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suction. Different areas and different surgeries can require
more concentrated lidocaine per liter of normal saline.
Another option considering this 100 kg patient is that the
surgeon can choose to mix 1000mg of lidocaine per liter.
This will achieve a denser degree of anesthesia within the
treatment eld, but the maximum volume of tumescent is
now decreased from 10 liters to 5 liters. One can easily see
that in cases where more volume is needed, that is, liposuction of the abdomen and back area, the dilution option would
be better suited for the 10-liter mixture. Using the stronger
concentration of 5 liters would not provide enough volume to
adequately tumesce the areas mentioned above. Other areas
of the body commonly need a higher concentration of
lidocaine. Some of these include facelifting and also awake
submuscular breast augmentation with implants [3].
Needless to say, there are several factors that need to be
considered to adequately calculate and mix the correct volume and concentration of tumescent solution. To complicate
things further, many patients take medications that can interfere with the timely metabolism of lidocaine in the liver. The
enzyme that is used by many medications as well as lidocaine for their respective metabolism of each is cytochrome
P-450 3A4. Many of these medications that patients take on
a regular basis may be difcult for them to stop before liposuction. Therefore, the surgeon will then need to assess this
and ultimately lower the maximum dose of lidocaine per
procedure/surgery. Many patients take anti-depressant/antianxiety medications such as the SSRI—serotonin specic
reuptake inhibitors—family. In this author’s experience,
attempting to stop these medications in the preoperative
period to avoid potential lidocaine toxicity can be challenging. These medications have to be tapered down over time. If
stopped abruptly, side effects can be overwhelming. Also,
even with proper tapering, symptoms of depression and/or
anxiety commonly return and can make an individual psychologically unt for surgery. Therefore, it is much easier to
wean what medications are possible while at the same time
lower the maximum dose of lidocaine per procedure. The
downside to this approach is that a smaller treatment area
will need to be considered due to the limited lidocaine dose
per case. This should be discussed with the patient prior to
proceeding with surgery and is commonly done during the
consultation period [3].
Tumescent anesthesia is an incredible tool in the eld of
cosmetic surgery; however, improper mixing or mistakes
made during such can lead to lidocaine toxicity and death.
Several deaths have been reported over the past couple of
decades that were directly related to lidocaine toxicity. In
most of these cases a simple oversight or mistake was made
while calculating and mixing the tumescent solution. In
some of these reported deaths, it was learned that the individual who prepared the tumescent solution was an inexperienced surgeon. In other cases the tumescent preparation was
done by an untrained medical assistant, and in another by a
massage therapist. Therefore, this author encourages all surgeons performing the planned surgery to be active during the
calculating and mixing of this solution [3].
Infusion of the tumescent solution can be performed in a
few different ways. A needle or a blunt-tipped cannula, connected either to a syringe full of the solution or from a
mechanical infusion pump, can be used. In the awake patient,
there can be discomfort sensed by the patient during the infusion. This can be reduced by using a smaller-diameter cannula or needle and also by decreasing the rate of infusion. In
the hands of a beginner or novice surgeon, the delivery of the
tumescent solution can seem difcult to evenly and fully
place the tumescent uid. If the solution is not properly distributed within the treatment eld, and not enough of the
needed volume, the lipo-aspiration portion of the surgery
will be met with pain and unwanted bleeding from the
patient. This can be very discouraging for the inexperienced
surgeon. The result will be an incomplete liposuction treatment and the patient experience will be unpleasant. For this
reason, it is recommended to have more than enough volume
of the tumescent solution on hand to ensure copious amounts
can be used. During the lipo-aspiration where the patient
experiences pain or more than average bleeding, the surgeon
can stop the aspiration and infuse more tumescent solution
and ameliorate these problems. After infusion of the tumescent solution, it is advised that a 30-mins time interval be
allowed to pass prior to lipo-aspiration [3].
Adequate tumescent solution can create a threefold effect
upon safety in this area. First, the tumescent solution creates
a widening or thickening of the adipose or treatment area
that gives more room for aspiration cannulas to travel within.
Secondly, the tumescent solution creates vasoconstriction
effect on the vessels. Thirdly, proper amounts of tumescent
solution will have an internal pressure or a “tamponade”
effect on the interstitial tissues thus collapsing vessels
(Fig.5.3). Additional care needs to be given when placing
adit sites in the antecubital fossa. An incision through the
skin in this area could unintentionally cut through a supercial vessel [3].
5.6.2 Placement ofAdits intheUpper Arm
Although there are a variety of opinions about adit (cannula
entry sites), this author’s preference is as follows. The goal
of adit placement is determined by the structural anatomy of
the upper arm, and also placed to reduce visibility of scars.
Placement is carefully determined by avoiding danger areas
to reduce complications. Additionally, adit sites have to be
also placed to allow the surgeon the ability to have access to
the entire treatment area. Some common entry sites are
shown below (Fig.5.4).
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Fig. 5.3 Skin blanching seen after inltration of tumescent uid in the
arm
As mentioned previously, the aspiration of fat can be done
in a few different ways. Blunt-tipped cannulas are the standard of care and accepted way to minimize tissue trauma
while evacuating the adipose tissue [3, 8, 12]. Cannulas
come in several different tip designs, lengths, and diameters.
For upper arm liposuction, this author encourages the inexperienced surgeon to use no more than a 3mm diameter cannula. A common “Mercedes” or “tri-port” tip design will
offer the surgeon a less aggressive aspiration option, thus
decreasing the chance of unwanted contour irregularities
(Fig.5.5).
A common question asked of me by many inexperienced
surgeons is: “When do you know how much fat to remove?”
Unfortunately, experience is the best teacher. I have discovered a good rule to follow: always error on the side of not
removing enough fat. Judging the end point of arm liposuction can be confusing. Another point to stress is: stop the
lipo-aspiration of the upper arm treatment just shy of the
desired size. Once the tumescent solution is gone and healing is complete, the end result will reect a smaller arm size.
In 2012, as a much less experienced cosmetic surgeon, I
was sitting and discussing liposuction with another colleague
at a conference. This surgeon had a few more years of experience than me in the cosmetic surgical eld. His analogy to
liposuction in the postoperative period was that of pouring
concrete.
G. Alouf
He stated: “You only have a period of time before concrete hardens and sets up in place. During the time that the concrete is still
a liquid, you need to smooth it and nish it. Liposuction is the
same. After you nish liposuction and the aspiration of a determined volume of adipose tissue, the remaining adipose layer has
been disrupted. Additionally, there is a certain volume of liquid
fat that has not been aspirated and is free oating under the skin
within the treatment area. Like pouring concrete, you have a
certain amount of time to make sure your adipose sculpture is
smooth and nished prior to it becoming hard and indurated.”
Initially I thought how in the world can he compare liposuction to pouring concrete. Through the years and having
performed thousands of liposuction procedures, this analogy
has come to have much more meaning to me. In the beginning stages of liposuction, the young surgeon is excited
about how much fat is removed. With time and experience,
the surgeon learns that it is not the fat that you remove, but
instead the fat you leave behind that denes the silhouette
and sculpture that the skin will drape over. This ultimately
presents as the nal result.
Another pearl of learning is the technique of lipo-shifting.
Liposuction surgeons use this technique both right before
and/or right after the lipo-aspiration. Disruption is performed
with a cannula within the liposuction eld. The mechanical
movement of the cannula in and out of the adipose layer is
performed without suction. The diameter and style of tip on
the cannula can vary from surgeon to surgeon; however, the
mechanism and desired result of this technique remain the
same [14].
During lipo-aspiration, suction is added to the cannula
within the adipose layer. As the cannula travels in and out,
the suction applied to the cannula pulls in fragments of adipose tissue through the openings of the cannula and collects
these in aspiration containers. Within any adipose compartment, different suction forces are needed to remove different
fragments of fat. Therefore, some adipose fragments will
easily be aspirated while others adjacent to them will take
higher suction and mechanical disruptive forces to break
them free. Experienced liposuction surgeons can agree that
when trying to aspirate and reduce the adipose layer in a certain area, contour irregularities and unwanted indentations
can preside even with the most graceful movements [14].
Lipo-shifting is a tool that can and should be used, in this
author’s opinion, at the end of the liposuction case to help
prevent contour irregularities. Since this technique uses no
suction, the only force emitted on the adipose layer is
mechanical disruptive forces. Now all pockets of adiposity
become equally fragmentable, despite differing amounts of
connective tissue walling them off. The second, additive,
benet of lipo-shifting is that the small adipose particles that
are created are not removed from the treatment site and act to
ll voids, hollows, or contour irregularities [14].
Another analogy to describe “Disruption” or “Lipo-
Shifting” is that of sanding a piece of wood. If one takes a
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a
b
c
Fig. 5.4 (a) Adit site 1 is placed in the anterior axillary fold. (b) Adit site 2 is placed in the posterior axillary fold. (c) Adit site 3 is placed in the
lateral or medical antecubital fossa. (d) Adit site 4 is placed in the skin fold of the elbow
piece of rough wood with deep grooves within and applies
sandpaper to it, a similar phenomenon takes place. As the
sandpaper works and breaks off small fragments of the rough
sawdust, that is, “Fat-Dust.” The end result is that the “Fat-
Dust” is left behind to ll up grooves and irregularities of the
adipose layer left behind [14].
wood layer, two things happen. First off, the rough layer is
broken down on a small scale of mechanical forces that break
off tiny fragments of the wood thus making the ridges on the
wood smaller. Secondly, the sawdust that is created will ll
the grooves of the wood and it will appear smoother to the
eye. So the cannula breaking up the adipose layer is that of
the sandpaper, while the adipose fragments are similar to the
upper adit sites allows these to close quicker with less scarring. It is always a good idea to leave the most dependent adit
sites open to allow the tumescent solution to drain out of the
arms. Drainage after liposuction is an expected event. It can
take more than 24 h before the drainage stops. That said, it is
important to wrap the arms with absorbent padding to catch
d
I have found that placing an interrupted suture to close the
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G. Alouf
a
d
e
b
f
c
Fig. 5.5 (a–f) Access to various parts of the arm using a 3-mm diameter, 30-cm long straight cannula. The different arm positions based on the
access point used is well displayed
the drainage. A plastic barrier should be applied over the
5.6.3 Postoperative Consideration
padding to prevent leaking on furniture or patient bedding. A
compression garment should be applied over top of the padding and not removed for 24 h. This author feels it is important for the patient to be seen at 24 h postoperatively, and the
surgical site should be inspected by the clinical team. At this
time, the garment and the soaked padding are to be removed.
The area should be cleaned and at this time inspected for any
issues or concerns. Additionally, the patient’s vitals should
be taken, and the patient should be clinically assessed for
stability.
During the 24-h visit, the adit sites should be dressed
and properly covered. A tighter, more tted compression
garment should be placed. This visit will also allow the surgeon and staff to further stress post-care instructions and
address any concerns. Additionally, post-care massages as
well as additional postoperative visits can be set up or
scheduled.
In our practice we perform the following protocols. During the
interview and preoperative period, it is important to evaluate
the entire person. It cannot be stressed enough that patient participation and a willingness to follow postoperative instructions
is a must. While conducting the patient interview, the surgeon
as well as his/her staff needs to educate the prospective patient.
Education to the individual regarding their involvement in postsurgical care has to be delivered and stressed multiple times.
The surgeon and staff spend a few hours performing the surgery, as well as on postoperative visits, while the rest of the
healing time and care is delivered from the patient as well as
supportive, responsible family members or friends. It needs to
be stressed to the prospective patient that they are a viable part
of the team during the healing period. A separate consent form
should be included that highlights a patient’s understanding of
their part of the care and that they agree to such.
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Additionally, this author puts together care packs for the
patient and their responsible adult. This packet includes
gloves, vitamins, necessary topical ointments/creams, gauze,
tape, and all other necessary supplies. Most patients are not
in the health care eld and have limited education as to what
to purchase for the postoperative period. Within the care
packet are detailed, simplied instructions on how to use
each product. During the preoperative visit, the nursing staff
goes over all post-care instructions as well as the supplies
given. Furthermore, providing patients with contact numbers
of both staff and the surgeon is important. This allows
patients to have direct access to the medical staff for inquiries or any questions about both surgical progress and post
care.
The use of postoperative massage after liposuction has
proven to be of benet in our practice over the years. There
are vast differing opinions about what type of massages to
perform, when to start these in the postoperative period, how
long, how often, and when to stop this treatment. Each surgeon and their respective team will determine the application
of massages or not.
Furthermore, I believe that garment wear is essential to
creating a smooth contour as well as massaging. There exists
a multitude of garment companies worldwide and the opinion about garment wear differs with each surgeon and practice. Historically, garment wear was primarily employed to
help compress the treated area to prevent bleeding and hematoma formation. Early on, liposuction was used without
copious amounts of tumescent solution and therefore blood
loss was more profound. The garments used had much more
compression than the average garment used today. Garment
use, as liposuction, has had its own evolution. Today, garments have much less compression and the options for style
and coverage are vast.
This author prefers certain types of garment wear for
post-liposuction of the upper arms. The garments should not
have too much compression. A stage 2 garment is preferable.
Also, there should not be any seems or zippers along the
treatment area if possible. The coverage of the garment needs
to extend at least 10cm past the treatment area. A type of
body shaper that is in the form of a long-sleeve shirt is preferred. Remember, if a garment ends within a treatment area,
there will be compression up to the end of the garment and
no compression on the area not covered by the garment. This
can leave permanent creases and indentations within the
skin. Additionally, garment wear during the healing period
needs to be addressed every 4–7days. During the healing
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Fig. 5.6 Before and 1year after upper arm liposuction
process, the treatment area will have different levels of
edema and induration. Typically, the diameter of the arms
will reduce as the days move along. Therefore, reassessing
the size of the garments will need to be a process until full
healing and reduction in inammation have taken place.
Garment wear is commonly required for at least 3-months
duration, and longer if needed. Figures5.6, 5.7, 5.8, 5.9, 5.9,
5.10, 5.11, 5.12, and 5.13 show before and after images of
people who have undergone liposuction of the arms and are
happy about their results.
5.6.4 Complications
Unfortunately, unwanted outcomes happen in all surgical
practices. Despite a surgeon and their clinical staff’s efforts,
complications have to be expected. Protocols and plans need
to be in place to address all possible complications related to
each surgery offered. Part of the initial consultation should
be for the surgeon to give proper informed consent. It cannot
be stressed enough for the learning surgeon to rst learn to
manage all possible complications prior to performing any
liposuction (Table5.3).
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Fig. 5.7 Before and 1week
post upper arm liposuction
G. Alouf
Fig. 5.8 Before and 6months after upper arm liposuction
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Fig. 5.9 Before and
3months after upper arm
liposuction
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Fig. 5.10 Pre and post 5weeks after upper arm liposuction
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Fig. 5.11 Before and
6months after upper arm
liposuction
G. Alouf
Fig. 5.12 Before and 1year
after upper arm liposuction
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Fig. 5.13 Before and 2months after upper arm liposuction
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Table 5.3 Complications from liposuction
• Hematoma/seroma.
• Infection.
• Skin necrosis.
• Lipo ab igne.
• Contour irregularities.
• Adit site keloid or hypertrophic scar.
• Nerve damage.
• Dysesthesia.
• Extensive bruising.
• Delayed healing.
• Excessive bleeding.
• Severe pain.
• Deep venous thrombosis (DVT).
• Pulmonary embolus (PE).
• Fat embolism.
• Lidocaine toxicity.
• Death.
• Loose skin.
• Unsatised patient.
• Litigation.
5.7 Before andAfter Photographs
5.8 Pearls
1. Assess skin laxity as well as extent of fat deposits. Not all
large arms contain only fat.
2. Marking in standing position with arms at right angles as
well as by the side of the body is crucial.
3. Make sufcient entry points so that all areas requiring
tumescence and liposuction are well addressed.
4. Lipo-shifting to be done in all cases.
5. Garments and massages are of utmost importance. Can
make your own protocol and adhere to it.
References
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editors. Liposuction. Philadelphia, PA: Elsevier; 2006. p.105–11.
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Dekker; 2003.
3. Klein JA. Tumescent technique: tumescent anesthesia and microcannular liposuction. St. Louis, MO: Mosby; 2000.
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G. Alouf
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