A successful body contouring patient must satisfy four key elements to achieve and maintain optimal results. As is evident above, only one of four factors the final one, in italics is influenced by the operating surgeon. As has been shown previously, patients who embrace diet, exercise, and a healthy lifestyle are much more likely to lose weight, be satisfied with results, have higher self-esteem, and have increased productivity.
Especially important are notations in the medical history of diabetes, massive weight loss, previous surgery, previous liposuction, and full detailed list of medications. It is prudent to notify the consulting physician of expected operative times and the amount of expected aspirate and infiltrate. Often, our medical colleagues view liposuction as a very benign operation with minimal operative time and morbidity when in fact a large-volume liposuction case can have significant fluid shifts and time under general anesthesia.
With regard to medication review, it is essential that the surgeon identify all medications prescribed to the patient, as well as any supplements or vitamins the patient may be taking. Herbal remedies and supplements are not regulated by the Food and Drug Administration FDA and thus may have unknown or adverse consequences with respect to bleeding complications or hypercoaguability. If there is a medical indication for these drugs, consultation with the primary physician or appropriate specialist should be completed before discontinuation.
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Oral contraceptives and estrogens are discontinued one month prior to the procedure. A detailed physical exam is performed at the first visit. Specific attention to prior scars, presence or absence of hernias, evidence of venous insufficiency, and presence of preexisting asymmetry or contour irregularity should be discussed and noted in the chart. At the initial and subsequent visits, height and weight with calculation of body mass index BMI is paramount for safety, as well as for observation of long-term trends during follow-up.
For liposuction candidates, six key elements should be documented:. Zones of adherence 5. The exam is best performed in front of a mirror. Any areas of cellulite should be pointed out to the patient, and a specific discussion of expected outcome in these areas should be noted. This will allow for documentation of results, as well as objective evaluation of outcomes by both patient and physician. When feasible, a medical photographer should be employed to provide consistent, high-quality images. Informed consent is a crucial process required by law to protect both the patient and the operating surgeon.
It allows the patient to fully appreciate the risks and benefits of the operation and make informed decisions.
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This process should detail the procedure itself, as well as the risks, benefits, alternatives, and expected outcomes. The common risks, as well as those specific to liposuction, should be discussed. Risks such as ecchymosis, edema, seroma, volume changes, and fluid overload should be included if ultrasound or other modalities are to be used. Specific additional risks such as thermal injury and paresthesias should also be disclosed.
These discussions should occur well before the initial surgery; often, a follow-up visit prior to surgery is scheduled to answer additional questions.
Preoperative marking is paramount to successful liposuction. The patients should be marked in the standing position and in front of a mirror, if possible. This allows the patient to contribute to the process and further confirms exactly what will be addressed during the procedure.
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The four-position stance noted above is preferred. Areas to be suctioned are marked with a circle; zones of adherence and areas to avoid are marked with hash marks.
Asymmetries, cellulite, and dimpling are marked for their respective treatment. When complete, the marks are once again reviewed with the patient to ensure that all areas of concern are addressed. With liposuction, it is beneficial to choose access points that can treat multiple areas. Incisions should also allow each area to be treated from different directions for optimal contouring.
Incisions should be no longer than 3 to 4 mm in length and placed in well-concealed areas. Of note, ultrasound-assisted liposuction UAL requires slightly larger incisions mm than traditional liposuction to account for skin protector placement when utilized , which prevents heat transmission to the skin edge. The surgeon should not hesitate in placing additional incisions if access is insufficient with the existing markings.
Figure 3 shows the preoperative markings and preferred placement of access incisions based on areas to be suctioned. Cosmetically, it is preferable to stagger incisions in an asymmetric fashion to camouflage their appearance.
click We close these as we would any other wound. Intraoperative patient positioning will vary based on the location to be treated and whether any additional procedures are planned.
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In general, the prone and supine positions are preferred for liposuction because patients can be treated bilaterally, and the surgeon can visualize each side to confirm symmetry. We prefer to avoid the lateral decubitus position, as access is limited and there is no ability to compare sides for symmetry. The supine position is utilized for the remainder of thighs and abdomen. Figure 4 shows a diagram of prone positioning. Prone positioning. Ultrasound-Assisted Liposuction.
The choice of anesthesia technique for liposuction varies based on multiple factors: operating surgeon preference, anesthesiologist preference, amount of expected lipoaspirate, length and extent of procedure, patient positioning, and overall health of the patient. Descriptions of local anesthesia, various forms of sedation mild, moderate, heavy , and general anesthesia are present in the literature.
No single technique of anesthesia has proven superior over another. However, the practice advisory on liposuction does recommend avoiding epidural and spinal anesthesia in office-based settings because of potential hypotension and volume overload issues. Small-volume liposuction cases can be performed with local anesthesia, with or without mild sedation. Complex, large-volume liposuction and combined cases should be performed under general anesthesia. Our institutional preference has been to perform the majority of cases under general anesthesia.
Deep-sedation cases and general anesthesia procedures are performed under supervision of board-certified anesthesiologists in licensed surgery centers or hospitals. All prone cases are performed with general endotracheal anesthesia for airway control. It is ultimately up to the operating physician and the anesthesiologist to choose the most effective modality for treating the patient, but the ultimate goal should be patient safety.
Operative location should be determined after careful patient evaluation, assessment of the complexity of operation, and appropriate evaluation of medical comorbidities. The anticipated postoperative course and the need for possible overnight observation both factor into choice among inpatient, observation, or outpatient hospital settings. Special importance should be given to medical comorbidities such as obstructive sleep apnea.
Initially, liposuction was performed without any wetting solutions.
Marcaine should be avoided because of its potential cardiac effects and duration of action; it has yet to be proven clinically as a suitable anesthetic in wetting solutions. The current options for wetting solutions are dry, wet, superwet, and tumescent Tables 2 and 3. The dry technique actually employs no wetting solution and has few indications in liposuction. The superwet technique employs an infiltration of 1 mL per estimated mL of expected aspirate, and this is the technique practiced at our institution.
At our institution, a concern over volume of infiltrated lidocaine and possible toxicity levels has led to a modification in the mixture of wetting solution in large-volume liposuction cases. In large-volume cases with aspirate greater than mL, the initial five bags of solution are mixed in a standard Southwestern protocol outlined in Table 1. Despite the relatively low concentrations infiltrated, the use of lidocaine and epinephrine may result in toxicity in some cases.
Lidocaine toxicity has central nervous system and cardiac effects, with the first signs of toxicity being circumoral numbness, tinnitus, and lightheadedness.
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Intraoperative manifestations may include arrhythmias. Increasing levels cause tremors, seizures, and eventually cardiac and respiratory arrest. Kenkel et al 27 demonstrated that the peak levels of lidocaine and its active metabolite monoethylglycinexylidide MEGX occur within eight to 32 hours after initial infiltration. The time to peak systemic levels was greater than initially thought but still below the level of toxicity.
Epinephrine has been shown to have increased cardiovascular effects after infiltration and peaks at five hours after infiltration. Body contouring procedures can result in significant fluid shifts and intravascular volume changes for the patient. The operating surgeon should maintain a dialogue with the anesthesia provider, so that patients receive adequate replacement volume and proper fluid resuscitation.
Often, a Foley catheter is utilized to guide intraoperative and postoperative volume resuscitation. Awareness of four key elements will guide the intraoperative fluid management of liposuction patients 3 , 4 : intravenous IV fluid maintenance body weight dependent , third space losses, volume of wetting solution infiltrated, and total lipoaspirate volume. Large-volume liposuction patients can present an especially difficult challenge for fluid resuscitation. As previously mentioned by Rohrich et al in updated in , the following formula aids in fluid management for these patients.
Again, these recommendations serve as a guideline for fluid management of these complicated patients and are not meant to replace sound clinical judgment based on specific patient needs. Once candidates are identified for liposuction, several modalities exist for treatment.
Factors that influence type of treatment include surgeon preference, body area to be suctioned, amount of expected aspirate, and history of previous liposuction. Traditional liposuction, as popularized by Illouz, 2 is referred to as suction- assisted liposuction SAL. SAL remains the most common modality for liposuction.