: a new needle for liposuction. Plast Reconstr Surg. 2007;120(3):821.

Histological Study of the Aspirate from Breast Liposuction

22

Louis Habbema and Josephine J.M. Alons

Abstract

Liposuction for female breast reduction is a new treatment modality that has many advantages over the generally accepted procedure of excision, which can damage glandular tissue and impair breastfeeding capacity. To assess any potential damage to glandular tissue caused by liposuction of the female breast, specimens of the aspirate from 61 consecutive female patients who underwent liposuction of the breast using tumescent local anesthesia and powered cannulas were sent for histological evaluation. In all cases, fat tissue was the main component observed in the breast aspirate specimens. In 58 cases, fragments of fibrotic tissue were found. In nine cases, minor fragments of the smallest glandular tissue ductuli were detected. In no case was there any sign of larger glandular structures. Histological evaluation of 61 specimens of the aspirate obtained from breast liposuctions using TLA and PC showed only minor signs of damage to glandular tissue in a small minority of patients. There was no indication that lactation might be impaired using this procedure.

22.1

Introduction

In a study of a series of 151 patients, we have proven that breast reduction by liposuction using tumescent local anesthesia (TLA) with powered cannulas (PC) is a safe and effective treatment L. Habbema, M.D. (*) Medisch Centrum’t Gooi, Olmenlaan 42, Bussum 1404 DG, The Netherlands e-mail: [email protected]; [email protected] J.J.M. Alons, M.D. Pathologisch-AnatomischLaboratorium Amsterdam, Reguliersgracht 130-132, Amsterdam 1017 LZ, The Netherlands e-mail: [email protected]

modality [1]. The resulting smaller breasts have a natural appearance, which is mainly due to tissue contraction providing a lifting effect to the whole breast. A potential complication of the procedure, which until now has not been investigated in detail, could be damage to the large glandular breast structures, resulting in the inability to breastfeed. Although it is widely accepted that damage to subcutaneous structures is insignificant when liposuction is performed using TLA with PC, there have been no reported detailed histological studies to investigate the potential damage to glandular tissue by liposuction of the breasts using this technique. To address this

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omission, we have conducted a comprehensive histological evaluation of the aspirate obtained from a consecutive series of 61 breast liposuctions using TLA with PC, paying particular attention to examining for the possible presence of glandular structures.

22.2

Patients and Methods

The histological study was carried out on all 61 patients who underwent breast reduction by liposuction using TLA with PC at our clinic in the period from September 2006 to May 2009. The average age of the patients was 48 years, ranging from 16 to 73 years, 15 patients were under the age of 40, and 29 patients were under the age of 50. The average volume of the breast was 1018 mL per breast, ranging from 350 to 4000 mL.

22.3

in the inframammary crease, followed by aspiration of the more superficial layers. In general, the areas where most glandular tissue was to be expected, i.e., subareolar and in the upper lateral quadrant, were relatively spared from aggressive suction. However, in cases where only a small volume of supranatant was aspirated, more aggressive liposuction was also performed in the more glandular areas in order to collect as much fat as possible. The surgeon judged the glandular density by the resistance encountered with the cannula during the suction.

22.4

Material

The aspirate was collected in a canister, and the infranatant, blood-tinged solution was allowed to separate from the supranatant during a period of 60 min. Subsequently, a non-fixated specimen taken from the midportion of the supranatant was

Technique

A preoperative mammogram, detailed photodocumentation, and precise measurements for volume and ptosis were performed. The breasts were infiltrated with the tumescent solution, using a peristaltic infiltration pump and sharp, 21-gauge spinal needles. As a guideline, the volume of tumescent solution infiltrated into the breast was approximately 1.5–2 times the volume of the breast, and the average amount infiltrated into both breasts, including the axillary tails, was 5000 mL, ranging from 2800 to 9000 mL. After infiltration, a period of approximately 30 min was required to allow the infiltrated solution to diffuse through the breast tissue and develop adequate anesthesia and vasoconstriction. Subsequently, suction was performed using a powered cannula of 3 mm in diameter with a blunt triport tip (Fig. 22.1). The powering of the cannula resulted in a 2-mm reciprocating movement at 4000 cycles per minute and a slight sideward movement at the tip in free air, although it is not clear if this sideward movement also occurs in subcutaneous tissue. No remarks are made about the sideward movement in the technical information given by the producer (MicroAire Surgical Instruments LLL). Suction commenced in the deep planes of the breast from two incisions

Fig. 22.1 Powered cannula of 3 mm in diameter with a blunt triport tip

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Histological Study of the Aspirate from Breast Liposuction

sent to the pathological laboratory for histological analysis. In the pre-study phase, both fixated and non-fixated specimens were prepared to determine the best way to prepare the material for further histological evaluation, and from this study, it was decided to send the material without fixation. From the aspirate of three patients, four samples were taken from different parts of the aspirate to investigate the differences in histological findings in these samples and to determine the most representative part of the aspirate to serve as source for the samples taken during the study. The four samples, labeled A–D, were taken, respectively: 1 cm below the upper margin of the supranatant fat (A), 1 cm above the lower margin of the supranatant fat (B), in the midportion of the supranatant fat (C), and in the middle of the infranatant (D). Samples A, B, and C showed no significant differences in the histological findings in all three patients. Sample D, however, showed a nonrepresentative picture with some sparse erythrocytes. To prevent unintended mixture with the oil fragment floating on top of the supranatant fat and to prevent unintended dilution by the infranatant solution, we decided to choose the midportion of the supranatant fat (sample C) as the target portion for histological evaluation. An average of 10 mL supranatant per procedure was received by the laboratory. Fresh specimens were divided into volumes of 2.5 mL and wrapped in permeable paper before fixation in an ethanol/polyethyleneglycol fixative. Fat was subsequently extracted with acetone. Tissue was further dehydrated in ethanol and isopropanol in two steps, using an industrial microwave oven (Amana®), and embedded in paraffin. Tissue blocks were cut at 6 μ on two levels and mounted on glass objectives. Slides were stained with hematoxylin and eosin.

22.5

Results

The fat was organized in small fragments of 2–2.5 mm in width, as measured with an ocular micrometer (Olympus). In 58 specimens, there was sparse slim septate fibrous tissue, some of them with the smallest caliber blood vessels.

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There was no gross connective tissue or thick fibrous septum. In 52 specimens, there was no glandular tissue detectable. In nine cases, some parts of small ducts or lobules were visible, scattered in the fat tissue (Fig. 22.2). There were no complete lobules. Hardly any erythrocytes were present. The average preoperative breast volume and average BMI did not differ significantly between the group found to have glandular tissue in the aspirate (n = 9) and the group without glandular tissue in the aspirate (n = 52). In the group with glandular tissue, the average values were influenced disproportionately by one patient from whom 4000 mL of supranatant fat was removed. Table 22.1 shows the data of each group and also from the group with glandular tissue minus this one patient. It is observed that the average age of the smaller group, which had glandular tissue in the aspirate, was younger and both the average total volume of supranatant fat and the average percentage of breast volume that was removed were considerably lower than the major group, in which no glandular tissue was detected in the aspirate.

22.6

Discussion

Breast reduction by excision is a common procedure that is performed worldwide. The surgery involves selective removal of fat tissue or, if required to reach the target volume, removal of glandular tissue combined with fat tissue, which can impair future breastfeeding. An alternative and relatively new procedure involves liposuction of the female breast without the need for excision [1–4]. Breast reduction performed by liposuction using TLA with PC has proven to be a safe and effective procedure with good cosmetic results, a high rate of patient satisfaction and without the occurrence of serious complications. Because liposuction involves removal of only fat tissue, the degree of volume reduction obtainable is variable. Adequate patient selection is crucial to achieving a high rate of patient satisfaction [1]. It is commonly assumed that a low BMI indicates a low percentage of fat in the breast and that a high BMI indicates a high percentage of fat. However,

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Table 22.1 Average and range of values from 61 patients who underwent breast reduction by liposuction

All

Nr. 61

Average age (years) 48 (16–73)

Average BMI (kg/m2) 25.0 (19–43)

GT

9

40 (16–61)

27.1 (21–43)

GT-1

8

41 (16–61)

25.1 (21–33)

52

49 (19–73)

24.7 (19–36)

No GT

Average volume per Average volume breast (mL) reduction (%) 1018 56 (25–86) (350–4000) 1305 46 (25–62) (575–4000) 1013 42 (25–62) (575–1675) 968 (350–2250) 59 (33–86)

Average volume reduction (mL) 573 (175–1375) 610 (175–2040) 421 (175–800) 569 (225–1375)

Figures in brackets give the range of values for the 61 patients GT: Patients with glandular tissue found in the aspirate GT-1: Same as GT, minus 1 patient with gigantomasty No GT: Patients where no glandular tissue was found in the aspirate BMI: Body mass index

many women with large fat deposits in the legs (i.e., patients with lipedema) have a high BMI, but they do not necessarily have a high percentage of fat in the breasts. The BMI, therefore, is not an absolute selection criterion when assessing the suitability of younger women for breast liposuction. In older women, there is no direct relationship between BMI and the fat content of the breast because breasts of older women tend generally to be more fatty. In our series, no relationship was observed between the BMI and the appearance of glandular tissue in the aspirate. We

have shown in a previous study that preoperative mammograms are not a reliable method for the estimation of the fat content of the breast [1]. In fibro-glandular tissue such as found within the female breast, using a powered cannula enhances the removal of fat and seems to create significantly less damage to the surrounding tissues than encountered with the use of nonvibrating cannulas. Endoscopic observations [5] and cadaver studies (personal observation) show that the subcutaneous fibrotic network remains intact, and small blood vessels and lymph vessels

22

Histological Study of the Aspirate from Breast Liposuction

are protected by the use of blunt vibrating cannulas. Consequently, it is likely that there is negligible damage to breast glandular tissue, and the capability to breastfeed will not be influenced by liposuction using TLA with PC. However, there are no data available in the literature on histological examination of the aspirate using this technique, and studies providing data on damage to glandular tissue after conventional liposuction of the female breast are minimal. Abboud et al. [6] performed a histological evaluation of the breast aspirate in 170 patients and found breast cells in only one specimen. However, there was a strict selection in the aspirated materials that were sent for histological evaluation. Only the material obtained from fatty breasts, which would not be expected to contain glandular tissue, was examined. When suction was ceased early in the procedure, either because the tissue consistency suggested glandular breasts or breasts with fat lobules surrounded by glandular tissue, the aspirate was not examined. Walgenbach et al. [7] performed biopsies on three groups of ten patients per group who underwent excisional breast reduction, where ultrasonic-assisted liposuction was performed prior to the excision. The first control group underwent conventional liposuction prior to the excision, and the second control

Fig. 22.3 There were no histological signs of damage of large structures

215

group underwent excision only. In all three groups, biopsies were taken from the excised breast tissue. The results showed the breast tissue to be mostly intact, the glandular structure was undamaged, and the cellular integrity was unaltered. The authors noted mechanical destruction by the probe and cannulas, but they give no further details. The only significant difference between the three groups was in the ultrasound group, where the connective tissue appeared to lose its close cell-to-cell contact. Matarasso [2] performed histology of the aspirate in nine patients and reported that fat was the main component and some parenchyma was observed, although he did not specify these findings. Our study provides the first histological data on aspirate from liposuction of the breast using TLA with PC. Our findings show that glandular tissue is absent in most specimens. In those specimens containing glandular tissue, only scattered groups of cells from the smallest ductuli or a single lobulus were found, and there were no histological signs of damage of large structures (Fig. 22.3). Although there is a possibility that in some patients minimal damage of secretionproducing structures could be involved, it is very unlikely that this would have a substantial impact on future lactation properties. These findings

216

support the presumption that there is no functional damage of milk-producing and milktransporting tissues. In the series of 200 patients, there was 1 patient who became pregnant after liposuction, and she encountered no problems with breastfeeding. With involution of the breast, changes in the supporting tissues are as profound as in the parenchyma, although less complex. By a process that is far from clear, the banal connective tissue partly or largely disappears and is replaced by adipose tissue. This leads either to a small atrophic and flabby breast or, at the other extreme, to a voluminous and pendulous breast, which consists mainly of adipose tissue in which there are widely dispersed ductal remnants of the parenchyma and lobules that have escaped involution. This may explain the glandular fragments found in the aspirate of the six patients in the peri- and postmenopausal age group. However, in the group of 15 patients under the age of 40, and consequently probably being in a premenopausal state, the aging process had no major influence on the amount of glandular tissue – in specimens from these patients, virtually no sign of glandular tissue was found. In three patients, of 16, 17, and 30 years of age, only minor fragments from ductules were detected, and we conclude that lactation is not impaired in this most important group. The average age of the group with glandular tissue in the aspirate was lower compared to the other group. The percentage of volume reduction was substantially larger in the group without glandular tissue in the aspirate (59 %) compared to the other group (42 %), while the preoperative breast volumes were similar for both groups (968 mL versus 1013 mL). This supports the presumption that it was not easy to remove a large

L. Habbema and J.J.M. Alons

amount of fat in the group where glandular tissue was detected, thus needing more aggressive or prolonged suction, which could contribute to the damage and removal of glandular tissue. Theoretically, a fibrotic reaction during the healing process after liposuction could interfere with the lactation, but because the area of the densest glandular tissue is relatively spared during the suction, this is considered unlikely. Moreover, glandular and ductal structures are embedded in specialized fibrous tissue, the perilobular stroma being the most abundant and constituting the major part of the actual lobule during the fertile age [8]. The presence of glandular tissue might result from accidental aspiration, but this is unlikely because of the use of blunt cannulas. Another explanation for the presence of the minor fragments of glandular tissue in the aspirate could be that also in young women, some sparse fragments of glandular structures may be present in the fatty tissue of the breast. Alternatively, the combination of the use of a blunt cannula with the negative pressure of the aspiration pump could create forces that lead to the aspiration of the ductular fragments. In the future, more histological data should become available from those patients who underwent liposuction of the breast and who undergo an excisional procedure at a later stage. It is vital, therefore, that the surgeon performing the excision should send the material for histological examination to evaluate any possible damage of the glandular tissue resulting from the previous liposuction. The reason for the excision is irrelevant; it can be for cosmetic or functional reasons or as part of the treatment from a malignancy. The histological examination is required because imaging techniques will probably not

22

Histological Study of the Aspirate from Breast Liposuction

reveal the relatively minor damage caused by liposuction. In our patients, the postoperative mammograms show no signs of damage to glandular tissue. A theoretically negative effect of using TLA with PC for breast reduction could be that it might contribute to the intramammary spread of an undiagnosed breast cancer. Although a preoperative mammogram is made in all cases, small tumors might be overlooked, and malignant cells could possibly spread throughout the mamma by damaging the tumor with the cannula. As negligible damage is caused to tissues in general, this is considered unlikely, but all breast cancer surgeons and oncologists should be alert to this possibility when confronted with a breast cancer patient who also has a history of breast liposuction. Another issue open to discussion is the possible influence of liposuction on the risk of contributing to the development of a malignancy in the breast due to trauma. On theoretical grounds, it seems unlikely if not impossible that this shortterm trauma of about 30 min in the breast could enhance or induce a malignant transformation. With respect to the influence of trauma, the current view of experts in the field is that this potential effect is limited to chronic and repetitive trauma and not to incidental short-term trauma. Further discussion of this topic is, however, beyond the scope of this article.

Conclusions

The evaluation of 61 specimens taken from the supranatant fat after liposuction of the female breast using TLA with PC showed

217

only minor fragments of ductuli in a small minority of younger patients. It is extremely unlikely that lactation will be impaired by this minimal damage. In some older, mostly postmenopausal, women, fragments of remnants of glandular tissue were found. The aspiration of this tissue has no consequence for lactation. The possible effect of a fibrotic reaction in the healing phase on the glandular tissue is not known.

References 1. Habbema L. Breast reduction using liposuction with tumescent local anesthesia and powered cannulas. Dermatol Surg. 2009;35:41–52. 2. Matarasso A, Courtiss EH. Suction mammaplasty: the use of suction lipectomy to reduce large breasts. Plast Reconstr Surg. 1991;87(4):709–17. 3. Gray LN. Update on experience with liposuction breast reduction. Plast Reconstr Surg. Philadelphia: 2001;108(4):1006–10. 4. Di Giuseppe A. Breast reduction with ultrasoundassisted lipoplasty. Plast Reconstr Surg. 2003;112(1):71–82. 5. Wörle B, Sattler G, Hanke CW. Wound healing in liposuction. In: Hanke CW, Sattler G, editors. Procedures in cosmetic dermatology series: liposuction. Philidelphia: Elsevier Saunders; 2005. p. 149–55. 6. Abboud M, Vadoud-Seyedi J, De Mey A, et al. Incidence of calcifications in the breast after surgical reduction and liposuction. Plast Reconstr Surg. 1995;96(3):620–6. 7. Walgenbach KJ, Riabikhin AW, Galla TJ, et al. Effect of ultrasonic assisted lipectomy (UAL) on breast tissue: histological findings. Aesthet Plast Surg. 2001;25(2):85–8. 8. Azzopardi JG. Problems in breast pathology. Textbook. Philadelphia: W.B. Saunders; 1979. p. 8–22.

Large-Volume Liposuction for the Treatment of the Metabolic Problems of Obesity

23

Beniamino Palmieri

Abstract

Large-volume liposuction offers weight loss in patients who need faster loss of weight in order to get immediate compliance to lower caloric intake and higher physical, calorie-consuming activity. This psychological reinforcement is even more strongly specifically achieved by a narcissistic self-evaluation of the improved body contour. Liposuction in obesity is worthwhile to consider as a reasonable alternative to other medical and surgical slimming methods, accordingly with some essential physical and psychological details. The author discusses the technique. The metabolic claims and long-term impact on wellness of LVL need larger multicentric trials to determine whether LVL might improve the life quality of type 2 diabetic obese patients.

23.1

Introduction

Large-volume liposuction (LVL) according to the 1999 Plastic/Cosmetic Surgery Committee of the California Medical Board relates to liposuction volumes greater than 5,000 mL that should be specifically required to be performed in a proper hospital setting and not on outpatient basis. As a matter of fact, liposuction has become an exclusively outpatient cosmetic procedure as a method to subtract substantial amounts of fat B. Palmieri, M.D. Department of Surgery, University of Modena and Reggio Emilia, Via delPozzo, 71, Modena 41100, Italy e-mail: [email protected]

tissue because of the apparent ease and technical simplicity and the expectancy of the moderately or frankly obese patient. With the wet and superwet tumescent technique, the minimally invasive approach to the treatment of obesity by liposuction or ultrasound lipolysis offers a unique model for overweight patient treatment to obtain sudden weight loss and potentially increase immediate compliance to lower caloric intake and higher physical, calorie-consuming activity. The author explains during the initial doctor–patient communication that treatment of an obese patient with restricted diet or with one of the gastrointestinalsurface-reducing techniques is like preparing the patient to reach the “top of the mountain” to get slim through very difficult and prolonged food

© Springer-Verlag Berlin Heidelberg 2016 M.A. Shiffman, A. Di Giuseppe (eds.), Liposuction: Principles and Practice, DOI 10.1007/978-3-662-48903-1_23

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B. Palmieri

220

abstinence (or whatever might be the alimentary style modifications). When the thin (finally) patient is then asked to perform some physical exercise, very often he or she will not comply because he or she is exhausted and will then gradually start recovering some weight. In the case of surgical trauma due to major obesity surgery procedures, the patient also has to face the surgical stress, the amount of which has recently been reduced with laparoscopic banding and stapling procedures, but is very relevant, because it is followed by a steady and sudden modification of the gut physiology. When weight is reduced with fat-trimming liposuction, the patient is brought to the top of the mountain, not climbing on it, as with the other procedures, but rather with an elevator without any sacrifice. When the patient is then asked to perform regular exercise, his or her untried willpower will be more efficiently dedicated to weight maintenance. This psychological reinforcement is even more strongly specifically achieved by a narcissistic self-evaluation of the improved body contour. In addition, fat tissue trimming and withdrawal by liposuction reduce the number of fat cells and their caloric requirements. This is quite different in terms of appetite and hunger than having stored the same number of adipocytes deflated of their intracytoplasmic contents owing to starvation or hypocaloric diet. In the author’s experience, a certain number of patients that have been unable in the past to lose weight will start a progressive catabolic process that further reduces their fat volume after liposuction (Table 23.1). This phenomenon is as if some inner weight balance has been cracked and some lipolytic activation has been facilitated by the operation, through postoperative physical exercise and the suggested maintenance diet. About 75 % of the patients interviewed at 6 months declared themselves to be less hungry and to have less compulsive behavior toward food intake. Half of them were motivated by the psychological change related to the fear of wasting their new beloved body shape. Liposuction in obesity is worthwhile to consider as a reasonable alternative to other medical and surgical slimming methods, accordingly with some essential physical and psychological details.

Table 23.1 Postoperative late fat breakdown effect of liposuction: enzymatic or hormonal changes probably play a role in enhancing the lipolytic effect of an active behavior that is facilitated by the abrupt weight loss Breakdown effects of liposuction 1. Hormones? 2. Behavior? 3. Enzymes?

23.2

Technique

The author asks all patients to stop smoking a few weeks before surgery. Routinely, some meaningful tests are included such as effort EKG, pulse oximetry, end-tidal CO2 respiratory functional tests, and a full coagulation balance including activated partial thromboplastin time, C-protein, antithrombin III, and homocystinemia anticardiolipin antibodies, in an exhaustive up-to-date thromboembolism prevention strategy. Routine preoperative examinations include liver and kidney function tests, glycolipid and electrolyte parameters, autoantibody investigation, thyroid function tests, and basal prolactinemia. Autologous blood predeposits are obtained according to the patient’s basic hematocrit and to the fat volume to be lipoaspirated. In suitable cases, donation of two to three units will contribute to partial hemodilution, which means a safer surgical procedure. Erythrocytes will be reinfused during and after the operation, to prevent dramatic hemoglobin drops and to induce a quick patient recovery. Preoperative erythropoietin injection 60–30 days before surgery (50 IU weekly) should also be considered in the hemoglobin fall prevention. Low-molecular-weight 400-U/kg heparin should be added the day before operation and followed up for 15 days after the operation. Cephalosporin (1 g) is administered before starting the liposuction and for the three following days. As to high-dosage adrenaline administration, it has universally been judged safe from the cardiovascular point of view, and a very careful anesthetic surveillance with hemoglobin fluid and electrolyte balance is mandatory for a prompt recovery after the procedure has been completed.

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Large-Volume Liposuction for the Treatment of the Metabolic Problems of Obesity

The patients are catheterized at the operation time, and the catheter is left in place for 24–48 h. Elastic bandages are applied to the legs and a thermal pad is placed on the back of the patient. General anesthesia is usually preferred to the spinal one, especially in the low-risk high-obesity patient, where liposuction is addressed to multiple sites. For tumescence fluid, 1-L Ringer’s lactate (at 21 °C) with 25 mL of 1 % lidocaine and 1-mg 1:1,000 adrenaline is used. The maximum advisable safety dosage of epinephrine ought not to exceed 0.150-mg/kg body weight and lidocaine no more than 35 mg/kg. During surgery the anesthetist monitors the blood parameters and infuses 1–3 L of crystalloid solutions and, if necessary, one to two units of blood. The procedure utilizes 2–4-mm Mercedes cannulas when lipoaspirating trying to obtain parallel defatting tunnels, without nodules or thickening of the skin. Usually only one surgeon operates in order to have a homogenous approach to the operative field. It is useful for an assistant to work contralaterally in the deep planes, but as long as lipoaspiration approaches the subdermal fat, the main operating surgeon refines the surface. Two vacuum drainage tubes are applied and left in place for 3–5 days. The patient is wrapped with Reston polyurethane (3M) and inelastic adhesive bandage (Tensoplast). Elastic stockings (collants) are applied in the operating room and fissured with scissors in the perineal area for bladder and rectum voiding. These garments will not be removed for at least 1 week. Mobilization starts as soon as possible but not until after the first postoperative day. An antiemetic drug (granisetron) and hydrocortisone (500 mg) are administered at the end of the procedure, and furosemide plus aldactone can be injected in case of postoperative fluid retention. When diabetes or hypertension has to be managed in surgical patients, a very careful therapeutic regimen is dedicated to the glucose–electrolyte balance and to cardiovascular and renal followup. The authors have not had major complications using this protocol and in properly selecting cases. The surgery time was between 2.5 and 4 or 5 h in patients whose body mass indices were over

221

Table 23.2 Suggested protocols according to various obesity degrees: one-, two-, or three-step procedures in different anatomic areas with a maximum of 15 L of lipoaspirate perfusion Optional steps HVL HVL

Session 1 1,2

HVL

1,2,3

Lipoaspirate Area volume (L) Total body 5−15 Abdomen, 5−15 back Flanks, thighs 5−15 Abdomen, 5−15 back Flanks, thighs 5−15 Legs 5−15

HVL high-volume liposuction

35 and where more than 15 L of tumescence solution had been required. In young obese patients with removal of 18–21 L of lipoaspirate, two to four autotransfusion units of blood and two to six units of 20 % albumin infusions were postoperatively required to counteract hypo-onchia and edema. The authors, with moderate or severely obese patients, use two- to three-step lipoaspiration procedures in order to better cosmetically refine the treated areas and to prolong the attempt to have the patient comply with diet and exercise (Table 23.2). The abdominal area is usually approached first, the dorsum and shoulder second, and the arms and legs in the third procedure. The patient usually accepts this program and substantial shape changes can be achieved, at low risk, removing up to 20–30 kg of total fat tissue. As a rule we remove 8–12 L, per session, and the results on the body contour are very impressive. Seromas were usually detected in 15 % of patients. Echographic needle exploration and suction after the fifth postoperative day is the author’s choice of treatment.

23.3

Discussion

The population spontaneously choosing to be submitted to LVL includes obese patients with very definite conservative feelings toward their physical integrity, with a self-image imprinted by a strong narcissistic nuance, but with a less sophisticated aesthetic expectancy of the LVL

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B. Palmieri

Fig. 23.1 (a) Preoperative 47-year-old female patient before removal of 12 kg of fat by liposuction. (b) Postoperatively with improved glucose tolerance test

Fig. 23.2 (a) Preoperative 16-year-old male patient affected by insulin-dependent diabetes. (b) Postoperatively, the insulin administration was reduced after 6-kg subcutaneous fat liposuction

cosmetic outcome compared with nonobese liposuction candidates (Fig. 23.1). In fact the obese patient is usually very happy to have the reduced body contour even with skin irregularities that

are considered minor deformities in comparison with the previously overstored fat. The lean subject, in contrast, does not forgive any mistake by the surgeon and is very concentrated upon

23

Large-Volume Liposuction for the Treatment of the Metabolic Problems of Obesity

potentially suing because of a less than perfect outcome in every detail of her or his aesthetic appearance. The method is quite effective, and even though we lack long-term data, our phone interview at 36 months with the patients showed a 75 % compliance with the fitness programs and caloric intake. These patients showed great care in maintaining the new body shape, assuring an improved social self-confidence (Fig. 23.2), even if, sometimes, other concerns such as anxiety and depression might cause some dropout. The metabolic claims and long-term impact on wellness of LVL need larger multicentric trials to determine whether LVL might improve the life quality of type 2 diabetic obese patients. The author firmly believes that in the next 10 years, a well-defined role for this procedure will be outlined as a major ethical issue, especially if safety guidelines give definite assurance that no major complications have to be expected anymore. Acknowledgment The author wishes to thank Giorgia Benuzzi, University of Modena Medical School, for her kind and outstanding collaboration.

References 1. Albin R, De campo T. Large volume liposuction in 181 patients. Aesthetic Plast Surg. 1999;23(1):5–15. 2. Barak A, Har-Shai Y, Ullmann Y, Hirsowitz B. Insulin induced lipohypertrophy treated by liposuction. Ann Plast Surg. 1962;37:415–7. 3. Cardenas Camarena L, Gonzalez LE. Large volume liposuction and extensive abdominoplasty: a feasible alternative for improving body shape. Plast Reconstr Surg. 1998;102(5):1698–707. 4. Commons GW, Halperin B, Chang CC. Large volume liposuction: a review of 631 consecutive cases over 12 years. Plast Reconstr Surg. 2001;108(6):1753–63. 5. Faga A, Valdatta I, Mezzetti M, Buoro M, Thione A. Ultrasound assisted lipolysis of the omentum in dwarf pigs. Aesthetic Plast Surg. 2002;26(3):193–6. 6. Giese SY, Bulan EJ, Commons GW, Spear SL, Yanovski JA. Improvements of cardiovascular risk profile with large volume liposuction: a pilot study. Plast Reconstr Surg. 2001;108(6):510–9.

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7. Fournier P. Obesitè et liposculpture. Rev Chir Esthet Lang Fr. 1992;17(67):17–20. 8. Gonzalez-Ortiz M, Robles-Cervantes JA, CardenasCamarena L, Bustos-Saldana R, Martinez-Abundis E. The effect of surgically removing subcutaneous fat on the metabolic profile and insulin sensitivity in obese women after large volume liposuction treatment. Horm Metab Res. 2002;34(8):446–9. 9. Hauner H, Olbrisch RR. The treatment of type-1 diabetics with insulin-induced lipohypertrophy by liposuction. Dtsch Med Wochenschr. 1994;119(12):414–7. 10. Ioannidis G, Ioannidis TH, Fikioris A. Liposculpture et obesitè. Rev Chir Esthet Lang Fr. 1992;17(67):13–6. 11. Liszka TG, Dellon AL, Im M, Angel MF, Plotnick L. The effect of lipectomy on growth and development of hyperinsulinemia and hyperlipidemia in the Zucker rat. Plast Reconstr Surg. 1998;102(4):112–7. 12. Palmieri B, Bosio P, Palmieri G, Gozzi G. Ultrasound lipolysis and suction lipectomy for treatment of obesity. Am J Cosmet Surg. 1997;14:289–96. 13. Palmieri B, Bosio P, Catania N, Gozzi G. La liposcultura con ultrasuoni: un trattamento miniinvasivo della Obesità. Rec Prog Med. 1995;86:220–5. 14. Alegria Peren P, Barba Ghomez J, Guerrero-Santos J. Total corporal contouring with megaliposuction (120 consecutive cases). Aesthetic Plast Surg. 1999;23(2):93–100. 15. Palmieri B, Benuzzi G. Tumescent anesthesia in plastic surgery. Riv Ital Chir Plast. 2003;35:51–5. 16. Samdal F, Amland PF, Sandsmark M, Birkeland KL. Diabetic lipohypertrophy treated with suctionassisted lipectomy. J Intern Med. 1993;234(5):489–92. 17. Sidor V. De la liposculpture a la megaliposculpture. Aspects cliniques. Evolution et perspectives. Rev Chir Esthet Lang Fr. 1994;19:57–9. 18. Siddor V. De la megaliposculpture a la megalipoaspiration therapeutique. Rev Chir Esthet Lang Fr. 1994;19:31–7. 19. Talmor M, Fahey TJ, Wise J, Hoffman LA, Barie PS. Large volume liposuction complicated by retroperitoneal management: principles and implications for the quality improvement process. Plast Reconstr Surg. 2000;105(6):2244–50. 20. Teimourian B, Gotkin RH. Contouring of mid trunk in overweight patients. Aesth Plast Surg. 1989;13(3):145–53. 21. Weber RV, Buckley MC, Fried SK, Kral JG. Subcutaneous lipectomy causes a metabolic syndrome in hamsters. Am J Physiol Regul Integr Comp Physiol. 2000;279(3):R936–43.

Large-Volume Liposuction for Obesity

24

Enrique Hernández-Pérez, Jose A. Seijo-Cortes, and Hassan Abbas Khawaja

Abstract

The authors discuss the evolution of liposculpture; development, structure, and biochemistry of fat; fat and adipose tissue metabolism; health implications of regional obesity; and impact of liposuction on general health risks. Their technique of large-volume liposuction for obesity is described. Large-volume liposculpture can be performed safely on healthy overweight patients, and it not only improves body contour and body image but also reduces cardiovascular risk factors such as obesity, systolic blood pressure, and plasma insulin.

24.1

E. Hernández-Pérez, M.D. () Private Practice, 7801 NW 37th St., Club VIP, Suite 369, Miami, FL 33166-6503, USA e-mail: [email protected] J.A. Seijo-Cortes, M.D. 7801 NW 37th St., Club VIP, Suite 369, Miami, FL 33166-6503, USA e-mail: [email protected] H.A. Khawaja, M.D. Cosmetic Surgery & Skin Center, 53 A, Block B II, Gulberg III, 54660 Lahore, Pakistan e-mail: [email protected]; [email protected]

Introduction and General Concepts

Liposuction surgery has generally been divided into volume liposuction and liposculpture [1]. In the former, large volumes of fat are aspirated in order to substantially improve the shape and contour of the body. This is a form of surgery directed toward the control of aesthetics and health in general, and it can even be used in cases of true obesity. In liposculpture, small fat deposits are aspirated with the sole purpose of giving the body a better shape. This surgery is basically practiced for aesthetic reasons. However, a new technique has been developed in which large volumes of fat are aspirated and body contour is improved at the same time. Attention is paid to detail, especially in the flanks, back, waist, and hips [1].

© Springer-Verlag Berlin Heidelberg 2016 M.A. Shiffman, A. Di Giuseppe (eds.), Liposuction: Principles and Practice, DOI 10.1007/978-3-662-48903-1_24

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E. Hernández-Pérez et al.

226 Table 24.1 Volume liposculpture emphasizes body contouring: abdomen, waist, and hips The three types of liposuction Volume liposuction Liposculpture Volume liposculpturea a

A combination of volume liposuction and liposculpture

The word sculpture comes from the Latin sculpere, meaning to carve or scratch. It is a variant of scalpere, from which the English word scalpel is derived. Its past participle, sculptus, and the noun sculptura are other variants from which the word sculpture gets its origin [2]. The traditional volume liposuction implies performing large aspirations from specific sites of the body [3]. The authors’ goal is to perform liposuction surgery for the whole body. In other words, the surgery is performed in different parts of the body at the same time. This is a combination of volume liposuction and liposculpture called volume liposculpture [1] (Table 24.1). Because of cultural, social, and ethnic reasons, most of the patients operated on are overweight.

24.2

The Evolution of Liposculpture

In 1921, Dujarrier, a French surgeon, tried to remove adipose tissue from knees and ankles of a ballerina with a uterine curette. Severe complications resulted and the leg had to be amputated. The procedure was forgotten until the German surgeon Schrudde, in 1964, attempted to remove fat from the lower extremities and later on from other parts of the body using a curette. He named this procedure lipoexheresis. It had the frequent complication of seroma formation, which he partially solved utilizing prolonged drainage. In the mid-1970s, Giorgio Fischer and his father Arpad Fischer, in Rome, began experimenting with a suction instrument, the cellusuctiotome [4]. In 1977, Giorgio Fischer went to Paris to demonstrate liposculpture on a patient of Pierre Fournier’s at the Clinique La Mouette. The

French magazine Paris Match published an article on the procedure of liposculpture carried out with Fournier. This fact increased the popularity of liposculpture [5]. Fournier promoted the concept of crisscross tunneling to minimize surface irregularities as well as liposuction through the use of a syringe. The involvement of dermatologic surgeons in liposculpture began in 1977, when Lawrence Fields, a dermatologist form California, visited Paris and observed cases of liposuction [6]. In 1982, otolaryngology-based cosmetic surgeons led by Julius Newman joined with several dermatologic surgeons to form the American Society of Liposuction Surgery, and live education courses in liposuction began in Los Angeles in June 1983 [7]. Stegman and Tromovitch made the first presentation on liposuction at the American Academy of Dermatology in 1983. The most important advancement to perform liposuction in a safer manner was developed by Jeffrey Klein in 1986 [5]. As a pharmacologist and dermatologic surgeon, he introduced the tumescent technique with a very dilute local anesthetic mixture that could be used in large volumes and achieved excellent anesthesia without the need for general anesthetics. Finally, the concept of megaliposculpture (megalipoplastie) was developed by Fournier [8]. In this area, as Fischer [4] says “Fournier is a real pioneer” and also we can add “a generous teacher.”

24.3

Development, Structure, and Biochemistry of Fat

24.3.1 Development and Structure The subcutaneous adipose tissue develops from specific reticuloendothelial structures known as primitive organs appearing in the subcutis during the third or fourth fetal month [9]. It originates in the subdermal perivascular connective tissue from the adipoblasts which develop into preadipocytes. The preadipocytes convert into mature fat cells by accumulating triglycerides. Adipocytes grouped in an organized manner form a lobule having its own blood supply with a

24

Large-Volume Liposuction for Obesity

central artery feeding a capillary network surrounding every fat cell. These lobules are separated by fibrous septa which, when organized in a large number, form what is known as adipose tissue. This represents 20 % of the total body weight. Subcutaneous tissue receives its vascularization from the fascial network, which form a subdermal plexus. From there, branches arise to form a subpapillary plexus, which is the origin of the papillary loops. The fat lobules receive their blood supply from the descending branches of the subdermal plexus. Where the adipose tissue is thick (more than 10 mm), it receives its blood supply both from the descending branches of the subdermal plexus, which feed the upper layer of fat, and from the ascending fascial arteries, which feed the lower layer [9]. When adipose tissue achieves a certain thickness, the descending and the ascending vessels meet at a level where a third subcutaneous vascular plexus is formed. A septum is not unusual at this level creating two relative separate layers of subcutaneous fat [9]. The number of fat cells and consequently lobules increases until late puberty to adolescence (see later). This process takes place in a phasic manner, reaching its peak in late childhood. Recent evidence points to the existence of adipocyte precursor cells in adults [9]. New adipocytes are formed with large weight gains to store excess lipids. This is stimulated by the growth of existing fat cells to a critical size. The initial phase is termed hypertrophic fat deposition. Once cells have reached a critical size, the formation of new adipocytes is termed hyperplastic fat deposition [9]. The lipid content of the cells can be decreased by dieting, but cells cannot be eliminated. This is termed the “ratchet effect” [9]. This theory could explain the gradual increased deposition of fat in localized areas. Race, gender, and heredity could determine exact distribution of excess fat [9].

24.3.2 Fat Biochemistry and Adipose Tissue Metabolism Fifty percent of the daily metabolic energy requirements come from fat metabolism [10].

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There are two metabolic functions of adipose tissue. First, it provides storage of triacylglycerol (formerly called triglyceride) as a long-term energy reserve, and, second, it has a very dynamic pattern of metabolism, which responds on a minute-to-minute basis to the energy requirements by modulating the supply of lipid energy released to the rest of the body in the form of nonesterified fatty acids. Pure carbohydrate or protein liberates 16–17 kJ/g (about 4 kcal/g), while pure triacylglycerol liberates around 36 kJ/g (9 kcal/g). Of course, the body cannot store pure triacylglycerol without some associated cellular structure, and that is why the adipose tissue has evolved to fill this lipid-storage role [11]. Therefore, the primary function of the adipose cell is the storage and release of energy. Fat is stored as triglyceride, is deposited in the adipocyte by lipoprotein lipase (lipogenesis), and is released by hormone-sensitive lipase (lipolysis). Glucose from the blood vessels is converted into α-glycerophosphate, which forms triglycerides utilizing free fatty acids in the fat cells. The free fatty acids reach the fat cells by the action of lipoprotein lipase on triglycerides in the blood vessels, which form free fatty acids and glycerol. Free fatty acids are utilized in the formation of triglycerides in the fat cells, where they are interconvertible with the triglycerides. The free fatty acids from the fat cells reach the blood vessels, where they are carried by albumin. Glycerol from the fat cells and released from the triglycerides by the action of lipoprotein lipase reaches the blood vessels, where it combines with the free fatty acids to form triglycerides. Over a 2–3-week period, all of the stored triglycerides in an adipose cell are turned over, that is, catabolized for energy production or broken down into free fatty acids to be reformed into new triglyceride molecules [10]. In association with its function in energy production and release, the adipocyte participates in insulin regulation and glucose metabolism [11]. The liver is the second primary organ of fat metabolism. It can metabolize fatty acids for energy production, synthesize triglyceride from carbohydrates and to

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a lesser extent from proteins, and esterify fatty acids to form other lipid compounds such as triglycerides and phospholipids. After carbohydrate intake, the amount in excess of that used for energy or stored as glycogen is converted by the liver into triglycerides, which are then stored in the adipocytes [12]. Exogenous dietary fats are hydrolyzed in the gut and then packed into chylomicrons by the intestinal cells, which are finally released into the lymphatics and the bloodstream. Endogenous fatty acids are synthesized by the liver from carbohydrates and to a lesser extent from proteins. These fatty acids are then metabolized into triglycerides, packed as the very lowdensity lipoproteins, and released into the circulation [12]. Lipolysis is under the influence of hormonesensitive lipase. It can be activated by epinephrine, norepinephrine, corticotropin, glucocorticoids, growth hormone, thyroid hormone, and decrease in plasma insulin. Regarding lipogenesis, the action of lipoprotein lipase is the rate-limiting step that mediates the uptake of free fatty acids into the adipocyte. An integral part of the formation of triglycerides is the formation of α-glycerophosphate in the fat cells. Glucose transport is facilitated by insulin receptors on adipocytes [12]. Finally, there are some mediators of fat metabolism. In fact, insulin and catecholamines are the most important. Catecholamines primarily stimulate lipolysis. β-Adrenergic receptors promote lipolysis and predominate over α-adrenergic receptors, which promote lipogenesis. α-Adrenergic receptors predominate in certain abnormal metabolic states such as fasting, diabetes mellitus, hypothyroidism, and possibly pregnancy, all of which are associated with greater fat deposition. Other mediators of lipolysis include adrenocorticotropic hormone, thyroid-stimulating hormone, growth hormone, and vasopressin [12]. Insulin promotes lipogenesis by activation of lipoprotein lipase. Obese patients exhibit insulin resistance and glucose intolerance; however, other insulinmediated pathways of glucose metabolism persist, such as hepatic conversion of glucose to triglycerides for fat storage. Thus, glucose ingestion in obesity leads to increased fat stores, and a vicious cycle is initiated [12].

24.4

Obesity

Obesity is defined as body weight 20 % or more above the normal. Obesity has been subclassified into hyperplastic (referring to increased fat cell number) or hypertrophic (referring to increased fat cell size). Childhood-onset obesity is hyperplastic, whereas adult-onset obesity is characterized by hypertrophic changes. An exception is the morbidly obese adult, defined as being greater than twice the normal weight, in whom hyperplastic as well as the expected hypertrophic changes are demonstrated. In this situation, adipocytes reach a maximum size, and when no further increase is possible, a message is sent to the adipoblast/preadipocyte pool for recruitment of new cells [13].

24.4.1 Regional Fat Distribution by Gender and Race There are some gender differences in fat distribution. The male or android distribution is characterized by subcutaneous fat deposition in the upper body as well as by central visceral fat deposits [13]; thus, the typical adult man has disproportionate fat deposits in the subcutis of the abdomen, the waist, the shoulders, and nape of the neck. These deposits are associated with androgen receptors on adipocytes. The female or gynecoid distribution refers to fat accumulation in peripheral stores, specifically those below the waist, like the femoral and gluteal areas. These deposits are associated with estrogen receptors on adipocytes [12, 13]. Peripheral fat deposits, characteristic of women, tend to be fixed and become active during lactation and pregnancy. Truncal deposits (android shape) are more metabolically active, change with dietary habits, and correlate with disease risk. With fasting, in the first week, lipolytic activity appears centrally but not in peripheral stores. Paradoxically, these peripheral stores in obese and nonobese women increase in the face of diminished food supply. These peripheral deposits of fat are not significantly affected by diet restriction [1].

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Finally, there exist ethnic differences in the shape of the body. In Latin American women, the fat distribution occurs predominantly in buttocks and thighs, but in others, fat is seen mostly on the shoulders.

24.4.2 Health Implications of Regional Obesity Abdominal obesity is a strong risk factor for the development of diabetes mellitus [14, 15], hypertension [16–18], and possibly some female cancers (endometrial, ovarian) [16, 17]. A measure of the relationship between central and peripheral obesity was developed and compares the circumference of the abdomen to that of the hips. This waist–hip ratio (WHR) has been shown to be a predictor for those health risk factors related to central obesity [19, 20]. The WHR very accurately predicts intra-abdominal adipose collections [21]. However, simplest by far, measurement of the degree of obesity is calculated through the traditional height and weight measurements, that is to say the body mass index (BMI). The BMI represents a concise, objective, mathematical formula, and pivotal to the BMI concept is that the body surface is directly proportional to height squared and body surface area essentially is independent of weight. In plain words, the BMI normalizes body weight per unit surface area, that is, weight divided by squared height (w/h2) in metric units of kilograms and meters. This estimation requires only a hand calculator to divide the patient’s weight in kilograms by the height in meters, then dividing the result by height again, to yield the BMI (ordinarily rounded to one decimal place precision) in units of kilograms per square meter. Using the BMI, the surgeon is able to objectively classify a patient’s obesity as one of the following: 1. 2. 3. 4. 5. 6.

Class I: Lean range (18.5–19.9) Class II: Optimal (normal) (20–25) Class III: Overweight range (25.1–29.9) Class IV: Obese range (30–34.9) Class V: Morbidly obese range (35–39.9) Class VI: Extremely obese (40 or greater)

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BMI is gender independent in adults and is as applicable to women as it is to men. Finally, and very important, BMI is an estimator of sedative or anesthetic risk. Morbid obesity (BMI > 35) imparts a threefold to fourfold greater risk of respiratory depression from sedative drugs, perhaps because sleep apnea is severalfold more common in that group. Determination of the BMI should be made as a routine part of the preoperative record like blood pressure or hemoglobin content [22]. The visceral fat cells are hypothetically of particular importance because of their relationship to the portal circulation. The breakdown products of lipolysis from these adipocytes drain directly into the portal circulation and can expose the liver to high concentrations of free fatty acids; these, in turn, can cause hypertriglyceridemia [16]. Obesity also plays a major role in the development of insulin resistance and impaired glucose tolerance, which are the likely precursors of type 2 diabetes [23]. Insulin resistance also seems to be a part of a cardiac dysmetabolic syndrome which includes hypertension, dyslipidemia, obesity, impaired glucose tolerance or diabetes, and macrovascular arterial disease resulting in atherosclerotic cardiovascular and peripheral disease [24]. Hyperinsulinemia has been shown to promote arterial smooth muscle cell proliferation in vitro [25]. Arora [26] has shown that patients with diabetes and deficient glucose tolerance and even firstdegree relatives of diabetic patients have impaired vasoreactivity and endothelial dysfunction. This is thought to be a result of hyperinsulinemia or insulin resistance.

24.5

Impact of Liposuction on General Health Risks

The scope of liposuction has progressed from a small amount of regional fat removal to circumferential body contouring with increased safety. A significant evacuation of subcutaneous fat by large-volume liposuction creates marked changes in body composition by rapidly decreasing the amount of subcutaneous adipose tissue. There

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has been concern that removal of subcutaneous adipose tissue by liposuction may result in a redistribution of fat with an increased deposition of intra-abdominal fat cells [27], which, in turn, could potentially increase health and specifically cardiovascular risk factors; however, these are hypothetical considerations only. There is a very good body of evidence demonstrating the health benefit effects of liposuction. In fact, the future derivations of these studies in the long-term follow-up of patients with metabolically different health problems seem to be promising. The correction of the abnormal level of serum lipids after liposuction was demonstrated in one study [28]. The patients showed improvement in cholesterol, low-density lipoproteins, and triglycerides 4–12 months postoperatively. The conclusion was that reducing the large amount of adiposity by liposuction in patients with elevated serum lipid values may be a factor regarding circulating lipids through the equilibrium of adiposity, circulating lipids, and fat metabolism. In another study, by Giese et al. [29], 14 overweight and obese but otherwise healthy premenopausal women with a mean BMI of greater than 27 kg/m2 underwent large-volume liposuction, achieving a mean weight, a BMI, and fat reduction of 6.5 kg, 2 kg/m2, and 17 %, respectively by 4 months after surgery. An additional benefit was a reduction in fat content in the non-suctioned areas of the body, such as the arms. There was also a significant reduction in the mean fasting plasma insulin level by nearly 50 %. More importantly, patients who had higher preoperative fasting insulin levels had a more marked reduction in that parameter, at both 6 weeks and 4 months after surgery. Insulin resistance also declined dramatically by 4 months. Finally, there was also a significant decrease in systolic blood pressure. The authors found that liposuction positively impacts some vital cardiovascular risk factors such as obesity, systolic blood pressure, and high plasma insulin levels. This beneficial effect might translate into reduced cardiovascular morbidity and mortality in these patients. If insulin levels can be brought down by liposuction of the subcutaneous fat in these patients, one might be able to

prevent significant cardiovascular morbidity and mortality with the procedure by preventing or slowing the development of atherosclerosis. As Arora [26] concludes, “to go one step further, one might even be able to prevent the development or delay the development of diabetes in the patient population.” Nowadays, in our talks concerning liposuction, we use the statement “At this time liposuction is performed not only for aesthetic reasons, but also for general health purposes.”

24.6

Technique

24.6.1 Preoperative Preparation The authors prefer to work only with patients classified as ASA I and II. Irrespective of the age, all patients are sent to the cardiologist for a complete cardiac and vascular checkup, and hematological studies are carried out which include fasting blood sugar and HIV tests. An abdominal ultrasound/computed tomography scan is carried out in cases of suspected visceromegaly or mass in the abdomen. A careful check of hernial orifices is carried out, and any suspected hernias are carefully excluded. Diabetes is not a contraindication for liposuction as is generally speculated. With careful control of the blood sugar using insulin/oral antidiabetic agents, light sedation, and medium to large liposuctions in one sitting, these patients do well. With careful control of the blood pressure, hypertension is also not a contraindication for medium to large liposuction. Generally, both of these parameters improve with liposuction. Careful assessment and written agreement by the endocrinologist/cardiologist is needed. It is convenient to stress the importance of the careful sterilization of all the instruments (autoclave or gas, and not antiseptic solutions). Unnecessary medications are specifically prohibited, mostly aspirin, beta blockers, estrogens, vitamins, and the so-called herbal drugs 10 days before surgery. Three days prior to surgery, the patient uses an antiseptic soap containing povidone-iodine or chlorhexidine. One day before surgery, a prophylactic antibiotic is given

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Large-Volume Liposuction for Obesity

(cefadroxil), and this continues for 3 days after surgery. One hour prior to the surgical procedure, all the patients receive 150 mg, one tablespoonful, of oral ranitidine, 10 mg metoclopramide, and 0.1 mg clonidine. Clonidine is used only if the blood pressure is not less than 90/60 mmHg and the pulse rate is not less than 60 bpm. Preoperative marking of the operative areas that include important blood vessels in the groin is carried out in the operating room with the patient standing up. All patients sign an informed written consent form. Immediately before surgery, all are weighed in kilograms and measured in centimeters. Careful circumferential measurements (in centimeters) of the areas to be operated upon are performed. This is usually repeated after 1 month. Pulse and blood pressure are carefully determined.

24.6.2 Anesthesia and Sedation Regardless of the volume to be aspirated, all cases are handled on an outpatient basis. Intravenous sedation/analgesia is performed by a certified anesthesiologist in a fully equipped operating room. The drugs combined to obtain this sedation/analgesia are mostly midazolam and fentanyl. The total dose of midazolam varies from 15 to 20 mg (0.3 mg/kg). The total dose of fentanyl fluctuates from 300 to 500 μg (5–10 μg/ kg). If adequate sedation is not reached, propofol is added as a continuous infusion up to a total of 100–200 μg/kg/min or a maximum of 4 mg/kg/h. Only rarely is there need to add small doses of ketamine. These drugs are short acting; therefore, there is no risk for the patient who is being carefully monitored (noninvasive pulse oximetry, blood pressure, pulse rate, temperature, EKG in three derivations). Parenteral fluid replacement is hardly necessary, and Ringer’s solution is infused only to allow the administration of sedatives and in order to have an intravenous line [1]. Concerning local anesthesia, a minor modification of the classic formula developed by Klein [30–35] is utilized. Our local anesthesia consists

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only of 0.05 % lidocaine plus 1:1 × 106 epinephrine in saline solution. Some authors suggest using different concentrations of lidocaine depending on the area to be worked on [32]. According to those authors, higher concentrations may be necessary in places that are recognized for special sensitivity, such as the periumbilical and trochanteric areas. The authors use the same concentration in all the areas. In the more sensitive ones, larger volumes of the solution are tried. The procedure is well tolerated with minimal discomfort in some sites where it is transitory and of low intensity and can be controlled by the analgesics and sedatives. The use of various concentrations could possibly result in a mistake or confusion in the dose and possible toxicity. Corticosteroids and sodium bicarbonate are not used in the solutions. The steroid is given intravenously. There exists the possibility that sodium bicarbonate can increase and prolong the inflammation as well as shorten the duration of anesthesia. Under intravenous sedation, the patients do not experience any conscious pain when the local anesthesia is administered [1, 33].

24.6.3 Total Injected Volume There are two fundamental principles of the tumescent technique: (1) use of the Klein formula (highly diluted lidocaine and epinephrine) and (2) injection in large volumes until true tumescence is reached (swollen and firm tissue hard as wood or rock). Only in this manner can profound, enduring anesthesia and vasoconstriction be obtained. Some surgeons do not understand this. The injection of modest amounts of Klein’s solution is nothing more than a wet method. What then should be understood by large volume? It is the volume necessary to cause tumescence. The volumes injected and aspirated are barely the same (1:1 ratio approximately). If aspiration of 3, 6, or 8 L of fat is planned, the injection should be 3, 6, or 8 L of Klein’s solution, respectively (Table 24.2). The surgeon’s left hand should determine the necessary stiffness or firmness (the true tumescence). Although greater

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Table 24.2 The amount of aspirated fat is almost the same as the amount of Klein’s solution injected Injected/aspirated Klein’s solution Aspirated fat

Minimum 250 400

Average 4,500 4,500

Maximum 11,600 13,400

From 220 cases Table 24.3 Estimation of the total amount of Klein’s solution to be injected is generally easy when using this method. Correlation of body weight, San Salvador units (SSU), and volume to be infiltrated Body weight (kg) 70 80 90 100 130 150

Milligrams per SSU 490 560 630 700 910 1,050

Volume (l)a total 7.5 9 9 10.5 12.5 15

To get the central column, multiply the left figure by 7; this will give a number in SSU. For example, 70 × 7 = 490. Then, approximate this to the nearest figure, i.e., 490 = 5. For the right column, always multiply by 1.5 (a constant). This will give 55 mg/kg/body weight. This is an upper limit. Try to be always below it a Volume of Klein’s solution

volumes have been injected without evidence of toxicity, owing to the principal concern for patient safety, the authors prefer to stay below a ceiling of 55 mg/kg body weight range in relation to lidocaine, which has already been extensively tested [33]. Traditionally, the maximum safe dose of lidocaine is 7 mg/kg body weight, which we call one San Salvador unit (1 SSU) [36]. Based upon this figure, the total amount of Klein’s solution to be infused can be estimated (Table 24.3). Even though the injected and aspirated volumes should ideally be the same, we generally bypass this rule by injecting somewhat more and aspirating somewhat less. If the tumescent preparation is good (“the real tumescence has to be seen and felt” [33]), the fat aspiration will be simple, safe, and without ecchymoses in the postoperative period. In any case, since large-volume infiltration is used, it is safer to inject by sections, even if it means the duration of the procedure is prolonged. In this way a specific area is injected and extracted and then the next area is treated. Under intrave-

nous sedation, it is not necessary to use warmed local anesthetic solution [12]. Chilled (cryoanesthesia) solutions are used to increase the vasoconstrictive effect [1]. To maintain the safety of the procedure, the body temperature is continuously checked by noninvasive monitoring. The authors try to avoid complications by setting reasonable limits and taking into consideration the fact that we are dealing with ambulatory patients. General versus local anesthesia plus intravenous sedation: In the past, local anesthesia was reserved for the treatment of small and localized fat deposits in liposuction surgery. Now, using careful intravenous sedation, and the true tumescent method, current liposuction procedures, regardless of the volume extracted, can be carried out under local anesthesia. If the intravenous sedation is administered by a certified anesthesiologist, there is no reason for the patient to experience any pain or discomfort during the administration of anesthesia or during the procedure itself. Any surgicenter should be properly equipped to handle any emergency. Aspiration volumes: Previously, the most important limiting factor in the extraction of large volumes of fat was the degree of blood loss. Using the true tumescent method, blood loss is less than 1 % of the total extracted volume. Major aspirations of 8–10 L imply a blood loss of no more than 80–100 mL, which in no way compromises the patient’s safety. Strict application of the current technique allows us to carry out large liposuction procedures at ambulatory facilities with no risk. What do we understand by large liposuctions? Until recently, 2,500 mL was considered a safe and reasonable upper limit. Technical innovations have also modified our concepts. The authors consider a liposuction to be “large” when it is over 4,000 mL. In general, we try not to extract over 10,000 mL per session. Although it is still very safe for patients over this limit (with

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minimum blood loss and normal vital signs), the duration of the procedure is prolonged, which involves fatigue for both the patient and the surgeon. While performing large liposuctions, the anesthetic solution is injected simultaneously with two infusors, and the extraction procedure is performed using two suction machines at the same time through small incisions (Fig. 24.1). If extraction over 10 L is considered, it is preferred to do the liposuction in two sessions. Since the blood loss is minimal, the surgical trauma is low, and the drugs used as sedatives and analgesics are quickly metabolized, the second procedure can be done 1–2 weeks later. In some cases, 17 L of fat has been extracted in two sessions, with only a 10-day interval. In other instances, up to 26 L of fat has been extracted in three sessions with a 2-week interval between each session. In these

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cases, there was excellent recovery. Sometimes, for foreign patients, three sessions in 1 week have been scheduled (Wednesday, Saturday, and Wednesday liposuctions). In this way, if a patient comes from outside of our country and needs to return very quickly, as much as 24 L of fat is aspirated in three sessions, 8 L each time. No problems have occurred using this regimen. The most important advantage of tumescent local anesthesia is to eliminate the risk of general anesthesia and the massive bleeding that was associated, in the early days, with liposuction [33]. The pharmaceutical principles of tumescent anesthesia are (1) more diluted lidocaine is safer, (2) a large volume of anesthetic solution is infiltrated better, and diffusion and a uniform anesthetic effect is obtained, and (3) because of the great liposolubility of lidocaine, the relative avascularity of fat, and the vasoconstriction induced by epinephrine, there

Fig. 24.1 The incisions must be very small and easy to camouflage

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is slow absorption of the anesthetic and very late plasma peak levels [34]. It has been demonstrated that the maximum peak levels of lidocaine are reached 14 h after the infiltration but always in a safe range (1.2 μg/mL) [35]. It is necessary to know the drugs interacting with lidocaine, because they inhibit cytochrome P450 3A4 in the liver, which metabolizes 70 % of the lidocaine that enters the hepatic circulation. The commonest interacting drugs are terfenadine, astemizole, cisapride, ketoconazole, itraconazole, erythromycin, clarithromycin, and some dietary factors like grape fruit juice that can also inhibit cytochrome P450 3A4 [37].

24.6.4 Transoperative and Postoperative Facts A strict sterile operating room technique is followed. Each surgeon and the assistants use povidone-iodine for 10 min for scrubbing the hands and forearms up to the elbows, following a double brush technique. Disposable sterile surgical gowns are worn during the procedure. Double cleaning of the operative area and well beyond is carried out with povidone-iodine. Excess povidone-iodine is wiped away with sterile roller towels, which are discarded. Incisions are small, no more than 2 mm, and do not need suturing at the end. It is good to remember the saying “In cases of liposuction, entry points are small, but the wound is large.” The approach is essential to get nicer results with almost imperceptible scars or no scars at all. Generally, abdominal and hip liposuctions are started with a 4-mm Keel Cobra tip cannula, and final touchups are carried out with a 2–3-mm Keel Cobra tip or lightweight French cannulas [38]. Handling of the tissues is gentle at all times during the procedure. Both hands are used for the procedure, the working hand and the brain hand. While the working hand performs the liposuction, the brain hand feels the tip of the cannula and molds the tissues for the proper functioning of the working hand. When the working hand is tired, the brain hand becomes the working hand and vice versa. In this way, the procedure

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becomes less tiring. The base of the cannulas is always protected by a padded gauze to avoid trauma to the lips of the entry points during the procedure. The assistant surgeon or the nurse takes care to protect the skin with the gauze. This is the method that better protects the lips of the small incisions. Liposuction of the periumbilical and trochanteric areas is performed at the end, and generally more tumescent infiltration is used here, rather than a higher concentration of Klein’s solution, in view of the higher sensitivity of these areas. For the hips, only deep liposuction is performed [38]. In the hip and thigh areas, feathering is carried out at the end. Cannula strokes without suctioning are used well beyond the operative area in a radial manner. Both of these maneuvers are helpful in preventing irregularities in the hip and thigh areas. In the tough upper back, first deep liposuction is used and then relatively superficial liposuction. The area of the lower abdomen is generally more sensitive to pressure and avascular necrosis. Very superficial liposuction is avoided in this area. Assistants use roller towels to gently remove the remaining saline solution and broken down fat cells from the entry points in the end. Sutures are not applied to the entry points. This allows for easy dripping of the fluids. Sterile padded dressing is applied with Micropore tape. On top of this, French tape is applied in the form of an X (the first application) and later horizontally (the rest of the abdomen) followed by pressure garments when finishing (Fig. 24.2). At the end of surgery, the patients remain 1–2 h more before returning home by their own means, following the criteria of Aldrete. However, the authors always insist that the patients must be accompanied by some other person (friend or relative). The French tape and gauzes are removed on the second postoperative day. This makes lymphatic drainage easier and promotes, at the same time, a quicker reduction of inflammation. Pressure garments are removed on the seventh day, but the patients are allowed to use them 12 h a day for 1 week more. Moderate physical activity is begun on the second day, and heavy physical activity (including gym, jogging, and all sorts of

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235 Table 24.4 Most of the liposuctions in the Center for Dermatology and Cosmetic Surgery are large. The time spent in the procedure may be long Type Small Medium Large Mega

Volume (l) 10

Percentage 12 34 48 6

Operating time Minimum 1.00 h Average 3.18 h Maximum 6.00 h

From 220 cases Fig. 24.2 French tape is applied on the top of a sterile padded dressing

extreme physical exercise) is strongly recommended starting at the second week. To improve the body contour further, and to provoke quicker reduction of inflammation, external ultrasound is used starting the next week after the surgery. Transoperative ultrasound is time-consuming and does not add anything to a well-done tumescent liposuction [39]. The new costly reciprocating cannulas have not been found to be of additional advantage as compared with the conventional cannulas. The most transcendental advancement in the field of liposuction is tumescence, and its impact continues to be enormous [30–35].

24.7

Statistics in Our Surgicenter

We reviewed our cases of liposuctions performed between May 1997 and June 1998. Volume liposculpture was performed on 220 patients. Fat was extracted from 815 different areas during this period [1]. The parts of the body most worked on were the upper and lower abdomen, flanks, hips, waist, back, and trochanteric regions. The oldest patient was 74 years old and the youngest 16 years old, and the average age of the patients was 43 years. There were 190 women (86 %) and 30 men (14 %). The minimum operating time was 1 h with a maximum of 6 h and an average of 3 h 18 min. The volume of Klein’s solution infiltrated varied between a minimum of 2,500 mL and a maximum of 11,600 mL, with an average of

4,500 mL. The total supranatant fat extracted fluctuated between 1,400 mL and 13,400 mL with an average of 4,500 mL. Volume liposculpture was small (less than 2 L) in 12 % of the cases, medium (2–4 L) in 34 % of the cases, large (4–10 L) in 48 % of the cases, and mega (more than 10 L) in 6 % of the cases (Table 24.4). Major complications were not observed in any of the cases. Minor irregularities occurred in 10 % of the cases, and only 5 % of the cases required a touchup procedure. Seventy percent of the large and mega cases showed variable degrees of postinflammatory pigmentation, which lasted from 1 to 3 months. This situation is probably related to the skin type of the patients (Hispanics). Treatment consisted of emollient creams and local tretinoin as well as time and avoidance of sun exposure and rubbing. The authors’ figures and the types of complications strongly contrast with those reported by others [40–45].

24.8

Final Considerations

Ninety-seven million Americans (nearly 55 % of the adult US population) are obese (BMI more than 30) and/or overweight (BMI between 25 and 30) [22]. As the prevalence of obesity continues to increase, so do the accompanying risks to health and lifespan from hypertension, diabetes, coronary artery disease, and increased surgical morbidity and mortality [22]. Large-volume liposculpture can be performed safely on healthy overweight patients, and it not only improves body contour and body image but also reduces cardiovascular risk factors such as

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obesity, systolic blood pressure, and plasma insulin. Therefore, the resultant morbidity and mortality decrease. It may even prevent or delay the development of diabetes or impaired glucose tolerance if the previously mentioned beneficial effects are long-lasting [26, 29]. When fat is extracted simultaneously from various sites of the body in the same session, mainly the waist, hips, flanks, and back, it is possible to obtain increased patient satisfaction. If the patient is very obese, the procedure should be divided into several interventions rather than one. Liposuction as a cosmetic procedure, in the right hands, is a safe and efficient method to improve body contour [42]. This has been demonstrated in different publications focused on the safety of liposuction [40–44]. The impact upon the self-esteem is so important that we summarize this saying to our patients: “We are going to operate on your body, but the most important effect will be felt on your mind.” It is worth emphasizing that liposuction is only one of the weapons to fight against being overweight. After surgery patients are better motivated to start a program including a dietary regimen and physical exercise, or in other words, a complete change in their lifestyle.

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11. 12. 13.

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autologous fat transplantation. Norwalk: Appleton & Lange; 1988. p. 5–6. Guyton AC. Lipid and protein metabolism. In: Guyton AC, editor. Human physiology and mechanisms of disease. Philadelphia: WB Saunders; 1992. p. 520–5. Frayn KN. Adipose tissue metabolism. Clin Dermatol. 1989;7(4):48–61. Lack EB. Fat metabolism and its relevance to liposuction. Am J Cosmet Surg. 1997;14:263–7. Skouge JW. The biochemistry and development of adipose tissue and the pathophysiology of obesity as it relates to liposuction surgery. Dermatol Clin. 1990;8(3):385–94. Kissebah AH, Peiris AN, Evans DJ. Mechanisms associating body fat distribution to glucose intolerance and diabetes mellitus: window with a view. Acta Med Scand Suppl. 1988;723:79–89. Lonroth P. Potential role of adipose tissue for the development of insulin resistance in obesity. Acta Med Scand Suppl. 1988;723:91–4. Bjönstorp P. The associations between obesity, adipose tissue distribution and disease. Acta Med Scand Suppl. 1988;723:121–34. Lapidus L, Bengtsson C. Regional obesity as a health hazard in women. Prospective studies. Acta Med Scand Suppl. 1988;723:53–9. Larsson B. Regional obesity as a health hazard in men. Prospective studies. Acta Med Scand Suppl. 1988;723:45–51. Lapidus L, Bengtsson C, Larsson B, Pennert K, Rybo E, Sjostrom L. Distribution of adipose tissue and risk of cardiovascular disease and death: 12 year followup of participants in the population study of women in Gothenburg, Sweden. Br Med J. 1984;289(6454): 1257–61. Larsson B, Svardsudd K, Welin L. Abdominal adipose tissue distribution, obesity and risk of cardiovascular disease and death: 13 year follow-up of participants in the study of men born in 1913. Br Med J. 1984;288(6428):1401–4. Dixon AK. Abdominal fat assessed by computed tomography: sex difference in distribution. Clin Radiol. 1983;34(2):189–91. De Jong RH. Body mass index: risk predictor for cosmetic day surgery. Plast Reconstr Surg. 2001;108(2):556–61. Benzi L, Ciccarone AM, Cecchetti P, DiCianni G, Caricato F, Trincavelli L, Volpe L, Navalesi R. Intracellular hyperinsulinism: a metabolic characteristic of obesity with and without type 2 diabetes. Intracellular insulin in obesity and type 2 diabetes. Diabetes Res Clin Pract. 1999;46(3):231–7. De Fronzo RA, Ferrannini E. Insulin resistance: a multifaceted syndrome responsible for NIDDM, obesity, hypertension, dyslipidemia, and atherosclerotic cardiovascular disease. Diabetes Care. 1991;14(3):173–94. Avena R, Mitchell M, Carmody B, Arora S, Neville RF, Sidaway AN. Insulin like growth factor-1 receptors mediate vascular smooth muscle cell proliferation in response to glucose and insulin. Am J Surg. 1999;178(2):156–61.

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26. Arora S. Improvements in cardiovascular risk profile with large-volume liposuction: a pilot study (discussion). Plast Reconstr Surg. 2001;108(2): 520–1. 27. Kral JG. Surgical reduction of adipose tissue hypercellularity in man. Scand J Plast Reconstr Surg. 1975;9(2):140–3. 28. Hildreth B. Liposuction and serum lipids. Am J Cosmet Surg. 1997;14:345–6. 29. Giese SY, Bulan EJ, Commons GW, Spear SL, Yanovski JA. Improvements in cardiovascular risk profile with large-volume liposuction: a pilot study. Plast Reconstr Surg. 2001;108(2):510–9. 30. Klein JA. The tumescent technique for liposuction surgery. Am J Cosmet Surg. 1997;14:463–5. 31. Klein JA. Tumescent technique for local anesthesia improves safety in large volume liposuction. Plast Reconstr Surg. 1993;92(6):1085–198. 32. Klein JA. Tumescent technique chronicles. Local anesthesia, liposuction and beyond. Dermatol Surg. 1995;21(5):449–57. 33. Seijo-Cortes JA, Hernandez-Perez E. Anestesia tumescente de Klein: Una opción segura en cirugía dermatológica. Acta Ter Dermatol. 1997;20:451–9. 34. Lillis PJ. The tumescent technique for liposuction surgery. Dermatol Clin. 1990;8(3):439–50. 35. Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol. 1990;16(3):248–53. 36. Hernandez-Perez E, Henriquez A, Gutierrez J. Clarifying concepts in modern liposuction. Int J Aesthet Restor Surg. 1994;2:65–7.

237 37. Klein JA, Kassardjan N. Lidocaine toxicity with tumescent liposuction. A case report of probable drug interactions. Dermatol Surg. 1997;23(12):1169–74. 38. Klein JA. Tumescent liposuction with local anesthesia. In: Lask GP, Moy RL, editors. Principles and techniques of cutaneous surgery. New York: International Edition: Mc Graw Hill; 1996. p. 529–42. 39. Hernandez-Perez E, Meda Alvarez Y, Seijo-Cortés JA. External ultrasonic tumescent liposuction vs conventional tumescent liposuction: a gross and microscopic study. Int J Cosmet Dermatol Aesthet Dermatol. 2001;3:283–7. 40. Hanke CW, Bernstein G, Bullock S. Safety of tumescent liposuction in 15, 336 patients. National survey results. Dermatol Surg. 1995;21(5):459–62. 41. Coleman WP, Hanke CW, Glogau RG. Does the specialty of the physician affect fatality rates in liposuction? A comparison of specialty specific data. Dermatol Surg. 2000;26(7):611–5. 42. Hernandez-Perez E, Valencia-Ibiett E. Analysis of liposuction-related complications and mortality in the United States and Latin America. Cosmet Dermatol. 2000;15:23–8. 43. Grazer F, de Jong R. Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast Reconstr Surg. 2000;105(1):436–46. 44. Teimourian B, Rogers B. A national survey of complications associated with suction lipectomy: a comparative study. Plast Reconstr Surg. 1989;84(4): 628–31. 45. Guidelines for liposuction surgery. The American Academy of Cosmetic Surgery. 2001.

Megaliposculpture and Therapeutic Megaliposculpture

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Pierre F. Fournier

Abstract

Megaliposculpture refers to the aspiration of 10 l or more by liposuction. The author describes the procedure and the before and after care as well as possible complications. The author has had many successful results from the procedure. The author shows many of these patients and their followup. However, because of advances in bariatric surgery, drugs, and diets, there is no longer a need for this complex operation.

25.1

Introduction

Thirty years ago, the author proposed the name megaliposculpture for all liposculpture procedures during which 10 l or more is extracted of a mixture composed of adipose tissue, normal saline from the subcutaneous infiltration, and the patient’s blood. The proportions of each of these elements vary according to the case, and only the quantity of adipose tissue will be taken into consideration. The evaluation at the same time of the blood extraction, the visible fraction of the blood loss that conditions the pursuit or the abandonment of the intervention, is of such importance that it is

P.F. Fournier, M.D. Private Practice of Aesthetic Surgery, 57 avenue de villiers, 75017 Paris, France e-mail: [email protected]

necessary to closely watch over this parameter. The qualitative and quantitative blood loss is important in determining the volume of pure lipoextraction. For a long time, surgeons hesitated to extract more than 2.5 l of adipose tissue from a patient. The technique and the conditions in which the procedure took place limited the amount that could safely be removed. This included hospitalization, general anesthesia, the use of large cannulas and of the suction machine, absence of infiltration (“dry technique”), infiltration without adrenaline, a large number of blood transfusions, sometimes laborious fluid and electrolyte balance, hypovolemic shock, long convalescence, lack of practice by surgeons, complications or unsatisfactory results, and lack of updating the procedure. Through the years, liposuction has advanced, now allowing megaliposculpture to be performed so that more than 10 l can be extracted without posing any greater risk to the patient than a conventional aesthetic liposculpture.

© Springer-Verlag Berlin Heidelberg 2016 M.A. Shiffman, A. Di Giuseppe (eds.), Liposuction: Principles and Practice, DOI 10.1007/978-3-662-48903-1_25

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Little by little, the quantity of adipose tissue extracted increased, when it was certain that large extractions would not pose any additional risk to patients who were candidates for such operations. The author first practiced megaliposculpture in two stages at 6-month intervals with 8 l extracted from the lower extremities during the first stage and 6 months later 6–8 l from the abdominal wall. The maximum amount extracted slowly increased over 12 years to a total of 23 l. Deeb and Eed [1] in Saudi Arabia and Ioannidis et al. [2] and in Greece using the same technique were performing similar large extractions. Large-volume extractions must only be performed by a surgeon trained in megaliposculpture with careful selection of patients and an anesthesiologist trained for operations on obese persons and working in coordination with the surgeon and his team. Both the anesthesiologist and the surgeon must know when to stop before going too far and never pose greater risks to the patient than would be possible during the course of a standard liposculpture.

25.2

Why Perform Megaliposculpture?

Failures in current medical or surgical therapies for the obese justify megaliposculpture. Although the cause obesity is not treated by megalipoextraction of adipose cells, the result is reached in part since lipectomy is only concerned with superficial excess and not the deeper excess of adipose tissue. A certain portion of hypertrophy or hyperplasia of adipose cells is definitively removed from the catastrophic influence of the cause of the obesity. In this way, one can expect an improvement in the physical condition of the patient while provoking disturbances in the generative process of the obesity. One could compare this disease, obesity, to a war in which there is one enemy and several victims. If a counterstroke leading to victory is not possible, the first thing to do is to protect the victims, or at least, in the case of obesity, to shield them from the catastrophic results of this disorder. In this way, one can expect that the lower the quantity of fat tissue subjected to the disastrous results, the better the body can fight against this

biologic and metabolic anomaly. This attempt to reduce the vulnerable tissue territory can expect the attenuation of potential life-threatening consequences of obesity. It is well known that obesity can cause or aggravate the following pathologies: cardiac diseases, high blood pressure and stoke, pulmonary diseases, diabetes, gall bladder disease, gout, certain cancers, osteoarthritis of weight-bearing joints, an abnormal level of lipids and plasma lipoproteins, and irregularity of the menstrual cycle. In addition, obesity is often an enormous psychological burden. When all the conventional treatments have failed, megalipoextraction is the last operation to be performed. It should be regarded as a major lifesaving operation and not as an aesthetic procedure. The goals of megaliposculpture or therapeutic megalipoextraction are: 1. To extract in a single operation the greatest possible quantity of subcutaneous adipose tissue for the patient, without running any greater risk than in the course of a normal liposculpture and without the need for blood transfusion (autologous or not). The result of this operation is a numerical reduction of the subcutaneous adipose cells. 2. To provoke biological metabolic or psychological modifications in the operated patient that, following a diet, exercise, or medical treatment, will result in decreasing the intra-abdominal and intramuscular adipose tissue, residual components of the excess adipose tissue. The result of these postoperative biological modifications is a reduction in the volume of the adipose cells in these two areas where a mechanical reduction is impossible to perform.

25.3

Indications

Megaliposculpture above 10 l of supranatant fat is a major operation that can produce serious complications and is selected only after thorough reflection by both patient and surgeon. Potential patients are failures of other medical or surgical treatments. The patient must be informed of the risks and is asked to reflect for a period of time. Patients selected should weigh between 100 and 150 kg with no comorbidities, e.g., high

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blood pressure, cardiac or pulmonary problems, and diabetes. Eventually we may be able to operate on patients over 150 kg. To remove over 10 l of supranatant fat, the weight of the patient should be at least over 100 kg. At the present time, we accept, with the agreement of our anesthesiologist, certain obese patients who also have high blood pressure and cardiac, pulmonary, or diabetic problems, if the risk does not appear to be too great. Megaliposculpture will not bring a solution but is an additional treatment for patients with obesity, high blood pressure, certain cardiac or pulmonary problems, and other problems associated with obesity. In certain cases of ambulatory difficulties and in cases of vertebral osteoarthritis or arthritis of the hip, an abdominal megaliposculpture can reduce chronic vertebral pain and chronic pain in the hips or knees, or as orthopedic surgeons have suggested, it might prolong the life of hip prostheses by removing the excess weight. Having obtained positive results, we have become more venturesome in the operative indications. We are convinced the megaliposculpture has a place in the treatment of obesities, whether general or regional.

25.4

Technique

Surgery is preceded by the physical and psychological selection done by the surgeon and the anesthesiologist. Megalipoextraction is possible owing to a large amount of normal saline. We have learned that it is possible to inject into the subcutaneous area 10, 15, or even 20 l of normal saline, which is cold at 2 °C, and each liter can contain 1 mg of adrenaline (1 mL if 1:1,000). This amount of normal saline allows us to avoid postoperative hypovolemia and considerably limits preoperative and postoperative bleeding.

25.4.1 Anesthesia Simple megalipoextraction or therapeutic megaextraction is done under general or epidural anesthesia. We prefer epidural, which is the least toxic for the obese patients and permits them to be moved, if necessary, without risk. However, the

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patients often request general anesthesia, even if they are informed that it is slightly riskier and that there will be more bleeding. The anesthesiologist must be accustomed to operations on obese patients and be trained for this type of operation, which is completely different from the current cosmetic liposculpture. The anesthesiologist and the surgeon work in close collaboration with each other [3]. Once the actual operation has been completed, the surgeon must monitor the operated regions and must take part in the follow-up. Our anesthesiologist has the major responsibility for the patient’s fluid and electrolyte balance and the monitoring of the vital functions. His role during a megaextraction is of utmost importance in the selection of the patient, the resuscitation, the follow-up of the operation, and the convalescence.

25.4.2 Technique of Subcutaneous Infiltration The operation begins as soon as the epidural anesthetic has taken effect or immediately after induction of general anesthesia. The surgeon will inject the solutions either himself or with the assistance of an operating assistant who must be equally competent. The only syringes used are 60 mL syringes with a Luer Lock tip fitted with a cannula of 2.5 mm external diameter and 28 cm length. A second assistant will fill them in a basin that contains several liters of solution and will hand them to the operating surgeons. The infiltration is done in the thick part of the subcutaneous tissue and is a retrograde injection, each operating surgeon injecting symmetrical locations drawn in advance. Rapid infiltration should be avoided. It must be done in about 30 min or longer if the area to be operated upon is very extensive. The infiltration can be done at one time or, if the area is extensive, at three sequential separate times, allowing 30 min between infiltration and lipoextraction. The first infiltration will be in the abdomen, then the sides, the thorax, and the breasts, and then the hips, outer and inner thighs, the front of the thighs, and the knees. The head of the operating table is elevated 15°. The surgery begins as soon as the abdomen is

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ready to be operated on, i.e., 20–30 min after the end of the infiltration. An infiltration machine could also be used, but we prefer to infiltrate with syringes. During the abdominal operation, a third assistant will inject the second region to be operated upon, the upper body and the sides, which will be ready for surgery when the abdominal part has been completed. Finally, while the surgeon and his assistant are operating on the second region, the third and last region is injected. Up to 10 or 12 l of cold normal saline with adrenaline has been injected at one time before operating with no major complications. Even so, the occasional occurrence of arrhythmia has made us prefer, in the case of large injections (more than 8 l), to inject the

Fig. 25.1 Toomey syringe and attachments

areas to be operated upon in two or three intervals. An intravenous injection of normal saline is instituted at the beginning of the operation with only 1–2 l given during the course of the operation (this is very important). There is no reason to start this intravenous rehydration in the preoperative period even though certain surgeons do. Fatal complications happen when too much fluid is given intravenously as well as subcutaneously [3].

25.4.3 Operative Technique The operation is done exclusively with the aid of 60 mL plastic Toomey syringes (Fig. 25.1). The vacuum machine is not used and could even be

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harmful in cases of aesthetic liposculpture and even more so during therapeutic megalipoextraction. Sixty-milliliter syringes mounted with cannulas of 4- or 5-mm external diameter are used. The cannulas have only one opening with or without four accelerators. The French model of the cannula, passing through the barrel of the syringe, is preferred to the American Tulip cannula, fixed externally on the end of the syringe. In order to lock the plunger of the syringe during an extraction, a groove in the form of a hook is made on one of the wings of the plunger of the syringe (Fig. 25.2). This system of locking the plunger allows us to avoid the use of metallic, heavy, cumbersome, and useless locks. This instrument is therefore light and thus does not “scrape” the adipose tissue, as did the cumbersome and heavy instruments when the machine was used and there was significant preoperative and postoperative bleeding [3]. A light instrument is more comfortable, more efficient, better controlled, and less fatiguing for

the surgeon. In order not to lose time, the surgeon will have at his or her disposal four systems of cannula syringes with intrinsic lockage and will commence the operation after having waited 30 min once the injection has been completed. Once the syringe is filled, each surgeon will exchange it for another cannula-syringe unit prefilled with 5 mL of normal saline, which will be given to him by a third assistant. The role of this assistant is solely to empty and fill in advance the syringes that are taken from or returned to the two operating surgeons. It takes about 10 s to fill a 60 mL syringe. This method with two operating surgeons and one assistant allows a considerable amount of time to be gained and is much rapider than the machine technique. Overall it does not have the disadvantage of preoperative and postoperative bleeding, which becomes more important without the buffering action of the 5 mL of normal saline that is present in the syringe at the moment of the extraction. An average operating surgeon will extract about 5 l/h; thus, two surgeons would take 2 h to extract 20 l (Fig. 25.3). The injection itself and the time for it to take effect is 1 h. The preparation of the patient and the epidural anesthesia

Fig. 25.2 A groove in the plunger of a 60 mL syringe can be used to maintain suction

Fig. 25.3 Over 20 l can be extracted during megaliposculpture

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take another hour. The preoperative drawing which determines the operating regions in exactly symmetrical zones permits each operating surgeon to do his or her job efficiently, rapidly, and with identical quality. The work of the first assistant must replicate that done by the principal operating surgeon. Throughout the entire operation, the anesthesiologist will inform the surgeon of all possible variations in vital functions and assure fluid and electrolyte balance of the patient. The operation must have the minimal bleeding possible. A prolonged extraction that is too bloody will force the procedure to be stopped. Sometimes it will be necessary to turn the patient over, which will be done with the usual precautions. The operating table is head-up at 15° during the entire operation. The extraction is done according to the usual crisscross technique. Once the operation has been completed, the cutaneous penetration points are sutured, and an Elastoplast bandage (strips 10 cm wide) is used unless one uses the elastic garment right away. The patient will then remain in the recovery room under strict observation for 2 h before being taken back to his or her room.

Fig. 25.4 In surgery. From left to right: Pierre Fournier, Vladimir Sidor, and Giorgio Fischer

Another elastic garment will be used later for 6 weeks. During the majority of large lipoextractions, the megaliposculpture was completed when there was no more subcutaneous adipose tissue to be extracted. In the regions that were completely treated, the residual excess of the patient’s adipose tissue was represented only by the intraabdominal or intramuscular adipose tissue. Even for a patient weighing 210 kg, once 21 l had been removed, the operation had to be interrupted since almost the entire subcutaneous tissue had been extracted. This demonstrates the importance of a postoperative dietary regime, as the problem is not entirely solved by a single surgical operation.

25.4.3.1

Follow-Up and Postoperative Care (Figs. 25.4 and 25.5) In his or her room, the patient is kept in a semirecumbent position, in order to facilitate easy breathing and to avoid compression of the diaphragm muscle. The same evening the patient will sit up, and as soon as able, he or she is recommended to move his or her legs several times per hour and to breathe deeply.

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Fig. 25.5 Postoperative care. Monitoring for 24 h with pulse, blood pressure, temperature, urinary output, and checking operative site

The postoperative monitoring (electrocardiogram, pulse, blood pressure) is maintained for 24 h. The epidural catheter is maintained for 24–48 h, and only the anesthesiologist decides when the analgesic solution should be injected. The urinary Foley catheter is maintained for 24–48 h. Temperature and urine output are monitored, as well as hemoglobin, serum proteins, and electrolytes. The anesthesiologist must be accustomed to such operations because hemodilution can persist for several days. Antibiotics are routinely administered (100 mg Vibramycin BID for 5 days), as well as anti-inflammatories (Reparil or extranase, two pills TID). In our patients, the anesthesiologist does fluid and electrolyte balance. In general, one gives either 1 l of normal saline or Ringer’s solution every 6 h for 2–3 days. The surgeon observes the dressing, which sometimes needs to be changed owing to light bloody saline discharge. The importance of this discharge should be explained before the patient’s operation in order to avoid useless worries. It is psychologically beneficial to tell the patient that the greater the discharge, the better the postoperative result and the less residual edema. Thus, the patient views this unavoidable discharge favorably.

25.5

Results

In the days following the operation, an inflammatory reaction occurs that lasts 6–8 weeks. The operated tissues will harden and become sensitive, which is completely different from the immediate postoperative period when they were soft. When the bandages are changed after 24 h, the modification of the silhouette is impressive. Then, over a few days, the inflammatory reaction begins, and the patient finds himself or herself with the same configuration as in the preoperative period. It is this inflammatory reaction that explains why the patient’s weight is not always modified in the first few weeks. It is not until 2, 3, or sometimes 4 weeks that weight loss will begin. It will be more or less rapid right away, but it varies from one patient to the next. It is also associated with a softening of the operated tissues, which become less tender, allowing the patient to move more easily. The urine output also increases considerably. This weight loss will be approximately equivalent to the weight of the quantity of adipose tissue that was extracted. After this weight loss begins, it is determined whether the patient should follow a diet. In about 20 % of patients,

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the weight loss in the months following the operation is less than the quantity of adipose tissue extracted. The majority of patients noticed a sudden loss of appetite that lasts several months. Whatever its origin, whether psychological or due to metabolic modifications, it is very frequent. Fatigue is variable from one patient to another, and is not necessarily linked to the volume of blood loss. The drop in hemoglobin is not as important as one would think. Megaliposculpture of 15 l does not vary the hemoglobin level by more than 1 mg. The drop can sometimes be greater than 1, 2, or 3 mg, but one must take into account the hemodilution, which makes the appreciation of the true blood loss difficult. Strict iron therapy is, however, routine for several weeks.

a

Fig. 25.6 (a) Preoperative. (b) Postoperative

The hospital stay varies from 2 to 5 days according to the patient. Following discharge from the hospital, convalescence of 1 week is necessary. Normal activities may be resumed 10–15 days after the operation. Aided by a nutritionist, the patient commences dieting after 8–10 days. Iron supplements, vitamin C in normal doses, and a high-protein diet are recommended. The patient will see the surgeon at frequent intervals. Surgery results in patient satisfaction because of weight loss, better contouring, and improvement over a long period of time (Figs. 25.6, 25.7, 25.8, 25.9, 25.10, 25.11, 25.12, 25.13, 25.14, 25.15, 25.16, 25.17, 25.18, 25.19, 25.20, 25.21, 25.22, and 25.23). Megaliposculpture can improve medical conditions (Figs. 25.24, 25.25, 25.26, 25.27, 25.28, 25.29, 25.30, 25.31, and 25.32).

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Fig. 25.7 (a) Preoperative. (b) Postoperative

Fig. 25.8 (a) Preoperative weighing 87 kg. (b) Six months postoperative with 14 kg weight loss

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Fig. 25.9 (a) Preoperative. Weight 132 kg. (b) Postoperative day 2. (c) Nine months postoperative and weighing 105 kg (27 kg less). (d) Five years postoperative

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Fig. 25.10 (a) Preoperative weighing 97 kg. (b) One year postoperative with 22 kg weight loss

weighing 135 kg, but no recurrence in areas of liposuction. Has weight excess in thighs

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Fig. 25.11 (a) Preoperative. (b) One year postoperative with 22 kg weight loss

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Fig. 25.12 (a) Preoperative. (b) One year postoperative with 13 kg weight loss

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Fig. 25.13 (a) Preoperative weighing 106 kg. (b) One year postoperative with 26 kg weight loss

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Fig. 25.14 (a) Preoperative weighing 100 kg. (b) Postoperative the day of surgery after aspiration of 10 l. Thirteen kilogram lost after 1 month

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Fig. 25.15 (a) Preoperative. (b) Two months postoperative with 9 kg weight loss

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Fig. 25.16 (a) Preoperative. (b) One year postoperative with 15 kg weight loss

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Fig. 25.17 (a) Preoperative patient weighing 118 kg. (b) Six month weighing 105 kg, 13 kg weight loss

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Fig. 25.18 (a) Preoperative. (b) One year postoperative with 12 kg weight loss

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Fig. 25.19 (a) Preoperative. (b) One year postoperative with 15 kg weight loss

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Fig. 25.20 (a) Preoperative. (b) Two years postoperative with 21 kg weight loss

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Fig. 25.21 (a) Preoperative patient. (b) Six months after 13 l removed. Weight loss was 5 kg

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Fig. 25.22 (a) Preoperative patient. (b) Eight months postoperative after 14 l removed. Loss of 8 kg of weight

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Fig. 25.23 (a) Preoperative. (b) Five days postoperative after 14 l removed. Weighs 113 kg. (c) Two years later, the weight remains the same, but no recurrence in the treated areas. (d) Further weight loss after bariatric surgery

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Fig. 25.24 (a) Preoperative patient weighing 145 kg and having difficulties breathing. (b) Had lipoextraction of 17 l and 2 months later had no difficulty breathing. One

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year postoperative he lost had 30 kg and still had no troubles breathing

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Fig. 25.25 (a) Preoperative patient who is depressed and refusing to work. Treated unsuccessfully for 10 years. (b) One year postoperative after losing 27 kg. She is not depressed and is happy to work

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Fig. 25.26 (a) Preoperative 20-year-old weighing 113 kg. Has mild high blood pressure and moderate diabetes mellitus being treated. Blood lipoproteins high. (b) One

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year postoperative after losing 23 kg. On diet only for diabetes and has normal blood pressure and blood lipoproteins

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Fig. 25.27 (a) Preoperative patient weighing 152 kg has bilateral painful hip arthritis. (b) One year postoperative after 15 l removed and losing 30 kg. No longer has pain in hips

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Fig. 25.27 (continued)

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Fig. 25.28 (a) Preoperative patient weighing 85 kg. Height 1 m 53 cm. Has diabetes mellitus under treatment and high blood pressure under treatment. (b) One year

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postoperative after losing 17 kg of weight. Has normal blood pressure and normal blood sugar on diet only for 10 years (phone call)

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Fig. 25.29 (a) Preoperative. Married female with infertility for 10 years. (b) One year postoperative after losing 13 kg. She had one child 1 year after surgery. Had another child 3 years after surgery

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Fig. 25.30 (a) Preoperative. Blood pressure 160/110. Sleep apnea needing night pulmonary assistance because of difficulties breathing. (b) General anesthesia with intu-

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bation. (c) One year postoperative with weight loss of 32 kg. No sleep apnea and does not need pulmonary assistance to sleep. Blood pressure lowered

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Fig. 25.30 (continued)

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Fig. 25.31 (a) Weight 150 kg, blood pressure being treated. (b) One month after surgery has lost 27 kg. Has normal blood pressure without treatment

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Fig. 25.32 (a) Weight 50 kg, blood pressure over 200 systolic. (b) One year after loss of 30 kg. Blood pressure reduced

25.6

Complications

Moderate anemia, fatigue, and a loss of appetite may occur postoperatively. It is unavoidable that a large extraction of adipose tissue causes localized as well as generalized reaction, and a patient that cannot understand this should not be operated on. The psychological motivation of the patient is indispensable for a favorable outcome. It is a question of an operation that is therapeutic and not aesthetic even if aesthetics play a role. The goal is to obtain an almost certain weight loss due to the lipoextraction that is followed in most patients by a second weight loss which is related to dieting, exercise, and therapeutic medication administered postoperatively.

25.6.1 Local complications Skin necrosis can occur, but this heals eventually with good wound care (Figs. 25.33, 25.34, and 25.35). In three patients, moderate cutaneous

Fig. 25.33 Postoperative skin necrosis that healed in 2 months

necrosis of a few square centimeters occurred on the abdomen and was attributed to a liposculpture that was too superficial. Surface irregularities, excess of skin, and depression of the adipose tissue are treated by dermolipectomy if the patient wishes after 6 months, but few patients ask for it since cutaneous retraction is good or the patients do not want to be treated. A normal appearance is often noted spontaneously because of the thinning process

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Fig. 25.34 Postoperative skin necrosis

postoperatively. Before the operation, the patient is duly informed of the possible local aesthetic discrepancies and the possibility of eventual surgical operations (Fig. 25.36). When working on the abdominal region, there were several lymphatic effusions. These are frequent when the megaliposculpture reaches 15, 17, or 20 l. One can notice them on the third postoperative day. They disappear after 5–6 weeks and can be tapped two to three times. The quantity extracted varies from 1 to 3 l. An infection has not been noted in between the punctures. Patients have moderate compression by the elastic garment postoperatively and also receive antibiotics. Recently, in one case of minor abdominal effusion, we injected sterile air as recommended by Shiffman [4] and the effusion stopped in 3 days (Fig. 25.34).

25.6.2 General Complications We have not had hypovolemic shock due to the preoperative and postoperative fluid and electro-

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lyte balance. Aside from the cold saline injections, the intravenous therapy is left entirely to the anesthesiologist. This intravenous therapy discontinued 24–48 h after the operation. In one patient, acute pulmonary edema occurred the night following the operation. Bloodletting of 1 l rapidly improved the condition of this 150 kg patient from whom 15 l had been extracted without difficulty. The 15:l lipoextraction corresponded to the essential excess of subcutaneous adipose tissue from the abdomen and thorax, the remaining excess being mostly intra-abdominal. The patient left the hospital on the fourth postoperative day, and when he returned 6 weeks later, he had lost 26 kg. The analysis of this unusual and dramatic complication was a learning experience. The obese patient was breathing mostly with his diaphragm and a little with his ribs, which were laden with adipose tissue. The cause of this acute edema appeared to be due to the abdominal bandage made of Elastoplast strips that were unintentionally too compressive and also to the strictly horizontal position of the patient in his bed. This excessive compression and the vertical pressure due to the weight of the intra-abdominal internal organs (where excess blood had accumulated) considerably hindered the movements of the diaphragm, further accentuated by the strict horizontal position of the patient on the operating table and then in his bed. The 15° head-up position of the operating table has subsequently been adopted as a matter of routine. Also in the bed, this semi-recumbent position is maintained long after the operation. The bandaging should be occlusive, but not compressive. One could think that this acute edema was due to a fluid excess, owing to the 8 l of normal saline that was injected subcutaneously. However, we have injected in all patients large quantities of normal saline at 2 °C (with 1 mg of adrenaline per liter) and sometimes up to 21 l, without problem. We have never experienced complications due to the utilization of normal saline at 2 °C. Sometimes a moderate decrease in the central temperature of 0.5 °C is registered in the postoperative period, but without serious consequences. The 2 °C cold saline injection produces

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Fig. 25.35 (a) Six months postoperative after megaliposculpture. (b) Requesting abdominoplasty. (c) Skin necrosis after large undermining. Large undermining should be avoided after megaliposculpture due to extended

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fibrosis and poor blood supply. (d) After abdominoplasty, it is mandatory to keep the removed skin in the refrigerator (+4 °C) with antibiotics. (e) After skin graft applied. (f) Final closure

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Fig. 25.35 (continued)

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Fig. 25.36 The patient had seroma postoperatively that was treated with aspiration, compression, and antibiotics. Ultimately had room air injections (Shiffman procedure) and the seroma resolved

a better quality anesthetic than with a pure local anesthesia, either classical or using Klein’s tumescent formula, and above all a more important local vasoconstriction.

25.7

Discussion

Fischer, in 1974, used a specially built suction machine and blunt cannulas of different diameters for the extraction of adipose tissue from localized fat deposits on the body. The equipment used was simplified in 1977. The abortion cannulas and suction machine of Karmann allow the surgeon to perform a procedure identical to that of Fischer. In 1985, 60 mL plastic syringes were used, and a special cannula was passed through the syringe mounted on the tip of the barrel. For many surgeons, the syringe replaced the suction machine. Lipoextraction is simple, efficient, and rapider. Liposculpture is indicated for patients having excess fat in some part of the body. Lipoextraction of over 10 l of supranatant adipose fat is now rou-

tine. To achieve this, the surgeon has to inject large amounts of normal saline at 2 °C with epinephrine (1 mg/L). The lipoextraction is performed with 60 mL syringes, by one or two surgeons to decrease the duration of anesthesia. Up to 20 l of adipose tissue mixed with normal saline and some blood can be extracted in one session without blood transfusion. In most patients, between 5 and 10 l are injected and only a few patients have had injected 15–20 l. It appears that adrenaline is quickly metabolized after the injection. In many cases we inject in two or three stages during the operation to avoid major modifications in blood pressure. Most of the patients are healthy and obese and weigh more than 100 kg. Now we operate also upon patients with weights between 100 and 130 kg without major diabetes, high blood pressure, and heart or pulmonary disease and who have tried diets and medical and surgical treatment without success. Patients should understand that this is not intended as an aesthetic procedure, that complications may occur, and that “touch-up” may be necessary as well as other operations to get rid of skin excess, should it occur. Lipoextraction can be performed in patients with a maximum weight of 160 kg, but these patients should understand that the risks of the operation are slightly increased. Contraindications are (1) patients who have never tried dieting, exercise, or medical treatment; (2) patients who do not understand that this is a major procedure, that there are some risks, and that a “touch-up” or a future skin resection may be necessary; and (3) patients who have serious disease secondary to their obesity. Our main goal has been to prove that major amounts of subcutaneous fat can be removed with minimum risk and without blood transfusion. Our patients who understood that it was a lifesaving operation and not a cosmetic procedure have accepted the complications that we had. Gastrointestinal operations for massive obesity have significant morbidity. In the long term, regain of weight may occur. All bariatric abdominal operations leave the fat cells in place, and these can once again hypertrophy if the cause

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of the obesity was not suppressed at the same time. Only large dermolipectomies, which are major operations, reduce the number of adipose cells. They are burdened with a significant morbidity in the obese patient. In contrast, closed megaliposculpture reduces greatly the number of adipose cells. This treatment is minor compared with large dermolipectomies. If a large number of adipose cells remain and can once again hypertrophy, megaliposculpturing is the only moderately aggressive treatment compared with other techniques. Although it does not treat the cause of the obesity, it considerably diminishes the number of the patient’s adipose cells. Megaliposculpture has shown that large quantities of adipose tissue can be extracted with minimal risk and those large, localized obesities provoking a functional hindrance that can be definitively improved or eliminated. It opens new horizons in the treatment of osteoarthritis of the lower extremities and possibly of the comorbidities. This operation can be used to treat residual adiposities following gastroplasty or bypass procedures and may be used for patients who have insufficient weight loss from dieting. Nowadays in 2015, megaliposculpture and therapeutic megaliposculpture are not any indicated any more thanks to the new advances made since we started 20 years ago: new drugs, new diets, and the present good results of bariatric surgery! Megaliposculpture or therapeutic megaliposculpture has been requested by patients who had unsatisfactory results previously with medical treatments or previous operations. They have accepted possible serious complications as their lives were difficult or after the failure of previous medical or surgical procedures. They have been informed for possible complications or for the failure to obtain good results or for unsatisfactory results. We are extremely grateful to all of them as their acceptation was a stimulation for the surgeons, physicians, and anesthesiologists working

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with us. Such procedures have been carried out after several clinical, biological examinations and a careful long preparation. In our number of 50 patients, we had no death and no complaint for sequelae or complications. We had only one acute pulmonary edema the night following the operation successfully treated by our anesthesiologist on duty. The patient left the hospital 4 days after his operation in good condition. Our follow-up has not been what we desired as many patients came from foreign countries, communicated with us only when they needed some type of information. We had no news of a great number of them despite our need of information. Postoperatively, sometimes a phone calls from a few of them or a letter. Happy patients do not show up postoperatively very often, but unhappy ones always complain and do show up. Such uncommon operations gave us a great professional satisfaction, and we are happy of the results that we obtained. They are included in this book, and they may be useful in the future. Only numerical reduction of adipose tissue gives efficient long-term results. Megaliposculpture seems to be an interesting treatment in morbid obesity, but it had many detractors.

References 1. Deeb M, Eed A. Mega-liposuction: analysis of 1520 patients. Aesthet Plast Surg. 1999;23(1):16–22. 2. Ioannidis G, Ioannidis T, Fikioris A. Liposculpture et obésité. Rev Chir Esthet Lang Franc. 1992;17(67): 13–6. 3. Sidor V. From megaliposculpture to therapeutic megalipoaspiration. In: Fournier PF, editor. Liposculpture: the syringe technique. Paris: Arnette Blackwell Publishers; 1996. 4. Shiffman MA. Liposuction disasters. World Congress of Aesthetic and Restorative Surgery, February 10–12, Mumbai. 2001.

Ultrasound-Assisted Lipoplasty for Face Contouring with Vaser

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Alberto Di Giuseppe, George Commons, and Luca Grassetti

Abstract

The authors discuss Vaser-assisted face and neck contouring technique with explanations of indications, preoperative marking, incisions, infusion contents, aspiration, postoperative care, and warnings to prevent complications and also present a number of cases using Vaser-assisted technique.

26.1

Introduction

Vaser-assisted neck contouring should only be performed by surgeons experienced with the Vaser system for fatty tissue emulsification. At least ten cases of standard Vaser-assisted lipoplasty are recommended before moving to application to the face and neck [1].

A. Di Giuseppe, M.D. () The Hospital Group, London, UK Department of Plastic and Reconstructive Surgery, University of Ancona, Ancona, Italy e-mail: [email protected] G. Commons, M.D. Private Practice, 1515 El Camino Real, Suite C, Palo Alto, CA 94306, USA e-mail: [email protected] L. Grassetti, M.D. Department of Plastic and Reconstructive Surgery, University of Ancona, Ancona, Italy e-mail: [email protected]

1. Indicated patients: patients seeking contouring of the neck and jowl areas who have heavy neck and/or chins with moderate to good skin tone and where extra volume is expected to be excess fatty tissue. 2. Informed consent: includes use of photos for educational purposes. 3. Preoperative marking and planning: strategic plan for volume removal (locations). 4. Incisions: under chin and in front of/behind ears (bilaterally). Possible bilaterally in the neck at the lowest anticipated level of treatment. 5. Infusion: the face/neck is more vascular and has more innervations than typical fat layers in the body. Epinephrine at 1:500,000 and lidocaine at 0.3–0.5 % in lactated Ringer’s solution. Wait 8–10 min (mandatory!). Infuse with a small-diameter blunt infusion cannula (2.0 mm or smaller, 14 gauge or smaller), not a needle. Infuse uniformly and evenly into any and all locations where the Vaser or the suction cannula may be used.

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Typical expected infusion volume is 200– 400 cc in total (both sides and submental), depending on size of patient and areas to be treated. Infuse slowly: 100 mL/min. 6. Skin protection: used in each incision. Use the black skin ports with the orange silicone disks. Suture the skin port disk into place (three anchor sutures) using 3-0 or 4-0 nylon. Make sure the knots are tight as the silicone disk tends to cause the knots to unwind. These skin ports protect the incision edges and greatly reduce visible incision scarring. Stretch the incisions and tissues below the incision with a hemostat to ease insertion. 7. Emulsification: 2.2 mm diameter (17 cm long) or 2.2 mm diameter (8 cm long) probes, 20–40 % amplitude, Vaser mode. Begin with the short 2.2 probe if possible. Twenty percent amplitude if the face/neck is very soft. Thirty percent amplitude for a moderate/ average fat. Move to 40 % amplitude if the face is fibrous. Never exceed 40 % with the 2.2 mm probes, they may break. Apply Vaser until targeted fat is emulsified, likely 2–3 min total per side depending on volumes, with an additional 2–3 min under the chin depending on how the Vaser was applied on the sides. Total Vaser time is 6–10 min depending on patient and infused volumes. Try to achieve the targeted 6–10 min of Vaser time to minimize aspiration trauma. 8. Aspiration: 2.4 mm cannula with gentle port patterns. Avoid aggressive use of suction. Apply the suction only as long as it takes to

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remove the emulsified fluids and tissue. Expected aspiration volumes are 25–125 mL depending on infused volume, size of patient, and areas treated. Suction phase should be as short and atraumatic as possible. Remember: it is not what you take out but what you leave behind that is the key to smooth and even skin redrape and retraction. Two small stab incisions are sometimes placed in the lateral aspects of the neck at the lowest point of treatment and left open for drainage purposes. A small suction cannula with no vacuum applied is passed through the stab incisions to open channels into the treated areas [2]. 9. Massage/press the treated areas to push any remaining free fluids out of the incisions. 10. Postoperative taping/dressing/support: the key is gentle, even compression to help the skin redrape and settle into position and to prevent ripples or folds in the skin. Consider the following options: cotton pads with elastic wraps, cold compresses, and silicone foam padding. Elastic face garments are typically applied for 2–4 days and then overnight for 1–2 weeks, depending on preference. Keep the head elevated at night. 11. Follow-up: 1 day, 1 week, 6 weeks, and 6 months, as needed. External ultrasound and light massage may be beneficial. Protocol for external ultrasound: setting of 10 W for 5 min with small head, twice a week for minimum of 3 weeks (Figs. 26.1, 26.2, 26.3, 26.4, 26.5, and 26.6) [3].

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Ultrasound-Assisted Lipoplasty for Face Contouring with Vaser

Indicated patients Patients seeking contouring of the neck and jowl areas who have heavy neck and /or chins with moderate to good skin tone and where extra volume is expected to be excess fatty tissue

Fig. 26.1 Indicated patients

Marking and incisions • Strategic plan for volume removal and associated marking.

• Landmarks • Lower border of mandible

• Cricoid • Thyroid cartilage • Divide neck into thirds infiltrating about 100 cc in each

Fig. 26.2 Marking and incisions

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Fig. 26.3 The neck and chin are divided in four subunits. Each allows around 50 mL of tumescent solution, or less

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Fig. 26.5 Vaser undermining in a classic facelift

Fig. 26.6 Tunnels appear after Vaser undermining

Fig. 26.4 Vaser 2.2 mm in action, set at 30 % of power, through earlobe incision

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26.2

Technique

Usually the technique is performed under local tumescent anesthesia and E.V. sedation.

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The operation is an office procedure (Figs. 26.7, 26.8, 26.9, 26.10, 26.11, 26.12, 26.13, 26.14, 26.15, and 26.16).

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Fig. 26.7 (a) Preoperative 50-year-old patient, with heavy neck, heavy chin, lack of cheek definition, neck laxity, upper and lower blepharochalasis. (b) Preoperative marking. Red lines: lower limits of neck clavicle undermining. Black lines: upper limits of Vaser undermining. Dotted lines: center of the neck. (c) (1) Starting tumescent infiltration with blunt needle and syringe. (2) Tumescent in central neck. (3) Tumescent in mandible region. (d) Temporary suture of chin incision to avoid fluid reflow. (e) (1) Suturing skin protector submental. (2) Skin protector at the earlobe incision. (f) (1) After 11 min, the surgeon starts Vaser 2.2 mm probe undermining on the superficial layer. Power

is set at 30 % of total. (2) Vaser on action from chin incision on the deeper layer, to emulsify fat. (3) Right hand guides the probe, while left hand controls depth of action. Movements have to be gentle, avoiding too deep action. (4) Treating the lateral side. (g) (1) Using Ventex 1.8 mm suction cannula to evacuate emulsion. (2) Continuing aspiration. (h) Vaser system. Timing: 9.40 min of action. (i) (1) Completing aspiration, removing skin adhesions, checking undermining and free skin. (2) Checking thickness of the neck flap. (j) Procedure ended. (k) Suture of skin incision with 6/0 nylon. (l) Postoperative garment, to be worn 3 days full time and then for 2 weeks at night time

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Fig. 26.7 (continued)

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Fig. 26.7 (continued)

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Fig. 26.7 (continued)

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Fig. 26.8 Case 2 (Left): preoperative 38-year-old patient. (Right) Postoperative jowl-chin-neck contouring

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Fig. 26.9 Case 3 (a, b) (Left): preoperative 42-year-old patient. (Right) Postoperative jowl-chin-neck contouring

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Fig. 26.9 (continued)

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Fig. 26.10 Case 4 (Left): preoperative 27-year-old patient. (Right) Postoperative jowl-chin-neck contouring

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Fig. 26.11 Case 5 (Left): preoperative 45-year-old patient. (Right) Postoperative neck-jowl-chin contouring

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Fig. 26.12 Case 6 (Left): preoperative 38-year-old patient. (Right) Postoperative neck Vaser

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Fig. 26.13 Case 7 (Left): preoperative 50-year-old patient. (Right) Postoperative neck Vaser

Fig. 26.14 Case 8 (a): preoperative 46-year-old patient. (b) Postoperative neck Vaser

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Fig. 26.15 Case 9 (Left): preoperative 35-year-old patient. (Right) Postoperative neck Vaser

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Fig. 26.16 Case 10 (Left): preoperative 40-year-old patient. (Right) Postoperative neck Vaser

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26.3

Clinical Cases

Case 1 (Fig. 26.7): A 50-year-old patient, with heavy neck, heavy chin, lack of cheek definition, neck laxity, upper and lower blepharochalasis treated with Vaser to neck, mandible, and submentum. Cases 2–5 (Figs. 26.8, 26.9, 26.10, and 26.11): Patients who had jowl-chin-neck contouring.

Cases 6–10 (Figs. 26.12, 26.13, 26.14, 26.15, and 26.16): Patients who had neck contouring.

References 1. Shiffman MA, Di Giuseppe A, editors. Liposuction, principles and practice. Berlin: Springer; 2006. 2. Shiffman MA, Di Giuseppe A, editors. Body contouring, art, science and clinical practice. Berlin: Springer; 2010. 3. Shiffman MA, Di Giuseppe A, editors. Cosmetic surgery, art and technique. Berlin: Springer; 2013.

Excisional Body Contouring Surgery and Vaser

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Dennis J. Hurwitz

Abstract

Sophisticated body contouring surgery combines excision with liposuction. Liposuction of flaps and neighboring tissues requires fat removal that best preserves residual cytoarchitecture. Following the assessment of a variety of modalities, the author has discovered that Vaser provides the gentlest extraction of fat along with capability to harvest for lipoaugmentation. Methods: A review of clinical series and four case presentations demonstrate the utility of combining Vaserlipo with excision surgery. Vaserlipo assists in sculpturing during excisional body contouring surgery, reducing the extent of surgery, increasing safety, and correcting secondary deformities.

27.1

Introduction

Excisional body contouring surgery relies on the artful removal of large areas of skin and subcutaneous tissues, followed by tight closures that leave long scars to remove excess skin, suspend tissues, and enhance gender-specific contours. The residual skin may be undermined, partially defatted, and closed under considerable tension. Moreover there are borderline areas that are betD.J. Hurwitz, M.D. Hurwitz Center for Plastic Surgery, 3109 Forbs Avenue, Suite 500, Pittsburgh, PA 5213, USA Clinical Professor of Plastic Surgery, Department of Plastic Surgery, University of Pittsburgh Medical School, 3550 Terrace Street, Ste. 613, Pittsburgh, PA 15216, USA e-mail: [email protected]

ter liposculpted with more or less fat. As desirable as that might be, the interphase of liposuction and lipoaugmentation with excisional surgery is controversial. Undoubtedly the trauma of liposuction on a major flap to be tightly closed risks major wound healing issues such as wound dehiscence, skin necrosis, and seromas. Liposuction needs to be performed in the most effective and yet least injurious method possible. Over the past 18 months that has been accomplished by the judicious use of preliminary internal ultrasound energy through Vaser. Liposuction is minimally invasive surgery for safe removal of undesirable fat between the skin and muscular fascia. Through small scattered incisions, the target adipose layers are meticulously and uniformly infused with saline containing dilute amounts of Xylocaine and epinephrine until turgid. With traditional liposuction, long

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hollow 2–6 mm wide probes with side cut openings near the end are passed through the tissues while connected through tubing to high-pressure vacuum aspirators. Slow and steady evacuation under visual and palpatory guidance leads to smoothly reduced contours. Unavoidable collateral damage to supportive connective tissue and neurovasculature may reduce the desire yield of fat and increase postoperative hemorrhage, swelling, induration, seromas, neuropraxia, skin laxity, minor contour deformities, and even skin necrosis. Nevertheless as liposuction has become an increasingly integral part of major body contouring excisional operations, it is compelling to increase our use of safe and sophisticated technology. For the purposes of liposuction, a variety of technologies have been developed to deliver preliminary energies through probes to more specifically target the adipose cell and/or provoke skin retraction. These machines increase the ease of evacuation and are purported to improve results. High-powered water infusion, focused ultrasound, laser, and radiofrequency destructive forces are commercially available. Highpowdered water infusions appear to be difficult to manage leading to fluid excess. Both lasers such as Smartlipo by Cynosure and radiofrequency such as BodyTite by InVasix use thermal injury to lyse fat and tightened subcutaneous tissues by damaging collagen leading to new collagen deposition. MicroAire provides a modified drill that facilitates traditional liposuction. Through personal experience with all the modalities being noted, the author has found the most effective and gentle liposuction, especially through fibrous areas such as the back and epigastrium, is provided by preliminary focused internal ultrasound. Then the subsequent aspiration of fat is less damaging to remaining tissues. Both the LySonix (Mentor Corporation, Santa Barbara, California) and the Vaser (Sound Surgical Technologies, Louisville, CO) ultrasound systems serve this purpose. Bleeding rarely occurs, and if spot bleeding is seen in the cannula, it is probably due to a singular torn vessel and is of no consequence to skin vitality.

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The author has a two-decade experience with UAL, starting with joining the 1995 teaching faculty jointly sponsored by several national plastic surgery societies and the two competing companies of Mentor Corporation and Allergan. UAL uses high-frequency sound to implode adipose tissue to the point of emulsification. A piezoelectric handle transfers electrical energy to a metal probe that pistons to-and-fro at 25–36 kHz over a 1 mm excursion. Unfortunately, the early teaching was to apply energy until the desired contour was obtained. This approach resulted in excessive heat, leading to a thermal injury causing seromas, paresthesia, subcutaneous fat necrosis, and scarring. Without special care there could be end hits that cause skin burns and necrosis. Now the emphasis is on continually but slowly moving the probe through the tissues until there is reduced tissue resistance. With these fundamental changes in technique, seroma became uncommon. LySonix® 3000 offers hollow probes with inline suction and tips which are named by their resemblance to a golf tee and a bullet. The circular sharp edge of the golf tee tip can cause considerable injury to subcutaneous tissue, leading to prolonged induration leading to extensive scarring. Switching to the pulse mode will decrease the extraneous heat and effectiveness. Regardless of the settings, the accumulated aspirate from preliminary LySonix ultrasound is a homogenized yellow, indicative of triglycerides and fatty acids exploded from adipose cells. With probe inline suction, the creamy yellow aspirate provides slightly delayed real-time feedback as to the effectiveness of the emulsification. If the emulsion has particles, then the operator is stroking too fast, the power is too low, the probe end is overused, or the machine is malfunctioning. Bloody aspirate is an indication to stop application of energy, even if tissue resistance is high. Traditional liposuction with a multiholed cannula follows. The endpoint occurs when the desired contour is achieved. For symmetry and accountability, the time of exposure to ultrasound and amounts of aspiration are recorded. Close proximity of the end of the probe is needed to transfer the damaging energy

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through cavitation bubbles and direct percussion hits. The magnitude of power is adjusted as a percentage of total energy available. While its overuse does cause thermal injury, UAL is not intended to melt but rather to emulsify fat. By its mechanical design, LySonix disrupts cell membranes through cavitation and percussion to release triglycerides and fatty acids. The emulsion is evacuated through multiholed 3–5 mm diameter liposuction cannulas connected to high suction. Ideally, subsequent post UAL limited tissue contraction is due to preservation of elastic subcutaneous connective tissue and healing of damaged collagen fibers. Prolonged exposure to ultrasound energy causes necrosis and scarring which leads to contraction and firm tightening of the skin. Sound Surgical Technologies of Louisville, Colorado, have refined UAL for reduced traumatic evacuation of undesirable fat. A sophisticated design called Vaser of ultrasound energy dispersing multi-ringed solid probes is connected to pulsing adjustable power that in experienced hands delivers the least amount of damaging energy needed to disperse the fat. Animal research and clinical studies show the fat disruptive cavitation caused by the vibrating probe coalesces micro air bubbles of the saline infusion and not within the fat cell cytoplasm, thereby causing extracellular fragmentation, leaving small aggregates of fat cells [1]. Follow-up aspiration is through vented three-holed cannulas called VentX that further preserves fat cell membrane integrity. As such, these 1–3 mm adipose particles can be isolated for grafting. These patients characteristically experience less swelling and minimal induration and bruising than with LySonix or traditional liposuction. Even in large-volume extractions, blood loss is inconsequential. Furthermore, the cytoarchitecture of connective tissue and neurovasculature of flaps is seen to be minimally damaged. While always advantageous, this tissue damage-sparing effect is critical for skin flap vitality when combing liposuction with excisional body contouring surgery. Commonly, areas of body excisions such as abdominoplasty are bordered by oversized epigastrium, and flanks

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which are best reduced by liposuction. Traditional liposuction, with its vigorous back and forth traumatic passage under 27 in Hg vacuum, is too traumatic to body flaps. When the aspiration of the fat results in a bloody return, it may signal significant damage to the flap vasculature, leading to distal fat and skin necrosis. In addition to minimally traumatic aspiration, there increasing interest for concurrent harvest and back table preparation of usable fat for esthetic augmentation through blunt needle injection. Recent Vaser models offer solid probes from 1 to 5 rings at the working end. The more the rings, the more the energy is dispersed over a wider area. More rings mean more fat disruption at lower power intensity per ring. Use the most rings that the resistance of the tissues will permit for easy passage. Power and heat are further reduced in the pulsing Vaser mode which slows the emulsification but also reduces extraneous heat and thereby collateral soft tissue damage. The subsequent aspirate has much particulate fat parcels, viable for fat grafting. Vaser pulsing is like shaking grapes from a vine. The Vaser is also effective in emulsifying fat in secondary cases due to contour irregularities and scarring. All ultrasound probes release energy during long strokes with continuous palpation and massage of the helping flattened hand under the moving tip. The helping hand maintains awareness of desired tip position and helps deliver the fat to the tip. Unless a depression is desired or there is simply no other way to deliver the fat, the helping hand does not grasp and squeeze the tissues around the moving probe. The pace of the thrusts and returns are slower than traditional liposuction. They relate to the tissue resistance. Some resistance needs to be felt to each stroke, if not, with no obstacle to advancement, heat is accumulated to injurious levels. To assist in your understanding, apply UAL to an abdominoplasty specimen and watch effectiveness of the right speed. If too slow, the tissues are overheated. If too fast, the adipose is not emulsified. The contact time is analogous but considerably slower than the application of radiofrequency electrosurgery for hemostasis.

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27.2

Technique

27.2.1 Case 1 (Fig. 27.1) The surgery combines Vaserlipo within and around flaps preserved during excisional body contouring surgery. The vascular-sparing effect of Vaserlipo reliably allows thorough removal of excess fat without damaging flap neurovasculature or significantly impeding wound closure. This 59-year-old patient with a BMI of 27, 3 years after losing 65 lb from Lap-Band surgery, seeks removal of mid- and lower torso rolls. Never blessed with a sensual form, she agrees to maximum accentuation of her waist and fat augmentation of her buttocks. She is marked for Vaser lipoabdominoplasty, deep oblique flank excisions, and lipoaugmentation of the buttocks. Her early postoperative result reveals tight, flat abdomen with deep long waists, more so on her right then her left, because she had initial musculoskeletal asymmetry. Her postoperative buttocks are shorter, wider, and more projecting. For the first time, she happily wears form fitting clothes that reveal her appealing curvaceous torso. Her operation began with lipoabdominoplasty that included Vaser application of focused internal ultrasound through a five-ring solid probe at 90 % power to the entire abdomen and lateral chest. Slow strokes, not faster than the tissue resistance allowed, systematically passed in a laminar manner from subdermal to supramuscular fascia level. The ultrasound was stopped at 15 min when no further resistance to probe passage was appreciated. As soon as the epigastrium was cleared, the assistant surgeon aspirates with a three-holed, 3 mm in diameter VentX cannula. While the surgeon continued with VASER to the lateral chest, the assistant started harvesting 2100 mL of fat emulsion, first from the entire abdomen and then to the lateral lower chest. After the premarked superior incision of the abdominoplasty is made, the midline is directly undermined with electrosurgery. The remainder of the epigastric flap is discontinuously undermined by the prior liposuction and spreading of the LaRoe dissector (ASSI). A Scarpa’s fasciasparing incision of the lower abdominoplasty is

made. Then the lower abdominal flap is electrosurgically excised with sparing of the areolar tissue over the muscular fascia. Under moderate torso flexion, the thinned and released epigastric flap is sutured advanced to the mons pubis and along the groins. The umbilicoplasty closure causes central high tension of the epigastric flap. During the closure, an assistant is preparing the fat from the 2 liter harvester. After infranate fluid is poured from lower spout, the remaining fat is poured into a kitchen colander which allows remaining liquids to drain. Antibiotic rinses can be performed, before the fat is scooped into 10 mL syringes. Once she is turned prone, the flank excisions are performed as marked. The left elliptical extension of the abdominoplasty is excised first. As that left-side wound is being closed with #2 PDO Quill and then 3-0 Monoderm Quill, the right ellipse is being excised with electrosurgery. Three hundred milliliters of processed fat was injected into each buttock with larger Coleman cannulas through 10 mL syringes. The six-month results are satisfying.

27.2.2 Case 2 (Fig. 27.2) The surgery is a more traditional two-stage body contouring in an overweight patient. The first stage being extensive Vaserlipo of the back with lipoaugmentation of the buttocks. The second stage is lipoabdominoplasty with further lipoaugmentation of the buttocks. This 50-year-old, 5′4″, 208 lb woman is seeking rid of bulging body rolls, reduction of hips and thighs, and enlargement of buttocks. She preferred outpatient surgery, and so for safety, the treatment was two staged. For the first stage, she was marked from one to three plus for Vaserlipo of the arms, back, lateral chest, flanks, lower back, and upper thighs. After the tedious infusion of 4 l of saline with Xylocaine and epinephrine, a three-ring Vaser in 80 % Vaser mode emulsifies the fat. Four thousand five hundred milliliters of fatty emulsion is removed with 1200 mL of filtered fat lipoinjected into the buttocks. Within 2 weeks of her largevolume Vaserlipo, she returned to work.

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Fig. 27.1 (a1–5) Preoperative markings of 59-year-old patient. Moderate excess mid- and lower torso fat with sagging skin. Broad flanks indistinctly flow over her hips to narrow flat buttocks. Lower abdomen contours are distorted by a midline vertical surgical scar. Markings are for lipoabdominoplasty with oblique flank excisions, plus marks for 2100 mL liposuction and green minus marks for 300 mL lipoaugmentation of each buttock. Note the midlateral torso liposuction markings to help narrow the waist both superior and close to the oblique excisions. (b1–5) Six month postoperative result after combined excision and Vaserlipo reveals tight, flat abdomen with deep long waists, more so on her right then her left, because she had initial musculoskeletal asymmetry. There is the desired improved abdominal contours that have been obtained with the long low-lying symmetrical abdominal scar that obliquely extends over the iliac crests to the mid back. Deep waists abruptly expand over the hips to broader, more project, and firm buttocks. (c) Five-ring Vaser ultrasonic probe positioned next to

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patient’s abdomen. (d) After 3800 mL of saline with Xylocaine and epinephrine infiltration, the Vaser probe, at 90 % power and in Vaser mode, is methodically drawn through the subcutaneous tissues from stab wound incisions in either side of the umbilicus. Since the inferior abdominal skin will be resected, it need not be protected. (e) (Right) Three millimeter/three-holed VentX cannula is rapidly passed through the Vaser fat. (Left) A sterile close collection system behind the surgeon’s head. Between is the Vaser generator with its lit digital readout. Slightly pink fat is seen in the tubing and canister. (f) In addition to the liposuction, the epigastric flap is discontinuously undermined with LaRoe dissectors. The Deaver retractor shows the direct electrosurgically assisted midline undermining. (g) Three operators are closing the abdominoplasty at the umbilicus and along each groin in two layers. (h) The fat aspirate after the Vaserlipo is poured through a kitchen colander to be drained and rinsed before loading into 10 mL syringes. (i) Lipoaugmentation of her buttocks

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Four months later, the patient was marked for central high-tension lipoabdominoplasty (CHTLA) with Vaserlipo of the epigastrium, lateral abdomen, and medial thighs. One thousand two hundred milliliters of fatty aspirate was collected yielding 600 mL of usable fat for the lower lateral buttocks. Selected images of her operation show critical

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Fig. 27.2 This 5′ 4″, 208 lb woman desires to get rid of torso and thigh bulges. (a) Preoperative marking with the purple markings for stage 1 Vaserlipo of the excess adipose of the arms, back, waist, and thighs with 4500 mL of lipoaspirate. Green markings on the buttocks are areas for 1200 mL of filter-harvested fat for lipoaugmentation. (b) Markings for second stage, consisting of Vaserlipo of the epigastrium and abdomen with CHTLA and lipoaugmentation of the lower lateral buttocks (not seen). Two lines are marked for the superior incision. A conservative line is drawn through the umbilicus. A more aggressive superior line is drawn to eliminate the thinned transverse adherence. After mobilizing the flap, the more superior line was safely incised. (c) Fully suctioned and dissected epigastric flap. The epigastric flap is held with a central Deaver retractor and lateral towel clamps. Vaserlipo removed 1800 mL from the abdomen. Following direct undermining over the medial superior rectus abdominis muscles, discontinuous undermining of the abdominoplasty flap was performed with opening and closing of the long LaRoe dissector, lying on the lower abdomen. The bloodless, honeycomb appearance of these treated subcutaneous tissues is clearly seen. Stretching and debulking of this flap allows it to easily reach a suprapubic transverse abdominoplasty incision. (d) Three small deepithe-

steps to achieve the central high tension. Four months later, Case 2 has achieved excellent torso and upper thigh transformation by combining staged Vaserlipo with CHTLA. Lipotransfer from her back, abdomen, and thighs to her buttocks has smoothly reduced her midtorso and enlarged her buttocks to the desired body shape.

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lialized dermal flaps are created by an inverted Y incision for the umbilicoplasty cutout. With no removal of underlying adipose, a straight path is bluntly dissected. Through this path, four previously placed sutures with their attached needles are passed with the aid of a clamp. The first is a 3-0 blue Prolene suture from the 12 o’clock position on the umbilical skin sutured to the same position on the abdominal circle. The next three are 2-0 PDS from the fascial base of the umbilicus to their respected 3, 6, and 9 o’clock positions on the deepithelialized small flaps in the epigastric flap. (e) Tying the 2-0 PDS sutures umbilicates the epigastric flap around the umbilicus. It also tenses the midline of the epigastric flap and relieves some of the tension along the suprapubic closure. The two-layer #2 PDO Quill and 3-0 Monoderm Quill closure is being performed during the umbilical inset. A 4-0 Prolene running baseball closure finely approximates the cutaneous umbilicus to the abdominal flap inset. (f) Four months postoperative after the second stage, she weighs 13 lb less than when she started, which is consistent with the weight of fat removed. The arms, abdomen, and thighs are smaller and curvaceous. Back, chest, and thigh rolls are corrected or markedly diminished. The buttocks are fuller and spherical. Abdomen is flat with narrow waist and sharply protruding large buttocks matches the patient’s expectations

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27.2.3 Case 3 (Fig. 27.3) Expert application of Vaser technology has recently changed our approach to MWL young patients with borderline skin laxity and adiposity. Major excisional surgery has been either reduced or eliminated. This 24-year-old patient is 5′2″ and lost 100 lbs after gastric Lap-Band 4 years earlier. She is marked for a CHTLA along with 4000 mL of Vaserlipo of the arms, trunk, and left lateral thigh with 250 mL lipoaugmentation of each breast from the processed adipose. Deep and superficial application of highly selective low-energy ultrasonic surgery removes fat at all levels and preserved subcutaneous tissue elasticity. Impressive was the reduction in the arm fullness without sagging skin and appropriate smooth concavities of the waist.

27.2.4 Case 4 (Fig. 27.4) The use of Vaserlipo with lipoaugmentation treats a lower torso and thigh deformity after excisional body contouring surgery. This is a 42-year-old 5 ft, 115 lb female, requesting body contouring surgery. Ten years earlier, at 300 lb she had gastric bypass surgery, followed by an abdominoplasty and hernia repair. She is marked for a low-lying lower body lift. Her narrow waist leads to flared hips. The buttocks are wrinkled, sagging, and flat with lateral depressions and no inferior gluteal fold. Her saddlebags are wrinkled. The thighs have bellowing skin redundancy with severe cellulite. The most severe skin laxity is along the mid medial and upper lateral thighs. Her prior abdominoplasty has tightened the skin and rounded her mons pubis. The plan is to remove skin laxity of the thighs and create rounder and fuller buttocks and lateral thighs. A lower body lift (LBL) with adipose fascial flap augmentation of the buttocks is planned with a spiral thighplasty with a medial vertical extension. Ten days following her operation, her curvatures are excellent with improved definition of medial gluteal-thigh fold. She had fully rounded buttocks and hips tapering into the flat lateral

thighs and arching to a recessed waist. The tightskinned posterior thighs end at well-defined medial buttock crease. However, within 3 months she had partial and disappointing recurrence of her saddlebag and medial thigh deformity. The thin LBL scar across the lateral buttocks and thigh has descended about 4 cm with depressed underlying subcutaneous tissues. The LBL scar and thinning hip subcutaneous tissues is probably due to no inherent strong subdermal retinacular adherences at that level. In addition there is intrinsic residual upper lateral thigh skin laxity and loss of elasticity. The etiology of this recurrence appears to be that in some low-lying LBLs, the superior anchor hip line is inadequate over time to hold up the tight and heavy thigh closure. Since her lateral thigh closure was too tight for revision, Vaserlipo and lipoaugmentation were used to treat the problem. She was marked for Vaserlipo of the thighs and processing of the effusion for 500 mL lipoinjection in the greenmarked lateral gluteal contour depressions. The harvesting and injection of fat for lipoaugmentation in body contouring surgery involves far greater quantities than in the face. An opengravity straining technique through a common kitchen colander is our approach to process suctioned fat for infusion of over 100 mL. Valiant offers a 2000 mL fat harvester for its Vaserlipo system that serves as a sophisticated inline vacuum trap. The infranate liquid is allowed to pour out through a base valve. The drained fat is poured into a kitchen colander and spoon stirred during a Ringer’s lactate with antibiotic wash. The mound of particulate fat is spoon-fed into 10 mL syringes for lipoinjection into the lateral gluteal contour depressions. The saddlebags and other contour deformities were corrected, solving a difficult iatrogenic deformity.

27.3

Discussion

During the past 18 months, in 42 cases of Vaserlipo with excisional body contouring surgery, there has been a low rate of complication and high rate of patient satisfactions [2]. There

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Fig. 27.3 Reducing excisional surgery by combining abdominoplasty with Vaserlipo in a 5′ 2″ 25-year-old woman who went from 250 to 152 lb after gastric bypass surgery. (a, b) Preoperative left anterior oblique and right posterior views with markings for an abdominoplasty along with 4000 mL Vaserlipo of the arms, back, flanks, and left lateral thigh with 300 mL lipoaugmentation of

each breast. (c, d) 15 months postoperative demonstrates esthetic reduction of adipose; skin retraction along the arms, back, and waist; lateral thigh symmetry; an athletic abdomen; and fully and larger-shaped breasts. The slimming of the upper arms, lateral chest, and back establishes hip and buttock dominance. Unlike after traditional liposuction, the skin of the trunk is exceptionally smooth

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Fig. 27.4 (a) Saddlebag deformity. (Left) This 42-yearold, 5′, 115 lb with massive weight loss patient is marked for lower body lift with adipose fascial flap for buttock augmentation and spiral thighplasty with medial vertical extension. (Middle) 11 days postoperative shows the desired body and thigh contours. (Right) 3 months later she shows sagging of the scar with early recurrence of the saddlebags. (b) One year after lower body lift and spiral thighplasty with medial vertical extension, there were severe lateral gluteal depressions and bulging saddlebags. Preoperative markings for aspiration excess fat in blue/black followed by transfer of that filtered fat to depressed lateral gluteal areas in green. (c) A heavily weighted back table sterile glass harvester traps 600 mL

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of avulsed and bloodless particulate fat through two 3.7 mm diameter, 3-holed gentle Vaser VentX aspirating cannulas. The adipose was previously emulsified from systematically applying pulsed ultrasound at 80 % full power through three-ringed solid Vaser probes. The infranate fluid is released through a bottom valve prior to transfer for Ringer’s solution wash through a kitchen colander. (d) After draining through a colander, the fat is spoon-fed into 10 mL syringes for hand injections through long Coleman infiltration cannulas. (e). Six months after Vaserlipo, her bikini tan confirms approval of the hip to knee contours. Vaserlipo with lipoaugmentation solves severe postsurgery contour deformity

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has been one abdominal seroma, requiring a second drain, two distal flap limited necrosis of a fleur-de-lis abdominoplasty, and no transfusions. With frequent assistance of Vasershape

external massage, the return to most activities has usually been within 2 weeks. Limited revision liposuction was recommended in six patients.

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Conclusions

Advanced body contouring surgery combines gentle aspiration of difficult to extract fat often followed by large-volume lipoaugmentation. Intelligent use of VASER technologies is the optimal approach in comprehensive body contouring surgery.

References 1. Garcia O. In: Rubin P, Jewell ML, Richter DFD, Uebel CO, editors. Ultrasonic liposuction in body contouring and liposuction. Edinburgh: Elsevier; 2013. p. 543–59. 2. Hurwitz DJ. Comprehensive body contouring surgery: theory and practice. New York: Springer; 2016.

Vaser-Assisted Breast Reduction

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Alberto Di Giuseppe

Abstract

Ultrasound energy is being applied to the breast tissue to achieve breast reduction and correction of mild- to medium-degree breast ptosis. The ideal candidate for a breast reduction with ultrasound-assisted lipoplasty is a patient with juvenile breasts that are usually characterized by fatty parenchyma or a patient with postmenopausal involution parenchyma, with good skin tone and elasticity present. The author describes the technique of Vaser-assisted breast reduction in combination with the Passot method of breast reduction.

28.1

Introduction

Ultrasound energy has been applied to the adipose component of the breast parenchyma in case of breast hypertrophy to reduce the volume of the breast mold. As is known, ultrasound energy was initially used by Zocchi [1–6] to emulsify fat. A special instrument, composed of an ultrasound generator, a crystal piezoelectric transducer, and a titanium probe transmitter, was utilized to target adipocyte cell.

This new technology was first applied to body fat to emulsify only fat cells while sparing the other supporting vascular and connective components of the cutaneous vascular network. More recently, Goes [7], Zocchi [1–6], Benelli [8], and the author [9–12] have started to apply this technology to the breast tissue to achieve breast reduction and correction of mild- to mediumdegree breast ptosis.

28.2

Preoperative Preparation

28.2.1 Patient Selection

A. Di Giuseppe, M.D. Department of Plastic and Reconstructive Surgery, University of Ancona, Ancona, Italy e-mail: [email protected]; [email protected]

The ideal candidate for a breast reduction with ultrasound-assisted lipoplasty (UAL) is a patient with juvenile breasts, which are usually characterized by fatty parenchyma, or a patient with postmenopausal involution parenchyma, with

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good skin tone and elasticity present. Between 60 and 70 % of women with large breasts are candidates for reduction with UAL. Preoperative assessment includes a mammographic study, breast clinical history, evaluation of breast ptosis, and evaluation of the consistency of breast parenchyma.

28.2.2 Preoperative Mammography Preoperative mammograms (anteroposterior and lateral views), the so-called the Eklund view, are taken to evaluate the nature and consistency of the breast tissue (fibrotic, mixed, or fatty parenchyma), the distribution of the fat, the presence of calcifications, and areas of dysplasia or nodularity that might necessitate further study or biopsy (Fig. 28.1). The presence of fibroadenomas, calcifications, and other suspected or doubtful radiologic findings should be double-checked with ultrasound and a radiologist experienced in breast tissue resonance.

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Fig. 28.1 Mammographic evaluation of candidates for breast reduction with the use of ultrasound-assisted lipoplasty (UAL). (a) A typical fatty breast. This patient is an ideal candidate for UAL. (b) Fibrotic glandular tissue is a

28.3

Contraindications

Patients with a history of breast cancer or mastodynia and fearful of potential sequelae from this new technique were not considered for the author’s study. Furthermore, because the amount of fat in the breast is variable as is its distribution, not all women are candidates for breast volume reduction with UAL. If fat tissue and glandular tissue are mixed, penetration of the tissue may be impossible, as noted by Lejour [13] and Lejour and Abboud [14]. If the breast tissue is primarily glandular, the technique is not indicated.

28.4

Preoperative Planning

The distance from infraclavicular notch and the nipple is drawn by hand (Fig. 28.2). Circles indicate the area of major volume to be addressed. A circle of about 5 cm diameter is marked around the nipple. This area is not addressed by ultrasound as it clearly contains 90 % of the breast

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contraindication for UAL. (c) Fibrotic mixed tissue. This patient is a candidate for UAL of the posterior upper and lower cone

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Fig. 28.2 Distance from infraclavicular notch and nipple: circles indicate the area of major volume to be addressed, and a circle of about 5 cm diameter is marked around the nipple

tissue. Ultrasound energy targets only the fatty tissue of the breast, sparing the parenchymal components.

Fig. 28.3 The three different layers of infiltration (superwet infusion) of the breasts: deep, intermediate, and superficial (1.5:1/2:1 ratio)

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28.5.2 Skin Incisions

Surgical Technique

28.5.1 Infiltration Infiltration should be divided into the three different layers of the breast: deep, intermediate, and superficial (Fig. 28.3). In deeper layers and intermediate, I expect a 1.5:1 ratio between infiltration and aspirate; in the superficial layer, I normally infiltrate twice of what I expect to extract (2:1 ratio). Blunt infiltration cannulas are used as described by Klein, 15–20 cm long. A meticulous infiltration of the superficial layers is essential and then wait for 15 min minimum to allow adrenaline make its effect, before starting ultrasound. In a total of 500 mL of infiltration, normally 400 mL is for deeper and intermediate layers, 100 mL for superficial layers.

The operation begins with the introduction of the skin protector placed at the incision site, normally placed 1 cm below the inframammary crease (Fig. 28.4). This skin port is designed to protect against friction injuries of the solid titanium probe during its continuous movement. The fatty breast is emulsified in the lateral and medial compartments, the upper quadrants, and the inferior aspect of the periareolar area. All the periareolar areas, where most of the glandular tissue is localized (5 cm circumference around the nipple-areola complex), are preserved. The deep portion, mostly fat, is also emulsified, allowing the breast mound to regain a natural shape through upward rotation thus

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28.5.3 Probes With the existing technology, a solid probe has been found to be more efficacious than a hollow probe for cavitation, which is the physics phenomenon that allows fat fragmentation and destruction. Moreover, the level of ultrasound energy, conveyed by a hollow probe, is limited, and consequently the level of the cavitations obtained in the tissue is diminished. The Vaser system (Valeant Pharmaceuticals North America LLC, Bridgewater, NJ) provides different sizes and length of solid titanium probes, expressively designed to fulfill all purposes in body contouring, as well as in capability of emulsification through the cavitation effect produced by the ultrasound energy (Fig. 28.5). The piezoelectric transducer transforms electric energy into “vibration energy,” thus allowing the solid titanium probe to emulsify the target fat cells. Four different probe diameters are actually provided by the manufacturers: Fig 28.4 Skin ports

increasing the elevation from initial position, taken from the midclavicular notch. Up to 4 cm of breast elevation is obtained after proper reduction and stimulation to allow skin retraction and correction of the ptosis. Two 15–2.0 cm stab incisions, one at the axillary line and the other 2 cm below the inframammary crease, are made to allow entrance of the titanium probe. A periareolar incision can be made in patients with very lax skin for further subcutaneous stimulation. Through these incisions the surgeon can reach all the breast tissues, working in a crisscross manner. The skin is protected from friction injuries with a specially made skin protector. Recently, the ultrasound device software has been upgraded to provide the same degree of cavitation with less power, which reduces the risk of friction injury and burn at the entrance site, which even allows discontinuing the use of the skin protector.

1. 2.2 mm diameter, for the face. 2. 2.9–3.7 mm diameter, for body contouring, including breasts. 3. 4.1 mm diameter, for larger areas and big volumes of fat. 4. 3.7 mm diameter probe with a special “cone tip” designed to emulsify male breasts but very aggressive also in fibrous tissue (Fig. 28.6). The efficacy of these probes, which are narrower than the previous technologies available on the market, is connected with their design, as they are provided with rings (one, two, or three) at the tip of each probe. Rings have two special scopes: 1. To enhance the efficiency of the emulsification that is not limited to the tip but extended to the last 1.5 cm of shaft 2. To allow a larger selection of options, for targeting the various tissue types (purely fat, mixed, fibrotic), by utilizing different probes The number of rings to be chosen depends on types of tissue encountered: the most fibrotic is

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Fig. 28.6 Probes

Recently, the Vaser surgeon may utilize two further options: 1. The 4.5 mm large probe, for larger volumes, which has a higher percentage of fat emulsification for minute of time/depending on the diameter of the probe (Fig. 28.8) 2. The “cone” tip probe, which is very aggressive in fibrous tissue and has been designed for male breast (gynecomastia) for breast tissue destruction (Fig. 28.9)

Fig. 28.5 The Vaser system (Valeant Pharmaceuticals North America LLC, Bridgewater, NJ)

treated with one ring, the less dense tissue (pure fat) with the three rings. These options are not purely an academic difference: the energy and the wavelength of each probe are selected for the target tissue, avoiding unnecessary extra power, thus energy which is useless and a potential cause of secondary unwanted complications (already seen with previous technologies). In breast reduction with pure Vaser, the preferred probe is 2.9 mm, one ring, for deep layers, and the 3.7 mm, three rings for superficial layers (Fig. 28.7).

Larger probes are recommended in all massive volume cases, including big breasts, and the cone tip in really fibrotic breast.

28.5.4 Technique 28.5.4.1 Fat Emulsification In breast reduction with UAL, the duration of the procedure varies depending on the volume of reduction, the type of breast tissue encountered, and the amount of skin retraction required. A breast with purely fatty tissue is easier to treat than one with mixed glandular tissue, in which fat cells are smaller, stronger, and denser.

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Fig. 28.9 One ring: 4.1 mm

Fig. 28.7 Technique: 2.9 mm probe, one ring for deep layers; 3.7 mm probe, three rings for superficial probe emulsifying deep layers and undermining the superficial layers

Fig. 28.8 New probe

The author started utilizing the Vaser ultrasound device with solid probes (2.9–3.7 mm wide). It delivers 50 % of the ultrasound energy in comparison with the older sculpture unit (by SMEI, Casale Monferrato, Italy), which was used from 1990 to 2001, while emulsifying fatty tissue much more efficiently. The duration of the procedure and the amount of energy required to liquefy the excess fat may vary depending on the characteristics of the tissues encountered, the volume of

Fig. 28.10 Timing. Superficial layers: 2–3 min maximum. Deeper layers: 7–20 min depending on fat to emulsify

the planned reduction, and the type of the breast tissue. Purely fatty breast tissue is easier to treat than mixed glandular tissue, in which fat cells are smaller, stronger, and denser. Treatment of the target tissues starts with 10–15 min of ultrasound energy in fat tissue, which usually produces between 250 and 300 mL of emulsion (Fig. 28.10).

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Fig. 28.11 Incisions placed at the inframammary crease, axilla, and areola margin: upper quadrants, superficial layers, 2–3 min; lower quadrants, deep layers, 7–20 min

The surgical planes, with good crisscross tunneling and adequate undermining, are routinely followed, as planned in the preoperative drawings. If large undermining is required for skin retraction, the superficial layers are treated initially. Then the deeper planes are reached, more time is spent in thicker areas. Surgeons inexperienced in the procedure should be especially cautious when performing the technique, particularly in the subdermal planes [9–12, 15–19].

28.5.4.2

Subcutaneous UAL Undermining Together with UAL application to the fat layers, starting from the deeper layers and progressing to the more superficial ones, it is advisable to thin the superficial layer of the subcutaneous tissue of the upper and lower quadrants by using a different angle pattern, as in standard lipoplasty [20, 21]. This superficial undermining with lowfrequency ultrasound energy helps to enhance the retraction of the breast skin and to redrape the breast skin to the newly shaped and reduced mammary cone (Fig. 28.11).

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28.5.4.3 Optimizing Outcomes To facilitate these maneuvers, a second tiny incision is often placed at the axilla and (sometimes) at the areola border. This helps the superficial work of the probe. The undermining has to be complete, with full liberation of all adherences with the deeper layers. The purpose is to thin the dermal flap all over the breast tissue, thus maintaining its vascularity, sensibility, etc. Vaser is selective; does not interfere with the vascular network of the dermal tissue, if properly performed since it spares the connective and supporting structures of the skin [22]; and showed the great potential of the dermal layer in wound contracture. As much as the dermis is thinned, much of the contraction will result providing the tissue vascularization preserved. And this is what happens at all tissue when superficial dermal thinning is realized. Tissues contract more easily, and combined with the gravity forces which help the upward rotation of the gland (when decreased in weight), the final result is a greater contraction of the breast, with a superior antigravity effect. 28.5.4.4 Postoperative Care Suction drainage is routinely applied in the breast for at least 24–48 h. A custom-made elastic compression support (silicone-backed adhesive foam pads) is applied for 7–10 days, and a bra completes the dressing. These items together with skin redraping help support the breast in the immediate postoperative period.

28.6

Clinical Results

Results were visible immediately after surgery with the skin envelope redraped nicely and nice contour of the new breast shape and mound. The skin and treated breast tissue appeared soft and pliable. The elevation of the nipple-areola complex resulting from skin contraction and the rotation of the breast mold were immediately visible. The major postoperative nipple-areola complex elevation was 5 cm. Emulsification of fatty breast tissue ranged from a minimum of 300 mL per breast in mild

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reductions and breast lifts to a maximum of 1200 mL of aspirate for each breast in large breasts. The author was able to easily obtain a mean of 500 mL of fat emulsion from each breast, after infiltration of 700 mL of Klein’s modified solution for tumescence, followed by wide thinning of the subcutaneous breast envelope, to allow skin redraping. Elevation of the nipple-areola complex up to 5 cm was obtained in large-volume reductions in combination with thinning of the subcutaneous layer. There was no evidence of suspicious calcifications resulting from surgery at the 5-year postoperative follow-up. Essentially, an increase in breast tissue fibrosis was noticeable in the postoperative mammograms, which was responsible for the new consistency, texture, and tone of the breasts. The increase was also responsible for the lifting of the breasts (Figs. 28.12, 28.13, and 28.14).

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28.7

Mastopexy

Vaser can be applied in breast surgery and also in clinical cases which present minor degree glandular ptosis. As we know, by decreasing the volume of the breast, it is normal to have an upward rotation of the gland itself. Also the areola tends to shrink when the underlying tissue is diminished in size and volume. The upward rotation of the breast and the retraction can finally elevate the breast by 2–4 cm from initial position (Fig. 28.15). The result is already visible a week after surgery, with minimal bruising and edema (Fig. 28.16). A supporting bra has to be applied for the first 4 weeks after surgery, despite that a similar bra should be advised forever in a patient with large breast or a tendency to ptosis, which with age is common to majority of female people.

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Fig. 28.12 (a) Preoperative breast hypertrophy and planning: red dotted area indicated fibrotic breast tissue not to be addressed. (b) One-year postoperative breast nipple raised from 21 to 18 cm from infrasternal notch

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Fig. 28.13 (a, c) Preoperative 32-year-old woman. (b, d) Postoperative 6 months after 25 min of ultrasound-assisted lipoplasty through a submammary of 500 mL of fat per site

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Fig. 28.14 (a, c) Preoperative 28-year-old woman. (b, d) Postoperative 6 months after 25 min of ultrasound-assisted lipoplasty through a submammary of 450 mL of fat per site

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28.8

Histologic Changes

The breast tissue that underwent emulsification with ultrasound-assisted lipoplasty was analyzed histologically by Chun et al. [23]. They had operated on ten patients with large breasts with the Genesis Contour device (by Mentor HS, Santa Barbara, CA, US), with breast UAL. With open surgery they removed a breast specimen with a weight that varied from 430 to 1530 g. No gross pathological changes were noted at the time of surgery, and microscopic diagnosis included fibrocystic change stromal fibrosis. No atypia and no malignancy was found. The longterm follow-up shows clearly that the emulsified fat, when not aspirated, will eventually dissolve in few days or weeks. Area of relative fibrosis may appear at 1 and 2 months interval, and palpable nodes or lumps were a rare event in the

large series of patients operated on from 2002 to 2006. There were 200 breast reductions and/or mastopexies that were performed (alone or in combination with other body contouring procedures).

28.9

The Passot Technique

In 2006, Nagy and Mc Craw [24] presented the combination of breast fat emulsification by Vaser with open surgery breast reduction. They reintroduced the technique of Passot [25] who in 1925 published the so-called Button mammoplasty or the no vertical scar reduction which became the most common method of breast shaping in Europe before World War II (Fig. 28.17).

a

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Fig. 28.15 (a, c) Preoperative 26-year-old patient. (b, d) Postoperative after 550 mL aspirate per side, UAL 21 min

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Fig. 28.16 (a, c) Preoperative 24-year-old patient. (b, d) Postoperative after 450 mL aspirate per side, UAL 22 min

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Fig. 28.17 (a, b) The Passot method

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Fig. 28.18 (a) New inframammary visually marked at best range of 15–23 cm. (b) Pointing to inframammary fold. (Arrow) Show the point of entrance of the cannula

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Fig. 28.19 (a) Flap margin 8–9 cm. (b) Inframammary fold. (Arrow) Show lines where the skin will be cutted

28.9.1 Markings The new nipple position is marked, which is between 19 and 21 cm from midclavicular point (as in all classic measurement, it is the Pitanguy referral point). The new inframammary fold is marked, which ranges from 15 to 23 cm (Fig. 28.18). The flap margin (Fig. 28.19) is 8–9 cm below the new nipple site. The existing inframammary fold is marked. Medial (Fig. 28.20) and lateral (Fig. 28.21) points are marked.

28.9.2 Procedure The upper quadrants of the breast are infiltrated with tumescent solution, and then Vaser is applied to emulsify the fat of this area (Fig. 28.22). In this case, no skin protector is applied, as the skin in this area is due to be deepithelialized for breast reduction. After completing aspiration of emulsified fat, the lower flap is detached from the chest

wall, with a central large inferior pedicle based on perforators from the pectoralis muscle (Fig. 28.23). The upper quadrants, already treated with Vaser (Fig. 28.24), show the network of the subcutaneous breast tissue, as it appears after emulsification of fat and aspiration. All the supporting structures of the skin, as elastic bundles, vessels, nerves, and connective supports, are conserved. This pattern is similar to what happens in close breast reduction. As the flap is reduced, it is advanced to fill the empty space (Fig. 28.25). The new nipple is positioned and centered on its pedicle (Fig. 28.26). The Passot technique combined with Vaser has been applied to several types of breast ptosis. This technique has been performed on large reduction (up to 2900 g per side) (Fig. 28.27) or on the so-called long breast (Figs. 28.28, 28.29, 28.30, and 28.31) with 1500 g removal per side. The typical case where the Passot technique is combined with Vaser is a moderate degree pto-

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Fig. 28.20 (a, b) Medial point. (Arrow) Show lines where the skin will be cutted

a Fig. 28.21 (a, b) Lateral point. (Arrow) Show lines where the skin will be cutted

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Fig. 28.22 (a) Before injection. (b) After Vaser and 500 mL aspiration

a Fig. 28.23 (a) After 500 mL aspiration. (b) After 500 mL aspiration

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Fig. 28.24 (Left and right) Vaser effect

Fig. 28.25 (Left and right) After 500 mL aspiration

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sis, 26–28 cm from midclavicular point, with a mild to moderate hypertrophy (Fig. 28.32). Results are satisfactory and tend to improve by time. The secrets of the success of the Passot technique combined with the breast reduction are:

Fig. 28.26 Method: accentuate medial fullness and center nipple on pedicle. Both (arrows) to indicate the medial fullness and the centered nipple after surgery

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1. Shaping under control the upper and lower quadrants of the breast. 2. Maintaining the vascularization of the upper quadrants by using Vaser, as it is a selective technique of emulsification. 3. Repositioning of nipple-areola complex without tension, which ensures good scar (no distortion, no widening). 4. Surgeons must possibly reconsider the priority in scar selection for breast reduction. For most women, the inframammary scar is preferable to the vertical scar, as less visible, despite it is longer. This could be a subject of debate among modern plastic surgeon who advocated the short vertical scar techniques for all types of breast reduction.

b

Fig. 28.27 (a) Large reduction: (Left) preoperative. (b) Postoperative following 2900 g per side

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Fig. 28.28 (Left and right) The long breast

Fig. 28.29 (Left and right) Five months postoperatively. 1500 g per side

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Fig. 28.30 (Left) Preoperative patient. (Right) Mastopexy without excision

Fig. 28.31 (Left) Preoperative patient. (Right) Mastopexy without excision

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Fig. 28.32 (a) (Left and right) Preoperative patient. (b) Three days, 600 g removed from each side. (c) Two months. (d) Five months

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28.10 Complications and Their Management No major complications occurred in the author’s series of patients. It should be emphasized that such good results require extensive experience with UAL. As stated by a task force on UAL established by the American Society for Aesthetic Plastic Surgery (ASAPS), the Plastic Surgery Educational Foundation (PSEF), the Lipoplasty Society of North America (LSNA), and the Aesthetic Society Education and Research Foundation (ASERF), the learning curve for UAL is longer than that for standard lipoplasty. Specifically, practitioners must learn how to work close to the subdermal layer with a solid titanium probe to defat this layer and obtain good skin retraction while avoiding complications, such as skin burns and skin necrosis. To safely work close to the skin, two conditions are mandatory. The surgeon must be experienced in ultrasound-assisted body contouring, and the correct ultrasound device (one that is able to maximize the cavitation’s effects while minimizing the thermal effects) must be selected.

28.10.3 Hematoma Hematoma formation is another potential complication, though no cases occurred in this series.

28.10.4 Mastitis Mastitis, an inflammatory response of the breast parenchyma to surgery, occurred in a few patients early in the series. Once surgery was avoided for patients at or near their menstrual period, only a minor inflammatory response was noted. When encountered, mastitis rapidly subsided with immediate treatment consisting of oral antiinflammatory drugs and wide-spectrum antibiotics for 3 days.

28.10.5 Seroma Seroma formation is a potential complication of any breast surgery. Regular application of suction drainages and breast compression for several days with a foam pad and a bra prevent this event.

28.11 Selectivity and Specificity of Ultrasound 28.10.1 Skin Necrosis Fat necrosis with secondary tissue induration is a typical sequela of ultrasound surgery. When it is localized in small areas, such necrosis can be treated with massage or local infiltration of corticosteroids to soften the area.

28.10.2 Loss of Sensation Loss of sensation is generally limited to the first 3 weeks after surgery. Recovery is rapid because the central cone of the breast is composed mainly of pure parenchyma and is not touched during surgery. Skin sensation is recovered in a few weeks time.

Large amounts of fat are often found in patients with breast hypertrophy, even among thin adolescents. Lejour and Abboud [14] emphasized that once the fat is removed by lipoplasty before breast reduction, the proportion of glandular tissue, connective tissue vessels, and nerves is increased. These structures are important for maintaining vascularity, sensitivity, and lactation potential. Unlike fat, they are not likely to be affected by patient weight fluctuations. Lejour [13] affirmed that if the breasts contain substantial fat, weight loss may result in breast ptosis. The degree of recurrent ptosis can be minimized if lipoplasty is performed preoperatively to reduce the fatty component of the breasts. This observation anticipated the great potential of UAL for breast surgery.

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The clear limits of standard lipoplasty with mechanical indiscriminate destruction of fat and surrounding elements followed by power aspiration of the destroyed tissue are particularly enhanced in breast surgery, where specialized structures (e.g., lactation ducts, vessels, sensitive nerves, elastic bounding structures of the subcutaneous tissue) have to be carefully preserved. Because it is a selective technique, UAL may be applied in breast surgery to destroy and emulsify only the fatty component of the breast tissue without affecting the breast parenchyma for which the ultrasound energy has no specificity. The specificity of the technique is connected with the cavitation phenomenon and the efficiency of the system hinges on the type of the titanium probe used and the energy level selected. Lejour [13] argued that the suctioning of breast fat also made the breast suppler and more pliable, which facilitates shaping, especially when the areola pedicle was long. This consideration is particularly important with fatty breasts, which have a less reliable blood supply. These benefits are significantly increased by the use of UAL because the specificity of this technique spares the vessel network. The selectivity of UAL was demonstrated by Fisher et al. [26] and Palmieri [27] in their studies on the action of the ultrasound probe in rat mesenteric vessels. Later Scheflan and Tazi [28] introduced endoscopic evaluation of UAL. They used a Stortz endoscopic system and camera (Stortz, Tuttlingen, Germany) to videotape the action of the titanium probe within the ultrasound device in the superficial layers of the subcutaneous fat, verified by needle depth, after standard infiltration with the tumescent technique. UAL was performed with crisscross tunnels, and the procedure was recorded on videotape. An adjacent area was treated with standard lipoplasty. The technique was compared with standard lipoplasty, which was also endoscopically assisted and monitored. The authors found that standard lipoplasty appears to be the more aggressive technique, characterized by the mechanical destruction of the subcutaneous tissue, including vessels, nerves, and supporting structures, despite the use of 2–3 mm wide blunt cannulas.

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By contrast, UAL spared vessels, nerves, and elastic supporting fibers. Alteration in breast tissue resulting from the use of UAL was a thickened dermal undersurface, markedly thickened vertical collagenous fibers, intact lymphatic vessels, and intact blood vessels. The horizontal and vertical thickening and shortening of the collagen in the dermis and ligamentous fibers are responsible for the remarkable skin tightening that follows subcutaneous stimulation with the ultrasound probe. The closer to the skin and the more complete the removal of fat from the intermediate subdermal space, the greater the skintightening effect. This is of great value in breast surgery, where volume reduction has to be accomplished by skin redraping and recontouring of the breast shape. As noted by Lejour [13], retraction of the skin after standard lipoplasty cannot be expected to be sufficient to produce a satisfactory breast shape. Subcutaneous aspiration must be extensive to obtain the necessary skin retraction, and the risk of localized skin necrosis resulting from excessive superficial liposuction cannot be ignored [29].

28.12 Calcifications Lejour [13] and Lejour and Abboud [14] argued that the risk of postoperative fat necrosis or calcifications was the reason many surgeons avoided the use of lipoplasty in the breast. The main cause of fat necrosis is breast ischemia brought about by extensive dissection or mechanical direct damage, with resultant venous drainage. This phenomenon is typical in open breast surgery. Calcification in breast reduction surgery may derive from area of fat necrosis or breast necrosis and subsequent scarring. Such calcifications are most often located at the incision lines (periareolar, or vertical scar in the inverted T approach), where more tension is placed in approximating the lateral and medial flaps. However, when the tension is too high, areas of necrosis could arise from the approximating suture and later cause calcifications that are visible on mammography. However, the risk of such complications in UAL procedures is quite low.

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Calcifications in breast parenchyma are to be expected after any mammoplasty procedure. In reduction mammoplasty, it is preferable that they be localized along the breast scars [30]. When lipoplasty is performed in addition to the mammoplasty procedure, benign macro-calcifications are slightly more numerous in the parenchyma than they are in breasts reduced without lipoplasty. This may occur because of the trauma caused by lipoplasty or because lipoplasty suction is applied to the most fatty breasts, which are more prone in lipo-necrosis [31]. However, 1 year after fatty breast reduction with UAL, follow-up mammography revealed only a slight increase of small microcalcifications, similar to those found after other mammary procedures.

28.13 Potential Risks In November 1998, a conference on UAL safety and effects was held in St Louis, MO, USA, sponsored by the ASERF and the PSEF at which a panel was organized in response to an article by Topaz [32] that raised questions about the safety of UAL. Topaz speculated that thermal effect and the free radicals generated during UAL might result in neoplastic transformation and other longterm complications, as a consequence of the physical effect known as sonoluminescence. Those attending the conference represented multiple scientific disciplines, including plastic surgery, physics, lipid chemistry, cancer biology, and mechanical biophysics. The participants agreed that scientists did not yet understand the mechanism of UAL action, though multiple mechanisms were probably involved, such as mechanical forces, cavitations, and thermal effects. Additional research has revealed that long-term complications or negative bioeffects (including DNA damage and oxidation-free radical attack) are probably not serious safety concerns for UAL. With reference to the application of UAL to breast surgery, the author investigated the histology of the breast fat tissue before and after UAL breast surgery (with serial biopsies at 6 months and 1 year after surgery) and the mammographic appearance of the breast before and 1, 2, and 3 years after surgery, particularly with respect to

calcification. The results were evaluated by a senologist not directly involved with the clinical research [33]. Histologic studies revealed an increased fibrotic response to thermal insult, with a prevalence of fatty scar tissue, in all specimens evaluated. Mammography showed a significant increase in breast parenchymal fibrosis, with a denser consistency and thicker breast trabeculae that were constant over time. The calcifications that appeared were benign and were typically small, round, less numerous, and more regular than those characteristic of malignancy. Comparison of the mammographic results typical of a standard breast reduction and those typical of breast reduction with UAL showed that microcalcifications are less likely to develop with UAL. It is likely that scar tissue caused by breast reduction with electrocautery or by necrosis resulting from the tension of internal sutures may more frequently cause calcifications or irregular mammographic aspects of the operated parenchyma. Particularly, in standard breast reduction surgery, they can appear at the areola line and at the site of the vertical scar. From a mammographic viewpoint, the typical appearance of a breast reduction with UAL demonstrates predictably less scarring and fewer calcifications than those that occur in the standard open technique. Courtiss [34] reported similar mammographic evidence in a denser breast after breast reduction by lipoplasty alone. No malignancies were reported. The question of whether potential lactation is affected by UAL remains unanswered. The technique was used for breast reduction and mastopexy in younger and older patients. In the younger group, 16 patients breast-fed their babies regularly. The other 14 patients were lost to followup. However, none of these patients or their gynecologists reported any problems to the surgeon or to the hospital, and no complications have been reported by other surgeons around the world who use this technique. Conclusions

The use of UAL for reduction of fatty breasts and mastopexy is effective and safe when applied in selected patients and performed by a surgeon with expertise in ultrasound-assisted

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body contouring. The selectivity of UAL enables emulsification of the fatty component of the breast parenchyma while sparing the glandular tissue and vascular network. Furthermore, long-term mammographic studies have revealed no alteration of morphology of the breast parenchyma resulting from this technique. The typical mammographic appearance of breast tissue after UAL is a denser breast.

References 1. Zocchi M. Clinical aspects of ultrasonic liposculpture. Perspect Plast Surg. 1993;7(2):153–72. 2. Zocchi M. The ultrasonic assisted lipectomy (U.A.L): physiological principles and clinical application. Lipoplasty. 1994;11:14–20. 3. Zocchi M. Ultrasonic assisted lipectomy. Adv Plast Reconstr Surg. 1995;11:197–221. 4. Zocchi M. The ultrasonic assisted lipectomy, instructional course. ASAPS Annual Meeting, San Francisco. 20 Mar 1995. 5. Zocchi M. The treatment of axillary hyperadenosis and hyperhidrosis using ultrasonically assisted lipoplasty. Presented at the Meeting of the International Society of Ultrasonic Surgery, Faro. November 1995. 6. Zocchi M. Basic physics for ultrasound assisted lipoplasty. Clin Plast Surg. 1999;26(2):209–20. 7. Goes JC. Periareolar mammoplasty: double skin technique with application of polyglactine or mixed mesh. Plast Reconstr Surg. 1997;97(5):959–68. 8. Benelli L. A new periareolar mammaplasty: the “round block” technique. Aesthet Plast Surg. 1990; 14(2):93–100. 9. Di Giuseppe A. Mammoplasty reduction and mastopexy utilizing ultrasound liposuction. Mammographic study preoperative. Act from 46° National Congress of Italian Society of Plastic Reconstructive and Aesthetic Surgery. Venice. June 1997. 10. Di Giuseppe A. Ultrasonically assisted liposculpturing: physical and technical principles and clinical applications. Am J Cosmet Surg. 1997;14(3):317–27. 11. Di Giuseppe A. Reducion mamaria y pexia con la asistencia de la lipoplastia ultrasonida. Lipoplastia. 1998;1(1):16–26. 12. Di Giuseppe A. UAL for face-lift and breast reduction. Abstract for World Congress on Liposuction Surgery. Pasadena. October 1998. 13. Lejour M. Reduction of large breasts by a combination of liposuction and vertical mammoplasty. In: Cohen M, editor. Master of surgery: plastic and reconstructive surgery. Boston: Little, Brown and Co.; 1994. 14. Lejour M, Abboud M. Vertical mammoplasty without inframammary scar and with liposuction. Perspect Plast Surg. 1990;4(2):67–90.

327 15. Di Giuseppe A. Ultrasound assisted for body contouring, breast reduction and face lift. How to do it? Abstract at the 3rd European Congress of Cosmetic Surgery. Themes: Berlin; 1999.p. 23–5. 16. Di Giuseppe A. Harmonic lift or ultrasonically assisted skin remodelling of face (Video). Abstract at the XV Congress of the International Society of Aesthetic Plastic Surgery (ISAPS). Ultrasonic Assisted Lipoplasty of the Breast (Poster). Tokyo. April 2000. 17. Di Giuseppe A. Ultrasonically assisted breast reduction and mastopexy. Int J Cosmet Surg Aesthet Dermatol. 2001;3(1):23–9. 18. Di Giuseppe A. Ultrasound assisted breast reduction and mastopexy. Aesthet Surg J. 2001;21(6):493–506. 19. Di Giuseppe A. Breast reduction with ultrasound assisted lipoplasty. Reconstr Surg. 2003;112(1): 71–82. 20. Teimourian B. Suction lipectomy and body sculpturing. St. Louis: CV Mosby; 1987. p. 219–51. 21. Teimourian B, Massac Jr E, Wiegering CE. Reduction suction mammoplasty and suction lipectomy as an adjunct to breast surgery. Aesthet Plast Surg. 1985;9(2):97–100. 22. Rudolph R, Vande Berg J. The myofibroblast in Dupuytren’s contracture. Hand Clin. 1991;7(4):683–92. 23. Chun IT, Taylor W, Van-Meter L. American Society of Aesthetic and Plastic Surgery meeting, Las Vegas. April 27–May 3, 2002. 24. Nagy M, Mc Craw J. American Society of Aesthetic and Plastic Surgeons meeting. Orlando. April 20–23, 2006. 25. Passot R. La correction esthetique du prolapsus mammarie par le procede de la transposition du mamelon. Presse Med. 1925;33:317–8. 26. Fisher PD, Narayanan KN, Liang MD. The use of high frequency ultrasound for the dissection of small diameter blood vessels and nerves. Ann Plast Surg. 1992;28(4):326–30. 27. Palmieri B. Studio sull’ azione degli ultrasuoni sul tessuto vasculare del ratio. Riv Ital Chir Plast. 1994;9: 635–9. 28. Schleflan M, Tazi H. Ultrasonically assisted body contouring. Aesthet Plast Surg. 1991;16(2):117–22. 29. Becker H. Liposuction of the breast. Presented at the Lipoplasty Society of North America Meeting. September 1992. 30. Mitnick JS, Roses DF, Harris MN, Colen SR. Calcifications of the breast after reduction mammoplasty. Surg Gynecol Obstet. 1980;171(15):409–12. 31. Lejour M, Abboud M. Reduction of mammaplasty scars: from a short inframammary scar to a vertical scar. Ann Chir Plast Esthet. 1990;35(5):369–79. 32. Topaz M. Possible long-term complications in U.A.L. induced by sonoluminescence sonolution, sonochemistry, and thermal effects. Aesthet Surg J. 1998;18(1): 19–24. 33. Young VL, Schorr MV. Report from the conference on ultrasound assisted liposuction safety and effects. Clin Plast Surg. 1999;26(3):481–524. 34. Courtiss EH. Breast reduction by section alone. In: Spear S, editor. Surgery of the breast: principles and art. Philadelphia: Lippincott-Raven; 1998.

The Clinical Applications of Multifrequency Ultrasound Technology in Body Reshaping

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Giovanni Zoccali, Benedetta Cinque, Gino Orsini, Paolo Palumbo, Salvatore Scandura, Gianfranca Miconi, Cristina La Torre, Maria Grazia Cifone, and Maurizio Giuliani

Abstract

The basic rules of UAL as described by Zocchi were followed without regard to other limitations such as ultrasonic energy site times, body areas, and level of tissue planes. US alters adipose tissue through micromechanical disruption and cavitation with minimal thermal effect. The cavitational effect is a dynamic phenomenon, triggered by the accomplishment of resonance frequency of cell membrane. Resonance frequency is dependent on the kind of tissue and surrounding environment characteristics that usually change continually during treatment. To use the better frequency in all conditions and to maintain the maximum effectiveness, the MAUL technology was introduced. This new technology uses last-generation microchips to determine the best resonance frequency every 10 s by measuring tissue humidity and impedance. By maintaining the better frequency during treatment, the new technology concentrates the entire ultrasound energy on the adipose cells minimizing the thermal effect on the cutaneous deeper layer and maximizing the lipoclastic effect.

G. Zoccali, M.D. () Department of Life, Health and Environmental Sciences, Plastic and Reconstructive Surgery Section, L’Aquila University, P.le Salvatore Tommasi, 1, L’Aquila 67100, Italy e-mail: [email protected] B. Cinque, M.D. • P. Palumbo, Ph.D. • G. Miconi, M.D. C. La Torre, Ph.D. • M.G. Cifone, M.D. Department of Life, Laboratory of General Pathology, Immunology and Immunopathology, Health and Environmental Sciences, L’Aquila University, P.le Salvatore Tommasi, 1, L’Aquila 67100, Italy e-mail: [email protected]; paola. [email protected]; [email protected]; [email protected]; [email protected]

G. Orsini, M.D. • M. Giuliani, M.D. Department of Life, Health and Environmental Sciences, Plastic and Reconstructive Surgery Section, L’Aquila University, P.le Salvatore Tommasi, 1, L’Aquila 67100, Italy e-mail: [email protected]; maurizio.giuliani@ cc.univaq.it S. Scandura, M.D. Plastic Surgery Unit, C.A.M. Day Surgery Clinic, Monza, Italy

© Springer-Verlag Berlin Heidelberg 2016 M.A. Shiffman, A. Di Giuseppe (eds.), Liposuction: Principles and Practice, DOI 10.1007/978-3-662-48903-1_29

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29.1

Introduction

Sound wave is the result of a sequence of compressions and decompressions through a medium (gaseous, solid, or liquid). This definition encloses the base of sound traveling, that is, the presence of a substance lets the wave propagation (Fig. 29.1) [1]. According to its frequency, the sound spectrum can be divided into audible, infrasound, and ultrasound (Fig. 29.2) [1]. The infrasound frequencies are felt as vibrations by a body, whereas the ultrasound cannot be perceived by the human ear [1–3]. Infrasound has a few clinical applications, e.g., kidney stones or tendon disease treatment [4–7]. Ultrasound waves are generally applied in diagnostic procedures due to the absence of interactions with biological tissues; the discovery of particular wavelengths having the ability to interact with them, thus activating collagen metabolism or inducing cell apoptosis, led to the use of ultrasounds as therapeutic tool [4–7]. Ultrasounds in plastic surgery are generally

applied to destroy the adipose tissue during body reshaping [8–11]. Their use in liposuction began with Kloehn [12, 13] who introduced a harmonic probe for administering sound energy to the fat tissue. Then, several machines have been commercialized but most of them had a high complication rate. Zocchi and Maxwell [9, 14] designed the second generation of ultrasound generators providing a solution to the extended time needed with the old device. The new technology used a cannula which, while being a solid probe, provided ultrasound energy and suction at the same time. The second-generation cannulas were more manageable but they presented a not negligible risk to damage the skin [8, 9, 14]. In fact, as the power of ultrasounds in those devices was related to cannula dimension, it was necessary to use large cannulas to reach an effective energy even if this increased the mechanical and thermal damage to surrounding tissue [15].

Fig. 29.1 Sound propagation through a solid medium. In blue the phenomenon of compression and decompression of molecules at the base of sound traveling

z

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Fig. 29.2 Classification of sound wave according to its frequency

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The last generation of US devices has been introduced and uses again a solid probe, but the new materials and technology increased the selectivity for adipose tissue improving the effectiveness and reducing the risk of skin damage [8, 16]. The ultrasound energy, generated by these probes, induces adipocyte destruction through the cavitational effect. The oil and the fatty acid released by cells are drained away or caught out by phagocytes. Suction with traditional cannulas could be also performed, if a quick result would be achieved.

29.2

Physics of Ultrasound Wave

Ultrasound (US) is a sound wave with a frequency higher than 20 KHz that, in presence of a medium, is transmitted from one molecule to the next [1]. The characteristics at the base of US are: 1. Wavelength (λ) is the distance between two consecutive wave peaks and derives from the rapport of propagation speed and frequency (λ = v/f) (Fig. 29.3). 2. The frequency (f) is the number of cycles of compression and rarefaction repeated every second in a specific point of the conduction medium. According to their frequency, ultrasound can be divided into three categories: low frequency between 20 and 100 KHz, medium frequency among 100 KHz and 1 MHz, and high frequency up to 10 MHz.

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3. Propagation speed (v = λ × f) depends on the conduction medium. In biological tissues, it is about 1500 m/s with the exception of the bone tissue (3360 m/s). 4. Attenuation is the amount of lost energy passing through a medium. This is due to two physical phenomena, absorption and dispersion. In soft tissues, 80 % of attenuation is caused by absorption (Fig. 29.4). In front of these wide possibilities, which should be the frequency to choose? What is the frequency that has the deeper penetration (δ)? The theoretical physics provides the answer to these questions. Considering the same number of cycle wavelength, low-frequency ultrasound penetrates deeper than the high-frequency ultrasound. Theoretically, using a single wave cycle so that the phenomenon of attenuation is excluded, the penetration depth is equal to the wavelength λ = υ/ν. The amount of energy that reaches a specific site depends on the US characteristics and the tissues it travels through. So, at higher frequencies, the sound beam will have less sound energy available to propagate through a tissue since more energy is absorbed (Fig. 29.5) [16].

29.3

US and Adipose Tissue Interaction

US alters adipose tissue through micromechanical disruption and cavitation with minimal thermal effect [13, 17, 18]. Thermic effect is due to

Wavelenght

t

Fig. 29.3 Definition of wavelength: the distance between two consecutive wave peaks

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Fig. 29.4 Phenomenon of attenuation. Ultrasound loss of energy traveling through a medium. Soft tissue adsorbs 80 % of the energy

High frequency

Low frequency

l

d

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Fig. 29.5 The different penetrations of high-frequency (blue) and low-frequency (brown) ultrasound. In the right square the experimental condition to explain why low fre-

quency penetrates deeper than high. Considering only one wave cycle, in order to exclude the attenuation, the penetration is equal to the wavelength (δ = λ)

the increase in molecular kinetic energy: by Joule’s law, the potential energy of moving electric charges is partly released as heat with consequent increase in temperature of the treated material. Mechanical effect is linked to the com-

pression and decompression of biological membrane under wave action. Cavitational effect, by causing microcavities in the adipose tissue with consequent cell destruction and fat liquefaction, is considered

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the most important mechanism through which US causes tissue disruption, even though the micromechanical effect produced directly by the action of the ultrasonic waves on organic molecules should also be considered [13, 16, 19]. Cavitation refers to the oscillatory activity of vapor-filled bubbles and produces important cell fragmentation and diffusion of the lipid material through the intercellular space (Fig. 29.6) [13, 16, 19]. Of note, the cavitational effect is not extinguished immediately after treatment’s end, leading to a progressive destruction of adipose cells [16]. It was also shown that as ultrasound induces the activation of cell apoptosis cascade which could be responsible of the prolonged lipoclastic effect [16].

29.4

What about Multifrequency Technology

The cavitational effect is a dynamic phenomenon, triggered by the accomplishment of resonance frequency of cell membrane [8, 16].

Compression

Rarefaction

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Resonance frequency is dependent on kind of tissue and surrounding environment characteristics (e.g., temperature and moisture). Numerous available devices can work with different frequencies, but no one can modulate the frequency during the procedure. Of note, the initial device setting allows the ultrasound generator to choose the best frequency on the basis of the environment. A continuous frequency adjustment during the treatment is indeed fundamental because the environmental parameters change continually during ultrasound administration. Due to the lymphatic drain, the amount of fluid infiltration decreases, and fat acids and triglycerides increase due to adipose cell destruction. Under these conditions, the tissue impedance decreases and reduces the selectivity of ultrasound for adipose tissue. To use the better frequency in all conditions and to maintain the maximum effectiveness, a new technology was introduced. This new technology uses lastgeneration microchips to determine the best resonance frequency every 10 s by measuring tissue humidity and impedance [8, 16]. Bubble maximum expansion

Implosion

Positive pressure

Negative pressure

Cannot absorb more energy

Fig. 29.6 The cavitation phenomenon. According to the wave phases, adipocyte membranes were compressed and decompressed; this causes an increase in kinetic energy

and the formation of steam bubbles until they cannot absorb more energy, leading to a cell implosion

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By maintaining the better frequency during treatment, the new technology concentrates the entire ultrasound energy on the adipose cells, thus reducing the sonication time, minimizing the thermal effect on the cutaneous deeper layer and maximizing the lipoclastic effect. The ultrasound device (Microlipocavitation, Lain Electronic S.R.L., Milan, Italy) is composed of a high-frequency generator, a radiofrequency transmission cable, and a probe with piezoelectric crystal. The device uses modern microprocessors, capable of monitoring the session peak cavitation, to manage the enormous amount of energy produced by low-frequency US (37.2–42.2 kHz).

29.5

Clinical Practice

The multifrequency technology can be used in a lot of conditions: localized fat deposit, defect contour, massive liposuction, orange peel, pannicolopatia edemato-fibro-sclerotica (PEFS), and skin tone loss are the principal indications. Modulating the amount of administered energy and the kind of handpiece as well, all of those can be treated. In fact US energy can be administered in different ways according to the clinical features of defect target by a surgical probe or transcutaneous handpiece. There are few criteria at the base of this methodology guiding the machine setup. Tissue tone and the defect extension are the most important. Tissue texture has to be checked because fibrotic area or organized edema should be treated in pulsed mode. The mechanical effect reaches the peak at the beginning of the cycle, and then the effect of shock wave is progressively reduced until the resonance frequency is reached. Mechanical effect acts more on fibrous than on adipose tissue where the continuous mode is more indicated. An accurate examination has to be done on tissue tone. Skin tightening is more achievable by a surgical probe than a transcutaneous treatment because the effect on deeper structures is higher. The transcutaneous probe is useful to treat wide and superficial defect or small localized fat deposits.

There are a few contraindications to ultrasound treatment: medical conditions such as coagulative disturbances, in both ways hyper- or hypocoagulation, anomalies in lipid metabolism, or cardiac implantations (pacemaker, defibrillator) are considered absolute contraindications. Whereas hearing prosthesis or other metal implantations could be considered as relative.

29.6

Surgical Application

In the United States, UAL developed mainstream popularity during the mid- to late 1990s after several years of development and application in Europe and South America [9]. The basic rules of UAL as described by Zocchi were followed without regard to other limitations such as ultrasonic energy site times, body areas, and level of tissue planes. Zocchi’s [9] basic rules of UAL are (1) never apply ultrasonic energy to dry tissue and (2) never apply ultrasonic energy without probe movement [20]. It is postulated that the energy of ultrasound will have a minimal effect on intervening connective tissue and other structures (Fig. 29.7). The safety and efficacy of the method have been shown in several papers [14, 21]. The introduction of multifrequency technology improves the selectivity of ultrasound for adipose tissue, and the construction of new harmonic probes that stay cooled during the sonication reduced the surrounding tissue damage. The first multifrequency probe had a maximum diameter of 6.5 mm and a diameter of 4.2 mm at the tip. The probes of multifrequency are made in titanium present diameter reduction along their length in order to concentrate and accelerate the ultrasound energy. During clinical and experimental use of these probes, the authors noted that they had a temperature increase at those points and transmitted heat to surrounding tissue. The reduced diameter, proximal to the handle, reached high temperature and damaged the skin near the surgical access point. To avoid this effect in early cases using the older-generation cannula, a silicon protective tro-

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Fig. 29.7 A drowning of MUAL surgical probe function liquefying fat tissue without damaging the other structures

29.7

Fig. 29.8 The old MUAL probes were hotter than newer damaging the surrounding tissue. In order to protect the skin, a trocar was placed before sonication

Multifrequency ultrasound-assisted liposuction (MUAL) can be used to treat several problems such as diffuse fat deposit or body reshaping. After an initial period in which the authors treated any kind of obesity, the limit to BMI was moved to 30 because liposuction in general cannot be considered an instrument to weight loss. Other contraindications are the same as those of the other surgical procedures and are reported in Table 29.1.

29.8 car is used, which necessitated a 10-mm skin incision (Fig. 29.8). In the new probes, the larger diameter has been reduced in the area which has no contact with the skin during the procedure. These probes, which now have a constant diameter, stay cold during treatment and maintain a lower temperature along all of their length (Fig. 29.9). The introduction of the new probe profile eliminated thermal injury to the skin. The lack of a diameter transition zone reduces the friction injury on the skin, thus improving the skin-healing quality. The high effectiveness of the newgeneration probe allows us to reduce the ultrasound administration time and the secondary damage to surrounding tissue, thus allowing us to avoid trocar positioning or keeping the surrounding skin wet.

Indications and Contraindications

Surgical Procedure

29.8.1 Preoperative Planning The patient must stand in order to identify contour defects; the areas have to be sonicated or those where the probe should be used switched off should be highlighted. Volume defects to be filled are identified. In those cases, according to the amount of tissue lack, a part of lipoaspirate extracted was not exposed to ultrasound.

29.8.2 Cavitation Effect and Infiltration The ultrasound frequencies used with this technology primarily affect tissue with the lowest density, defined as tissue impedance. Fat has the lowest tissue impedance, and wetting of the

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336 Fig. 29.9 MUAL probes (the upper is the new generation) with their temperature measured by a thermocouple after 20 min in ambient air. The new generation shows a lower and more constant temperature

25 ºC

29.8 ºC 29 ºC

Table 29.1 Exclusion criteria High degree of obesity (BMI >30) Presence of hernia at the operative site Low skin elasticity Significant striae (local score >2 according to the Pittsburgh Weight Loss Deformity Scale) Internal metallic prostheses Previous oncologic breast treatment Suspicion of adipose neoformation such as lipoma Pregnancy Coagulation diseases Active inflammation process

adipose tissue with saline infiltration can lower the impedance value even further [20]. The result is a high degree of selectivity for fat cells, thus reducing blood loss, postoperative edema, and ecchymosis and avoiding contour irregularities. Ultrasound energy is known to propagate better in a wet environment, so before sonication, Klein’s solution is administered. Numerous proportions of fluid infiltration and lipoaspirate are reported in the literature. In numerous studies, the tumescent proportion (more than 2:1) is preferred, and the authors used it in their early experience [13, 20]. According to Millàn Mateo and Vaquero Pérez [22], tumescent infiltration does not allow optimal skin palpation. So UAL is performed using a super-wet technique. Ultrasound needs a

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wet environment to act, but the authors progressively reduced to the wet ratio of 1:1. No changes in the functional aspect were apparent, but clinical and technical advantages were observed, including reduced distortion of the area due to infiltration and reduced postoperative swelling [13].

29.8.3 Surgical Time After infiltration is administrated, the appropriate probe according to the defect width is introduced under the skin. The sonication is activated and the probe is passed forward and backward in wide fan-shape movements. The vectors’ orientation follows the principles of traditional liposuction (Fig. 29.10). Generally the treatment is begun from the deeper layers to the dermis plane. In fibrous area such as the male chest, dorsum or secondary treatment the ultrasound is supplied in pulsated way. The average sonication time is 10 min each area. Is easy to get small districts like the inner aspect of the knee requires shorter time, whereas the abdomen needs more time to be treated. After the sonication is over, the fat emulsion is aspirated through a 3 mm blunt cannula connected to a vacuum (−80 mmHg). It reduces the inflammation triggered by the cell destruction.

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for 15 days, and wide spectrum antibiotics are administered during the 5 succeeding days.

29.9

Fig. 29.10 How to administer ultrasound energy to the tissues by fan-shape (blue arrows) movements starting from the deeper layer to the dermis

Case 1 (Fig. 29.11)

This 29-year-old woman with optimal skin tone and texture had MUAL of the abdomen, flanks, and inner thighs. All creases were treated in continuous mode, flanks and thighs were sonicated for 10 min each, whereas the abdomen was sonicated for 15 min.

29.10 Case 2 (Fig. 29.12) After the authors had demonstrated in laboratory that the cavitation causes the apoptosis that carries to a tardive release of oil and cell debris [16], a suction drain is placed through the same incision every time the amount of lipoaspirate is more than 1000 mL. The device remains inserted until the amount of fluid is less than 30 mL per day. On the other hand, when the lipoaspirate is less than 1000 mL, the surgical access is left open to let the spontaneous evacuation of fluid. After a treatment a compressive girdle is worn for 30 days. The compression encloses the treated and contiguous anatomic areas in order to have a more homogeneous cutaneous distribution during the healing process.

A 36-year-old man with good skin tone and texture received pulsed MUAL of the chest and upper part of the abdomen. Lower abdomen and flanks were treated in continuous mode 10 min each.

29.11 Case 3 (Fig. 29.13) This 35-year-old woman received MUAL for fat deposits of the abdomen, knees, and trochanteric areas. Knees were treated in pulsed mode, whereas continuous supply was preferred for the others.

29.12 Case 4 (Fig. 29.14) 29.8.4 Postoperative Treatment and Patient’s Activities Restarted In massive liposuction (more than 2000 mL of aspirate) conducted under general anesthesia, fluids are given during the 24 postoperative hours in order to balance the equilibrium with the surgical loss. The patient’s mobilization begins the following morning and then they return to their daily activities. Sporting activity is progressively restarted after 2 weeks. In small liposuction performed with local anesthetic, no fluids are administered and patients do not interrupt their activities. Every patient receives heparin according to their own weight

A 41-year-old man had fat deposits localized on the back and at the flanks. The back received a pulsated MUAL treatment.

29.13 Transcutaneous Ultrasound Treatment Nowadays the noninvasive treatment for fat tissue has become the most requested among the outpatient procedures. The possibility to improve the body contour without risk and downtime allows the diffusion of this technology. The lowfrequency transcutaneous ultrasound hits the adipose layer without skin damage (Fig. 29.15).

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Fig. 29.11 (Left) Preoperative. (Right) Postoperative

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Fig. 29.12 (a) Preoperative. (b) Postoperative

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Fig. 29.13 (Left) Preoperative. (Right) Postoperative

a

b

Fig. 29.14 (a) Preoperative. (b) Postoperative

That technology uses a different probe according to the energy intensity to administrate the ultrasound energy. The large probe provides the lowest energy intensity; the smaller gives the same energy amount of the bigger but through a

small operative surface traducing it in a higher intensity (Fig. 29.16). The effects of cavitation begin immediately after treatment and due to the triggering for the apoptosis continue during the following days.

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Clinically the effect is appreciable after two sessions by an improvement of skin texture or fluid retention as well, but to achieve a contour modification, more sessions are necessary.

29.13.1 Clinical Indication

Fig. 29.15 A drowning of MUAL external probe function liquefying the subcutaneous fat without damaging the cutaneous structures

The treatments of diffuse and superficial defects are the main indications for transcutaneous cavitation. Orange peel, PEFS, or skin contour irregularities find a solution in this technology, and also fluid retention can be approached; localized adiposities for which liposuction could be considered an overtreatment can be removed by external ultrasound. The authors have tried to treat few small lipomas (45 years of age Previously unoperated large breasts Large breasts after surgical reduction Asymmetry in volume in unoperated breasts Asymmetry in volume after surgical reduction Patients who are poor candidates for general anesthesia Table 33.10 Contraindications for breast reduction by liposuction using tumescent local anesthesia (TLA) A personal history of breast cancer Pendulous breast, with minimal fat content Unrealistic expectations Undiagnosed breast mass Young women with low BMI Women who want reduction of >50 % (unless postmenopausal) Women who want a breast lift, rather than reduction Family history of breast cancer (relative contraindication) Fibro-glandular breasts (relative contraindication)

experience, TLA in combination with powered cannulas facilitates the removal of fat while eliminating the traumatic force that is required for manual cannulas. The powered cannula glides through all tissues easily. Di Giuseppe [7] finds the same advantage with ultrasonic liposuction. Asymmetry of the breasts is a common finding during initial consultation; however, most women are neither concerned about nor, indeed, aware of any asymmetry. If the asymmetry is due to differences in breast volume, this can be reduced by aspirating more fat from one breast than from the other. However, if the asymmetry is caused by a difference in shape or position of the breasts or of the thoracic wall, this cannot be solved by this method. Our findings suggest a number of indications (Table 33.9) and contraindications (Table 33.10) for breast reduction by liposuction which can be used for patient selection. Conclusions

Breast reduction by liposuction using tumescent local anesthesia and powered cannulas is a safe and effective treatment modality in

properly selected patients. Complications are minor and infrequent, and patients are able to return to normal daily activities within 3–4 days after the procedure. Sports and heavy physical activities can be gradually resumed, and patient satisfaction is excellent. Acknowledgment The valuable comments of Dr. C. William Hanke and Prof. Dr. H.A. Martino Neumann in reviewing this article are gratefully acknowledged.

References 1. Davis GM, Ringler SL, Short K, Sherrick D, Bengtson BP. Reduction mammaplasty: long-term efficacy, morbidity, and patient satisfaction. Plast Reconstr Surg. 1995;96(5):1106–10. 2. Rohrich RJ, Gosman AA, Brown SA, Tonadapu P, Foster B l. Current preferences for breast reduction techniques: a survey of board-certified plastic surgeons 2002. Plast Reconstr Surg. 2004;114(7):1724–33. 3. Kerrigan CL, Collins ED, Striplin DM, Kim HM, Wilkins E, Cunningham B, Lowery J. The health burden of breast hypertrophy. Plast Reconstr Surg. 2001;108(6):1591–9. 4. Thoma A, Sprague S, Veltri K, Duku E, Furlong W. A prospective study of patients undergoing breast reduction surgery: health-related quality of life and clinical outcomes. Plast Reconstr Surg. 2007;120(1): 13–26. 5. Mizgala CL, MacKenzie KM. Breast reduction outcome study. Ann Plast Surg. 2000;44(2):125–34. 6. Matarasso A, Courtiss EH. Suction mammaplasty: the use of suction lipectomy to reduce large breasts. Plast Reconstr Surg. 1991;87(4):709–17. 7. Di Giuseppe A. Breast reduction with ultrasoundassisted lipoplasty. Plast Reconstr Surg. 2003;112(1): 71–82. 8. Mellul SD, Dryden RM, Remigio DJ, Wulc AE. Breast reduction performed by liposuction. Dermatol Surg. 2006;32(9):1124–33. 9. Sadove R. New observations in liposuction-only breast reduction. Aesthetic Plast Surg. 2005;29(1): 28–31. 10. Gray LN. Update on experience with liposuction breast reduction. Plast Reconstr Surg. 2001;108(4): 1006–10. 11. Fulton Jr JE, Rahimi AD, Abuzeni P. Breast reduction with tumescent liposuction. Am J Cosm Surg. 2001; 18:15–20. 12. Klein JE. Female breasts. In: Klein JE, editor. Tumescent technique. Tumescent anesthesia & microcannular liposuction. St. Louis: Mosby; 2000. p. 413–26. 13. Habbema L, Hanke CW. Female breast reduction by liposuction using tumescent local anesthesia. In:

33 Breast Reduction by Liposuction Using Tumescent Local Anesthesia and Powered Cannulas

14.

15.

16.

17.

Hanke CW, Sattler G, editors. Proceedings in cosmetic dermatology: liposuction. Philadelphia: Elsevier Saunders; 2005. p. 47–53. Sattler G, Sommer B, Hanke CW, et al. Weibliche Brust. In: Sattler G, Sommer BC, Hanke W, editors. Lehrbuch der Liposuktion. Stuttgart: Georg Thieme Verlag; 2003. p. 122–5. Moskovitz MJ, Muskin E, Baxt SA. Outcome study in liposuction breast reduction. Plast Reconstr Surg. 2004;114(1):55–60. Teimourian B, Massac Jr E, Wiegering CE. Reduction suction mammaplasty and suction lipectomy as an adjunct to breast surgery. Aesthetic Plast Surg. 1985;9:97–100. Lejour M. Vertical mammaplasty and liposuction of the breast. Plast Reconstr Surg. 1994;94(1):100–14.

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18. Bolivar de Souza Pinto E, Erazo PJ, Muniz AC, Salazar GH. Breast reduction: shortening scars with liposuction. Aesthetic Plast Surg. 1996;20(2): 481–8. 19. Toledo LS, Matsudo PKR. Mammoplasty using liposuction and the periareolarincision. Aesthetic Plast Surg. 1989;13(1):9–13. 20. Abboud M, Vadoud-Seyedi J, De Mey A, et al. Incidence of calcifications in the breast after surgical reduction and liposuction. Plast Reconstr Surg. 1995;96(3):620–6. 21. Di Giuseppe A, Santoli M. Ultrasonically assisted breast reduction and mastopexy. Int J Cosm Surg Aesthet Dermatol. 2001;3(1):23–9.

34

Laserlipolysis Diego E. Schavelzon, Guillermo Blugerman, and Anastasia Chomyszyn

Abstract

Laser lipolysis destroys fat in-situ prior to suctioning. The authors discuss the Nd:YAG laser’s photothermal effect with histologic studies as well as the surgical technique of laser-assisted liposuction. The advantages for the surgeon are that it softens areas with hard or compact adiposity, which results in less fatigue, less force is necessary, and it also allows a softer and more relaxed surgery. The advantages for the patient is the preservation of the fibroelastic septum, fatty tissue selectivity with preservation of the nerves and less postoperative pain because it maintains the innervation integrity.

34.1

Introduction

Laserlypolysis is derived from the terms laser (light amplification by stimulated emission of radiation), lipo, which refers to fat, and lysis, which means destruction. The procedure consists in using the light emitted by a laser to selectively produce lysis of the fat cell. D.E. Schavelzon, M.D. (*) • A. Chomyszyn, M.D. B&S Centro de ExcelenciaenCirugiaPlastica, Billinghurst 2192, C1425DTR, Buenos Aires, Argentina e-mail: [email protected]; [email protected] G. Blugerman, M.D. B&S Centro de ExcelenciaenCirugiaPlastica, Billinghurst 2192, C1425DTR, Buenos Aires, Argentina e-mail: [email protected] Private Practice, Laprida 1579, Buenos Aires 1425, Argentina e-mail: [email protected]

In the 1980s, Illouz [1], Fournier, and Fischer presented the traditional liposuction procedure treating fat mechanically. Laserlipolysis like other procedures destroys the fat in situ before it is evacuated from the human body and has been used since 1998. The authors have treated over 2,215 patients with this procedure using a painless ambulatory method and the results have been most satisfactory. Supported by a peristaltic pump that injects the tumescent anesthesia, this procedure benefits both the patient and the practitioner because of its comfortable application.

34.2

Nd:YAG Laser

The Nd:YAG laser is a solid laser formed by a granite aluminum yttrium crystal (the YAG) [2] contaminated with an unusual soil (the neodymium) that emits IR radiation of 1,064 nm. The

© Springer-Verlag Berlin Heidelberg 2016 M.A. Shiffman, A. Di Giuseppe (eds.), Liposuction: Principles and Practice, DOI 10.1007/978-3-662-48903-1_34

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authors use the EN060 model made by Deka Laser in Italy. It is a pulsed laser with 200-μs pulses. The energy is 30–150 mJ and the frequency is 10–40 Hz. The fluence is 0.3–6.0 W, it is air-refrigerated and controlled by a microprocessor. This special laser operates by contact because the laser light is transmitted through a 300-μm silica/silica fiber optic. The penetration into soft tissue is approximately 1.4 mm. Because of its low penetration, it does not produce distant trauma, and acts locally, facilitating the progression of a very thin probe. The laser operates through a twofold mechanism known as selective photothermolysis: photomechanical and photothermal. The photomechanical effect produces mechanical destruction of the fat cell, which can be achieved via coagulation and vaporization because of local heating. The photohyperthermia acts selectively on the proteins in the fat cell membrane producing necrosis by coagulation and denaturalization by the effect of heat on these proteins. The thin cell membrane contains a large vacuole full of liquid lipids that sheds its content into the extracellular space (Fig. 34.1). The photothermal effect is the destruction of the fat cells that involves rapid thermal expansion

Fig. 34.1 Large vacuoles full of liquid lipids

[3] and causes violent cavitation from shock waves. This is produced in an indirect manner. When the lipids absorb the laser energy, the light is turned into caloric energy, causing a sudden rise in the temperature inside the fat cell and ending in its rupture. The fatty emulsion produced remains and it is immediately identified by the immune system in order to restore the damaged tissue [4]. To reabsorb the rest of the fat cells of the oily emulsion, the immune system produces nodular lipophagic vacuoles [5]. Following the levels of triglycerides and cholesterol in the blood of ten patients, we observed no significant increase in the amount of these elements over the 10 days after surgery [6]. Apparently most of the triglycerides are eliminated through the kidneys and the rest reach the liver, where they become lipoproteins.

34.3

Histological Studies

Comparative histological studies were made with the fat that was drained out through cannulas from a patient who gave her consent to be treated in one leg with tumescent liposuction and with laserlipolysis in the other leg at the same surgical time.

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Fig. 34.2 (a) Fat removal without laserlipolysis showing intact fat cells. (b) Fat removed following laserlypolysis showing disruption of the cell walls

In conventional liposuction with tumescent anesthesia, studies show areas of involution of fat tissue with piknotic hyperchromatic nucleus and sectors in acidophilic lysis, with thickening of the cells membrane (Fig. 34.2). In the sample of fat tissue treated with laserlipolysis there was fat necrosis with loss of nucleus and large sectors of total adipose lysis (Fig. 34.2). In another patient histological studies were performed 30 min after laserlipolysis from a piece of tissue resected in a dermolipectomy. It was possible to observe areas with necrobiotic adipose tissue with accumulation of lipophagic macrophages cells forming granulomatous lipophagic nodules. Twenty-five days after laserlipolysis it was possible to observe adipose tissue with breakage of the cell walls surrounded by histiocytes with foamy cytoplasm. There were also areas with scar fibrosis, and the nerve threads were intact (Fig. 34.3). The use of the laser causes a destruction of the fat cell specifically protecting the nerves, while in a tumescent liposuction the fat cell is evacuated intact. The remaining tissue is immediately phagocytized by the macrophages and the immune system while fibrosis covers and retracts the empty spaces.

34.4

Surgical Technique

Laserlipolysis is an ambulatory technique supported by tumescent anesthesia. On the basis of the patient’s weight, doses of tumescent anesthesia must be calculated up to 50 mg/kg. All patients are treated on an ambulatory basis. The patient receives sublingual premedication of 2 mg lorazepam 1 h before surgery. In the operating theater 10 min before tumescent infiltration, 1–2 mL of a mixture of medications is given intravenously: 5 mg midazolam, 0.8 mg fentanyl, and 10 mg metoclopramide. The next step consists of injecting tumescent anesthesia with a solution including [7, 8] 1,000 mL saline solution containing 30 ml of 2 % lidocaine with 1:200,000 epinephrine, 1 mL 1:1,000 adrenaline, and 15 mL sodium bicarbonate (1 M). The saline solution is prewarmed in a microwave oven for 1 min in order to reduce the pain produced by hypothermic shock during the injection maneuver. A specially designed peristaltic pump (Fig. 34.4) [9] is used to ensure accurate filtration into adipose tissue until the expected tumescence is achieved. Beveled needles and multihole infiltration cannulas are used in this maneuver. The tumescent fluid is infiltrated in a fanlike manner in one or two layers depending on the

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Fig. 34.3 Intact nerves following laserlipolysis (M/E stain)

Fig. 34.4 Peristaltic pump

amount of fat. The tumescent infiltration is complete when the area of fat tissue is so firm that the interphase between fat and muscle cannot be identified. When palpating the treated area, it is harder and whiter than untreated skin. This is what is called the “tumescent point” [10]. When the tumescent point is reached, the optic fiber of the laser is introduced through a 1 mm

diameter microprobe. Once under the dermis, forward and backward movements are performed in a fanlike manner in the area. This is done twice in each area, the first time at the level of the deep subcutaneous cellular tissue and the second time in the superficial subcutaneous cellular tissue at the subdermal level in search of stimulation of the deep dermis. While the laser is being used, it

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is possible to hear the so-called popcorn effect caused by the bursting of the fat cells when the laser light reaches them. The fat cell bursting determines the liberation of the triglycerides from the fragmented intra-adiposity vacuole. The tumescent anesthesia homogenizes the work of the laser and facilitates the diffusion of heat to the neighboring cells. The moment to stop the laser application is when there is no resistance to the advance of the bevel-pointed needle. At that time, the oily emulsion is drained. When the total fat treated exceeds 500 g, we prefer to drain the fatty emulsion through a specially designed 3- or 4-mm vacuum cannula, with multiple microholes at 500-mmHg vacuum. The same peristaltic pump is inverted and the fatty emulsion is drained out of the body.

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34.5

Results

In the authors’ series, from 1999 to 2002, 2,215 patients were treated with laserlipolysis. There were 1,684 women and 531 men. A total of 7,352 areas of the body were treated with the trochanteric (Fig. 34.5) and the inside of thighs most often requested by the patients (Table 34.1). Gynecomastia (Fig. 34.6), double chin, and hump were also treated with this method. Most areas of the body were treated and most often patients had three body areas treated in one procedure (Tables 34.1 and 34.2). Also six to nine areas were treated and a maximum of 4 l of fatty emulsion was drained, always in an ambulatory setting. Complications were infrequent, 0.041 % (Table 34.3).

Fig. 34.5 Trochanteric region treated with laserlipoysis. (a) Before, (b) after

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Fig. 34.6 Gynecomastia treated with laserlipolysis. (a) Before, (b) after Table 34.1 Areas and number of patients Area Trochanteric Inside of thighs Knees Waist Lower abdomen Upper abdomen Hips Arms Anterior upper leg Back of thigh Back Buttocks Gynecomastia Ankles Arm pits Double chin Hump Breast

Number of patients 428 394 350 314 281 231 220 94 74 48 44 40 39 26 20 20 5 4

Conclusions

Laserlipolysis is safe, simple, and seems to be advantageous for the patient and for the surgeon. The advantages for the surgeon are that it softens areas with hard or compact adiposity,

Table 34.2 Number of bilateral areas in each surgery Surgery 1 2 3 4 5 6–9

Number of bilateral areas 63 52 160 88 52 39

Table 34.3 Complications in treated areas were low (0.041 %) Complication Seroma Asymmetry Hypocorrection Hypercorrection Burn Iction

Number of Complication rate areas (%) 26 0.009 40 0.015 40 0.015 2 0.0007 1 0.0003 1 0.0003

which results in less fatigue, less force is necessary, and it also allows a softer and more relaxed surgery. More areas can be treated at the same time with the same physical effort. Correction of secondary flaws is simplified. It

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provides visual control through transillumination. On the other hand, it is possible to treat areas with little adiposity with less risk of over-resection. For the patient, the preservation of the fibroelastic septum is an advantage. Also fatty tissue selectivity with preservation of the nerves was demonstrated histologically. That implies less postoperative pain because it maintains the innervation integrity. Smaller incisions are necessary and there is better skin retraction in a homogenous manner owing to the delicate tunneling of the laser. Fewer ecchymoses occur. Because it is an ambulatory treatment, recovery is quicker, hospitalization costs are lower, and no working days are lost. Retraining of the staff is necessary for the adequate use of this technique. Even though the results are promising, more clinical long-term follow-up and histopathologic studies are necessary. Besides it is a new challenge in the treatment of gynecomastia, hyperhidrosis, and cellulite [5], which has already shown good results. Acknowledgement Portions of this work are reprinted from Blugerman et al. [11]. With permission from the International Journal of Cosmetic Surgery and Aesthetic Dermatology, Mary Ann Liebert, Inc.

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References 1. Illouz YG. Une nouvelle tecnique pour les lipodistrophies localisees. Rev Chir Esth Lang Franc. 1980;6:9. 2. Goldman A, Schavelzon DE, Blugerman GS. Laserlipolysis: liposuction using Nd-Yag laser. Rev Soc Bras Cir Plast. 2002;17(1):17–26. 3. Schavelzon DE. Laserlipolysis for the treatment of localized adiposity. World congress on liposuction surgery. Westminster, 4–6 Oct 2002. 4. Sandhofer M, Douwens KE, Sandhofer-Novak R, Blugerman GS. Laserlipolyse und liposkulptur. Ästhet Chir. 2002;3:20–6. 5. Blugerman GS. Laserlipolysis for the treatment of localized adiposity and cellulite. World congress on liposuction surgery, Dearborn, 13–15 Oct 2000. 6. Schavelzon DE, Blugerman GS, Goldman A. Laserlipolysis 10th International symposium on cosmetic laser surgery, Las Vegas, 27–29 Apr 2001. 7. Klein JA. Tumescent technique—tumescent anesthesia and microcannular liposuction. St. Louis: Mosby; 2000. p. 297–440. 8. Klein JA. Tumescent technique chronicles. Local anesthesia, liposuction and beyond. Dermatol Surg. 1995;21(5):449–57. 9. Kawano Horibe E. Estética Clinica & Cirúgica. Sao Paula: Revinter Ltd; 2002. p. 273–8. 10. Hanke CW, Sommer B, Sattler G. Tumescent local anesthesia. New York: Springer; 2001. p. 102–6. 11. Blugerman G, Schavelzon D, Drezman R. Mixed gynecomastia: reduction by laserlipolysis and transmammilar adenectomy. Int J Cosmet Surg Aesth Dermatol. 2003;4(3):233–8.

Combination Laser-Assisted Liposuction and Minimally Invasive Skin Tightening with Temperature Feedback for Treatment of the Submentum and Neck

35

Macrene Alexiades

Abstract

Nonsurgical alternatives for addressing excessive fat and skin laxity of the submentum and neck are highly desirable treatment options. The purpose of this chapter is to present the combination of laser-assisted liposuction and minimally invasive skin tightening of submentum and neck under direct temperature control. In a randomized, prospective, three-arm study of single laser-assisted liposuction and skin tightening (LAL-ST) treatment, 1064 nm, 1319 nm, and blended 1064/1319 nm were comparatively analyzed [1]. Subjects were randomized to three treatment arms. LAL was laser-fiber administered into the adipose layer, followed by aspiration. ST was laser-fiber administered into subdermal plane in multiple passes until uniform 45–48 °C was attained and total energy of 5000–7000 J was delivered. Subjects were photographed at baseline, and monthly posttreatment through 6 months, and assessed using four-point quantitative laxity grading scale and fat-aspirate quantitation. The mean percentage improvement in laxity grades was 43.8(18.5)% for 1064 nm, 36.6(5.9)% for 1319 nm, and 39.3 (12.9)% for 1064/1319 nm. The mean (SD) fat-aspirate volumes were 6.13 (3.28) mL for 1064 nm, 8.25 (2.50) mL for 1319 nm, and 6.50 (5.74) mL for 1064/1319 nm [1]. The results were comparable and the differences between the groups were not statistically significant. Combination temperature-controlled LAL-ST treats provide a nonsurgical treatment option for addressing excess fat and skin laxity of submentum and neck with excellent safety and efficacy.

M. Alexiades, M.D., Ph.D. Dermatology and Laser Surgery Center of New York, 955 Park Avenue, New York, NY 10028, USA Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA

Dermatology & Laser Surgery Center of New York, New York, NY, USA e-mail: [email protected]

© Springer-Verlag Berlin Heidelberg 2016 M.A. Shiffman, A. Di Giuseppe (eds.), Liposuction: Principles and Practice, DOI 10.1007/978-3-662-48903-1_35

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35.1

Introduction

The lower face and neck surgical lift involve not only the excision of skin to address skin laxity but also lipectomy to remove fat excess in the submentum and neck. Nonsurgical alternatives to surgical lifting have included traditional tumescent liposuction, laser-assisted liposuction (LAL), skin surface skin tightening (ST) technologies, and minimally invasive ST. Traditional tumescent and LAL of neck, while very effective at fat removal, failed to fully address the residual skin laxity [2–4]. In contrast to skin surface technologies, minimally invasive ST delivers energy directly into the dermis or subdermal plane via needle electrodes or by fiber cannula to treat lower face and neck laxity [5, 6]. In a randomized, blinded comparison to the surgical facelift, minimally invasive ST with fractional radiofrequency achieved 37 % the laxity reduction of the surgical facelift [6]. The combination of LAL and subdermal ST has been applied to the abdomen and more recently by the author to the submentum and neck [7, 8]. Therefore, combination laser fiber-mediated LAL-ST targets both fat excess and skin laxity in a nonsurgical approach to better approximate the clinical results of the surgical facelift. LAL had been variably effective and associated with adverse events due to the lack of immediate in situ temperature feedback during the procedure. Until recently, skin surface thermography was used to estimate subdermal temperatures. This lack of direct temperature feedback bore unpredictable efficacy and complications such as dermal and epidermal thermal injury, blistering, burns, and subsequent adhesions [7–12]. By attaining and controlling ideal target temperature, the temperature feedback serves to maximize fat lysis and collagen denaturation for each step, without exceeding threshold temperatures that cause thermal burns. LAL and ST employing real-time temperature feedback with preselected, quantitative, uniform target temperatures throughout the fat and subdermal planes appear to improve efficacy and safety.

This approach was employed using a neodynium: yttrium aluminum garnet (Nd:YAG) laser that delivers via fiber cannula 1064 nm and 1319 nm, alone or in combination. In prior reports, it was hypothesized that the 1064-nm wavelength is responsible for lipolysis and 1319 nm for tissue tightening. In a recent three-arm study, each wavelength was evaluated independently and in combination, for LAL and ST steps under direct temperature control [1]. Twelve subjects (Fitzpatrick skin types I–IV; eight women, four men; mean age 55.25 (SD ± 8.25, range 36–68) with submental and neck fat and skin laxity (minimum grade 2 on a four-point laxity grading scale, Table 35.1) were enrolled and randomly assorted by sequential allocation to receive treatment in one of the three treatment arms (Fig. 35.1). Subjects with excessive submental fat and neck laxity who consented to the study: age range 35–68; minimal submental laxity grade, 2 (Table 35.1) [1].

Table 35.1 Alexiades skin laxity grading scale Grading scale 0 1 1.5

Descriptive parameter None Mild Mild

2

Moderate

2.5

Moderate

3

Advanced

3.5

Advanced

4

Severe

Laxity None Localized to nl folds Localized, nl and early ml folds Localized, nl/ml folds, early jowels, early sm Localized, prominent nl/ml folds, jowels and sm Prominent nl/ml folds, jowels and sm, early neck strands Deep nl/ml folds, prominent jowels and sm, prominent neck strands Marked nl/ml folds, jowels and sm, neck redundancy and strands

Laxity grading scale. The grading scale has been tested and validated for determining laxity grade based on clinical findings. The scale was employed to evaluate laxity grades for each subject at baseline and each follow-up timepoint nl nasolabial folds, ml melolabial folds, sm submental/ submandibular

35 Combination Laser-Assisted Liposuction and Minimally Invasive Skin Tightening

Fig. 35.1 Submentum–neck sections. The trapezoidal sections of the submentum and neck were marked with a skin marking pen prior to treatment. The area to be treated was bordered superiorly by the mental and mandibular borders, inferiorly by the superior border of the cricothyroid cartilage, and laterally by the medial borders of the sternocleidomastoid muscles. This area was subdivided into three equivalent sections as shown

35.2

Technique

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crease and extended in fat plane with blunt-tip (mini Metzenbaum) scissors. Tumescent anesthesia composed of 0.25 % lidocaine with 1:800,000 epinephrine buffered with 0.21 % sodium bicarbonate in lactated Ringer’s solution and is injected using a 30-mL syringe with a 22–27 ½-gauge 1.5in. spinal needle. Thirty milliliters of tumescent anesthesia is injected into the subcuticular layer of the submentum. A Byron tumescent 16-gauge infiltrating cannula attached to a Klein Tumescent Pump is introduced subcutaneously. Setting the pump at low (approximately 2), 150 mL of tumescent anesthetic is delivered uniformly into the subcutaneous space by dragging the cannula along the underside of the skin in radial extensions from the submental tip toward the superior border of the cricothyroid cartilage inferiorly, and the medial borders of the sternocleidomastoid muscles laterally, while staying inferior to the mandible to avert contact with the marginal mandibular nerve.

35.2.1 Subject Preparation 35.2.3 LAL Step The patient’s face and neck should be photographed at baseline prior to treatment with standardized digital photography from front, side and three-fourth views. One hour prior to the procedure, mild sedation with diazepam 10 mg should be instituted. The patient is then prepared in a sterile fashion using benzalkonium chloride 1:750 and sterile draped. The treatment area is marked with a sterile pen extending from the submental and submandibular borders superiorly to the superior border of the cricothyroid cartilage inferiorly and to the medial aspect of the sternocleidomastoid muscles laterally. This marked three grids per neck corresponding to right, left, and center (Fig. 35.1).

35.2.2 Tumescent Anesthesia Anesthetize the submental skin with 0.1 mL of 1 % lidocaine containing 1:200,000 epinephrine, which is injected intradermally into the center of the submental crease. With a no. 10 blade, a 1–2mm incision is made in the anesthetized submental

The thermometer (TempASSURE) accessory is connected to the neodynium: yttrium aluminum garnet (Nd:YAG) LAL system that delivers via fiber cannula 1064 nm and 1319 nm (Sciton ProLipo PLUS system, Sciton, Palo Alto, CA). A 1-mm laser cannula, 18 gauge, outfitted with a 1000-μm Bare Laser Fiber with Orb tip is inserted under the skin via the submental incision directed into the central marked section. The cannula is inserted and moved in a backand-forth fanning pattern at a rate of 2–5 cm/s. The specified wavelength or blended ratio is selected on the device. This includes 1064 nm alone, 1319 nm alone, or a blend of 1064/1319 nm at 70 %:30 % as specified in Table 35.2. The laser energy is initially set at 8 W and applied in a first set of passes into the fat plane while monitoring internal temperature with TempASSURE. Once a temperature of >40 °C is attained, the laser energy is titrated down to 6–7 W. The laser passes are delivered in a fanning pattern to the central section until a uniform target temperature of 45–48 °C is attained

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Table 35.2 Improvement submental and neck laxity grades before and after treatment and percentage improvement over baseline [1] Subject ID 1064 nm 1 4 7 10 Mean 1319 nm 2 5 8 11 Mean 1064/1319 nm 3 6 9 12 Mean Overall Means

Gradea PreTx

PostTx

Grade difference

Improvement (%)

3 3 3 3.75 3.19 (0.38)

1 1.5 2 3 1.88 (0.85)

2.00 1.50 1.00 0.75 1.31 (0.55)

66.7 % 50.0 % 33.3 % 25.0 % 43.8 (18.5)%

4 4 3.5 3.5 3.75 (0.29)

2.5 2.5 2 2.5 2.38 (0.25)

1.50 1.50 1.50 1.00 1.38 (0.25)

37.5 % 37.5 % 42.9 % 28.6 % 36.6 (5.9)%

3 3.5 4 3 3.38 (0.48) 3.44 (0.43)

2 2 3 1.5 2.13 (0.63) 2.13 (0.61)

1.00 1.50 1.00 1.50 1.25 (0.29) 1.31 (0.36) p < 0.005

33.3 % 42.9 % 25.0 % 50.0 % 39.3 (12.9)% 39.4 (12.1)% p < 0.005

Improvements in laxity grades for each subject, each treatment arm, and across the study. The pre- and posttreatment laxity grades, differences in laxity grades, and percentage improvement over baseline are presented for each subject, means for each treatment arm and means across the study along with statistical analysis a Scale is shown in Table 35.1

throughout the central submentum section, no residual resistance is experienced when tunneling with the laser cannula, and a total of approximately 1000 J is delivered to each section. The cannula is then reinserted via the submental incision and oriented into one of the lateral sections. The procedure is repeated for each flanking trapezoidal marked section. A total of 2500–3500 J should be administered to the submentum and neck per subject during the LAL step.

35.2.4 Fat Aspiration Once all three sections are treated to the target temperature and energy delivery and a uniform liquid consistency were attained, fat aspiration is conducted. A blunt-tipped Tulip Cannula is fitted to a 10-mL Toomey syringe. The liquefied fat is aspirated with gentle manual suction. The volume of fat aspirated should be recorded.

35.2.5 ST Step A second set of laser passes is performed targeting the laser energy to the underside of the dermis while temperature monitored. The laser wavelength is selected on the device as 1064 nm alone, 1319 nm alone, or a blend of 1064 nm:1319 nm at 70 %:30 %. The laser energy is commenced at 7–9 W. The cannula is first introduced into the central section, followed by each flanking lateral section in series. The laser energy is titrated to a maximum of 10 W and to a minimum of 5 W as determined by the rate of heating. The cannula is inserted and moved in a back-and-forth fanning pattern at a rate of 2–5 cm/s within the trapezoidal section. The passes must be administered within each section until target temperature of 45–48° is attained uniformly throughout the section and a total of 800–1500 J are administered. The cannula is then inserted in each of the lateral sections flanking the central section and the process is repeated.

35 Combination Laser-Assisted Liposuction and Minimally Invasive Skin Tightening

A total of 2500–3500 J should be administered to the total submentum and neck in the ST step.

35.2.6 Postoperative Management The submental incision is closed with a single superficial interrupted 5.0 nylon suture and a Tegaderm dressing applied. A head and neck compression garment should be applied and worn for 3 days postoperatively. Mild pain relievers are prescribed during the first 24 h postoperatively, including acetaminophen or acetaminophen with codeine q 6 h prn.

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significant differences. If the pre- and posttreatment grades are compared for each group, the differences between arms are not significant (p = 0.1250, 0.1250, and 0.1250 for 1064, 1319, and 1064/1319-nm combination, respectively) by the Wilcoxon signed-rank test. The Kruskal– Wallis test for differences in percentage improvement between the three groups was not significant. If the data in the three groups are combined (n = 12), the median posttreatment grade is significantly lower than the median pretreatment grade (p = 0.0005).

35.3.2 Efficacy of Fat Lysis 35.2.7 Follow-Up Patients should be assessed at 24 h, 1 week, and up to 6 months after procedure with photographs of the face/neck in frontal, three-quarter, and side views.

The mean fat aspirates were 6.1 (3.3) mL for 1064 nm, 8.3 (2.5) mL for 1319 nm, and 6.5 (5.7) for 1064/1319 nm blend. The mean volume of fat aspirate obtained across the study was 7.0 (3.8) mL.

35.3

35.3.3 Clinical Outcomes

Results

35.3.1 Efficacy of Skin Laxity Reduction The mean (SD) percentage improvement in laxity grades was 43.8(18.5)% for 1064 nm, 36.6 (5.9)% for 1319 nm, and 39.3 (12.9)% for 1064/1319 nm. The mean (SD) fat-aspirate volumes were 6.13 (3.28) mL for 1064 nm, 8.25 (2.50) mL for 1319 nm, and 6.50 (5.74) mL for 1064/1319 nm. The results were comparable and the differences between the groups were not statistically significant (Table 35.2). Across the entire study population, the mean pre- and posttreatment laxity grades were 3.44 and 2.13 for a mean grade difference of 1.31 and a 39.4 % mean grade improvement, which were statistically significant (Table 35.2). All subjects achieved at least 0.75 grade improvement in each treatment group (Table 35.2). Although the numbers in each group are insufficient for further statistical analysis, the data suggest a slight trend toward the greatest improvement in the 1064-nm treated group. Since the data were not all normally distributed, nonparametric tests were used to test for

The clinical improvements are highly consistent across all subjects (Figs. 35.2, 35.3, and 35.4). As shown in the serial photographs, the fat removal is observed by 1-month follow-up with progressive improvement in skin laxity through 6 months.

35.3.4 Safety and Recovery Subjects will experience the following symptoms immediately postoperatively: edema, numbness, difficulty speaking, focal ecchymoses, and minimal erythema. The numbness and difficulty speaking resolve within several hours. During the first 24 h, discomfort is expected in the treated area, described best as “soreness,” and is completely alleviated by pain relievers. The edema persists for approximately 2 weeks, with residual induration evident up to 3 months. Focal ecchymoses resolve within 7 days. Erythema resolves within 2–3 days. Erythema and warmth or tenderness extending inferiorly to the treatment area on the neck or worsening over the course of the first postoperative day are signs of infection and should be evalu-

M. Alexiades

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a

b

Fig. 35.2 (a) Preoperative. (b) Posttreatment following LAL-MIST with 1064 nm only. Subjects randomized to the 1064-nm treatment arm received a single LAL and

a

MIST treatment wherein each step entailed laser energy at 1064-nm wavelength for both steps

b

Fig. 35.3 (a) Preoperative. (b) Posttreatment following LAL-MIST with 1319 nm only. Subjects randomized to the 1319-nm treatment arm received a single LAL and

MIST treatment wherein each step entailed laser energy at 1319-nm wavelength for both steps

ated and treated promptly. Treatment with a cephalosporin orally, such as cephalexin 250 mg po qid for 5 days, should result in prompt resolution of symptoms and signs within 24 h after commencing antibacterial antibiotic and complete resolution of erythema within 3 days.

of the two wavelengths via fiber cannula reported previously and described here is safe and effective in the treatment of both fat excess and skin laxity of the submentum and neck [1]. The protocol achieves a concurrent in situ uniform temperature of 45–48 °C in the targeted plane for the LAL and ST steps, with a total energy delivery of 5000–7000 J and yields consistent clinical improvements in both LAL and ST. The fat removal efficacy was similar for 1064 nm, 1319 nm, and the combination of the two wavelengths with a mean aspirate of 7.0 (SD 3.8; range: 3.0–15.0) mL per subject across the study.

35.4

Discussion

The protocol of combination LAL-ST with realtime temperature control and an Nd:YAG laser delivering 1064 nm, 1319 nm, or a combination

35 Combination Laser-Assisted Liposuction and Minimally Invasive Skin Tightening

a

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b

Fig. 35.4 (a) Preoperative. (b) Posttreatment following LAL-MIST with blended 1064/1319 nm. Subjects randomized to the 1064/1319-nm treatment arm received a single LAL and MIST treatment wherein the LAL step

entailed a blend of 1064/1319 nm at a ratio of 70 %/30 % and the MIST step entailed a blend of 1064/1319 nm at a ratio of 30 %/70 %

Significant laxity reduction was observed across the study population with mean pre- and posttreatment laxity grades of 3.44 (SD 0.43) and 2.13 (SD 0.61), respectively, a mean grade difference of 1.31 (SD 0.36) and a mean percent grade improvement of 39.4 % (SD 12.1) over baseline, which were statistically significant (p = 0.0005, Table 35.2). The percent improvements in laxity grade reductions were similar for 1064 nm, 1319 nm, or a combination of the two wavelengths. The real-time temperature feedback may be the explanation for the lack of thermal injury complications, suggesting that the in situ temperature feedback may improve the safety profile of LAL and ST. In the past, tumescent liposuction, LAL, and ST have treated either fat excess or skin laxity, suggesting that a combination approach would be optimal. While traditional tumescent and LAL addressed fat excess and in selected patients also provided excellent recontouring, in many cases, the residual skin laxity resulted in poor patient satisfaction [2–4, 13]. While skin surface ST devices yield conservative efficacy, minimally invasive ST delivers energy directly into tissue via needle electrodes or fiber cannula which has increased efficacy in laxity reduction, achieving 37 % the laxity reduction of the surgical facelift in a randomized, blinded comparison trial [5, 6]. ST alone fails to

address the submental or neck fat excess, which is excised during surgical facelift through lipectomy [6]. Combination LAL-ST has been applied to the abdomen to date [7, 8]. The protocol presented here demonstrates that combination LAL-ST safely and effectively targets fat excess and skin laxity to the submentum and neck. The application of direct in situ temperature feedback and control to attain preselected uniform temperatures is an important advance to improve safety and efficacy of laser procedures. Skin surface temperature thermography had been used in the past for LAL to estimate temperatures in the subdermal plane, resulting in dermal and epidermal injury, thermal burns, blistering, and subsequent adhesions in numerous reports [8–11, 14]. In the current protocol, direct in situ temperature feedback was employed to maintain a uniform target temperature of 45–48 °C in the targeted plane (adipose layer or subdermal plane). Across the study, no incidence of thermal burn complications and consistent efficacy of at least 0.75 grades in each treatment group was observed (Table 35.2). The consistency of safety and efficacy may be a function of the control for uniform target temperatures precluding thermal burns and optimizing collagen denaturation. Fat and laxity reductions appear to be similar whether 1064-nm or 1319-nm wavelength is

392

employed for LAL and/or ST. The mean volumes of lysed fat aspirated ranged between 6.1 and 8.3 cc with an average of 7.1 mL across the three treatment arms. The small volumes obtained via this protocol are likely due to the restriction of the treatment area to the submentum. Most LAL studies do not report fat-aspirate volumes, particularly on the neck and submentum; though, one study calculated by mathematical modeling in the submentum a 5 mL volume reduction per 3000 J delivered [15]. This is consistent with the data presented here, wherein an average of 7 (range 3–15) mL is obtained after a total energy delivery of 5000–7000 J. In addition, manual aspiration was used as opposed to mechanical, which may account for differences in amount aspirated, when comparing to aspirates from abdominal cases. Laxity reductions were also found to be similar for the two wavelengths with mean laxity grade reductions ranging from 1.25 to 1.38 (average 1.31) on the four-point laxity grading scale. These findings suggest that either 1064 nm or 1319 nm or a combination of the two are similar in efficacy for the treatment of fat excess and skin laxity to the submentum and neck. The protocol presented here is the first clinical comparison of the 1064-nm and 1319-nm wavelengths, either alone or in combination for LAL and ST. A combination of 1064-nm and 1319-nm wavelengths for lipolysis was shown to result in ST on the abdomen; however, these protocols involve a blend of the two wavelengths without temperature control [14–18]. It had been hypothesized that 1064-nm wavelength was responsible for melting the fat while the 1319-nm wavelength was responsible for the tissue-tightening effect, though these hypotheses had not been tested. Surprisingly, the current findings do not support the hypothesis that 1064 nm would be more effective at fat lysis and 1319 nm more effective at skin tightening. While the sample size in each arm did not detect statistically significant differences among the three arms, a slight trend toward greater efficacy in skin laxity reduction was observed for 1064 nm. A skin-tightening effect of 1064 nm had been suggested before by Badin [14], hypothesizing that the thermal effect

M. Alexiades

resulted in collagen contracture. Histological evaluation of LAL demonstrated rupture of adipocytes accompanied by some collagen coagulation [16]. The slight trend toward greater efficacy of 1064 nm and the lack of statistically significant differences among 1064 and 1319 nm are unexpected findings and deserving of further study. Several wavelengths have been employed for LAL, though the protocol presented here presents a randomized clinical comparison among wavelengths. One histologic study in the porcine model compared three continuous wave lasers at 980, 1370, and 1470 nm and three pulsed lasers at 1064, 1320, and 1440 nm [19]. No statistically significant differences in neocollagenesis were detected, but continuous-wave lasers were associated with greater hemorrhage [19]. A retrospective LAL study of 980 nm showed clinical ST, with ultrasound-detected changes in collagen [20]. Three separate clinical studies evaluating 1064 nm, 1320 nm, and the two wavelengths combined were compared [12]. LAL with 1064 nm showed no difference from tumescent liposuction alone. A second showed no difference between 1064 and 1320 nm. A third indicated that combination of 1064 and 1320 nm demonstrated fat and skin laxity reduction [12]. The findings from the published study of the current protocol appear to be consistent with these prior reports in showing no statistically significant difference between 1064 and 1319 nm or the combination of the two in the treatment of fat excess or skin laxity. Wavelength-dependent effects on lipolysis and heat diffusion have been evaluated in porcine skin for 1064, 1320, and 1444 nm. Fat and water absorption analyses for neodymium-doped LAL reveals low and slightly higher absorption coefficients for fat and water for 1064 nm and 1320 nm, respectively [21, 22]. Recently, it was shown that 1,064 and 1,320 nm LAL does not work through selective photothermolysis of fat; rather, collagen or water within fibrous tissue septae is preferentially targeted by these wavelengths with injury to adjacent adipocytes occurring secondarily [21]. The thermal diffusivity, the relative measure of heat conduction through tis-

35 Combination Laser-Assisted Liposuction and Minimally Invasive Skin Tightening

sue, is lowest at 1444 nm, intermediate at 1064 nm, and greatest at 1320 nm [23]. In contrast, thermal confinement, heat localization near the source of laser irradiation, is greatest at 1444 nm, intermediate at 1064 nm, and least at 1320 nm [23]. Greater thermal confinement from 1444 nm or 1064 nm and the stricter limitation of the potential for collateral thermal injury may be of clinical benefit during LAL of confined areas such as the submentum and neck [23, 24]. The potential for undesirable collateral thermal injury is higher during LAL of facial structures (e.g., melolabial folds, jowls) where target tissue volumes are much smaller and where nerves are easily damaged [23]. Another recent study demonstrated greatest ablation crater depth and width and mass removal in porcine fat at the 1444-nm wavelength followed sequentially by 1320 and 1064 nm [24]. Thus, while the clinical data comparing 1064, 1320, and 1444 nm have yet to firmly establish differences in fat removal or ST efficiency, the basic science data are beginning to reveal rankings of ablative and thermal properties among the wavelengths that may impact usage in particular anatomic areas such as submentum and neck. Other combination procedure LAL protocols have been employed in the past. Neck liposuction has been combined with laser resurfacing and platysmal muscle plication [25]. Tumescent liposuction has also been combined with CO2 laser to the subdermal tissue with descriptive improvement [13]. The current protocol combines LAL with ST but offers the ease and facility of a single device, single laser cannula, single entrance point, and, as demonstrated, that fact that both steps may be performed with a single wavelength. The single 2-mm entrance point in the submentum heals without sequelae, offering a nonsurgical option with rapid recovery and excellent posttreatment cosmesis. Conclusions

In sum, combination LAL-ST under immediate in situ temperature control appears to improve safety and possibly efficacy in treating fat excess and skin laxity of the submentum and neck. This protocol results in

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consistent improvement with similar efficacies in fat removal and laxity reductions with either 1064 nm or 1319 nm or a combination of the two wavelengths as a nonsurgical alternative for this anatomic region.

References 1. Alexiades M. Combination laser-assisted liposuction and minimally invasive skin tightening with temperature feedback for the submentum and neck. Dermatol Surg 2012;1–11. 2. Langdon RC. Liposuction of the neck and jowls: fiveincision method combining machine-assisted and syringe aspiration. Dermatol Surg. 2000;26(4):388–91. 3. Gryskiewicz JM. Submental suction-assisted lipectomy without platysmaplasty: pushing the (skin) envelope to avoid a face lift for unsuitable candidates. Plast Reconstr Surg. 2003;112(5):1393–405. 4. Alegría Perén P, Barba Gómez J, Guerrero-Santos J. Total corporal contouring with megaliposuction (120 consecutive cases). Aesthetic Plast Surg. 1999;23(2):93–100. 5. Hantash BM, Renton B, Berkowitz RL, Stridde BC, Newman J. Pilot clinical study of a novel minimally invasive bipolar micro-needle radiofrequency device. Lasers Surg Med. 2009;41(2):87–95. 6. Alexiades-Armenakas M, Rosenberg D, Renton B, Dover J, Arndt K. Blinded, randomized, quantitative grading comparison of minimally invasive, fractional radiofrequency and surgical face-lift to treat skin laxity. Arch Dermatol. 2010;146(4):396–405. 7. DiBernardo BE, Reyes J. Evaluation of skin tightening after laser-assisted liposuction. Aesthet Surg J. 2009;29(5):400–7. 8. McBean JC, Katz BE. A pilot study of the efficacy of a 1,064 and 1,320 nm sequentially firing Nd:YAG laser device for lipolysis and skin tightening. Lasers Surg Med. 2009;41(10):779–84. 9. Zelickson BD, Dressel TD. Discussion of laser-assisted liposuction. Lasers Surg Med. 2009;41(10):709–13. 10. DiBernardo BE, Reyes J, Chen B. Evaluation of tissue thermal effects from 1064/1320-nm laser-assisted lipolysis and its clinical implications. J Cosmet Laser Ther. 2009;11(2):62–9. 11. Katz B, McBean J. Laser-assisted lipolysis: a report on complications. J Cosmet Laser Ther. 2008;10(4):231–3. 12. Woodhall KE, Saluja R, Khoury J, Goldman MP. A comparison of three separate clinical studies evaluating the safety and efficacy of laser-assisted lipolysis using 1,064, 1,320 nm, and a combined 1,064/1,320 nm multiplex device. Lasers Surg Med. 2009;41(10):774–8. 13. Noodleman FR, Harris DR. The laser-assisted neck lift: modifications in technique and postoperative care to improve results. Dermatol Surg. 2002;28(6):453–8.

394 14. Badin AZ, Moraes LM, Gondek L, Chiaratti MG, Canta L. Laser lipolysis: flaccidity under control. Aesthetic Plast Surg. 2002;26(5):335–9. 15. Mordon SR, Blanchemaison PH. Letter to the editor, histologic evaluation of interstitial lipolysis comparing a 1064, 1320 and 2100 nm laser in an ex vivo model. Lasers Surg Med. 2008;40(8):519. 16. Ichikawa K, Miyasaka M, Tanaka R, Tanino R, Mizukami K, Wakaki M. Histologic evaluation of the pulsed Nd:YAG laser for laser lipolysis. Lasers Surg Med. 2005;36(1):43–6. 17. Sasaki GH, Tevez A. Laser-assisted liposuction for facial and body contouring and tissue tightening: a 2-year experience with 75 consecutive patients. Semin Cutan Med Surg. 2009;28(4):226–35. 18. Sasaki GH. Quantification of human abdominal tissue tightening and contraction after component treatments with 1064-nm/1320-nm laser-assisted lipolysis: clinical implications. Aesthet Surg J. 2010;30(2):239–45. 19. Levi JR, Veerappan A, Chen B, Mirkov M, Sierra R, Spiegel JH. Histologic evaluation of laser lipolysis comparing continuous wave vs pulsed lasers in an in vivo pig model. Arch Facial Plast Surg. 2011;13(1):41–50.

M. Alexiades 20. Reynaud JP, Skibinski M, Wassmer B, Rochon P, Mordon S. Lipolysis using a 980-nm diode laser: a retrospective analysis of 534 procedures. Aesthetic Plast Surg. 2009;33(1):28–36. 21. Khoury JG, Saluja R, Keel D, Detwiler S, Goldman MP. Histologic evaluation of interstitial lipolysis comparing a 1064, 1320 and 2100 nm laser in an vivo model. Lasers Surg Med. 2008;40(6):402–6. 22. Curcio J, Petty CC. The near infrared absorption spectrum of liquid water. J Opt Soc Am. 1951;41(5):302–4. 23. Holcomb JD, Turk J, Baek SJ, Rousso DE. Laserassisted facial contouring using a thermally confined 1444-nm Nd-YAG laser: a new paradigm for facial sculpting and rejuvenation. Facial Plast Surg. 2011;72(4):315–30. 24. Youn JI, Holcomb JD. Ablation efficiency and relative thermal confinement measurements using wavelengths 1,064, 1,320, and 1,444 nm for laser-assisted lipolysis. Lasers Med Sci. 2013;28(2):519–27. 25. Cook Jr WR. Laser neck and jowl liposculpture including platysma laser resurfacing, dermal laser resurfacing, and vaporization of subcutaneous fat. Dermatol Surg. 1998;24(5):596–7.

Radiofrequency-Assisted Liposuction of the Upper Arms

36

Diane Irvine Duncan

Abstract

Brachioplasty is a good solution for women with pendulous lax skin, but the resulting scar is difficult for most patients to accept. Liposuction leaves almost no scar and can remove the fat tissue from a large fatty arm. The author discusses the problems of radiofrequency in liposuction patients and the use of radiofrequency in obtaining skin contraction. Multiple cases are presented.

36.1

Introduction

Upper arm laxity is, for many patients, a problem without a straightforward solution. Most women strongly prefer a treatment option that leaves minimal to no scarring. To date, no noninvasive device has been objectively shown to significantly produce a long-term improvement in the appearance of the upper arm region. Simple liposuction can improve the appearance of upper arms in young patients with lipodystrophy and no laxity or extremely mild laxity. Problems arise when surgeons over-resect fat in the volar aspect, which leads to cannula marks or localized skin contour irregularities. Patients then complain that they still cannot wear sleeveless clothing; they have only traded one problem for another. D.I. Duncan, M.D. Plastic Surgical Associates of Fort Collins, 1701 East Prospect Road, Fort Collins, CO 80525, USA e-mail: [email protected]

Brachioplasty is a good solution for women with pendulous lax skin, but the resulting scar is difficult for most patients to accept. Short scar brachioplasty has been offered as a solution; but bunching and distortion of the axilla is frequently seen. This deformity is just as problematic as the original deformity for many women. A newer treatment option for upper arm laxity plus lipodystrophy is radiofrequency-assisted liposuction (RFAL), or laser-assisted liposuction (LAL). Up to 34 % skin surface area contraction can be achieved with RFAL [1]. About 13–17 % skin surface area contraction can be seen with LAL [2, 3]. However, early techniques with both modalities that mirrored the traditional liposuction approach rarely resulted in a smooth and taut contour (Fig. 36.1). Further study showed that overtreatment with RFAL in only the volar upper arm can result in a smaller arm circumference but with a crenellated skin appearance (Fig. 36.2). Overtreatment of the fibroseptal network with RF heat can result in over-contraction of the skin,

© Springer-Verlag Berlin Heidelberg 2016 M.A. Shiffman, A. Di Giuseppe (eds.), Liposuction: Principles and Practice, DOI 10.1007/978-3-662-48903-1_36

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RFAL can reduce the pendulosity of the upper arm skin by about 50 % in good candidates [4]. However, aesthetic posttreatment smoothness of the volar upper arm skin following any surgical treatment depends on initial skin quality, the fat to skin ratio, and the skill and judgment of the operator.

36.2

Fig. 36.1 A52-year-old patient 1 year following UAL plus short scar brachioplasty of upper arms

Fig. 36.2 Crenellated appearance of volar upper arm skin following localized liposuction

which then acquires an unattractive crumpled appearance. Overtreatment of the volar upper arm with LAL can result in cannula marks and skin surface irregularities, especially when surgeons use a superficial technique in those patients with thin skin.

Review of Treatment Series

Thirty-two patients were treated for upper arm lipodystrophy between 2008 and 2014. According to the classification of El Khatib [5] and Teimourian [6], 6 were classified as type I, 17 as type 2, 11 as type III, and 8 as type IV. Table 36.1 shows the characteristics of each classification and how many patients of each type were treated with RFAL alone vs. RFAL plus brachioplasty. Interestingly, three patients with a type 4 deformity were successfully treated with RFAL alone. A skin caliper/distance gauge device was used in all patients to determine treatment type. In those patients with a pendulosity measurement of 0.05). Compared to conventional liposuction, UAL had significantly lower rates of intraoperative Total breasts Open conversion Postop revision

14 12

Number

10 8 6 4

Fig. 50.6 Number of ultrasonic liposuction cases performed per year including associated intraoperative conversions to open excision and postoperative revisions

2 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Year

C.M. Malata and K.Y. Wong

518 Fig. 50.7 Number of conventional liposuction cases performed per year including associated intraoperative conversions to open excision and postoperative revisions

Total breasts Open conversion Postop revision

70 60

Number

50 40 30 20 10 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Year

50 40

39 %

30

SAL

25 % 19 %

% 20

UAL

10 2%

0 Open conversation p < 0.05

Postop revision p < 0.001

Fig. 50.8 Intraoperative conversion to open excision and postoperative revision rates (± standard deviation) for the ultrasound-assisted liposuction (UAL) and suctionassisted lipectomy (SAL) treatment groups. Using Fisher’s exact test, there was a significant difference in these definitive outcome measures between the two treatment groups

conversion to open excision (25 % (23/91 breasts) versus 39 % (113/293 breasts); p < 0.05) and postoperative revision (2 % (2/91 breasts) versus 19 % (55/293 breasts); p < 0.001) using Fisher’s exact test (Fig. 50.8). Therefore patients treated with UAL were therefore 8.5 times less likely to undergo subsequent revision surgery and 1.5 times less likely to have intraoperative conversion to open excision. Interestingly, the volume of fat aspirated was also significantly higher with UAL as assessed by Student’s t test (p < 0.05). Revisional surgery was performed for residual or persistent breast tissue or asymmetry. The haematoma rate for each technique was 1 %. As this was a retrospective study, it was not possible to assign

a grade of gynaecomastia to all the patients; thus a subgroup comparison based on gynaecomastia grade was not performed. Both UAL and conventional liposuction techniques were used since 1999 with no obvious temporal trend, thus eliminating the potential surgeon experience bias on the two definitive outcome measures. Representative cases of the results of gynaecomastia treated by conventional liposuction (Fig. 50.9) and UAL (Fig. 50.10) are illustrated. The study was the first to document an objective comparison of conventional and ultrasonic liposuction in gynaecomastia treatment [11]. A prospective study of 100 patients comparing conventional and UAL at different sites found no difference in postoperative ecchymosis, swelling, complication rate or skin contraction [51]. However, these comparative parameters were largely subjective. Despite the retrospective nature of the study herein reported, it utilised unambiguous and definitive endpoints, namely, intraoperative conversion to open excision and postoperative revisional surgery rates. The latter has a negative effect on patient experience and incurs additional financial costs for the patient and the institution. It is our contention that the present comparison is valid as this single surgeon study eliminates inter-operator variability. Although the senior author was not blinded to the treatment modality used, the only selection bias was the patient’s ability to pay for the ultrasonic liposuction. Conventional liposuction was freely available on the National Health Service (NHS).

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A Comparison of Conventional with Ultrasonic Liposuction in Gynaecomastia Surgery

Fig. 50.9 A 20-year-old patient with gynaecomastia of large size and moderate consistency treated by conventional liposuction and open excision. (Left) Preoperative. (Right) Five months postoperative. Note the destruction of the inframammary fold and loss of the gynaecoid shape of

519

the breasts on the oblique view. On the lateral view, note the restoration of a male chest contour with minimal scarring. The ballooned out areolas have been deflated by the liposuction whilst avoiding tethering of the nipple papillae

520 Fig. 50.10 A 51-year-old patient with gynaecomastia of moderate size and consistency treated by ultrasound-assisted liposuction only. (Left) Preoperative. (Right) Five months postoperative in addition to his completed arm tattoo. Skin contraction was satisfactory despite his age and less than ideal skin quality. Wide liposuction enabled adequate redraping of the skin and the smooth disruption of the inframammary folds

C.M. Malata and K.Y. Wong

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A Comparison of Conventional with Ultrasonic Liposuction in Gynaecomastia Surgery

The ability to pay and thus receive ultrasonic liposuction is to all intents and purposes not related to gynaecomastia grade or consistency. Furthermore, all private patients received fixed price surgery packages, which included free revisions during the first postoperative year. Hence cost did not discourage UAL patients who were not entirely happy with their cosmetic outcomes from seeking or undergoing revisional surgery. Although it was not a positive encouragement for them to pursue this, at worst our results may have overestimated the revisional surgery rate in UAL patients. On the other hand, there may have been differences in socioeconomic status and lifestyle factors between the two treatment groups that could have affected the outcomes. There were, however, no significant differences in the ages, gynaecomastia grades, breast sizes and smoking rates between the treatment groups. Despite the limitations of the present retrospective cohort study, it clearly demonstrates that the intraoperative conversion to open excision and revisional surgery rates was significantly higher using conventional liposuction compared to UAL. This is despite the fact that our study underestimates the revisional surgery rate in the SAL group in that a number of patients had more than one revision. More specifically, in this group, 31 patients (55 breasts) required 61 revisional surgeries, but this was crudely assessed as one revision per patient. None of the reoperated patients in the UAL group required more than one postoperative revision. The clinical significance of our study lies in its implications for patient counselling. Based on these two parameters, it can be confirmed that UAL is a better treatment modality for gynaecomastia. Conventional liposuction patients should be informed that they are almost twice as likely to need intraoperative conversion to open excision as those undergoing ultrasonic liposuction and 8.5 times more likely to need postoperative revision. Conclusions

When surgery is indicated for gynaecomastia, the aim is to consistently achieve a natural-looking male chest with minimal scarring whilst maintaining the viability of the nipple-areola

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complex. In our practice, surgical treatment always starts with liposuction as it is minimally invasive and frequently successful as a single modality. UAL is a more effective treatment modality for gynaecomastia than conventional liposuction as determined by the objective parameters of intraoperative conversion to open surgery and subsequent need for revision. Whenever available, UAL may be a more efficacious liposuction method for treating gynaecomastia.

References 1. Williams MJ. Gynecomastia: its incidence, recognition and host characterization in 447 autopsy cases. Am J Med. 1963;34(1):103–12. 2. Carlson HE. Gynecomastia. N Engl J Med. 1980;303(14):795–9. 3. Johnson RE, Murad MH. Gynecomastia: pathophysiology, evaluation, and management. Mayo Clin Proc. 2009;84(11):1010–5. 4. Simon BE, Hoffman S, Kahn S. Classification and surgical correction of gynecomastia. Plast Reconstr Surg. 1973;51(1):48–52. 5. Graser F. Body contouring. In: McCarthy J, editor. Plastic surgery. Philadelphia: WB Saunders; 1990. p. 3964–4028. 6. Rohrich RJ, Ha RY, Kenkel JM, Adams Jr WP. Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. Plast Reconstr Surg. 2003;111(2):909–23. 7. Fruhstorfer BH, Malata CM. A systematic approach to the surgical treatment of gynaecomastia. Br J Plast Surg. 2003;56(3):237–46. 8. Malata CM, Lau CK, Kumiponjera D. Gynaecomastia: an algorithmic approach to surgical management (with special emphasis on liposuction). In: Stone C, editor. The evidence for plastic surgery. Shrewsbury: TFM Publish Ltd; 2008. p. 273–85. 9. Malata CM, Rabey NG. Surgery for gynaecomastia. Association of Breast Surgery Yearbook 2011, London 2011. p. 72–6. 10. Adekunle A, Malata CM. Gynecomastia: evolving paradigm of management and comparison of techniques. Plast Reconstr Surg. 2012;129(2):366–7e. 11. Wong KY, Malata CM. Conventional versus ultrasound-assisted liposuction in gynaecomastia surgery: a 13-year review. J Plast Reconstr Aesthet Surg. 2014;67(7):921–6. 12. Ridha H, Colville RJ, Vesely MJ. How happy are patients with their gynaecomastia reduction surgery? J Plast Reconstr Aesthet Surg. 2009;62(11):1473–8. 13. Zocchi M. Ultrasonic liposculpturing. Aesthet Plast Surg. 1992;16(4):287–98.

522 14. Apfelberg DB. Results of multicenter study of laserassisted liposuction. Clin Plast Surg. 1996;23(4): 713–9. 15. Jewell ML, Fodor PB, de Souza Pinto EB, Al Shammari MA. Clinical application of VASERassisted lipoplasty: a pilot clinical study. Aesthet Plast Surg. 2002;22(2):131–46. 16. Hodgson EL, Fruhstorfer BH, Malata CM. Ultrasonic liposuction in the treatment of gynaecomastia. Plast Reconstr Surg. 2005;116(2):646–53. 17. Webster JP. Mastectomy for gynecomastia through a semicircular intra-areolar incision. Ann Surg. 1946;124(3):557–75. 18. Pitanguy I. Transareolar incision for gynecomastia. Plast Reconstr Surg. 1966;38:414–9. 19. Letterman G, Schurter M. Surgical correction of gynecomastia. Am Surg. 1969;35:322–5. 20. Huang TT, Hidalgo JE, Lewis SR. A circumareolar approach in surgical management of gynecomastia. Plast Reconstr Surg. 1982;69:35–40. 21. Saad MN, Kay S. The circumareolar incision: a useful incision for gynecomastia. Ann R Coll Surg Engl. 1984;66:121–2. 22. Freiberg A, Hong C. Apple-coring technique for severe gynecomastia. Can J Surg. 1987;30:57–60. 23. Lai YL, Weng CJ, Noordhoff MS. Areolar reduction with inner doughnut incision. Plast Reconstr Surg. 1998;101:1695–9. 24. Becker H. The intra-areolar incision for breast augmentation. Ann Plast Surg. 1999;42:103–6. 25. Chiu DTW, Siegel HW. The pinwheel technique: an adjunct to the periareolar approach in gynecomastia resection. Ann Plast Surg. 1999;42:465–9. 26. Persichetti P, Berloco M, Casadei RM, Marangi GF, Di Lella F, Nobili AM. Gynecomastia and the complete circumareolar approach in the surgical management of skin redundancy. Plast Reconstr Surg. 2001;107(4):948–54. 27. Coskun A, Duzgun SA, Bozer M, et al. Modified technique for correction of gynecomastia. Eur J Surg. 2001;167:822–4. 28. Atiyeh BS, Al-Amm CA, El-Musa KA. The transverse intra-areolar infra-nipple incision for augmentation mammaplasty. Aesthet Plast Surg. 2002;26: 151–5. 29. Sarkar A, Bain J, Bhattacharya D, Sawarappa R, Munian K, Dutta G, Naiyer GJ, Ahmad S. Role of combined circumareolar skin excision and liposuction in management of high grade gynaecomastia. J Cutan Aesthet Surg. 2014;7(2):112–6. 30. Ohyama T, Takada A, Fujikawa M, Hosokawa K. Endoscope-assisted transaxillary removal of glandular tissue in gynecomastia. Ann Plast Surg. 1998;40(1):62–4. 31. Prado AC, Castillo PF. Minimal surgical access to treat gynecomastia with the use of a power-assisted arthroscopic-endoscopic cartilage shaver. Plast Reconstr Surg. 2005;115(3):939–42. 32. Morselli PG. “Pull-through”: a new technique for breast reduction in gynecomastia. Plast Reconstr Surg. 1996;97(2):450–4.

C.M. Malata and K.Y. Wong 33. Hammond DC, Arnold JF, Simon AM, Capraro PA. Combined use of ultrasonic liposuction with the pull-through technique for the treatment of gynecomastia. Plast Reconstr Surg. 2003;112(3):891– 5; discussion 96–7. 34. Bracaglia R, Fortunato R, Gentileschi S, Seccia A, Farallo E. Our experience with the so-called pullthrough technique combined with liposuction for management of gynecomastia. Ann Plast Surg. 2004;53(1):22–6. 35. Lista F, Ahmad J. Power-assisted liposuction and the pull-through technique for the treatment of gynecomastia. Plast Reconstr Surg. 2008;121(3):740–7. 36. Benito-Ruiz J, Raigosa M, Manzano M, Salvador L. Assessment of a suction-assisted cartilage shaver plus liposuction for the treatment of gynecomastia. Aesthet Surg J. 2009;29(4):302–9. 37. Petty PM, Solomon M, Buchel EW, Tran NV. Gynecomastia: evolving paradigm of management and comparison of techniques. Plast Reconstr Surg. 2010;125(5):1301–8. 38. Iwuagwu OC, Calvey TA, Ilsley D, Drew PJ. Ultrasound guided minimally invasive breast surgery (UMIBS): a superior technique for gynecomastia. Ann Plast Surg. 2004;52(2):131–3. 39. Qutob O, Elahi B, Garimella V, Ihsan N, Drew PJ. Minimally invasive excision of gynaecomastia – a novel and effective surgical technique. Ann R Coll Surg Engl. 2010;92(3):198–200. 40. Illouz YG. Body contouring by lipolysis: a 5-year experience with over 3000 cases. Plast Reconstr Surg. 1983;72(5):591–7. 41. Rosenberg GJ. Gynecomastia: suction lipectomy as a contemporary solution. Plast Reconstr Surg. 1987;80(3):379–86. 42. Rosenberg GJ. A new cannula for suction removal of parenchymal tissue of gynaecomastia. Plast Reconstr Surg. 1994;94(3):548–51. 43. Rosenberg GJ. Gynecomastia. In: Spear SL, editor. Surgery of the breast: principles and art. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 1210–9. 44. Becker H. The treatment of gynaecomastia without sharp excision. Ann Plast Surg. 1990;24:380–3. 45. Samdal F, Kleppe G, Amland PF, Abyholm F. Surgical treatment of gynaecomastia. Five years’ experience with liposuction. Scand J Plast Reconstr Surg Hand Surg. 1994;28(2):123–30. 46. Rosenberg GJ, Colon GA. Gynecomastia: two perspectives. In: Marchac D, Granick MS, Solomon MP, editors. Male aesthetic surgery. Boston: Butterworth Heinemann; 1996. p. 287. 47. Mladick RA. Gynecomastia. Liposuction and excision. Clin Plast Surg. 1991;18(4):815–22. 48. Boni R. Tumescent power liposuction in the treatment of the enlarged male breast. Dermatology. 2006; 213(2):140–3. 49. Scuderi N, Dessy LA, Tempesta M, Bistoni G, Mazzocchi M. Combined use of power-assisted liposuction and trans-areolar incision for gynaecomastia treatment. J Plast Reconstr Aesthet Surg. 2010;63(1):e93–5.

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50. Maxwell GP, Gingrass MK. Ultrasound-assisted lipoplasty: a clinical study of 250 consecutive patients. Plast Reconstr Surg. 1998;101(1):189–202. 51. Fodor PB, Watson J. Personal experience with ultrasound-assisted lipoplasty: a pilot study comparing ultrasound-assisted lipoplasty with traditional lipoplasty. Plast Reconstr Surg. 1998;101(4):1103–16. 52. Baker JL. A practical guide to ultrasound-assisted lipoplasty. Clin Plast Surg. 1999;26(3):363–8. 53. Rohrich RJ, Beran SJ, Kenkel JM. Operative principles and basic procedure. In: Rohrich RJ, Beran SJ, Kenkel JM, editors. Ultrasound-assisted liposuction. St Louis: Quality Medical Publishing; 1998. p. 121–52. 54. Baxter RA. Histologic effects of ultrasound-assisted lipoplasty. Aesthet Surg J. 1999;19(2):109–14. 55. Perez JA. Treatment of dysesthesias secondary to ultrasonic lipoplasty. Plast Reconstr Surg. 1999;103(5):1534. 56. Gerson RM. Avoiding end hits in ultrasound-assisted lipoplasty. Aesthet Surg J. 1997;17(5):331–3. 57. Grolleau JL, Rouge D, Chavoin JP, Costagliola M. Severe cutaneous necrosis after ultrasound lipolysis: medicolegal aspects and review. Ann Chir Plast Esthet. 1997;42(1):31–6. 58. Troilius C. Ultrasound-assisted lipoplasty: is it really safe? Aesthet Plast Surg. 1999;23(5):307–11. 59. Lack EB. Safety of ultrasonic-assisted liposuction (UAL) using a non-water-cooled ultrasonic cannula: a report of six cases of disproportionate fat deposits treated with UAL. Dermatol Surg. 1998;24(8):871–4. 60. Doida Y, Brayman AA, Miller MW. Modest enhancement of ultrasound-induced mutations in V79 cells in vitro. Ultrasound Med Biol. 1992;18(5):465–69.7. 61. Fuciarelli AF, Sisk EC, Thomas RM, Miller DL. Induction of base damage in DNA solutions by ultra-

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sonic cavitation. Free Radic Biol Med. 1995;18(2):231–8. Kondo T, Yoshii G. Effect of intensity of 1.2 MHz ultrasound on change in DNA synthesis of irradiated mouse L cells. Ultrasound Med Biol. 1985;11(1): 113–9. Miller DL, Thomas RM. The role of cavitation in the induction of cellular DNA damage by ultrasound and lithotripter shock waves in vitro. Ultrasound Med Biol. 1996;22(5):681–7. Topaz M. Long-term possible hazardous effects of ultrasonically assisted lipoplasty. Plast Reconstr Surg. 1998;102(1):280–3. Young VL, Schorr MW. Report from the conference on ultrasound-assisted liposuction safety and effects. Clin Plast Surg. 1999;26(3):481–524. Di Giuseppe A. Breast reduction with ultrasonicassisted lipoplasty. Plast Reconstr Surg. 2003;112(1): 71–82. Herr J, Hofheinz H, Hertl C, Olbrisch RR, Wieland E. Is there evidence for excessive free radical production in vivo during ultrasound-assisted liposuction? Plast Reconstr Surg. 2003;111(1):425–9. Aiache AE. Surgical treatment of gynecomastia in the body builder. Plast Reconstr Surg. 1989;83(1):61–6. Blau M, Hazani R. Correction of gynecomastia in body builders and patients with good physique. Plast Reconstr Surg. 2015;135(2):425–32. Keskin M, Sutcu M, Cigsar B, Karacaoglan N. Necessity of suction drains in gynecomastia surgery. Aesthet Surg J. 2014;34(4):538–44. Graf R, Auersvald A, Damasio RC, Rippel R, de Araújo LR, Bigarelli LH, Franck CL. Ultrasoundassisted liposuction: an analysis of 348 cases. Aesthet Plast Surg. 2003;27(2):146–53.

Aspiration of Breast Cysts with Liposuction

51

Shridhar Ganpathi Iyer, Thiam Chye Lim, and Jane Lim

Abstract

The authors discuss the common variety of breast cysts, their etiology and manifestations, indications for suction aspiration of breast cysts with liposuction, the technique, and complications. The technique of suction aspiration of breast cysts may be useful for patients with painful breasts riddled with cysts full of debris or who are symptomatic with a congealed galactocele which cannot be decompressed with a 14G needle with the aspiration pressure of a 10 or 20 mL syringe.

51.1

S.G. Iyer, M.D. Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yong Loo Lin School of Medicine, National University Cancer Institute, Singapore, 5 Lower Kent Ridge Road, Singapore 119074, Singapore e-mail: [email protected]; [email protected] T.C. Lim, M.D. (*) Division of Plastic, Reconstruction & Aesthetic Surgery, National University Hospital (Singapore), 5 Lower Ridge Road, Singapore 119074, Singapore National University of Singapore, Singapore, Singapore e-mail: [email protected] J. Lim, M.D. Division of Plastic, Reconstruction & Aesthetic Surgery, National University Hospital (Singapore), 5 Lower Ridge Road, Singapore 119074, Singapore e-mail: [email protected]

Introduction

The clinical and pathological aspects of cystic diseases of the breast were described as far back as 1845 by Reclus [1]. Cooper [2], in his monograph Illustrations of Diseases of the Breast, published in 1929, described in detail cystic disease and many other aspects of benign diseases of the breast. Although the foundations for understanding benign breast diseases were laid early, uncoordinated and sporadic work over several decades has created a confusing array of terminology, including fibrocystic disease, chronic cystic mastitis, cystic mastopathy, hyperplastic cystic disease, and Shimmelbusch’s disease. The absence of cancer has often been equated with breast health. The result is that benign breast disorders, which contribute the majority of outpatient visits, receive little emphasis and understanding. Cysts are one of the commonest findings in women presenting to a breast clinic.

© Springer-Verlag Berlin Heidelberg 2016 M.A. Shiffman, A. Di Giuseppe (eds.), Liposuction: Principles and Practice, DOI 10.1007/978-3-662-48903-1_51

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526 Table 51.1 Common varieties of breast cysts 1. ANDI

Microcysts Macrocysts

2. Galactocele 3. Traumatic 4. Infective 5. Neoplastic

6. Parasitic 7. Postoperative

Liquefied hematoma Fat necrosis Duct ectasia, chronic abscesses, antibioma Papillary cystadenoma Necrotic phyllodes tumor Intracystic papillary carcinoma Cystic degeneration of ductal carcinoma Hydatid cyst Liponecrotic pseudocysts peri-implant fluid collection

ANDI aberration of normal development and involution

The precise epidemiology of gross cysts is not known. Most breast cysts are the result of aberration of normal development and involution [3]. There are other less common varieties of breast cysts (Table 51.1).

51.2

Etiology

Cyst formation possibly occurs owing to a minor aberration of lobular involution, under the influence of estrogen. This common clinical problem has several etiologic theories but none have ever been proven. It is proposed that unopposed action of estrogen in premenopausal patients maintains the acini in a dilated state. Haagensen [4] regards estrogen administration as a potent cause of cyst formation in menopausal women. Dixon et al. [5, 6] have demonstrated that intravenously administered dehydroepiandrosterone sulfate appears in an apocrine cyst against a concentration gradient. This process seems to be inhibited by danazol, spironolactone, and evening primrose oil. High concentrations of several hormones are found in breast cysts, including androsterone, epiandrosterone, dehydroepiandrosterone, and estrogen and their conjugates [7, 8]. Simpson [9], a cytoskeletal structural protein expressed in normal breast epithelial tissue, is absent in all breast cysts. Whether this is a primary

event or a secondary phenomenon remains unclear. All true macrocysts start with an area of apocrine epithelium in the terminal ductal lobular unit. The accumulation of secretion gives rise to progressive dilatation of the terminal ductal lobular unit forming a microcyst. Enlargement of microcysts gives rise to two variants of macrocysts. A type I cyst contains fluid with composition resembling intracellular fluid (high potassium and low sodium), and a type II cyst contains fluid similar to extracellular fluid [3]. The majority of type I cysts are metabolically active with epithelia containing “tight junctions.” Such epithelia generate or maintain a large transepithelial ion concentration or osmotic gradient with secretion by active transport. Type II cysts are metabolically inactive with loose junctions and passive fluid movement. Cysts contain a variety of substances, including lipofuscin products, breakdown products of hemoglobin, steroid hormones, βHCG, relaxin, gross cystic disease protein, growth factors, and tumor markers such as α-fetoprotein and carcinoembryonic antigen [3]. Although there is vast amount of literature concerning cyst fluid biochemistry, the significance of it still is not clear. Galactocele is an uncommon benign cystic lesion filled with milky fluid usually occurring in pregnant and lactating women. Galactoceles often present as non-tender, smooth, and mobile swellings with characteristics of a cyst. Milky fluid of varying viscosity may be obtained on aspiration, which may be diagnostic as well as therapeutic in most cases. Galactoceles have been described in male infants. It appears that three major predisposing factors are required for development of galactocele: (1) present or previous stimulation by prolactin, (2) secretory breast epithelium, and (3) some cause of ductal obstruction [10].

51.3

Clinical Features

Macroscopic cysts are mostly asymptomatic. Distension of the cyst makes it palpable, drawing attention to it. Any pain experienced may be due to the sudden distension of the cyst, and/or leakage of fluid into the surrounding breast tissue, causing chemical irritation. Most cysts occur in

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Aspiration of Breast Cysts with Liposuction

women between the ages of 40 and 50 years, disappearing by menopause unless the woman is on hormone replacement therapy. Examination may reveal a variety of findings depending on the number, size, location, and locularity of cysts, the amount of fluid, and the amount of breast tissue. A cyst with lax walls may be impalpable. Very tense cysts may be hard, resembling a carcinoma. Large cysts may displace Cooper’s ligaments causing what Haagensen [4] described as false skin retraction. The precise incidence of painful gross cystic disease is unknown. A patient presenting with a cyst as a palpable mass or with a cyst discovered on screening should undergo a routine evaluation with mammography, ultrasound (US) examination, and needle aspiration. The typical ultrasonographic appearance of a cyst is a circumscribed, thin-walled, anechoic structure with increased through transmission of sound [11]. US is 96–100 % accurate in the diagnosis of a cyst if the following criteria are applied: round or oval lesions, sharp margins, lack of internal echoes, and posterior acoustic enhancement. Cysts may also show deformability on compression and refractive lateral wall shadowing, which is a nonspecific characteristic of benign breast lesions. Some breast cysts may appear complicated because of proteinaceous material, blood, cellular debris, infection, or cholesterol crystals and are termed complex cysts. An asymptomatic woman with a typical breast cyst on US examination requires no further evaluation. Most other breast cysts are adequately treated by aspiration, which may be diagnostic as well as therapeutic. A 21-gauge needle with a 10 or 20 ml syringe is used and the cyst is aspirated as completely as possible. The fluid may be discarded unless it is bloodstained. The breast is palpated to exclude a residual mass, which, if present, will require evaluation with fine-needle cytology (if necessary under US guidance). Placement of the fluid on white gauze is a useful technique to assess color. Routine cytology of breast fluid is unnecessary as the incidence of cancer in breast cysts is approximately 1:100,000 [12]. It should be borne in mind that cysts per se are not premalignant and

527

do not require excision, but gross cysts may be associated with a small increased risk of subsequent breast cancer [3, 13].

51.4

Indications for Suction Aspiration of Breast Cysts with Liposuction

As most gross cysts can be managed with needle and syringe aspiration, the indications for suction aspiration with the liposuction apparatus are relative. These include: 1. Symptomatic cysts failing needle aspiration (due to debris or inspissated contents) 2. Congealed galactocele 3. Organizing hematoma 4. Encysted paraffin or silicone 5. Abscesses

51.5

Preoperative Evaluation

Evaluation of the patient for the procedure follows the same recommendations as for any patient for liposuction. A thorough medical history that gives special attention to any history of bleeding diathesis, thromboembolism, infectious diseases, hypertension, and diabetes mellitus is taken. Patients with a medical history of these conditions receive medical clearance before undergoing the procedure. A complete blood cell count with quantitative platelet assessment, prothrombin time, and partial thromboplastin time, chemistry profile including liver function tests, and pregnancy test for women of childbearing age are sufficient for most patients. In selected cases, a chest X-ray and an electrocardiogram may be done.

51.5.1 Anesthesia The procedure is performed under general anesthesia but may also be done under local anesthesia with intravenous sedation. Caution against the use of general anesthesia for tumescent liposuction

S.G. Iyer et al.

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[14] may not be applicable in this setting as the procedure is done without tumescent solution and involves aspiration of only cysts.

51.5.2 Technique

other hand. The resistance of the cyst wall is initially felt, and entry into the cavity is felt as a “give way” or loss of resistance. Suction is commenced only after entering the cyst and after obtaining an aspirate to confirm the position (Fig. 51.3). The suction pressure used is 1 atm. The cyst is aspirated completely by tilting the cannula gently into all the limits of the cyst. Gentle movement of the cannula against the cyst walls may be done to ensure complete emptying. Care is taken to prevent aspiration of the intervening breast tissue, which may result in asymmetry of the breasts. The suction is stopped; the cannula is withdrawn and then advanced into

The technique is simple and differs from the standard liposuction in that it is done without infiltration of the area to be aspirated. The suction pressure is started only when the cannula is in the cyst. No ultrasonic or reciprocating device is needed. The site of the painful gross cysts is marked preoperatively after an adequate clinical examination in sitting and supine positions (Fig. 51.1). A periareolar stab incision adequate to accommodate the cannula is made (Fig. 51.2). A Mercedes or single port 3–4 mm cannula is used. Although a sharp-tip or open-end cannula can be used for ease of penetration through the cyst wall, the risk of bleeding from the passage is higher. A double Mercedes cannula can be used if the cyst is very large, but there is a risk of aspirating normal breast and fatty tissues by the proximal holes. Larger-bore cannulas can be used, but it is more difficult to control the rate suction and too much of the surrounding tissue may be aspirated. The cannula is advanced toward the cyst without suction, first in the subcutaneous tissues, and it is then angled to enter breast tissue to penetrate the cyst, which has been immobilized by the

Fig. 51.2 Liposuction cannula guided into the cyst (without applying suction initially), through a periareolar incision

Fig. 51.1 Sites preoperatively

Fig. 51.3 Suction and aspiration commenced after entering the cyst

of

painful

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cysts

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Aspiration of Breast Cysts with Liposuction

another cyst. The procedure is repeated till the symptomatic cysts are adequately addressed. A trap bottle along the suction tubing may be used if the contents are to be analyzed or sent for cytology. A pressure dressing is applied to prevent postoperative hematoma, bruising, and seroma and to reduce pain. Follow-up of the patient will be as indicated by the pathology.

51.6

Complications

The potential complications may include those related to anesthesia and local complications such as bruising, infection, hematoma, recurrence, and breast asymmetry. Further experience in the procedure will determine the long-term outcomes and complications.

51.7

Discussion

The use of liposuction has evolved considerably over the last decade. The indications are expanding with increasing experience in the technique. Liposuction has been used since 1985 as an adjunct to breast reduction by Teimourian et al. [15] and Avelar and Illouz [16]. Originally it was used to address the difficult surgical area of the tail of breast during reduction mammoplasty. In 1991, Matarasso and Courtiss [17] recommended suction mammoplasty for patients with an optimally well-located nipple-areolar complex. Initially it was thought that liposuction might be used only on fatty breasts. Experience with treating gynecomastia has shown that the glandular breast can also be aspirated. Improved liposuction instrumentation and experience has led to increasing applications. Suction-assisted lipectomy has also been used successfully to treat a variety of medical conditions, including extraction of lipomas, axillary hyperhidrosis, benign symmetric lipomatosis (Madelung’s disease), congenital body asymmetry, congenital or acquired lymphedema, flap defatting, traumatic or postoperative hematomas, and fat necrosis [18–24].

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The majority of symptomatic breast cysts can be treated by aspiration alone. The consistency of breast cyst fluid may vary from serous to heavily turbid and occasionally may contain inspissated secretions. Some patients may present with painful breasts riddled with cysts containing thick fluid, which can be aspirated only with difficulty. Suction aspiration of breast cysts was first described in a 28-year-old patient presenting with painful contour-distorting cysts containing thick inspissated secretion in both breasts [25]. It was effective in relieving the pain and distortion. Locker et al. [26] showed a reduction of cysts requiring aspiration after a course of 100 mg danazol three times a day for 3 months. It should be stressed to the patient that this treatment is not innocuous in that it involves considerable alterations of hormone levels and that recurrence of symptoms such as breast pain, discomfort, and recurrence of the cyst is not uncommon after cessation of therapy. The technique of suction aspiration of breast cysts may be useful for patients with painful breasts riddled with cysts full of debris or who are symptomatic with a congealed galactocele which cannot be decompressed with a 14G needle with the aspiration pressure of a 10 or 20 mL syringe. It may decrease the number of repeat aspirations and visits to the outpatient clinic. It is emphasized that the procedure should be used judiciously in selected patients with the same care exercised as in any patient undergoing the liposuction procedure.

References 1. Reclus P. La maladie kystique des mamelles. Bull Soc Anat Paris. 1883;58:428–33. 2. Cooper AP. Illustrations of the diseases of the breast. London: Longman, Rees & Co; 1829. 3. Huges LE. Cysts of the breast. In: Huges LE, Mansel RE, Webster DJT, editors. Benign disorders of the breast. 2nd ed. London: Saunders; 2000. p. 123–35. 4. Haagensen CD. Diseases of breast. Philadelphia: WB Saunders; 1986. 5. Dixon JM, Telford J, Elton RA, Miller WR. Uptake of dehydroepiandrosterone sulphate into human breast cyst fluids. Breast. 1997;6(1):12–6.

530 6. Dixon JM, Telford J, Miller WR. Effects of spironolactone, danazol and efamast on the uptake of titrated dihydroepiandrosterone sulphate into human breast cyst fluid. In: Mansel RE, editor. Recent developments in the study of benign breast disease. Carnforth: Parthenon Publishing; 1993. p. 265–70. 7. Miller WR, Dixon JM, Scott WN, Forrest AP. Classification of human breast cysts according to electrolyte and androgen conjugate composition. Clin Oncol. 1983;9(3):227–32. 8. Bradlow HL, Rosenfeld RS, Kream J, Fleisher M, O’Connor J, Schwartz MK. Steroid hormone accumulation in human breast cyst fluid. Cancer Res. 1981;41(1):105–7. 9. Simpson JF, Page DL. Loss of expression of fodrin (a structural protein) in cystic changes of human breast. Lab Invest. 1993;68(5):537–40. 10. Raso DS, Greene WB, Silverman JF. Crystallizing galactocele. A case report. Acta Cytol. 1997;41(3): 863–70. 11. Smith DN. Breast ultrasound. Radiol Clin N Am. 2001;39(3):485–97. 12. Marchant DJ. Benign breast disease. Obstet Gynecol Clin N Am. 2002;29(1):1–20. 13. Bodian CA, Lattes R, Perzin KH. The epidemiology of gross cystic disease of the breast confirmed by biopsy or by aspiration of cyst fluid. Cancer Detect Prev. 1992;16(1):7–15. 14. Coleman 3rd WP. Guidelines of care for liposuction. J Am Acad Dermatol. 2001;45(3):438–47. 15. Teimourian B, Massac Jr E, Wiegering CE. Reduction suction mammoplasty and suction lipectomy as an adjunct to breast surgery. Aesthet Plast Surg. 1985;9(2):97–100.

S.G. Iyer et al. 16. Avelar JM, Illouz YG. Lipoaspiracao. Sao Paulo,: Editora Hipocrates; 1986. p. 148–52. 17. Matarasso A, Courtiss EH. Suction mammaplasty: the use of suction lipectomy to reduce large breasts. Plast Reconstr Surg. 1991;87(4):709–17. 18. Apesos J, Chami R. Functional applications of suction-assisted lipectomy: a new treatment for old disorders. Aesthet Plast Surg. 1991;15(1):73–9. 19. Lillis PJ, Coleman WP. Liposuction for treatment of axillary hyperhidrosis. Dermatol Clin. 1990;8(3): 479–82. 20. Pinski KS, Roenigk HH. Liposuction of lipomas. Dermatol Clin. 1990;8(3):483–92. 21. O’Brien BM, Khazanchi RK, Kumar PA, Dvir E, Pederson WC. Liposuction in the treatment of lymphoedema: a preliminary report. Br J Plast Surg. 1989;42(5):530–3. 22. Martin PH, Carver N, Petros AJ. Use of liposuction and saline washout for the treatment of extensive subcutaneous extravasation of corrosive drugs. Br J Anaesth. 1994;72(6):702–4. 23. Fahmy FS, Moiemen NS, Frame JD. Liposuction for drainage of large hematoma. Injury. 1993;24(1):61–8. 24. Coleman WP. Noncosmetic applications of liposuction. J Dermatol Surg Oncol. 1988;14(10):1085–90. 25. Iyer SG, Lim J, Lim TC. Aspiration for gross cystic disease of breast: a technique using liposuction apparatus. Plast Reconstr Surg. 2002;110(7):1810–1. 26. Locker AP, Hinton CP, Roebuck EJ, Blamey RW. Long-term follow up of patients treated with a single course of danazol for recurrent breast cysts. Br J Clin Pract Suppl. 1989;68:100–1.

Refinements in Liposculpture of the Buttocks and Thighs

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Luiz S. Toledo

Abstract

The author discusses his experience with the variety of methods in liposuction, the technique of syringe liposculpture, anesthesia, the use of the cannula, and liposculpture of the buttocks and thighs. The approach to body contouring does not rely on one surgical technique alone. It is a combination of different procedures to obtain the best possible result. Beauty is an activity, not a state. Aristotle

52.1

Introduction

It has been more than 20 years now since Illouz’s [1] first lipoplasty paper was presented in Brazil by way of a film. It was a technique which allowed us to see new possibilities for improvement in many areas of plastic surgery. This paved the way for the “minimally invasive” procedures that followed, creating a new perspective for plastic surgeons and patients, with the possibility of altering the shape of the face and body through minimal incisions. Lipoplasty is a simple idea and this is why it works. We should not complicate it and, as Illouz points out, sometimes it is very difficult to be simple. Throughout the world the initial idea, spread by Illouz, has seen many changes in instrumentaL.S. Toledo, M.D. ISAPS National Secretary – UAE, Jumeirah, PO Box 213522, Dubai, UAE e-mail: [email protected]

tion, tactics, depth of aspiration, and anesthesia techniques. The principle, however, has remained the same: treating the localized fat deformities by aspirating subcutaneous fat. The improvement of body contour irregularities need not be limited to fat suction alone. The treatment ideally should be global, involving different specialties. Plastic surgeons need to be familiar with the array of modern techniques available to obtain the best result. This evolution involves change. After working with the traditional liposuction techniques of the early 1980s, the author decided to try the syringe liposculpture technique introduced by Fournier [2] eliminating the aspirator and using disposable syringes. It became simpler than liposuction with the aspirator, with the same effectiveness and without increasing its risks. In 1985 the author began using the syringe technique for facial work, not only to remove excess fat but also to reinject aspirated fat in

© Springer-Verlag Berlin Heidelberg 2016 M.A. Shiffman, A. Di Giuseppe (eds.), Liposuction: Principles and Practice, DOI 10.1007/978-3-662-48903-1_52

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specific areas. At this stage the aspirator was still being used to treat the body, collecting the fat in a vial and transferring it to 60-mL syringes for reinjection. In 1988 the author started using the tumescent technique of local anesthesia for face and body work. The original Klein formula was modified in 1989 to suit my needs, increasing the lidocaine and epinephrine concentration and replacing the saline solution with Ringer’s lactate [3]. In 1989, contrary to the belief held at that time that we should aspirate from only the deep layers of fat, Gasparotti presented superficial liposuction for the first time in São Paulo at the first “Recent advances in plastic surgery—RAPS symposium.” The introduction of superficial liposculpture in 1989 widened the indication for lipoplasty to include older patients with a more flaccid skin tone [4]. The author modified the Gasparotti technique of superficial liposuction with the aspirator to using the syringe for both aspiration and injection of fat. This technique was called superficial liposculpture [5]. Skin care and manual lymphatic drainage has helped enormously in improving patient satisfaction and postoperative comfort. The mirror image system was introduced to my patients in 1992. The computer consultation is a key tool in surgeon/patient understanding of projected postoperative results. Using the patient’s own images, the patient can have an explanation and be shown the change that can be expected through surgery alone. The degree of patient involvement needed is explained to the patient in order to obtain the final result and estimate the improvement. From 1995 to 1997 internal ultrasound was used but ultimately this technique was abandoned. The introduction in 1995 of megaliposculpture, the removal of large amounts of fat in one procedure, increased the risks and provoked skin irregularities. I prefer multiple procedures if more than 5–8 % of the total body weight has to be aspirated. I never aspirate more than 8 % in one procedure.

Since 1997, external ultrasound has been used for body contouring [6] alone or in conjunction with liposculpture when indicated [7]. Endermology was then used working with endocrinologists and personal trainers. 1999 saw the arrival of titanium-fused cannulas for the Toomey-tip syringes. The interior of the cannula is also treated, reducing friction to a minimum. Body contour surgery today ideally involves several techniques, including syringe liposculpture, external ultrasound, manual lymphatic drainage, endermology, skin care, exercise, and diet. The goal in some cases is to motivate the patient to a change in lifestyle. The modern facility should offer several options to improve what can be obtained through surgery.

52.2

Syringe Liposculpture

52.2.1 Instruments Over the last 5 years, the Tulip CF (cell-friendly) cannulas, a titanium-fused instrument system, have been used with Toomey-tip 60-mL syringes. These cannulas are light and easy to handle, as there is almost no friction, resulting in the integrity of the aspirated fat cells being maintained to a higher degree, a desirable state if they are needed for reinjection. For the body 2–4.6-mm cannulas with lengths from 15 to 45 cm are used according to the areas to be treated. For the face and other delicate work, 10-mL syringes and cannula gauges between 1 and 3 mm are preferred. The tips are either the Pyramid type or one lateral hole. Specific tips are used for difficult areas, such as the flat tip with two holes, the Tiger tip, and the Toledo V-tip dissector cannula in different gauges and lengths for facial and body work (Fig. 52.1). The V-dissector is sharp on the inside of the V to cut the fibrous tissue and with blunt tips to avoid perforation of the skin. It is manufactured in different gauges, from 1.5 to 4 mm, and lengths, from 12 to 45 cm, to be used on the face or to treat problems on the body (Fig. 52.1).

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Refinements in Liposculpture of the Buttocks and Thighs

a

c

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b

d

Fig. 52.1 (a) Clockwise from bottom: CF cannulas, titanium-fused for less friction, a plunge locker (both by Tulip), a Toomey-tip 60-mL syringe, and a 60–10-mL transfer with decanting stand (by Richter). (b) From left: a 3-mm-

gauge multihole tip infiltrator and 3-, 3.7-, and 4.6-mm-gauge CF cannulas (Tulip). (c) Special cannulas for difficult areas of aspiration, the two-hole flat tip and the Tiger tip (Grams Medical). (d) The Toledo V-tip dissector cannula (Byron)

Blunt multihole cannulas are used for anesthesia infiltration. This helps avoid damage to the surrounding tissues, and this means less postoperative edema and ecchymoses. Long cannulas are used to treat large adiposities, at least 10 cm longer than the area to be treated. A cannula shorter than the area of the deformity can provoke irregularities. The fat deposits are treated in units, terminating one area and then moving to another. Final passage with a fine cannula is necessary to feather any irregularities.

Heavy sedation is not needed. This combination also has a considerable advantage over general anesthesia [8] and, most importantly, the reduction of bleeding during suction. For small procedures, oral sedation with 15 mg midazolam can be used. For larger procedures, intravenous sedation with midazolam, propofol, and fentanyl is administered by the anesthesiologist. The local infiltration formula contains 20 mL of 2 % lidocaine, 1 mL of adrenaline, 500 mL of Ringer’s lactate, and 5 mL of 3 % sodium bicarbonate [9]. Sodium bicarbonate balances the pH, neutralizing the acidity of the lidocaine, and decreases the discomfort of the injection. The whole body is not injected before suctioning, but one side is injected, treated, and completed before turning the patient [10]. Three to 4 l of pure fat can be removed safely without the need for blood replacement, keeping in mind that

52.2.2 Anesthesia Syringe liposculpture performed with a combination of “twilight” sedation and tumescent anesthesia means a faster recovery from the surgery.

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no more than 5–8 % of the patient’s body weight should be liposuctioned at one time. One liter of decanted fat (after removing the local anesthesia) weighs about 1 kg. It is difficult to calculate the exact amount of anesthesia being injected in any one area when using an injection pump. For this reason injection using the syringe is preferred. It is fast, and I know exactly the amount of anesthesia injected and can measure and record the exact amount of fat and fluid aspirated from each area. It is important to record precisely not only the total volume of aspirate of all the treated areas but also the volume of pure fat. If we remove 3 l of fat from only one body area, the trauma is less than if we aspirate the same 3 l from several areas of the body. Ten to 15 min after the injection of the anesthesia, the skin of this area will become whiter, owing to the vasoconstriction, a sign that we can start liposuctioning. If we do not wait, too much fluid and blood will be aspirated. The tumescent fluid is injected slowly, at body temperature, i.e., 37 °C [11], to avoid the patient shivering and trembling during and after surgery, a discomfort provoked by the injection of lowtemperature fluid. Warming the solution also significantly reduces pain [12]. The use of warm air blankets during and after the surgery helps in maintaining the ideal body temperature and helps improve patient comfort postoperatively. The anesthesia solution is injected deeply, close to the muscle fascia, which allows for good tumescence and avoids distortions. For every 1000 mL of aspirated fat, only 9.7 mL of blood is suctioned. The tumescent technique is a very safe method of liposuction, eliminates the need for general anesthesia and blood transfusions, and has fewer complications. Two milliliters of anesthetic solution is injected for each milliliter of aspirate to be aspirated. The blood loss with this tumescent technique is dramatically reduced compared with that with the dry or classical infiltration technique [13, 14]. Drug toxicity with local anesthesia was one of the most serious potential complications and a limiting factor of this type of anesthesia, owing to the peak concentration in the plasma. The safe upper limit of the lidocaine dose in

tumescent anesthesia for liposuction has been reported to be 35 mg/kg, but there are studies that suggest that tumescent anesthesia with a total lidocaine dose of up to 55 mg/kg is safe for use in liposuction [15]. With the author’s anesthesia formula [16] for the tumescent technique (a modification of the original Klein formula), up to 6 l of this solution can be injected safely during a single liposculpture procedure. Several factors help in keeping this formula safe. First is the fact that the entire body is not injected at the beginning of the surgery; it is preferred to inject and aspirate one side before going to another area. Some of the solution is removed with the aspirated fat, reducing the amount that will be reabsorbed. The solution with epinephrine allows the lidocaine dose to be increased because of the delayed clearance from the injection site. The serum lidocaine levels at 3, 12, and 23 h following infiltration of the tumescent solution with the tumescent technique have a mean of 22.3 mg/kg [17]. The peak epinephrine levels occurred at the 3-h blood draw and were approximately four times the physiologic level. There were no subjective or objective signs of lidocaine or epinephrine toxicity. The peak lidocaine level occurs 12 h after the infiltration of the solution. Normally between 2 and 3 l of solution is injected evenly and painlessly. The tumescent state is reached when palpation shows the typical tension of the injected area.

52.2.3 Regularity The depth and the regularity of the cannula strokes are controlled with an outstretched hand, the skin wet, and an antiseptic solution, allowing the outstretched hand to move easily over the skin surface. To detect any irregularities the “pinch test” is used with dry skin to measure thickness. Skin irregularities are checked using light reflections on the wet skin. I call this “the panel beater trick.” In tennis you “keep your eye on the ball” and in liposculpture you “keep your eye at the cannula tip,” which is fundamental in preventing

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Refinements in Liposculpture of the Buttocks and Thighs

secondary irregularities and sequelae. Once the syringe is full, liposuction is immediately resumed with an empty syringe and with the same-sized cannula. When the cannula gauge is the same, suction takes the same time either with the aspirator or with the syringe, because vacuum is vacuum. Each area is treated with the body in a specific position on the operating table [18]. With the patient in the lateral position, the flanks and lateral thighs, the gluteal fold, and the “banana” fold are treated. In the prone position we treat the dorsal region, arms, flanks, and dorsal and medial thighs plus the knees. In the supine position the abdomen, medial thighs, calves, ankles, and axillary region are treated. By bending and separating the patient’s knees, the treatment of the medial thighs, calves, and ankles is completed. With the patient in the lateral position to treat the lateral thigh, it becomes more difficult to provoke a depression, usually owing to repeated suction of the subdermal layer. To treat the abdomen in the supine position, the abdominal wall is hyperextended either by bending the table or by placing a pillow under the hips. This is one of the simplest ways to reduce the possibility of abdominal wall perforation. In this position the cannula introduced in the pubic area can reach the skin of the epigastrium. Intra-abdominal penetration with intestinal perforation is a relatively uncommon complication of liposuction, but eight cases have been reported in the literature, with a mortality rate above 50 %. It is important to establish an early and aggressive diagnosis and treatment of liposuction patients who have gastrointestinal complaints in the early postoperative period [19].

52.2.4 Buttocks and Thighs A flaccid buttock will have an accumulation of fat in its lower third and a depression in the gluteal trochanteric area. The excess weight provokes the so-called banana fold, a subgluteal accumulation of fat. To handle this problem, the flanks and lateral thighs are aspirated, and then the area cephalic to the gluteal fold is treated with

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superficial suction to remove some of the weight of the buttock, provoking a slight retraction of the skin. If the subgluteal fold is too long, the lower third of the buttock is liposuctioned and the banana fold area reduced and treated with superficial suction while fat is injected into the trochanteric depression. The banana fold is always liposuctioned superficially. If suctioned deeply, the fibrous structures that hold the buttock in place will be broken, and this will result in a lengthening of the subgluteal fold. In secondary cases of the banana fold deformity, it might be necessary to inject fat in the “banana” area that was overaspirated. Injecting fat into the trochanteric region produces the illusion of an elevation of the buttock. Fat grafting done in multiple tunnels is an efficient and safe procedure to correct or enhance contour deformities of the lower limbs [20]. In some cases the removal of excess fat from the lateral and posterior thigh will shorten the subgluteal fold and create a more gracious look. This combined procedure will result in the shortening of the gluteal fold and an illusion of an elevation of the buttock. The leg looks longer when there is a continuation of the buttock with the thigh. It is impossible to have the precision needed when treating these delicate areas using thick cannulas and traditional liposuction.

52.2.5 Internal Ultrasound It has been said that ultrasound-assisted liposuction (UAL) was a revolutionary contouring technique with several advantages over the existing methods of suction-assisted lipectomy. My interest was to compare these advantages with syringe liposculpture. From April to December 1995, the author used the UAL technique on 20 patients, varying from 25 to 55 years of age, treating one side with syringe liposculpture and the other with UAL, under local anesthesia with sedation. First the Brazilian Liposonic ultrasound aspirating machine was used with 20 MHz frequency on one side of the body and Toomey-tip syringes with Tulip cannulas on the other. My first experience was presented at the ASAPS meeting in

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Fig. 52.2 Aspiration of the lateral thigh with the Liposonic internal ultrasound machine showing bloody drainage. Blood was squeezed from the lateral thigh and the area had to be compressed to stop bleeding

April 1996 [21]. In 1996 and 1997 the author tried the American Lysonics and the Italian SMEI machines over several months. These were some of my findings. One advantage is that there is no need for physical strain. The ultrasound handpiece weighs 2 lb and the syringe weighs about 50–60 g, which is much lighter. The ultrasound probe/cannula slides more easily through the tunnels than the stainless steel cannula, but after you have held this handpiece for 1 h, it can get heavy. The syringe with the zirconium-fused cannula is also very easy to use and there is almost no friction. I have had two cases of hemorrhage with UAL (Fig. 52.2). In one patient, compression of the area and cessation of liposuctioning eliminated the bleeding. The second patient had a hemorrhage 10 h after the end of the surgery and needed two units of blood administered. In this case the lateral thigh was being treated, which is an area with no large blood vessels that would provoke this degree of bleeding. Possibly it was due to destruction of superficial capillaries. This is the only blood transfusion I have prescribed since 1985, when I was still using the dry technique. When I reported skin and tissue burns, a hemorrhage, and that my patients felt more pain and itching on the side treated with UAL, I was told it was due to technical problems either with the machine or my timing. I was advised to use the ultrasound for only 3 min and then proceed with a normal suction. I preferred not to use it at all.

The ultrasound should eliminate only the fluid fraction of the adipocytes, leaving in place the adipocyte wall and intercellular substances, producing a smooth and regular cutaneous surface. It is said that the ultrasound shows “a selective destruction of the underlying tissues” as opposed to an “anarchic and traumatic removal destruction of the area treated,” as apparently seen in traditional liposuction. I found that that was not the case. The advantages of UAL over the syringe technique should also produce a lifting effect and better skin retraction, but I did not see the evidence of this in the final result. The retraction was similar, the bruising was similar, and the procedure time much longer. Not only is it more expensive, but it can increase the risk of bleeding and tissue and skin necrosis and cause prolonged pain and itching.

52.2.6 External Ultrasound Lewis, Pruitt, and Hetter advocated external ultrasound to reduce edema after lipoplasty in 1984. The external ultrasound machine to destroy localized fat deposits was developed in California by Silberg and popularized by Hoefflin. I called the technique lipotripsy, a noninvasive method using external ultrasound for body contouring. I used the Silberg-Wells Johnson external ultrasound machine for the nonsurgical decrease of localized fat cells by increasing the intracellular volume and rupturing the cellular membrane with vectored ultrasound. The 30-W machine produces ultrasound in continuous and 20 % pulsed modes with two applicators 10 cm2 at 1 MHz for the body and 5 cm2 at 1 MHz for the face and can be used in isolation or in conjunction with other body contouring procedures [7]. The indication varied according to the volume of fat to be treated. The main indication for the isolated use of external ultrasound with no suction is for the noninvasive treatment of localized fat deposits of volume smaller than 300 mL. For volumes larger than 300 mL, we can combine lipotripsy (external ultrasound) with syringe liposculpture (Fig. 52.3).

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Refinements in Liposculpture of the Buttocks and Thighs

a1

a2

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c

Fig. 52.3 (a) Preoperative patient. (b) Forty-eight hours postoperatively after external ultrasound lipoplasty with a total aspiration of 7265 mL including the anterior thighs, medial knees, lateral thighs, pretibial regions, flanks, back, and arms. (c) Thermometer inserted to measure the

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d

temperature of the fat during the procedure. There was a 5 °F elevation of the temperature. (d) The anterior thighs were aspirated from the inguinal region and knees with special 45-cm-long cannulas

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It can be performed on different areas of the body with good results, on the neck of men and women and on primary or secondary cases and fat deposits with fibrosis. Although the use of external ultrasound alone, i.e., with no liposuction, can reduce the lipodystrophies, what it cannot do is alter the shape of the body. For that it is necessary to use liposculpture. The technique can be performed under local anesthesia alone or combined with sedation. The local anesthesia formula is injected slowly at body temperature, in the proportion of 1:1 (500 mL of Ringer’s lactate, 20 mL of 2 % lidocaine, 1 mL of 1:1000 adrenaline, 5 mL of 3 % sodium bicarbonate). After the area becomes numb, this solution is injected at body temperature in the proportion of 0.5:1 with 400 mL of normal saline, 600 mL of distilled water, l mL of absolute alcohol, 2 mL of 2 mEq/mL potassium chloride, 0.5 mL of verapamil, 0.5 mL of 1:1000 adrenaline, and 5 mL of hyaluronic acid. The main advantages when external ultrasound is used alone are that it is noninvasive, there is a fast recovery time, and there is no morbidity. The disadvantages are unpredictability, it only works for small adiposities, patients with metal prosthesis have to be treated cautiously, there is a possibility of cholesterol increase, and there is a theoretical possibility of release of free radicals. Combined with tumescent liposculpture, clinical results reveal that, although it increases the operating time, because of the application, liposculpture after use of external ultrasound was easier for the surgeon and required less physical effort, and there was less postoperative bruising, swelling, and discomfort for the patient. External ultrasound combined with tumescent liposculpture produced significant physician and patient benefit both operatively and postoperatively [22, 23].

52.3

Discussion

Syringe liposculpture is a gentler technique than traditional liposuction performed with the aspirator owing to the precision the syringe allows. The syringe is safe, inexpensive, disposable, light,

and silent. The aspirator is cumbersome, imprecise, costs a few thousand dollars, and is usually very noisy. Fat aspirated with this machine cannot be reinjected. When treating the face or small areas of the body, the precision that the syringe gives in measuring fat removed is vital in obtaining an even result. When treating larger areas, the aspirate is precisely decanted and the volumes recorded. With this method the shape of the thighs, legs, and buttocks can be improved according to the patient’s needs, remodeling, reducing, and augmenting. The results are different from those of traditional liposuction. We weigh, measure, and photograph our patients before and at regular intervals after surgery. The possible dissatisfaction of the patients usually ends when they are shown their map recording the precise amounts of fat aspirated from each part of the body. The photographs sometimes do not clearly show the postoperative change if the patient’s weight remains the same, it is the measurements that will show the difference. This precise measurement of aspirated fat is important when comparing sides during the procedure, in keeping the patient’s blood and fluid balance records, and also for medical-legal reasons. With the tumescent technique, large volumes of fluid with lidocaine and epinephrine are infused subcutaneously. There are reports [24] of cardiopulmonary complications, and, although they have been few, the anesthesiologist needs to take into account the fluid injected subcutaneously and balance the intravenous solutions injected to avoid this problem. Preventive antibiotic therapy plus the constant wetting of the skin with an antiseptic solution helps to avoid infection. The instruments are gas sterilized before use. Liposuction may result in major complications or death, especially when medical personnel are unfamiliar with the possible complications and underestimate the risks. Pain out of proportion to clinical findings is a hallmark of necrotizing fasciitis and should be considered even in the absence of cutaneous signs of infection. A definitive diagnosis is made by biopsy and rapid section histological analysis.

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Refinements in Liposculpture of the Buttocks and Thighs

In two reported cases of massive necrotizing fasciitis treated in a burn center after liposuction surgery, one patient died, and the second required lengthy hospitalization, extensive debridement, and split-thickness skin grafting of 22 % of the total body surface area [25, 26]. Depressions on the body and on the face provoked by previous liposuction can be treated by breaking the fibrous adhesions with the Toledo V-tip dissector cannula and injecting fat to help prevent the reattachment of these adhesions. I usually do not overinject on the face, but do overinject in the body by 50 %. The reabsorption of fat varies from patient to patient, but there is always a significant improvement over the initial result with a second and sometimes a third injection of fat. Retracted scars can be treated without resection by freeing the scar from the underlying tissue with the V-tip dissector cannula. Old scars from cesareans or abdominoplasty can be improved when combined with superficial suction of the surrounding area, and the result can be excellent. Scars on the face and neck, acne scars, and facial depressions are treated in the same manner but with more delicate instruments, in combination with facial procedures.

52.4

Postoperative Care

The incisions of liposuction are not sutured, only the fat injection incisions. Liposuction incisions are covered with sterilized disposable diapers, to collect the oozing of the anesthetic solution for the first 24 h. This oozing of fluid diminishes the swelling and bruising and increases comfort. Patients are informed that there will be some leaking of a slightly bloody solution from the incisions for the first 24 h. Young patients with good skin tone who undergo deep body liposculpture do not usually need to wear a girdle, but they should avoid wearing tight clothes and underwear to prevent marking of the skin. After body liposculpture, elastic adhesive tape is applied and worn for 5 days, plus a girdle for 1 month to control edema and bruising and secure the skin while it retracts to its normal position. If after 24 h the

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dressing is marking the skin, or the girdle is provoking a depression, the dressing and girdle are removed, and manual lymphatic drainage is prescribed to avoid permanent depressions. Manual lymphatic drainage, a French massage technique, reduces swelling and bruising in the early postoperative days, increasing comfort and reducing pain. Although rare, infection is always a possibility, and 2 g of cephalosporin is administered intravenously intraoperatively and then 2 g every 2 h on the first day (a total of 8 g) and 500 mg every 8 h orally for 1 week postoperatively. Conclusions

My approach to body contouring does not rely on one surgical technique alone. It is a combination of different procedures to obtain the best possible result. The patient should always be aware that the degree of involvement postoperatively is proportional to the quality of the final result (Fig. 52.4). Body contour improvement does not depend on surgical technique alone. Ideally the treatment should involve different specialties. In many cases one needs to help motivate the patient to a change in life style to obtain a lasting result. A computer consultation helps the patient understand the limits of surgical improvement and in this way we can establish realistic postoperative expectations. We indicate the degree of patient involvement needed to obtain a lasting result and estimate the improvement according to this degree. The contour is improved using the syringe liposculpture technique, often with the help of the external ultrasound to facilitate difficult areas and even out the results of the suction; manual lymphatic drainage is recommended from the second postoperative day, when the areas are too sensitive. A high-protein, lowcarbohydrate diet is discussed with insistence that the patient start walking 2 miles a day on the third postoperative day. After 20–30 days, patients can start exercising, preferably under the instruction of a professional trainer.

L.S. Toledo

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a

Fig. 52.4 (a) Preoperative 35-year-old patient wanting to improve her dorsal region, flanks, and buttock irregularities provoked by injections. (b) Six months postoperatively after aspiration of 1920 mL from the dorsal region,

b

flanks, abdomen, and waist. After freeing the buttock depressions, 90 mL of autologous fat was injected into each area of depression

References 12. 1. Illouz Y. A new surgical technique for localized lipodystrophy. Brazilian Congress of Plastic Surgery, Forteleza, Brazil, 28 Nov 1980. 2. Fournier P. Liposculpture–Ma Technique. Paris: Arnette; 1989. 3. Klein JA. Tumescent technique for local anesthesia improves safety in large-volume liposuction. Plast Reconstr Surg. 1993;92(6):1085–98. 4. Toledo LS. Superficial syringe liposculpture. Annals of the International Symposium “Recent Advances in Plastic Surgery–RAPS/90”, March 3–5, 1990. São Paulo, Brazil. p. 446. 5. Toledo LS. Syringe liposculpture. A two-year experience. Aesthetic Plast Surg. 1991;15:321–6. 6. Hoefflin SM. Personal communication. May 6, 1997 ASAPS Congress in New York. 7. Toledo LS. The use of internal and external ultrasound for body contour. In: Batuira Tournieux AA, editor. Atualização em Cirurgia Plástica, Sociedade Brasileira de Cirurgia Plástica. São Paulo: Robe Editorial; 1999. p. 369. 8. Hunstad JP. Tumescent and syringe liposculpture: a logical partnership. Aesthetic Plast Surg. 1995;19:321–33. 9. Toledo LS. Total liposculpture. In: Gasparotti M, Lewis CM, Toledo LS, editors. Superficial liposculpture. New York: Springer; 1993. p. 34. 10. Toledo LS. Lipoescultura superficial. In: Avelar JM, editor. Anestesia Loco Regional em Cirurgia Estética. São Paulo: Hipócrates; 1993. p. 344–9. 11. Toledo LS, Regatieri FLF, Carneiro JD. The effect of hypothermia on coagulation and its implications for

13.

14.

15.

16.

17.

18.

19.

20.

21.

infiltration in lipoplasty: a review. Aesthet Surg J. 2001;21(1):40–4. Kaplan B, Moy RL. Comparison of room temperature and warmed local anesthetic solution for tumescent liposuction. A randomized double-blind study. Dermatol Surg. 1998;22:707–9. Samdal F, Amland PF, Bugge JF. Blood loss during liposuction using the tumescent technique. Aesthetic Plast Surg. 1994;18:157–60. Pitman GH, Aker JS, Tripp ZD. Tumescent liposuction. A surgeon’s perspective. Clin Plast Surg. 1996;23:633–41; discussion 642–5. Ostad A, Kageyama N, Moy RL. Tumescent anesthesia with a lidocaine dose of 55 mg/kg is safe for liposuction. Dermatol Surg. 1996;22:921–7. Samdal F, Amland PF, Bugge JF. Plasma lidocaine levels during suction-assisted lipectomy using large doses of dilute lidocaine with epinephrine. Plast Reconstr Surg. 1994;93(6):1217–23. Burk 3rd RW, Guzman-Stein G, Vasconez LO. Lidocaine and epinephrine levels in tumescent technique liposuction. Plast Reconstr Surg. 1996;97:1379–84. Toledo LS. Positioning the patient. In: Toledo LS, editor. Refinements in facial and body contouring. Philadelphia: Lippincott–Raven; 1999. p. 59. Talmor M, Hoffman LA, Lieberman M. Intestinal perforation after suction lipoplasty: a case report and review of the literature. Ann Plast Surg. 1997;38:169–72. Pereira LH, Radwanski HN. Fat grafting of the buttocks and lower limbs. Aesthetic Plast Surg. 1996;20:409–16. Toledo LS. Syringe versus ultrasound liposculpture. 29th Annual ASAPS Meeting. Orlando, Florida. 28 February–3 May 1996.

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22. Cook Jr WR. Utilizing external ultrasonic energy to improve the results of tumescent liposculpture. Dermatol Surg. 1997;23:1207–11. 23. Havoonjian HH, Luftman DB, Menaker GM, Moy RL. External ultrasonic tumescent liposuction. A preliminary study. Dermatol Surg. 1997;23:1201–6. 24. Gilliland MD, Coates N. Tumescent liposuction complicated by pulmonary edema. Plast Reconstr Surg. 1997;99:215–9.

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25. Barillo DJ, Cancio LC, Kim SH, Shirani KZ, Goodwin CW. Fatal and near-fatal complications of liposuction. South Med J. 1998;91:487–92. 26. Gibbons MD, Lim RB, Carter PL. Necrotizing fasciitis after tumescent liposuction. Am Surg. 1998;64:458–60.

Liposuction and Lipofilling for Treatment of Symptomatic Silicone Toxicosis of the Gluteal Region

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Rebecca C. Novo, Leela S. Mundra, Nicole Miller, and Christopher J. Salgado

Abstract

Silicone has sometimes been injected into tissues indiscriminately causing debilitating pain, infection, skin changes, and deformation. The authors discuss complications of silicone injections, stages of silicone toxicosis, preoperative evaluation, patient selection, imaging, and the technique of ultrasound-assisted liposuction (UAL) for removal of siliconomas. The outcomes have been very good with complete reduction in episodes of cellulitis and infection requiring antibiotics, as well as emergency room visits, which are relatively frequent preoperatively in this population. Although not a cure for this disabling problem, this technique can improve patients’ quality of life, helping to avoid extensive surgical resections as well as achieve favorable aesthetic results.

53.1

Introduction

Silicone injections in the gluteal region have been well established to cause a spectrum of complications including debilitating pain, infection, skin changes, and deformation. Liposuction has recently been described as a useful adjunct to

R.C. Novo, M.D. • L.S. Mundra, B.S. N. Miller, B.S. • C.J. Salgado, M.D. (*) Division of Plastic, Aesthetic and Reconstructive Surgery, University of Miami, Clinical Research Bldg., 1120 NW 14th St., 4th Floor, Miami, FL 33136, USA e-mail: [email protected]; [email protected]; [email protected]; [email protected], [email protected]

treating patients with complications from gluteal injections, as a way of reducing the toxin load and inflammatory effects of the foreign body reaction. Recently, fat grafting and lipofilling of the gluteal region have been utilized to minimize the deformational changes that occur from removal of toxin, preserving the aesthetic appearance. Both techniques will be presented in detail in this chapter.

53.2

Complications of Silicone Injections

Impure liquid silicone injections are currently illicitly used for gluteal augmentation. Complications are well established, and after an

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initial latent period, chronic inflammation ensues in the local and even distant areas, months to years after injection. Skin discoloration, induration, and thickening can all occur. Nodules and granulomas also form in variable distributions. In severe cases, overlying tissue may atrophy and ulcerate as the foreign body exudes from the tissues. Systemic complications due to migration of product [1] such as chronic respiratory disease, collagen vascular disorders, sepsis, and death have even been reported [2].

53.3

Ultrasound-Assisted Liposuction for Removal of Siliconomas

Surgical therapies proposed for removal of silicone-affected tissue include en bloc excision, dermolipectomy, liposuction, and most recently ultrasound-assisted liposuction (UAL). Due to the significant inflammatory response of surrounding tissues due to the silicone, the traditional closed blunt-tip liposuction cannula is difficult to push through tissues in a controlled fashion. Ultrasound-assisted liposuction has been utilized with great effectiveness and ease when faced with dense fibrotic tissues [3]. In the authors’ practice, surgical intervention is determined by the severity and stage of disease. In an effort to simplify the treatment algorithm, we have instituted a gluteal silicone toxicosis staging system. By establishing the clinical stage, we can easily determine the appropriate intervention which will optimize symptomatic relief and aesthetic outcomes.

53.4

Fig. 53.1 Stage 1 gluteal silicone toxicosis. This patient presented with the chief complaint of occasional gluteal warmth at the time of menses. Her symptoms were controlled with conservative management

Stages of Silicone Toxicosis [4]

53.4.1 Stage I Patients present with no previous or only occasional symptoms and typically an absence of physical findings (Fig. 53.1). Computed tomography (CT) scan or magnetic resonance imaging (MRI) commonly demonstrate foreign body with associated inflammation in the subcutaneous

Fig. 53.2 Inflammatory changes seen on computed tomography in the lateral thighs after silicone injection 1 year previously

gluteal tissue (Fig. 53.2). Treatment is usually supportive consisting of anti-inflammatory medication (NSAIDS) and steroids. Symptoms are not commonly constant and therefore medical therapy is beneficial.

53 Liposuction and Lipofilling for Treatment of Symptomatic Silicone Toxicosis of the Gluteal Region

53.4.2 Stage IIa Patients suffer from more frequent pain, tenderness, and cellulitis or abscesses, often prompting emergency room visits. Physical findings are often absent or may be evident by palpable nodules. Usually no chronic skin changes are evident (Fig. 53.3). Patients may present with significant pain and tenderness although no other physical findings may be elicited. A CT scan is recommended, which may demonstrate foreign body in the gluteal subcutaneous tissue.

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or MRI will demonstrate foreign body substance occasionally with appearance of silicone spheres or biopolymer beads in gluteal subcutaneous tissue associated with a strong inflammatory response and lymphadenopathy (Fig. 53.5).

53.4.4 Stage III Stage III patients present with minimal to significant symptomatology, and the gluteal region may have visible scarring from previous drainage procedures, significant leatherlike changes in skin

53.4.3 Stage IIb Patients also suffer from occasional pain, tenderness, and infections demonstrated by cellulitis or abscesses. Physical findings are often present as evidenced by redness, tenderness, palpable masses, and contour abnormalities. Chronic skin changes are present compared to stage IIa, with skin thinning and nodules (Fig. 53.4). A CT scan

Fig. 53.4 Stage IIb with chronic skin changes. This patient experiences more frequent pain associated with nodules

Fig. 53.3 Stage IIa gluteal silicone toxicosis in transgendered patient with no chronic skin changes, but frequent severe pain associated with palpable nodules and bouts of cellulitis requiring antimicrobial therapy and steroids

Fig. 53.5 Computed tomography of bilateral thighs and buttock after gluteal silicone injections. Dense bilateral distribution of biospheres is evident

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quality, contour abnormalities, palpable tender masses, open nonhealing wounds, or frequent drainage of silicone oil (Fig. 53.6). In patients who are symptomatic with mild to moderate skin changes, such as in stages IIa and b, ultrasonic followed by suction-assisted liposuction with or without autologous fat grafting in the muscular plane is used to reduce the local inflammatory reaction of the foreign body response while maintaining desirable contour. For the most severe cases with chronic fullthickness skin changes, resection may still be the only option. The treatment algorithm is summarized in Table 53.1.

53.5

Preoperative Evaluation

53.5.1 History

Fig. 53.6 Stage III gluteal silicone toxicosis with a history of ulcerating wounds. This patient was treated with wide excision and tissue rearrangement

Patients commonly present with the chief complaint of pain and/or recurrent infections associated with hard nodules or contour deformities. Most often is a history of “injection of a liquid”

Table 53.1 Classification system of gluteal silicone toxicosis and treatment strategy Stage I

Symptoms Absent or occasional pain and tenderness

Physical findings Absent

IIa

Pain occasional infection (cellulitis, abscesses)

Absent or minimal tenderness (palpable nodules)

IIb

Pain occasional infection (cellulitis, abscesses)

III

Minimal to significant symptomatology. Frequent pain

Imaging (CT, MRI) Foreign body with associated with inflammation in gluteal subcutaneous tissue Foreign body with strong inflammatory response in gluteal subcutaneous tissue

Treatment NSAIDS, steroids, during symptoms

Ultrasonic and suction-assisted liposuction. Tetracycline antibiotics, steroids, etanercept, tacrolimus, imiquimod, cyclosporine, allopurinol, 5-FU Present palpable Foreign body with More challenging for masses, redness occasionally appearance of liposuction as skin is thin and tenderness, skin silicone spheres or may be compromised. If patient contracture, contour biopolymer beads in has lipodystrophy, you may abnormalities, skin subcutaneous tissue, strong suction these areas first, prepare quality – thin inflammatory response, fat, and inject in muscular lymphadenopathy layers (deeper and different plane that toxin injected) following evacuation of toxin Palpable masses, Foreign body with Excision (with concealment of redness, tenderness, occasionally appearance of scarring as possible within contour abnormalities, silicone spheres or undergarments) scarring, fibrosis biopolymer beads in drainage, open subcutaneous tissue, wounds, skin lymphadenopathy quality – leatherlike

53 Liposuction and Lipofilling for Treatment of Symptomatic Silicone Toxicosis of the Gluteal Region

into the gluteal area, by an acquaintance. The “liquid” has been shown to range from silicone oil to biopolymer silicone-filled beads but is often of unknown etiology. Tests performed on the substances are cost-prohibitive and not routinely performed at our institution or others and thus explain the lack of data on substances actually injected here in the United States and abroad. If biopsy is performed or results are available, pathology typically reveals adipose tissue with focal fat necrosis, fibrosis, and histiocytic infiltrate consistent with reaction to silicone. Any active infection is a contraindication for UAL and should be treated acutely with oral or intravenous antibiotics depending on the severity of infection, until resolution. Incision and drainage and at times debridement may need to be performed for abscesses or tissue necrosis.

53.5.2 Imaging A preoperative CT scan of the abdomen and pelvis in the prone position is mandatory to determine the depth and distribution of tissue involvement. The imaging is obtained in the prone position to minimize the distortion of affected tissues by pressure. The CT scan is analyzed for intramuscular involvement, as this is an exclusion criterion for UAL. Silicone injections will appear hyperdense on normal x-ray and may have accompanying calcifications. On CT the collections can appear circumscribed or diffuse. If obtained, MRI reveals silicone as heterogeneous in intensity on T1-weighted imaging [5].

53.5.3 Patient Selection The ideal patients for UAL are stage IIa and b. Candidates for lipofilling would include patients with adequate unaffected adiposity for harvest, with expected larger volumes of toxin removal. It is these patients that may require fat grafting to prevent deflated or irregular contour after maximum affected tissue is removed.

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53.5.4 Patient Expectations Although we have seen significant improvements in patient’s subjective pain scores and overall satisfaction with quality of life post-UAL and lipofilling, it is paramount to set realistic patient expectations preoperatively. It is impossible to remove “all” foreign material and affected tissue even with radical excision. It is important to gently remind this patient population that there is no “cure,” but we continue to have improved modalities to hopefully decrease their overall pain, while optimizing form and function.

53.6

Intraoperative Details and Techniques

53.6.1 Preparation and Positioning Preoperative topographical markings are made on the fat harvest areas in preoperative holding in the standing position. In candidates for lipofilling, a circumferential, awake, standing prep is performed. The patient is placed on a bean bag and given general anesthesia. When lipofilling is planned, patients are placed in supine position for anterior abdominal fat harvest or lateral decubitus position for flank and hip regions. The patient is placed in the prone position for removal of the silicone-affected tissue, as well as subsequent intramuscular fat transfer.

53.6.2 Tumescence A solution of 1 l of warmed 0.9 % normal saline with 1 ampule (1 mg) of epinephrine (1:1000) is established. This is infiltrated to target areas in the super-wet fashion, using 1 mL of solution per anticipated mL of lipoaspirate. Aspirate is collected into sterile fat transfer canisters.

53.6.3 Fat Preparation Upon completion of liposuction, the fat is prepared by filtration to gravity through a lap sponge.

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Fat is then transferred into 10 mL syringes with Luer-lock caps in place and plungers removed. The top oil layer is allowed to separate from the center purified layer. The bottom aqueous layer is decanted by removing the Luer-lock cap and allowing the liquid to drain. Telfa (nonadherent dressing) is placed into thin strips as a wick to absorb the oil layer. Minimal fat manipulation is performed, to prevent further lipolysis and necrosis of injected fat.

53.6.4 Ultrasound-Assisted Liposuction (UAL) With the patient in the prone position, 4 mm skin incisions are created with a #11 blade in the superior gluteal cleft and bilaterally along the inferiorlateral gluteal fold. The super-wet infiltration technique is also implemented through these incisions, typically instilling 500 mL per side via a 10 in. blunt infiltration cannula. The skin sites are protected by placing the cut end of a 5 mL syringe as a “port site” which is secured with a 2-0 silk suture to the skin (Fig. 53.7). After waiting approximately 15 min for adequate infiltration of the tumescent solution, UAL is performed with a #5 cannula. Targeted areas for UAL are guided by the preoperative CT, as well as by manual palpation of the exterior gluteal surface, focusing on any nodular or hardened areas or contour deformities. Upon completion of UAL, standard liposuction removal is performed using both #4 and #5 Mercedes-tip cannulas. This is performed in a plane deep to the dermis and superficial to the gluteus maximus.

53.6.5 Lipofilling After completion of standard liposuction for removal of the silicone and affected tissue, the prepared fat is injected using a 10-in., blunt, fatinjection cannula. Fat is injected intramuscularly into the upper, central, and lower buttock. The

Fig. 53.7 Cut 3 mL syringe introduced to protect skin from thermal injury potentially caused by ultrasonic liposuction cannula

micro-aliquot technique is implemented in which 1 mL of fat is deposited on withdrawal of each pass of fresh tissue plane. After completion of contour reconstruction, all incisions are closed using a two-layered absorbable suture, followed by surgical skin glue.

53.6.6 Postoperative Care Postoperatively, all patients receive an abdominal binder and are placed in a compression garment with the buttock portion open to air so that there is no compression on areas which were injected with autologous fat. They are instructed not to lie in the supine position for 4 weeks. If there is ever a concern for overlying skin viability, we implement an air-fluidized bed for our inpatients for 5–7 days. After 7–10 days, patients are allowed to resume a limited sitting position, during which time a doughnut-shaped foam cushion

53 Liposuction and Lipofilling for Treatment of Symptomatic Silicone Toxicosis of the Gluteal Region

is provided, to prevent fat necrosis from external pressure.

53.7

Outcomes

Significant improvements in pain, most often complete remission by 12 weeks postoperatively, have been observed when lipofilling is used in conjuncture with UAL and SAL removal of silicone granulomas in the gluteal region. There has been a complete reduction in episodes of cellulitis and infection requiring antibiotics, as well as emergency room visits, which are relatively frequent preoperatively in this population [6].

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revealed subcutaneous inflammation and foreign body reaction through the gluteal and hip regions (Fig. 53.9). Because the inflammation was supramuscular, the patient was determined to be a candidate for UAL/SAL. Due to the extent of affected tissue and expectant deflation, fat grafting was performed in addition, to maintain the patient’s ideal gluteal aesthetics (Figs. 53.10 and 53.11). The patient’s symptoms resolved postoperatively, and she is overall satisfied with the maintenance of her original gluteal contour.

53.7.1 Case Example A 29-year-old female presented to our service with a history of gluteal “silicone injections” for augmentation 2 years previously by an unlicensed “provider” and was experiencing frequent pain and emergency room visits every 3 months for symptoms (Fig. 53.8). Preoperative CT

Fig. 53.8 A 29-year-old female with history of gluteal silicone injections for augmentation 2 years previously, experiencing frequent pain and multiple emergency room visits for symptoms

Fig. 53.9 Computed tomography revealing inflammation throughout bilateral gluteal and hip subcutaneous tissue

Fig. 53.10 400 mL of lipoaspirate removed from bilateral gluteal areas after initial ultrasound-assisted lipectomy performed to address the dense inflammatory tissue

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Preoperative CT imaging can help determine the distribution of inflammatory response and guide surgical therapy. Intramuscular involvement of silicone granulomas is a contraindication to performing UAL and SAL for removal of toxin. Although not a cure for this disabling problem, this technique can improve patients’ quality of life, helping to avoid extensive surgical resections as well as achieve favorable aesthetic results.

References

Fig. 53.11 Six weeks postoperatively the patient is painfree. Gluteal deflation or extreme changes in contour were avoided after removing a significant amount of affected tissue by utilizing auto-augmentation with fat grafting

Conclusions

Implementation of UAL with lipofilling improves cosmesis in patients with gluteal silicone toxicosis and simultaneously reduces medical complications seen in infections, pain, and emergency service utilization. This technique is best applied to patients with frequent pain and contour deformities.

1. Narins RS, Beer K. Liquid injectable silicone: a review of its history, immunology, technical considerations, complications, and potential. Plast Reconstr Surg. 2006;118(3 Suppl):77S–84. 2. Hage JJ, Hanhaie RC, Oen A, van Diest P, Karim R. The devastating outcome of massive subcutaneous injection of highly viscous fluids in male-to-female transsexuals. Plast Reconstr Surg. 2001;107(3): 734–41. 3. Bassetto F, Abatagnelo S, Massetto L, Vindigni V. Ultrasound-assisted liposuction as a safe and effective method for the removal of siliconomas. Aesthetic Plast Surg. 2012;36(1):220–2. 4. Salgado CJ, Novo RC. Classification system for silicone toxicosis of the gluteal region. Aesthetic Surg J. 2015. In publication. 5. Frank SJ, Flusberg M, Friedman S, Sternschein M, Wolf EL, Stein MW. Aesthetic surgery of the buttocks: imaging appearance. Skeletal Radiol. 2014;43(2): 133–9. 6. Salgado CJ, Sinha VR, Desai U. Liposuction and lipofilling for treatment of symptomatic silicone toxicosis of the gluteal region. Aesthet Surg J. 2014;34(4): 571–7.

Liposculpture of the Lower Extremities Using a Tourniquet

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Kamal Cherif-Zahar and Soraya Bensenane-Hasbelaoui

Abstract

The calf and the ankles have not been considered good for liposuction because of significant postoperative pain and edema. The authors have described a method using a tourniquet for liposuction of the lower extremities. The anatomy, classification established based on both the degree of weight excess and the morphological type, the physiopathology of the heavy legs syndrome and lipoedema, surgical technique, and complications are discussed. Liposuction under a pneumatic tourniquet of the leg permits the treatment of zones that are known to be difficult and of which the indication has been challenged up to now.

54.1

Introduction

The calf and the ankles have not been considered good for liposuction because of significant postoperative pain and edema [1–5]. A pneumatic tourniquet, as orthopedic surgeons have used for a long time, allows precise liposculpture without infiltration and minimal postoperative sequelae even in the case of very large extractions [6, 7]. Experience with over 150 cases over a period of more than 7 years has enabled the authors to formulate some new notions concerning the physiopathology of the heavy legs syndrome and modifications of the surgical technique. K. Cherif-Zahar, M.D. (*) Private Practice, 6 Rue D’Estrées, Paris 75007, France e-mail: [email protected] S. Bensenane-Hasbelaoui, M.D. Private Practice, 60 Rue Candle, Alencon 61000, France

54.2

Definition

Legs liposculpture using a touniquet is the extraction of adipose tissue from the inferior extremity (ankle, calf, knee, and inferior third of the thigh) by the use of a pneumatic tourniquet. This aspiration is performed without tumescent infiltration and after interruption of the blood circulation by inflating the pneumatic tourniquet. The operation begins as soon as the leg is emptied of its blood. When terminated, it is mandatory to place an elastic bandage before removing the tourniquet.

54.3

History

In 1985, Teimourian [6] proposed (unpublished data) a liposuction technique under tourniquet but he infiltrated the tissues. In 1993, the authors

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devised the idea of using a pneumatic tourniquet in a case of adipose excess localized in the ankles, as practiced by orthopedic surgeons for the cure of hallux valgus. The postoperative course and results were surprisingly excellent. The procedure was repeated in other cases with similar encouraging results [8–10].

54.4

Anatomy

No precise description of the distribution of the adipose tissue in the human organism is found in classical anatomy books. Feminine and masculine morphologies are different. The gynecoid distribution results in a particular feminine morphology with excess fat distribution in the hips and thighs. It is, however, necessary to distinguish anatomical varieties according to the degree of excess weight and the morphological type. The underlying conventional anatomy should be considered for both technical and esthetic reasons. For convenience, the leg is considered as the part of the lower limb situated beneath the pneumatic tourniquet. It comprises regions and spaces: 1. Regions: • Inferior third of the thigh included in the knee • Knee • Calf • Ankle • Foot 2. Spaces: • In reference to a surgical plan, one can consider that the adipose tissue is organized as extractable spaces. They are not partitioned anatomical entities with distinct limits and they are accessible by different surgical approaches. • The leg can be divided into four spaces by a sagittal and a frontal plane passing, respectively, by the tibial crest and the two malleoli. This permits an anatomical division. (a) The ankle: This comprises the anteroexternal malleolar space that extends from the tibial crest at the front to the fibula at the back, with a round inferior limit

forming an inferior convexity. The fibula superposes the anteroexternal muscular compartment. At this level, a cutaneous pinch of the top of the foot can reveal in some individuals a true lipoma in the anteroexternal compartment. Above this, the space is in continuity with the anterior surface of the leg. The posteroexternal space extends from the fibula at the front to Achilles tendon at the back. It continues below with the retro and external submalleolar compartment. Above, it continues with the internal adipose space of the knee and the subpopliteal space. The anterointernal space extends from the anterior tibialis tendon and the tibial crest at the front to the internal malleolus at the back. In some cases, the internal malleolus is surrounded by adipose tissue that effaces its normal contour. Here also, a cutaneous pinch can make a distinction between the zone of excess adiposis and the skin of the foot. The posterointernal space extends from the internal malleolus at the front to Achilles tendon at the back. It is prolonged below by the retro and submalleolar space and above by the internal adipose space of the knee. The external submalleolar adipose lump at the ankle level is often a true lipoma situated above and slightly in front of the inferior edge of the external malleolus. (b) Knee: The superior internal knee space is limited anteriorly by the prominence of the vastus internus of the quadriceps muscle, posteriorly by the grand adductor, superiorly by the tourniquet, and inferiorly by the articular interline. In muscular persons, a depression can be observed behind the vastus internus. The inferior internal knee space is limited anteriorly by the fibular tendon, the anterior tuberosity of the tibia, and the tibial crest. Posteriorly, it continues below with the adipose spaces of the calf.

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The supra-fibular space comprises the vastus internus and externus, which meet forming an inverted V, thus limiting the depression observed in muscular persons. The internal and external subfibular lumps are situated on each side of the fibular tendon and efface its normal contour. At stages IV or V (see classification infra), the fibula forms a depression in connection with the surrounding zones. The superior external knee space extends from the vastus externus to the crural biceps tendon. The inferior external knee space extends from the tibial crest to the relief of the anteroexternal leg muscle. (c) Calf: The muscular rounded contour can be covered by a thick panniculus adiposus (a large calf). A subpopliteal space has been described that reaches from the popliteal fold above to the junction of the pulpy bodies of the gemelli interior and exterior. This space joins the Achilles space. This long and tedious description is more useful for the surgical applications of the technique than the classical anatomical one is.

54.5

Classification

A classification can be established based on both the degree of weight excess and the morphological type: 1. Stage I: Quasi-total absence of adipose tissue. The skin directly covers the osteo-musculotendinous plan with no layer of fatty tissue. This is seen in lean subjects as well as in body builders who follow a protein diet. 2. Stage II: The adipose tissue is distributed harmoniously with an effacement of certain anatomical protrusions but with the presence of the bimalleolar and Achilles tendon contours. This is the case of the famous beautiful legs of actresses and models. 3. Stage III: This corresponds to a light excess of subcutaneous adipose tissue but to the point

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that in certain zones, it can be pinched like a lipoma. The surcharge can predominate at the knee or the ankle or be distributed uniformly. The quantity of fat extracted at this stage ranges from 300 to 400 mL. 4. Stage IV: The adipose excess is quite important and is distributed over the whole leg. It leads to a fading out of the normal contours to the point that the malleoli form a depression. The foot is little or not concerned. The quantity of fatty tissue aspirated can reach 1,500 mL on each limb. Such a situation corresponds to true elephantiasis. 5. Stage V: This is the extreme stage, with venolymphatic complications. The lipoedema is permanent. Extractions exceed 1,500 mL. The authors have artificially defined stages III, IV, and V as a function of the volume of fat extracted. A more precise classification could probably be established, based on the exact assessment of subcutaneous adiposis by an investigation such as magnetic resonance imaging.

54.6

Physiopathology of the Heavy Legs Syndrome and Lipoedema

Improvement of the sensation of heaviness of the legs that is obtained by liposuction under pneumatic tourniquet, while no other apparent cause outside of the adipose excess was in evidence, came as an unexpected event. This led us to a reflection on the physiopathology of heavy legs in general, as well as to propose an explanation of lipoedema. The notion of lipoedema is not new. It was mentioned in 1940 by Allen [11], who gave the name of lipoedema to this pathology. In 1949, he defined it as an anatomo-clinical entity and attempted to establish specific criteria. The literature is scarce on this subject. It recognizes the existence of lipoedema but does not explain the mechanism or the treatment [12, 13]. In addition, no mention of lipoedema is found in present-day medical books [14]. However, the notion of obesity is often evoked in the etiology,

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and a slimming cure is part of the therapeutic attempts to cure lipoedema. The main data generated by the authors’ study are the following: • The adipose excess of the lower limbs almost always concerns women (99 % of our cases). • The average age is 44 years. • A family history of adipose excess is frequent. • The sensation of heavy legs is found in 80 % of cases. • The adipose surcharge is rarely associated with an obvious venolymphatic insufficiency (absence of varicosities). • The adipose surcharge is associated with simple edema rather than lipoedema. • Large-scale adipose excess simulating the features of elephantiasis is associated with venolymphatic disorders. Such a notion is found in the literature. The physiopathological mechanisms of edema of the lower limbs are well known in general etiologies such as cardiac, renal, and venolymphatic insufficiencies, hypoproteinemia, etc. However, they are still poorly known in cases of isolated adipose excess. Therefore, how can one explain these edemas and this heaviness of the legs in so many patients with no apparent venolymphatic pathology and no cardiac or renal disorder? When an adipose dysmorphia exists, even discrete, the increase in the quantity of tissue that must be oxygenated and nourished augments the local arterio-venolymphatic flow in proportion. Likewise, the interstitial space increases in parallel to this augmentation of the flux of interstitial liquids. At this stage, the edema stays discrete in situ, but it is already symptomatic. Beyond a certain increase in the flux associated with larger adipose excess, the capacity of venolymphatic adjustment may be overrun. This occurs by outbreaks upon the occasion of a prolonged sitting or standing position (e.g., longlasting flights), by water retention of alimentary origin (meal too rich in NaCl), or by a hormonal cause (pregnancy, second part of menstrual

cycle). Edema with pitting on pressure or an impression left by the stocking can be observed. This edema can be resorbed by a reclining position or avoided by an elastic support (varicose stockings). In extreme adipose surcharges, the increase of the interstitial flux proportional to the quantity of tissue to nourish creates a larger edema that cannot be resorbed by rest or a change of position. The chronic functional lymphatic insufficiency finally results in organic lesions. This corresponds to the stage of elephantiasis, similar to a classical and unilateral one, which is secondary to an initial disorder of the lymph ducts.

54.7

Surgical Technique

In most cases, the operation is performed under general anesthesia with endotracheal intubation. Sometimes, a locoregional anesthesia is administered (e.g., peridural) but never a purely local anesthetic. During the whole surgical intervention, the patient is placed on dorsal decubitus. The pneumatic tourniquet is placed on the mid thigh. Two pneumatic tourniquets; one or two sterile Esmarch bandages; an aspiration pump; several cannulas of gauges 2, 3, 4, and 5 mm; or Fournier’s syringes [2, 14] are required for this intervention. The antiseptic must not erase the marks on the skin. The surgeon should check that all the equipment is ready for use in order not to loose time, because the tourniquet imposes a limited operation time of 1 h maximum. The choice of approach is guided by two factors: (1) the cannula must stay parallel to the main axis of the leg and (2) the scars should be the least apparent possible and as few as possible. Eight incisional approaches of a diameter of approximately 3 mm are prepared without necessarily using all of them. 1. At the ankle, there are four approaches: (a) Anterointernal: situated at one-finger width in front of the anterior edge of the malleolus internus

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(b) Posterointernal: situated in the middle of a line extending from the malleolus internus to the heel (c) Anteroexternal: situated at mid distance between the malleolus externus and the anterior tendon of the leg at one-finger width toward the outside (d) Posteroexternal: situated in the middle of the line joining the malleolus externus to the heel 2. At the knee level, there are three approaches: (a) Internal: situated at the junction of the internal and external meridians of the leg and the thigh (b) External: situated at one-finger width above the contour of the peroneal head (c) Subfibular: Situated at the level of the superior edge of the fibula 3. At the calf level, there is one approach. Posterior: situated at the median part of the gastrocnemius muscle (calf) between the contours of the gemelli externus and internus at the level of their musculotendinous junction.

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Fig. 54.1 Esmarch elastic bandage is applied, and then the tourniquet is inflated

54.7.1 Measurements Starting at the inferior edge of the malleolus internus, the perimeters of the leg are measured every 5 cm with a measuring tape and marked on the skin. These measurements are taken all along the leg up to the tourniquet.

54.7.2 Operation Tactics • The leg is emptied of its blood with the help of an aseptic Esmarch bandage (Fig. 54.1). • The tourniquet is inflated to 30–35 mmHg. • The Esmarch bandage is removed as soon as the tourniquet is inflated. • The incision is at the selected accesses previously marked with a felt-pen marker. • The adipose extraction should be fan-shaped, homogeneous, and regular. Experience has enabled us to develop and codify all of the surgical maneuvers for a complete

Fig. 54.2 Incision sites are marked at the ankle and the knee

sculpture of the leg. Short (3–5 mm) incisions are used in the direction of the natural fold and in positions that permit the best access to the areas of liposculpture (Fig. 54.2). Surgery is begun with the ankle at the end of the operation table, with the surgeon seated on a stool. The excess fatty tissue of the anteroexternal space is emptied by an anteroexternal incision, followed by the anterointernal space of the ankle by an anterointernal incision, the internal retromalleolar groove is hollowed out via a posterointernal incision, and the posterointernal space is treated. A posteroexternal incision of the ankle is used to hollow out the external retromalleolar groove and the posteroexternal space is sculptured. Subsequently, with the surgeon standing at the right of the table at knee level, the internal side of the knee toward the lower end is incised, which permits the sculpture of the whole internal face of

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the leg. Moving to the left of the table, an incision and a fan-shaped extraction are performed in the direction of the anterior tuberosity of the tibia and the subfibular area, and continuing without stopping, we return backward to the right and upward to the left superointernal space. With the leg flexed, its external face is treated via an external incision of the knee. With the leg in extension and in internal rotation, while the surgeon is standing at the end of the table, there is access to the external subfibular adipose lump, to the external edge of the fibula, and, with the knee in flexion, to the external superior space of the knee. The supra-fibular space of the knee can be aspirated either in flexion or in extension via a fibular incision and then turning interiorly toward the superior internal space of the knee and the internal subfibular adipose lump. The same fanlike gesture permits the passage from the vastus externus to the tibial crest. Lastly, via a posterior incision of the calf with the hip flexed, the knee in extension, and the foot held in flexion by the assistant, the Achilles tendon, the calf, and the subpopliteal space can be precisely sculptured. The leg is transformed and sculptured according to the patient’s request. During the surgical procedure, a notice of the elapsed time is given every 10 min. Whether the incisions are closed or not depends on the surgeon’s habits. The measurements of the leg circumference are taken again and noted, and photographs are taken at the end of the operation. They will serve as a reference for a procedure on the other leg. The fat collected is pure yellow without any blood (Fig. 54.3). It takes approximately 30–40 min to do one leg and the other leg is operated on in a similar fashion (Fig. 54.4). A large aseptic operative field isolates the opposite leg. Compression is mandatory before removing the tourniquet (Fig. 54.5). It consists of an elastic bandage by a double stocking for varicose veins (70 deniers) and then by a superposed elastic band of Biflex type. When the tourniquet is released, the capillary pulse of the toes is closely monitored after cutting off the stocking at toe level.

Fig. 54.3 Three liters of fat with no blood

The fat volumes extracted from each space are noted during the operation in order to aspirate the same amounts on the other leg.

54.8

Postoperative Period

The immediate postoperative course is usually simple, with pain remaining moderate in spite of the large amounts of adipose tissue extracted. Edema and ecchymosis are practically absent. Patients are authorized to get up the next day. The day after surgery, it is possible for stage III patients to go home, while one or two more days may be necessary for stage IV and V patients. Sutures are removed between the eighth and the tenth days. Postoperative visits are made on days 1, 2, 6, 12, and 30. Compression devices are kept on for 1–2 months.

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Liposculpture of the Lower Extremities Using a Tourniquet

Fig. 54.4 (a) Right leg with completed liposculpture with tourniquet. (b) Posterior aspect on other patient

a

b

54.9

Fig. 54.5 Compression dressing applied to the leg

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Complications

The authors observed five undesirable events. They were diverse in nature, but none of them were really serious or unresponsive to appropriate therapeutic actions. The worst adverse reaction was in a patient who developed a paralysis of the popliteus externus. The latter was attributed to the slipping of the elastic bands due to movements of the knee. This induced a compression of the external popliteal branch of the sciatic nerve. Since then, we have abandoned the use of two elastic bands applied directly to the skin. The authors prefer compression by a pair of tights for varicose veins. The elastic bands put in place at the end of the intervention are then definitely removed 1 h later. One case of a unilateral cellulitis was observed in a diabetic patient. The infection was treated and rapidly cured by several small cutaneous discharge incisions combined with antibiotics. A case of major edema occurred after a large adipose extraction (1,500 mL) in one patient who

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returned to work the next day, in spite of our advice not to do this. The edema regressed after 3 months and the result after 1 year remained excellent. In two cases, in the course of the operation, the tourniquet let go on one leg. In one of these cases, the surgery was continued without putting the tourniquet back. The immediate postoperative consequences were simple for the side where the tourniquet stayed in place, but there was more edema, pain, and ecchymosis in the leg where the tourniquet let go. Thus, we had the unsolicited opportunity to compare the two methods. In the other case, the blood of the leg was reemptied by the use of an Esmarch bandage and the tourniquet was reinflated. The aspiration was carried on including both the adipose tissue and the extravasated blood. In this case, the immediate postoperative reactions were the same for the two legs.

54.10 Discussion In our series of patients, we did not control the results of the treatment by comparing the classical technique on one leg and the technique under tourniquet on the other leg, except for one case. Obviously, such a comparative approach would be of interest for a more rigorous evaluation of the procedure. With respect to the complications, the authors observed a rate of 3.4 % in 150 cases. There was no occurrence of life-threatening or otherwise major adverse events. In a review of the literature looking for potential complications associated with the use of pneumatic tourniquet, one can find mention of hemodynamic and biological changes such as an increase of the PCO2 and a decrease of the PO2 . These changes are rare and, when present, are temporary and follow the release of the tourniquet. Most often, this occurred in older patients. Phlebitis and pulmonary embolism represent the most frequently reported complications because of the use of the tourniquet [7]. These problems have been reported by orthopedic

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surgeons, who are the main ones to use pneumatic tourniquets. Our logical theoretical response is that if there is no blood, there will be no clot. Correct emptying of the blood of the lower limb before inflating the tourniquet is mandatory and can avoid the formation of clots since the vessels are emptied of their blood. Liposuction under tourniquet offers several significant advantages: • No infiltration of solution is necessary. This permits not only a valid appraisal of the quantity of fat extracted but also a satisfactory sculpture because of the absence of injectioninduced modification of the form of the leg to be operated upon (Fig. 54.6). • The absence of bleeding during the surgical procedure prevents the modification of the anatomical form that would occur by infiltration of the tissues. It thus permits a sculpture that corresponds to the precise image of the final result. • Ecchymosis is rare and only minor. • Pain and postoperative edema are practically absent, which permits early walking and a reduced length of hospital stay. • Patients can rapidly return to their socioprofessional activities, usually 1 week after the operation. Liposuction under tourniquet also presents a few drawbacks: • The absence of local anesthesia leads to the prescription of larger amounts of analgesics generally administered during the first postoperative hours. • The duration of the procedure is limited by the use of the tourniquet. We voluntarily limit this time to 1 h. This is usually sufficient to achieve a complete sculpture of the leg. For large extractions, cannulas of larger gauge are used and touch-ups are left for a second operation. • This technique does not permit the treatment of areas above the tourniquet during the same operating time, leaving them to be operated on secondarily by the classical technique.

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a

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Fig. 54.6 (a) Preoperative patient with lipodystrophy of the legs. (b) Postoperatively following liposculpture with the tourniquet

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Conclusions

Liposuction under a pneumatic tourniquet of the leg permits the treatment of zones that are known to be difficult and of which the indication has been challenged up to now. The results obtained over a 7-year period of time were most satisfying esthetically with the precision of the sculpture of the leg having never been achieved before. The unexpected functional improvement has led to a better understanding of the physiopathology of the heavy legs syndrome and of lipoedema.

Acknowledgment The English translation was by Andre Morin. Portions of this work are reprinted from Ref. [10] with permission from the International Journal of Cosmetic Surgery and Aesthetic Dermatology, Mary Ann Liebert, Inc.

References 1. Schmitz R. Lipoedema from the differential diagnostic and therapeutic viewpoint. Z Haufkr. 1987;62: 146–57. 2. Fournier PF. Liposculpture, Ma technique. Paris: Arnette; 1989.

K. Cherif-Zahar and S. Bensenane-Hasbelaoui 3. Illouz YG, deVillers YT. Body sculpturing by lipoplasty. New York: Churchill Livingstone; 1989. p. 270–80. 4. Lucchi M, Tucci S. Clinical and diagnostic criteria. Angiologia. 1990;42:133–7. 5. Cherif-Zahar K. Liposuccion des jambes sous garrot pneumatique. J Méd Esthet Chir Dermatol. 1995; 22(86):89–92. 6. Teimourian B. Tourniquet after suction lipectomy of the lower extremity. Plast Reconstr Surg. 1985; 75(3):442. 7. Brorson H, Svensson H. Liposuction combined with controlled compression. Plast Reconstr Surg. 1998;102(4):1058–67. 8. Cherif-Zahar K. La liposuccion des chevilles sous garrot pneumatique. Série personnelle de 25 cas. Rev Chir Esth Lang Fran. 1995;10(79):51–4. 9. Cherif-Zahar K. Liposculpture of legs using tourniquet. Am J Cosmet Surg. 1999;6(3):207–15. 10. Cherif-Zahar K. Leg lipostructure under tourniquet. Int J Cosmet Surg Aesthet Dermatol. 2001;3(1): 31–5. 11. Allen E, Hines EA. Lipedema of the legs: a syndrome characterized by fat legs and orthostatic edema. Proc Staff Mayo Clin. 1940;15:184–7. 12. Young JR. The swollen leg. Am Fam Physician. 1977;15(1):163–73. 13. Beninson J, Edelglass JW. Lipoedema (the noun) lymphatic masquerader. Angiology. 1984;35(8): 506–10. 14. Harrison TR. Principes de Médecine Interne. Paris: Flammarion; 2000.

The Transverse Upper Gracilis Flap for Breast Reconstruction Following Liposuction of the Thigh

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Anita T. Mohan, Corrine Wong, and Michel Saint-Cyr

Abstract

Liposuction is a common aesthetic procedure and it has been used in defatting flaps and other procedures than aesthetic. Reconstruction with flaps needs good blood supply. If liposuction has previously been done, there can be a question of the vascularity of a flap. The authors present a patient who had prior liposuction of the abdomen and medial thighs, and also bilateral mastectomies were reconstructed with implants and the latissimus dorsi on the left. Because the abdomen was not suitable for further reconstruction, bilateral transverse gracilis myocutaneous flaps were utilized and there were no postoperative complications. Although the history of previous liposuction contouring procedures may present a potential increased risk in perforator flap harvest, it has been demonstrated that it is not an absolute contraindication.

55.1 A.T. Mohan, MRCS Division of Plastic Surgery, Mayo Clinic, Mayo Building 12th Floor, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA e-mail: [email protected] C. Wong, MRCS Division of Plastic Surgery, UT Southwestern, 1801 Inwood road, Dallas, TX 75390, USA M. Saint-Cyr, M.D. (*) Director, Division of Plastic Surgery, Wigley Professorship in Plastic Surgery, Baylor Scott and White, 401 S. 31st Street, Temple, TX 76508, USA e-mail: [email protected]

Introduction

Liposuction body contouring is now the most common cosmetic procedure carried out in the United States according to the American Society of Aesthetic Plastic Surgery, with approximately 342,000 procedures carried out in 2014 [1]. Perforator flaps are commonly used for autologous reconstruction following mastectomy, as they can provide ample tissue, long-lasting results, and minimal donor site morbidity. A history of previous liposuction is conventionally considered as a relative contraindication for perforator flap harvest because of concern regarding direct perforator damage, scarring, and potential compromise to the blood supply of the overlying skin and fat [2, 3].

© Springer-Verlag Berlin Heidelberg 2016 M.A. Shiffman, A. Di Giuseppe (eds.), Liposuction: Principles and Practice, DOI 10.1007/978-3-662-48903-1_55

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However, some clinical and anatomical studies in the literature have contested the conventional belief on the impact of liposuction on musculocutaneous and fasciocutaneous perforators and tissue vascularity [2, 4, 5]. In the last 10 years, small case series have demonstrated successful reconstruction free transverse rectus abdominis myocutaneous flaps following liposuction [6–8]. A few small studies have also shown that perforator flaps such as the deep inferior epigastric artery perforator (DIEP) and superior gluteal artery perforator (SGAP) flaps [2, 3, 9]. The transverse upper gracilis myocutaneous (TUG) flap is a well-described option in autologous breast reconstruction [10–14]. Although it is considered a second-choice option, the abdomen being a primary donor site when tissue is available, in selected patients the TUG flap provides a reliable reconstructive option for smallto medium-sized breasts. A case of bilateral breast reconstruction is presented with transverse gracilis myocutaneous flaps in a patient following a previous liposuction contouring procedure [15].

55.2

Case Presentation

A 50-year-old female with a history of bilateral mastectomy for breast cancer had undergone implant-based reconstruction of the right breast and a latissimus dorsi (LD) flap in combination

with an implant reconstruction of her left breast (Fig. 55.1). Following postmastectomy radiotherapy to her left breast, she developed a subsequent capsular contracture and breast asymmetry. The patient did not desire augmentation to her breast volume. Following patient consultation, the surgical plan was to perform a tertiary bilateral autologous reconstruction to improve symptoms and cosmesis. Four years ago the patient had undergone previous cosmetic surgical procedures including an abdominoplasty and liposuction to both thighs. On examination of available autologous donor site, there was insufficient tissue to afford an abdominal-based reconstruction. Given the history of liposuction of the medial thigh, this site had been initially excluded as a potential donor site, and the superior gluteal artery perforator flap was recommended as the most suitable option. Unfortunately the patient refused this option, despite appropriate counseling; therefore, a reevaluation was made to consider use of bilateral TUG flaps, to which the patient was more amenable. The skin paddles were designed 7 × 31 cm in size, in a transverse orientation 1 cm below the inferior gluteal crease (Fig. 55.2). The distance from the posterior border of the gracilis to the posterior border of the skin paddle was 17 cm. The flap was harvested using a subfascial dissection and inclusion of fascia from the adductor longus. All perforators along the anterior

Fig. 55.1 Preoperative 50-year-old female following previous bilateral mastectomy and implant reconstruction on the right, LD and implant reconstruction on the left, and previous irradiation of the left breast reconstruction

55 The Transverse Upper Gracilis Flap for Breast Reconstruction Following Liposuction of the Thigh

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Fig. 55.2 Left TUG flap skin paddle design. Right following flap harvest

Fig. 55.3 Six months postoperative following bilateral TUG flaps and early postoperative results 11 days following insertion of bilateral implants

border of the gracilis muscle and all musculocutaneous perforators to the skin paddle and between the septum of the adductor longus and gracilis were maintained. The skin paddle was secured to the gracilis muscle to minimize any shearing forces on the perforator. To maximize volume and vascularity, the skin is undermined along the length of the gracilis muscle to maximize the amount of fat harvested with the flap. The pedicle length was 6 cm and the flap was anastomosed to the contralateral internal mammary artery and vein in the third intercostal space. Costal cartilage from the resections was used for immediate nipple reconstruction. The donor site was closed with progressive tension sutures and over closed suction drains. No donor

site or flap complications occurred and all wounds healed uneventfully (Fig. 55.4). Six months following her autologous reconstruction, she underwent bilateral implant insertion (Figs. 55.3 and 55.4).

55.3

Discussion

Traditional donor site selection for autologous breast reconstruction most commonly includes the lower abdomen, medial thigh, and gluteal area depending on the patient’s body habitus and preferences. These areas coincide with common areas for liposuction and body contouring procedures. This situation poses a dilemma in that

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Fig. 55.4 Left Preoperative planning of TUG flap skin paddle. Right Early postoperative donor site

these areas would be traditionally excluded as a perforator flap donor site. Body contouring liposuction is the most common cosmetic procedure being performed in the

United States. It can be appreciated that with this increasing trend, more patients who seek reconstructive surgery, for example, breast reconstruction following mastectomy, may have a history of

55 The Transverse Upper Gracilis Flap for Breast Reconstruction Following Liposuction of the Thigh

these cosmetic procedures. The impact of liposuction on perforator anatomy and overall vascularity has traditionally supported the concept that these procedures lead to reduction in the number of perforators available, direct trauma to the perforators, increased risk of necrosis of overlying tissue, and scarring in the subcutaneous tissue and around the perforators [9, 16]. Clinical and anatomical studies which have reviewed the impact of liposuction on vascular integrity of overlying tissue have been published; however, these are small case series and there is still a dearth of available evidence in this area. Ozcan et al. [17] had identified that there was a significant correlation in direct damage to the perforating vessels and compromise to the microcirculation following vacuum-assisted liposuction in a rat model. In a second experiment, the comparison of different liposuction cannulas, the Fournier and the spherical tip, was shown to be less traumatic with increasing number of passes and had a lower incidence of flap necrosis. In a cadaveric study by Blondeel et al. [18] investigating the effect of ultrasound-assisted versus conventional liposuction on perforating vessels in the lower abdominal wall in 20 fresh cadavers, no difference was seen between the two techniques. However, examination of the microangiographic vascularity of the lower abdominal skin and fat demonstrated some degree of vessel damage. In a clinical assessment of patients using color Doppler ultrasonography following suctionassisted liposuction, it was found that there was an immediate reduction in the number of perforators detected, 58 % in the abdomen and 54 % in the medial thigh. This observation was consistent at a 2-week and 3-month postoperative assessment. No correlation could be made between the number of passes and amount of lipoaspirate and the reduction in number of perforators, but this was due to the study being underpowered [16]. However, over a longer follow-up period, it may be expected that there would be some recovery of initial trauma, including recanalization of traumatized vessels or neovascularization to form new perforators to the overlying skin. In contrast, in a cadaveric study, Teimourian et al. [4] had found that following liposuction, the

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vessels located within the fibrous septa remained intact, which was confirmed on histological examination. This finding was supported by Emeri et al. [5] brief correspondence evaluating the perforator anatomy of the musculocutaneous perforators of abdominal tissue in fresh cadavers following liposuction. Through anatomical studies and radiological imaging following contrast injection into the deep inferior epigastric artery, it was demonstrated that principal perforators in the region remained unchanged. However, the notable limitation of these studies was that they do not account for the possible derangement of vessel integrity through continuous negative pressure and action of liposuction which may lead to more subtle trauma, vessel rupture, vasospasm, and development of intravascular thrombosis which may occur immediately in a clinical setting. Although there is a paucity of clinical data on the use of perforator flaps following liposuction, successful autologous reconstruction has been demonstrated in small case series including our case report [3, 6–9, 15]. These case series have shown successful reconstruction of deep inferior epigastric artery perforator (DIEP), superior gluteal artery perforator (SGAP), and TUG flaps following liposuction. Salgarello et al. [2] performed follow-up color and pulse-wave Doppler sonography to assess deep inferior epigastric artery perforators 6 months following liposuction without any evidence of loss in number of perforators. In reports of successful flap reconstruction following liposuction, an assessment was carried out preoperatively to evaluate number of perforators and perfusion to the overlying skin using Doppler sonography, preoperative computed tomographic angiography (CTA), and intraoperative indocyanine green fluorescence angiography. It was not uncommon to identify some degree of scarring around perforating vessels, which may make the dissection more challenging, but this did not hinder the perforator flap dissection, and flaps were successfully harvested without flap loss or partial necrosis. The key point to address in the harvest of the TUG flap would be to ensure the dissection is carried out in the subfascial plane. The techniques adopted to increase the vascularity of the

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flap harvested include the harvest of adductor longus fascia, preservation of all perforators along the length of the gracilis and within the septum between the gracilis and adductor longus, and incorporation of as much fat directly over the gracilis muscle as an extended approach, which has been previously described [14].

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Conclusions

The evidence in the published literature is still very limited; however, this patient population may represent a rising trend that will be seen in reconstructive surgery practice. Although the history of previous liposuction contouring procedures may present a potential increased risk in perforator flap harvest, our experience and other case series have demonstrated that it is not an absolute contraindication. The use of preoperative and intraoperative imaging such as fluorescence angiography or Doppler sonography can be a useful adjunct to the assessment of perforator vessel anatomy and tissue perfusion for safe flap harvest. Perforator flaps can be safely and successfully harvested for autologous reconstruction following liposuction; however, a thorough history, clinical examination, and appropriate counseling of the patient is essential, and the use of noninvasive preoperative and intraoperative imaging techniques can provide further information to plan and assess viability of the flaps when harvested.

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9.

10.

11.

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14.

References 1. American Society of Aesthetic Plastic Surgeons Press release. http://www.surgery.org/media/news-releases/ the-american-society-for-aesthetic-plastic-surgeryreports- americans-spent-more-than-12-billion-in2014--pro Accessed 10 Jun 2015. 2. Salgarello M, Barone-Adesi L, Cina A, Farallo E. The effect of liposuction on inferior epigastric perforator vessels: a prospective study with color Doppler sonography. Ann Plast Surg. 2005;55(4):346–51. 3. 3rd Casey WJ, Connolly KA, Nanda A, Rebecca AM, Perdikis G, Smith AA. Indocyanine green laser angiography improves deep inferior epigastric perforator flap outcomes following abdominal suction lipectomy. Plast Reconstr Surg. 2015;135(3):491e–7. 4. Teimourian B, Adham MN, Gulin S, Shapiro C. Suction lipectomy: a review of 200 patients over a

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17.

18.

six year period and a study of the technique in cadavers. Ann Plast Surg. 1983;11(2):93–8. Emeri JF, Krupp S, Doerfl J. Is a free or pedicled TRAM safe after liposuction? Plast Reconstr Surg. 1993;92(3):1198. Godfrey PM, Godfrey NV. Transverse rectus abdominis musculocutaneous flaps after liposuction of the abdomen. Ann Plast Surg. 1994;33(2):209–10. Karanas YL, Santoro TD, Da Lio AL, Shaw WW. Free TRAM flap breast reconstruction after abdominal liposuction. Plast Reconstr Surg. 2003;112(7): 1851–4. Kim JY, Chang DW, Temple C, Beahm EK, Robb GL. Free transverse rectus abdominis musculocutaneous flap breast reconstruction in patients with prior abdominal suction-assisted lipectomy. Plast Reconstr Surg. 2004;113(3):28e–31. De Frene B, Van Landuyt K, Hamdi M, Blondeel P, Roche N, Voet D, Monstrey SJ. Free DIEAP and SGAP flap breast reconstruction after abdominal/gluteal liposuction. Plast Reconstr Aesthet Surg. 2006;59(10):1031–6. Arnez ZM, Pogorelec D, Planinsek F, Ahcan U. Breast reconstruction by the free transverse gracilis (TMG) flap. Br J Plast Surg. 2004;57(1):20–6. Wechselberger G, Schoeller T. The transverse myocutaneous gracilis free flap: a valuable tissue source in autologous breast reconstruction. Plast Reconstr Surg. 2004;114(1):69–73. Buntic RF, Horton KM, Brooks D, Althubaiti GA. Transverse upper gracilis flap as an alternative to abdominal tissue breast reconstruction: technique and modifications. Plast Reconstr Surg. 2011;128(6): 607e–13. Fansa H, Schirmer S, Warnecke IC, Cervelli A, Frerichs O. The transverse myocutaneous gracilis muscle flap: a fast and reliable method for breast reconstruction. Plast Reconstr Surg. 2008;122(5): 1326–33. Saint-Cyr M, Wong C, Oni G, Maia M, Trussler A, Mojallal A, Rohrich RJ. Modifications to extend the transverse upper gracilis flap in breast reconstruction: clinical series and results. Plast Reconstr Surg. 2012;129(1):24e–36. Saint-Cyr M, Shirvani A, Wong C. The transverse upper gracilis flap for breast reconstruction following liposuction of the thigh. Microsurgery. 2010;30(8): 636–8. Inceoglu S, Özdemir H, Inceoglu F, Demir H, Önal B, Çelebi C. Investigation of the effect of liposuction on the perforator vessels using color Doppler ultrasonography. Eur J Plast Surg. 1998;21(1):38–42. Ozcan G, Shenaq S, Baldwin B, Spira M. The trauma of suction-assisted lipectomy cannula on flap circulation in rats. Plast Reconstr Surg. 1991;88(2):250–8. Blondeel PN, Derks D, Roche N, Van Landuyt KH, Monstrey SJ. The effect of ultrasound-assisted liposuction and conventional liposuction on the perforator vessels in the lower abdominal wall. Br J Plast Surg. 2003;56(3):266–71.

The Combined Use of Liposuction and Arthroscopic Shaver in Contouring Lower Limb Fasciocutaneous Flaps

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Adrian SH Ooi and Yee Siang Ong

Abstract

The goals of reconstruction in the lower limb are to restore ambulation and enable the patient to use normal footwear. Free fasciocutaneous flaps provide pliable protection and gliding of tendons but have problems with contour and bulk. Combination of liposuction and arthroscopic shaving to remove fatty and fibrous tissue achieve effective flap contouring in a single session. Perform the procedure at least 5 months post-reconstruction to allow for neovascularization and reduction in swelling. Subepidermal and dermal vascular plexuses must be preserved. Suction drains and compression garments should be used postoperatively. Hematoma and superficial skin loss are the most common complications.

56.1

Introduction

Soft tissue defects of the lower limb are debilitating and can result from multiple causes including trauma, infection, and tumor resection. In modern microsurgery, the goals of reconstruction should not be to just afford coverage of defects but to restore ambulation and at the same time enable

A.SH. Ooi, MBBS, MRCS (Ed), MMed (Surg) (*) Y.S. Ong, MBBChir, FAMS (Plastic Surgery) Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Outram Road, Singapore 169608, Singapore e-mail: [email protected]; [email protected]

the patient to use normal footwear. Traditionally, the proximal two-thirds of lower limb defects can be covered by pedicled muscle flaps such as the soleus and gastrocnemius. Due to the paucity of local tissue, defects in the distal third of the lower limb including the foot and ankle commonly require free tissue transfer for reconstruction. In the past, muscle flaps were favored due to their bulk, reliable anatomy, and ability to counteract infection [1, 2]. However, they mandated the sacrifice of functioning muscle, often leading to not insignificant donor-site morbidity. Thanks to the groundbreaking work by pioneers in the field, knowledge of anatomy and techniques for flap harvest have led to the increasing popularity of fasciocutaneous flaps for reconstruction of complex defects [3, 4]. Fasciocutaneous flaps have gained increasing

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568 Fig. 56.1 Common fasciocutaneous flap donor sites

Lateral arm

Lateral thoracic

Ulna forearm

Radial forearm

Deep inferior epigastric

Gluteal artery perforator

Groin

Superficial circumflex iliac

Antero-medial thigh

Antero-lateral thigh

Medial sural

Dorsalis pedis

popularity in reconstruction of foot and ankle defects and are advantageous for their versatility, low donor-site morbidity, and ability to give pliable protection to vital structures [5–8]. There are numerous donor sites, with the commonly used flaps including the anterolateral thigh (ALT), lateral arm, radial forearm, and groin flaps (Fig. 56.1). They can be harvested as pure skin flaps or with any combination of muscle, fascia, or bone. These provide further advantages including the obliteration of dead space, smooth tendon gliding, and the option of vascularized bone reconstruction, respectively (Table 56.1). However, flaps with a thick layer of subcutaneous fat can lead to a bulky contour and inability to use normal footwear, which is especially pertinent in the foot and ankle area. While muscle flaps usually atrophy, fasciocutaneous flaps retain their subcutaneous tissue and fatty layer and even fluctuate with the patient’s weight changes. Excessively bulky flaps can be unsightly and lead to the inability to wear normal clothing. Primary flap thinning has been described by various authors and provides excellent contour in a single sitting [9, 10]. However, the procedure has a steep learning curve and inherent danger of injuring the flap pedicle [11, 12]. Moreover, a final

Table 56.1 Advantages and disadvantages of fasciocutaneous flaps Advantages Low donor-site morbidity Pliable protection to vital structures Preservation of muscle

Disadvantages Bulky skin paddle No bulk for deeper wounds Tedious perforator dissection

Incorporate sensory nerves Reduced postoperative recovery time Numerous donor sites Can incorporate a variety of tissues

acceptable contour should only be assessed with the flap at the wound site after it has healed and edema has settled. Postoperative resurfacing of these fasciocutaneous flaps is often necessary to achieve the ultimate reconstructive goals. Previous techniques of flap contouring that have been described include laser ablation, open excision with or without skin grafting, liposuction, and arthroscopic shaving [13–18]. The authors employ the latter two techniques in a single procedure to achieve the desired contour outcome for lower limb fasciocutaneous flaps.

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Layers of fasciocutaneous flap

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Microvascular plexuses

Epidermis Subepidermal

Dermis

Dermal Subdermal

Subcutaneous

Subcutaneous Deep fascia Deep fascial

Muscle

Feeding artery Fig. 56.2 The layers of the fasciocutaneous flap and the five microvascular plexuses

56.2

Anatomy of the Fasciocutaneous Flap

56.2.1 Tissue Layers From the external surface inward, fasciocutaneous flaps consist of epidermis, dermis, subcutaneous fat, and deep fascia just above the muscle (Fig. 56.2). In certain areas of the body, there is an intervening layer of superficial fascia that divides the subcutaneous fat into a superficial and deep layer, such as the Scarpa’s fascia in the abdomen [19]. The subcutaneous layer of fasciocutaneous flaps contains a varying amount of fat and fibrous tissue (Fig. 56.3). The latter anatomically anchors the deep fascia to the dermis. The ratio of each is dependent on the site of harvest as well as the patient’s body habitus.

56.2.2 Blood Supply The fasciocutaneous flap is supplied by a rich blood supply from five microvascular plexuses which run parallel to the skin. These are the

Fig. 56.3 Endoscopic view of the subcutaneous layer of the fasciocutaneous flap with fatty component removed showing anchoring fibrous tissue

subepidermal, dermal, subdermal, subcutaneous, and deep fascial networks (Fig. 56.2). These plexuses are nourished by feeding vessels running from source vessels through septum, muscle, and the fibrofatty subcutaneous tissues. Venous outflow is through the capillary network and vena comitans which accompany the arterial inflow.

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56.3

Combined Use of Liposuction and Arthroscopic Shaver

56.3.1 Advantages

Liposuction, whether manual, power assisted, or ultrasound assisted, has been successfully described by various authors in achieving an acceptable contour, either for aesthetic purposes or for fasciocutaneous flaps [16, 17]. However, it only addresses the fatty component of the fasciocutaneous flap and cannot remove the fibrous component that is present, resulting in suboptimal contour correction especially in areas with a high density of fibrous tissue. The arthroscopic shaver has been described for successful debulking in head and neck myocutaneous flaps and reduction of fibrous gynecomastia [18, 20]. The tip of the shaver is blunt and consists of an outer and inner sheath. The inner sheath has serrated teeth that provide the cutting edge for sharp excision (Fig. 56.4). The teeth can oscillate at up to 3000 rpm, with constant irrigation to the debrided area to prevent choking and thermal injury. It enables fine control and is effective at removing tough fibrous structures such as joint cartilage. With the two methods addressing different aspects of fasciocutaneous subcutaneous tissue, we therefore combine the use of liposuction and arthroscopic shaving to achieve effective removal of all flap fibrofatty tissue in one stage.

1. Removal of the majority fatty and fibrous tissue in the subcutaneous layer. 2. Minimally invasive. 3. Fine control of contour. 4. Short-operating time. 5. At 5–6 months post reconstruction, neovascularization would have occurred in the flap, negating the risk of pedicle damage during contouring surgery. 6. Contraction of the skin of the thinned flap and bedding down to the wound bed via scar tissue formation, minimizing need for skin excision.

56.3.2 Disadvantages • In areas of excessive arthroscopic shaving, the dermal blood supply is damaged, leading to superficial skin loss. These can be treated with dressings. • Suction drains and post-procedural compressive therapy are required to prevent hematoma formation.

56.3.3 Technique The procedure is performed at least 5 months after primary flap reconstruction to allow for neovascularization from the edges of the flap, resolution of

Pyramidal teeth Inner sheath Outer sheath Tube for suction

Tube for irrigation

Microdebrider tip

Fig. 56.4 Arthroscopic shaver (Medtronic, Minneapolis, Minnesota, USA) cannula showing a blunt tip with outer and inner sheaths. The inner sheath has serrated blades which rotate to cut soft tissue

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edema, and accurate assessment of final postprimary reconstruction flap dimensions. Two port sites are marked in the longitudinal and horizontal planes (Fig. 56.5). One liter of normal saline solution mixed with 1 ml of 1:1000 epinephrine is infiltrated into the flap subcutaneously till skin turgor is achieved, and adequate time (>7 min) is given to allow for vasoconstriction before beginning the contouring procedure. Through the port sites, liposuction is first performed. A power-assisted liposuction (PAL) system is used with a blunt cannula ranging from 2 to 5 mm. The position of the port sites facilitates cross-hatching in the superficial and deep subcutaneous planes, while the nondominant hand is used to pinch up the flap tissue and gauge the extent of suction lipectomy needed (Fig. 56.5). Fat removal is deemed adequate when only fibrous tissue can be palpated beneath the skin of the fasciocutaneous flap.

a

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Once liposuction is complete, arthroscopic shaving of fibrous tissue is then performed through the port sites with the jaws of the shaver facing upward toward the dermis to avoid injuring any deeper vital structures protected by the flap (Fig. 56.5). Shaving should be performed in an even, broad plane through both port sites (fanning technique similar to liposuction), avoiding excessive focus on one area as this can lead to damage to the dermis and potential skin necrosis. Shaving is deemed complete when appropriate tactile and visual contouring is achieved. The flap can be thinned leaving up to 2 mm of subdermal tissue, preserving the subepidermal and dermal vascular plexuses. A small-bore suction drain is inserted through one of the port sites, and skin closure is performed with transcutaneous interrupted sutures. Compression dressings are applied.

b

c

Subepidermal plexus Dermal plexus

Fig. 56.5 (a) Two incision sites for access, (b) crosshatching with liposuction to ensure even debulking, and (c) microdebridement of fibrous tissue with the arthroscopic shaver blades facing upward

Subdermal plexus Fibrous tissue removed by arthroscopic shaver

Deeper structures protected by flap

Arthroscopic shaver blades facing upward

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56.3.4 Postoperative Care Patients are kept in hospital overnight. The operation site is inspected the following day for any hematoma or skin necrosis and suction drains are removed. Ambulation with compression garments is allowed on the first postoperative day (POD). Patients are usually discharged the evening of POD 1 and followed up in the clinic at 2 weeks, 6 weeks, and 6 months postoperatively. Sutures are removed at the first postoperative visit.

56.3.5 Complications The two main complications are hematoma formation immediately postoperatively and potential for skin loss resulting from excessive arthroscopic debridement. A late complication is undercorrection and remaining contour deformity which a second, similar procedure can resolve. 1. Hematoma: The insertion of postoperative drains aids in reducing the chance of hematoma formation. If necessary, the hematoma can be evacuated by bedside and manual compression applied. If 10–15 min of manual compression does not stop the bleeding, the patient should be brought back to the operating theater, a longer incision made and the bleeding points identified and hemostasis rendered. 2. Skin loss: This is usually superficial and simple dressings result in healing over the course of 2–3 weeks. On the rare occasion where skin loss is full thickness, secondary skin grafting procedures can be considered.

56.4

Technical Tips

1. Await tissue equilibrium and the resolution of post-reconstructive edema before attempting contouring procedures.

2. Suction drains and post-procedural compressive therapy are essential. 3. Manual or PAL as opposed to ultrasoundassisted liposuction as the latter can result in thermal damage to the dermis. 4. Use of blunt suction cannula to avoid injuring vasculature and compromising flap blood supply.

56.5

Outcomes

Over 2 years, we performed power-assisted suction lipectomy and arthroscopic shaving on 12 fasciocutaneous flaps in 11 patients who underwent reconstruction for foot and ankle defects. Patients who opted for the procedure complained of flap bulk and inability to wear shoes. Flaps debulked included ten ALT, one medial sural artery perforator, and one groin flap. The average interval between the initial reconstructive procedure and flap debulking was 7 months. Total operative time ranged from 30 to 60 min. There were three minor complications: two flaps suffered superficial epidermal loss that healed with dressings and one patient developed a hematoma on postoperative day 2 after he was discharged. The hematoma was evacuated and the flap healed well with dressings. At an average of 9 months follow-up, six patients reported that they were very satisfied with the procedure, four were satisfied, and one was dissatisfied. Nine of the 11 patients were ambulant with their original covered footwear at the time of follow-up.

56.6

Case Examples

56.6.1 Case 1: Right Foot Dorsum Degloving Injury with Groin Flap Coverage A 20-year-old female sustained a right foot dorsum degloving injury with exposed tendons. She underwent free groin flap coverage and flap

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Fig. 56.6 Free groin flap coverage of dorsal foot degloving injury. The pictures show the 8-month post-contouring result

contouring surgery 5 months post-coverage. She is very satisfied with the result and able to ambulate normally with covered footwear (Fig. 56.6).

56.6.2 Case 2: Left Foot Open Fracture with Perforator Flap Coverage A 22-year-old male sustained a left foot open first metatarsal fracture. This was successfully covered with a medial sural artery perforator free flap, but the patient complained of bulk after the flap healed. He underwent flap contouring 7 months later. The drain was removed on POD 1, and he was allowed full weight-bearing ambulation. Unfortunately he did not wear his compression dressings and developed a hematoma on POD 2. This was evacuated under local anesthesia, and with dressings, the flap

eventually recovered well and the patient is very satisfied with the result, ambulating normally with covered footwear (Fig. 56.7).

56.6.3 Case 3: Left Ankle Crush Injury with ALT Flap Coverage A 27-year-old male sustained a left foot and ankle crush injury at work. His extensive skin and soft tissue injuries exposed vital structures at the medial ankle and lateral sole. After wound debridement and orthopedic fixation, he successfully underwent two separate ALT flap coverage to the defects in the same sitting. Flap contouring was done 6 months postcoverage. He wears normal shoes occasionally but gets superficial abrasions on the medial ankle flap at the junction between the shoe and skin (Fig. 56.8).

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Fig. 56.7 Free medial sural artery perforator flap coverage of open first metatarsal fracture. Flap contouring was done but patient developed hematoma postoperatively.

Evacuation of hematoma and dressings were applied. The pictures show the 6-month post-contouring result

Fig. 56.8 Two separate ALT flaps used to cover medial ankle and lateral sole defects. The pictures show the flaps 4 months post-contouring surgery. The medial ankle flap

sustained superficial epidermal loss postoperatively but healed well with dressings

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Conclusions

Besides coverage of vital structures and enabling patients to ambulate, the goals of foot and ankle reconstruction should include restoration of contour to allow use of normal footwear. Fasciocutaneous flaps have been shown to be an excellent reconstructive option but can be bulky. With the simple and effective technique of combining the use of liposuction and arthroscopic shaving, along with precautions to avoid potential complications, we are now able to achieve these goals.

References 1. Gosain A, Chang N, Mathes S, Hunt TK, Vasconez L. A study of the relationship between blood flow and bacterial inoculation in musculocutaneous and fasciocutaneous flaps. Plast Reconstr Surg. 1990;86(6): 1152–62. 2. Calderon W, Chang N, Mathes SJ. Comparison of the effect of bacterial inoculation in musculocutaneous and fasciocutaneous flaps. Plast Reconstr Surg. 1986;77(5):785–94. 3. Taylor GI, Pan WR. Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr Surg. 1998;102(3):599–616. 4. Geddes CR, Morris SF, Neligan PC. Perforator flaps: evolution, classification, and applications. Ann Plast Surg. 2003;50(1):90–9. 5. Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg. 2002;109(7):2219–26. 6. Dayan JH, Lin CH, Wei FC. The versatility of the anterolateral thigh flap in lower extremity reconstruction. Handchir Mikrochir Plast Chir. 2009;41(4):193–202. 7. Lee JC, St-Hilaire H, Christy MR, Wise MW, Rodriguez ED. Anterolateral thigh flap for trauma reconstruction. Ann Plast Surg. 2010;64(2):164–8.

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8. Engel H, Lin CH, Wei FC. Role of microsurgery in lower extremity reconstruction. Plast Reconstr Surg. 2011;127 Suppl 1:228S–38. 9. Misra A, Shoaib T, Soutar D. Thinning the anterolateral thigh flap using a MATT-finish. J Plast Reconstr Aesthet Surg. 2010;63(9):e706–8. 10. Yang WG, Chiang YC, Wei FC, Feng GM, Chen KT. Thin anterolateral thigh perforator flap using a modified perforator microdissection technique and its clinical application for foot resurfacing. Plast Reconstr Surg. 2006;117(3):1004–8. 11. Ross GL, Dunn R, Kirkpatrick J, Koshy CE, Alkureishi LW, Bennett N, Soutar DS, Camilleri IG. To thin or not to thin: the use of the anterolateral thigh flap in the reconstruction of intraoral defects. Br J Plast Surg. 2003;56(4):409–13. 12. Sharabi SE, Hatef DA, Koshy JC, Jain A, Cole PD, Hollier Jr LH. Is primary thinning of the anterolateral thigh flap recommended? Ann Plast Surg. 2010;65(6): 555–9. 13. Brightman L, Brauer J, Anolik R, Weiss ET, Karen J, Chapas A, Hale E, Bernstein L, Geronemus RG. Reduction of thickened flap using fractional carbon dioxide laser. Lasers Surg Med. 2011;43(9): 873–4. 14. Lin TS, Jeng SF, Chiang YC. Resurfacing with fullthickness skin graft after debulking procedure for bulky flap of the hand. J Trauma. 2011;65(1): 123–6. 15. Hallock GG. Liposuction for debulking free flaps. J Reconstr Microsurg. 1986;2(4):235–9. 16. Hallock GG. Conventional liposuction-assisted debulking of muscle perforator flaps. Ann Plast Surg. 2004;53(1):39–43. 17. Yamanaka K, Ichikawa T, Horiuchi Y. Flap defatting with an ultrasonic surgical aspirator. Plast Reconstr Surg. 1997;99(3):888–91. 18. Tan NC, Cigna E, Varkey P, Liu YT. Debulking of free myocutaneous flaps for head and neck reconstruction using an arthroscopic shaver. Int J Oral Maxillofac Surg. 2007;36(5):450–2. 19. Hong JP, Sun SH, Ben-Nakhi M. Modified superficial circumflex iliac artery perforator flap and supermicrosurgery technique for lower extremity reconstruction: a new approach for moderate-sized defects. Ann Plast Surg. 2013;71(4):380–3. 20. Goh T, Tan BK. Song C use of the microdebrider for treatment of fibrous gynaecomastia. J Plast Reconstr Aesthet Surg. 2010;63(3):506–10.

Liposuction and Dermolipectomy

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Ivo Pitanguy, Henrique N. Radwanski, and Bárbara H.B. Machado

Abstract

Correct diagnosis of contour deformities should include a detailed history of weight fluctuation, endocrinological status, careful physical examination, and photographic inspection. The patient’s psychological motivation should be investigated in detail, in order to avoid expectations that are unacceptable or impossible to accomplish. The authors discuss the various surgical techniques in body contouring. Liposuction and dermolipectomy are described.

57.1

Introduction

Before the advent of modern plastic surgery, body contour alterations were reluctantly accepted and hidden under heavy clothing. Not until the second half of the last century did medical advances permit, for the first time, the surgical correction of contour deformities. Currently, the greater exposure of the body together with the desire to demonstrate fitness and youthfulness in an increasingly competitive society has created a stereotype model of slimness that is constantly reinforced by mass media and propaganda. This greater consciousness of the human form is further emphasized by the high value placed on physical beauty, especially as regards the female

body, where social and professional success is often a consequence of attractiveness. On the other hand, sedentary lifestyle and dietary excesses, associated with factors such as genetic determination, pregnancy, and the aging process, contribute to alterations of body contour that create a strong psychological motivation for their correction. Localized fat deposits and skin flaccidity are sometimes resistant to the sincerest effort in weight loss and sport activities. This ever-increasing request for contour surgery has been favorably met by safe anesthesiology and efficient surgical techniques, resulting in a high degree of patient satisfaction.

57.2 I. Pitanguy, M.D. (*) • H.N. Radwanski, M.D. B.H.B. Machado, M.D. Rua Dona Mariana, 65, Rio de Janeiro, Brazil e-mail: [email protected]

Technique

Correct diagnosis of contour deformities should include a detailed history of weight fluctuation, endocrinological status, careful physical

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examination, and photographic inspection. The relationship between “content and container,” that is, the amount of excess fat and skin flaccidity, is an important aspect that will determine between a procedure with minimal incisions, such as liposuction (also called suction-assisted lipectomy), and surgical resection of excess tissue (i.e., dermolipectomies). Finally, the patient’s psychological motivation should be investigated in detail, in order to avoid expectations that are unacceptable or impossible to accomplish. Whenever a dermolipectomy is deemed necessary, the position and extent of scars should be carefully described and demarcated. Explanation regarding the healing process helps patients understand how scars will become more acceptable over time. The possibility of combining procedures should be considered. Factors that determine the feasibility of operating on more than one anatomical region in a single operation include the patient’s status (general health, age), anesthetic considerations (total amount of drugs, accumulative blood loss), and correct training of the surgical team in order to reduce the surgical time. In combined procedures, it is most important that the surgeon act as the leader in directing his or her assistants and nurses, so that each step is anticipated, with no loss of movement or time. The senior author has described this as an “orchestration” of the surgical team. There has been an evolution of the different techniques for the correction of body contour deformities, as performed by the senior author in over five decades of experience [1–22]. While it is true that liposuction has attained a position of great popularity owing to its efficacy and safety when well indicated, redundant skin and adipose tissue may only be removed by surgical resection. This is particularly true of secondary cases that have been initially treated with liposuction alone and are seen to have a poor aesthetic result and particularly for post-obese patients. Obesity has spread worldwide, and bariatric surgery has permitted for an increased number of patients asking for dermolipectomies and reminiscent fat removal.

57.2.1 Surgical Techniques The number of indications for excisional body contour surgery decreased substantially since the advent of liposuction in the late 1970s. Dermolipectomy of the trochanteric region as well as the medial thigh, which was relatively common, became more limited. Currently, these procedures have returned due to a greater indication in patients with great weight loss. This approach is indicated in cases where significant skin flaccidity is present, either alone or associated with increased adiposity. On the other hand, there are a few cases in which we do not indicate aspiration, such as below knee level. In a personal communication, Illouz made the following comments regarding liposuction: “Although we are favorable to safe scientific innovations, many of the alterations that were done to the classical procedure have created more problems than solutions. I think that, to deviate from the classic, simple technique, one should be very careful, assuring that there are true advantages.” Ultrasound and laser-assisted liposuction, although shown to have improvement on skin flaccidity in the hands of some colleagues, in our service, have not shown that the results are worth the risk of complications. Intense fibrosis, risk of burns, and skin necrosis are reported in some articles, and the senior author has opted not to adopt these newer instruments.

57.2.2 Liposuction Liposuction has proved to be an excellent technique in cases of moderate fat accumulation with minimal or absence of cutaneous flaccidity. This may be performed in many different anatomical regions simultaneously, in association with other procedures or by itself. In the gynecoid type of fat distribution, which is typical of the female patient, fat cells are actually hyperplastic and accumulate on the lower abdomen, thighs, and buttocks. These cells do not respond very well to adrenergic stimulation, and this explains why women have greater difficulty in mobilizing this type of adiposity and

57 Liposuction and Dermolipectomy

losing weight. Suction-assisted lipectomy is particularly efficient in treating this form of lipodystrophy (Fig. 57.1). Preparation of the patients for the procedure includes preoperative tests and a thorough clinical evaluation. The total amount of fat that is intended to be removed is discussed with the patients, especially if they present with accentuated lipodystrophy. Removing large amounts of fat can lead to important metabolic, electrolytic, and hemodynamic alterations. To avoid these occurrences, staged procedures should be planned with an interval of at least 6 months between each session. Just as importantly, this staged approach permits a more gradual accommodation of the skin. The largest volume that has been aspirated in our service in a single procedure was 9.8 l, from a patient weighing 83 kg. Megaliposuction, which is the removal of fat corresponding to more than 10 % of the patient’s

a

Fig. 57.1 (a) Areas to aspirate are exactly the same as the demarcation for the classic riding-breeches technique. Liposuction may be thus considered as a “closed riding-breeches technique.” (b) Result from a simple liposuction after 6 months for a 27-year-old woman

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body weight, should only be considered with great reserve. As a routine, if it is decided to remove close to 7 % of the corporal weight in liters of fat, we encourage our patients to be submitted to an autotransfusion procedure. Close to 450 mL of total blood can be harvested by a hematologist usually between 10 and 30 days before the surgery. This collected blood must be reinfused at the latest 32 days after its harvest; otherwise, this collected blood starts losing its properties and hemolysis increases. Hemodilution, which implies on the removal of whole blood before surgery, with rapid infusion of Ringer’s lactate or normal saline, is less indicated due to the fact that its efficacy is contested. This causes a decrease in blood loss in the aspirate and retains 400 mL of whole blood to be infused at the end of the procedure. Demarcation of the areas to be treated is done preoperatively with the patient in a standing

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position, and preoperative photographs are taken at the office from different angles, which will serve to guide the surgeon during the actual procedure. After appropriate anesthesia, local infiltration is done with preheated saline solution (close to 37 oC) and epinephrine at a concentration that varies from 1:500,000 to 1:1,000,000. The wet technique is used, and the amount to be infiltrated depends on how much is expected to be aspirated. Older patients and patients in use of contraceptives and beta-blockers, among other medications, must be under supervision for the infiltration due to the risk of pulmonary congestion. Infiltration of more than 1–1.5 times the amount expected to be aspirated may cause substantial hemodilution, with consequent hemodynamic effects. This is especially true if lidocaine is used. The appropriate cannula is chosen and inserted through a stab incision placed in a natural crease. Pre-tunneling (passing of the cannulas with no vacuum) can help to establish the correct planes. Care should be taken to preserve connections between the subcutaneous tissue and the skin to avoid interrupting superficial innervation and vascularization, allowing for adequate lymphatic drainage. Therefore, superficial liposuction has to be done with moderation. With the cannulas connected to the aspirator, smooth strokes are applied in a fan-shaped fashion, in different planes of the subcutaneous tissue. Inspection of the regions and palpation serve as guides to check for adequate and equal removal of adiposity. By introducing the cannula through a different incision, crisscrossing can be established. A feathering pattern should be applied, so as to smooth the edges of the treated areas. With experience, the surgeon will “feel” how much fatty layer should be left. This is approximately 1–2 cm (depending on the anatomical region) and serves to protect the overlying skin while avoiding unsightly depressions and adherence of skin to muscle. It is better to perform less fatty tissue removal than to have to proceed to immediate correction of irregularities with fat injection. In the postoperative period, fluid replacement is dependent on the preoperative status and the amount aspirated. Hemodilution is expected due to fluid reposition, thus turning the hematocrit a

not completely reliable parameter by itself for 24–36 h after the procedure. Replacement is done with saline solution, Ringer’s lactate, or glucose for small- to medium-volume aspiration. Though autotransfusion, collected as mentioned before, cannot be a warranty of keeping the hematocrit high, with its use, the recovery is faster and the postoperative period is more comfortable. Lipotimia (fainting) is less common. If the patient presents with hemoglobin inferior to 7 g/dL, blood replacement may be utilized. This should be discussed with a clinical consultant. The patient is given large amounts of isotonic fluids in the first week postoperatively. Adequate treatment with a physiotherapist is indicated and can usually start 48 h after the surgery. The idea is to diminish the fluid retention and to avoid adherences, excessive fibrosis, and small irregularities. Endermology (mechanical deep massage) is begun close to 15 days, to free possible fascial adherences and even out small irregularities. The use of compressive, elastic garments is continued from the immediate postoperative period through the first 2 months. Localized compression can be complemented with neoprene plaques placed inside the elastic garment, in an attempt to improve the definition of areas such as flanks and wrist. On the other hand, this compression can help prevent fluid accumulation (seroma).

57.2.3 Dermolipectomies 57.2.3.1 Trochanteric Dermolipectomy for Correction of Drooping Buttocks and Interfemoral Flaccidity Prior to the advent of liposuction, this procedure was used for most cases of large trochanteric lipodystrophy and offered satisfactory results when well understood and executed. Although the treatment of choice is currently liposuction alone, in very large deformities or in post-obese patients, this surgical technique associated with liposuction can result in a very satisfactory contour while maintaining well-hidden incisions. This is particularly effective for the treatment of interfemoral flaccidity and the heavy, ill-defined

57 Liposuction and Dermolipectomy Fig. 57.2 (a, b) Excision of skin and subcutaneous tissues in a fusiform area that extends laterally and superiorly toward the anterior superior iliac spine and medially along the inner aspects of the thigh

a

drooping buttocks. The patient must be properly informed of the placement of final scars and should actively participate in decision-making, understanding that there will be a definite enhancement of contour, while accepting the inevitable incisions. Most of the patients desire a total improvement of the inner thigh that reaches the region just above the knees. It is important to emphasize the limitations of the technique and to explain that such lifting is not achievable. Secondary cases of trochanteric lipodystrophy on patients previously treated by liposuction alone were more satisfactorily addressed by the dermolipectomy procedure. With the patient in the standing position, the areas to be corrected are marked. The planned excision of skin and subcutaneous tissue corresponds to a fusiform area that extends laterally and upward toward the anterior–superior iliac spine and medially along the inner aspects of the thigh (Fig. 57.2). The inferior segment of the demarcation falls in the gluteal crease. The incision is carried out initially along the superior border of the demarcated area, and the flap is lifted off the aponeurosis and undermined, including the lateral depression that is sometimes

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present. The inferior flap is then advanced upward in three vectors: superiorly, medially, and laterally (Fig. 57.3). The excess tissue is excised in segments, equally distributed, and adapted to its new bed. Recently, a smaller resection for the treatment of the drooping buttocks was performed, associated with liposuction of the flanks and trochanteric region. This technique can also be associated with liposuction of the inner thighs and the knee (Fig. 57.4). Interfemoral flaccidity is corrected by dermolipectomy, placing the scar in the natural inguinal crease. Excessive tension on the flap must be avoided, especially medially, so as not to cause the pulling down of the labia majora. The resultant scar should be well disguised within the gluteal and inguinal folds (Fig. 57.5).

57.2.3.2 The Upper Limbs Treatment of contour deformities of the upper limbs requires a very critical appraisal of the patient’s complaints and expectations. The surgeon should be emphatic regarding limitations and possibilities of surgical procedures. A scar placed along the inner aspect of the arm is relatively visible when treating brachial lipodystro-

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Fig. 57.3 (a, b) The inferior flap is advanced superiorly in three vectors: superiorly, medially, and laterally

phies; therefore, resection of excess tissue is only indicated in very selected cases where the deformity causes a significant disharmony between the upper limbs and the patient’s overall body contour. Liposuction has become the procedure of choice in moderate cases of fat accumulation on the posterior aspect of the arm, removing adipose tissue through minimal incisions. Skin resection is warranted when the patient presents with visible looseness of skin secondary to the aging process or after considerable weight loss. An elliptical demarcation is done along the posterior and inner aspects of the arm, thus assuring that the final scar is placed at the least visible location of the upper limb, which is at the internal bicipital sulcus. Dissection of tissues is done in a posterior direction in order to bring the excess flap inward (Figs. 57.6 and 57.7). Some patients present with loose skin that affects the elbow, the upper limbs, and the lateral aspect of the thorax. These cases are treated by a technique that was described in 1975, called a thoraco-brachial dermolipectomy [7]. The patient is examined and marked standing up and with the

arms open so as to demonstrate excess tissue. A sinuous demarcation begins distally, at the elbows, moves along the inner aspect of the arms, and continues along the armpit, where it is “broken” by a Z-plasty, avoiding scar retraction. The demarcation proceeds along the lateral aspect of the upper trunk and finishes at the submammary sulcus. The final scar is considered more satisfactory with this sinuous demarcation when compared with other techniques that employ straight lines, which risk developing a “bow-string” deformity along anatomical creases with consequent unfavorable retractions (Fig. 57.8). Suction-assisted lipectomy has become a valuable adjunct to this procedure.

57.2.3.3 The Abdomen Abdominal alterations may be summarized as being of three types: cutaneous deformities (excess, stretch marks, scars, flaccidity, and retractions), accumulation of subcutaneous tissue (lipodystrophy), and those affecting the musculoaponeurotic system (diastasis, hernia, eventra-

57 Liposuction and Dermolipectomy Fig. 57.4 (a) A 42-year-old patient had prior liposuction aspiration. (b) Contour was reestablished with dermolipectomy. Currently, femoral dermolipectomy is reserved for cases that present with excess skin, or in severe irregularity, as in cases secondary to liposuction

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tion, and convexity). Procedures have, therefore, been described to correct the integument (skin and loose subcutaneous cellular tissue), the aponeurosis, and the muscle structure. The ultimate goal of surgery is to achieve an aesthetic contour

Fig. 57.5 The resultant scar from thigh lift should be within the gluteal and inguinal folds

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with acceptable scars and the return of full function of the abdominal wall. A system of classification has been established to correlate presenting deformity and surgical planning (Table 57.1). In association with the classic procedure, liposuction has decreased the necessity for extensive undermining of the abdomen, thus contributing to a lesser rate of complications such as serosanguinous collection and flap ischemia. The liposuction should be restricted to non-undermined though can be conservatively performed in the midline. Two primary arterial plexuses are responsible for the irrigation of the abdominal wall: (1) a subdermal superficial system and (2) a deeper, more profound musculoaponeurotic system. Many blood vessels form anastomotic connections between the two levels, particularly in the periumbilical region. This vascular anatomy must be respected so as not to risk causing a decrease in vascularization of the abdominal flap. b

Fig. 57.6 (a, b) Dissection in brachioplasty is performed in a posterior direction in order to bring the excess flap inward

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Fig. 57.7 (a) A 59-year-old patient with simple brachial flaccidity. (b) Corrected by removal of an atypical ellipse of skin and subcutaneous tissue

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Fig. 57.8 (a, b) The final scar should be sinuous Table 57.1 Pitanguy’s classification of aesthetic abdominal deformities Type I II III

IV O

Clinical presentation Abdominal lipodystrophy without skin flaccidity; absence of diastasis or hernia Moderate abdominal lipodystrophy with diastasis Accentuated abdominal lipodystrophy with cutaneous flaccidity and excess; presence of diastasis; with or without associated scar Skin flaccidity and/or lipodystrophy, with diastasis or eventration; associated scar Marked generalized abdominal lipodystrophy with absence of excess skin

The senior author’s personal approach to abdominal deformities was described in 1967 [3], where attention to both function and aesthetics was emphasized. The functional aspect of abdominoplasties was deemed to be especially pertinent in the older, overweight, multiparous woman. The reinforcement of the abdominal wall, as proposed, was done by plication of the aponeurosis from top to bottom, without opening the fascia. A pleasing curvature was given to the waist – not by pulling on the skin, but by tension on the aponeurosis and the muscles.

Suggested technique Liposuction Lipominiabdominoplasty or endoscopic abdominoplasty Standard abdominoplasty

Atypical approach These patients are not ideal candidates for an abdominoplasty and should be prepared for surgery by strict clinical treatment to lose weight

excess adiposity through minimal incisions. On the other hand, patients may still present with deformities that require a dermolipectomy, and planning must be based on sound surgical experience. More important than the technical procedure, however, are a correct diagnosis of the deformity and a thorough interpretation of the psychological and motivational structure of the patient. The real goal of body contour surgery is to reestablish the structural and psychosocial harmony of the individual, so that he or she may achieve a balance between his or her self-image and the social environment.

Conclusions

The surgical treatment of body contour deformities is a constantly evolving art that seeks to improve individual alterations while maintaining an overall well-proportioned balance. Liposuction has revolutionized the surgical treatment of contour alterations by removing

References 1. Pitanguy I. Trochanteric lipodystrophy. Plast Reconstr Surg. 1964;34:280–6. 2. Pitanguy I. Vantaggi dell’impiego di contenzione gessata nelle plastiche abdominali. Minerva Chir. 1967; 22(10):595–8.

586 3. Pitanguy I. Abdominal lipectomy: an approach to it through an analysis of 300 consecutive cases. Plast Reconstr Surg. 1967;40(4):384–91. 4. Pitanguy I. Thigh lift and abdominal lipectomy. In: Goldwyn RM, editor. Unfavorable results in plastic surgery. Boston: Little Brown; 1972. p. 387. 5. Pitanguy I. Lipectomy abdominoplasty and lipodystrophy of the inner side of the arm. In: Grabb W, Smith J, editors. Plastic surgery: a concise guide to clinical practice. 2nd ed. Boston: Little Brown; 1973. p. 1005–13. 6. Pitanguy I. Abdominal lipectomy. Clin Plast Surg. 1975;2(3):401–10. 7. Pitanguy I. Correction of lipodystrophy of the lateral thoracic aspect and inner side of the arm and elbow dermosenescence. Clin Plast Surg. 1975;2(3):477–83. 8. Pitanguy I. Dermolipectomy of the abdominal wall, thighs, buttocks and upper extremity. In: Converse JM, editor. Reconstructive plastic surgery. 2nd ed. Philadelphia: Saunders; 1977. p. 3800–23. 9. Pitanguy I, Cavalcanti MA. Methodology in combined aesthetic surgeries. Aesthetic Plast Surg. 1978;2(1):331–40. 10. Pitanguy I. Combined aesthetic procedures. In: Pitanguy I, editor. Aesthetic plastic surgery of head and body. Berlin: Springer; 1981. p. 353–9. 11. Pitanguy I, Ceravolo M. Our experience with combined procedures in aesthetic plastic surgery. Plast Reconstr Surg. 1983;71(1):56–63. 12. Pitanguy I. The abdomen. In: Pitanguy I, editor. Aesthetic surgery of head and body. Berlin: Springer Verlag; 1984. p. 100–27.

I. Pitanguy et al. 13. Pitanguy I. Treatment of abdominal wall eventrations associated with abdominoplasty techniques. Aesthetic Plast Surg. 1984;8(3):173–9. 14. Pitanguy I. Upper extremity: dermolipectomy. In: Pitanguy I, editor. Aesthetic surgery of head and body. Berlin: Springer Verlag; 1984. p. 153–8. 15. Pitanguy I. Body contour. Am J Cosm Surg. 1987;4:283–93. 16. Pitanguy I. Thigh and buttock lift. In: Lewis JR, editor. The art of aesthetic surgery. Boston: Little Brown & Co.; 1989. p. 1060–7. 17. Pitanguy I. Abdominoplasty: classification and surgical techniques. Rev Bras Cir. 1995;85(1):23–44. 18. Pitanguy I. Evaluation of body contouring and facial cosmetic surgery today: a 30 year perspective. Plast Reconstr Surg. 2000;105(4):1499–514. 19. Pitanguy I, Amorim NFG, Radwanski HN. Contour surgery in the patient with great weight loss. Aesthetic Plast Surg. 2000;24(6):406–11. 20. Pitanguy I, Radwanski HN. Personal approach to aesthetic abdominal deformities. In: Shiffman MA, Mirrafati S, editors. Aesthetic surgery of the abdominal wall. Berlin: Springer Verlag; 2005. p. 102–14. 21. Machado BHB, Vasconcelos C, Bernacchi A, Pitanguy I. Braquioplastia e toracobraquioplastia. In: Resende JHC, editor. Tratado de Cirurgia Plástica na Obesidade Chapter 56. Rio de Janeiro: Editora Rúbio; 2008. 22. Pitanguy I, Radwansky HN, Machado BHB. Liposuction and dermolipectomy. In: Shiffman MA, di Giuseppe A, editors. Liposuction: principles and practice. Berlin: Springer; 2006. p. 146–53.

Deformation of Dermal-Adipose Tissue: Resolution of Cases Rejected by Traditional Medicine

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Néstor L. Asurey

Abstract

Very large adipose deposits (megadiposities) are difficult to treat and may require two or more procedures to reduce the amount of fat. These are not cosmetic procedures but may help to slim down growths that distort the body. The author discusses the selection of patients, previous treatments, preoperative testing, anesthesia, and technical sequence. There is a description of postoperative care and possible complications. Multiple cases are shown.

58.1

Introduction

When dealing with cases of obesity which involve body deformity, in general, the professional reacts negatively to any other solution than to “slim down and come back.” We are talking about patients with significant deformities in the adipose tissue, located in some particular area (localized) or found in the whole body. These deformities referred to are important skin and fat pendulum-like formations, resistant to medical-nutritional treatments (including the gastric balloon technique), for which bariatric surgeries are not recommended due to the risk these cases may present.

N.L. Asurey, M.D. Private Practice, °8 Calle Perdiu, Valencia CP 46117, Spain e-mail: [email protected]

The changes in the volume, weight, and body shape, seriously deforming on some occasions, can prove to be so incapacitating that the patient may behave as socially handicapped. They are in need of assistance even in everyday routines. In summary, they are people with reduced mobility, hygiene, and clothing impediments and lacking in satisfactory integration to social, working, and romantic life [1]. Psychologically affected by their own reality, these patients are medically complex, with increased morbidity and mortality, generally hypertensive, diabetic, and prone to develop alveolar hypoventilation, with high risk of thromboembolism, hyperlipidemias, vesicular and renal lithiasis, and musculoskeletal disorders and with an increased risk of breast cancer, endometrial cancer, and other diseases. According to Bray, severe obesity in patients under 40 years of age is a high-risk medical situation. According to Van Itallie, obesity is extremely dangerous to life, though it is not clear

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enough whether it is harmful per se or not, as it exacerbates the risk factors. “The regular treatment for obese patients is clearly disappointing.” Faust defines this type of obesity as an “intractable excess of adiposities” [8]. In view of all this, it is intended to show contribution to the problem by considering plastic surgery. Although there is awareness of the limitations to turn an obese patient into an ordinary individual, the author hopes to help them cross a threshold toward a promising way to normal life.

2. Antibiotic therapy should be administered 48 h prior to the procedure. 3. Platelet-suppressive agents: the dose is calculated according to body weight and will be applied 12 h prior to surgery 4. Hospital admission: between 12 and 24 h for proper hydration plan prior to surgery. 5. Complete preoperative fasting for 24 h. 6. Sedation administered the previous night.

58.5 58.2

Selection of Prospective Candidates for Surgery

1. Obese patients who are clinically stable but who present localized or generalized pendulum-like deformities in their body contours and extremities 2. Patients who present records of repetitively failed clinical-nutritional treatments and who dismiss the possibility of bariatric surgery 3. Double psychological assessment which may consider both the present psychopathological scenario and the enquiries of the patient who requests this type of treatment

58.3

General, epidural, or local anesthesia is used. The latter includes deep sedation. The choice of anesthesia depends on each particular case to be treated. In case of the use of local anesthesia and deep sedation is decided upon, it will be performed by an anesthesiologist. Local anesthesia corresponds to Klein’s formulation [7]. In many cases, pendulum-like areas have a reduced sensitivity or a complete lack of it, owing to stretched nerve endings. This particular situation facilitates the surgical procedure. Reducing the surgery time and simplifying the anesthesia that will be used is essential for minimizing the risk of complications during surgery, especially when we are treating patients with an ideal presurgical state.

Preoperative Testing

Surgical risk evaluation, EKG, complete blood count (hemogram), blood testing for type and Rh type, storage of “self- donated” blood, coagulogram, urinalysis, CXR, abdominal CT scan and/or ultrasonography if the abdominal area is involved, lymphatic system assessment will be ordered, and lymphogram, if deformity of the limbs is involved.

58.4

Anesthesia

Previous Treatment

1. Since infection by fungi is frequent in some cases, patients are advised to use cutaneous antiseptic therapy in the area to be treated, at least a week prior to surgery.

58.6

Proposed Surgery and Its Objectives

The proposed surgery for this type of pathology is the en bloc resection of different deforming adiposities located in both abdomen and limbs (Figs. 58.1 and 58.2). For procedures which involve multiple areas, the author opts to perform them sequentially in time in order to avoid important surgical trauma (Fig. 58.3). The surgery may accomplish two purposes for the patients. On the one hand, it seeks the practical and functional elimination of a part of their body which is presented as deforming, heavily invalidating, contaminated by fungi, and on many

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Fig. 58.1 Marked fat deposits

Fig. 58.2 Measurement and surgery en bloc of adiposities

occasions painful. On the other hand, it may cover a subjective aspect when the patients find a possible solution to their basic problem. This may allow them to have access to further treatments, not only medical-nutritional but surgical as well. The patients, therefore, may adopt a different attitude toward the problem they face. This type of surgery may be dubbed “a la carte” since the patients express their own choice. That is to say, they choose which step would be the first and when to finish procedures (Fig. 58.4). The surgical team proposes the procedure, which is, in general, en bloc resection of the deformities, accompanied or not by a megaliposculpture [6] or traditional liposculpture. The latter could be performed at the same or different surgical time.

58.7

Technical Sequence

The patient is marked in the standing position and afterwards on dorsal decubitus. One of our hands is placed underneath the adipose pannus to be resected, and that hand is made to meet the other hand which will be placed on the exact opposite side so that this can be marked as the extent of the incision in each side of the pannus. Regardless of the anesthetics used, the area of the incision is instilled with a solution proportionally composed of 1,000 mL saline solution, 1 mL adrenaline, and 10 mL lidocaine. Afterwards, at the base of the adipose pannus, over the previously marked line, a “U-shape tie or tutor” is placed piercing through the front side to the back side and from the back side to the front

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Fig. 58.3 Result of resection of unilateral deformity

side, tying with a strong knot. The ties are made of twisted sterile bandages as if they were a suture, placing each “U” and separating them 10–15 cm from each other, over the line of the cut (Fig. 58.5). This step is meant to favor hemostasis by diminishing the bleeding due to compression, to reduce the thickness of the operating field and to be an invaluable guide in the operative plane. Once prepared this way, all the adipose tissue is resected in full thickness (Fig. 58.6). On some occasions a technique must be resorted to that involves hitching up the highest area to be resected. That area will be pulled up and hung to an arc by means of chains (Fig. 58.7). This technique permits more accuracy in the surgical procedure; it helps reduce the bleeding considerably and avoids tiredness among assistants and surgical team. The incisions used in this procedure require cold scalpel, since high temperatures produced by electrosurgical devices weaken unnecessarily the tissue, producing lipolysis, large areas of necrosis after burn, and making postoperative recovery more complex with delay in the healing, secretions, and superimposed infections.

Fig. 58.4 Patient elects the zones to be treated by en bloc resection

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Fig. 58.5 Collocation of tutors marking the resection limit, representing a surgical guide and favoring hemostasis

Fig. 58.6 En bloc resection of adiposity in the inner thigh

All necessary planes are sutured with strong sutures both internal and external (Fig. 58.8). The ties are removed, and the wound is covered and wrapped with a compressive Lycra™ girdle. The skin that was removed is defatted and stored in containers with saline solution and antibiotics. They are kept refrigerated for about 10–20 days. They should be labeled with date and patient’s name. This practice is meant to treat necrosis cases or wound dehiscence by keeping it as a prospective biological dressing or full thickness graft.

58.8

Postoperative Care

This is an en bloc type of surgery, without detaching and without the devitalization/weakening which occurs when flap formation is created and

Fig. 58.7 “Hanging from the zenith” of abdominal pendulum areas. This position facilitates resection and minimizes interoperative bleeding

with scarce fat necrosis (Fig. 58.9). These elements stimulate a faster recovery and determine that the period of hospitalization or stay in intensive Care Unit (ICU) will depend more on the resected volume rather than the surgical trauma. Resection of large volumes can cause electrolyte imbalance, with severe fluid and protein loss,

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in a similar pattern as manifested by seriously burned patients [10]. Early perambulation is essential when we refer to these patients. They should be administered with platelet-suppressive agents until they can perambulate normally, together with antibiotic therapy and electrolytic recovery, if necessary. The time of hospitalization may vary according to the resected volume. It may take from 48 h up to 10 days for cases of more significance. Fig. 58.8 Final suture

Fig. 58.9 The magnitude of abdominal resection without detachment and in one piece

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58.9

Clinical Cases

Case 1 (Fig. 58.10) a

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Fig. 58.10 (a–c) (Left) Preoperative. (Right) Postoperative resection of thigh

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Fig. 58.10 (continued)

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Case 2 (Fig. 58.11) a

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Fig. 58.11 (a) Preoperative arm adiposities. (b) Preoperative arm with retract ties in place. (c) En bloc resection of adiposity in arm. (d) Completed with sutures in place

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Case 3 (Fig. 58.12) a

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Fig. 58.12 (a) Armpit adiposities. (b) Unilateral resection with local and roving anesthesia. (c) (Left and right) Resection of armpit adiposity with lipo-aspiration of arm.

(d–f) (Left) Preoperative. (Right) Fifteen days postoperative after resection of armpit adiposity with lipo-aspiration of arm

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Fig. 58.12 (continued)

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Fig. 58.13 (a) Preoperative megalipodystrophies. (b) Postoperative resection of thigh adiposities and lipo-aspiration of hips

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Case 5 (Fig. 58.14) a

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Fig. 58.14 (a–e) (Left) Preoperative. (Right) Postoperative. (f) Elevation of abdominal hanging dermofat. (g) Abdominal resection. (Left) Preoperative. (Right) Postoperative

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Fig. 58.14 (continued)

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Fig. 58.14 (continued)

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Case 6 (Fig. 58.15) a

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Fig. 58.15 (a–c) (Left) Preoperative. (Right) Postoperative. (a, d, e) Preoperative. (b) Postoperative. (f) Hanging thigh dermofat. (Left) Preoperative. (Right) Postoperative. (g) Surgical abdominal piece

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Fig. 58.15 (continued)

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Fig. 58.15 (continued)

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Case 7 (Fig. 58.16) a

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Fig. 58.16 (a–d) (Left) Preoperative. (Middle) After secondary lipo-aspiration. (Right) Postoperative abdominal resection and secondary lipo-aspiration. (e) Marking of lipo-aspiration. (f) Part of lipo-aspiration. (g) Dressing applied

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Fig. 58.16 (continued)

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Case 8 (Fig. 58.17) a

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Fig. 58.17 (a)(left) Patient frontal view. Preoperative (right) Patient frontal view. Postoperative. (b) (left) Patient three quarters right profile. Preoperative (right) Patient three quarters right profile. Postoperative. (c) (left) Patient three quarters left profile. Preoperative (right) Patient three quarters left profile. Postoperative. (d) (left) Patient right profile. Preoperative (right) Patient right profile. Postoperative. (d) (left) Patient left profile. Preoperative (right) Patient left profile. Postoperative.

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Fig. 58.17 (continued)

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Fig. 58.17 (continued)

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Case 9 (Fig. 58.18) a

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Fig. 58.18 (a, b) (Left) Preoperative. (Right) Postoperative following abdominal dermofat resection. (f) Preoperative hanging fat. (g) Resected abdominal dermofat

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Fig. 58.18 (continued)

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Case 10 (Fig. 58.19)

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Fig. 58.19 (a–e) (Left) Preoperative of mega-abdomen and pendular lipodystrophy of the inner right thigh. (Right) Postoperative. (f) Patient in dorsal position with abdominal marking. (g) Intraoperative hanging abdomen. (h) Re-dried abdominal dermofat piece. (i) (Left)

Preoperative pendular lipodystrophy of inner thigh. (Right) Intraoperative resection. (j) Suture of inner thigh and abdomen. (k) Pendular lipodystrophy of inner thigh. (l) Excised lipodystrophy of thigh

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Fig. 58.19 (continued)

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Case 11 (Fig. 58.20) a

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Fig. 58.20 (a–e) (Left) Preoperative. (Right) Postoperative. (f) Patient on operating table showing the magnitude of the case. (g) Intraoperative installation of guide “tutors.” (h, i)

Intraoperative resection. (j) Re-dried piece of resected lipoadipose tissue. (k) (Left) Dehiscence in an arm. (Right) Closing using skin graft for later attention

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Fig. 58.20 (continued)

58.10 Complications Following this technique as it has been stated so far, we may say that we have not had serious complications and we are convinced that the reason is the absence of major sweeping or flap creation. However, it would not be surprising that with this type of patient, there may be some kind of complication in surgery as during postoperative recovery; therefore, we may be particularly careful to reduce those complications to a minimum. Dehiscence in an arm was our worst complication. In that circumstance, we resorted to the skin which had been kept refrigerated. We used it as biological dressing over the exposed area in order to facilitate the production of granulation tissue. Among the cases, there was a situation in which it was necessary to restore the fluid balance. The loss was calculated by weighing the sheets soaked by the wound suffusions every 12 h. On that occasion, the significance of the

loss was major and the possibility of assessing the amount was difficult. There has been no infection or embolism; however, there was a serious case of aspiration of gastric contents caused by anesthesia failure. Conclusions

Being able to respond to the demand the patients make for surgical treatments is equivalent to responding to the definition of our specialization itself. Below follow some quotations from the experts about this technique: 1. “Restoring, corrective and reconstructive surgery of the teguments and the shapes” [5]. 2. “The same way as fine arts reproduce or interpret shapes, Plastic Surgery masters the realms of the human body contours” [5]. 3. “The ultimate objective in any restoring surgery is to restore the normal anatomy and function. In the treatment of acquired deformities, the clinical experience and the

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observation of the pathology make up the foundations of the new operative techniques” [9]. 4. “Plastic Surgery is a specialization which deals with the correction of congenital and acquired defects” [2]. 5. Plastic Surgery is a surgical specialty whose objective is the functional and esthetic reconstruction of the tissues. The term “plastic” is used in the sense of “creating, modeling and reconstructing” [3]. 6. “Plastic Surgery is a specialization of surgery which concerns tegument and musculoskeletal deformities and defects” [4]. A number of patients have been presented suffering severe obesity and deformities whose quantity and shape render important physical, psychological, and social disabilities to them. The author has portrayed these patients’ problems, surgical techniques, and results.

References 1. Asurey N. Megalipoaspiracion. Rev Arg De Cirugía Plástica. 1997;3 N°4 Dic. 2. Barsky A. Cirugia Plastica. Buenos Aires: Panamericana; 1967. 3. Coifman F. Texto de Cirugia Plastica Edit Salvat, Barcelona. 1986. 4. Converse J. Reconstructive plastic surgery. Philadelphia: Saunders; 1977. 5. Dufurmentel C, DufurmentaL L, Moully R. Chirurgie Plastique. Paris: Editions Medicales Flammarion; 1959. 6. Fournier PF. La megalipoextraccion Terapeutica o megalipoescultura. In: Société Française de Lipoplastie, L’Union Internationale des Sociétés deLlipoplastie, Anales de Lipoplastia, Edit Solal, Marseille. 1996. 7. Klein J. The tumescent technique for liposuction surgery. Am J Cosmet Surg. 1987;4:263–7. 8. García-Caballero M, Morell Ocaña M, editors. La Obesidad Tratamiento Medico y Procedimientos quirurgicos. Malaga: Universidad de Malaga; 1996. 9. Skoog T. Atlas de Cirugia Plastica. Barcelona: Salvat; 1976. 10. Spadafora A, Torres San Marco J. Cirugia de la Obesidad, Flaccidez Cutánea y Envejecimiento. Buenos Aires: López Libreros; 1974.

The Modern Lipoabdominoplasty

59

Jorge I. de la Torre and Luis O. Vásconez

Abstract

The goals of abdominal contouring surgery are to maximize the aesthetic outcome, reduce recovery, and minimize morbidity. The authors discuss the history, clinical anatomy, patient evaluation, surgical technique, postoperative care, and complications. The rate of seromas with standard abdominoplasty techniques is over 20 %, while with the lipoabdominoplasty technique, it is 2–4 %. In addition, rates of hematoma formation, wound separation, and wound infection are similarly decreased. Since the umbilicus is not reinserted the umbilical necrosis is almost nonexistent.

59.1

Introduction

Current abdominal contouring procedures consist of suction-assisted lipectomy, dermolipectomy, musculoaponeurotic plication, or some combination of these approaches. Ideally, this results in sufficient reduction of subcutaneous adipose tissue volume, maximum resection of excess skin and tightening of musculoaponeurotic laxity to create an aesthetic contour of the abdominal wall. As with all aesthetic surgical J.I. de la Torre, M.D. (*) • L.O. Vásconez Mountain Brook Plastic Surgery & Laser Center, 2850 Cahaba Rd, Birmingham, AL 35223, USA Division of Plastic Surgery, School of Medicine, University of Alabama, 1720 2nd Ave South, Birmingham, AL 35294-0113, USA e-mail: [email protected]; [email protected]; [email protected]

procedures, the goals of abdominal contouring surgery are to maximize the aesthetic outcome, reduce recovery, and minimize morbidity.

59.2

History

The initial abdominoplasty procedures consisted of resecting a significant abdominal pannus. Kelly [1] described the use of a large horizontal midabdominal incision. A variety of incisions were subsequently described, but the lower abdominal transverse incision presented by Thorek [2] was the basis for the modern abdominoplasty incision. The modern evolution of abdominoplasty as a contour procedure was described by Vernon [3]. It included not only musculoaponeurotic plication but also transposition of the umbilicus. Subsequent refinements and modifications were

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proposed, including variation in the specific incision design, musculoaponeurotic plication technique, and extent of dissection [4–6]. These techniques, however, are all limited because the contouring is achieved by surgical excision of tissue and closure, often under tension, which leave significantly visible scars. Mini abdominoplasty uses a relatively small transverse lower abdominal incision to permit limited resection of redundant infraumbilical skin in conjunction with aggressive liposuction of the abdominal wall. The modified abdominoplasty elevates a skin flap from the pubic region to the subcostal margin. The umbilicus is detached from the fascial midline, fat resection is performed sharply or with limited liposuction, and the fascial midline is tightened both above and below the umbilicus. Standard abdominoplasty requires aggressive elevation of the upper abdominal flap to the level of the subcostal margin. It includes wide undermining of the superior flap, translocation of the umbilicus, and repair of diastasis recti. Traditionally, liposuction has been avoided with aggressive undermining to minimize necrosis of the elevated abdominal flap. In contrast suction-assisted lipectomy can provide dramatic contour improvement with minimally apparent scars. Early techniques in the 1960s, as described by Schrudde [7], utilized sharp curettage and suction. Kesselring and Meyer [8] introduced the use of strong suction. However, the most significant advance in body contour surgery may have been the introduction of the blunt-tip cannulas by Illouz [9]. Another significant improvement in the safety of liposuction came with the utilization of the “wet techniques” to infuse dilute local anesthesia with epinephrine to the operative field [10]. Additional modifications include the use of ultrasoundassisted liposuction by Zocchi [11], as well as laser-assisted liposuction and power-assisted liposuction [12–14]. While liposuction uses minimal incisions to provide improved contour, it does not address the redundant skin redundancy or muscle laxity. Concerns regarding disruption of the abdominal wall vascularity limited liposuction in conjunction with the standard abdominoplasty

procedure. The “marriage abdominoplasty” combines abdominoplasty with more conservative liposuction. As the traditional contour techniques were reevaluated, new concepts regarding the safety of prudent combinations of liposuction with abdominoplasty resection emerged [15]. Liposuction abdominoplasty is now understood to effectively preserve the neurovascular supply of the abdominal wall, facilitate mobilization of the upper abdominal wall, and improve aesthetic contouring [16]. In fact, some research has indicated that within 1 week of surgery, there is no significant impairment of skin perfusion following suction-assisted lipectomy [17]. This allows a new paradigm in body contouring, to combine extensive suctionassisted lipectomy with sharp lipectomy and surgical abdominoplasty techniques [18–20].

59.3

Clinical Anatomy

The overall shape of the abdomen varies depending on the fat distribution and musculoaponeurotic constitution. The ideal body shape for women is narrow at the waist and wider at the hips, while in men it should progressively narrow from the chest to the hips [21]. Fat accumulation also differs between the genders [22]. Women demonstrate weight gain in the lower abdomen, hips, and buttocks; in men fat accumulation occurs intra-abdominally and circumferentially around the mid-abdomen and flanks. While abdominal wall lipodystrophy can be contoured to obtain a desirable result, intra-abdominal adiposity will limit the level of improvement and should be recognized preoperatively. The surface landmarks of the abdomen include the costal margin superiorly, the anterior iliac crest and the mons pubis inferiorly, and the umbilicus. Located approximately midway between the xiphoid and the pubis, the umbilicus is the most prominent surface feature of the abdominal wall. In the youthful abdomen, the lateral border and inscriptions of the rectus muscles are visible as well; the umbilicus is hooded superiorly and tightly adherent to the deep fascia.

59 The Modern Lipoabdominoplasty

The subcutaneous tissue consists of superficial and deep fat, separated by Scarpa’s fascia. The superficial layer is typically dense and fibrous in nature with what has been described as a superficial fascial system [23]. This pervasive system of connective tissue encases and shapes the fat of the trunk and extremities. Scarpa’s fascia is a fibrous layer of connective and adipose tissue that forms a discrete layer in the lower abdominal wall. The deep adipose layer is loose with poorly organized septae [24]. It is the disproportionate enlargement of this deep layer in the torso and upper thigh which characterizes fat accumulation even in thin women. When planning abdominal contouring, careful consideration should be given to the three major vascular zones of the abdominal wall. The midabdomen is supplied by the superior epigastric and inferior epigastric arteries, which form the deep epigastric arcade in the region of the umbilicus. Perforators extend through the anterior fascial sheath to supply the overlying skin. The external iliac artery supplies the lower abdomen. The lateral abdomen is supplied by both the intercostal and subcostal arteries. The intercostal arteries originate from the thoracic aorta and extend to the internal mammary between the external and internal oblique. The superficial external pudendal artery, the superficial epigastric artery, and the superficial and deep circumflex iliac arteries are branches of the femoral artery, which also contribute to the lower abdominal wall skin. The venous drainage system runs parallel to the arterial system. Subsequent consideration will be given to the blood supply to the abdominal wall as related to planning abdominoplasty techniques with particular regard to concomitant liposuction. The abdominal lymphatic drainage is to the axillary lymph nodes above the level of the umbilicus. Below the level of the umbilicus, drainage is to the superficial inguinal lymph nodes. Disruption of the inferiorly directed drainage will result in postoperative swelling, just above the incision, which with time will resolve. Innervation of the upper abdomen is predominantly from the intercostal nerve. Because both the nerves pass deep into the abdominal muscula-

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ture and there is overlap of these dermatomes, it is unusual for patients to experience significant paresthesias in the mid and upper abdomen. Sensory abnormalities are commoner in the lower abdomen and pubis, inferior to any incisional disruption of the sensory nerves.

59.4

Patient Evaluation

The three key elements to consider when evaluating abdominal contour patients are skin quality, musculoaponeutic laxity, and degree of lipodystrophy. With rapid weight gain or pregnancy, significant abdominal wall stretching can occur, leaving persistent skin excess and loss of elasticity. In addition, striae or stretch marks are visible where the dermis has been disrupted. Diastasis recti are often present: a weakness of the fascia is almost always identifiable in multiparous females. Moderate lipodystrophy typically results from hypertrophy of the existing adipocytes; however, with weight gain, adipocyte hyperplasia will occur [25]. This results not only in undesirable adiposity but also in the formation of cellulite as the fibrous septae within the subcutaneous adipose cause changes in the reticular dermis indentations on the skin surface [26, 27]. Patients seeking abdominoplasty can be classified on the basis of the physical examination and the plan for operative management [28, 29]. Type 1 patients are usually younger, with good skin elasticity and minimal lipodystrophy and good muscle tone. Good results can be obtained with suctionassisted lipectomy alone. A type 2 patient has mild skin excess, a normal musculoaponeurotic layer, and mild to moderate lipodystrophy, particularly inferior to the umbilicus. Minimal lower abdominal skin resection in combination with liposuction is effective for these patients. A type 3 patient has mild skin excess, lower abdominal laxity with diastasis of the recti, and mild to moderate lipodystrophy inferior to the umbilicus. In addition to the skin resection and liposuction, plication of the rectus sheath from the pubis to the umbilicus is required. A type 4 patient has skin excess, significant laxity of the musculoaponeurotic layer, and lipodystrophy. Skin resection, liposuction, and plication along the

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entire rectus sheath offers improvement but may require transaction of the umbilical stalk. A type 5 patient presents with severe upper and lower abdominal skin excess and laxity. Diastasis of the rect is severe and the patient is often moderately obese. Traditional standard abdominoplasty with placation of the rectus sheath and defatting is necessary.

59.5

Surgical Technique

59.5.1 Preoperative Treatment Aesthetic improvement of the abdomen is achieved with a continuum of procedures ranging from liposuction alone to multistage belt lipectomy with

repair of musculofascial defects. Modern abdominoplasty is a concept-oriented procedure to address lipodystrophy, musculoaponeurotic laxity, and redundant skin (Fig. 59.1). It combines aggressive liposuction of the abdomen and flanks with dermolipectomy in the suprapubic region. Undermining is limited to the midline to allow plication of the fascia. Preoperative evaluation and markings (Fig. 59.2) are made with the patient in the standing position. The anticipated area for skin resection is marked as are the areas for liposuction. Prior to induction of general anesthesia, lower extremity compression devices are placed and preoperative antibiotics are given. Once the patient is asleep and the Foley catheter has been placed, several small-access incisions are made.

Fig. 59.1 (a) Preoperative lipodystrophy, musculoaponeurotic laxity and loose skin. (b) Postoperatively

59 The Modern Lipoabdominoplasty

Usually these are placed at the umbilicus, the top of the pubic hairline, and laterally within the bikini or underwear line to minimize visible scaring; however, additional incisions are often used. Liberal placement of access incisions permits infusion of Klein’s solution and facilitates fat aspiration with the greatest control to improve the contour while limiting irregularities and asymmetries. Standard Klein’s solution is infused into the areas of planned suctionassisted lipectomy and dermolipectomy. The infusion volume is 1:1 with the anticipated aspiration volume.

Fig. 59.2 (a) Preoperative evaluation in the standing position. (b) Markings in the standing position

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59.5.2 Suction Lipectomy After allowing the epinephrine to take affect, liposuction is performed deep to Scarpa’s fascia beneath the planned skin resection. Major contouring of the remainder of the abdomen is performed by suctioning in both the deep and the superficial fat layers. A 4-mm cannula is typically used, with either the Luer Loc syringe system or vacuum aspiration. Aspiration volumes for the abdomen are usually between 2 and 4 L. If more than 4 L of fat is aspirated, in-patient observation is recommended. Once the result of the liposuction

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has been checked for irregularities and asymmetries and has been found to satisfactory, resection of the redundant skin is performed.

59.5.3 Dermolipectomy The skin is incised with a scalpel along the preoperative markings. Sharp dissection is performed through the subcutaneous tissue continuing down through Scarpa’s fascia. The infiltration of the Klein’s solution minimizes bleeding and permits

Fig. 59.3 Dermolipectomy

J.I. de la Torre and L.O. Vásconez

rapid dissection with serrated Mayo scissors. With the incision complete to each lateral margin, the ends of the skin paddle are grasped with Kocher clamps and the segment is avulsed. Even when aggressive suction lipectomy has been performed, some adipose tissue will remain deep into Scarpa’s fascia (Fig. 59.3). Additional deep contouring can be performed on the abdominal wall fascia using a flat cannula with the vacuum aspirator. However, to minimize the risk of seromas, the fascia should not be stripped clean, but rather at least a fine layer of overlying soft tissue should be left intact.

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59.5.4 Fascial Repair

59.5.5 Management of the Umbilicus

Management of the fascia is of even greater importance when skin resection and undermining is limited. Dissection is performed sharply to elevate the subcutaneous tissue from the midline fascia, creating an area 4–5 cm in width. The use of a lighted retractor or an endoscope allows visualization of the diastasis and facilitates the fascial placation. This can usually be performed while preserving the umbilical attachment to the fascia. Correction of the diastasis is achieved by approximating the fascia at the medial border of the rectus muscles; however, additional tightening can be performed. The amount of additional tightening which will be tolerated can be evaluated by grasping the fascia with two Kelly clamps and approximating the margins. The fascia can then be marked with methylene blue to allow precise placement of the sutures, tapering the amount of planned plication at the cephalad and caudal limits. The midline is closed using several 0 Prolene simple interrupted sutures both above and below the umbilicus. Using interrupted sutures offers additional control over the degree of plication achieved. A running suture of 2-0 looped nylon is placed to imbricate the midline. The midline fascia can be plicated and imbricated from the level of the xiphoid to the suprapubic region. When no undermining of the superior flap is performed, transverse plication of the musculoaponeurotic tissue can be readily performed within the area that has been exposed by dermolipectomy. The fascia is readily exposed and significant abdominal wall tightening can be obtained. Plication and imbrication is performed along a transverse line inferior to the umbilicus. Although this method avoids undermining the superior flap, it tightens the abdomen in a longitudinal direction. Although it will not correct rectus diastasis, it is however helpful to further emphasize the desirable contour of both the lateral and the anterior aspect of the lower abdomen.

Plication around the location of the umbilical stalk may compromise vascularity of the umbilicus and should therefore be performed carefully or avoided. Placement of the plication can be discontinued just above the umbilicus and then restarted below it. Permanent knots should be buried using a smaller slow-absorbing suture such as Vicryl or polydioxanone. This avoids any palpable sutures in the thin tissue around the umbilicus. The umbilicus usually remains attached; however, if additional exposure is required, it can be “floated.” The periumbilical depression is re-created by using liposuction with a flat cannula 2–3 cm surrounding the umbilicus. If the umbilical stalk is long, tacking sutures can be used to attach the deep dermis of the umbilicus to the facial midline. If the umbilical stalk must be detached, use of landmarks, such as the iliac crest, is helpful to avoid resetting it too low.

59.5.6 Wound Closure Wound closure is facilitated by the liposuction in the upper abdomen, which creates mobility of the sliding flap [30]. In addition, because the subdermal thickness of the upper flap is reduced, the wound edges align properly and give an aesthetic closure. Staples are used to temporarily approximate the skin edges and ensure that no dog ears are created. Closure is in layers including the superficial fascial system and deep dermal layers. If any final touch-up contouring is required, it can be performed at this point prior to the subcuticular closure. If needed, closed suction drains can be brought out through the lateral aspect of the incision and secured with nylon sutures.

59.6

Postoperative Care

Immediately following the procedure, a light dressing and a compression garment are placed. This serves to hold the dressing in place without

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tape, decreasing edema, seroma formation, and contour irregularities. Drains are removed when drainage is 1 year) onset and should be treated if causing an inflammatory or painful effect. Management in the literature includes hyaluronidase (if caused by hyaluronic acid (HA)), possible biopsy for culture, intralesional steroid injection (although there is a risk of making the inflammation worse and fat atrophy), cyclosporine, multiple antibiotics and removal via irrigation and suction or exci-

Example Collagen gel, hyaluronic acid gel, polyacrylamide gel, silicone oil Polylactic acid (PLA) based, calcium hydroxylapatite based Collagen gel, e.g. 1. Zyderm (Inamed Aesthetics, Irvine, CA) Hyaluronic acid (HA) based, e.g. 1. Restylane (Medicis, Scottsdale, AZ, USA) 2. Juvederm (Allergan, Irvine, CA, USA) PLA based, e.g. 1. New-Fill (Medifil, London; Biotech Industry, Luxembourg) 2. Sculptra (Dermik Laboratories, Berwyn, PA) Inorganic calcium hydroxylapatite based, e.g. 1. Radiesse (BioForm Medical Inc., San Mateo, CA) Biological Hydrophilic alloplastic, e.g. 1. Polyacrylamide hydrogel (PAAG), e.g. Aquamid (Contura International, Denmark) 2. Polyalkylimide gel, e.g. Bio-Alcamid (Polymekon, Brindisi, Italy) Silicone alloplastic, e.g. 1. Silicone oil, e.g. Silikon (Alcon Laboratories, Fort Worth, TX) PLA based, inorganic calcium hydroxylapatite based, polyacrylamide gel, silicone oil Autologous implants, e.g. fat from patient Allogenic implant, e.g. human cadaveric collagen Xenogenic implants, e.g. bovine collagen Bacterial derived, e.g. certain hyaluronic acids

sion [3, 5]. Biofilms can be difficult to culture and difficult to treat with antibiotics. They present as low-grade infections presenting as lateonset angry red lumps whose differential diagnosis includes foreign granulomas [3]. Although the focus of this chapter is on the treatment of permanent fillers, it is still important to be aware of the side effects of temporary ones. Hyaluronic acid was first discovered in the vitreous humour of the eye in 1934 [6]. Its side effects can range from inflammation and dyspigmentation to tissue necrosis (especially in facial danger zone areas, e.g. the glabellar and nasal ala) and granuloma formation. Therefore, management of these problems again ranges from conservative management to hyaluronidase and surgical excision [7].

74 Liposuction Technique for Extraction of Bio-Alcamid and Other Permanent Fillers

Permanent fillers include liquid injectable silicone, polyacrylamide hydrogel (PAAG) and polyalkylimide gel. Numerous articles have been published describing potential adverse events after injection of permanent filler materials. Liquid silicone has been used for correcting various facial contour defects, but it has been proposed that it is contraindicated in inflamed and infected sites, eyelids and breasts. The most problematic outcomes are related to silicone granulomas and migration [8]. Silicone drift is defined as the movement of the material from the injected site to a distant place. Large-volume placement causes gravitational displacement due to lack of a real fibrous capsule surrounding the silicone [8]. The literature also reports other complications including infection, seroma and bone erosion [9]. Treatments for silicone granuloma have included medical therapy (e.g. allopurinol, oral or intralesional steroids and imiquimod) and surgical removal [8]. PAAG, e.g. Aquamid, is atoxic and biocompatible. It has been advocated as a safe injectable filler for soft tissue augmentation. However, it can support possible bacterial infections and low-virulence bacteria present in the skin, hair follicles and mucous membranes, that can be introduced during injection [1]. It has also been associated with severe complications in the face (e.g. facial ulceration and bony erosion) and breast (e.g. infection, nodularity and migration) [10]. Polyalkylimide gel, e.g. Bio-Alcamid, has been used to treat difficult reconstructive defects, e.g. pectus excavatum, Poland syndrome, postbreast reconstruction contour deformity and HIV-associated lipoatrophy. It is called an endoprosthesis as it undergoes encapsulation within days to weeks after injection which isolates it from the rest of the body [11]. However, due to possible side effects, warning has been given for cosmetic indications. Possible complications including infection and abscess formation, excessive capsule formation and capsular contraction, asymmetry, dislocation and especially migration are known [12–15]. Migration is thought to result from gravity or muscle-induced displacement of the filler material. Methods described for removal include using large-bore needles with squeezing

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and surgery [13, 16]. Some advocate that surgery should be performed by a direct short route to the injected material to prevent contamination to surrounding tissues [15]. However, we now describe methods to remove these fillers using a liposuction technique [17].

74.3

Liposuction Technique for Extraction of Permanent Fillers

The main indication for liposuction removal of permanent filler is for contour irregularities due to large-volume placement of filler or large migration. The advantages of liposuction over direct surgical incision are the ability to utilise inconspicuous scars yielding higher aesthetic results. There are many factors to consider preoperatively. A comprehensive history should be taken from the patient including functional and aesthetic concerns and associated expectations. Medical history including risk factors for bleeding disorders should be noted. On examination the skin quality, the extent of the filler and relations to anatomical boundaries should be noted. An MRI scan may be useful in determining the extent of the filler. Preoperative photos should also be taken and documented. Patients should be consented including risk of inability to remove the filler and conversation to open procedure and contour irregularities. Preoperatively, the patient should be marked both upright and supine highlighting both the boundaries of the filler and the incision sites. Incision sites should be inconspicuous (and discussed with the patient) and in areas that would allow extension should an open procedure be required. For example, in the breast the incision should be placed in the lateral inframammary fold, and in the abdomen it should be placed in the umbilicus or the lateral lower abdomen. Intraoperatively, the patient should be given intravenous antibiotics, deep vein thrombosis prophylaxis and pads placed over pressure areas. Generally, dry liposuction is performed. Liposuction should be carried out using a

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Fig. 74.1 Liposuction of permanent fillers using a standard Mercedes tip 3.7 mm-diameter cannula

Mercedes tip and a wide-bore cannula and high vacuum suction (Fig. 74.1). Power-assisted liposuction may be helpful. Residual fluid can be massaged out. The wound is closed with the suture of choice and an occlusive dressing placed. The operation can be performed as a day case procedure. However, if there is a large dead space, then there should be consideration of drain placement, and if there is a large cavity, compression garments should also be considered. Patients should be discharged with oral analgesia.

References 1. Christensen LH. Host tissue interaction, fate, and risks of degradable and nondegradable gel fillers. Dermatol Surg. 2009;35 Suppl 2:1612–9. 2. Buck DW, Alam M, Kim JYS. Injectable fillers for facial rejuvenation: a review. J Plast Reconstr Aesthet Surg. 2009;62(1):11–8. 3. Narins RS, Coleman WP, Glogau RG. Recommendations and treatment options for nodules and other filler complications. Dermatol Surg. 2009;35 Suppl 2:1667–71.

K. Bisarya et al. 4. Lemperle G, Gauthier-Hazan N, Wolters M, Eisemann-Klein M, Eisemann-Klein M, Zimmermann U, Duffy DM. Foreign body granulomas after all injectable dermal fillers: part 1. Possible causes. Plast Reconstr Surg. 2009;123(6):1842–63. 5. Sage RJ, Marsha LC, Kouba DJ. Granulomatous foreign body reaction to hyaluronic acid: report of a case after melolabial fold augmentation and review of management. Dermatol Surg. 2009;35 Suppl 2: 1696–700. 6. Price RD, Berry MG, Navsaria HA. Hyaluronic acid: the scientific and clinical evidence. J Plast Reconstr Aesthet Surg. 2007;60(10):1110–9. 7. Park TH, Seo S-W, Kim J-K, Choong-Hyun C. Clinical experience with hyaluronic acid-filler complications. J Plast Reconstr Aesthet Surg. 2011; 64(7):892–7. 8. Moscona RA, Fodor L. A retrospective study on liquid injectable silicone for lip augmentation: long-term results and patient satisfaction. J Plast Reconstr Aesthet Surg. 2010;63(10):1694–8. 9. Requena L, Requena C, Christensen L, Zimmermann US, Kutzner H, Cerroni L. Adverse reactions to injectable soft tissue fillers. J Am Acad Dermatol. 2011;64(1):2–34. 10. Liu HL, Cheung WY. Complications of polyacrylamide hydrogel (PAAG) injection in facial augmentation. J Plast Reconstr Aesthet Surg. 2010;63(1): e9–12. 11. Lahiri A, Waters R. Experience with bio-alcamid, a new soft tissue endoprosthesis. J Plast Reconstr Aesthet Surg. 2007;60(6):663–7. 12. Thioly-Bensoussan D. Non-hyaluronic acid fillers. Clin Dermatol. 2008;26(2):160–76. 13. Kadouch JA, Kadouch DJ, Fortun S, Rozelaar L, Karim RB, Hoekzema R. Delayed-onset complications of facial soft tissue augmentation with permanent fillers in 85 patients. Dermatol Surg. 2013; 39(10):1478–85. 14. Nelson L, Stewart KJ. Experience in the treatment of HIV-associated lipodystrophy. J Plast Reconstr Aesthet Surg. 2008;61(4):366–71. 15. Karim RB, Rozelaar L, Lange CAH, Raaijmakers J. Complications of polyalkylimide 4% injections (Bio-Alcamid): a report of 18 cases. J Plast Reconstr Aesthet Surg. 2006;59(12):1409–14. 16. Schelke LW, Elzen HJ, Canninga M, Neumann MHA. Complications after treatment with polyalkylimide. Dermatol Surg. 2009;35 Suppl 2:1625–8. 17. Khan I, Shokrollahi K, Bisarya K, Murison MS. A liposuction technique for extraction of Bio-Alcamid and other permanent fillers. Aesthet Surg J. 2011; 31(3):344–6.

Part VI Lipedema (Lipoedema) and Lymphedema

Lipedema and Lymphatic Edema

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Manuel E. Cornely

Abstract

The differential diagnosis of symmetrical leg swellings needs to distinguish clearly between lipedema and lymphatic edema. Obesity followed by lipohypertrophy can have bilateral leg swelling. The author describes the anatomy and pathophysiology, clinical categories of lipedema, pretherapeutic diagnostics, the therapeutic options, and the surgical therapy. Early lymphological liposculpture will prevent the development of dynamic insufficiency and thus the progress of the lipedema. Today, liposuction of lipedema is a relieving therapy option.

75.1

Introduction

The differential diagnosis (Fig. 75.1) of symmetrical leg swellings needs to distinguish clearly between lipedema and lymphatic edema. Both volume and form changes often lead to misdiagnosis. These changes occur symmetrically in lipedema of the upper extremities. This may be due to an underused technical means of diagnosis in favor of the clinician’s subjective impression. The most frequent misdiagnosis certainly is obesity followed by lipohypertrophy. However, adequate exploration of the patient’s history and

M.E. Cornely, M.D. CG Lympha, Bachemer Str. 31, 50931 Köln, Germany Private Practice, Kaiserswerther Str. 296, Düsseldorf 40474, Germany e-mail: [email protected], [email protected]

thorough clinical examination can regularly uncover whether the clinical changes are due to lipedema, lymphatic edema, lipohypertrophy, or obesity.

75.2

Anatomy and Pathophysiology

Primary lymphatic edema of the extremities, which mainly results from hypoplasia or aplasia of the lymphatic system, appears less frequently than secondary edema. Primary lymphatic edema rarely appears completely symmetrically: usually, the left side is worse. In the lower extremity, secondary, i.e., after infectious disease or after surgery, lymphatic edema is much more frequent than primary lymphatic edema. Although both entities differ in origin, a relative asymmetry characterizes the clinical aspect of lymphatic edema. Furthermore, lymphatic edema is characterized by painlessness and

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Fig. 75.1 Differential diagnosis. (a) Lipedema (b) Lymphatic edema is asymmetrical, Stemmer test can be and erysipelas can be present

usually is not accompanied by hematoma. Dorsal pedal edema and erysipelas frequently accompany lymphatic edema. Ideally, the Kaposi– Stemmer sign [1] is positive. Lymphatic edema is rich in protein and arises from the reduced transport capacity of the lymphatic system despite normal protein load; therefore, it can be clearly distinguished from the phlebedema owing to its specific gravity. Phlebedema results from varicosis and is low in protein. Ninety percent of the arterial blood flow of the extremities forms the venous blood flow. The remaining 10 % constitutes the liquid part of the lymph. If the valve-bearing drainage system called the “lymphatic system” works insufficiently or is constituted poorly, the result is the corresponding edema. The lack in return transport capacity leads to retention of the respective liquids. Liquid retention can also be a clinical sign of varicosis, if less than 90 % of the liquid is transported back via the venous system, thus putting an additional strain on the lymphatic system.

Phlebedema displays a lymphatic component additionally by increasing the load to be transported via lymph. According to Földi and Földi [2], the load to be transported via lymph is called prelymph before entering the lymphatic vessels (Fig. 75.2). The prelymph flows via the prelymphatic channels toward the lymph capillaries and the precollectors, which in their entirety are also called initial lymphatic vessels. The physiologic inflow toward the lymph collectors can be compared with a cascade, with the lymph collectors having a diameter of approximately 0.5 mm. The following lymphatic trunks are about 2 mm in diameter. Then, the protein-rich lymph gets back to the venous vascular system via the thoracic duct. Lymph transported from the periphery to the center in this semicircular system essentially consists of products which cannot be transported via the venous system. Among these products, plasma proteins represent the main protein load. They are transported within the water load and

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717 Table 75.1 Földi’s staging system

100% Venös

10% Lymphe

100% Arteriell

Stage 0 Stage 1 Stage 2 Stage 3

Incipient Reversible, tissue is soft Spontaneously reversible, tissue is harder Irreversible, fibroscleroses

90% Kapillär

Fig. 75.2 Lymphatic system. Differential diagnosis of lymphedema. Cardiologic: foot edema; nephrogenic: foot edema; phlebogenic: foot edema; lymphogenic: edema includes fingers and toes Fig. 75.3 Feet with papillomatoses

are accompanied by immobile cells, foreign substances, and long-chained fatty acids. These loads are addressed as cell load and fat load. The normal transport capacity of the lymphatic systems is 2–4 l/day. If the lymph flows anatomically correctly, it floods the lymph nodes at filter points in which the lymph has direct contact with the immunocompetent cells. The differentiation of B and T lymphocytes also takes place in these lymph nodes, which are filter points of specific anatomic regions like guards, i.e., sentinels, of the immune system. The further milky and cloudy liquid follows the thoracic duct, venous angle, left subclavian vein, and the left internal jugular vein. The appearance of the lymph in these anatomical structures led the old anatomists to the term “lactiferous glandular duct.” Földi and Földi [2] distinguish four stages (0– III) of lymphatic edema (Table 75.1). Stage 0 is an incipient edema. In stage I, the edema is present but reversible, and the tissue is soft. In stage II, there is a spontaneous reversibility with sclerosis of the tissue. Only stage III is described as an irreversible lymphatic edema characterized by fibrosclerosis. These congestion phenomena change the state of the skin in a serious and very impressive manner and result in papillomatosis (Fig. 75.3). These changes are strictly lympho-

Fig. 75.4 Crural ulcer due to lymphostasis in lipedema

static and need a therapeutic way corresponding to the pathophysiology. Lymphatic edema can also lead to deficiencies of the skin due to papillomatoses and congestion. Lymphostatic crural ulcers typically are refractory to treatment. In contrast to venostatic ulcers, surgical intervention is not feasible for lymphostatic ulcers (Fig. 75.4). Apart from the patient’s history, the examiner will interpret clinical signs and symptoms. Thus, the palpation abilities are of utmost importance. Ideally, a Kaposi–Stemmer sign is present (Fig. 75.5). This means that on the back of the second toe, a cutaneous fold cannot be elevated. This poor elevation can be a sign of edema or of

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Fig. 75.5 Kaposi–Stemmer sign

the already fibrotically altered skin tissue. The cutaneous fold test can also be used in different anatomic regions, such as the side comparison of the thoracic wall in breast cancer patients with secondary lymphatic edema. A palpable difference in skin thickness clearly hints at the deposition of protein resulting in fibrosis. Furthermore, imaging techniques provided by nuclear medicine help in establishing the diagnosis: Fig. 75.6 Marshall clefts in duplex sonography

1. Functional lymph scintigraphy elucidates dynamics and transport capacity of the lymphatic vascular system. 2. Indirect lymphangiography displays the vascular situation. 3. In lymphedema, lymph vessels are made visible by duplex sonography using a 13-MHz probe, thus facilitating differential diagnosis, e.g., lipedema. These sonographically documented vessels are called Marshall clefts (Fig. 75.6). This new technique may lead to a higher rate of correctly diagnosed lymphedema and lipedema. The correlation between the findings in 13-MHz duplex sonography and in histology is remarkable.

75.3

Clinical Categories of Lipedema

While the clinical findings in lymphatic edema have been known for decades, the findings in lipedema remained largely unknown. Allen and Hines [3] first described “lipedema of the legs” in

1940 and reported a clinical syndrome found in women. This clinical picture always comes with a symmetrical increase of the adipose tissue of the extremities, leading to a disproportion between extremities and trunk. Arms and legs appear symmetrically volume increased; trunk, hands, and feet are not involved. Thus, lipedema differs clearly from Dercum’s disease [7]. Lipedema is strictly accompanied by increased vascular fragility resulting in subcutaneous hematoma after minor bruising and an orthostatic tendency to lymphatic edema leading to tenderness. Herpertz [4] developed an easy and pragmatic clinical differentiation (Table 75.2). He differentiates a painless fat distribution of the extremities called “lipohypertrophy” from a painful one, which is then called “lipedema.” According to Herpertz, lipedema without pain does not exist. This corresponds to the clinical findings: 1. Lipedema is an increase in leg fat volume which is always symmetrical, painful, and similar to saddlebags reaching from the iliac crest down to the ankles. It is always

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Table 75.2 Clinical differentiation [4]

upper dermis and to the development of a dynamic insufficiency. The microlymphangiographic studies by Amann-Vesti et al. [5] confirm the presence of microaneurysms in the skin of lipedema patients. The pathophysiology of the lipedema’s fat is supported by the data presented by Tiedjen and Schultz-Ehrenburg [6]. Using function scintigraphy, the uptake of lipedema patients in comparison with that of the normal population and of lipolymphatic edema patients was evaluated. In lipedema patients, the lymphatic system tries to compensate for the huge amount of lymphatic ultrafiltrate by increasing the transport capacity to a high volume. Beyond the fifth decade, the uptake values decrease under the lower limit of normal. This situation may result in lipolymphedema.

Lipohypertrophy Painless malfunction of the distribution of fat at the extremities Lipedema Painful lipohypertrophy of the extremities

accompanied by a dynamic insufficiency of the lymphatic system. 2. There is tenderness on pressure and an increased vascular fragility. 3. The dorsal pedal pulses are slim; the Kaposi– Stemmer sign is negative. 4. Similar symmetrical changes are to be found in the arms in up to 30 % of patients.

75.4

Differential Diagnoses

The disproportion between extremities and trunk, the restriction of lipedema to the ankles and the wrists (30 %), and the lack of involvement of the feet and hands clearly distinguish lipedema from adiposity. Lipedema is congenital, restricted to women, and finally formed, at the latest, by the end of the third decade. This congenital maldistribution cannot be influenced nutritionally. “Adiposity” as the most frequent false diagnosis can be ruled out by the simple question whether the circumference of the legs and arms could be reduced by a diet or physical activities. A change of the genetically determined body shape cannot be achieved [8].

75.6

Even if the clinical findings seem to be unequivocal, it is nevertheless necessary to exclude lymphedema and to confirm the presence of lipedema by indirect functional lymph scintigraphy, indirect lymphangiography, and the examination of the fatty tissue with 13-MHz duplex sonography. These instrumental methods allow an estimate of the progression of the disease and differentiation between lipophlebedema, lipolymphedema, and lipolymphatic phlebedema.

75.7 75.5

Pathophysiology

Pain in lipedema is due to the dynamic insufficiency of the lymph flow. The forming and coping of the edema in the fat tissue are structurally marked by a drainage weakness. Fatty lobules do not contain lymphatic vessels but have a strong blood flow. This results in a large amount of lymph ultrafiltrate having to be transported via the septae in which lymphatic vessels run. The resulting higher blood ultrafiltrate is undercompensated by capillary drainage. This structural drainage weakness leads to the transport to the

Pretherapeutic Diagnostics

Therapeutic Options

It is uncontested that manual lymph drainage and complex therapy against congestion have a place in the treatment of lymphatic disease. Sufficient compression and skin care are always part of the manual lymph drainage concept.

75.8

Surgical Therapy

So far, surgical interventions have not produced truly positive results in lymphatic edema but the situation is different with lipedema. The development of dynamic insufficiency is just a question

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of time as the findings of Tiedjen and SchultzEhrenburg [6] and Amann-Vesti et al. [5] have shown. It appears reasonable to remove the fat tissue. After the presurgical diagnostic testing and exclusion of further angiologic diseases, lipedema can be treated curatively by microcannular liposuction. Prerequisites are thorough clinical examination; complete vascular analysis of artery, vein, and lymphatic vessel systems; and duplex sonography. Incisions should spare lymph vessels. This is followed by a microcannular liposuction under tumescence anesthesia. For the success of the sufficient tumescence, it is decisive that the action time lasts between 1 and 1.5 h. In the extremities, long cannulas should be used for liposuction according to the axes. This procedure results in the maximum protection of the lymphatic vessels: 1. In lipedema, lymphatic edema would represent a local contraindication to surgical intervention. 2. There are some surgical methods for the restoration of secondary lymphatic edema as lymph node flaps and vessel transplants in secondary lymphatic edema. The size of the arm can just be reduced by liposuction [8]. 3. Tumescence local anesthesia allows a water dissection of cells and vessels by carefully dilating the tissue. 4. Injury of lymph and blood vessels does not happen. 5. Manual lymph drainage is useful and necessary in order to speed up the recovery after surgical treatment. 6. The presurgical procedure requires a clear picture about the complete vessel situation of

the extremity, the dynamics of the lymph transport, and the situation of the fat. The clinical examination of a lipedema has to prove increased vessel fragility and painful tenderness.

75.9

Discussion

Early lymphological liposculpture will prevent the development of dynamic insufficiency and thus the progress of the lipedema. Today, liposuction of lipedema is a relieving therapy option. Lipedema is an unequivocal medical indication for the liposuction of the extremities.

References 1. Stemmer R. Stemmer’s sign—possibilities and limits of clinical diagnosis of lymphedema. Wien Med Wochenschr. 1999;149(2–4):85–6. 2. Földi E, Földi M. Die Therapiemöglichkeiten des Lipödems, dessen mit verschiedenen Ergebnissen kombinierten Formen sowie der benignen symmetrischen Lipomatose. Swiss Med. 1984;6:19–24. 3. Allen E, Hines EA. Lipedema of the legs: a syndrome characterized by fat legs and orthostatic edema. Proc Staff Mayo Clin. 1940;15:184–7. 4. Herpertz U. Das lipödem. Lymphologie. 1995;19:7. 5. Amann-Vesti BR, Franzeck UK, Bollinger A. Microlymphatic aneurysms in patients with lipedema. Lymphology. 2001;34(4):170–5. 6. Tiedjen KU, Schultz-Ehrenburg U. Isotopenlymphographische befunde beim lipödem. In: Holzmann H, Altmeyer P, Hör G, Hahn K, editors. Dermatologie und Nuklearmedizin. Berlin: Springer; 1985. p. 432–8. 7. Cornely M. Lipohyperplasia dolorosa. Zeitschrift Phlebologie. vol. 1. Stuttgart: Schattauer Verlag; 2005. p. 17–9. 8. Brorson H. Liposuction in arm lymphedema treatment. Scand J Surg. 2003;92(4):287–95.

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Emma Hansson and Håkan Brorson

Abstract

Lymphedema is the accumulation of lymph fluid in the interstice with secondary tissue changes. The accumulated lymph stimulates adipose tissue deposition, and a marked adipose tissue hypertrophy can be seen in patients with chronic lymphedema. The basis for all lymphedema treatment is adequate compression therapy. However, if the lymphedema has started to transform into adipose tissue, conservative therapy is no longer sufficient, and liposuction can then give complete and permanent reduction of the excess limb volume.

76.1

E. Hansson, M.D., Ph.D., M.A., (*) Associate Professor, Department of Clinical Sciences Malmö, Lund University, Lund, Sweden Plastic and Reconstructive Surgery, Skåne University Hospital, Jan Waldenströms gata 35, SE-205 02 Malmö, Sweden e-mail: [email protected] H. Brorson, M.D., Ph.D., Associate Professor Plastic and Reconstructive Surgery, Skåne University Hospital, Jan Waldenströms gata 35, SE-205 02 Malmö, Sweden e-mail: [email protected]

Introduction

The lymphatic system plays a vital role in active maintenance of fluid tissue homeostasis and the transport of immunocompetent cells from the periphery to the central lymphoid tissue [1]. Lymphedema is the accumulation of lymphatic fluid in the interstice with secondary tissue changes. The presence of edema in the tissue is a reflection of an imbalance between the rate of interstitial tissue fluid generation and the degree to which the lymphatic vasculature is malfunctioning; hence, the lymph transport capacity is lowered [1]. Lymphedema can therefore occur when there is an anomalous development of the lymphatic system (primary, congenital lymphedemas), such as malformation, syndromes, or when there is an injury to the lymphatic system (secondary, acquired lymphedema), caused by infection (filariasis), direct neoplastic invasion,

© Springer-Verlag Berlin Heidelberg 2016 M.A. Shiffman, A. Di Giuseppe (eds.), Liposuction: Principles and Practice, DOI 10.1007/978-3-662-48903-1_76

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trauma, or earlier treatments, such as surgery and radiation [2]. Cancer treatment is the most common cause of lymphedema in developed countries [2]. Removal of regional lymph nodes and postoperative irradiation are common in cancer treatment, for instance, in the treatment for breast, gynecological and urological cancer, as well as for malignant melanoma and head and neck tumors. Lymphedema prevalence among all cancer survivors has been estimated to be between 1 and 2 % [2] and considerably higher in some subgroups such as breast cancer survivors treated with traditional axillary lymph node dissection (ALND) [3]. According to the traditional view, lymphatic capillaries filter at their arteriolar end, while they reabsorb fluid at the venular end of the capillary. However, according to modern evidence, considering all Starling forces, including intestinal colloid osmotic and hydraulic pressures, there is a net filtration along the entire length of the capillary and no venous reabsorption. This implies that accumulation of lymph in the tissue normally is avoided through lymph drainage and not by reabsorption as previously thought. Chronic lymphedema develops when the microvascular filtration exceeds the lymph drainage capacity [4, 5]. In lymphedema, a distortion of the cellular architecture takes place in the tissue [1]. The accumulated lymph stimulates adipose tissue

Fig. 76.1 Cross section of upper arms, autopsy samples. The hypertrophied adipose tissue of the lymphedematous left arm is clearly seen (Source: Håkansson CH, Dept. Of Oncology, c/o Southern Swedish Regional Tumor Registry Lund University Hospital, Lund Sweden. Reprinted with permission)

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deposition, and a marked adipose tissue hypertrophy can be seen in patients with chronic lymphedema (Figs. 76.1 and 76.2) [6–12]. Eventually, an increase in fibrosis also occurs in lymphedema. In the affected tissue, an increase in fibroblasts, histiocytes, and neutrophils can be seen. Collagen deposition is profound and progressive in a lymphedema [1]. The process is probably mechanistically linked to the inflammatory response to the stimulus of lymph stasis and tissue damage, and upregulation of fat differentiation genes, driving adipose-derived stem cells toward adipogenic differentiation and promoting fibroadipose deposition. Hence, there is a clear lymphatic-adipose link (Fig. 76.3) [10–13]. In fact, there is a theory that deposition of fat and obesity might, in part, be regulated by factors released from lymphatic vessels. Hence, lymph vessel defect or damage and lymph fluid accumulation might not only contribute to deposition of adipose tissue in the affected limb but also contribute to general obesity (Fig. 76.4) [14]. Moreover, weight gain has been demonstrated as a risk factor for the development of breast cancerrelated lymphedema [5]. One might think that the longer the duration of the lymphedema, the more adipose tissue is deposited. However, there is no such correlation. In fact, the deposition of fat starts already when the lymphedema starts or soon thereafter (Fig. 76.5) [7, 8].

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Fig. 76.2 (a) MRI showing a right-sided secondary arm lymphedema after breast cancer treatment. Not the honeycomb pattern. (b) The healthy left side in the same patient for comparison [8] (Reprinted with permission)

Injury

Impaired lymphatic function

Interstitial fluid accumulation

Inflammation

Fibrosis and adipose deposition

Obesity

Fig. 76.3 Hypothetical model of adipose deposition [12] (Reprinted with permission)

Thus far, there is no cure for lymphedema. The basis for all lymphedema treatment is adequate compression therapy. However, if the lymphedema has started to transform into adipose tissue, conservative therapy is no longer sufficient, and liposuction can then give complete reduction of excess limb volume [15, 16].

76.2

Diagnosis

A thorough history regarding family history, previous surgery, and lymphadenectomy/lymph node biopsy and/or irradiation, penetrating trauma, travel to areas endemic for filariasis is important, as well as information on when, where, and how the edema started, its progression, and tried treatments and results.

It is important to exclude other conditions, that cause overgrowth of an extremity, such as other vascular anomalies, venous stasis, obesity, lipedema, and systemic causes of edema [17]. Clinical examination should include thorough skin exam, noting the presence of skin reddening, hyperkeratosis, pigmentations, lymph fluid leakage, scars, wounds, and irradiation dermatitis. Moreover, affected area(s) and all regional lymph nodes should be palpated, and the range of motion of the nearby joints measured. It is essential to establish if the lymphedema has a fluid component or is completely transferred to fat and fibrous tissues. Clinically, a fatty edema becomes firm and denser, and pitting becomes less pronounced and is sometimes absent. The most important clinical test is the pitting test. A positive pitting test implies that a

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WT

Prox+/–

Lymph fluid

Lymphedema

Blood vessels leak lymph

Lymph vessels drain lymph

Abnormal lymph vessels fail to drain lymph

Lymph stimulates fat cell differentation Fat cell and growth

Fat cell precursor Fig. 76.4 Defects in the lymph vessels might promote fat deposition and obesity. In wild-type (WT) mice, fluid extravasating from blood capillaries is collected by lymph vessels and transported back to the blood circulation. A study has shown that in mice, with damaged lymph ves-

sels, lymph fluid accumulation promotes differentiation of fat cell precursors into fat cells, and deposition of fat cell hypertrophy can be seen. The factors determining the process are not fully known [14] (Reprinted with permission)

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Fig. 76.5 No correlation can be seen between the duration of the lymphedema and the excess fat in the lymphedematous arm, as measured by dual energy X-ray absorptiometry (DXA) [7] (Reprinted with permission)

Excess fat volume in lymphedematous arm estimated by DXA (ml)

1600 1400 1200 1000 800 600 400 200 0 0

5

10 15 20 25 30 Duration of lymphedema (years)

35

40

76 Liposuction of Lymphedema of the Extremities

a

Fig. 76.6 (a) Marked lymphedema with deep pitting of several centimeters (arrows) (grade I edema). The edema is dominated by fluid, that is, accumulation of lymph fluid, and therefore conservative treatment with compression is indicated. (b) Lymphedema where there is no pit-

depression is formed when pressure is exerted to the edematous tissue. This is caused by lymph fluid being squeezed into the surroundings. To standardize the pitting test, the examiner should press as hard as possible so that the nail bed of the pressuring thumb whitens, during at least one minute, and the resulting depression is estimated in millimeters (Fig. 76.6) [18]. Lymphedema dominated by hypertrophied adipose tissue and/ or fibrosis demonstrates little or no pitting. In addition, in leg lymphedema, a positive Stemmer’s sign can be seen, which implies that a skin fold cannot be pinched and lifted at the base of the toes due to skin fibrosis. Also the normal depressions next to the Achilles tendon have disappeared [19]. The volume of the edema can be measured easily directly with the water displacement method (plethysmography), where the affected extremity is lowered into water and the displaced volume constitutes the volume of the extremity. The difference between the lymphedematous and healthy extremity gives the edema volume (Fig. 76.7) [20, 21]. The edema volume can also be measured indirectly, that is, calculated with the help of repeated circumferential measurements along the extremity, the same standardized measurements that are used to order compression garments, and the formula for a truncated cone (Fig. 76.8) [21].

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b

ting despite of hard digital pressure for 1 min (arrows) (grade III edema). The lymphedema is dominated by hypertrophied adipose tissue and no or minimal amount of lymph fluid, and therefore liposuction can be performed (Copyright Håkan Brorson. Reprinted with permission)

Fig. 76.7 Measurement of lymphedema volume by plethysmography, where the displaced water is weighed on a scale. The weight (grams) of the water equals the displaced volume in mL (Copyright Håkan Brorson. Reprinted with permission)

If imagining is needed to supplement the clinical investigation, lymphoscintigraphy is the

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may occur. An increase in various proliferating cells might also be seen. 3. Stage II signifies that limb elevation alone rarely reduces tissue swelling and pitting is manifest. Late in Stage II, the limb may or may not pit as excess fat and fibrosis supervenes. Stage III encompasses lymphostatic elephantiasis where pitting can be absent and trophic skin changes such as acanthosis, further deposition of fat, and fibrosis, and warty overgrowths have developed. Fig. 76.8 Estimation of the lymphedema volume with circumference measurements [21] (Reprinted with permission)

“gold-standard” technique with a 92 % sensitivity and 100 % specificity for lymphedema [22, 23]. Lymphedema is diagnosed by delayed transit time to the regional lymph nodes, dermal backflow, or presence of collateral lymphatic channels, that can be seen after Tc99-labeled antimony sulfur or albumin has been injected [22–24]. Scintigraphy should always be performed in primary lymphedema [25]. Color Doppler can be used to further delineate the venous system [26]. Other imaging modalities, such as MRI and CT, are less specific and sensitive for diagnosing lymphedema, but are useful in differentiating lymphedema from other diagnoses and when primary or secondary malignancy in enlarged lymph glands is suspected [26].

76.3

Staging and Severity

The International Society of Lymphology has adapted a staging system [27]: 1. Stage 0 (or Ia) which refers to a latent or subclinical condition where swelling is not yet evident despite impaired lymph transport, subtle changes in tissue fluid/composition, and changes in subjective symptoms. It may exist months or years before overt edema occurs. 2. Stage I represents an early accumulation of fluid relatively high in protein content (in comparison with, e.g., “venous” edema), which subsides with limb elevation. Pitting

In addition, based on the volume difference between the affected and the healthy extremity, the severity can be classified into [27]: Mild Moderate Severe

76.4

≤20 % difference =20–38 % difference ≥38 % difference

Technique

Surgical treatment of lymphedema becomes indicated in patients who do not respond to conservative treatment, have subjective discomfort of a heavy extremity, and have a negative pitting test due to hypertrophy of the subcutaneous adipose tissue. The surgical treatment is directed toward the excess adipose hypertrophy. Contraindications are active malignant disease and ulcerations [28]. General anesthetics are used in most cases. Made-to-measure compression garments (two sleeves and two gloves) are measured and ordered 2 weeks before surgery, using the extremity as a template. Nowadays, power-assisted liposuction, with a negative atmospheric pressure of 0.9, is used as the vibrating cannula facilitates the liposuction. This is especially true in the lymphedema leg, which is more demanding to treat. To minimize blood loss, a tourniquet in combination with tumescence technique is utilized [29, 30] Through approximately 10–15, 3–4-mmlong incisions, liposuction is performed using 15- and 25-cm-long cannulas with diameters of 3 and 4 mm and 3 openings at the tip. The cannula openings differ from normal liposuction cannulas in that they constitute almost half of

76 Liposuction of Lymphedema of the Extremities

the circumference in order to facilitate the liposuction, especially in lymphedema with excess fibrosis (Fig. 76.9). Liposuction is executed a

Fig. 76.9 (a) Side view: Standard cannula in the upper part, and liposuction cannula in the lower part of the figure. The lymphedema cannulas are 15-cm long and have an outer diameter of 3 and 4 mm. In the tip, there are three openings. Note that the openings of the cannula constitute

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circumferentially, stepwise from distal to proximal, and the hypertrophied fat is removed as completely as possible (Fig. 76.10). b

almost half of the circumference, compared to standard liposuction cannulas. (b) Frontal view: The same cannulas as in (a) (Copyright Håkan Brorson. Reprinted with permission)

Fig. 76.10 Perioperative pictures from the start of the operation, during, and at the end of surgery (Copyright Håkan Brorson. Reprinted with permission)

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When the arm distal to the tourniquet has been treated, a sterilized made-to-measure compression sleeve is applied (Jobst® Elvarex, BSN medical, compression class 2) to the arm to stem bleeding and reduce postoperative edema. A sterilized, standard interim glove (Cicatrex interim, Thuasne®, France), in which the tips of the fingers have been cut to facilitate gripping, is put on the hand. The tourniquet is removed and the most proximal part of the upper arm is treated using the tumescent technique. This involves infiltration of 1 L of saline containing low-dose adrenaline and lignocaine [29, 30] Finally, the proximal part of the compression sleeve is pulled up to compress the proximal part of the upper arm. The incisions are left open to drain through the sleeve. The arm is lightly wrapped with a large absorbent compress covering the whole arm (60 × 60 cm, Cover Dri, www. attends.co.uk). The arm is kept at heart level on a large pillow. The compress is changed when needed. The following day, a standard gauntlet (i.e., a glove without fingers, but with a thumb; Jobst® Elvarex, BSN Medical, compression class 2) is put over the interim glove after the thumb of the gauntlet has been cut off to ease the pressure on the thumb. If the gauntlet is put on straight after surgery, it can exert too much pressure on the hand when the patient is still not able to move the fingers after the anesthesia. Operating time is, on average, 2 h. An isoxazolyl penicillin or a cephalosporin is given intravenously for the first 24 h and then in tablet form until incisions are healed, about 10–14 days after surgery. Liposuction technique for leg lymphedema is similar to that for the arm.

76.5

Postoperative Care

Garments are removed 2 days postoperatively so that the patient can take a shower. Then, the other set of garments is put on and the used set is washed and dried. The patient repeats this after another 2 days before discharge. The standard glove and gauntlet is usually changed to the madeto-measure glove at the end of the hospital stay.

The patient alternates between the two sets of garments (one set = one sleeve and one glove) during the 2 weeks postoperatively, changing them daily or every other day so that a clean set is always put on after showering and lubricating the arm. After the 2-week control, the garments are changed every day after being washed. Washing “activates” the garment by increasing the compression due to shrinkage. Anticoagulants, low molecular heparin, should be given pre- and postoperatively.

76.5.1

Controlled Compression Therapy (CCT)

A prerequisite to maintaining the effect of liposuction is the continuous use of a compression garment [28]. Compression therapy is crucial, and its application is therefore thoroughly described and discussed with the patient at the first clinical evaluation. If the patient has any doubts about continued CCT, he or she is not accepted for treatment. After initiating compression therapy, the custom-made garment is taken in, when needed, at each visit using a sewing machine, to compensate for reduced elasticity and reduced arm volume. This is most important during the first 3 months when the most notable changes in volume occur. At the 3-month visit, the arm is measured for new custom-made garments (two sets). This procedure is repeated at 6, 9, and 12 months. If complete reduction has been achieved at 6 months, the 9-month control may be omitted. If this is the case, remember to prescribe garments for 6 months, which normally means double the amount than would be needed for 3 months. It is important, however, to take in the garment repeatedly to compensate for wear and tear. This may require additional visits in some instances, although the patient can often make such adjustments himself/herself. When the excess volume has decreased as much as possible and a steady state is achieved, new garments can be prescribed using the latest measurements. In this way, the garments are renewed three or four times during the first year. Two sets of sleeve-andglove garments are always at the patient’s disposal; one being worn while the other is washed. Thus, a

76 Liposuction of Lymphedema of the Extremities

garment is worn permanently, and treatment is interrupted only briefly when showering and, possibly, for formal social occasions. The patient is informed about the importance of hygiene and skin care, as all patients with lymphedema are susceptible to infections, and keeping the skin clean and soft is a prophylactic measure [20, 28]. The life span of two garments worn alternately is usually 4–6 months. Complete reduction is usually achieved after 3–6 months, often earlier. After the first year, the patient is seen again after 6 months (1.5 years after surgery) and then at 2 years after surgery. Then the patient is seen once a year only, when new garments are prescribed for the coming year, usually four garments and four gloves (or four gauntlets). For very active patients, six to eight garments and the same amount of gauntlets/gloves a year are needed. Patients without preoperative swelling of the hand can usually stop using the glove/gauntlet after 6–12 months postoperatively. For legs, the authors’ team often uses up to two, sometimes three, compression garments, on top of each other, depending on what is needed to prevent pitting. A typical example is a panty with a leg-long garment, Jobst® Elvarex, BSN Medical compression class 3 and Jobst® Elvarex, BSN medical, compression class 2; the latter being a leg-long garment. Sometimes, in a very large leg lymphedema, a leg-long Jobst® BSN Medical, Bellavar¨ compression class 2 (or Elvarex® compression class 2) is added when needed. Thus, such a patient needs two sets of two to three garments/set. One set is worn while the other is washed. Depending on the age and activity of the patient, two such sets usually last for 2–4 months. That means that they must be prescribed three to six times during the first year. After complete reduction has been achieved, usually around 12 months, the patient is seen once a year when all Fig. 76.11 A 74-year-old woman with a non-pitting arm lymphedema for 15 years. (Top) Preoperative excess volume 3,090 mL). (Bottom) Complete reduction after 1 year (Copyright Håkan Brorson. Reprinted with permission)

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new garments are prescribed for the coming year. After complete reduction, the panty with a leglong garment can be changed to one without a panty. During night, only one leg-long garment is used. CCT can also be used primarily to effectively treat a pitting edema as an alternative to CDT, which, in contrast to CCT, comprises daily interventions [28].

76.6

Discussion

Long-term studies on liposuction of arm (Fig. 76.11) [20, 28, 31–33] and leg lymphedema (Fig. 76.12) [34, 35] have not shown any recurrence of the swelling. After liposuction, the incidence of cellulitis and of erysipelas is reduced in patients with lymphedema. This might be explained by the improved skin blood flow that can be seen [36]. In patients with lymphedema, the lymph transport system is damaged and its function compromised. Theoretically, liposuction could further damage the lymphatic system. However, research has shown that liposuction in patients with lymphedema does not further impair the lymph transport [24]. Liposuction of lymphedema improves the patients’ quality of life, especially qualities associated with everyday activities, that is, activities that can be directly related to the usage of the affected extremity [37].

76.7

Patient Selection

Liposuction is beneficial when conservative treatment has not achieved satisfactory results and the patient experiences subjective discomfort

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Fig. 76.12 A 21-year-old woman with primary lymphedema since 17 years of age. Preoperative excess volume 6,630 mL (left). Complete reduction at 2 years (right) (Copyright Håkan Brorson. Reprinted with permission)

and impaired quality of life of the heavy extremity, and the lymphedema consists of adipose tissue. Subjective problems can particularly be seen in chronic arm lymphedemas of 1 liter and more in volume or when the affected/healthy extremity ratio is ≥1.3 [37, 38]. Liposuction should never be performed in a patient with pitting edema (Fig. 76.6), as this implicates that the edema is dominated by lymph fluid. Fluid should be removed with compression therapy, not surgery. If early lymphedemas, consisting of only lymph fluid, are treated immediately by correct conservative regimes with compression, the edema will most likely not be transformed to adipose tissue, and hence surgical treatment will not be needed. In cases where the lymphedema consists of a combination of fluid

and adipose tissue, the first and most important goal is to remove the fluid component, that is, to transform a pitting edema into a non-pitting one with conservative regimes. When the patient has been treated conservatively and shows no pitting, liposuction can be performed (Fig. 76.13). A prerequisite for liposuction is that the patient accepts lifelong usage of compression garments. If garments are not used, the lymph fluid will continue to accumulate and eventually induce new adipose tissue deposition, and the effect of the surgery is hence not maintained. There is no upper age limit to be accepted for surgery. Active tumor disease, skin ulcerations or wounds, and unwillingness to wear compression garments are considered contraindications.

731

76 Liposuction of Lymphedema of the Extremities Goal

Fat

Bandaging

Liposuction

Lymph

Fat

Lymph/fat

Fat

Complete reduction

Fig. 76.13 Only lymphedemas dominated by fat (nonpitting edema) should be operated on with liposuction. Edemas dominated by lymph fluid (pitting edema) should

first be treated with conservative compression therapy to eliminate the fluid component (Copyright Håkan Brorson. Reprinted with permission)

76.8

reconstruction before, during, or after liposuction of grade III lymphedemas has never been scientifically studied. Also, in chronic late stage lymphedema, lymph vessels are dilated, stiff and have lost their intrinsic contractions that are needed to transport lymph, which militates the effect of any microsurgical reconstruction. In addition, there is always a risk of donor-site lymphatic vessel dysfunction after microvascular lymph node transfer [43–45] that has to be taken into consideration when contemplating using such techniques.

The Lymphedema Team

For successful treatment, a lymphedema team is a crucial prerequisite. The team should include a surgeon competent in liposuction, an occupational therapist, a physiotherapist, and, if possible, a social welfare officer. During visits, arm volumes are measured, garments are adjusted or renewed, the social circumstances are assessed, and other matters of concern are discussed. A lymphedema team is fundamental for both thorough preoperative considerations and adequate information to the patient and for successful maintenance of the result and usage of correct compression garments [26].

76.9

Microsurgery

In recent years, microsurgical approaches have become increasingly popular in the treatment of lymphedema [39–42]. Nonetheless, microsurgical reconstruction can never remove adipose tissue, and hence liposuction is undoubtedly needed in the treatment of lymphedemas dominated by adipose tissue. If liposuction potentially can be combined with microsurgical reconstruction of the lymphatic system to reduce the need for postoperative compression, microsurgical

Conclusions

Excess extremity volume without pitting implies that there is excess adipose tissue present. It is possibly to permanently remove the excess adipose tissue with liposuction. The lifelong usage of compression garments is mandatory for maintaining the effect of surgery.

References 1. Rockson SG. Update on the biology and treatment of lymphedema. Curr Treat Options Cardiovasc Med. 2012;14(2):184–92. 2. Rockson SG, Rivera KK. Estimating the population burden of lymphedema. Ann N Y Acad Sci. 2008;1131:147–54.

732 3. McLaughlin SA, Wright MJ, Morris KT, Sampson MR, Brockway JP, Hurley KE, Riedel ER, Van Zee KJ. Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: patient perceptions and precautionary behaviors. J Clin Oncol. 2008;26(32): 5220–6. 4. Levick JR, Michel CC. Microvascular fluid exchange and the revised Starling principle. Cardiovasc Res. 2010;87(2):198–210. 5. Mortimer PS, Rockson SG. New developments in clinical aspects of lymphatic disease. J Clin Invest. 2014;124(3):915–21. 6. Dylke ES, Ward LC, Meerkin JD, Nery L, Kilbreath SL. Tissue composition changes and secondary lymphedema. Lymphat Res Biol. 2013;11(4):211–8. 7. Brorson H, Ohlin K, Olsson G, Karlsson MK. Breast cancer-related chronic arm lymphedema is associated with excess adipose and muscle tissue. Lymphat Res Biol. 2009;7(1):3–10. 8. Brorson H, Ohlin K, Olsson G, Nilsson M. Adipose tissue dominates chronic arm lymphedema following breast cancer: an analysis using volume rendered CT images. Lymphat Res Biol. 2006;4(4):199–210. 9. Brorson H, Åberg M, Svensson H. High content of adipose tissue in chronic arm lymphedema – an important factor limiting treatment outcome. Lymphology. 1999;32(Suppl):52–4. 10. Zampell JC, Aschen S, Weitman ES, Yan A, Elhadad S, De Brot M, Mehrara BJ. Regulation of adipogenesis by lymphatic fluid stasis: part I. Adipogenesis, fibrosis, and inflammation. Plast Reconstr Surg. 2012;129(4):825–34. 11. Aschen S, Zampell JC, Elhadad S, Weitman E, De Brot M, Mehrara BJ. Regulation of adipogenesis by lymphatic fluid stasis: part II. Expression of adipose differentiation genes. Plast Reconstr Surg. 2012;129(4):838–47. 12. Mehrara BJ, Greene AK. Lymphedema and obesity: is there a link? Plast Reconstr Surg. 2014;134(1): 154e–60. 13. Rockson SG. The unique biology of lymphatic edema. Lymphat Res Biol. 2009;7(2):97–100. 14. Schneider M, Conway EM, Carmeliet P. Lymph makes you fat. Nat Genet. 2005;37(10):1023–4. 15. Brorson H. Liposuction gives complete reduction of chronic large arm lymphedema after breast cancer. Acta Oncol. 2000;39(3):407–20. 16. Brorson H. Liposuction normalizes – in contrast to other therapies – lymphedema-induced adipose tissue hypertrophy. Handchir Mikrochir Plast Chir. 2012;44(6):348–54. 17. Maclellan RA, Couto RA, Sullivan JE, Grant FD, Slavin SA, Greene AK. Management of primary and secondary lymphedema: analysis of 225 referrals to a center. Ann Plast Surg. 2015;75(2):197–200. 18. Brorson H. From lymph to fat: complete reduction of lymphoedema. Phlebology. 2010;25 Suppl 1:52–63.

E. Hansson and H. Brorson 19. Stemmer R. Stemmer’s sign – possibilities and limits of clinical diagnosis of lymphedema. Wien Med Wochenschr. 1999;149(2–4):85–6. 20. Brorson H, Svensson H. Complete reduction of lymphoedema of the arm by liposuction after breast cancer. Scand J Plast Reconstr Surg Hand Surg. 1997;31(2):137–43. 21. Brorson H, Hoijer P. Standardised measurements used to order compression garments can be used to calculate arm volumes to evaluate lymphoedema treatment. J Plast Surg Hand Surg. 2012;46(6):410–5. 22. Szuba A, Shin WS, Strauss HW, Rockson S. The third circulation: radionuclide lymphoscintigraphy in the evaluation of lymphedema. J Nucl Med. 2003;44(1): 43–57. 23. Weissleder H, Weissleder R. Lymphedema: evaluation of qualitative and quantitative lymphoscintigraphy in 238 patients. Radiology. 1988;167(3):729–35. 24. Brorson H, Svensson H, Norrgren K, Thorsson O. Liposuction reduces arm lymphedema without significantly altering the already impaired lymph transport. Lymphology. 1998;31(4):156–72. 25. Maclellan RA, Greene AK. Lymphedema. Semin Pediatr Surg. 2014;23(4):191–7. 26. Brorson H. Liposuction in arm lymphedema treatment. Scand J Surg. 2003;92(4):287–95. 27. International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2013 Consensus Document of the International Society of Lymphology. Lymphology. 2013;46(1):1–11. 28. Brorson H, Svensson H. Liposuction combined with controlled compression therapy reduces arm lymphedema more effectively than controlled compression therapy alone. Plast Reconstr Surg. 1998;102(4):1058–67. 29. Klein J. The tumescent technique for lipo-suction surgery. Am J Cosmet Surg. 1987;4(4):263–7. 30. Wojnikow S, Malm J, Brorson H. Use of a tourniquet with and without adrenaline reduces blood loss during liposuction for lymphoedema of the arm. Scand J Plast Reconstr Surg Hand Surg. 2007;41(5):243–9. 31. Schaverien MV, Munro KJ, Baker PA, Munnoch DA. Liposuction for chronic lymphoedema of the upper limb: 5 years of experience. J Plast Reconstr Aesthet Surg. 2012;65(7):935–42. 32. Damstra RJ, Voesten HG, Klinkert P, Brorson H. Circumferential suction-assisted lipectomy for lymphoedema after surgery for breast cancer. Br J Surg. 2009;96(8):859–64. 33. Brorson H, Freccero C, Ohlin K, Svensson B, Åberg M, Svensson H. Seventeen years’ experience of complete reduction of arm lymphedema following breast cancer. Progress in lymphology XXIII. Proceedings of the 23rd International Congress of Lymphology; 19–23 Sept 2011, Malmö. Lymphology. 2012;45(Suppl):279–81. 34. Brorson H, Freccero C, Ohlin K, Svensson B, Åberg M, Svensson H. Liposuction normalizes elephantiasis of the leg – a prospective study with an eight-year follow-up.

76 Liposuction of Lymphedema of the Extremities

35.

36.

37.

38.

39.

40.

Progress in Lymphology XXIII. Proceedings of the 23rd International Congress of Lymphology; 19–23 Sept 2011, Malmö. Lymphology. 2012;45(Suppl):292–5. Brorson H, Ohlin K, Olsson G, Svensson B, Svensson H. Controlled compression and liposuction treatment for lower extremity lymphedema. Lymphology. 2008;41(2):52–63. Brorson H, Svensson H. Skin blood flow of the lymphedematous arm before and after liposuction. Lymphology. 1997;30(4):165–72. Brorson H, Ohlin K, Olsson G, Långström G, Wiklund I, Svensson H. Quality of life following liposuction and conservative treatment of arm lymphedema. Lymphology. 2006;39(1):8–25. Brorson H. Liposuction and controlled compression therapy in the treatment of arm lymphedema following breast cancer. PhD Thesis. Malmö: Lund university; 1998. Becker C, Vasile JV, Levine JL, Batista BN, Studinger RM, Chen CM, Riquet M. Microlymphatic surgery for the treatment of iatrogenic lymphedema. Clin Plast Surg. 2012;39(4):385–98. Campisi C, Eretta C, Pertile D, Da Rin E, Campisi C, Maccio A, Campisi M, Accogli S, Bellini C, Bonioli E, Boccardo F. Microsurgery for treatment of periph-

733

41.

42.

43.

44.

45.

eral lymphedema: long-term outcome and future perspectives. Microsurgery. 2007;27(4):333–8. Koshima I, Inagawa K, Urushibara K, Moriguchi T. Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities. J Reconstr Microsurg. 2000;16(6):437–42. Baumeister RG, Siuda S, Bohmert H, Moser E. A microsurgical method for reconstruction of interrupted lymphatic pathways: autologous lymph-vessel transplantation for treatment of lymphedemas. Scand J Plast Reconstr Surg. 1986;20(1):141–6. Sulo E, Hartiala P, Viitanen T, Maki M, Seppanen M, Saarikko A. Risk of donor-site lymphatic vessel dysfunction after microvascular lymph node transfer. J Plast Reconstr Aesthet Surg. 2015;68(4):551–8. Vignes S, Blanchard M, Yannoutsos A, Arrault M. Complications of autologous lymph-node transplantation for limb lymphoedema. Eur J Vasc Endovasc Surg: Off J Eur Soc Vasc Surg. 2013; 45(5):516–20. Pons G, Masia J, Loschi P, Nardulli ML, Duch J. A case of donor-site lymphoedema after lymph nodesuperficial circumflex iliac artery perforator flap transfer. J Plast Reconstr Aesthet Surg. 2014;67(1): 119–23.

Tumescent Liposuction in Lipoedema

77

Wilfried Schmeller, Axel Baumgartner, and Yvonne Frambach

Abstract

Lipoedema is a chronic progressive disease in women, which is characterized by circumscribed increased subcutaneous fatty tissue, oedema, pain and bruising. While conservative methods with combined decongestive therapy (manual lymphatic drainage, compression garments) are able to minimize oedema, liposuction is used for reducing the fatty tissue with correction of shape and normalization of body proportions. This also causes a long-lasting improvement – and sometimes a complete disappearance – of pain, oedema and bruising with a marked increase of quality of life.

77.1

Introduction

Over the last years liposuction has been used for the treatment of various medical diseases like lipomas [1], benign symmetrical lipomatosis [2], lymphoedema [3] and lipoedema. Especially in patients with lipoedema, the removal of subcutaneous fatty tissue has proved to be of enormous benefit; in Germany liposuction was added to the lipoedema guidelines in 2005 [4].

77.2

The disease, first described in the 1940s in the United States [5, 6], occurs exclusively in women and is characterized by a bilateral symmetric enlargement mainly of the legs. This is a result of abnormal deposition of subcutaneous fatty tissue in combination with oedema.

77.2.1

W. Schmeller, M.D. (*) • A. Baumgartner, M.D. Y. Frambach, M.D. Hanse-Klinik, St-Juergen-Ring 66, 23564 Luebeck, Germany e-mail: [email protected]; [email protected]; [email protected]

Lipoedema

Clinical Aspects

In most cases hips, thighs (“jodhpur-like riding breeches”), knees and lower legs – sometimes with a fatty cuff at the ankles (Turkish pants phenomenon, inverse shouldering effect) – are affected; arms are rarely and hands and feet are never involved. The accumulation of fluid in the

© Springer-Verlag Berlin Heidelberg 2016 M.A. Shiffman, A. Di Giuseppe (eds.), Liposuction: Principles and Practice, DOI 10.1007/978-3-662-48903-1_77

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W. Schmeller et al.

736 Table 77.1 Synonyms for lipoedema Lipalgia Adiposalgia Adipoalgesia Adiposis dolorosa Lipohypertrophy dolorosa Painful column leg Painful lipoedema syndrome

form of severe orthostatic oedema results in spontaneous pain and sensitivity to pressure (tenderness). Together with easy bruising, it causes significant physical morbidity. The pain is expressed in the synonyms in Table 77.1. While lipoedema may appear in women with generalized obesity, in many patients – especially in early stages – the weight is normal. The obvious disproportion between slim upper half of the body and huge lower extremities cannot be eliminated by weight loss due to diet or physical exercise, what often results in considerable psychological problems [6, 7].

77.2.2

Aetiopathogenesis

Aetiology and pathomechanisms of lipoedema are still unclear. Hormones and genetic factors seem to play an important role [8]. An autosomal dominant inheritance with sex limitation has been postulated [9].

77.2.3

Chronicity and Progression

In the majority of patients, the disease starts almost imperceptibly after puberty, but may also develop in other age groups, especially at times of hormonal changes like pregnancy or menopause; it persists lifelong and progresses gradually. At the beginning, the skin is smooth and the subcutaneous layer is thickened, soft and with even structure (stage I); the skin may be cool in certain areas as a result of a functional vascular disbalance. Over time, nodules can be felt underneath and the skin surface becomes uneven (stage II). After years patients may present with huge amounts of tender sub-

Table 77.2 Grading of lipoedema Stage I Skin surface smooth, homogenous fatty tissue structure Stage II Skin surface uneven, nodular fatty tissue structure Stage III Huge leg volumes, deformation with bulging protrusions of subcutaneous fatty volume

cutaneous tissue and bulging protrusions of fat, mainly at the inner side of the thighs or knees (stage III); this may interfere with normal gait. The characteristics of these different stages are summarized in Table 77.2. It should be kept in mind that this grading is only characterized by the amount of fatty tissue, but not by the quantity of oedema or the amount of pain.

77.2.4

Differential Diagnosis

Many clinicians are still unaware of this disease, and lipoedema is frequently unrecognized or misdiagnosed [10, 11]. Confusion often exists concerning the differentiation from lipohypertrophy, primary and secondary lymphoedema, phleboedema, obesity, Dercum’s disease and benign symmetric lipomatosis Launois-Bensaude. Table 77.3 shows the important criteria of those conditions. In most cases the diagnosis of lipoedema can be made by the patient’s clinical signs and symptoms only [12, 13]; for exact localization and quantification of fatty tissue or for follow-up studies, ultrasound or MRI can be used [11].

77.2.5

Therapy

The modern standard of therapy is a combination of conservative and surgical treatment.

77.2.5.1 Conservative Treatment For about 60 years, conservative treatment with manual lymphatic drainage and compression hosiery or bandages (combined decongestive

Female male Benign symmetric Female lipomatosis (Madelung’s male disease) Dercum’s disease Mostly female

Obesity

Phleboedema

Primary lymphoedema

Lipohypertrophy

Lipoedema

Sex Only female Only female Mostly female Female, male

Mainly neck, shoulders, pelvis Legs, trunk

Adulthood

Mostly menopause

Total body

Legs, rarely arms

Mostly legs

Mostly legs

Localization Legs, arms

All age groups

Frequently puberty Adulthood

Mostly puberty

Onset Mostly puberty

Table 77.3 Lipoedema: important differential diagnoses

Yes

Yes

No

Yes

No

No

Yes

Fat increase Yes

Yes

Yes

No

No

Yes

Symmetry Yes

No

No

No

Yes

Yes

Mostly no

No

No

No

No

No Yes

Pain Yes

Oedema Yes

No

No

No

No

Yes

No

Feet involved No

No

No

Yes

No

No

No

Diet successful No

Often alcohol abuse, liver damage Muscle weakness, often depression

Widely distributed Stemmer’s sign positive Abnormal venous function tests BMI >30 kg/m2

Others Bruising

77 Tumescent Liposuction in Lipoedema 737

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738

physiotherapy, CDT) was used as the only standard regime worldwide [4, 14]. This treatment is able to reduce or eliminate oedema and pain, but cannot stop the progression of the disease, meaning the increase of fatty volume with worsening of oedema and associated complaints (spontaneous pain, pain due to pressure).

77.2.5.2 Surgical Treatment In 2002, first results concerning surgical therapy of lipoedema by tumescent liposuction to reduce the pathological subcutaneous fatty tissue were reported during the 20th World Congress of Dermatology in Paris [15, 16]. In the following years various studies have demonstrated the success of liposuction without serious side effects like lymph vessel damage [17–19]. Since 2005 liposuction is an integrated part of therapy in the guidelines of lipoedema of the German Society of Phlebology [4]. For the surgical treatment of lipoedema in tumescent local anaesthesia (TLA), the same technical principles are used as for the treatment of lipohypertrophy. These principles are mentioned in other chapters of this book and have also been described in detail before [13, 20].

77.3

Long-Term Effects of Liposuction in Lipoedema

Concerning the duration of the surgical treatment effects, up till now only a very limited number of long-term studies exist [20]. We herewith report about a new study with 85 patients and an average follow-up of nearly 8 years (7 ¾ years) after liposuction(s).

77.3.1

Patients and Methods

The Hanse-Klinik in Luebeck, Germany, is a specialized clinic for the surgical treatment of patients with lipoedema. In 2014 the authors

were able to evaluate 85 from 112 patients, who had tumescent liposuction between 2002 and 2009. All patients had received standardized questionnaires before and after an average of 7 years and 8 months (5 years and 1 month – 11 years and 4 months) following surgery. They were evaluated for spontaneous pain, pain upon pressure, oedema and bruising. The quantification for these items was done with a 5-point score (Likert): 0 = none, 1 = minor, 2 = medium, 3 = strong and 4 = very strong. Many patients could either be examined as well or additional photographs could be analyzed. The patient’s average age at the time of operation(s) was 40.1 (22–68) years. Twenty four patients presented with lipoedema stage I and 61 patients with stage II; there were no patients with stage III. All had undergone conservative therapy for many years before liposuction and either experienced no obvious improvement of complaints or noticed a progression of subcutaneous fatty volume. Liposuction had been performed in legs, hips and arms in pure tumescent local anaesthesia with blunt vibrating microcannulas of 3 and 4 mm diameter (power-assisted liposuction, PAS). From the 85 patients, nine patients were operated once, 25 patients twice, 21 patients three times, 19 patients four times, five patients five times and six patients six to ten times. In the former study with 112 patients, we could show that the average amount of TLA solution infiltrated in patients with lipoedema was 7,700 (2,560–13,450) mL and the average time of surgery was 2 h (40 min – 3 h 35 min). The average amount of fatty tissue removed was 9,850 (1,000–25,600) mL per person or 3,080 (450– 6,450) mL per session, depending on the size and number of operated areas [21]. From all parameters of the questionnaire, the values before the first liposuction were available. Statistical analysis was performed with SPSS 16.0 for Windows (SPSS, Chicago, IL, USA). The term “significant” (used for P values 6 months N = 299

1-week intensive outpatient follow-up treatment at the patient’s residence: 1 h of lymphatic drainage per day and wearing the appropriate compression garments 24 h a day. In the second, third, and fourth

week of the follow-up treatment, the frequency is halved. The first week is accompanied by antibiosis as well as a heparinization in order to avoid side effects. Symptoms occurred in less than 0.2 % of

79

Update Lipoedema 2014: Cologne Lipoedema Study

Fig. 79.9 Cologne Lipoedema Study 2012: postoperative discomfort

761

How many patients still experience discomfort (bruising, etc.)?

17 %

83 % Discomfort No discomfort N = 299

Fig. 79.10 Cologne Lipoedema Study 2012: satisfaction cosmetic result

How satisfied are patients with the cosmetic result?

11 %

34 %

55 % Very satisfied Satisfied Not satisfied N = 299

Fig. 79.11 Cologne Lipoedema Study 2012: improvement of life quality

How do patients evaluate improvement to their quality of life? 5% 22 %

73 % Obvious improvement Improvement No improvement N = 299

patients: panniculitis, hematoma, muscle aches, wound infections, erysipelas, thrombosis, and pulmonary embolism. Despite the large amount of tissue to be operated on, the authors believe that the operation must be carried out as outpatient surgery, but carefully planned, due to the low side effect rate (Fig. 79.11).

Since 97 % of the patients did not undergo further complex decongestive therapy, the authors of the 2012 Cologne Lipoedema Study allowed themselves to continue talking of “healing” the disease lipohyperplasia dolorosa by means of lymphological liposculpture (Fig. 79.12).

M.E. Cornely and M. Gensior

762 Fig. 79.12 Cologne Lipoedema Study 2012: surgery recommendation

How many patients would have the surgery again and/or recommend it?

5%

95 % Yes No N = 299

Fig. 79.13 Cologne Lipoedema Study 2012: findings at a glance

Findings at a glance 3140

Lipodema patients examined since 1997 Lipodema surgeries since 1997

1645 surgeries on 592 patients (299 patients) 57 %

Response rate How many patients are still undergoing CDT?

3%

Satisfaction with cosmetic result

89 %

Evaluation of improvement to quality of life

95 %

How many would have the surgery again/recommend it?

95 %

It is reported, encouragingly, that colleagues Schmeller (in Lübeck) and Rapprich (in Darmstadt) have had similarly good results in the surgical treatment of lipoedema. Professor Schmeller [15] reported on 114 patients and Rapprich [14] on 27 cases. Regardless of the surgical procedure’s excellent results on lipoedema, it should be noted that it is not advisable to try to cure the lymphatic disorder “lipohyperplasia dolorosa” by means of lymph surgery alone. Furthermore, up to 80 % of the patients at the CG Lympha center in Cologne are treated successfully using primarily nonoperative procedures, even though the curative treatment is increasingly becoming more accepted (Fig. 79.13). Conclusions

Surgical treatment on patients with a lymphatic illness is a special one. It should certainly not be confused with plastic surgery procedures.

Both preoperative and above all postoperative patient care require qualified, conventional lymphological procedures. Patients with lipohyperplasia dolorosa should be examined carefully on the legs and arms; they should be offered both conventional and surgical therapy. Healing rates following surgical procedures are established at 97 % in the largest sample size study with 592 patients and a follow-up term of 15 years.

References 1. Cornely ME. Dicker durch Fett oder Wasser – Lipohyperplasia dolorosa vs. lymphödem. Hautarzt. 2010;61(10):873–9. 2. Allen EV, Hines EA. Lipedema of the legs: a syndrome characterized by fat legs and orthostatic edema. Proc Staff Meet Mayo Clin. 1940;15:184–7.

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Update Lipoedema 2014: Cologne Lipoedema Study

3. Wienert V, Földi E, Jünger M, Partsch H, Rabe E, Rapprich S, Schmeller W, Stenger D, Stücker M, Waldermann F. Lipödem. Leitlinien der Deutschen Gesellschaft für Phlebologie. Phlebologie. 2009;38: 164–7. 4. Brauer WJ. Altersbezogene Funktionslymphszintigraphie beim Lipödem und Lipolymphödem. LymphForsch. 2000;2:74–7. 5. Marsch WC. Ist das Lipödem ein lymphologisches Krankheitsbild? J Lymphologie. 2001;1:22–4. 6. Meier-Vollrath I, Schneider W, Schmeller W. Lipödem – neue Therapiemöglichkeiten für ein oft übersehener Krankheitsbild. Dermatol Prakt Dermatol. 2007;13:297–304. 7. Cornely ME. Lipödem und lymphödem. In: Plewig G, Prinz J, editors. Fortschritte der praktischen Dermatologie und Venerologie 2002. Berlin: Springer; 2003. p. 255–63. 8. von Runnebaum B, Rabe T. Gynäkologische Endokrinologie. Grundlagen, Physiologie, Pathologie, Prophylaxe, Diagnostik, Therapie. Berlin: Springer; 2012. p. 5. 9. Cornely ME. Liposuktion (liposculpture). In: Weissleder H, Schuchhardt C, editors. Erkrankungen des Lymphgefäßsystems. Köln: Viavital; 2000. p. 384–97.

763 10. Cornely ME. Lipedema and lymphatic edema. In: Shiffman MA, Di Guiseppe A, editors. Liposuction: principles and practice. Berlin: Springer; 2006. p. 547–55. 11. Sattler G, Hasche E, Rapprich S. Neue operative Behandlungsmöglichkeiten bei benignen Fettgewebserkrankungen. Z Hautkrh. 1997;72:579–82. 12. Habbema L. Safety of liposuction using exclusively tumescent local anesthesia in 3,240 consecutive cases. Dermatol Surg. 2009;35(11):1728–35. 13. Bender H, Cornely ME, Pleiß C, Risse JH. Lymphszintigraphie beim Lipödem. Einfluss einer Liposuktion. Vasomed. 2007;19:60–2. 14. Rapprich S, Dingler A, Podda M. Liposuktion ist eine wirksame Therapie beim Lipödem – Ergebnisse einer Untersuchung mit 25 Patientinnen. J Dtsch Dermatol Ges. 2011;9:33–41. 15. Schmeller W, Meier-Vollrath I. Langzeitveränderungen nach Liposuktion bei Lipödem. LymphForsch. 2010; 14(2):17–28. 16. Cornely ME. Liposculptur bei Lipödem – ein Eingriff in höchster Sicherheit. J Lymphol. 2002;1:1–3. 17. Cornely ME. Liposuktion bei Lipödem (cellulite) – follow up bei 140 operierten Patienten nach 7 Jahren. Akt Dermatol. 2004;10:3–21.

Part VII Complications

Analysis of Postoperative Complications of Superficial Liposuction

80

Sang Wha Kim and Youn Hwan Kim

Abstract

Superficial liposuction techniques have become well accepted and offer numerous advantages over conventional liposuction. However, superficial liposuction manipulates the superficial fascial system and has the potential risk of higher complication rates than with conventional liposuction. Treating the complications of liposuction is not simple, and prevention is more important than attempts at treatment after a complication has occurred. With better understanding of the basic technique and overall awareness of possible complications, superficial liposuction can be performed successfully with consistent results.

80.1

Introduction

Liposuction is a popular aesthetic procedure in plastic surgery [1, 2]. In recent years, superficial liposuction techniques have become well accepted and offer numerous advantages over conventional liposuction. S.W. Kim, M.D., Ph.D. Department of Plastic and Reconstructive Surgery, College of Medicine, Seoul National University, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea e-mail: [email protected] Y.H. Kim, M.D., Ph.D. (*) Department of Plastic and Reconstructive Surgery, College of Medicine, Hanyang University, 17 Haengdang-Dong, Seongdong-Gu, Seoul 133-792, Korea e-mail: [email protected]

Superficial liposuction was first described by Illouz in 1983 [3]. Since then, there have been various modifications and advances, such as subdermal liposuction, superficial lipoplasty, dermolipolift, and dual-plane lipoplasty [4–7]. Numerous cannulas and instruments have been introduced for use in superficial liposuction [5, 6, 8–10], and the tumescent technique and the concepts of ultrasonic and laser lipolysis are now widely accepted for safer liposuction [11, 12]. However, even with these advances, there are major concerns related to superficial liposuction [13]. The technique manipulates the superficial fascial system and has the potential risk of higher rates of complications, such as contour irregularity, than with conventional liposuction. With better understanding of the basic technique and overall awareness of possible complications, which can range from aesthetic to

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life-threatening, superficial liposuction can be performed successfully with consistent results.

80.2

Technique

In the first step, a tumescent solution consisting of lactated Ringer’s solution (1000 mL), epinephrine 1:1000 (2 mL), lidocaine 2 % (40 mL), sodium bicarbonate 8.4 % (6 mL), and gentamicin 80 mg is infiltrated. The extent of infiltration varies depending on the area involved and proceeds from the deep to the superficial adipose layers. In power-assisted liposuction, the cannula calibers vary from 2 to 4 mm, with an average length of 200–450 mm. The 2 and 3 mm cannulas are used for superficial and intermediate layers, 3 and 4 mm for deep layers, and 2 mm for facial liposuction. After the selection and insertion of the appropriate cannula, all areas are pretunneled. The pretunneling plane is at an intermediate level in the deepest part of the subdermal fat, approximately 5 mm below the skin. Next, liposuction is carried out systematically, starting from the intermediate layer and proceeding towards the deep layer. The cannula is then changed to the smaller caliber ones for superficial liposuction which follows. The deeper portion of the superficial adipose layer is suctioned with the 3 mm cannula, and the superficial portion is suctioned with the 2 mm cannula. The hole of the cannula must be positioned downwards throughout the procedure. The pinch test (Pizzaiolo test) and refinement test are used to decide the end point of liposuction. During liposuction, it is important to set the maximum vacuum pressure between 250 and 400 mmHg to prevent oversuction and destruction of normal adipose architecture. After completion of the liposuction, a lower incision is made, and the region is irrigated with gentamicinsaline solution. The thin cutaneous adipose flap is subsequently supported by self-adhering light dressing pads for 7 days. This is followed by the application of compression garments for the next month.

80.3

Discussion

Although superficial liposuction has attractive advantages, there are major concerns about complications related to superficial suctioning. These complications can be classified as lifethreatening/systemic and aesthetic.

80.3.1

80.3.1.1

Life-Threatening or Systemic Complications

Fat Embolism Syndrome (FES) There is still confusion about the use of the terms fat embolism and fat embolism syndrome (FES). The latter is a phenomenon secondary to fat embolism and is a more accurate term for complications after liposuction, as the patient suffers a cascade of symptoms. The incidence of FES in liposuction is unknown. The classic triad includes respiratory distress, cerebral dysfunction, and petechial rash. Other signs and symptoms include thrombocytopenia, anemia, tachycardia, hypocalcemia, and pyrexia. Diagnosis using a ventilation-perfusion scan may show these defects [14–16]. Differential diagnosis includes fluid overload, pulmonary edema, aspiration pneumonia, and some other causes of acute respiratory distress syndrome (ARDS) [17]. Differentiation of FES from pulmonary embolism is especially important because the treatment is far different. Heparin can be harmful, for obvious reasons, in the early postoperative course of FES. There are no definitive preventive methodologies for FES; however, the use of a small-caliber cannula and serial suction rather than megavolume liposuction is generally recommended. Treatments with intravenous ethanol, heparin, and low-molecular-weight dextran have largely fallen from favor. Medical management now consists mainly of high-dose corticosteroid, which has been shown to prevent the development of FES in several randomized prospective trials [18–20]. The role of the corticosteroids is considered to be inhibition of inflammatory reactions.

80 Analysis of Postoperative Complications of Superficial Liposuction

80.3.1.2

Deep Vein Thrombosis and Pulmonary Embolism The three major factors influencing the development of deep vein thrombosis and pulmonary embolism are venous stasis, activation of the blood coagulation cascade, and injury to the vascular endothelium [21]. The prevention of possible risks is most important for avoiding the life-threatening complications of deep vein thrombosis and pulmonary embolism (Fig. 80.1). A program for preoperative and early postoperative ambulation is crucial. Epidural anesthesia will increase blood flow to the lower extremity, lessen stagnant blood flow, and may reduce thrombotic complications. Shortening the anesthesia time may be beneficial; thus, serial liposuction rather than mega-volume liposuction is also recommended. For high-risk patients, intermittent pneumatic pressure devices rather than continuous devices may be beneficial. Low-dose subcutaneous heparin (2500 U every 12 h, beginning 2 h preoperatively) may further reduce the incidence of deep vein thrombosis, but it should be used carefully as it can also simultaneously increase the risk of bleeding. Initial therapy consists of intravenous heparinization, usually with a bolus dose of 5000– 10,000 U. A heparin drip at approximately 1000 U/h is then titrated to maintain an activated partial thromboplastin time (aPTT) of approximately twice

Fig. 80.1 Chest computed tomography of fat embolism resulting acute respiratory distress syndrome

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the normal time. This necessitates hospitalization and frequent blood sampling. Oral anticoagulant therapy with warfarin is usually started shortly thereafter and continued for a minimum of 6 weeks. Prothrombin time (PT) levels must be monitored during follow-up.

80.3.1.3

Extended Infection

Although infection is rare in liposuction-only cases, combined procedures including abdominoplasty and brachioplasty for reducing skin laxities may cause serious infections. Superficial liposuction involves heavy manipulation of the superficial fascial system, with the possibility of ascending infections via the fascial system, and there have been reports of necrotizing fasciitis resulting from these procedures [22]. Hematoma and seroma can become sources of infection; hence, meticulous hemostasis and drainage of seroma are important for prevention of infection (Figs. 80.2, 80.3, 80.4, and 80.5). Moreover, maintenance of aseptic techniques throughout the procedure is of utmost importance, especially during positional changes of the patient. Hospitalization and administration of broadspectrum intravenous antibiotics in the early stages of infection can prevent its further dissemination.

80.3.1.4 Hypovolemia/Anemia Tumescent infiltration provides profound hemostasis in large-volume liposuction [23]. Bloodless aspiration may prevent the possible sequelae of shock and hypovolemia. The ideal ratio of infiltrated subcutaneous fluid to total aspirate is controversial. Thus, a 1:1 ratio is adequate in patients with excellent skin tone; however, patients with extreme skin laxity may require a greater volume of subcutaneous infiltration for bloodless liposuction. On the other hand, shifts of fluid between interstitial fluid and plasma volume can result in intravasation (hypervolemia) or extravasation (third spacing). Obviously, excessive infiltration should be avoided, and the surgeon must weigh the risk of excessive blood loss (inadequate subcutaneous fluid) against pulmonary edema (excess subcutaneous fluid).

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Fig. 80.2 Severe wound infection and irregularity of the abdomen. (a) AP view (b) Lateral view

Fig. 80.3 Pseudobursae occur in undermined spaces where there is repeated fluid formation and accumulation

In our experience, autologous blood transfusion is rarely needed. It should be borne in mind that aspiration of about 2000 mL supernatant fat is regarded as a decrease of hemoglobin count by 1. Healthy normovolemic patients tolerate moderate reduction in hemoglobin with multiple compensatory mechanisms; in clinical settings, normal tissue oxygenation is maintained with hematocrits as low as 20 in healthy patients [24]. It is important to avoid large-volume liposuction and to balance the infiltration of tumescent solution so that the result lies between pulmonary edema caused by excessive infiltration and bleeding tendency caused by insufficient infiltration.

Fig. 80.4 Seroma can become sources of infection resulting pseudobursae

80.3.1.5 Lidocaine Toxicity Early signs and symptoms of lidocaine toxicity include lightheadedness, restlessness, drowsiness, tinnitus, slurred speech, metallic taste in the mouth, and numbness of the lips and tongue; these subjective signs may occur at lidocaine plasma levels between 3 and 6 ug/mL. Shivering, muscle twitching, and tremors may occur as plasma levels reach 5–9 ug/mL, followed by convulsions, CNS depression, and coma at plasma levels >10 ug/mL. As plasma concentration increase above this level, respiratory depression and eventually cardiac arrest can occur [25]. Multiple variables add to patient risk. Conservative treatment is advised in patients taking

80 Analysis of Postoperative Complications of Superficial Liposuction

oral contraceptives, beta blockers, or tricyclic antidepressants, because these medications increase serum lidocaine levels. In addition, hypovolemia, hypocalcemia, hypophosphatemia, and hypoalbuminemia may exacerbate the effects of lidocaine. Preexisting liver disease slows lidocaine breakdown. Prevention of lidocaine toxicity requires strict adherence to the currently accepted maximal recommended dose of 35 mg/kg, together with early recognition of the symptoms of lidocaine toxicity. Theoretically, gradual infusion over several hours may lead to lower peak lidocaine levels, compared with rapid bolus infusion. Treatment consists of hyperventilation and administration of benzodiazepines, which lower the seizure threshold. The airway should be protected to prevent aspiration.

80.4 80.4.1

Aesthetic Complications Contour Irregularities

Contour irregularity is a major complication of liposuction that significantly decreases the patient’s satisfaction. The most common complications are undercorrection (insufficient fat removal), overcorrection (excessive fat removal), and irregular fat removal (with palpable and visible irregularities) (Figs. 80.2 and 80.5). From an aesthetic view point, postoperative contour irregularities can be devastating and dramatically decrease patient’ satisfaction [26, 27].

Fig. 80.5 Contour irregularity of the abdomen. To correct the problem, exact preoperative markings and discrimination between false and true depression is important

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Improper selection of patients with sagging tissues, and oversuctioning those with good tissues, can lead to soft-tissue irregularities that are mostly unrepairable despite multiple repair techniques. Contour irregularity may be minimal in a young patient, but with aging, the loss of softtissue support and reduction of muscle mass may worsen the irregularities. Surgeons should keep a chart with markings of the patient and note the amount of aspiration from each area. By keeping the preoperative photographs visible during surgery, surgeons should be aware of what the deformities looked like when the patient was in a standing position. Bad positioning of the patient on the operating table can be the cause of the irregularities [26]. During liposuction, it is important to set the maximum vacuum pressure between 250 and 400 mmHg in order to prevent oversuction and destruction of normal adipose architecture, which are the main causes of contour irregularities. Pinto et al. divided the fatty layers into superficial-dense and deeper-loose areolar layers [10]. The superficial adipose layer has minimal fatty tissues compared with the deep adipose layer. Overzealous suctioning or manipulation of the superficial layer can cause complications. However, Illouz et al. identified a further intermediate layer that exists in the subdermal fat, approximately 5 mm below the skin. Liposuction of the intermediate level permits greater retraction of the skin than deeper level suctioning and produces almost the same amount of contraction as superficial suctioning but without the risk of complications [5, 27, 28]. Suctioning of the

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intermediate layer and detaching the skin in the superficial layer tend to maximize the skin retraction and contouring effect, as in superficial layer suctioning, while avoiding the complications of skin irregularities and skin ischemia. To prevent contour irregularity, Gasperoni recommended progression of the cannula gauge from small too big. However, for refinement and final contouring of the superficial layer, a decreasing order of gauge size is more convenient [6, 27]. Moreover, suctioning the very superficial layer must be avoided by using low pressure settings, and the suction hole should be positioned in a downward direction during suction procedures. There are disparities in specific methods of treating contour irregularity. Possible treatments include fat suction, injection, subcision, fat shifting or mobilization, and skin resection. Distinguishing between depression resulting from under-suction (false depression) and from oversuction (true depression) is important [28]. False depression can be easily solved by resuctioning. However, true depression resulting from very superficial liposuction cannot be corrected by re-suctioning, as that would amplify the irregularities. These true depressions should be corrected only by fat grafts or fat-shifting techniques [27]. There is debate regarding immediate correction versus delayed correction of contour deformities after superficial liposuction. In fact, it is very difficult to precisely evaluate sunken areas and areas with insufficient fat removal during the surgery. Hence, delayed correction, after the healing process is complete, is generally accepted [3]. If too much fat is aspirated from a localized point to a visible level during the procedure, Gasperoni [6] has recommended immediate correction of the depression by injecting some of the aspirated fat. However, survival rates for harvested fat that has been crushed by the ultrasonic energy cannot be estimated. Thus, when lipoinjection is necessary, harvesting healthy fat from areas where ultrasonic energy has not been applied is recommended. When severe sunken deformities are found during surgery, the outcome is exaggerated and often leads to asymmetry of the body. Hence, when

severe sunken deformities of the intermediate and deep adipose layers are found, these are corrected as soon as possible. Later on, after the healing process, refinement or secondary-touch operations can also be considered. Balanced use of immediate and delayed corrections of contour irregularities can yield more aesthetic final outcomes that lead to increased patients’ satisfaction. In 2001, a new technique called liposhifting was described by Saylan [29] as a safe and simple method for treating contour irregularities. Using the cannula, the fat is loosened around and under the defect by obstructing the open end of the cannula with a finger or a plug and not applying suction. Some cannulas may be more aggressive than blunter-tipped cannulas; crisscross and fan-shaped patterns with multiple layers should be used. The subdermal tissues in the area of the defect are treated in the same manner as the surrounding fat, using tunnels with no sweeping motions. The fat in the surrounding tissues is moved or shifted into the defect by rolling a cannula over the tissues with moderate pressure until the defect is at least flat. Fat can also be mobilized by massage maneuvers. Re-suction, fat graft, and fat shifting are useful tools for correcting contour irregularities, and as several procedures are always required, informed consent is essential [30].

80.4.2

Skin Necrosis

The most devastating complication of superficial liposuction is skin loss, which does occur but is rare with suction-alone procedures. The skin loss varies from small areas to areas large enough to require skin grafting. A variety of factors cause skin loss, and the most important of which is smoking. Patients should be encouraged to cease smoking at least 2 weeks before the procedure, and those undergoing suctioning in their lower extremities should be explicitly warned. The next most important factor is improper intraoperative management of fluid replacement, resulting in impairment of the microcirculation in the elevated flaps (Figs. 80.6 and 80.7). Another main cause is the application of

80 Analysis of Postoperative Complications of Superficial Liposuction

circular compressive garments that are too tight; these can induce a stasis that can result in thrombosis. These garments should be at a pressure higher than 18 mmHg to be efficient but 12 h) is recommended after any signs of cardiac toxicity because cardiovascular depression due to LAs can persist or recur after treatment © 2010 American Society of Regional Anesthesia (ASRA) and Pain Medicine. ASRA hereby grants practitioners the right to reproduce this document as a tool for the care of patients who receive potentially toxic doses of LAs. Publication of these recommendations requires permission from ASRA. The ASRA Practice Advisory on Local Anesthetic Systemic Toxicity is published in the society’s official publication Regional Anesthesia and Pain Medicine and can be downloaded from the journal Web site at www.rapm.org

tially fatal complication. It offers evidence-based and/or expert opinion-based recommendations for all physicians and advanced practitioners who routinely administer local anesthetics in potentially toxic doses. The Association of Anaesthetists of Great Britain and Ireland has put forth guidelines for the management of severe local anesthetic toxicity (Table 82.2) [91].

82.7

Proposed Mechanisms by Which Lipid Rescue Works

There are two proposed mechanisms by which lipid rescue therapy is thought to work [92]. In vitro studies suggest that the lipid infusion

creates a lipid phase, or “lipid sink,” in the plasma to which lipophilic drugs such as local anesthetics can partition into. The second possible mechanism is reversal of mitochondrial fatty acid transport inhibition. It is believed that local anesthetics inhibit carnitine acylcarnitine translocase (CACT), an enzyme used in mitochondrial fatty acid metabolism and transport. Because fatty acids are involved in 80–90 % of cardiac adenosine 5′-triphosphate (ATP) synthesis, inhibition of CACT may contribute to cardiac toxicity. Lipid infusion may increase the intracellular fatty acid content enough to overcome the inhibition of the CACT enzyme by the anesthetic. While the exact mechanisms of action of lipid emulsion infusion to treat LAST remain unclear, the key component is likely the binding property of

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Table 82.2 Guidelines for the management of severe local anesthetic toxicity Signs of severe toxicity: Sudden loss of consciousness, with or without tonic-clonic convulsions Cardiovascular collapse: sinus bradycardia, conduction blocks, asystole, and ventricular tachyarrhythmias all may occur Local anesthetic (LA) toxicity may occur at some point after the initial injection. Immediate management: Stop injecting the LA Call for help Maintain the airway and, if necessary, secure it with a tracheal tube Give 100 % oxygen and ensure adequate lung ventilation (hyperventilation may help by increasing pH in the presence of metabolic acidosis) Confirm or establish intravenous access Control seizures: give a benzodiazepine, thiopental, or propofol in small incremental doses Assess cardiovascular status throughout. Management of cardiac arrest associated with LA injection: Start cardiopulmonary resuscitation (CPR) using standard protocols Manage arrhythmias using the same protocols while recognizing that they may be very refractory to treatment Prolonged resuscitation may be necessary; it may be appropriate to consider other options: Consider the use of cardiopulmonary bypass if available Consider treatment with lipid emulsion. Treatment of cardiac arrest with lipid emulsion (approximate doses for a 70 kg patient, see below): Give an intravenous bolus injection of Intralipid 20 % 1.5 mg/kg over 1 min Give a bolus of 100 mL Continue CPR Start an intravenous infusion of Intralipid 20 % at 0.25 mL/kg over 1 min Give at a rate of 400 mL over 20 min Repeat the bolus injection twice at 5 min intervals if an adequate circulation has not been restored Give 2 further boluses of 100 mL at 5 min intervals After another 5 min, increase the rate to 0.5 mL/kg over 1 min if an adequate circulation has not been restored Give at a rate of 400 mL over 10 min Continue infusion until a stable and adequate circulation has been restored. Remember: Continue CPR throughout treatment with lipid emulsion Recovery from LA-induced cardiac arrest may take >1 h Propofol is not a suitable substitute for Intralipid Replace your supply of Intralipid 20 % after use. Follow-up action: Report cases from the United Kingdom to the National Patient Safety Agency (via www.npsa.nhs.uk). Cases from the Republic of Ireland should be reported to the Irish Medicines Board. Whether or not lipid emulsion is administered, please also report cases to the LipidRescueTM site: www.lipidrescue.org If possible, take blood samples into a plain tube and a heparinized tube before and after lipid emulsion administration and at 1 h intervals afterward. Ask your laboratory to measure LA and triglyceride levels (these have not yet been reported in a human case of LA intoxication treated with lipid) Know where your nearest bag of Intralipid is kept This guideline is not a standard of medical care. The ultimate judgment with regard to a particular clinical procedure or treatment plan must be made by the clinician in light of the clinical data presented and the diagnostic and treatment options available. © The Association of Anaesthetists of Great Britain and Ireland 2007 Intralipid 20 % has been shown to reverse LA-induced cardiac arrest in animal models [23, 24] and in human case reports, [34, 35] and its use has been reported in the treatment of life-threatening toxicity without cardiac arrest [37]. Its therapeutic potential has been highlighted by the National Patient Safety Agency [94] Intralipid 20 % 1000 mL should be immediately available in all areas where potentially cardiotoxic doses of local anesthetics are given, along with guidelines for its use In the United Kingdom, Intralipid is distributed by Fresenius Kabi Ltd. It is distributed in the Republic of Ireland by Cahill May Roberts Intralipid is readily available from most hospital pharmacies, which may also be able to help departments with timely replacement of bags nearing expiry

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Table 82.2 (continued) The usefulness of other lipid emulsions is not known, as published work to date has used only Intralipid Although some propofol preparations are provided in Intralipid (e.g., Diprivan), these are not a suitable alternative because of the significant cardiovascular depression caused by propofol. This does not preclude the use of small, incremental doses of propofol to control seizures The use of Intralipid in this way is relatively novel. Therefore, future laboratory and clinical experiences are likely to dictate further refinement of the method This guideline document will be reviewed regularly and updated when necessary. Updated versions will be available on http://www.aagbi.org and http://www.lipidrescue.org Further educational matter is available at http://www.lipidrescue.org

the emulsion [93]. Theoretically, the emulsified fat droplets that form a lipid compartment are drawn into a “lipid sink” into which lipophilic substances are partitioned when infused. Lipophilic substances, such as local anesthetics, are drawn into the “lipid sink” and a concentration gradient develops between tissue and blood which cause local anesthetics to move away from the heart or brain (areas of high concentrations) to the “lipid sink.” An alternate mechanism is that lipid emulsion could theoretically increase intracellular fatty acid content and therefore overcome the reduced ATP production, which results from LA block of fatty acid transport and oxidation. It is possible that the resulting increased intracellular fatty acid content contributes to improved ATP synthesis in the cardiomyocyte. Conclusions

It is incumbent on all physicians performing surgeries or blocks with local anesthetics, in hospitals, outpatient surgery centers, and office surgeries, to be aware of the possibility of local anesthetic toxicity and drug toxicities. The surgeon should have lipid solutions, such as 20 % Intralipid® (Fresenius Kabi, Canada), 20 % Liposyn® by Hospira in Lake Forest, Illinois, and Lipovenös® MCT 20 % (Fresenius Kabi AG, Bad Homburg, Germany), for rescue immediately available. It is also necessary to understand the amount needed in lipid rescue to achieve reversal of the effects of toxicity.

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Luiz Haroldo Pereira, Beatriz Nicaretta, and Aris Sterodimas

Abstract

Background: Liposuction has evolved tremendously over the past three decades and is the most frequently performed aesthetic procedure. Although liposuction has been considered a safe surgical procedure, reports indicate that it can have significant sequelae. The increasing number of liposuction procedures, often performed by inadequately trained physicians, has led to a growing number of iatrogenic post-liposuction contour complications. Methods: 105 patients with post-liposuction depressions were operated during June 2012 and September 2014. Seventy-nine female and 26 male patients were included in this study group. Age distribution of patients ranged from 22 to 72 years, with a mean of 43.9 years. All the patients that were included in this study were candidates for autologous fat transplantation. Patients underwent the stromal enriched lipograft technique for correction of their body liposuction sequelae. Results: The total amount of clean adipose tissue transplanted varied from 14 to 120 mL. There were no cases of liponecrosis, which developed in the grafted area, and no liponecrotic lumps were palpated on postoperative evaluation on any operated cases. There were no cases of cellulitis at the donor or grafted area, no deep vein thrombosis, and no pulmonary embolism. There were no cases that needed additional session of fat grafting.

L.H. Pereira, M.D. Department of Plastic Surgery, LH Clinic, Rua Xavier da Silveira 45/206, 22061-010 Rio de Janeiro, Brazil e-mail: [email protected] B. Nicaretta, M.D., M.Sc. Department of Plastic and Reconstructive Surgery, IASO General Hospital, 264 Mesogeion Avenue, Athens, Greece e-mail: [email protected]

A. Sterodimas, M.D. M.Sc. Ph.D, ARCS. (*) Plastic and Reconstructive Surgery Department, Regenerative Plastic Surgery Institute, IASO General Hospital, 264 Mesogeion Avenue, Athens, Greece e-mail: [email protected]

© Springer-Verlag Berlin Heidelberg 2016 M.A. Shiffman, A. Di Giuseppe (eds.), Liposuction: Principles and Practice, DOI 10.1007/978-3-662-48903-1_83

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Conclusion: Liposuction continues to be a safe surgical procedure, but for maximum avoidance of complications, the surgeon should be mindful of all the factors that could predispose to complications. Stromal enriched lipograft technique is a safe and effective technique that offers the possibility of finally fulfilling the key principle of replacing “like with like” as an aesthetic filler, without the drawbacks of the traditional autologous fat grafting technique.

83.1

Introduction

Liposuction has evolved tremendously over the past three decades since its introduction by Illouz [1]. The abdominal area, the banana fold, and the sensuous triangle are difficult regions to work in and are responsible for serious local sequelae that are difficult to correct [2]. Liposuction requires thoughtful planning and an artistic eye to achieve aesthetically pleasing postoperative results. Careful selection of patients, proper surgical technique, and diligent perioperative care of the patient help avoid contour irregularity sequelae. Outcome expectations should be based on realistic preoperative evaluation of the patient’s age, skin elasticity, volume of fat to be removed, and area of liposuction [3]. The increasing number of liposuction procedures, often performed by inadequately trained physicians, has led to a growing number of iatrogenic post-liposuction contour complications. These are classified as major or minor according to the size of the area, the severity of the irregularity, the difficulty of the correction, and the visual impact. These complications include undercorrection, overcorrection, and irregular fat tissue removal with palpable and visible irregularities [2, 4]. Human adipose tissue is an ideal source of autologous cells that is both plentiful and easily obtainable in large quantities through the simple surgical procedure of liposuction. Autologous fat transplantation is frequently used for a variety of cosmetic and reconstructive indications not limited to post-traumatic defects of the face and body, evolutional disorders such as hemifacial atrophy, sequelae of radiation therapy, and many aesthetic uses such as lip and facial augmentation and wrinkle therapy [5–9]. In the past 20 years, the advances in techniques

and instrumentation have produced results that make fat grafting a viable option for correcting liposuction sequelae [10, 11]. Successful, threedimensional repair of liposuction defects requires meticulous preoperative planning and optimizing the transplantation of adipose tissue. Modifications of lipoinjection techniques to improve the survival rate for injected fat have been attempted in the last 20 years. The role of adult stem cells in adipose tissue has gained much interest in the last decade [12–14]. Lipoaspirate, an otherwise disposable by-product of cosmetic surgery, has been shown to contain a putative population of stem cells, termed adipose-derived stem cells (ADSCs) that reside within the stromal vascular fraction (SVF) in fat tissue which is thought to harbor cells that display extensive proliferative capacity and multilineage potential [12]. For cell-based therapies, an approach is to harvest SVF and give it back to the patient within a single surgical procedure, thereby avoiding lengthy and costly in vitro culturing steps. In stromal enriched lipograft (SEL), freshly isolated SVF is attached to the aspirated fat, with the fat tissue acting as a living bioscaffold before transplantation [15–17]. In this chapter we are presenting clinical results of patients with liposuction sequelae using the SEL for the correction of liposuction sequelae.

83.2

Patients and Methods

One hundred and five patients with postliposuction depressions were operated during June 2012 and September 2014. Seventy-nine female and 26 male patients were included in this

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study group. Age distribution of patients ranged from 22 to 72 years, with a mean of 43.9 years. All the patients that were included in this study were candidates for autologous fat transplantation. Patients underwent the stromal enriched lipograft technique for correction of their body liposuction sequelae.

83.3

Surgical Technique

Marking of the areas to be liposucted and fat grafted for the correction of liposuction sequelae is made while the patient is in standing position (Fig. 83.1). Preoperative sedation in the surgical suite is administered. Anesthesia consists of an epidural block and intravenous sedation. The patient is placed in prone position. After the injection of normal saline wetting solution containing 1:500,000 of adrenaline by a small-bore cannula and waiting 15 min, a 60 mL syringe attached to a 4 mm blunt cannula is inserted through small incisions in the abdominal area. Fat is aspirated by using the syringe method. The fatty tissue aspirated is treated in the following manner (Fig. 83.2). Two-thirds of the aspirated fat is used in order to isolate the SVF. Digestion is done with 0.075 % collagenase (Sigma, St. Louis, MO) in buffered saline and agitated for 30 min at 37 °C. Transfer in 10 mL syringes is performed. Separation of the SVF containing ADSCs is then done by using centrifugation at 1200 × g for 5 min. The Lipokit centrifuge (Medikan International, Irwindale, CA, USA) is used. The SVF is located in the pellet derived from the centrifuged fat at the bottom of the lipoaspirate. The remaining one-third of the aspirated fat is treated in the following manner: with the syringe held vertically with the open end down, the fat and fluid are separated. Isotonic saline is added to the syringe, the fat and saline are separated and the exudate discarded. The procedure is repeated until the fat becomes yellow in color, free of blood and other contaminants. Mixing of the SVF containing ADSCs and the purified fat is done and transferred into 10 mL syringes for application (Fig. 83.3). This whole procedure is done inside the operating theater, by two tissue engineers, manually, and the time

Fig. 83.1 Marking of the areas to be liposucted and fat grafted for the correction of liposuction sequelae is made while the patient is in standing position

required is about 90 min. Initially, the adipose tissue graft enriched with SVF is woven into the deep tissues of the liposuction sequela areas with multiple passes, injecting only a tiny amount with each pass in order to obtain the most reliable clinical outcome. Then other planes are created by the same cannula in different trajectories, always from the deeper aspect to more superficial areas. The fat is injected as the cannula is withdrawn (Fig. 83.4). In some cases skin excision may be combined with stromal enriched lipograft in order to correct the liposuction sequelae (Fig. 83.5). Antibiotics, analgesics, and anti-inflammatory medications are prescribed during the following three postoperative days.

83.4

Results

The total amount of clean adipose tissue transplanted varied from 14 to 120 mL. There were no cases of liponecrosis, which developed in the

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Stromal vascular fraction (svf) Centrifugation

Colagenase digestion

Supercharged fat graft

Pure fat

Saline purification

Fig. 83.2 Stromal enriched lipograft

grafted area, and no liponecrotic lumps were palpated on postoperative evaluation on any operated cases. There were no cases of cellulitis at the donor or grafted area, no deep vein thrombosis, and no pulmonary embolism. There were no cases that needed additional session of fat grafting.

83.4.1

Case 1

This 38-year-old woman asked for treatment of her contour sequelae following liposuction in a different plastic surgery practice (Fig. 83.6). She requested the least invasive procedure in order to correct her right leg contour deformity. Stromal enriched lipograft was offered to her. Thirteen mL of SEL was inserted in the right leg. Result was good 14 months after the procedure.

Fig. 83.3 Stromal enriched lipograft in 10 mL syringes to be used for liposuction sequela correction

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Fig. 83.4 (a–d) Stromal enriched lipograft application in different tunnels in infragluteal region

Fig. 83.5 (a) Preoperative marking of liposuction sequelae and abdominal skin excision. (b, c) Liposuction of the flanks. (d) Stromal enriched lipograft application in the abdominal area after performing lipoabdominoplasty

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806 Fig. 83.6 (a) Preoperative 38-year-old woman requesting treatment of her contour sequelae following liposuction. (b) Fourteen months postoperative after stromal enriched lipograft

83.4.2

Case 2

This 47-year-old woman presented complaining of abdominal depressions following a liposuction procedure she had in a different institution (Fig. 83.7). Stromal enriched lipograft was offered to her together with lipoabdominoplasty (Fig. 83.8). Result was good 7 months after the procedure.

83.4.3

Case 3

This 29-year-old woman presented for correction of post-liposuction gluteal depressions (Fig. 83.9). Stromal enriched lipograft was offered to her. Postoperative results 22 months after the procedure were very good.

83.4.4

Case 4

This 35-year-old woman presented for correction of post-liposuction infragluteal depressions (Fig. 83.10). Stromal enriched lipograft was offered to her (Fig. 83.11). Postoperative results were very good 17 months after the procedure.

83.5

Discussion

True body sculpting with liposuction demands a three-dimensional artistic understanding of the anatomic and surgical adipose layers of the central trunk. This is essential to preventing complications from both ultrasound- and suction-assisted lipoplasty. The best results of liposuction are still obtained when treating moderate, localized fat deposits in a normal-weight patient that cannot be managed by diet and exercise. Physicians practicing liposuction surgery should have adequate training and experience in the field. This training and experience may be obtained in residency training, cosmetic surgery fellowship training, observational training programs, and CMEaccredited postgraduate didactic and live surgical programs with trained credentialed surgeons experienced in liposuction techniques. The methods reported in the literature for the treatment of iatrogenic contour defects include liposuction for the area of protuberance, liposuction around the area of depression, and simultaneous fat grafting and dermolipectomy. Our experience with autologous fat transplantation used to treat various tissue defects has led us to apply this technique for the correction of iatrogenic post-liposuction abdominal tissue deformities [18–20].

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Fig. 83.7 (a, b) Preoperative 47-year-old woman complaining of abdominal depressions following a liposuction procedure. (c, d) Seven months postoperative after stromal enriched lipograft combined with lipoabdominoplasty

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Fig. 83.8 (a, b) Preoperative marking of liposuction sequelae and infraumbilical skin excess of the 47-year-old woman

Adipose tissue is believed to constitute an ideal source of uncultured stromal stem cells to be used for liposuction sequela correction. The presence of adipose-derived stem cells has clinical implications for autologous fat transfer because adipose-derived stem cells may contribute to neoangiogenesis in the acute phase by acting as endothelial progenitor cells or angiogenic factor-releasing cells [21, 22]. Adipose-derived stem cells are known to secrete angiogenic factors such as vascular endothelial growth factor and hepatocyte growth factor [23]. In vivo, ADSCs demonstrate the capacity to proliferate in response to a hypoxic insult remote from their resident niche, and this has been supported by in vitro studies showing increasing ADSC proliferation with greater degrees of hypoxia [24]. ADSCs upregulate also their proneovascular activity in response to hypoxia and may harbor the capacity to home to ischemic tissue and function cooperatively with existing vasculature to promote angiogenesis [25]. ADSCs are thought to be more resistant to ischemia as is the case for

bone marrow-derived mesenchymal stem cells, which can be functional for 72 h under ischemia [22]. In addition, they can affect long-term survival of transplanted adipose by acting as preadipocytes [26]. The number of functional ADSCs is likely to be important for tissue repair and remodeling, and ADSCs differentiate into vascular endothelial cells which contribute to neoangiogenesis in the acute phase of transplantation [27]. A recent study has demonstrated no statistical differences in adipocyte viability among abdominal fat, thigh fat, flank fat, or knee fat donor sites [28]. The abdomen though seems to be preferable to the hip/thigh region for harvesting adipose tissue when considering SVF cells for stem cell-based therapies in one-step surgical procedures [29]. An important consideration for harvesting and refinement in preparation for grafting is to respect and maintain the tissue architecture of living fat. Any mechanical or chemical insult that damages the fragile tissue architecture of fat will result in eventual necrosis of the injected fat [30]. Based on

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Fig. 83.9 (a, b) Preoperative 29-year-old woman presented for correction of post-liposuction gluteal depressions. (b) Twenty-two months following stromal enriched lipograft to her gluteal area. (c, d) Postoperative photos, twenty-two months following stromal enriched lipograft to her gluteal area

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Fig. 83.10 (a) Preoperative 35-year-old woman presented for correction of post-liposuction infragluteal depressions. (b) Postoperative photo 17 months after stromal enriched lipograft to her infragluteal area

this principle, one-third of the aspirated fat is treated as above described without the use of any chemical or mechanical procedure, and it is used as a natural scaffold. Recent reports have shown that mechanical centrifugation does not appear to enhance immediate fat tissue viability before implantation [31]. Centrifugation, however, plays a beneficial role in concentrating SVF and adiposederived stem cells although excessive centrifugation can destroy adipocytes and adipose-derived stem cells. The degree of adipocyte destruction differs among patients, but it has been shown that there are only minor differences existing in the percentage of cell destruction between the different centrifugal forces [32]. In a previous study, it was found that centrifugation of aspirated fat at

1200 × g decreases the fat volume by 30 %, damaging 12 % of the adipocytes and 0 % of the ADSCs [33]. This has been confirmed by a recent study stating that cell survival rates are significantly lower when centrifugation forces of 1200 × g are used for more than 5 min and of 3000 × g when used for more than 1 min [34]. The actual recommendation is 1200 × g as an optimized centrifugal force among the tested centrifugal forces for obtaining good short- and long-term results in adipose transplantation. A recent study conducted in our department showed that the ADSC concentration is significantly higher in lipoaspirate that has been washed by saline compared to the decanted and centrifuged lipoaspirate samples. However, the pellet collected at the bottom of the centrifuged

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The experience in our department with the traditional autologous fat grafting in treating various tissue defects have been published extensively [19, 35, 36]. The results of traditional autologous fat transplantation have been predictable and satisfying on the condition that the treatment is performed in stages with small quantities of adipose tissue fat injected in various treatment sessions (three to five sessions). In this series of patients, only one treatment session produced aesthetically satisfactory results in patients who had liposuction sequelae. There are cases where there is little or no fat reserve. This is common in young patients who have undergone extensive liposuction procedures. In those cases, the challenge for the surgeon is to obtain the maximum possible amount of fat without creating more contour defects. The authors recommend a minimum of 6 months before any revision surgery. This period is critical to allow swelling and edema to subside and to enable correct evaluation of the contour abdominal deformities. Conclusions

Fig. 83.11 (a, b) Stromal enriched lipograft to the infragluteal area

lipoaspirate sample showed the highest concentration of ADSCs. Based on this finding, the washed autologous fat (one-third of lipoaspirate) is supercharged by the SVF isolated by centrifugation from two-thirds of the remaining lipoaspirate. The SVF contains erythrocytes, leukocytes, ADSCs, vascular endothelial cells, and pericytes. It is important for the SVF to adhere on the purified fat before transplantation is done. This is achieved by gently mixing SVF and fat, which serves as a scaffold, before placing in the 1 mL syringes. The time needed in order to process the collected fat for SVF extraction is around 80–90 min. This is a limitation when compared to the time taken in order to perform the traditional fat grafting to the face.

Liposuction continues to be a safe surgical procedure, but for maximum avoidance of complications, the surgeon should be mindful of all the factors that could predispose to complications. With the overall acceptance of aesthetic surgery increasing as well as the number of patients undergoing liposuction, it is likely that plastic surgeons will see more patients requesting correction of liposuction sequelae in the future. Stromal enriched lipograft technique is a safe and effective technique that offers the possibility of finally fulfilling the key principle of replacing “like with like” as an aesthetic filler, without the drawbacks of the traditional autologous fat grafting technique.

References 1. Illouz YG. Body contouring by lipolysis: a 5-year experience with over 3000 cases. Plast Reconstr Surg. 1983;72(5):591–7.

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26.

27.

28.

29.

30.

31.

32.

33.

of experience. Aesthetic Plast Surg. 2009;33(5): 706–15. Hamou C, Callaghan MJ, Thangarajah H, Chang E, Chang EI, Grogan RH, Paterno J, Vial IN, Jazayeri L, Gurtner GC. Mesenchymal stem cells can participate in ischemic neovascularization. Plast Reconstr Surg. 2009;123(2 Suppl):45S–55. Mylotte LA, Duffy AM, Murphy M, O’Brien T, Samali A, Barry F, Szegezdi E. Metabolic flexibility permits mesenchymal stem cell survival in an ischemic environment. Stem Cells. 2008;26(5):1325–36. Kilroy GE, Foster SJ, Wu X, et al. Cytokine profile of human adipose-derived stem cells: expression of angiogenic, hematopoietic, and pro-inflammatory factors. J Cell Physiol. 2007;212:702–9. Suga H, Eto H, Shigeura T, Inoue K, Aoi N, Kato H, Nishimura S, Manabe I, Gonda K, Yoshimura K. IFATS collection: fibroblast growth factor-2induced hepatocyte growth factor secretion by adipose-derived stromal cells inhibits postinjury fibrogenesis through a c-Jun N-terminal kinase-dependent mechanism. Stem Cells. 2009;27(1):238–49. Thangarajah H, Vial IN, Chang E, El-Ftesi S, Januszyk M, Chang EI, Paterno J, Neofytou E, Longaker MT, Gurtner GC. IFATS collection: adipose stromal cells adopt a proangiogenic phenotype under the influence of hypoxia. Stem Cells. 2009;27(1):266–74. Rehman J, Traktuev D, Li J, et al. Secretion of angiogenic and antiapoptotic factors by human adipose stromal cells. Circulation. 2004;109:1292. Kølle SF, Fischer-Nielsen A, Mathiasen AB, Elberg JJ. Enrichment of autologous fat grafts with ex-vivo expanded adipose tissue-derived stem cells for graft survival: a randomised placebo-controlled trial. Lancet. 2013;382(9898):1113–20. Ullmann Y, Shoshani O, Fodor A, Ramon Y, Carmi N, Eldor L, Gilhar A. Searching for the favorable donor site for fat injection: in vivo study using the nude mice model. Dermatol Surg. 2005;31(10):1304–7. Jurgens WJ, Oedayrajsingh-Varma MJ, Helder MN, Zandiehdoulabi B, Schouten TE, Kuik DJ, Ritt MJ, van Milligen FJ. Effect of tissue-harvesting site on yield of stem cells derived from adipose tissue: implications for cell-based therapies. Cell Tissue Res. 2008;332(3):415–26. Pereira LH, Sterodimas A. Long-term fate of transplanted autologous fat in the face. J Plast Reconstr Aesthet Surg. 2010;63(1):e68–9. Rohrich RJ, Sorokin ES, Brown SA. In search of improved fat transfer viability: a quantitative analysis of the role of centrifugation and harvest site. Plast Reconstr Surg. 2004;113(1):391–5. Kurita M, Matsumoto D, Shigeura T, Sato K, Gonda K, Harii K, Yoshimura K. Influences of centrifugation on cells and tissues in liposuction aspirates: optimized centrifugation for lipotransfer and cell isolation. Plast Reconstr Surg. 2008;121(3):1033–41. Yoshimura K, Sato K, Aoi N, Kurita M, Hirohi T, Harii K. Cell-assisted lipotransfer for cosmetic breast

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Correction of Liposuction Sequelae by Autologous Fat Transplantation

augmentation: supportive use of adipose-derived stem/ stromal cells. Aesthetic Plast Surg. 2008;32(1):48–55. 34. Kim IH, Yang JD, Lee DG, Chung HY, Cho BC. Evaluation of centrifugation technique and effect of epinephrine on fat cell viability in autologous fat injection. Aesthet Surg J. 2009;29(1):35–9. 35. Santana KP, Pereira LH, Sabatovich O, Sterodimas A. Foreign-body granulomas caused by polymethyl-

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methacrylate (PMMA) microspheres: successful correction by autologous fat transplantation. J Plast Reconstr Aesthet Surg. 2010;63(2):e139–41. 36. Pereira LH, Sterodimas A. Autologous fat transplantation and delayed silicone implant insertion in a case of Mycobacterium avium breast infection. Aesthetic Plast Surg. 2010;34(1):1–4.

Fat Shifting for the Treatment of Skin Indentations

84

Melvin A. Shiffman and Guillermo Blugerman

Abstract

“Liposhifting” is a safe and simple method to treat liposuction irregularities. This method moves fat from around the indentation into the depressed area. The author describes the procedure and possible complications. The procedure can be used for any depression, whether or not it is associated with prior liposuction. The depression may need subcision if a scar or fibrosis is involved.

84.1

Introduction

Saylan [1] was the first to describe a technique called “liposhifting” as a safe and simple method to treat liposuction irregularities. This method moves fat from around the indentation into the depressed area by injecting tumescent solution consisting of 1 L of normal saline containing 1 mg epinephrine and 12.5 mEq sodium bicarbonate. A 3–4-mm Becker cannula is moved in a crisscross fashion through multiple incisions to loosen the fat globules. The fat is then pushed M.A. Shiffman, M.D., J.D. Private Practice, 17501 Chatham Drive, Tustin, CA 92780, USA e-mail: [email protected] G. Blugerman, M.D. (*) Private Practice, Laprida 1579, Buenos Aires 1425, Argentina Centro B & S Excelencia en Cirugía Plástica, Buenos Aires, Argentina e-mail: [email protected]

into the defect by rolling a 6–10-mm cannula toward the indentation. A tape dressing is then applied to keep the fat in position. It takes about 2–4 days for the fat globules to become vascularized [2].

84.2

Technique

The area that is depressed and the surrounding elevated regions are marked prior to surgery. The injection of Klein’s solution containing 1 L of saline (or lactated Ringer’s solution) with epinephrine, lidocaine, and sodium bicarbonate is not necessary if general anesthesia is used. In that instance, a solution of 1,000 mL saline with 1 mg epinephrine is used. Local tumescent anesthesia can be utilized with or without sedation. The solution that is least painful for a patient under local tumescent anesthesia is 1 L of lactated Ringer’s solution with 1 mg epinephrine, 300 mg lidocaine, and 12.5 mEq sodium bicarbonate.

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The fat is loosened around and under the defect with a cannula by not applying suction and obstructing the open end with the finger or plug. Some cannulas may be more aggressive than the blunter tipped cannula, but crisscross and fanshaped patterns with multiple layers should be utilized. The subdermal tissues in the area of the defect are treated in the same manner as the surrounding fat utilizing tunnels and no sweeping motion. Subcision may be required if there is scar attachment of the skin to the underlying tissues. Special instruments devised by Blugerman can obtain predictable fat grafts and comprise a spatula (Fig. 84.1) and a tubular “scalpel” with a solid handle (Micro Graft Fat Cutter; LaserPoint, Nordkirchen, Germany) (Fig. 84.2). These are produced as reusable or disposable instruments. The spatula is utilized to create tunnels in multiple layers (Fig. 84.3), which can reduce the incidence of hematoma. If more fat mobilization is necessary, the instruments can be utilized again to produce more fat grafts. The fat in the surrounding tissues is moved or “shifted” into the defect by rolling a 6–10-mm cannula over the tissues with moderate pressure until the defect is at least flat (Fig. 84.4). Fat can be mobilized by massage maneuvers as well. Blugerman has devised a roller pin that is more efficient in shifting the fat. Absorption of the tumescent solution will result in a loss of any excess fullness within a few days. The incisions are not sutured. The area is sprayed with tincture of benzoin, and then stretch tape is applied around the repaired depressed area to hold the fat in its intended position (Fig. 84.5). A foam pad may be used under the stretch tape to reduce bleeding. Compression is maintained for 24 h. If blisters occur on the skin, the tape should be removed and any open blisters covered with antibiotic ointment daily until the skin has healed. Tincture of benzoin helps to prevent blisters but is not 100 % effective. The patient is placed on antibiotics, administered either orally starting the day before surgery or intravenously at least 30 min before the start of surgery. The oral administration of the antibiotic is continued for at least 5 days postoperatively.

M.A. Shiffman and G. Blugerman

Fig. 84.1 Blugerman spatula

Fig. 84.2 Tubular “scalpel” with solid handle (Micro Graft Fat Cutter)

Fig. 84.3 The spatula is used to create tunnels in multiple layers

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Fat Shifting for the Treatment of Skin Indentations

a

817

b

c

Fig. 84.4 (a) Fat shifted with a large cannula. (b) Fat shifted with manual massage. (c) Fat shifted with a large roller

Fig. 84.5 Stretch tape with foam applied around the fat grafted area of the depression

M.A. Shiffman and G. Blugerman

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84.3

Complications

required if the infection does not respond readily to the antibiotics. This may require needle aspiration to obtain a specimen if there is no drainage. Incision and drainage is rarely necessary. Undercorrected defects may require repeat liposhifting procedures. This can be performed after 3 months, when there is no longer fat reabsorption.

There may be bruising as with any liposuction procedure. Bruising will reduce the amount of fat survival. If the surgeon is too aggressive with the undermining, hematoma can occur. Blisters from the tape can be irritating to the patient, but if treated timely by removal of the tape, there will be no residual scarring or pigment loss. Blisters that are unbroken can be treated with protective dressings and observation. Open blisters are treated with antibiotic ointment. Infection would be devastating to fat survival and is treated by increasing the dose or changing the antibiotics. Culture and sensitivity may be

84.4

Discussion

The fat globules or “pearls” receive their new blood supply in 2–3 days with new blood vessel formation in the periphery of the globule [2]. The a

c

Fig. 84.6 (a) Traumatic depression of the left knee area. (b, c) Progressive filling of defect with liposhifting

b

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Fat Shifting for the Treatment of Skin Indentations

a

819

b

Fig. 84.7 (a) Preoperative depressions of medial thighs. (b) Postoperative improvement in the medial thighs following liposhifting

center of the globule will be reabsorbed. The amount of fat that survives will be permanent after 4 months. The technique is easy to learn and has not been associated with any major complications. The procedure can be used for any depression, whether or not it is associated with prior liposuction. The depression may need subcision if a scar or fibrosis is involved. The face is not a good area

to use liposhifting since there is not enough fat to move into a defect and the underlying bony structure makes shifting more difficult. However, a technique with a small diameter, short tube to roll the fat into place into a small depression may very well be developed. Reduction of surrounding elevated areas and elevation of depressed areas can be obtained in a single procedure (Figs. 84.6, 84.7, and 84.8).

M.A. Shiffman and G. Blugerman

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a

b

Fig. 84.8 (a) Preoperative defect of the right lateral buttock. (b) Postoperative improvement in the defect following liposhifting

References 1. Saylan Z. Liposhifting: treatment of postliposuction irregularities. Int J Cosmet Surg. 1999;7(1):71–3. 2. Shiffman MA. History of autologous fat transplant survival. In: Shiffman MA, editor. Autologous fat transfer: art, science, and clinical practice. Berlin: Springer; 2010. p. 5–10.

Liposuction Mortality

85

Melvin A. Shiffman

Abstract

Any surgery, minor or major, has risks of mortality associated with the procedure from complicating medical disorders, allergies, anesthesia, and physician error. The author discusses the risks of mortality from general anesthesia, medical problems that increase risk, and the risk with cosmetic surgery. No surgical procedure with any type of anesthesia is without significant risk.

85.1

Introduction

Any surgery, minor or major, has risks of mortality associated with the procedure from complicating medical disorders, allergies, anesthesia, and physician error. There are few true statistics that distinguish adequately between all the possible causes of mortality in a variety of cosmetic surgical procedures, especially liposuction. There have been statements that large-volume liposuction and megaliposuction are associated with a higher risk of mortality than with liposuction under 5,000 mL. It has been pointed out that local tumescent anesthesia for liposuction does not have a risk of mortality, which is untrue, although the risk of mortality is definitely less than with general anesthesia or deep sedation.

M.A. Shiffman, M.D., J.D. Private Practice, 17501 Chatham Drive, Tustin, CA 92780, USA e-mail: [email protected]

Statements have been made that general anesthesia is more of a risk for thromboembolic disorders than local tumescent anesthesia and that concomitant additional surgical procedures at the time of liposuction increase the risk of mortality, which may very well be true. Surgeons have claimed that thromboembolism does not occur with facelift, which is not true. Careful research into the risks of mortality with cosmetic surgery has not been done; mainly retrospective surveys have been utilized.

85.2

Risks of Mortality with General Anesthesia

Forrest et al. [1], in 1990, reported an incidence of 1.11:1,000 procedures resulted in deaths from anesthesia. Actually, out of 17,201 cases there were 19 deaths, in only 7 of which anesthesia may have been a contributing factor. All the patients were American Society of Anesthesiologists

© Springer-Verlag Berlin Heidelberg 2016 M.A. Shiffman, A. Di Giuseppe (eds.), Liposuction: Principles and Practice, DOI 10.1007/978-3-662-48903-1_85

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(ASA) physical status 1 or 2 and deaths from sepsis, bleeding, and pulmonary embolus were included. Other authors [2, 3] have reported a 1:10,000 risk of purely anesthesia-associated mortality. Coldiron [4] reported on 43 procedure-related complications and 8 deaths in a prospective study by the state of Florida through reporting requirements. Nineteen months of data were collected but the number of patients who had surgical procedures was not stated. Liposuction in 8 patients of the 43 had complications with general anesthesia and with 1 patient under deep sedation. There were three deaths from liposuction under general anesthesia and none were reported following local tumescent anesthesia. There was one case of acute anaphylaxis from lidocaine. Eichhorn [5], in 1989, showed that there were no complications or deaths in 319,000 patients having general anesthesia and monitored in accordance with the standards of the ASA. Cardenas-Camarena [6] reported no mortalities in 1,047 patients having liposuction with the tumescent technique and general anesthesia. The volume of aspiration ranged from 500 to 22,200 mL with a median of 6,230 mL. Major complications included one patient with two prior liposuction procedures who had skin necrosis, one patient who had abdominoplasty also developed infection, one patient with abdominoplasty as well as liposuction developed fat pulmonary embolism, and one patient who had breast implants as well as liposuction developed fat pulmonary embolism.

85.3

Medical Risks of Mortality

Obesity and body mass index (greater than 35) pose a significant risk to life [7], while severe untreated hypertension (over 120 mmHg) is likely to increase anesthetic morbidity [8]. Medical conditions such as diabetes mellitus, heart disease, and pulmonary disease pose significant risks with the use of general anesthesia. Allergies to medications can result in anaphylaxis with death. Oral contraceptives pose a 1:28,000 mortality risk [9] and it has been advised to avoid preoperative oral contraceptives [10].

85.4

Surgical Risks of Mortality

There has been reported a 1:1,000 patient mortality with hysterectomy and a 1:333 patient mortality with mastectomy [11]. Luft et al. [12] stated that high volumes of surgical activity were linked to lower mortality probabilities.

85.5

Cosmetic Surgical Procedures and Mortality

For cosmetic procedures performed under general anesthesia, the risks of mortality are: 1. Facelift: 1:922 [13] to 1:5,000 [14] 2. Abdominoplasty: 1:600 [15] Fatalities may occur when liposuction is combined with other adjunctive operations [16–18]. Bernstein and Hanke [19] reported no fatalities in 9,478 cases of liposuction with 71 % of patients receiving local anesthesia and 29 % given general anesthesia. Teimourian and Rogers [20] stated that there were 1:29,000 fatalities with liposuction from fat embolism and pulmonary thromboembolism. The causes of the fatal outcomes from liposuction were reported by Grazer and de Jong [21] (Table 85.1). There was a death reported from necrotizing fasciitis following liposuction [22] and several other deaths have been reported [23] but the Table 85.1 Fatal outcomes from liposuction: 496,245 cases from 1994 to 1998; 130 fatalities [1:3,817 cases or 26:100,000 (0.026 %)] Disorder Thromboembolism Abdomen/viscus perforation Anesthesia/sedation/medication Fat embolism Cardiorespiratory failure Massive infection Hemorrhage Unknown Reprinted with permission from Ref. [21]

Number of deaths 30 19 13 11 7 7 6 37

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causes of the deaths were not adequately described.

85.6

Discussion

Many of the statistics quoted are over 15 years old. Anesthetic agents and techniques have, since that time, advanced and helped to reduce mortality. Combining liposuction with abdominoplasty is a known risk for thromboembolism and mortality. Adding lengthy procedures to a significant volume of liposuction aspiration has been associated with deaths. Lidocaine, even in small doses, has caused acute anaphylaxis and death sometimes attributed to the presence of methylparaben as a preservative (G.A. Farber, personal communication, January 18, 1999) [24–26]. No surgical procedure with any type of anesthesia is without significant risk.

References 1. Forrest JB, Cahalan MK, Rehder K, Goldsmith CH, Levy EJ, Strunin L, Bota W, Boucek CD, Coucchiara RF, Dhamee S, Domino KB, Dudman AJ, et al. Multicenter study of general anesthesia. II. Results. Anesthesiology. 1990;72(2):262–8. 2. Lunn JN, Mushin WW. Mortality associated with anaesthesia. London: Nuffield Provincial Hospitals Trust; 1982. 3. Keenan RL, Boyan P. Cardiac arrest due to anesthesia: a study of incidence and causes. J Am Med Assoc. 1985;253(16):2373–7. 4. Coldiron B. Office surgical incidents: 19 months of Florida data. Dermatol Surg. 2002;28(8):710–3. 5. Eichhorn JH. Prevention of intraoperative anesthesia accidents and related severe injury through safety monitoring. Anesthesiology. 1989;70(4):572–7. 6. Cardenas-Camarena L. Lipoaspiration and its complications: a safe operation. Plast Reconstr Surg. 2003; 112(5):1435–41. 7. Gazet JC, Pilkington TR. Surgery of morbid obesity. Br Med J. 1987;295(6590):72–3. 8. Prys-Roberts C. Hypertension and anesthesia – fifty years on. Anesthesiology. 1979;50(4):281–4.

823 9. Pochin E. The acceptance of risk. Br Med Bull. 1975;31(3):184–90. 10. Guillebaud J. Surgery and the pill. Br Med J. 1985;291(6494):498–9. 11. Sloan FA, Perrin JM, Valvona J. In-hospital mortality of surgical patients: is there an empiric basis for standard setting? Surgery. 1986;99(4):446–55. 12. Luft HS, Bunker JP, Enthoven AC. Should operations be regionalized? The empirical relation between surgical volume and mortality. N Engl J Med. 1979; 301(25):1364–9. 13. Thompson DP, Ashley FL. Face lift complications: a study of 922 cases performed in a 6-year period. Plast Reconstr Surg. 1978;61(1):40–9. 14. Baker TJ, Gordon HL, Mosienko P. Rhytidectomy. A statistical analysis. Plast Reconstr Surg. 1977;59(1): 24–30. 15. Grazer FM, Goldwyn RM. Abdominoplasty assessed by survey with emphasis on complications. Plast Reconstr Surg. 1977;59(4):513–7. 16. Courtiss EH. Suction lipectomy: complications and results by survey. Plast Reconstr Surg. 1985;76(1):70. 17. Pitman GH, Teimourian B. Suction lipectomy: complications and results by survey. Plast Reconstr Surg. 1985;76(1):65–72. 18. Christman KD. Death following suction lipectomy and abdominoplasty. Plast Reconstr Surg. 1986;78(3):428. 19. Bernstein G, Hanke CW. Safety of liposuction: a review of 9478 cases performed by dermatologists. J Dermatol Surg. 1988;14(10):1112–4. 20. Teimourian B, Roger WB. A national survey of complications associated with suction lipectomy: a comparative study. Plast Reconstr Surg. 1989;84(4): 628–31. 21. Grazer FM, De Jong RH. Fatal outcomes from liposuction: census of cosmetic surgeons. Plast Reconstr Surg. 2000;105(1):436–46. 22. Alexander J, Takeda D, Sanders G, Goldberg H. Fatal necrotizing fasciitis following suction-assisted lipectomy. Ann Plast Surg. 1988;20(6):562–5. 23. Ginsberg MM, Gresham L. Deaths related to liposuction. N Engl J Med. 1999;341(13):1000. 24. Christie JL. Fatal consequences of local anesthesia: report of five cases and a review of the literature. J Forensic Sci. 1976;21(3):671–9. 25. Kennedy KS, Cave RH. Anaphylactic reaction to lidocaine. Arch Otolaryngol Head Neck Surg. 1986;112(6): 671–3. 26. Zimmerman J, Rachmilewitz D. Systemic anaphylactic reaction following lidocaine administration. Gastrointest Endosc. 1985;31(6):404–5.

Death After Liposuction

86

Claudio Terranova

Abstract

Liposuction, a surgical procedure that improves the body’s contour by removing excess fat from deposits, can be associated with complications or even fatal outcomes. Complications and fatalities may result in malpractice claims, with possible judicial consequences for the physician involved. This chapter’s review of the causes of death after liposuction and its analysis of risk factors related to fatal outcomes may be useful for surgeons and dermatologists performing liposuction and for experts evaluating a malpractice hypothesis related to this kind of intervention.

86.1

Introduction

Liposuction is a surgical procedure that improves the body’s contour by removing excess fat from deposits located between the skin and the muscle [1]. Currently, it is the first and second most common aesthetic operation performed in the United States for men and women, respectively [2]. In 2013, in the United States, women had more than 312,000 lipectomy procedures and men more than 51,000. Although this intervention is publicly perceived as a minor surgery, complications or posC. Terranova, M.D. Section of Legal Medicine and Toxicology, Department of Legal Medicine, Occupational Medicine, Toxicology and Public Health, Hospital University of Padova, Via Gabriele Falloppio 50, 35121 Padova, Italy e-mail: [email protected]

sibly fatal outcomes have been described [3–7]. Data concerning fatalities after liposuction procedures indicate that the mortality rate varies from 0 to 0.01 % in different surveys and cohort studies. A mortality rate of 1 death per every 5,000 procedures for liposuction performed by plastic surgeons has been noted in different surveys [4, 8, 9]. In particular, Grazer and de Jong [4] performed a survey in 2000 involving all 1,200 actively practicing North American board-certified members of the American Society for Aesthetic Plastic Surgery (ASAPS) who had performed operations between 1994 and 1998. The survey found 95 fatalities in approximately 500,000 lipectomy procedures, representing a mortality rate of 19.1 in 100,000; notably, 23 % of these fatalities were attributable to pulmonary embolism. Similarly, a study of more than 25,000 procedures reported a mortality rate of 0.01 %, pulmonary embolism being the major cause of death [8].

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In 2001, a survey conducted by the ASAPS [10] found a mortality rate after liposuction of 0.002 %. This survey indicated that the mortality rate after the performance of lipoplasty as an isolated procedure was 0.0021 %, or 1 death per 47,415 procedures. When lipoplasty was performed with other procedures, excluding abdominoplasty, the rate was 0.0137 %, or 1 per 7,314 procedures. When liposuction was combined with abdominoplasty, the rate was 0.0305 %, or 1 per 3,281 procedures—a rate 14 times greater than that for lipoplasty only. Conversely, a mortality rate of 0 % for the same procedure has repeatedly been reported in other studies [5, 11–15]. It has been argued that these findings are due to the bias of underreporting by the surgeons performing the liposuction [16] and the small number of studied patients— probably too small to detect such a rare occurrence [17–20]. Moreover, a bias due to the selection of patients may be present, because in many studies, the authors state that their findings are applicable only to “selected patients” [13, 21]. Another bias in the estimation of mortality rate can be attributed to the low response rate from surgeons in different surveys. The majority of surveys showed a response rate from the investigated surgeons lower than 70 % [10, 22] or even lower than 30 % [11]. On the other hand, the very low mortality rate reported in recent years may be due to advances in techniques, improvement in the education of residents in plastic and dermatologic surgery, more careful patient selection, and educational efforts related to lipoplasty safety carried out by different surgical societies. Complications and fatalities may result in a malpractice hypothesis, with possible civil and (in some countries) penal consequences.

86.2

Causes of Death after Liposuction and Risk Factors Related to Fatal Complications

Pulmonary embolism [23, 24], fat embolism [24, 25], sepsis [4], necrotizing fasciitis [22], perforation of abdominal or thoracic viscera [5–7], hem-

orrhages [5], thrombosis, hypotension [25], pulmonary edema [22], and cardiac arrest [22] have all been reported as possible fatal consequences of liposuction (Table 86.1). Thromboembolism has been proven to be the major cause of death after liposuction in the majority of surveys [4, 26], and it should be managed with preoperative risk stratification and treatment, as necessary. Interestingly, in 2012, the American Society of Plastic Surgeons (ASPS) published the “Venous Thromboembolism Task Force Report” to guide risk stratification and implementation of preventative measures [27]. Thromboembolism during liposuction includes both embolism due to deep vein thrombosis (DVT) and fat embolism. Some risk factors for DVT and thromboembolism have been identified. They include the combination of more than one procedure (e.g., abdominoplasty and liposuction) [5, 28, 29], a long procedure duration (surgery for more than 2 h) [4, 22], a large amount of fat removed [22], the lack of DVT prophylaxis

Table 86.1 Summary of major complications and fatalities following liposuction procedure Complication type associated with death Thromboembolism

Descriptions Deep vein thrombosis Fat embolism Arterial embolism with forefoot gangrene Basilar artery thrombosis Toxicity or drug Liposuction with tumescent interactions technique using lidocaine Infections Causative pathogens: Pseudomonas aeruginosa, Staphylococcus aureus, Streptococcus pyogenes, Enterococcus species, Escherichia coli, Aeromonas caviae, Bacteroides rheumatic, Candida albicans, Clostridium perfringens, Mycobacterium chelonae Visceral organ perforation Small intestine perforation Cardiocirculatory Hemorrhages complications Hypotension Pulmonary edema Cardiac arrest

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[30], and the presence of thrombophilic factors in patient history, including inherited hypercoagulable states, chronic smoking, obesity, dehydration, advanced age (>60 years), varicose veins, and use of oral contraceptive pills [31]. As far as fat embolism is concerned, specific risk factors for developing this complication after liposuction are not well established. Fat manipulation either by liposuction or transfer is likely a risk in itself. Other risks may include duration of procedure, the use of particular techniques (e.g., ultrasonic liquidation of fat cells), volume of aspirate, number of treated areas, and largevolume procedures [32–34]. Another relevant cause of death is the toxicity of anesthetic drugs used during surgery. A recent survey of office surgical procedures in Florida found that over 10 years, 56.5 % of deaths (26 out of 46) were associated with nonmedically necessary (cosmetic) procedures and that the majority of deaths (67 %) related to cosmetic procedures resulted from procedures performed on patients under general anesthesia [35]. The “Practice Advisory on Liposuction,” published in 2004 by the ASPS, provides a thorough review of anesthetic techniques and guidelines for surgeons who perform liposuction [36]. These guidelines state that various anesthetic infiltrate solutions, intravenous and oral sedation, general anesthesia, and, in select cases, epidural anesthesia are appropriate for liposuction. It is specified that physicians should select the method of anesthesia in view of the overall health of the patient, the estimated volume of the aspirate to be removed, and the postoperative discharge plan [36]. Interestingly, epidural and spinal anesthesia are discouraged because of the possibility of vasodilation, hypotension, and fluid overload [36]. Marcaine, according to another study, should be used with caution and is preferably avoided due to the severity of cardiac side effects, slow elimination, and inability to reverse potential toxicity [36]. In this context, it is important to remember that the completion of postgraduate training in a surgical specialty or in dermatology is recommended for physicians performing liposuction. Such physicians should have had adequate train-

827

ing that includes knowledge of fluid balance and potential complications related to both liposuction and anesthesia. Risk factors for side effects related to anesthesia depend on the type of anesthesia used. Tumescent local anesthesia is currently the most commonly used technique due to its good safe profile [37, 38]: it consists in subcutaneous infiltration of large volumes of dilute lidocaine with epinephrine to achieve vasoconstriction during the distribution of anesthesia over large areas without lidocaine toxicity [39]. Although lidocaine is in most cases harmless to humans, hazardous cardiac toxicity related to the use of high concentrations has been described [38]. Lidocaine concentrations of up to 35 mg/kg are generally considered safe. Even though death due to tumescent local anesthesia has been reported in some cases [39], this technique seems to be safe when used without general anesthesia [13, 14, 40]. Side effects of tumescent anesthesia have been related to the following risk factors: history of pheochromocytoma, severe hypertension, cardiac disease, hyperthyroidism, peripheral vascular disease [36], overweight and obesity, amount of fat removed, and duration of the procedure, although some recent studies have emphasized that anesthesia duration does not seem to increase the risk of death during liposuction [14, 41]. Severe infections are another cause of mortality related to liposuction, necrotizing fasciitis and sepsis being the types of infection most frequently detected [4]. A number of different pathogens have been identified as possible causative agents in different cohorts (Table 86.1). The risk factors for this complication are insufficient standard of hygiene, a high amount of fat removed, and permissive postoperative discharge [42]. Some general risk factors for fatal complications in liposuction have been identified (Table 86.2). The author has schematically divided them into four categories: patient related, anesthesiologic, procedural, and physician related. With regard to surgical and anesthesiologic risk factors [36], no single surgical or anesthesiologic approach is best suited for all patients in all circumstances. The characteristics of the patient,

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828 Table 86.2 Summary of risk factors associated with fatal complications Risk factor category Patient related

Anesthesiological

Surgical/procedural

Physician related

Risk factors Obesity Diabetes Generalized adiposity Preexisting medical conditions Previous venous thromboembolism Epidural and spinal anesthesia Tumescent anesthesia with or without intravenous sedation Large-volume liposuction Liposuction combined with other procedure Non-aseptic standards Surgeon’s lack of expertise and experience Technical deficiencies

the goal of the operation, the number of sites to be addressed, and any concomitant procedures should drive the choice of surgical and anesthesiologic approach. Concerning physician-related risk factors [43, 44], as previously highlighted, a surgeon’s lack of expertise and experience may play a role in the development of complications. Comprehensive training in aesthetic surgery with specific emphasis on surgical and anesthesiologic techniques should be provided to all residents interested in performing liposuction.

86.3

Medicolegal Consequences, Autopsy, and Analysis of Physician Technique

Civil and, in some countries, penal consequences are usually observed for unexpected fatalities following surgical procedures in relatively healthy patients. A malpractice hypothesis is followed by the analysis of the case by means of a methodologic approach based on the following phases: (1) expert definition, (2) collection and examination

of clinical and documentary data, (3) consultation with specialist, (4) autopsy, (5) analysis of physician conduct, and (6) analysis of causal value and causal link between error and death of the patient. The methodologic approach is defined according to the European Guidelines on Methods of Ascertainment and Criteria of Evaluation in Cases of Malpractice and Medical Liability [45]. Each phase presents specific features of the particular analyzed field. The appointed expert should be a specialist in legal medicine and forensic pathology with a theoretical and practical understanding of liposuction as well as expertise in forensic autopsies [45]. The analysis of clinical documentation is mandatory before autopsy execution because it may reveal the suitability of a particular type of dissection and the necessity of requesting the advice of one or more specialists (an anesthesiologist, dermatologist, or plastic surgeon) before, during, and after the dissection of the body. As indicated in Recommendation no. R (99) 3 of the Committee of Ministers to Member States on the Harmonisation of Medico-Legal Autopsy Rules [45, 46], autopsy is fundamental in medicolegal ascertainments. In cases of death after liposuction with suspected medical responsibility, autopsies should be performed with the help of the specialist supporting the forensic pathologist. Signs of recent medical and surgical intervention and resuscitation must be described. Internal examination should be performed according to the previously mentioned recommendations and, in specific cases, to guidelines of the Royal College of Pathologists [47]. During internal examination, the forensic pathologist for cases of death after liposuction should keep in mind the most frequent causes of death. This knowledge should drive the choice and methods of dissection. Deep vein thrombosis, fat embolism, signs of infection, and small intestine perforations should all be investigated. Dissection of the lower limbs could highlight signs of previous thrombosis. Extemporaneous microscopic examination of the lungs and cerebral parenchyma, previously prepared with Oil Red staining, may

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exclude or put in evidence the presence of fatty particles. After recognizing the cause of death by means of an integrated external, internal, and histopathological approach, the medicolegal expert along with one or more specialists must analyze the physician’s conduct. For a general discussion of the methodologic approach that should be followed in the analysis of physician conduct in cases of malpractice, the reader should refer to the previously cited European Guidelines on Malpractice. The analysis of physician conduct will be discussed only in relation to cases of death after liposuction. The first step of analyzing a physician’s conduct is to analyze scientific sources, such as guidelines [36, 48], consensus documents, evidence-based publications (Cochrane reviews, meta-analyses, etc.), and/or other data from the literature [45]. After analyzing scientific sources and reconstructing the ideal conduct, evaluation of the correctness of the various diagnostic, prognostic, and therapeutic phases is carried out by comparing the observed events to ideal conduct. The first thing that should be considered is informed consent. The patient should have signed a detailed consent form about the procedure and its possible complications, including fatal ones. The informed consent form should refer to the specific patient requiring the operation. As previously put in evidence, different preexisting conditions may result in different complications and require a targeted surgical and anesthesiologic approach, which should be verified. The reading of the informed consent form may provide some indications about the selection of the patient. Considering whether the patient was accurately selected is another fundamental step in the evaluation of the physician’s conduct. In 2004, the Committee on Patient Safety of the ASPS published the first “Practice Advisory on Liposuction” to guide appropriate selection and treatment of patients seeking liposuction. In this advisory, updated in 2009, it is stated that patients should be generally healthy and demonstrate a commitment to long-term lifestyle changes including both healthy diet and exercise [49]. As a general approach, the physician should always

829

examine the personal risk factors, consider the most appropriate surgical and anesthesiologic approach, and prevent morbidity and mortality by means of prophylactic procedures for the management of specific risk factors. A detailed history concerning any previous disease, drug intake, and surgical procedures should be taken. Severe cardiovascular disease, severe coagulation disorders including thrombophilia, and pregnancy are contraindications to liposuction. In relation to specific risk factors, it is necessary to verify whether the physician followed the applicable guidelines. For deep venous thrombosis, for example [27], patients should be told to stop smoking and taking contraceptive pills at least 2 weeks before surgery. The surgical procedure should not be combined with other lengthy procedures and attempts should be made to minimize operation time. Adequate hydration must be ensured perioperatively. The protocol should include the use of at least Elastocrepe bandaging after leg elevation before surgery in cases likely to require at least a 2 h intervention [30], and the dressing should be reapplied every 2 h until the patient is capable of walking [30]. Sequential compression stockings and anti-DVT pumps should be used whenever available [30]. Finally, postoperatively, excessively tight compression garments should be avoided [30]. Laboratory tests should be restricted to those subjects who have had one or more thrombotic episodes in youth, particularly if spontaneous [43]. Obese patients and those with certain preexisting medical conditions may not be suitable candidates [50]. In cases of fat embolism, it is important to detect promptly the symptoms associated with this complication. The error in this case is not the lack of prevention of fat embolism, which, as previously mentioned, is not easily made, but the late recognition of the complication. The physician must know and pay attention to the classic fat embolic syndrome, defined as the presence of two of three clinical findings including petechial rash, pulmonary distress, and mental disturbances within the first 48 h after the inciting event. Common signs include hypoxia, fever, tachycardia, and tachypnea with bilateral radiographic changes and urinary changes. Thus,

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surgeons should be able to promptly detect these symptoms and should advise patients to recognize and report these symptoms as soon as possible [32, 51]. Infections represent another event that may be either a complication or an error. In cases of death related to infections, late recognition of the complication always constitutes an error. Since the majority of severe infections after liposuction usually become clinically evident within 24 h after surgery, the observation time should be prolonged up to this time period before discharging the patient [22]. Consequently, an error may be identified also in a premature discharge of the patient. Other issues that should be carefully analyzed involve surgical and anesthesiologic procedures [36], and these choices are strictly related to patient selection. The evaluation of conduct related to surgical procedure is based on analysis of the risk factors and causes of death discussed above. Regarding anesthesiologic procedure, plastic surgeons should follow the available guidelines, such as the American Society of Anesthesiologists Guidelines for Sedation and Analgesia [52]. In particular, with respect to lidocaine, its level should be carefully analyzed considering that the generally safe level of 35 mg/kg may not always be safe in patients with factors interfering with certain concentrations of the drug (low protein and other medical conditions), in patients of a particular weight, or in combination with another surgical or anesthesiologic approach. Conclusions

Although death after liposuction is a rare event, the physician should be aware of this possibility, knowing the causes and risk factors, following a strict safety protocol, and implementing diagnostic-therapeutic preventive measures. Sound patient selection is the best approach to reducing the incidence of complications. Information regarding the remote possibility of serious complications should be given to the patient before collecting informed consent. The evidence of the information demonstrates both that the physician considered the

risk factors and that the patient was very motivated when consenting to the operation. The expert analyzing a hypothetical case of professional responsibility must act responsibly to ensure a correct evaluation of the work of colleagues. The responsibility of the expert is related to a requested awareness of the complications related to liposuction and a familiarity with the postmortem findings frequently observed in liposuction-related deaths. The expert, a forensic pathologist, must be supported by one or more specialists (e.g., a plastic surgeon or dermatologist) in the evaluation of the case.

References 1. Fodor PB. Fodor reflections on lipoplasty: history and personal experience. Aesthet Surg J. 2009;29(3):226–31. 2. American Society for Aesthetic Plastic Surgery. Statistics 2013. http://www.surgery.org/media/statistics, 2013. Accessed 12 Feb 2015. 3. Thomas M, Menon H, D’Silva J. Surgical complications of lipoplasty – management and preventive strategies. J Plast Reconstr Aesthet Surg. 2010;63(8): 1338–43. 4. Grazer FM, De Jong RH. Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast Reconstr Surg. 2000;105(1):436–48. 5. Housman TS, Lawrence N, Mellen BG, George MN, Filippo JS, Cerveny KA, DeMarco M, Feldman SR, Fleischer AB. The safety of liposuction: result of a national survey. Dermatol Surg. 2002;28(11):971–8. 6. Mallappa M, Rangaswamy M, Badiuddin MF. Small intestinal perforation and peritonitis after liposuction. Aesthet Plast Surg. 2007;31(5):589–92. 7. Sharma D, Dalencourt G, Bitterly T, Benotti PN. Small intestinal perforation and necrotizing fasciitis after abdominal liposuction. Aesthet Plast Surg. 2006;30(6):712–6. 8. Triana L, Triana C, Barbato C, Zambrano M. Liposuction: 25 years of experience in 26,259 patients using different devices. Aesthet Surg J. 2009; 29(6):509–12. 9. Dillerud E. Suction lipoplasty: a report on complications, undesired results, and patient satisfaction based on 3511 procedures. Plast Reconstr Surg. 1991;88(2):239–49. 10. Hughes CE 3rd. Reduction of lipoplasty risks and mortality: an ASAPS survey. Aesthet Surg J. 2001; 21(2):120–7. 11. Hanke CW, Bernstein G, Bullock S. Safety of tumescent liposuction in 15,336 patients: National survey results. Dermatol Surg. 1995;21(5):459–62.

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12. Hanke W, Cox SE, Kuznets N, Coleman WP 3rd. Tumescent liposuction report performance measurement initiative: National survey results. Dermatol Surg. 2004;30(7):967–78. 13. Chia CT, Theodorou SJ. 1,000 consecutive cases of laser-assisted liposuction and suction-assisted lipectomy managed with local anesthesia. Aesthet Plast Surg. 2012;36(4):795–802. 14. Boeni R. Safety of tumescent liposuction under local anesthesia in a series of 4,380 patients. Dermatology. 2011;222(3):278–81. 15. Scarborough DA, Herron JB, Khan A, Bisaccia E. Experience with more than 5,000 cases in which monitored anesthesia care was used for liposuction surgery. Aesthet Plast Surg. 2003;27(6):474–80. 16. Daane SP, Rockwell WB. Analysis of methods for reporting severe and mortal lipoplasty complications. Aesthet Plast Surg. 1999;23(5):303–6. 17. Roland B. Safety of liposuction of the neck using tumescent local anesthesia: experience in 320 cases. Dermatol Surg. 2012;38(11):1812–5. 18. Swanson E. Prospective clinical study of 551 cases of liposuction and abdominoplasty performed individually and in combination. Plast Reconstr Surg Glob Open. 2013;1(5):e32. 19. Kim YH, Cha SM, Naidu S, Hwang WJ. Analysis of postoperative complications for superficial liposuction: a review of 2398 cases. Plast Reconstr Surg. 2011;127(2):863–71. 20. Roustaei N, Masoumi Lari SJ, Chalian M, Chalian H, Bakhshandeh H. Safety of ultrasound-assisted liposuction: a survey of 660 operations. Aesthet Plast Surg. 2009;33(2):213–8. 21. Levesque AY, Daniels MA, Polynice A. Outpatient lipoabdominoplasty: review of the literature and practical considerations for safe practice. Aesthet Surg J. 2013;33(7):1021–9. 22. Lehnhardt M, Homann HH, Daigeler A, Hauser J, Palka P, Steinau HU. Major and lethal complications of liposuction: a review of 72 cases in Germany between 1998 and 2002. Plast Reconstr Surg. 2008;121(6):396–403. 23. Ahmad J, Eaves FF 3rd, Rohrich RJ, Kenkel JM. The American Society for Aesthetic Plastic Surgery (ASAPS) survey: current trends in liposuction. Aesthet Surg J. 2011;31(2):214–24. 24. Levy D. The fat embolism syndrome. A review. Clin Orthop Relat Res. 1990;261:281–6. 25. Fulde GW, Harrison P. Fat embolism–a review. Arch Emerg Med. 1991;8(4):233–9. 26. Rao RB, Ely SF, Hoffman RS. Deaths related to liposuction. N Engl J Med. 1999;340(19):1471–5. 27. Murphy RX Jr, Alderman A, Gutowski K, Kerrigan C, Rosolowski K, Schechter L, Schmitz D, Wilkins E. Evidence-based practices for thromboembolism prevention: summary of the ASPS Venous Thromboembolism Task Force Report. Plast Reconstr Surg. 2012;130(1):168e–75. 28. Saad AN, Parina R, Chang D, Gosman AA. Risk of adverse outcomes when plastic surgery procedures

831 are combined. Plast Reconstr Surg. 2014;134(6): 1415–22. 29. Gravante G, Araco A, Sorge R, Araco F, Nicoli F, Caruso R, Langiano N, Cervelli V. Pulmonary embolism after combined abdominoplasty and flank liposuction: a correlation with the amount of fat removed. Ann Plast Surg. 2008;60(6):604–8. 30. Dixit VV, Wagh MS. Unfavourable outcomes of liposuction and their management. Indian J Plast Surg. 2013;46(2):377–92. 31. Toledo LS, Mauad R. Complications of body sculpture: prevention and treatment. Clin Plast Surg. 2006;33(1):1–11. 32. Mentz HA. Fat emboli syndromes following liposuction. Aesthet Plast Surg. 2008;32(5):737–8. 33. El-Ali TG, Gourlay T. Assessment of the risk of systemic fat mobilization and fat embolism as a consequence of liposuction: ex vivo study. Plast Reconstr Surg. 2006;117(7):2269–76. 34. Cohen L, Engdahl R, Latrenta GD. Hypoxia after abdominal and thigh liposuction: pulmonary embolism or fat embolism? Eplasty. 2014;14:ic19. 35. Starling 3rd J, Thosani MK, Coldiron BM. Determining the safety of office-based surgery: what 10 years of Florida data and 6 years of Alabama data reveal. Dermatol Surg. 2012;38(2):171–7. 36. Iverson RE, Lynch DJ. American Society of Plastic Surgeons Committee on Patient Safety. Practice advisory on liposuction. Plast Reconstr Surg. 2004;113(5):1478–90. 37. Tierney EP, Kouba DJ, Hanke CW. Safety of tumescent and laser-assisted liposuction: review of the literature. J Drugs Dermatol. 2011;10(12):1363–9. 38. Mysore V. Tumescent liposuction: standard guidelines of care. Indian J Dermatol Venereol Leprol. 2008;74(Suppl S1):54–60. 39. Martínez MA, Ballesteros S, Segura LJ, García M. Reporting a fatality during tumescent liposuction. Forensic Sci Int. 2008;178(1):e11–6. 40. Habbema L. Safety of liposuction using exclusively tumescent local anesthesia in 3,240 consecutive cases. Dermatol Surg. 2009;35(11):1728–35. 41. Gordon NA, Koch ME. Duration of anesthesia as an indicator of morbidity and mortality in officebased facial plastic surgery: a review of 1200 consecutive cases. Arch Facial Plast Surg. 2006;8(1): 47–53. 42. Beaudoin AL, Torso L, Richards K, Said M, Van Beneden C, Longenberger A, Ostroff S, Wendt J, Dooling K, Wise M, Blythe D, Wilson L, Moll M, Perz JF. Invasive group A Streptococcus infections associated with liposuction surgery at outpatient facilities not subject to state or federal regulation. JAMA Intern Med. 2014;174(7):1136–42. 43. Terranova C, Sartore D, Snenghi R. Death after liposuction: case report and review of the literature. Med Sci Law. 2010;50(3):161–3. 44. Koulaxouzidis G, Momeni A, Simunovic F, Lampert F, Bannasch H, Stark GB. Aesthetic surgery performed by plastic surgery residents: an analysis of

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Harmful Effects of Liposuction and Lipolysis Procedures Questionable Safety and Scientific Validity: A Medico-Legal Perspective and Advantages of “Light” Hypo-osmolar Liposuction

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Michel Costagliola, Bishara Atiyeh, Florence Rampillon, and Benoit Chaput

Abstract

Liposuction (blunt suction lipectomy) is now well established and has generally gratifying aesthetic results. Since first described in 1977 by Illouz, changes or improvements to the technique of liposuction have been introduced regarding instruments (cannulas, pumps, syringes, and various devices), depth of suctioning (deep or superficial), volume of fluid infiltration (wet, super wet, tumescent), and osmolarity (isotonic, more or less hypotonic). Many other changes or “innovations” were also described that deserve being denounced. We report several complications resulting in severe skin necrosis, following liposuction and lipolysis methods of questionable scientific merits: ultrasonic liposuction, infiltration of hypo-osmolar solution, lipolysis without aspiration, or after unfortunately accidental infiltration of hypertonic saline solution. Ensuing skin necrosis required surgical

M. Costagliola, M.D. (*) Emeritus Professor, Department of Plastic, Reconstructive and Aesthetic Surgery, Toulouse University, 3, rue du Languedoc, 31000 Toulouse, France e-mail: [email protected] B. Atiyeh, M.D. Plastic and Reconstructive Surgery, American University of Beirut Medical Center, PO Box: 11-0236, Riad El Solh, Beirut 1107 2020, Beirut, Lebanon e-mail: [email protected]

F. Rampillon, M.D. Clinique du Parc, 33, rue des Bûchers, 31400 Toulouse, France e-mail: [email protected] B. Chaput, M.D. Department of Plastic and Reconstructive Surgery, CHU Toulouse University, 1, avenue Jean Poulhes, 31054 Toulouse, France e-mail: [email protected]

© Springer-Verlag Berlin Heidelberg 2016 M.A. Shiffman, A. Di Giuseppe (eds.), Liposuction: Principles and Practice, DOI 10.1007/978-3-662-48903-1_87

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debridement followed by prolonged secondary wound healing, resulting in severe aesthetic and functional sequelae with inevitable malpractice legal implications. It is essential that plastic surgeons be careful about using techniques widely advertised by the media but not yet scientifically validated; basic precautionary principles must be respected (light hypo-osmolar infiltration about 200 mOsm is safe), and the surgeons should not be dispensed from applying rigorous monitoring and strict safety measures in the operating room (checklist, traceability, qualification of nursing staff, etc.).

87.1

Introduction

Liposuction is a surgical procedure intended to remove fat deposits and shape the body. It is not a trivial surgery, not always benign [1, 2], not quite safe as claimed by glossy brochures as says Grazer. Nevertheless, since first described by Illouz in 1977 [3, 4], liposuction developed to become the most performed plastic surgery procedure worldwide. Numerous modifications and refinements of the basic original technique have been proposed regarding equipment (cannulas, infiltration pumps, aspiration syringes and machines), level of lipoaspiration (deep or superficial), nature of the infiltration solution, and the injected volume. A non-negligible incidence of complications, namely, severe skin necrosis, has been reported following the performance of more or less scientifically validated liposuction procedures. Similar complications have also been reported following the unfortunate or accidental infiltration with hypertonic solutions. Alternatively, numerous nonsurgical lipolysis modalities have been proposed. Infiltration of hypo-osmolar solution without aspiration has not only been proved to be ineffective, but it has resulted in severe complications such as infection and scarring. As new technologies are being continuously described and introduced, enthusiasm about these technologies must be tempered and only procedures with solid scientific basis and proven efficacy must be performed [5]. This report, without being an inclusive review, is intended to highlight several serious side effects following some of these procedures we have observed in our function of medical experts for medicolegal cases. Therefore, liposuction is now

well codified and generally has gratified results: simple precautionary principles must be respected to avoid these harmful effects, and for us, a light hypo-osmolar infiltration followed by aspiration is the technique of choice, safe, and effective: we will describe this procedure at the end of our paper.

87.2 87.2.1

Authors’ Cases Ultrasound Liposuction

Ultrasonic liposuction, also called ultrasonicassisted liposuction, or UAL for short, is one of the latest developments in the field. Liposuction with focused ultrasound energy cannulas has many supports in Europe [6] and South America but it has also numerous opponents because of its still questionable safety. Fat is removed from under the skin with the use of a vacuum-suction cannula (a hollow pen-like instrument) or using an ultrasonic probe that emulsify (breaks up into small pieces) the fat and then removes it with suction.

87.2.1.1 Case 1 This 44-year-old woman, employee in a pizzeria, underwent under local anesthesia ultrasound liposuction of the abdomen by a general practitioner. The procedure duration was 3 h 30 min. On examination, deep burn with extensive skin necrosis is observed on the left flank (Fig. 87.1). The physician tried to justify to no avail this complication by claiming that since the patient returned to work the following day, she was exposed too soon after the procedure to the oven heat. Delayed wound healing took 5 months to be completed at the expense of extensive scarring.

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Fig. 87.1 (a) Preoperative 44-year-old pizzeria maid. (b) Postoperative ultrasonic liposuction under local anesthesia showing burns of flanks. (1) Left flank. (2) Right flank. (c) Healing took 5 months

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87.2.1.2 Case 2 This 36-year-old woman underwent ultrasound liposuction by a general practitioner resulting in serious burns of the inner thighs (Fig. 87.2). Six months of conservative therapy were required for healing of the right thigh. The left thigh, however, required a STSG that was later excised

following tissue expansion and scar revision with flaps. Nevertheless, the patient was left with an obvious scar on the medial aspect of the left thigh with lesser scarring on the right [7]. In both cases, the expert legal opinion confirmed the total responsibility of the two physicians.

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Fig. 87.2 (a) 36-year-old woman underwent ultrasound liposuction, sustaining burns of the inner thighs. (b) The left thigh required a split-thickness skin graft (STSG). (c) The left thigh had tissue expansion before revision. (d)

c

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Healing of the right thigh took 6 months of conservative therapy. The left thigh had excision of STSG following tissue expansion and scar revision with flaps

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87.2.2

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Liposuction following Injection by Mistake of Hyperosmolar Solution

ated liposuction by a plastic surgeon. Within few days, skin necrosis developed more on right than left with obvious scars shown by Fig. 87.3 [8].

87.2.2.1 Case 3 A 44-year-old female with medial upper thighs lipodystrophy underwent medial thigh lift with associ-

87.2.2.2 Case 4 A young woman 24 years of age (Fig. 87.4) was operated on with liposuction only by another well-

a

b

c

Fig. 87.3 (a) Preoperative 44-year-old female with medial upper thigh lipodystrophy. (b) Skin necrosis developed within a few days after medial thigh lift with associ-

ated liposuction underwent by a plastic surgeon. (c) Seven months postoperative

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Fig. 87.4 (a) Preoperative woman 24 years of age. (b) (1) Patient developed rapid skin necrosis over the right medial thigh after liposuction. (2) Development of

c2

ulceration. (3) Following debridement. (c) Seven months postoperatively with severe scarring

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Harmful Effects of Liposuction and Lipolysis Procedures Questionable Safety and Scientific Validity

Fig. 87.5 The iso- and hyper-osmolar containers were placed on the same shelf in the pharmacy

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Necrosis explanation !!!

*Two successive necrosis during 1 month *Two differents surgeons *Same operating theater *Same staff Bad identification *Use of a 30 % hypertonic solution (normally employed to sterilise liver hydatic cysts) prepared by the same temporary nurse *Inadvertent injection of hypertonic saline solution: responsability of the clinic as it was the nurse’s employer *As head of medical team,the surgeon as to precise the role of each member of the team, but he not due verify the final product. *Therefore, no negligence or lack of attention; merits of check list

experienced plastic surgeon in the same clinic and the same operating theater as in Case 3. Similarly, this patient developed rapidly skin necrosis over the right medial thigh that slowly healed to result 7 months later in serious scarring. The occurrence of skin necrosis in two successive patients 1 month apart operated by two different surgeons but in the same clinic and operating theater and with the same nurse was highly suspicious. It was realized then that the fluid used for infiltration was in fact a 30 % hyper-osmolar solution usually used for treatment of hydatid cysts. Unfortunately, the iso- and hyper-osmolar containers were placed on the same shelf in the pharmacy (Fig. 87.5). The same nurse that was hired temporarily for replacement has prepared the infiltration solution. Apparently hyper-osmolar saline solution was used and was inadvertently injected. Skin necrosis of the second patient was more pronounced on the right side probably because liposuction was performed first at the left, resulting without knowing in early

aspiration of some infiltration solution, thus reducing its harmful effect. The expert legal opinion was that the nurse is to be blamed. For the judge, the head of the treating team, namely, the surgeon, had to instruct each member of his team about his or her duties; however, it is not possible for him to check the prepared solution and to know its final composition before injection. This is an important legal consideration to declare that the surgeon is not guilty of negligence and that he did not commit any surgical error. The clinic, employer of the temporary nurse, was held responsible; however, this ruling should not dispense the surgeon from preoperative checking of all material used [9–11].

87.2.2.3 Case 5 The figures illustrate the result following inadvertent subcutaneous injection of hyper-osmolar solution before aspiration. Necrotic tissues had to be subsequently excised (Fig. 87.6; republished with permission [12]).

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Fig. 87.6 Inadvertent subcutaneous injection of hyper-osmolar solution before aspiration. Necrotic tissues had to be subsequently excised

87.3

Lipolysis and Lipotomy

Many lipolysis procedures are widely advertised in magazines for women promoting nonsurgical incisions and resulting in a dream body shape and a sublime silhouette. These are “lunchtime procedures” utilizing the latest technologies such as laser (thermal laser technologies, lipo laser, micro lipolaser, UltraPulse fractional laser), ultrasound (focused external ultrasound or UltraShape), external application of highintensity focused ultrasound (HIFU) (Liposonix) for body sculpting equipment and the nonsurgical ultrasound lipoplasty [13] cryolipolysis (selective cryolipolysis controlled cooling of the

subcutaneous fat), infrared, or finally radiofrequency (BodyTite bipolar radiofrequency). All these nonsurgical techniques aiming at localized adipolysis have never been validated scientifically even though they have been unfortunately mentioned in the official plastic surgery journal reporting with conflicting and poorly verifiable results. 1. Injection lipolysis These various procedures such as Lipodissolve, Lipostabil, or phosphatidylcholine have many documented side effects (pain and hyperpigmentation) and are not authorized in France [14].

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Harmful Effects of Liposuction and Lipolysis Procedures Questionable Safety and Scientific Validity

Hypo osmolar lipotomy

841

Vacuolar adipocytes

Hyposmolar solution 90–150 mosm Water transfer in fat cells

(osmolarity intratissular tissue: 300 mosm)

Adipocytes Reverse osmosis

Increase of intra membrane pressure, Swelling and cellular explosion with interstitial triglyceride release Residues may be picked up by lymph or eliminated by urine?? Physiological mechanism of lipotomy

Triglycerides (glycerol, fatty acid)

Fig. 87.7 Swelling and cellular explosion with interstitial triglyceride release (glycerol and fatty acids) residues that should be picked up by lymph or eliminated by urine

2. Lipotomy (hypo-osmolar lipotomy) Adipocytolysis is presented by the authors as an alternative to liposuction technique, utilizing osmosis physiological mechanism.

87.3.1

What Is Osmosis?

From Greek osmos = pushing. It is a diffusion process (physiological fact) when two solutions with different concentrations are separated by partial permeability membrane; there is a transfer from the hypotonic toward the hypertonic solution through this membrane (water only but not dissolved substance).

87.3.2

Physical Mechanism of Lipotomy

Normal osmolar intra-tissue (isotonia) is about 300 mOsm. With hypo-osmolar solution (90/150 mOsm), the water is transferred into fat cells and increases intramembrane pressure (reverse osmosis). Swelling and cellular explosion with interstitial triglyceride release (glyc-

Table 87.1 Different names of lipotomy Hypo-osmolar meso-dilution Lipotomy Hydrolipectomy Cellulysis Liporeduction Adipotomy Lipodissolution

Meso-lipolysis Hydrolipotomy Lipodilution Osmolipolysis Lipostabilization Adipocytolysis Osmolipolysis

erol and fatty acids) residues that should be picked up by lymph or eliminated by urine (Fig. 87.7). This theory is very controversial and the authors insist on associated dispositions like musculation, sport activities, and external ultrasound to eliminate free fatty acids. So no fat aspiration is performed [15, 16]. Lipotomy procedures have different names (Table 87.1). Frequently these procedures are followed by superficial burns, abscess, oily collections, necrosis, and severe troubles of healing. In a clinical case, a 14-year-old female had a postoperative problem that was polymicrobial subcutaneous abscess that needed two surgical evacuations and had very bad aesthetic result (Fig. 87.8) [17].

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Fig. 87.8 (a) Magnetic resonance imaging (MRI) of abscess. (b) Drainage. (c) Postsurgical drainage

Other cases observed in medicolegal situations include a 60-year-old woman, 1.63 m, 95 kg after abdominal hypo-osmolar lipotomy with very bad result after a long healing evolution (Fig. 87.9), and a relative of the precedent, 41-year-old, 1.60 m, 72 kg, had bilateral hip lipodystrophy with the same technique. Postoperatively there was temperature elevation, abscess, and necrosis that occurred

5 months after, and after 1 year, it showed a worsening of lipodystrophy (Fig. 87.10). Lipolysis by hypo-osmolar lipotomy without liposuction is in fact a noninvasive technique invented for medical practitioners but has no true scientific evaluation (tolerance, efficiency) and had bad results and risk of serious complications. It is a non-validated technique in France.

87

Harmful Effects of Liposuction and Lipolysis Procedures Questionable Safety and Scientific Validity

843

a

b

Fig. 87.9 (a) Preoperative 60-year-old with hip lipodystrophy. (b) Postoperative after abdominal hypo-osmolar lipotomy with poor result

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a

b

Fig. 87.10 (a) Preoperative 41-year-old with moderate hip lipodystrophy. (b) Necrosis after surgery. (c) Five months postoperative. (d) One year after surgery

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c

d

Fig. 87.10 (continued)

87.4

Merits of Light Hypoosmolar Liposuction

Beware of confusing hypo-osmolar lipotomy (adipo-cytolyse without aspiration) with harmful effects described and hypo-osmolar liposuction with infiltration before aspiration is performed by a light hypotonic solution (200–

220 mOsm), so aspiration of burst adipocytes and fat liquefied is easier. Some examples of hypotonic solutions: 1. Saline 1,000 mL plus distilled water 200 mL = 230 mOsm 2. Saline 1,000 mL plus distilled water 300 mL = 200 mOsm

M. Costagliola et al.

846 Fig. 87.11 Liposuction begins 20 min after infiltration with at room temperature. Fat is more clear

Our wetting solution Infiltration - Saline:1 liter - Distilled water: 300 cc - Lidocanie - Epinephrine .hyposmolarity = 200 mOsm Lipoaspiration 20 min after infiltration (fat is more clear and easier to aspirate) Temperature solution: room temperature Fat quantity medium size : 2 l, 3 or 4 l sometimes

Post operative period Less discomfort More efficiency Fat: more clear Easier aspiration No complications Better skin retraction Early return to normal activity Better results after 1 month

Fig. 87.12 Postoperative period

3. Saline 1,000 mL plus distilled water 1,000 mL = 150 mOsm

Wetting Solutions 1. Majority use isotonic solutions (Fournier, Klein, Mang, Cook, Asken, Hetter, Hunstadt, Avelar, Rebello, Georgiade). 2. Minority use hypotonic solutions: Illouz: light hypotonia: 230 mOsm. 3. Strong hypotonia is used by Zocchi:150 mOsm. 4. Severe hypotonia: 90/150 mOsm is used by medical practitioners and is very dangerous, because there is no aspiration, only biological reabsorption.

Authors’ Wetting Solution Saline 1,000 mL plus distilled water: 300 mL plus lidocaine and epinephrine, light hypoosmolarity = 200 mOsm Liposuction begins 20 min after infiltration; temperature solution = room temperature. Fat is more clear (Fig. 87.11) and easier to aspirate, and fat is medium in quantity (3 or 4 l) (Fig. 87.12). Skin retraction is better; return to activity is earlier and better results are observed after 1 month. So do not reject the hypo-osmolarity concept. Many plastic surgeons, adding water to their solution, are unknowingly using a hypo-osmolar procedure. Liposuction, after a moderate hypoosmolar infiltration about 200 mOsm, is a good technique, safe, and efficient. Conclusion

Be careful to use techniques that are not yet validated but advertised by the media. Simple precautionary principles must be respected (light hypo-osmolar solution followed by aspiration is safe). Apply rigorous monitoring and safety measures in the operating room (checklist, traceability, qualification of nurse staff). Do not forget medicolegal aspect and choose good insurance.

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Harmful Effects of Liposuction and Lipolysis Procedures Questionable Safety and Scientific Validity

References 1. Mole B. Liposuction and extensive cutaneous necrosis. Ann Chir Plast Esthet. 1994;39(2):251–4. 2. Gibbons M, Lim R. Necrotizing fasciitis after tumescent liposuction. Ann Surg. 1998;64(5):458–60. 3. Illouz YG. Surgical remodelling of the silhouette by aspiration lipolysis or selective lipectomy. Aesthetic Plast Surg. 1985;9(1):7–21. 4. Illouz YG. Liposculpture et chirurgie de la silhouette. In: EMC, editor. Techniques Chirurgicales: Chirurgie Plastique Reconstructive et Esthétique. Paris: Elsevier Masson; 2008. p. 45–120. 5. Stephan PJ, Kenkel JM. Updates and advances in liposuction. Aesthet Surg J. 2010;30(1):83–97. 6. Zocchi M. Basic physics for ultrasound-assisted lipoplasty. Clin Plast Surg. 1999;26(2):209–20. 7. Grolleau JL, Rougé D, Chavoin JP, Costagliola M. Severe cutaneous necrosis after ultrasound lipolysis; medico legal aspects and review. Ann Chir Plast Esthet. 1997;42(1):31–6. 8. Chaput B, Fade G, Grolleau JL AA, Garrido I. Liposuction: an exceptional case of skin necrosis secondary to an error of infiltration. Plast Reconstr Surg. 2012;129(4):765e–6. 9. Campbell B, Callum K, Peacock N. Operating with the law a practical guide for surgeons and lawyers. London: Trinity Press; 2011.

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10. Rougé D, Escat J, Costagliola M. Responsabilité Médicale: de la Chirurgie à l’Esthétique. Paris: Arnette; 1992. 11. Costagliola M, Chaput B. What are the limits of the surgeon’s responsibility in the operating theater?, Aesthetic Plast Surg. 2014;38(4):830–1. doi: 10.1007/ s00266-014-0331-5. Epub 2014 May 31. 12. Kerfant N, Philandrianos C, Alliez A, Casanova D. Inadvertent subcutaneous injection of hypertonic saline solution during lipofilling. Aesthetic Plast Surg. 2013;37(4):709–10. 13. Fodor PB. Reflections on lipoplasty: history and personal experience. Aesthet Surg J. 2009;29(3): 226–31. 14. Journal Oficiel Ministère du travail, emploi et santé. Interdiction des techniques de lipolyse adipocytaires à visée esthétique; Décret n° 2011-382, 11 Avril 2011. http://legifrance.gouv.fr/eli/decret/2011/4/11/ ETSP1107628D/jo/texte Accessed 9 Apr 2015. 15. Hoeflin S. Lipoplasty with hypotonic pharmacologic lipo-dissolution. Aesthet Surg J. 2002;22(6):573–6. 16. Song A, Benett J, Marra K, Cimino W, Rubin P. Scientific basis of the use of hypotonic solutions with ultrasonic liposuction. Aesthetic Plast Surg. 2006;30(2):233–8. 17. Benjoar M, Lepage C, Hivelin M. Lantiéri Complications d’injection de solutés hypo osmotiques chez une patiente mineure. Ann Chir Plast Esthet. 2008;54(2):161–4.

Correction of Gluteal Contour Deformities After Overaggressive Liposuction Utilizing the Deepithelialized Fasciocutaneous Infragluteal (FCI) Flap

88

Dominik Duscher, Michael Pollhammer, and Georg M. Huemer

Abstract

The authors discuss a way to treat a deep depression deformity in the gluteal region after overaggressive liposuction utilizing a pedicled deepithelialized fasciocutaneous infragluteal (FCI) flap. The technique is described. A pedicled deepithelialized FCI flap can be a viable and elegant option for the correction of an extensive contour deformity of the gluteal region after overaggressive liposuction. The procedure is easy to perform, preserves gluteal anatomy, and has the additional benefit of a lifting effect.

88.1

D. Duscher, M.D. Department of Plastic, Aesthetic and Reconstructive Surgery, Kepler University Hospital, Krankenhausstraße 7a, 4020 Linz, Austria M. Pollhammer, M.D. Section of Plastic, Aesthetic and Reconstructive Surgery, Department of General Surgery, Kepler University Hospital, Krankenhausstraße 7a, 4020 Linz, Austria G.M. Huemer, M.D., M.Sc., M.B.A. (*) Section of Plastic, Aesthetic and Reconstructive Surgery, Department of General Surgery, Kepler University Hospital, Krankenhausstraße 7a, 4020 Linz, Austria Private Practice, Weissenwolffstrasse 13, 4020 Linz, Austria e-mail: [email protected]

Introduction

Liposuction is a very commonly performed and generally safe procedure [1]. The purpose of liposuction is to reshape certain areas of the body, and it is typically used on “problem” zones that have not responded well to diet and exercise. These areas are often on the outer thighs, hips, and the gluteal region. The face, neck, abdomen, back, buttocks, legs, and upper arms are also regularly treated areas [1]. Liposuction may also be used to treat medical conditions such as benign fatty tumors (lipomas), abnormal enlargement of the male breasts (gynecomastia), degenerative conditions of the body’s adipose tissue (lipodystrophy), or excessive sweating in the armpit area (axillary hyperhidrosis) [2]. Additionally, liposuction represents an excellent and minimal

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invasive source of lipoaspirate, which can be utilized as fat graft or for the isolation of adiposederived stem cells and subsequent reconstructive or aesthetic applications [3–5]. Despite being a procedure with a low incidence of adverse events, possible side effects and complications of liposuction include infections; toxic reactions to the injected tumescent solution; temporary swelling, bruising, soreness, and numbness in and around the treated areas; excessive blood loss leading to shock; pulmonary embolism; or a puncture of the thorax or abdominal cavity [6]. Additionally, there is the risk of unsatisfying aesthetic outcomes such as the residue of baggy or rippling skin as well as an uneven surface over the treated area [7]. Especially the latter is not an uncommon sequela of liposuction and challenging to treat. While minor skin irregularities or dimpling may be treated conservatively via massage, ultrasound, or vacuum suction pumps, major contour deformities often require surgical correction [8, 9]. The first-line surgical treatment options for contour defects after liposuction are repeat liposuction and fat grafting. However, when facing extensive deformities in certain anatomical regions, these standard procedures can be insufficient to correct the patient’s silhouette. Here, we present an innovative and elegant way to treat a deep depression deformity in the gluteal region after overaggressive liposuction utilizing a pedicled deepithelialized fasciocutaneous infragluteal (FCI) flap.

88.2

Technique

When confronted with an extensive contour defect of the gluteal area, classic methods of surgical revision can be complicated or insufficient to achieve a satisfying aesthetic result. If a patient presents with a bilateral deep depression deformity after overaggressive gluteal liposuction (Fig. 88.1) and additional laxity of the gluteal region, a local pedicled fasciocutaneous infragluteal (FCI) flap can be an elegant reconstructive option providing an additional lifting effect (Fig. 88.2). Before the beginning of the procedure, the defect area and the planned flap area are marked in a standing position (Fig. 88.3). The flap’s long axis should be outlined exactly in the existing infragluteal fold. The width and length of the flap can exceed the standard dimensions of the FCI flap to satisfy the need for additional volume to fill the defect sufficiently. In general no diagnostic evaluations for vessel localization are needed. The surgery is performed with the patient in a prone position. The first step is to incise the skin around the borders of the flap and to dissect down to the deep muscular fascia. Subsequently, the flap is raised from laterally to medially in a subfascial manner. The flap is then mobilized as much as necessary to reach the defect sufficiently (Figs. 88.4 and 88.5). Complete skeletonization of the main vessel, the descending branch of the infragluteal artery, should primarily be avoided

Fig. 88.1 Bilateral depression deformity in the gluteal region caused by overaggressive liposuction (Adapted with permission from [10])

88 Correction of Gluteal Contour Deformities After Overaggressive Liposuction

Fig. 88.2 Utilization of a pedicled deepithelialized fasciocutaneous infragluteal (FCI) flap for the correction of a gluteal contour deformity. (a) Outline of the planned flap area (blue). (b) Location of the descending branch of the

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infragluteal artery and vein. (c) The raised pedicled fasciocutaneous infragluteal (FCI) flap. (d) The deepithelialized FCI flap can be subcutaneously transposed into the defect area (green) to fill up the volume deficit

closed in three layers with a drain in place. The immediate postoperative result is a sufficient correction of the contour deformity with a concomitant reconstruction of the gluteal fold (Fig. 88.5). The final result at the 1-year follow-up is a definite improvement of the contour deformity and an additional improvement of the buttock shape (Fig. 88.6).

88.3 Fig. 88.3 Intraoperative view with the patient in the prone position showing the planned flap area marked in blue and the extent of the depression deformity in green. The flap is medially based, and the skin island will be deepithelialized (Adapted with permission from [10])

but, however, can be considered if additional reach is needed and one has sufficient microsurgical experience. Next, the defect has to be recreated by generously undermining the area of the contour deformity in the subcutaneous plane. Care has to be taken to ensure complete hemostasis. After complete deepithelialization, the flap is now tunneled into the defect cavity, completely filling up the volume deficit. The wound is then

Discussion

Liposuction is usually performed as an outpatient procedure in a properly equipped doctor’s office, ambulatory surgery center, or hospital. In general, it does not require an overnight hospital stay unless a large volume of fat is being removed. For more extensive liposculpturing, general anesthesia or deep sedation combined with a local anesthetic should be used [11]. Treating more than one or an extensive area, or removing a very large volume of fat, may increase the risk of complications during or after the procedure [12]. The popularity of liposuction has led to various technical advancements, which have made this procedure safer, easier, and less painful [13]. However, risks remain with all liposuction

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Fig. 88.4 Mobilization and transposition of the FCI flap. (a) The flap is mobilized, leaving the medial third including the descending branch of the inferior gluteal artery attached to the gluteal fascia. Next, the flap is completely

Fig. 88.5 Immediate postoperative result showing a sufficient correction of the gluteal contour deformity and a well-reconstructed gluteal fold (Adapted with permission from [10])

procedures, and complications are not uncommon especially with less-experienced surgeons. Contour deformities due to overcorrection represent especially difficult sequelae of liposuction, which are tough to treat without reoperation. In addition to repeat liposuction, there is the possibility of defect correction via fat grafting. The transplantation of autologous fat has been demonstrated to be a viable option for the correction of iatrogenic deformities after liposuction [7, 8]. However, in cases with extensive adherence of the skin to the underlying tissues, the applicability of

D. Duscher et al.

deepithelialized. (b) The flap is easily rotated into the defect, filling it up sufficiently (Adapted with permission from [10])

fat grafting is limited. The release of the subcutaneous scar and the tethered skin creates a rather large and deep cavity. In order to resolve such a contour deformity, a significant amount of transplanted fat would be necessary. Injection of such a large volume fat graft into an extensive subcutaneous cavity would result in a lack of adequate contact to adjacent healthy tissue and jeopardize the blood supply of the grafted material [14]. Inevitably, this would result in fat necrosis and the formation of oily cysts. Therefore, fat grafting for the correction of contour deformities should be reserved for smaller defects without tethered skin and extensive soft tissue scarring. When confronted with extensive contour defects that are impossible to correct with simple repeat liposuction or fat grafting, more invasive solutions must be considered. For instance, if there are irregularities after liposuction in the lower abdomen, these may be treated by a classic abdominoplasty procedure. If the correction of contour defects after liposuction is carried out via a lifting procedure, a larger scar is the inevitable result, and the patient must be consented accordingly. In other areas, such as the outer thigh, the flanks, or the gluteal region, correction through tissue excision may be problematic or inadequate. In the presented example with the lower gluteal region affected, a simple gluteal lifting procedure would not achieve a satisfying aesthetic result.

88 Correction of Gluteal Contour Deformities After Overaggressive Liposuction

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Fig. 88.6 Final result at the 1-year follow-up demonstrating a sufficient correction of the depression deformity and a lifting effect in the region (Adapted with permission from [10])

Therefore, a local flap reconstruction of the defect is a superior option to compensate for the lost volume. The fasciocutaneous infragluteal (FCI) flap is supplied by the descending branch of the infragluteal vessels and can be used as a local, regional, or free flap [15–21]. It has been applied as a useful tool in reconstructing the Achilles tendon, the breast, the buttock region, as well as the perineal and the vulvar region. The FCI flap is robust and can be raised in less than 1 h by the experienced plastic surgeon. When raising the flap, the posterior femoral cutaneous nerve has to be preserved to avoid numbness of the posterior aspect of the thigh. The donor-site scar is well hidden, and there is no functional loss caused by harvesting the tissue. Even without full skeletonization of the pedicle, a sufficient arc of rotation can be achieved, which makes this flap a versatile locoregional reconstructive option with aesthetically pleasing results. In case of more distant defects, preparation of the pedicle can be considered to improve the flap’s rotational reach. However, here, familiarity with microsurgical technique is a prerequisite. The buttock is an important element of sexual attraction, and iatrogenic or developmental irregularities of this region will pose significant discomfort to the patient [22]. The infragluteal fold is among the major characteristics of the gluteal region. Thus, every effort should be undertaken to preserve or reconstruct this important anatomical

landmark [23]. By utilizing an FCI flap for the reconstruction of a contour deformity in the region, the gluteal sulcus can be sufficiently reconstructed, and a pleasing buttock shape can be maintained. Conclusions

A pedicled deepithelialized FCI flap can be a viable and elegant option for the correction of an extensive contour deformity of the gluteal region after overaggressive liposuction. The procedure is easy to perform, preserves gluteal anatomy, and has the additional benefit of a lifting effect.

References 1. Matarasso A, Levine SM. Evidence-based medicine: liposuction. Plast Reconstr Surg. 2013;132(6):1697–705. 2. Atiyeh B, Costagliola M, Illouz YG, Dibo S, Zgheib E, Rampillon F. Functional and therapeutic indications of liposuction: personal experience and review of the literature. Ann Plast Surg. 2015;75:231–45. 3. Garg RK, Rennert RC, Duscher D, Sorkin M, Kosaraju R, Auerbach LJ, et al. Capillary force seeding of hydrogels for adipose-derived stem cell delivery in wounds. Stem Cells Transl Med. 2014;3(9):1079–89. 4. Garza RM, Paik KJ, Chung MT, Duscher D, Gurtner GC, Longaker MT, et al. Studies in fat grafting: part III. Fat grafting irradiated tissue – improved skin quality and decreased fat graft retention. Plast Reconstr Surg. 2014;134(2):249–57.

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854 5. McArdle A, Senarath-Yapa K, Walmsley GG, Hu M, Atashroo DA, Tevlin R, et al. The role of stem cells in aesthetic surgery: fact or fiction? Plast Reconstr Surg. 2014;134(2):193–200. 6. Illouz YG. Complications of liposuction. Clin Plast Surg. 2006;33(1):129–63. viii. 7. Rohrich RJ, Smith PD, Marcantonio DR, Kenkel JM. The zones of adherence: role in minimizing and preventing contour deformities in liposuction. Plast Reconstr Surg. 2001;107(6):1562–9. 8. Pereira LH, Nicaretta B, Sterodimas A. Correction of liposuction sequelae by autologous fat transplantation. Aesthetic Plast Surg. 2011;35(6):1000–8. 9. Saylan Z. Liposhifting instead of lipofilling: treatment of postlipoplasty irregularities. Aesthet Surg J/Am Soc Aesthet Plast Surg. 2001;21(2):137–41. 10. Seles M, Huemer GM. Utilization of bilateral infragluteal flaps for correction of overaggressive gluteal liposuction. Ann Plast Surg. 2014;72(3):270–3. 11. Boeni R. Safety of tumescent liposuction under local anesthesia in a series of 4,380 patients. Dermatology. 2011;222(3):278–81. 12. Tabbal GN, Ahmad J, Lista F, Rohrich RJ. Advances in liposuction: five key principles with emphasis on patient safety and outcomes. Plast Reconstr Surg Glob Open. 2013;1(8), e75. 13. Shridharani SM, Broyles JM, Matarasso A. Liposuction devices: technology update. Med Device. 2014;7:241–51. 14. Konczalik W, Siemionow M. Experimental and clinical methods used for fat volume maintenance after autologous fat grafting. Ann Plast Surg. 2014;72(4): 475–83. 15. Papp C, Todoroff BP, Windhofer C, Gruber S. Partial and complete reconstruction of Achilles tendon

16.

17.

18.

19.

20.

21.

22.

23.

defects with the fasciocutaneous infragluteal free flap. Plast Reconstr Surg. 2003;112(3):777–83. Papp C, Windhofer C, Gruber S. Breast reconstruction with the fasciocutaneous infragluteal free flap (FCI). Ann Plast Surg. 2007;58(2):131–6. Windhofer C, Michlits W, Gruber S, Papp C. Reconstruction in the buttock region using the local fasciocutaneous infragluteal (FCI) flap. J Plast Reconstr Aesthet Surg. 2010;63(1):126–32. Windhofer C, Michlits W, Heuberger A, Papp C. Perineal reconstruction after rectal and anal disease using the local fascio-cutaneous-infragluteal flap: a new and reliable technique. Surgery. 2011;149(2):284–90. Michlits W, Windhofer C, Papp C. Pectus excavatum and free fasciocutaneous infragluteal flap: a new technique for the correction of congenital asymptomatic chest wall deformities in adults. Plast Reconstr Surg. 2009;124(5):1520–8. Papp C, Windhofer C, Michlits W. Autologous breast augmentation with the deepithelialized fasciocutaneous infragluteal free flap: a 10-year experience. Ann Plast Surg. 2011;66(6):587–92. Windhofer C, Papp C, Staudach A, Michlits W. Local fasciocutaneous infragluteal (FCI) flap for vulvar and vaginal reconstruction: a new technique in cancer surgery. Int J Gynecol Cancer. 2012;22(1):132–8. Cuenca-Guerra R, Quezada J. What makes buttocks beautiful? A review and classification of the determinants of gluteal beauty and the surgical techniques to achieve them. Aesthetic Plast Surg. 2004;28(5): 340–7. Huemer GM, Dunst KM, Schoeller T. Restoration of the gluteal fold by a deepithelialized skin flap: preliminary observations. Aesthetic Plast Surg. 2005; 29(1):13–7.

Blindness and Necrotizing Fasciitis After Liposuction and Fat Transfer

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Briar L. Dent and John E. Sherman

Abstract

Liposuction occasionally has complications. The authors describe the symptoms, diagnosis, and treatment of necrotizing fasciitis and review the literature cases of visual loss and blindness and necrotizing fasciitis associated with liposuction surgery.

89.1

Introduction

Liposuction and fat transfer are generally considered safe procedures with a low complication profile. Together, they are the most popular cosmetic procedure performed worldwide. The complication rate for liposuction ranges from 0 to 10 % and increases with the volume of fat removed [1–3]. A census survey of plastic surgeons in 2000 revealed a mortality rate of 1 in B.L. Dent, M.D. Division of Plastic Surgery, Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA e-mail: [email protected] J.E. Sherman, M.D. (*) Division of Plastic Surgery, St. Barnabas Hospital, Bronx, NY, USA Division of Plastic Surgery, Department of Surgery, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA Private Practice, 1016 Fifth Avenue, New York, NY 10028, USA e-mail: [email protected]

5,224 procedures [4]. While serious complications are rare, it is imperative that providers be familiar with their presentation to ensure that patients receive appropriate postoperative monitoring and that any complications are identified and managed correctly. Severe complications that have been reported include necrotizing fasciitis (NF), blindness and visual loss, gas gangrene, sepsis and toxic shock syndrome, hemorrhage, perforation of abdominal viscera, pulmonary embolism, skin necrosis, and death [1]. Here, we will focus on the presentation and management of NF and visual loss following liposuction and fat transfer.

89.2

Necrotizing Fasciitis (NF)

NF is a rapidly spreading, life-threatening bacterial infection of the subcutaneous tissue and superficial fascia. It can develop at the site of any soft tissue injury, whether caused by surgery, trauma, or a chronic wound. It can also develop in the absence of an apparent wound. Two

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subtypes of NF have been described [5]. The infection can be polymicrobial and involve both aerobic and anaerobic bacteria. Alternatively, NF can be caused by an isolated Streptococcus pyogenes infection [5, 6]. Risk factors for NF include diabetes mellitus, immunosuppression, age over 50 years, gastrointestinal malignancy, alcohol and intravenous drug abuse, malnutrition, and peripheral vascular disease [3, 5]. NF was first described by Joseph Jones as “hospital gangrene” during the American Civil War [7]. Other terms that have been used in reference to NF include “hemolytic streptococcal gangrene,” “suppurative fasciitis,” “synergistic necrotizing cellulitis,” and “flesh-eating bacteria syndrome” [5, 6]. The term, “necrotizing fasciitis,” was first introduced by Wilson in 1952 [8]. The initial presentation of NF is often characterized by erythema, edema, and severe pain out of proportion to physical exam findings. Physical examination may also be notable for woody induration and crepitus [9]. The erythema and edema quickly progress to cyanosis, blister formation, and gangrene as associated vascular occlusion leads to compromised skin perfusion [5]. However severe the degree of skin necrosis may appear, the extent of underlying subcutaneous tissue and superficial fascia involvement is often much greater. Upon debridement, the subcutaneous tissue is pathognomonically gray, edematous, and so loosely adherent to the underlying deep fascia that it can be swept off with a finger [3]. The drainage is characteristically dishwater colored. In addition to the soft tissue injury, NF is associated with severe systemic toxicity and multiple organ failure. If not controlled, the rapidly spreading infection can lead to sepsis, toxic shock syndrome, acidosis, elevated creatine phosphokinase and troponin levels, respiratory distress and failure, oliguria and renal failure, and death. Mortality rates from NF range from 12.5 to 76 % and approach 100 % if radical surgical debridement is not performed promptly [3, 5, 10]. The diagnosis of NF is made clinically and is based on patient history and physical examination. NF should be suspected in any acutely ill patient with cellulitis that is spreading despite

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appropriate antibiotic therapy [6, 9]. Treatment of NF requires immediate radical surgical debridement of all necrotic and edematous tissue. Wide incisions have to be made to access all undermined areas [6]. Serial debridements are performed as necessary until the infection is controlled and all involved tissue excised. In addition to debridement, critical adjuncts include fluid resuscitation, broad-spectrum intravenous antibiotics with both aerobic and anaerobic coverage, supportive measures with intensive monitoring, and nutritional support. While rare, NF is a devastating complication that can develop following liposuction and fat transfer. Large volume liposuction can create a wound surface area of up to 1 m2 between the subcutaneous tissue and muscle fascia [1]. Prompt diagnosis of NF can be delayed for a number of reasons. Liposuction is often performed as an outpatient procedure and patients will usually go home soon after surgery. When erythema and edema do develop, they can easily be attributed to cellulitis and mismanaged [2]. Finally, since both patients and providers generally consider liposuction to be a safe procedure, the index of suspicion for NF among surgeons and emergency room physicians may be low. Fourteen case reports of NF following liposuction have been published in the literature and are summarized in Table 89.1. Furthermore, a survey-based study by Lehnhardt et al. [1] of practitioners in Germany, Austria, and Switzerland discovered an additional 14 cases of NF following liposuction with nine associated deaths; unfortunately, few specific details are provided about these cases. The rate of NF following liposuction has been estimated at 0.4 in 100,000 patients but is unknown for combined liposuction with fat transfer [5, 12]. Of the 14 case reports, all occurred in relatively healthy women, aged 22–62 years. Liposuction was performed in many sites, including the submentum, neck, chest, back, upper arms, abdomen, flanks, hips, buttocks, thighs, knees, and calves, and was occasionally performed in conjunction with other plastic surgical procedures, including platysma plication [9], breast augmentation [3], and gluteal augmentation with fat grafting [5]. The volume

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Blindness and Necrotizing Fasciitis After Liposuction and Fat Transfer

Table 89.1 Review of reported cases of necrotizing fasciitis following liposuction Age (years), gender Alexander et al. 36 F [11] Gibbons et al. [12]

31 F

Barillo et al. [10]

48 F

Barillo et al. [10] Umeda et al. [13]

31 F 27 F

Liposuction site, additional procedures Upper arms, thighs, knees Thoracic roll, flanks, hips, abdomen, medial thighs, and knees Neck, abdomen, back

Abdomen, chest, thighs Abdomen, buttocks, thighs

Volume of fat aspiration (cc) Causative organism 3,000 Escherichia coli Streptococcus pyogenes 2,551 NR

Outcome Death

NR

Death

NR

Bacteroides rheumatica Candida albicans Citrobacter species Clostridium rheumatica Enterococcus species Klebsiella species Prevotella ruminicola NR

NR

Staphylococcus aureus

Skin grafting

Skin grafting

Heitmann et al. 28 F [6] Beeson et al. [9] 62 F

Buttocks and thighs NR

Streptococcus pyogenes

Toxic shock syndrome Skin grafting Death

NR

Streptococcus pyogenes

Full recovery

Nagelvoort et al. 41 F [14]

Submental, with platysma plication Abdomen

NR

Streptococcus pyogenes

Bilateral thighs

NR

NR

Toxic shock syndrome Skin grafting Skin grafting

Abdomen, thighs

NR

NR

Skin grafting

Abdomen, with bilateral breast augmentation Abdomen, flank, buttock

NR

NR

Death

NR

Escherichia coli Pseudomonas aeruginosa NR

NR

30 F Anwar et al. [15] Desrosiers et al. 39 F [16] Sharma et al. [3] 55 F

Gonzalez Alana 29 F et al. [17] Lehnhardt et al. [1]

14 cases, age/ NR gender NR

Average 4,300 ± 1,000

Park et al. [2] Sherman et al. [5]

22 F 27 F

NR 800

Bilateral calves Abdomen, with fat transfer to bilateral buttocks

F female, NR not reported or unavailable

Aeromonas caviae Corynebacterium species Escherichia coli Group B Streptococcus Klebsiella species Peptostreptococcus magnus Streptococcus viridans

Death (9 cases) NR (5 cases) Skin grafting Blindness (resolved) Skin grafting and flap coverage

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of fat aspiration was only reported in three of the 14 case reports and averaged 2.1 L (range 0.8–3 L) [5, 11, 12]. For the 14 additional cases discovered by Lehnhardt et al. [1], the average fat aspiration was 4.3 ± 1 L. In five case reports, no causative organism was identified or reported [3, 10, 12, 15, 16]. Lehnhardt et al. [1] did not report any causative organisms. Cultures revealed isolated Streptococcus pyogenes infection in three cases [6, 9, 14]. Cultures revealed isolated Aeromonas caviae infection in one case [2] and isolated Staphylococcus aureus infection in another case [13]. Multiple organisms were identified on culture in four cases, including Bacteroides rheumatica [10], Candida albicans [10], Citrobacter species [10], Clostridium rheumatica [10], Corynebacterium species [5], Enterococcus species [10], Escherichia coli [5, 11, 17], Group B Streptococcus [5], Klebsiella species [5, 10], Peptostreptococcus magnus [5], Prevotella ruminicola [10], Pseudomonas aeruginosa [17], Streptococcus pyogenes [11], and Streptococcus viridans [5]. Lehnhardt et al. reported nine deaths from NF following liposuction [1]. Among the case reports, there were an additional four deaths [3, 6, 10, 11]. Of these, one patient was found to have extensive abdominal wall fascia necrosis, multiple mid-ileal perforations, and gross peritoneal cavity contamination when she was taken to the operating room for debridement and exploratory laparotomy [3]. A second of the deaths occurred in a patient who underwent liposuction of the neck, abdomen, and back by a family practitioner in the office [10]. At the time of operative debridement, perforation of the abdominal wall and small intestine were noted with herniation of the perforated viscus through the fascial defect and contamination of the anterior abdominal wall with enteric contents. Full recovery was reported in one patient who developed Streptococcus pyogenes-mediated NF following submental liposuction and platysma plication [9]. In eight other cases, the patients made a full recovery but required skin grafting for coverage of their wounds [2, 5, 10, 12–16]. Two of these eight patients suffered toxic shock syndrome in association with NF, one due to Staphylococcus

aureus infection [13] and the other due to Streptococcus pyogenes infection [14]. One patient who underwent abdominal liposuction with fat transfer to the bilateral buttocks developed occipital bacterial meningitis and transient blindness [5]. The bacterial meningitis is believed to have been caused by polymicrobial NF of the right buttock and retroperitoneal space with either direct seeding of the lumbar cerebrospinal fluid by bacteria or hematogenous spread of bacteria via the spinal venous plexus [5]. This patient ultimately recovered and underwent skin grafting and subsequent local flap closure (Fig. 89.1).

89.3

Visual Loss and Blindness

Reports of visual loss and blindness following liposuction are rare but do exist. Visual loss can be unilateral or bilateral, can range from mild transient deficits to irreversible total blindness, and can have an immediate or delayed presentation postoperatively [18]. Visual loss can have multiple different etiologies, including anterior and posterior ischemic optic neuropathy (ION), central retinal artery occlusion, and occipital meningitis. Eight reports of transient or permanent visual loss following liposuction exist in the literature and are summarized in Table 89.2 [5, 18–24]. These include five cases of anterior ION (three bilateral [18, 20, 22] and two unilateral [19, 21]), one case of possible unilateral posterior ION in conjunction with contralateral anterior ION [21], one case of unilateral posterior ION [23], one case of unilateral central retinal artery occlusion [24], and one case of transient unilateral blindness and contralateral near-blindness in the setting of occipital bacterial meningitis seeded by retroperitoneal NF [5]. ION is a general term that includes all presumed ischemic causes of optic neuropathy [18]. Anterior ION is characterized by visible optic disc changes on fundoscopy, which include swelling of the disc and peripapillary hemorrhages. In contrast, posterior ION is not associated with any initial apparent abnormalities of the optic disc. Anterior ION is more common and represents approximately 90 % of ION cases [18].

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Blindness and Necrotizing Fasciitis After Liposuction and Fat Transfer

a

859

b

c

d

e

Fig. 89.1 This is a 27-year-old female who underwent abdominal liposuction with fat transfer to the bilateral buttocks and developed polymicrobial NF of the right buttocks with extension into the retroperitoneal space, neural foramina, and lumbar spinal canal. Her course was complicated by the development of bacterial occipital meningitis and transient blindness. After serial debridements of the infected soft tissue, broad-spectrum intravenous antibiotics, and resuscitation and ventilator support in an intensive care unit, the patient made a full recovery. She underwent split-thickness skin grafting of her right buttock wound, which was subsequently excised and reconstructed with a local rotational flap. (a) Right buttock wound following

debridement of infected soft tissue and gluteus. (b) Abdominal computed tomographic image with contrast demonstrating extensive fat stranding in the right buttock soft tissues (short black arrows) and gas both in the subcutaneous fat of the right buttock (short white arrows) and tracking into the perineal, presacral, and retroperitoneal soft tissues (long white arrows). (c) Right buttock wound following treatment with vacuum-assisted closure device, prior to undergoing split-thickness skin grafting. (d) Ten months following discharge from the hospital, after undergoing excision of her skin graft and coverage with a local rotational flap. (e) Postoperative result, 1 year following discharge from the hospital

NR

36 F

49 F

34 F

43 F

58 F

27 F

Sibgatullah et al. [21]

Moura et al. [18]

Ribeiro Monteiro et al. [22]

Rath et al. [23]

Zandi [24]

Sherman et al. [5]

NR

22,000

Volume of fat aspiration (cc) 3,700

800

1,700

Central retinal artery occlusion OS Blindness OS and near-blindness OD from bacterial meningitis

PION OD

AION OU

AION OU

AION OS and possible PION OD

AION OU

Diagnosis AION OD

MTHFR homozygous, prothrombin II variant heterozygous Minimal carotid artery plaque

Idiopathic intracranial hypertension

Risk factors

Necrotizing fasciitis, bacterial occipital meningitis

Hypotension, possible blood loss

Blood loss

Perioperative complications Hypotension, blood loss Hypotension, blood loss, multiple pulmonary emboli, thrombosis of right internal jugular vein and transverse and sigmoid sinuses Blood loss

Full recovery of vision

Persistent visual acuity and field deficits Persistent visual acuity and field deficits Persistent visual acuity and field deficits Persistent visual acuity and field deficits Blindness

Persistent visual acuity and field deficits

Outcome Blindness

F female, AION anterior ischemic optic neuropathy, PION posterior ischemic optic neuropathy, OS left eye, OD right eye, OU bilateral eyes, NR not reported or unavailable, MTHFR methylenetetrahydrofolate reductase

Abdomen, with fat transfer to bilateral buttock

Waistline and hips, with abdominoplasty

Thighs, dorsum, and hips, 3,000 with breast nodule excision Bilateral dorsum and 5,500 gluteus region, with abdominoplasty Abdomen, with breast 2,800 augmentation

Unspecified, with abdominoplasty

30 F

Liposuction site, additional procedures Abdomen, thighs, arms

Foroozan and Varon [20]

Minagar et al. [19]

Age (years), gender 47 F

Table 89.2 Review of reported cases of visual loss following liposuction

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Blindness and Necrotizing Fasciitis After Liposuction and Fat Transfer

It is caused by an interruption of the oxygen supply to the optic nerve head anterior to the lamina cribrosa [18, 19]. Patients frequently have small optic discs on fundoscopy (also known as “small cup-disc ratio” or “crowded disc”), which implies a small optic disc diameter and smaller scleral canal [18]. Risk factors for ION include anemia, blood loss, hypotension, increased peripheral vascular resistance, and head-down, prone positioning, which can increase orbital pressure and thereby reduce arterial perfusion pressure [18, 19, 25]. Patients undergoing liposuction may be at risk for ION because of long operative times, significant fluid shifts and hemodynamic changes, blood loss, infusions of high doses of epinephrine and lidocaine in tumescent solution, and head-down, prone positioning [18, 25]. Visual loss from ION is typically sudden and painless and may be unilateral or bilateral [21]. While prompt evaluation and correction of any underlying anemia or hypotension is always essential, early diagnosis and aggressive management often do not affect the visual prognosis [21]. The initial ischemic injury causes axonal edema, which leads to compartment syndrome in a structurally crowded optic disc, resulting in axonal degeneration and a loss of retinal ganglion cells [25]. The resulting optic nerve atrophy often leaves patients with irreversible visual deficits [21]. The six reported cases of visual loss from anterior or posterior ION following liposuction occurred in women aged 30–49 years. One patient was diagnosed postoperatively with idiopathic intracranial hypertension, which was unknown to her surgeon preoperatively [22]. Another patient was homozygous for a mutation in methylenetetrahydrofolate reductase (MTHFR) and heterozygous for a prothrombin II mutation [23]. The volume of fat aspiration was reported in five of the six cases and averaged 7.4 L (range 2.8–22 L) [18–20, 22, 23]. All but one case were associated with perioperative hypotension and/or blood loss [18–22]. One patient who developed bilateral anterior ION suffered multiple pulmonary emboli postoperatively with thromboses of her right internal jugular vein and transverse and sigmoid sinuses [20]. All of the six patients were left with persistent visual acuity

861

and visual field deficits. In one case of unilateral anterior ION, the patient was left completely blind in her affected eye [19]. In 2009, Zandi reported a case of unilateral central retinal artery occlusion in a 58-year-old female who underwent liposuction of her waistline and hips in conjunction with abdominoplasty [24]. The patient was left irreversibly blind in her left eye. Postoperatively, she was found to have minimal plaque in her carotid artery, which is believed to have been the embolic source of her central retinal artery occlusion. In 2010, Sherman et al. reported a case of transient unilateral blindness and contralateral near-blindness in a 27-year-old female who developed NF and occipital bacterial meningitis following abdominal liposuction with fat transfer to the bilateral buttocks (Fig. 89.1) [5]. The patient developed polymicrobial NF of the right buttock with extension into the retroperitoneal space, neural foramina, and lumbar spinal canal. When she subsequently developed meningitis, it was attributed to either direct seeding of the lumbar cerebrospinal fluid or to hematogenous spread via the spinal venous plexus. MRI of the brain revealed severe leptomeningeal enhancement in the bilateral occipitoparietal cortex and cerebellum consistent with bacterial meningitis. Following serial debridements of the infected soft tissue, broad-spectrum intravenous antibiotics, and resuscitation and ventilator support in an intensive care unit, the patient made a full recovery, including recovery of her bilateral vision. The transient visual loss is believed to have resulted from local small vessel ischemia, local seizures not documented on electroencephalogram, or as a direct toxic effect of the infection. Conclusions

NF and visual loss are both rare but reported complications following liposuction and fat transfer. Knowledge of their risk factors, presentation, and management are critical to both preventing and appropriately managing these devastating complications. These diagnoses should always be considered when evaluating a patient with postoperative complaints.

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References 1. Lehnhardt M, Homann HH, Daigeler A, Hauser J, Palka P, Steinau HU. Major and lethal complications of liposuction: a review of 72 cases in Germany between 1998 and 2002. Plast Reconstr Surg. 2008; 121(6):396e–403. 2. Park S, Jeong W, Kim M, Lee K, Lee W, Lee D. Necrotising fasciitis in both calves caused by Aeromonas caviae following aesthetic liposuction. J Plast Reconstr Aesthet Surg. 2010;63:e695–8. 3. Sharma D, Dalencourt G, Bitterly T, Benotti PN. Small intestinal perforation and necrotizing fasciitis after abdominal liposuction. Aesthetic Plast Surg. 2006;30:712–6. 4. Grazer FM, de Jong RH. Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast Reconstr Surg. 2000;105(1):436–46. 5. Sherman JE, Fanzio PM, White H, Leifer D. Blindness and necrotizing fasciitis after liposuction and fat transfer. Plast Reconstr Surg. 2010;126(4):1358–63. 6. Heitmann C, Czermak C, Germann G. Rapidly fatal necrotizing fasciitis after aesthetic liposuction. Aesthetic Plast Surg. 2000;24:344–7. 7. Jones J. Investigation upon the nature, causes and treatment of hospital gangrene as it prevailed in the confederate armies 1861–1865. In: Hamilton FH, editor. United States sanitary commission, memoirs: surgical II. New York: Riverside Press; 1871. p. 146–70. 8. Wilson B. Necrotizing fasciitis. Am Surg. 1952;18(4): 416–31. 9. Beeson WH, Slama TG, Beeler RT, Rachel JD, Picerno NA. Group A streptococcal fasciitis after submental tumescent liposuction. Arch Facial Plast Surg. 2001;3:277–9. 10. Barillo DJ, Cancio LC, Kim SH, Shirani KZ, Goodwin CW. Fatal and near-fatal complications of liposuction. South Med J. 1998;91(5):487–92. 11. Alexander J, Takeda D, Sanders G, Goldberg H. Fatal necrotizing fasciitis following suction-assisted lipectomy. Ann Plast Surg. 1988;20:562–5. 12. Gibbons MD, Lim RB, Carter PL. Necrotizing fasciitis after tumescent liposuction. Am Surg. 1998;64(5): 458–60.

B.L. Dent and J.E. Sherman 13. Umeda T, Ohara H, Hayashi O, Ueki M, Hata Y. Toxic shock syndrome after suction lipectomy. Plast Reconstr Surg. 2000;106(1):204–7. 14. Nagelvoort RW, Hulstaert PF, Kon M, Schuurman AH. Necrotising fasciitis and myositis as serious complications after liposuction. Ned Tijdschr Geneeskd. 2002;146(50):2430–5. 15. Anwar UM, Ahmad M, Sharpe DT. Necrotizing fasciitis after liposculpture. Aesth Plast Surg. 2004;28(6): 426–7. 16. Desrosiers AE, Grant RT, Breitbart AS. Don’t try this at home: liposuction in the kitchen by an unqualified practitioner leads to disastrous complications. Plast Reconstr Surg. 2004;113(1):460–1. 17. Gonzales Alana I, Marin de la Cruz D, Palao Domenech R, Barret Nerin JP. Necrotizing fasciitis after liposuction. Acta Chir Plast. 2007;49(4):99–102. 18. Moura FC, Cunha LP, Ribeiro Monteiro ML. Bilateral visual loss after liposuction: case report and review of the literature. Clinics. 2006;61(5):489–91. 19. Minagar A, Schatz NJ, Glaser JS. Liposuction and ischemic optic neuropathy. Case report and review of the literature. J Neurol Sci. 2000;181(1–2):132–6. 20. Foroozan R, Varon J. Bilateral anterior ischemic optic neuropathy after liposuction. J Neuroophthalmol. 2004;24(3):211–3. 21. Sibgatullah M, Kupersmith MJ, Zerykier A, Volpe S. Ischemic optic neuropathy after liposuction: case report and review. Neuro-Ophthalmology. 2005;29:91–3. 22. Ribeiro Monteiro ML, Moura FC, Cunha LP. Bilateral visual loss complicating liposuction in a patient with idiopathic intracranial hypertension. J Neuroophthalmol. 2006;26:34–7. 23. Rath EZ, Falick Y, Rumelt S. Posterior ischemic optic neuropathy following breast augmentation and abdominal liposuction. Can J Ophthalmol. 2009;44(3):346–7. 24. Zandi I. Blindness, a rare complication of liposuction: report of a case of unilateral blindness; notes on the effect of compassionate care. Plast Reconstr Surg. 2009;123(6):211e–2. 25. Agostini T, Lazzeri S, Figus M, Nardi M, Pantaloni M, Lazzeri D. Ischemic optic neuropathy as a rare but potentially devastating complication of liposuction. Plast Reconstr Surg. 2011;127(4):1735–8.

Complications of Liposuction Beyond the Surgical Site: Focus on the Optic Nerve Damage

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Tommaso Agostini and Mario Dini

Abstract

Liposuction is one of the most performed surgical procedures, and its safety has improved along the last years, leading to increased volume aspiration up to 1,500 mL. Several complications beyond surgical site have been reported, pulmonary fat embolism, pituitary apoplexy, deep venous thrombosis, sepsis, and death, and most of them are linked to hemodynamic complications which increase the overall morbidity of a surgical procedure performed mainly for cosmetic reasons. Here we describe the complications of liposuction at the expense of the optic nerve, the socalled ischemic optic neuropathy, both in the anterior and posterior segment, the possible mechanism of pathogenesis, diagnosis, management, and medicolegal aspects.

90.1

Introduction

Liposuction and lipofilling (a procedure that has implicit fat aspiration) are two surgical procedures that have been performed frequently to treat fat deposits, and they are considered safe [1–3]. Nowadays, liposuction combined or not T. Agostini, M.D. (*) Deparment of Plastic and Reconstrutcive Surgery, Centro Chirurgico San Paolo, Via del Quadrifoglio 3, 51100 Pistoia, Italy e-mail: [email protected] M. Dini, M.D. Department of Plastic Surgery, University of Florence, Centro Bufalini, via Gino Capponi 26, 50129 Florence, Italy e-mail: [email protected]

with lipoinjection is the best surgical option to correct contour deformities, buttocks augmentation, breast augmentation, and facial rejuvenation [4–7]. In the light of the increasing demand of autologous fat, a complete overview of possible complications is necessary [8]. In this chapter is described the possible complications to the optic nerve related to local ischemia. Postoperative visual loss is catastrophic following nonocular surgery; the incidence is reported to be 0.003 and 0.0008 % and up to 0.11 % after cardiac and 0.08 % after spinal surgery. However, because of medicolegal issues, this injury may be underreported, and the majority of incidents are contained within individual case reports making an exact estimation difficult. No prospective studies exist [9].

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90.2

Definition and Classification

Ischemic optic neuropathy (ION) is defined as a sudden loss of central or side vision or both consequent to interrupted blood flow to the optic nerve [9, 10]. ION is classified according to the part of the optic nerve suffering ischemia: anterior ischemic optic neuropathy (AION), more common, when the ischemia involves the front part of the nerve, the so-called optic nerve head, and posterior ischemic optic neuropathy (PION), less common, involving the posterior segment of the optic nerve which is identified seldom if ever as a possible complication of liposuction. The anterior ischemic optic neuropathy is further classified into two subtypes: arteritic and nonarteritic. The arteritic ischemic optic neuropathy affects more females than males (3:1) over the age of 55 years, and the pathogenesis is acute inflammation of the arteries supplying the optic nerve, a condition potentially life threatening, which is diagnosed by incisional biopsy (giant cell arteritis); since this type of AION has inflammatory basis, its diagnosis can be relatively simple accompanied by typical symptoms such as fever and pain increasing with chewing in the temporal area. The non-arteritic form does not have predilection with patient’s age and sex, and it can affect people younger than 45; the pathogenesis relies in a sudden and temporary decrease of blood flow to the arteries supplying the optic nerve, but the prognosis is better than the arteritic form [9–16]. Some risk factors predisposing to the non-arteritic anterior ischemic optic neuropathy are listed in Table 90.1 [9]. This last type of complication is a prerogative of liposuction, more frequent of the posterior ischemic optic neuropathy.

90.3

Pathophysiology

The causes and the mechanism to optic nerve injury are still debated although, most probably, the origin relies in transient hypoperfusion of the optic nerve rather than microembolism [11]. Some intraoperative and perioperative risk factors have been identified and should be kept in

Table 90.1 Preoperative risk factors to non-arteritic ischemic optic neuropathy (NAION) Diabete mellitus Rheumatoid arthritis Heper zoster Anemia Syphilis Sickle cell trait Low blood pressure Gastric ulcer Cardiac disease Vasculitis Migraine

Table 90.2 Perioperative risk factors to non-arteritic ischemic optic neuropathy (NAION) Anemia Hypotension Long duration Anemia Intraoperative hydration Prone position

mind (Table 90.2). Preoperative risk factors would cause axonal edema that is supposed to be the trigger of a compartment syndrome in a structurally “crowed” optic disk with a resulting axonal degeneration and loss of retinal ganglion cells by means of apoptosis. Further predisposing factors are congenital optic nerve morphology alteration and faulty autoregulation of the optic nerve circulation [8, 9].

90.4

Discussion

90.4.1 Timing of Onset and Symptoms Prodromic signs and symptoms before partial or total visual loss characterize the arteritic AION, and this can be an advantage for physicians to prompt diagnosis and therapy to avoid permanent visual loss. On the contrary, the non-arteritic forms are more underhand and the diagnosis can be performed once the damage is permanent; the decrease or loss of the visual field is, indeed, painless and sudden, often referred by patients at

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Complications of Liposuction Beyond the Surgical Site: Focus on the Optic Nerve Damage

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the awakening and thus difficult to differential diagnosis between other conditions affecting the visual acuity (medial products, devices, accidental injury) [9–17].

along with clinical details (available at: http:// www.asaclosedclaims.org), and educational material both for patients and physicians can be downloaded for free [9].

90.4.2 Literature Overview and Analysis of the Registered Cases

90.4.5 Medicolegal Aspects

Until 2,011, six cases of ischemic optic neuropathy following high-volume liposuction have been identified [10–15]. The mean age was 39 years, range 30–49 years, and the average amount aspirated was 7,400 mL, range 2,800–22,000 mL. Of these described cases, three were bilateral anterior ischemic optic neuropathy [11, 12, 14], two were unilateral AION [13, 15], and one was unilateral PION [10]. Only two patients did not have any preoperative risk factors [13, 15].

90.4.3 Diagnosis and Management If a form of arteritic AION is suspected, then a diagnostic test known as fluorescein angiography should be performed as soon as possible, and corticosteroid drugs should be administered in order to protect the healthy globe. Pharmacological management of the non-arteric forms of ischemic optic neuropathy consists in the administration of acetazolamide and retinal diuretics as mannitol and furosemide combined to systemic corticosteroids and antiplatelet agents in order to contrast optic nerve edema [9].

90.4.4 Prevention The goal would be to identify those patients suffering risk factors who will develop visual impairment following surgery. To this aim, papilledema should be diagnosed in the preoperative by specific ophthalmologic consultation. To develop preventative measures, in 1999, ASA (America Society of Anesthesiologist) built the Postoperative Visual Loss Registry in which anonymously reported cases can be collected

Although the incidence of ION is low, the potential implications for patients are severe. Clinicians will have to make decisions on an individual basis in relation to disclosure of risk. However, it is important to be aware of the landmark case of Rogers v Whitaker where a patient suffered the complication of sympathetic ophthalmia (blindness in the eye contralateral to the operated eye, leading to complete blindness). The risk of this complication was estimated as 1:14,000 and was not disclosed. However, true to the principles of informed consent, it was decided that the complication was a material risk for that patient (i.e., should have been disclosed) based on the premise that the clinician should have appreciated that the specific patient had placed special emphasis on the sight in her good eye and would clearly not have undergone surgery had she known of the risk of blindness. The case was settled in the patients’ favor, and while the surgeon was not negligent in the performance of the surgery, he was negligent in failing to warn of the risk [9, 16, 17]. Conclusions

Ischemic optic neuropathy represents a severe though rare complication following liposuction. The prognosis is not poor since there is a partial recovery of the visual field in time, and in case of concerns, a prompt consultation by ophthalmologist is recommended. In order to avoid a complication like this in aesthetic procedures, physicians should identify patients with preoperative risk factors and avoid, at least in this group, high-volume liposuction, high-pressure jump and proper fluid resuscitation, and head-up position. All patients undergoing liposuction should be informed about the low but definite risk of this condition.

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References 1. Matarasso A, Levine SM. Evidence-based medicine: liposuction. Plast Reconstr Surg. 2013;132(6): 1697–705. 2. Wells JH, Hurvitz KA. An evidence-based approach to liposuction. Plast Reconstr Surg. 2011;127(2):949–54. 3. Haeck PC, Swanson JA, Gutowski KA, Basu CB, Wandel AG, Damitz LA, Reisman NR, Baker SB, ASPS Patient Safety Committee. Evidence-based patient safety advisory: liposuction. Plast Reconstr Surg. 2009;124(4 Suppl):28S–44. 4. Khouri RK, Smit JM, Cardoso E, Pallua N, Lantieri L, Mathijssen IM, Khouri Jr RK, Rigotti G. Percutaneous aponeurotomy and lipofilling: a regenerative alternative to flap reconstruction? Plast Reconstr Surg. 2013;132(5):1280–90. 5. Tonnard P, Verpaele A, Peeters G, Hamdi M, Cornelissen M, Declercq H. Nanofat grafting: basic research and clinical applications. Plast Reconstr Surg. 2013;132(4):1017–26. 6. Stewart DA, Taylor KO, Johnstone BR, Coombs CJ. Structural fat grafting to improve aesthetic outcomes in congenital hand surgery. Plast Reconstr Surg. 2012;130(2):386e–7. 7. Coleman SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg. 2006;118(3 Suppl):108S–20. 8. Pace MM, Chatterjee A, Merrill DG, Stotland MA, Ridgway EB. Local anesthetics in liposuction: considerations for new practice advisory guidelines to

9.

10.

11.

12.

13.

14.

15.

16. 17.

improve patient safety. Plast Reconstr Surg. 2013; 131(5):820e–6. Agostini T, Lazzeri S, Figus M, Nardi M, Pantaloni M, Lazzeri D. Ischemic optic neuropathy as a rare but potentially devastating complication of liposuction. Plast Reconstr Surg. 2011;127(4):1735–8. Rath EZ, Falick Y, Rumelt S. Posterior ischemic optic neuropathy following breast augmentation and abdominal liposuction. Can J Ophthalmol. 2009; 44(3):346–7. Moura FC, Cunha LP, Monteiro ML. Bilateral visual loss after liposuction: case report and review of the literature. Clinics (Sao Paulo). 2006;61(5):489–91. Ribeiro Monteiro ML, Moura FC, Cunha LP. Bilateral visual loss complicating liposuction in a patient with idiopathic intracranial hypertension. J Neuroophthalmol. 2006;26(1):34–7. Sigbatullah M, Kupersmith MJ, Zerykier A, Volpe S. Ischemic optic neuropathy after liposuction: case report and review. J Neuroophthalmol. 2005;29(2): 91–3. Foroozan R, Varon J. Bilateral anterior ischemic optic neuropathy after liposuction. J Neuroophthalmol. 2004;24(3):211–3. Minagar A, Schatz NJ, Glaser JS. Liposuction and ischemic optic neuropathy: case report and review of literature. J Neurol Sci. 2000;181(1–2):132–6. Rogers v Whitaker, 67 ALJR 47 (Aust 1992). Chalmers D, Schwartz R. Rogers v. Whitaker and informed consent in Australia: a fair dinkum duty of disclosure. Med Law Rev. 1993;1(2):139–59.

Fat Embolism After Liposuction in Klippel-Trenaunay Syndrome

91

Gaby Doumit and Mihiran Karunanayake

Abstract

Klippel-Trenaunay syndrome (KTS) is a congenital disorder that presents with a classic triad of findings including varicose veins or venous malformations, capillary malformation, and soft tissue or bone hypertrophy of the affected limbs. These patients can have lymphatic malformations and deep venous anomalies comprised of hypoplasia, aplasia, or venous incompetence. The authors describe a case of a patient with KTS who had liposuction for limb hypertrophy and developed fat embolism.

91.1

Introduction

Klippel-Trenaunay syndrome (KTS) is a congenital disorder that presents with a classic triad of findings including varicose veins or venous malformations, capillary malformation, and soft G. Doumit, M.D., M.Sc. (*) Department of Plastic Surgery, Centre Hospitalier Universitaire (CHU) Sainte Justine, 3175 Ch de la Côte-Sainte-Catherine, Montreal, QC H3T 1C4, Canada Division of Plastic Surgery, Dermatology and Plastic Surgery Institute, Cleveland Clinic, Cleveland, OH, USA e-mail: [email protected]; [email protected] M. Karunanayake, M.D. Service de chirurgieplastique, Centre HospitalierUniversitaire Saint-Justine, Université de Montréal, 3175 Ch de la Côte-SainteCatherine, Montreal, QC H3T 1C4, Canada

tissue or bone hypertrophy of the affected limbs [1, 2]. The majority of patients (63 %) have all three key features with the most prevalent trait being capillary malformations (98 %), followed by venous malformations (72 %) and limb hypertrophy (67 %) [2]. Additionally, these patients can have lymphatic malformations and deep venous anomalies comprised of hypoplasia, aplasia, or venous incompetence, which can be present in a significant proportion of KTS patients (72 %). These complexities render the management of KTS difficult and in turn welcome novel methods for addressing functional and cosmetic deficits. The surgical armamentarium for the treatment of symptomatic KTS includes stripping of varicose veins, excision of venous malformations, and epiphysiodesis and debulking procedures [3]. However, the benefits have to be weighed against the multiple risks of a surgical intervention including scars, infections, worsening edema, bleeding, and recurrence. Liposuction would

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a

b

c

Fig. 91.1 Preoperative patient demonstrating right lower extremity Klippel-Trenaunay syndrome (KTS). (a) Frontal view (b) Oblique view (c) Posterior view

appear to be a less invasive and a suitable technique, given the subcutaneous fat hypertrophy of the affected limb, for patients that desire contouring to improve symmetry. Given the widespread congenital vascular malformations in the affected limb, it can be speculated that patients have an increased risk of complications from liposuction. The authors present a case of a patient with KTS treated with liposuction for limb hypertrophy.

lower extremity was also intact with minimal dilation of superficial veins (Fig. 91.2). The patient’s medical history was significant for the aforementioned right lower extremity KTS, an atrial septal defect repaired at age 20 years and a patent foramen ovale (PFO) repaired at age 21 years.

91.3 91.2

Clinical Presentation

A 24-year-old woman with a history of KTS presented to our outpatient clinic with right lower extremity hypertrophy and capillary malformations involving 75 % of her right leg (Fig. 91.1). The patient desired contouring of her right lower extremity to improve symmetry. She had undergone endovascular laser ablation to the right greater saphenous vein as well as multiple stab phlebectomies 4 months prior. Preoperative magnetic resonance imaging demonstrated excess subcutaneous adipose tissue in the buttock, thigh, and calf. The deep venous system of the right

Operative Technique

Intraoperatively, a total of 3.5 L of tumescent solution (50 mL of lidocaine 1 % with 1 ampule of epinephrine in each liter of normal saline) was infiltrated through multiple 5-mm stab incisions along the right medial, anterior, and lateral thigh. A 4-m Mercedes tip cannula was used to remove 3 L of subcutaneous fat along with 500 mL of sero-sanguineous fluid from the thigh. There was minimal blood loss. The aesthetic result was quite satisfactory, and no immediate complications were encountered. The patient was sent to the recovery room in a stable condition. A blood sample taken in the recovery room demonstrated a hemoglobin level of 11.4 g/dL. She was

91 Fat Embolism After Liposuction in Klippel-Trenaunay Syndrome

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Fig. 91.2 Preoperative liposuction magnetic resonance imaging demonstrating right thigh fat hypertrophy and a few medially dilated superficial veins. (a) Axial view (b) Venous 3D reconstruction

discharged from the hospital after an uneventful immediate postoperative course.

91.4

Postoperative Course

Eighteen hours later, the patient awoke with increasing pain in her right lower extremity accompanied by fever. Upon arrival to her local emergency department, she was febrile (oral temperature 39.4 °C) and tachycardic (128 beats per minute) but remained normotensive (100/57 mmHg) and without respiratory distress (18 breaths per minute SpO2 98 % on room air).

The patient’s metabolic panel, coagulation panel, and complete blood count were within normal limits, including a white blood cell count of 7 k/ KL and a hemoglobin of 11.5 g/dL. She was transferred and readmitted to the institution’s surgical intensive care unit 36 h postsurgery, as her clinical picture was suspicious for sepsis secondary to necrotizing fasciitis vs pulmonary embolism. She was immediately placed on intravenous clindamycin and piperacillin/tazobactam. She was also urgently scheduled for a right thigh exploration in the operating room. While waiting for the operating room, she underwent radiographic imaging including chest

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Fig. 91.3 Postoperative (liposuction) magnetic resonance imaging of the right lower extremity shortly after surgery and just before surgical exploration. (a) Axial view (b) Coronal view

X-ray, spiral chest computed tomography, and lower extremity magnetic resonance imaging. The chest imaging demonstrated ground glass opacities and bilateral pleural effusions without any evidence of thromboembolic disease. The lower extremity magnetic resonance imaging demonstrated expected mild swelling in the subcutaneous tissue with minimal air bubbles. There were no signs of hematoma, fluid collection, muscle swelling, or myonecrosis (Fig. 91.3). Surgical exploration of the thigh revealed well-perfused soft tissues without evidence of hematoma or seroma. There was no dishwater or purulent drainage and no signs of myofascial necrosis. Tissue and fluid cultures were obtained along with an intraoperative gram stain, which were all negative for organisms. The wounds were copiously irrigated with a saline/bacitracin solution. The incisions were lightly packed and left open to allow drainage. Intraoperatively, the patient’s clinical picture deteriorated. She became tachypneic, with a PO2 of 73 mmHg and a PCO2 of 28 mmHg on 2 L of oxygen. She was febrile, tachycardic, and became hypotensive. Her white blood cell count decreased from 6.33 to 3.91 k/KL. Her hemoglobin dropped

abruptly from 11.4 to 6.8 g/dL. Her platelets decreased from 173 to 92 k/KL. Her international normalized ratio increased from 1.1 to 1.5. Her total bilirubin increased from 0.7 to 2.1 mg/ dL. She returned to the surgical intensive care unit intubated with vasopressor support. Her condition continued to worsen over the next 18 h requiring higher doses of vasopressors. Thereafter, her clinical picture suddenly improved. All vasopressors were discontinued, and she was extubated 20 h after surgical reexploration. Antibiotics were discontinued 2 days after admission as cultures were all negative. She was discharged home 4 days after admission. The patient has since made a full recovery with no long-term complications (Fig. 91.4).

91.5

Discussion

Since 1982, liposuction has been a safe and valuable tool for aesthetic surgeons practicing in the United States [4]. Complications are rare but extensive and range from minor (hematoma, seroma, wound infection, contour irregularities) to serious (lidocaine toxicity, fluid overload, skin

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Fig. 91.4 Six-month postoperative result of patient with Klippel Trenauney syndrome treated with liposuction. (a) Frontal view (b) Oblique view (c) Posterior view

necrosis, pulmonary embolism, and fat embolism) [4, 5]. There are only a few case reports of fat embolism syndrome (FES) after liposuction in the literature. However, this does not underscore its importance as it is a fatal syndrome that is difficult to diagnose [6, 7]. The clinician must be astute to this potential consequence as it can share features with the more common complications of liposuction, notably pulmonary embolism and sepsis secondary to necrotizing soft tissue infection [6]. There appears to be a higher risk of FES when liposuction has been performed in combination with other procedures [8, 9]. It has also been described as a risk in patients with varicose veins, with a higher volume of aspirate and number of areas treated, the speed of the surgery, the size of the cannula, and ultrasonic liquefaction of fat cells [6]. Given the rare incidence of this complication, the theories remain speculative and founded on physiologic principles. Interestingly, the relationship between fat embolism and liposuction has been explored in the animal model. In a study by El-Ali and Gourlay [10], lipid deposits were found in the lungs of every laboratory rat that underwent 30 min of liposuction. Kenkel et al. [11] found similar results in their porcine

model. The pathogenesis of fat embolism syndrome after liposuction involves both mechanical and biochemical processes [4, 7, 12]. Direct inoculation of fat globules into the venous circulation after mechanical rupture of these vessels can directly inhibit blood flow through pulmonary capillary beds. The pulmonary arterial pressure rises and can push the emboli into the systemic circulation where it can cause end-organ damage. KTS patients have a predilection for hypercoagulability, thrombosis, and pulmonary embolism, but this follows a distinctly separate physiological process when compared to the risk of fat embolism in these patients. The process of direct inoculation of fat globules is secondary to the mechanical shearing of the superficial veins with the liposuction cannula. KTS patients usually have dilated tortuous veins and their walls are thinner, thereby potentially increasing their risk of rupture. In addition, low blood flow in the dilated tortuous varicose veins renders fat globule inoculation in the venous circulation more likely. In addition to a thorough physical examination, KTS patients should be further evaluated with color duplex scanning of the venous system in their extremity. This will help to identify the

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patency and any venous anomalies, including thrombosis and valvular incompetence. MR angiography is another imaging technique, which provides high-resolution images that can further distinguish between the different soft tissue structures and assist in preoperative planning [3]. The deep venous system can be additionally examined with contrast venography depending on the imaging modalities available at ones institution, although the field of liposuction would remain in subcutaneous fatty tissue. There is evidence to suggest that patients with venous malformations and limb hypertrophy can have good functional outcomes as demonstrated in the 6 months postoperative pictures of our patient. These patients have few options available for management of the asymmetry secondary to hypertrophy of adipose tissue in the affected limb. Compression therapy is the most accepted and widely applied technique for symptomatic KTS. Careful patient selection and a thorough preoperative assessment with diagnostic imaging should be performed in all patients with vascular malformations that may be a candidate for contouring of a hypertrophic limb. FES will remain a risk and patients must be clearly informed and consent obtained. There are distinct symptoms and signs that the surgeon must be mindful of should the patient develop FES. Patients who develop FES experience a biochemical reaction in which pneumocytes are oxidized by free fatty acids in the circulation, inactivating surfactant production and triggering a systemic inflammatory response [12]. The result is a clinical picture that can mimic pulmonary embolism. Distinguishing these two entities is of paramount importance as the management of each differs significantly. The diagnosis of fat embolism syndrome can be guided by using the Gurd and Wilson criteria [13]. The three major criteria are respiratory insufficiency, cerebral involvement, and petechial rash. Our patient only had evidence of respiratory distress. She also displayed many of the minor criteria including fever, tachycardia greater than 120 beats per minute, a 20 % drop in hemoglobin, and a 50 % drop in platelets. She also had an elevated bilirubin, although not at a

level sufficient to produce jaundice (minor criteria). The treatment of FES is mainly supportive, aimed at improving the respiratory status and achieving hemodynamic stability. The use of highdose corticosteroids may limit the increase in circulating free fatty acids and reduce systemic inflammation, but its use is controversial [4, 5, 14]. Symptoms usually resolve within 1 week as this condition is typically self-limited. The risk of mortality ranges from 5 to 15 % [15]. Careful patient selection with a thorough preoperative assessment, reduced operative times, limiting the number of procedures in one sitting, and intravenous fluid administration for up to 24 h postoperatively are some of the reported prevention strategies [9, 12]. Conclusions

Although liposuction is a relatively safe procedure, clinicians need to be cognizant of the potential for FES in patients with vascular malformations presenting with fever of unknown origin in the immediate postoperative period. Although diagnostically challenging, aggressive supportive care needs to be immediately implemented to improve outcomes.

References 1. Capraro PA, Fisher J, Hammond DC, Grossman JA. Klippel-Trenaunay syndrome. Plast Reconstr Surg. 2002;109(6):2052–60. 2. Jacob AG, Driscoll DJ, Shaughnessy WJ, Stanson AW, Clay RP, Gloviczki P. Klippel-Trenaunay syndrome: spectrum and management. Mayo Clin Proc. 1998;73(1):28–36. 3. Gloviczki P, Driscoll DJ. Klippel-Trenaunay syndrome: current management. Phlebology. 2007;22: 291–8. 4. Iverson RE, Lynch DJ. American Society of Plastic Surgeons Committee on Patient Safety. Practice advisory on liposuction. Plast Reconstr Surg. 2004; 113(5):1478–90. 5. Gingrass MK. Lipoplasty complications and their prevention. Clin Plast Surg. 1999;26(3):341–54. 6. Mentz HA. Fat emboli syndromes following liposuction. Aesthet Plast Surg. 2008;32(5):737–8. 7. Platt MS, Kohler LJ, Ruiz R, Cohle SD, Ravichandran P. Deaths associated with liposuction: case reports and review of the literature. J Forensic Sci. 2002;47(1): 205–7.

91 Fat Embolism After Liposuction in Klippel-Trenaunay Syndrome 8. Abbes M, Bourgeon Y. Fat embolism after dermolipectomy and liposuction. Plast Reconstr Surg. 1989;84(3):546–7. 9. Erba P, Farhadi J, Schaefer DJ, Pierer G. Fat embolism syndrome after combined aesthetic surgery. J Plast Surg Hand Surg. 2011;45(1):51–3. 10. El-Ali KM, Gourlay T. Assessment of the risk of systemic fat mobilization and fat embolism as a consequence of liposuction: ex vivo study. Plast Reconstr Surg. 2006;117(7):2269–76. 11. Kenkel JM, Brown SA, Love EJ, Waddle JP, Krueger JE, Noble D, Robinson Jr JB, Rohrich RJ.

12.

13. 14. 15.

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Hemodynamics, electrolytes, and organ histology of larger-volume liposuction in a porcine model. Plast Reconstr Surg. 2004;113(5):1391–9. Wang HD, Zheng JH, Deng CL, Liu QY, Yang SL. Fat embolism syndromes following liposuction. Aesthet Plast Surg. 2008;32(5):731–6. Gurd AR, Wilson RI. The fat embolism syndrome. J Bone Joint Surg (Br). 1974;56B(3):408–16. Mellor A, Soni N. Fat embolism. Anaesthesia. 2001;56(2):145–54. Ross RM, Johnson GW. Fat embolism after liposuction. Chest. 1988;93(6):1294–5.

Massive Pulmonary Thromboembolism After Abdominoplasty and Liposuction

92

Cenk Conkbayir

Abstract

Liposuction is generally safe procedure but unfortunately this cosmetic surgery rarely can cause death due to pulmonary embolism. Pulmonary thromboembolism is very rare after this type of cosmetic surgery. In this chapter diagnosis and treatment of massive pulmonary thromboembolism after abdominoplasty and liposuction will be discussed. .

92.1

Introduction

In the literature, there are several cases that died from pulmonary embolism during or after liposuction and abdominoplasty operation. Most of them were diagnosed in autopsy unfortunately. Surgery involving abdominoplasty and liposuction performed for cosmetic reasons is generally regarded as a safe procedure with a low complication rate. A study from North America reported one fatal case and eight nonfatal cases of pulmonary thromboembolism among 75,591 patients undergoing liposuction [1]. Another study involving 48,527 patients reported five

deaths associated with liposuction [2]. Alderman et al. [3] reported abdominoplastyassociated complication rates as 0.3 % for deep venous thrombosis and 0.1 % for pulmonary embolism. The Japanese guidelines for prevention of venous thromboembolism recommend the use of elastic stockings and intermittent pneumatic compression of the lower extremities in moderate-risk patients undergoing surgery for nonmalignant disease and in patients undergoing malignancy surgery [4]. Uemura et al. [4] also recommended elastic stockings or intermittent compression of the lower extremities to avoid pulmonary thromboembolism following liposuction surgery.

C. Conkbayir, M.D. Cardiology Department, Near East University, Nicosia, Northern Cyprus, Turkey e-mail: [email protected]

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92.2

Pulmonary Thromboembolism

In the literature, pulmonary thromboembolism that developed following cosmetic abdominoplasty and liposuction surgery and showed unresponsiveness to thrombolytic therapy was successfully treated with thrombectomy. Echocardiography in the emergency room may show a mobile, echogenic mass, regular in shape, extending from the right ventricle into the right atrium, suggesting the diagnosis of thromboembolism. An elevated D-dimer level supports the diagnosis. Infective endocarditis should be excluded from the differential diagnosis because of normal body temperature and the lack of verrucous appearance of the lesion. Pulmonary thromboembolism occurring as a severe complication of cosmetic surgery should be first treated with heparin infusion, but if there was no therapeutic response, thrombolytic therapy should be administered. However if thrombolytic therapy is unsuccesfull for clinical and echocardiographic improvement then the patient should be submitted to invasive procedures such as percutaneous thrombolysis and reolysis and then should be submitted to cardiac surgery for pulmonary thrombectomy in which all these treatment programs failed. In one case due to literature proposed that the development of pulmonary embolism may be associated with the amount of fat removed during liposuction surgery (>1,500 g) and the length of operation time (>140 min) [5]. This patient, these risk factors were not applicable, in that the amount of fat removed during surgery was 1,300 g and the operation time was 125 min. She did not have protein C and S deficiency, nor factor V Leiden mutation. Prophylactic anticoagulation therapy was not initiated due to the absence of risk factors. However, as this case suggests, it would be more convenient to start prophylactic low-molecularweight heparin in obese patients undergoing liposuction surgery. Surgical embolectomy is the most invasive treatment in patients with pulmonary artery embolism [6]. In a study comparing surgical embolectomy and thrombolytic therapy, the success and mortality rates were both in favor

of surgical embolectomy, being 85 % versus 73 % for a successful outcome and 23 and 33 % for mortality, respectively [7]. It was emphasized in a case report from Turkey that surgical embolectomy might be a life-saving treatment following the occurrence of widespread pulmonary embolism [8]. There are other studies that showed lower mortality and morbidity rates for pulmonary embolectomy; the survival rate following early pulmonary embolectomy was 92 % in one study [9] and 89 % in another [10], with emphasis on the increase in survival with early diagnosis and early surgery. In a case, the priority was given to medical treatment of pulmonary embolism that developed as a serious complication of cosmetic surgery [11]. However, deterioration of the patient’s hemodynamic status and unresponsiveness to thrombolytic therapy required a shift to pulmonary embolectomy. Pulmonary embolectomy has an important place in the treatment of pulmonary thromboembolism. In the literature, there are few cases published about pulmonary embolism after and during liposuction and abdominoplasty [11, 12]. Conclusions

It recommended that plastic surgeons evaluate the risk for pulmonary embolism with their patients before abdominoplasty and liposuction operations. Prophylaxis for pulmonary embolism and prevention of obesity are two very important issues. Management should include early postoperative motion in obese patients and prophylactic treatment in patients with evident risks. The patient and the family should be made aware about this rare and fatal complication about liposuction and abdominoplasty.

References 1. Teimourian B, Rogers 3rd WB. A national survey of complications associated with suction lipectomy: a comparative study. Plast Reconstr Surg. 1989;84:628–31. 2. Platt MS, Kohler LJ, Ruiz R, Cohle SD, Ravichandran P. Deaths associated with liposuction: case reports and review of the literature. J Forensic Sci. 2002;47:205–7.

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Massive Pulmonary Thromboembolism After Abdominoplasty and Liposuction

3. Alderman AK, Collins ED, Streu R, Grotting JC, Sulkin AL, Neligan P, Haeck PC, Gutowski KA. Benchmarking outcomes in plastic surgery: national complication rates for abdominoplasty and breast augmentation. Plast Reconstr Surg. 2009;124(6):2127–33. 4. Uemura K, Kikuchi Y, Shintani-Ishida K, Nakajima M, Yoshida K. A fatal case of post-operative pulmonary thromboembolism with cosmetic liposuction. J Clin Forensic Med. 2006;13:41–3. 5. Gravante G, Araco A, Sorge R, Araco F, Nicoli F, Caruso R, et al. Pulmonary embolism after combined abdominoplasty and flank liposuction: a correlation with the amount of fat removed. Ann Plast Surg. 2008;60:604–8. 6. Augustinos P, Ouriel K. Invasive approaches to treatment of venous thromboembolism. Circulation. 2004;110(9 Suppl 1):I27–34. 7. Gulba DC, Schmid C, Borst HG, Lichtlen P, Dietz R, Luft FC. Medical compared with surgical treat-

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ment for massive pulmonary embolism. Lancet. 1994;343:576–7. Aslan A, Emiroğlu O, Kahraman D, Osmanağaoğlu S, Gökgöz L, Özyurda Ü. Massive pulmonary embolism caused by deep vein thrombosis following open heart surgery. Türk Klin J Cardiovasc Sci. 2009;18:170–3. Yalamanchili K, Fleisher AG, Lehrman SG, Axelrod HI, Lafaro RJ, Sarabu MR, Zias EA, Moggio RA. Open pulmonary embolectomy for treatment of major pulmonary embolism. Ann Thorac Surg. 2004;77(3):819–23. Aklog L, Williams CS, Byrne JG, Goldhaber SZ. Acute pulmonary embolectomy: a contemporary approach. Circulation. 2002;105:1416–9. Conkbayir C, Kenan S, Emiroglu O. Massive pulmonary thromboembolism after abdominoplasty and liposuction. Turk Kardiyol Dern Ars. 2011;39(5):410–3. Terranova C, Sartore D, Snenghi R. Death after liposuction: case report and review of the literature. Med Sci Law. 2010;50(3):161–3.

Part VIII Postoperative

Changes in Metabolic Syndrome Parameters After Liposuction

93

Juraj Payer Jr. and Kristína Brázdilová

Abstract

The adipose tissue is important in regulating insulin sensitivity and is a severe risk factor for metabolic syndrome. Clinical findings associated with metabolic syndrome include insulin resistance, dyslipidemia, central obesity, hypertension, impaired glucose tolerance or diabetes mellitus, and high rates of atherosclerotic disease. Liposuction is a surgical aspiration of fat from the subcutaneous layer, reducing the amount of subcutaneous fat, which might affect the potential of metabolic syndrome development both in means of its separate parameters and its clinical manifestations as a whole. This supports the theory that this procedure of plastic surgery might prevent various cardiovascular and other associated diseases.

93.1

J. Payer Jr., M.D. (*) Department of Plastic Surgery, Medical Faculty of Comenius University and University Hospital Bratislava, Ruzinovska 6, 826 06 Bratislava, Slovakia e-mail: [email protected] K. Brázdilová, M.D., Ph.D. 5th Department of Internal Medicine, Medical Faculty of Comenius University and University Hospital Bratislava, Ruzinovska 6, 826 06 Bratislava, Slovakia e-mail: [email protected]

Introduction

Liposuction is the surgical aspiration of fat from the subcutaneous layer leaving a more desirable body contour and leaving a smooth transition between the suctioned and non-suctioned areas [1]. It is the most commonly performed aesthetic surgical procedure in the USA [2]. In 1988, Reaven [3] proposed that insulin resistance is central to the etiology of type 2 diabetes mellitus, hypertension, and coronary artery disease. The concept of insulin resistance and associated metabolic abnormalities leading to increased risk of cardiovascular disease became known by a variety of names, including metabolic syndrome, dysmetabolic syndrome, syndrome X, cardiometabolic syndrome, and insulin resistance syndrome [4].

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882 Table 93.1 Definition of metabolic syndrome Central obesity (defined as waist circumference ≥94 cm for Europid men and ≥80 cm for Europid women, with ethnicity-specific values for other groups) plus any two of the following four factors

Raised TG level: ≥150 mg/dL (1.7 mmol/L) or specific treatment for this lipid abnormality Reduced HDL cholesterol: 3 months) in the adipose tissue, generalized overweight, and a number of associated symptoms (Fig. 95.1). The pain is often disabling and resistant to traditional analgesics [2, 3]. The most common locations for painful fat and lipomas are the extremities, the trunk, the pelvic area, and the buttocks (Fig. 95.2). When there are palpable lipomas, they vary in size and in firmness [1]. The onset of the disease can be abrupt or indolent [2], and it usually appears between the ages of 35 and 50 years [1, 5] and is 5 [1] to 30 [6] times more common in women than in men. The

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896 Symptoms and signs in AD Generalized Pain 99% Growths unaffected by weight loss 100% Easy bruisability 75%

Psychiatric Sleep disturbances 93% Impaired memory 86% Depression 66% Difficulty concentrating 66% Anxiety 85%

A few case reports have also suggested that the disease might be an autosomal dominant disorder with variable expression [13–16]. However, none of the theories have been proved [2, 17].

95.3

Diagnosis and Classification

Cardiovascular Rapid heartbeat 78%

Pulmonary Shortness of breath 77%

Endocrine Obesity 73% Diabetes 16%

Gastrointestinal Bloating 86% Constipation 83%

Rheumatological Fatigue 97% Weakness 95% Joint aches 94% Muscle aches 95%

Fig. 95.1 Signs and symptoms in Dercum’s disease [1]. Republished with permission

prevalence of the condition has not yet been established [2]. The prognosis of the disease is unclear, as little research has been conducted on the natural history of Dercum’s disease. Some case reports have suggested that the pain is aggravated over time [7]. However, a study with a 5-year followup demonstrated that, untreated, the average pain remains relatively constant (Fig. 95.3). Although on an individual basis, some patients experience less pain after 5 years and others more pain [8].

95.2

Etiology

The etiology of Dercum’s disease is unknown, but a number of theories have been proposed [2], such as nervous system dysfunction [9, 10], adipose tissue dysfunction [11, 12], and inflammation [1].

The diagnosis is based on criteria and should be made by systematic physical examination and thorough exclusion of differential diagnoses. Advisably the diagnosis should be made by a physician with a broad experience of patients with painful conditions of different varieties [2]. There are no laboratory markers for the disease, and laboratory tests for inflammation and autoimmune disease are commonly negative [1, 2]. Moreover, altered levels of neuropeptides that can be seen in some painful conditions cannot clearly be seen in Dercum’s disease [18]. On biopsy, an inflammatory response can be seen in the adipose tissue of patients with Dercum’s disease. However, the response is not more pronounced than in healthy aged-matched controls [17]. Different diagnostic criteria have been proposed for the disease, the most current being: 1. Generalized overweight or obesity 2. Chronic pain (>3 months) in the adipose tissue [2] Patients who have painful overweight/obesity of the lower extremity only should be diagnosed with lipoedema, and patients who only have excess fat accumulation in the head and neck region and upper torso should be diagnosed with Madelung’s disease (Launois-Bensaude syndrome). There are different varieties of the disease and different classifications have been proposed. The most recent one comprises [2]: I. Generalized diffuse form: A form with diffusely widespread painful adipose tissue without evident lipomas II. Generalized nodular form: A form with general pain in adipose tissue and intense pain in and around multiple lipomas

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Quality of Life in Patients with Dercum’s Disease: Before and After Liposuction

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Fig, 95.2 Typical pain distribution in Dercum’s disease [2, 4]. Republished with permission 10 [***]

[**]

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Fig. 95.3 Pain intensity, over 5 years, in operated and nonoperated patients with Dercum’s disease. The visual analogue scale (VAS) values are given as mean ± SEM. Mean significances within the groups depict difference in change over time from baseline and are shown

adjacent to respective error bars. Significances between the groups depict difference in change over time from baseline and are shown in the upper part of the figure. Only significant differences are shown [8]. *p = 0.05, **p = 0.01, ***p = 0.001. Republised with permission

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III. Localized nodular forms: A form with pain in and around multiple lipomas IV. Juxta-articular form: A form with solitary deposits of excess fat, for example, at the medial aspect of the knee It is important to classify the disease to be able to evaluate which patients may benefit from liposuction.

95.4

Treatment

Most of the medical treatment strategies of Dercum’s disease, such as injections of procaine and lidocaine, methotrexate, infliximab, interferon alfa, corticosteroids, calcium-channel modulators, and D-thyroxin, are based on case reports, and the actual effect on the disease is thus unclear [2]. Liposuction as a treatment for Dercum’s disease was first described in a case report of one patient in 1987 [19]. Since then a number of case reports have been presented (Table 95.1) and two prospective controlled studies [3, 20] performed, indicating that liposuction gives pain relief to the patients and improves quality of life. In all cases, suction-assisted liposuction was used. All investigators, with the exception of Wollina et al. [21], who used the tumescence technique, “wet” technique, with pilocarpine solution, applied the “dry” technique.

95.5

Technique

Extremities can be operated on with the use of a tourniquet, followed by treatment of the area previously covered by the tourniquet with tumescence technique, “superwet” technique. Before the release of the tourniquet, compression garments must be applied in order to decrease blood loss [25]. On the trunk, an elastic corset is recommended for the same reason. Compression should be maintained for at least 6 weeks [8]. Other areas can be operated on using tumescence technique, “superwet” technique, injecting wetting solution in amount equal to two to three times the fat that is to be removed, that is, with a ratio of 2–3:1 mL (infiltration to aspirate) as described by Klein [26]. Wetting solutions can be a mixture of 1 mL (1 mg/mL) adrenaline/1,000 mL normal saline (154 mmol/L, 0.9 %) or a mixture of 2 % lignocaine 40 mL, adrenaline 1 mL (1 mg/mL), sodium bicarbonate 25 mL (0.6 mmol/L, 50 mg/ mL), and normal saline 1,000 mL [25]. Painful areas such as the abdomen, flanks/hips and gluteal regions, proximal thighs/legs and arms, and the medial areas of the knees should be operated on. Four- to five-millimeter incisions should be made, and a bullet-shaped cannula, with two or three openings distally and an outer diameter of 3–4 mm, is recommended. A vacuum pump connected to the cannula gives rise to a negative atmospheric pressure of 0.9. Patients should receive anticoagulants.

Table 95.1 Studies on liposuction in Dercum’s disease Study Hansson et al. [20]

Year 2012

Type of study Prospective, controlled

Hansson et al. [8] Wollina et al. [21] Berenguer et al. [22] De Franzo et al. [23] De Silva and Earley [24] Scheinberg et al. [19]

2011 2010 2000 1990 1989 1987

Prospective, controlled Case series Case report Case report Case report Case report

Modified table from Hansson [3]. Republished with permission

Number of patients 53 53 4 1 1 2 1

Follow-up time 5 years 5 years Not stated Not stated 2 years 1 year Not stated

Results Improved quality of life Pain relief Pain relief Pain relief Pain-free Pain-free Pain-free

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Quality of Life in Patients with Dercum’s Disease: Before and After Liposuction

95.6

Discussion

Dercum’s disease is a rare disease characterized by chronic pain (>3 months) in the adipose tissue, generalized overweight, and a number of associated symptoms [2]. Liposuction of Dercum’s disease was first described in 1987 [19], and two prospective controlled studies [3, 20] have demonstrated that it can give pain relief [3] and improve quality of life [20].

95.6.1 Effect on Pain In a prospective study [8] of 53 patients with Dercum’s disease, pain was evaluated for 5 years after liposuction. As controls 58 nonoperated patients with Dercum’s disease and 41 obese otherwise healthy individuals were followed for 5 years. Both subjective and objective pain measurements revealed a decrease in the pain experienced by the Dercum patients after liposuction as compared with pain preoperatively and as compared with the

60

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nonoperated controls. However, the pain relief diminished over time as regards to VAS (Fig. 95.3) and pain pressure thresholds (Figs. 95.4 and 95.5). The patients still were not as pain-free as the healthy controls but had a significant pain reduction as compared to baseline and the nonoperated Dercum patients. The pain relief after treatment with liposuction could be explained with avulsion of possible abnormal connections between peripheral autonomic and sensory nerves causing pathological signals to the spinal cord [8, 9]. However, when chronic pain is treated, there is also a considerable association between the effect of treatment and the patient expectations [27, 28]. Hence, the patient’s belief in the treatment, the placebo effect, might explain the decrease seen in pain after liposuction. Liposuction might diminish pain in Dercum’s disease. However, it is difficult to determine whether the effect is due to the actual surgery or to other factors. Not all patients experience pain relief.

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]

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10 0 Baseline

2 years

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Fig. 95.4 Pain pressure thresholds (PPTs) for the knee. The PPTs are given as mean ± SEM. Significances within the groups depict difference in change over time from baseline and are shown adjacent to respective error bars. Significances between the groups depict difference in

change over time from baseline and are shown in the upper part of the figure. Only significant differences are shown [8]. *p = 0.05, **p = 0.01, ***p = 0.001 (Reprinted with permission)

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***

***

Abdominoplasty patients

*** ***

Dercum controls

30 ***

***

20 10

[

]

Dercum operated vs Dercum controls

(

)

Dercum operated vs Abdominoplasty pat.

0 Baseline

3 months

1 year

2 years

3 years

5 years

Time

Fig. 95.5 Pain pressure thresholds (PPTs) for the abdomen. The PPTs are given as mean ± SEM. Significances within the groups depict difference in change over time from baseline and are shown adjacent to respective error bars. Significances

between the groups depict difference in change over time from baseline and are shown in the upper part of the figure. Only significant differences are shown [8]. *p = 0.05, **p = 0.01, ***p = 0.001. Republished with permission

95.6.2 Effect on Quality of Life

ally [32], and Dercum’s disease, specifically. In summary, liposuction in Dercum’s disease improves quality. However, the improvement is discreet, and hence, an individual risk evaluation is warranted, and preoperative counselling should be performed before embarking on the treatment.

Quality of life was also measured in the patients described above. Measurements used were two general quality-of-life instruments, namely, the Psychological General Well-Being Index (PGWB) and the Nottingham Health Profile (NHP). The Dercum group had lowered quality of life than the healthy controls preoperatively (Table 95.2). After liposuction, a slight improvement could be seen in quality of life in the operated patients compared with preoperative status; however, it did not become as high as in the healthy controls (Tables 95.3 and 95.4) [8]. Quality of life is complicated to measure as it is a highly subjective variable, closely tied to an individual’s expectations. Moreover, it is debatable what the concept of quality of life should comprise and how it should be measured [31]. Nonetheless, patient-related outcomes and quality of life may be the most important outcomes measurement in liposuction, gener-

95.7

Complications

In the study comprising large-volume liposuction of 53 patients, no postoperative complications were seen [8]. No significant difference in vibratory and thermal sensation can be detected in patients with Dercum’s disease 1 year after liposuction, as compared with preoperative status [33]. In summary, there is no reason to believe liposuction is less safe in patients with Dercum’s disease than in other patients [34]. However, caution always has to be applied when treating patients with obesity and/or comorbidities with liposuction [35].

95

Quality of Life in Patients with Dercum’s Disease: Before and After Liposuction

901

Table 95.2 Untreated Dercum patients’ (preoperative values) and the matched controls’ Psychological General WellBeing Index (PGWB) and Nottingham Health Profile (NHP) total scores and subscale scores Quality of life PGWB Total score Subscales

NHP Total score Part I subscales

Part II subscales

Dercum patients (n = 113)

Abdominoplasty controls (n = 41)

Anxiety Depressed mood Well-being Self-control General health Vitality

77 (35–122) 19 (6–30) 13 (4–18) 12 (5–24) 13 (4–18) 9 (3–16) 10 (5–21)

111 (47–129) 27 (8–30) 16 (5–18) 18 (4–23) 16 (10–18) 16 (10–18) 19 (7–23)

Emotions Sleep Lack of energy Pain Physical mobility Social isolation Work Housework Social life Home life Sex life Hobbies Holidays

21 (0–86) 47 (0–100) 60 (0–100) 61 (0–100) 53 (0–100) 29 (0–100) 0 (0–78) 39 % 98 % 64 % 47 % 60 % 88 % 68 %

4 (0–36) 0 (0–64) 11 (0–77) 0 (0–76) 0 (0–23) 0 (0–53) 0 (0–49) 7% 15 % 10 % 10 % 24 % 37 % 20 %

Values are givens as medians and ranges. PGWB comprises 22 items evaluating the patient’s subjective feeling of wellbeing. Responses are given on a six-grade scale where a lower value indicates a more negative response than a higher value. The values are summarized to an overall index, ranging from 22 to 132. A lower value indicates a worse quality of life [29]. NHP has two parts. Part I comprising 38 yes/no questions divided into six different dimensions. Zero indicates no health problems and 100 that the patient has all of the mentioned problems of that particular dimension. Part II evaluates the effects of health on seven aspects of daily life, and the score is given as a percentage. All the values are weighed according to a standardized protocol and give a total index for each dimension. A higher score is associated with a worse quality of life [20, 30]. Republished with permission

95.8

Selection of Patients

Most patients with generalized diffused form (type I) and juxta-articular form (type IV) of Dercum’s disease have some pain relief after liposuction, but it is impossible to determine who will have a substantial decrease in pain [3] and improvement in quality of life [20]. Patients with palpable lipomas, nodular types of Dercum’s

disease (types II and III), should not be treated with liposuction as there is a risk that there is an implantation of fat cells and spread of the disease when the capsules of the lipomas are disrupted. Patients with nodular forms of Dercum’s disease are therefore better treated with excisions [36]. Based on the individual patient, careful preoperative evaluation and preoperative counselling and risk stratification is paramount [35].

53

53

52

53

52

Total 3 months Total 1 year

Total 2 years

Total 3 years

Total 5 years

5

9

7

7

17

Points 0

0.05

0.004

0.008