Liposuction
Liposuction
It was Illouz who made the method safe (1983) by using a dull suction canule instead of the sharp one, and introduced the so-called „wet technique", which means the injection of hypotonial salt solution into the treated area.
The Characteristics of Adipose Tissues
The adipose tissue is the energy-storehouse of the body, its functional unit is the fat cell, which releases or stores the free adipose-acids in accordance with the needs of the body.
Earlier it was assumed that we are born with a determined quantity of fat cells, and the number of these cells remains constant. However, according to current studies the so-called precursor cells, which exist even in adulthood, store the fat in case of large increases in weight. In the initial phases of weight increase the fat accumulates in the fat cells, their volume grows to the critical degree (hypertrophy), then due to the precursor cells the number of the fat cells also increases (hyperplasia).
In the case of women the accumulation of fat brings about rather a gynogen form: fat accumulates on the lower part of the abdomen, on the hips, the thighs and the buttocks.
In the case of men the android form develops: fat accumulates on the upper-lower regions of the abdomen and on the hips. This latter form increases the risk of cardiovascular diseases, artero-clerosis and diabetes.
It is very frequent for people to put on weight, then after several diets they realise that they put on still more adipose tissues when they return to their normal lifestyles. This can be explained with the hyperplasial phase, since in cases of severe weight increase the number of the fat cells also grows. Diets are able to decrease only the weight of the fat cells. Liposuction, or dermolipectomy is a technique with the help of which the localized excesses may be removed.
The experience of several decades has proved that the result is lasting, provided the patient's weight remains the same. After liposuction, if one puts on weight, the fat accumulates evenly in the body. Thus patients have to understand that it is recommended to retain their weight after the surgical procedure.
The adipose tissue is enclosed in a fibrotic network, which is called the superficial fascia system, and which divides the fat into two layers: the surface (areolar) and deep (lammellar) layers (cf. figure 162. ‘The position and layers of the adipose tissue’). The surface layer lies between the dermis and superficial fascia, and can be found in all parts of the body. It consists of small lobuli, which are condensed by fibrosus and vertical septums.
The frontal surface of the thigh, the calf, the ankle, the frontal-exterior and rear surfaces of the arm have only got areolar layers.
The position and layers of the adipose tissue
The lamellar layer can be found between the fascia superficial and the fascia covering the muscle. This layer can be found in such parts of the body as the abdomen (mainly in the central and lower regions, in accordance with the path of the abdominis), the hips, the trochanter region, the upper third of the interior thighs and the parts above the knee, and the rear parts of the upper arm.
Its thickness may change significantly, in the case of a fat person it can be ten times the thickness of a normal-weight person's. The thickness of the surface layer does not grow more than to its double.
The tumescent technique
It is a modified version of the wet technique. 50 ml 15% Lidocaine and 1 ml Epinepphrine are added to the 1000 ml Ringer lactate. Ringer lactate traumatizes the fat cells to a lesser degree than the normal salt solution, its application is significant mostly in cases where the removed fat is to be injected.
Besides this, the basic difference of the tumescent technique from the traditional wet method is that it uses much more solution to anaesthetize (up to 4-
Surgical Indication
The procedure is principally performed with an aesthetic indication,although there are rare cases in which the reason is different. These include the removal of lipomas, the treatment of axillar hyperhidrosis, defatting the lobes and the treatment of congenial lymphoedema.
Contraindication
The surgical procedure has no contraindication, adipose tissues may be removed from any parts of the body where excess fat occurs. The only obstacle is the patient's health condition (which can be a contraindication in other aesthetic surgical procedures as well).
The pinch test
The patient has to be examined in the standing position, so that gravitation is included. It is advisable to do the examination in front of a mirror so that the possible changes in the body-contour can be shown. The patient is asked to tense his musles, the skin together with the underlying adipose layer is lifted with the application of the so-called pinching test in order to judge the thickness of the adipose tissue. Thus we can demonstrate the differences of the body parts to the patient.
During the first consultation, the patient has to be examined to detect whether he has hernia on the wall of the abdomen (especially around the navel), which has to be avoided with the canule in the surgical procedure.
The elasticity of the patient's skin may also be estimated. If the skin of the abdomen wall is significantly expanded, it is unlikely to be able to shrivel completely. Otherwise the final result can be expected 6 months after the surgical procedure. The surgeon must endeavour to make the patient be able to decide by possessing the most possible information. The photos of previously operated patients, information brochures, videos and computer-aided picture analysis may help a lot in this.
It is useful for the patient to meet his surgeon once again 1-2 weeks before the operation, when he can ask questions on topics that he considers hardly understandable on the basis of the received information.
The laboratory reports may also be checked on this occasion. (Wbc, Rbc, Hgb, Hct, Thr, We, Serum Na, K, Glucose, complete urine, and other examinations if necessary)
If the liposuction of more than 2-
The Surgical Procedure
Everybody who can be prepared for the operation is a good candidate for liposuction. It is advisable to ask the patient to begin to use an antibacterial shower gel some days before the surgical procedure. He should arrive in a loose dress at the consulting-room. He has to sign his statement which contains the information of the patient and in which he consents to the operation together with the commission contract before two witnesses.
It is important to weigh the patient, and to repeat that if he puts on weight again, it will accumulate in all other parts of the body and not on the treated area, but may make the achieved result less spectacular.
It is essential to take a photo of the patient before the surgical procedure.
Outlining is carried out with the patient standing. The contours of fat accumulation are outlined with alcohol-resistant paint, the places of the incisions are marked with small circles, thus potential tattoos may be avoided after recovery. The most protruding parts are marked with a '+' sign, the shallow parts with '–', to know the exact places where the suction and injection are to be performed even when the patient is lying.
If the procedure is performed circularly (eg. on the trunk), it is advisable to perform washing when the patient is standing, or to sprinkle the disinfectant solution on the surface of the skin. The operating-table is covered with a sterile sheet, thus if the patient is turned, sterility is not risked.
The surgical procedure can be performed with general and regional anaesthesia or with local anaesthesia combined with IV sedation. Here the patient's request is decisive. The anaesthetist secures the vein, then the patient's oxygenisation with the pulse oxymeter, continuously paying attention to his pulse. Certain authors advise to give 1gr Mandokef as a preventive antibiotic, then 250 mg Solumedrol, then the anaesthetist applies other medication.
The skin is sedated at the places of the incisions, then from an incision pricked with trocar the treated area is filled with a solution with Lidocaine content of body temperature, using a tumescent needle (which has openings in all directions, thus the solution can be added more evenly and rapidly). If the infusion bag is put under pressure, the process can be enormously accelerated. The 1000 ml Ringer lactate can be combined with 50 ml of 1% Lidocaine and 1 ml Por 8. (Thus a solution of 0.05% concentration is gained that contains 500 mg Lidocaine. )
According to the present practice 35 mg/tskg is the maximum quantity of Lidocaine applicable. The advantages of the tumescent technique are that blood loss is smaller during the operation and practically painless until the sedative effect of the solution lasts, moreover the solution provides partial fluid supply during the procedure. After waiting 10-15 minutes, when the vasoconstrictor has carried out its effect, liposuction can be started.
Canules Applicable for Liposuction
The surface layer is treated with the thin 1.8-
Canules are distinguished by:
- • their length, bending and diameter
- • the number, size and position of the openings
- • the dullness of their ending, its round or flat shape
- • the position of the openings. These can be found on one side, at the top and bottom and at the side, close to or far from the ending
The surgeon may usually perform the operation routinarily with the help of 2 or 3 canules. After the insertion of the canules, the treated area can be pretunelized with their „broom-like" movement, then after vacuum is produced the broken adipose tissues may be sucked out through the openings with the same movement.
Canules
The different parts of the body can be reached from various directions, with this the evenness of the result may be ensured. It is advisable to perform this so-called „crisscross" technique vertically wherever it is possible, since practice shows that the irregularities of the surface are more often visible in the horizontal direction.
With the help of the tumulescent technique 2000-4000 ml of tissue can be removed, 2500 ml on average. In scientific literature even 10-
With the help of the pinching test the thickness of the adipose tissue can be checked continuously, and if irregularities are detected they can be corrected immediately. After some time the extract contains less and less adipose tissues, this almost indicates the end of the operation.
A lot of surgeons do not even stitch the wounds eg. in the inguinal bend or in the pubic hair. Partly because in this case the mucus may freely empty out, and partly because they leave almost no scars. Bigger wounds, however should be closed with a single stitch at the end of the procedure. Besides the application of Steri-Strip, the bandage does not stick into the wound.
Post-operative Treatment
The fixation of the patients skin is essential. Adhesion and the use of a compressional corset are essentia, this prevents fluid build-up and helps the skin in shrivelling to the given form.
Certain authors prefer the corset, since the discomforts caused by the sticking plaster (eg. irritation, difficulties in removal) can be avoided. The enormous disadvantage of the plaster is that the patient does not remove it, while he may take off the corset at his own will, thus reducing the result of the operating.
The developed tunnels must be compressed with a continuous pressing force, because the walls that are fixing to each other can give a fine result only this way.
One week later the plasters can be removed, but it is advisable to wear the corset. The more specilied corsets are developed, the less importance is given to adhesion, although in certain areas its application is advantageous, eg. on the neck, and in lifting the buttocks. The corset must be worn 24 hours per day for 2 weeks.
The patient can have a shower a day later, then the corset must be dried with a hair-dryer. After going home it is advisable to stay in bed and put ice on the treated are every 15 minutes, this reduces pain and swelling. Pain relief medication can be take in every 4 hours if necesarry, but it is usually needed only in the first days.
After the first day the patients feel very well. After the application of the tumescent technique blood loss is little, the orthostatic hypotension is of a small degree, but secretion may last even up to 48 hours. A lot of patients begin to work 2-3 days later, but they have to wait another 2-3 weeks until they can resume their exercises. The majority of the patients feel themselves better in the corset for a long time, which ensures fixation even when the patient moves.
The discolouring of the skin and the large swelling disappear in 2-4 weeks. The positive effect of massage, lymphadrainage and ultrasound treatment is not proved scientifically, but patients are usually convinced that these happen for the sake of their quicker recovery.
1-2 months after the surgical procedure it is recommented to check the patient, to take the final photo and to agree on a possible second operation. In case a large liposuction is planned that involves several parts of the body, it is advisable to perform the procedure at 2 week intervals.
Post-operative Complications and their Treatment
As all surgical activities, liposuction also carries risks. For this reason every patient must be informed on the possible complications, to make them aware of what is to be done in such situations.
The rate of severe complications is small, since liposuction is the most safely performable surgical procedure, provided the appropriate equipment is used.
The size of the haematoma my extend from some milimeters to several centimeters, however, in case it reaches the size of a golf-ball it must be drained. This requires only the puncture and aspiration of the haematoma. In the case of a still larger size the patient must be taken back to the operating theatre and the accumulated blood has to be drained with the help of a canule. In some cases direct incision and drainage are necessary. Haematomas can usually be prevented, in case patients with coagulation disorders are sifted out (cf. contraindication).
Seroma requires a similar treatment like haematoma. Seroma development is a rare phenomenon in the application of modern liposuction, since the thin, dull canules minimalize tissue traumas.
The treatment of infections has to be started right after the first symptom has been detected. Since liposuction usually covers large areas of the body, the danger of sepsis is great, if the infection spreads to the whole area. Patients have to be adequately monitored in order to be able to detect possible infection symptoms in time.
The patient's attention must be drawn that if he notices pain, high temperature or secretion, he should call the doctor immediately. In these cases the use of high spectrum antibiotica is reasonable. The antiobiotica may be changed with the full knowledge of the laboratory report following the bacteria growing.
There are some experts who use antibiotica in a preventive way, however, this is not inevitably necessary. Nevertheless, the appropriate sterilization of the tools and the observation of the sterility regulations are essential.
Pulmonal and fat embolisms practically occur in cases in which liposuction is performed together with abdominoplasty. The patient must be told to turn to the doctor immediately after he has detected any deviations from his general state of health.
Liquid- and electrolite disorders must be corrected during the surgical procedure, otherwise it may even cause circulation disorders. In the tumescent technique hypotension is rare and most patients have spontaneous urination within 1 or ½ 1 hours. In cases of liposuction that are over 2000 ml, plasma-substituting liquids or more rarely autologue blood transfusion may be necessary.
Adequate patient selection, pre-operative examination, the application of modern surgical techniques and appropriate post-operative treatment may prevent complications.
Other Possible Inconvenient Consequences
There are post-operative deviations which are treated not as complications but as accompanying consequences the spontaneous disappearance of which may be expected after a certain time.
These include:
- • bruise-like appearance
- • swelling
- • paraesthesia
- • oedema
- • fatigue
- • sensitivity to pressure
- • small red incision scars
The unevenness and undulating appearance above the treated area are also frequent phenomena, especially after the surgical procedure, but fortunately this usually disappears with time. However, greater hollows, in case they do not disappear for months, must be corrected with fat-reinjection. This phenomenon is usually caused by the over-agressive technique and canules of large diameter. In order to correct this, liposuction has to be performed around the hollow, while the deepest areas have to be filled. In case there is not an adequate quantity of injectable fat (from the areas around the hollows), then liposuction may be performed in other areas of the body as well (eg. abdomen, the interior side of thighs etc.). The fat removed with 3-
Scars are sometimes conspicuous, due to the trauma caused by the canules. A year later scar excision may take place.
Conclusion
Due to the development of liposuction plastic surgeons have been offered a safe and effective surgical procedure to perform body-contouring through the removal of the patient's excess fat deposits. However, when performing the procedure, we have to consider those factors without the consideration of which our treatment may be ineffective or even harmful.
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