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3 Preoperative Consultation andEvaluation
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Recommendation has been made in many publications that aesthetic surgeons must obtain an assessment, a written conrmation, and clearance from the
consultant psychiatrist that the patient is psychiatrically stable and does not have unrealistic expectations.
This would offer protection to the surgeon in any
adverse situation and also protect the patient as well.
3.6.6 Smoking History
• Major body contouring surgery requires skin removal and
the creation of large tissue aps. Vasoconstriction is caused
by nicotine and its products can result in necrosis of ap and
associated infection causing major wound- healing complications. Urine nicotine and cotinine tests can be a useful tool
to ensure cessation of smoking at the time of surgery [6].
Smokers should discontinue smoking for at least 2
weeks before to 4 weeks after surgery if they want to
undergo cosmetic procedures so as to reduce the chances of
wound-healing complications and improve outcome [7].
3.6.7 Nutrition
• A detailed history on the weight maintenance, exercise
regimen, and diet plan should be recorded.
• Preoperative tests should include complete blood count
(CBC), liver and kidney function tests, electrolytes, albumin, and prealbumin [6] at the least. It is not necessary to
screen for vitamin and micronutrient deciencies.
• The list in postbariatric body contouring should include
CBC; serum electrolytes; bleeding prole, which includes
prothrombin time, Indian rupee (INR), and partial thromboplastin time; ‘C’ reative protein and D-dimer; liver function tests, including serum albumin and prealbumin levels;
electrocardio gram (ECG); chest radiograph; 2 dimentional echocardiography (2D ECHO); pulmonary function
test (PFT); and Color Doppler of leg veins. Besides these,
it is important to check levels of ferritin, thiamine, cyanocobalamin, folic acid, calcium, magnesium, as well as
vitamin D3, which depends on the history of the weight
loss, physical examination, and type of bariatric procedure
[7] undertaken.
Anemia: Most patients after bariatric surgery have iron
deciency anemia. Assessment and correction of iron levels are important before surgery. Blood loss is possible
especially with large-volume liposuction as well as with
extensive tissue excision as part of body contouring procedures and can worsen an existing anemia, especially when
multiple procedures are undertaken at one time.
3.7 Examination ofDierent Body Parts
3.7.1 Physical Examination
• During physical examination the weight in kilograms and
height in feet should be measured. Weight should be measured on every subsequent visit.
• The body mass index (BMI) is calculated based on the
formula: weight in kg/height in m2.
• Depending on the patient’s requirements, the area of concern should be examined from all angles in sufcient light.
• When examined for particular body part surgery, the components to be examined include skin, subcutaneous tissue
or fat, muscles and their animation, and bony structure if
involved.
3.7.2 Skin
• The quality of skin should be noted, which should include
examination of scars, pigmentation, dryness, and stretch
marks (Fig.3.1).
• When examined for abdominal procedures, the skin should
be assessed to check for vertical and horizontal excess and
also for laxity in the different regions of the abdomen.
• The elasticity of the skin is of importance because it
determines the shrinkage that can take place after liposuction procedure.
• Check for scars, type of scars, and scar adherence to
deeper structures.
Fig. 3.1 Stretch marks over the abdomen and part of thighs
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3.7.3 Subcutaneous Fat
• When examined for body contouring, the thickness of the
subcutaneous fat of the anterior abdomen, anks, and the
back should be determined.
• Check for intra- or extra-abdominal fat deposits (Fig.3.2).
• Few patients may have both extra- (Fig. 3.3) and intraabdominal fat deposits and few patients may have predominantly intra-abdominal fat deposits (Fig.3.4).
Fig. 3.2 Patient presenting with extra-abdominal fat deposits
Fig. 3.3 Patient presenting with both intra-abdominal and extra-abdominal fat deposits
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Fig. 3.4 Patient presenting with predominant intra-abdominal fat deposits
• An abdomen that is protruding could be caused by a number of factors as mentioned below:
– Some male patients may be predisposed to depositing
large fat stores in the intra-abdominal area; in such
patients, the abdominal panniculus may be very thin in
spite of the person presenting with an extremely protuberant abdomen.
– These patients are not the most ideal candidates for
body contouring surgery such as liposuction and
abdominoplasty.
– Another reason for a protruding abdomen is a thick
panniculus as a result of massive weight loss (MWL).
• Pinch test.
– It is to assess the elasticity of the skin as well as mea-
sure the amount of fat under the skin (thickness of the
panniculus) in the area considered for treatment.
– If more than an inch of fat can be pinched, the area
may be suitable (Fig.3.5) for liposuction.
3.7.4 Abdominal Wall Laxity
• The protruding abdomen may also be caused due to the
laxity of abdominal wall.
Fig. 3.5 Demonstrating the pinch test
• Hernias should be looked for essentially, especially if
there is an unusual protrusion in the abdominal wall. If
present, check if the hernia is reducible and assess its contents which may be intestinal loops or visceral fat
(Figs.3.3 and 3.4).
• Diver’s test (Fig. 3.6) can be performed to assess the
abdominal laxity.
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M. Thomas and J. D’silva
• The patient is asked to stand with a straight back and told
to relax the abdominal wall completely. This exposes the
loose skin that may be present.
• Another test is performed where the patient is asked to lie
down in supine position and has to lift the neck and upper
back with legs kept straight while the surgeon palpates the
abdominal wall to check for bulges.
• This helps in assessing the laxity and extent of rectus
divarication as well as presence of hernias.
• Supraumbilical divarication is usually seen in some men
and women, whereas the infraumbilical rectus divarication was seen almost exclusively in women (Fig.3.7).
Fig. 3.6 Picture showing patient performing a classic diver’s test
• It may be difcult to assess laxity of abdominal wall in
obese people with thick subcutaneous fat.
• A clinical differentiation has to be made between subcutaneous and visceral fat as the no surgical body contouring technique can treat visceral fat. A simple way to
differentiate is to pinch the abdomen skin while asking
the patient to tighten the abdominal muscle; if pinch test
is signicant, then it is subcutaneous fat.
• Another helpful test is for such patients to be asked to lie
down supine and then observe their abdominal contour. If
the abdominal shape appears concave below the rib cage,
then they may require rectus fascia plication. This can be
conrmed by a leg-raising test. If the concavity is not
observed, then it is presumed that there is an excess of
intra-abdominal fat deposits.
• An abdominoplasty procedure on a patient having excess
intra-abdominal fat is fraught with danger and a bad
outcome.
3.7.5 Special Consideration intheMassive
Weight Loss (MWL) Patient
• Body shaping after massive weight loss requires combination of extensive procedures, which can cause signicant morbidity and possible mortality; hence a
comprehensive preoperative evaluation is mandatory.
• The history and examination should include discussion
on how the weight loss was done, surgery undertaken for
weight loss, any medical issues, laboratory tests, and also
examination of the abdomen for scars and hernias.
Fig. 3.7 Bodies with abdominal fat deposits and possible rectus divarication
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Fig. 3.8 A massive weight loss body
• The weight should have been stable for at least 3 months
with a maximum of 1kg uctuation at the time of undergoing body contouring [6] (Fig.3.8).
• Weight loss usually stabilizes within 18–24 months following bariatric surgery, and body contouring surgery
should be undertaken only after this weight stability is
achieved. If undertaken during weight loss, the skin laxity
will appear again thus defeating the purpose.
• Patients have to be counseled that body contouring surgery after MWL is composed of multiple stages and
hence can be considered as a process, as many procedures in different body parts with individual and compound risks and recovery times are required with added
expense [8].
3.7.6 Other Features
The examination of the abdomen should also include examination of the genital area and mons pubis. Fungal infection
and excoriation has been known to occur under the skin folds
of the abdominal pannus, which may cause suture line infection. Ptosis of the mons with excess fat must be noted, especially in patients who had very high BMI prior to the bariatric
procedure. Examination should also include checking for
buried penis or absence of testes or any deformity.
While examining the back, attention should be paid to fat
deposits in the waist, hips, ank, and lateral thigh regions.
Deviations in the spine (kyphosis), the depth of lumbar lordosis, and the extent of buttock’s projection also have to be noted.
3.8 Discussion About theBody
Contouring Procedure [9]
Not all the fat deposits in the body (fat deposits in various
areas) respond the same to restriction of calories or burning
of energy. Certain fat deposits are mobilized faster than others. It has been seen that calorie restriction and exercise in
obese women cause preferential loss of intra-abdominal fat
as compared to fat at the skin level. This can be explained in
part by studies that show different fatty acid composition
present in adipose tissue of different body sites. Studies by
Phinney etal. [10] have shown that higher levels of saturated
fat content is present in the subcutaneous fat of the abdomen
as compared to that from the outer thigh, which has higher
levels of polyunsaturated fatty acids. Different fatty acid
composition in different adipocytes may result in varied
response of those adipocytes to caloric restriction or excess.
Body contouring procedures to be discussed (based on
need) in aesthetic surgery include:
• Liposuction
• Lipoabdominoplasty
• Lower body lift—a combined procedure designed to treat
the lower trunk and outer thigh as a single unit
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• Belt lipectomy—the circumferential excisional tissue is
located at a higher level on the back and anks, as compared with a lower body lift
• Medial thigh lift
• Arm lift (brachioplasty)
• Shaping of the upper body in a male (upper body lift)
• Breast procedures (augmentation, lift)
With regard to body contouring vast majority of patients
often have unrealistic expectations, which may stem from
misleading advertisements on the Internet, TV programs,
social media, or unethical practice. Often, patients desire to
look like their favorite celebrities and many who desire aesthetic surgery have body dysmorphic disorder, which can lead
to troublesome lawsuits that can be emotionally and nancially draining as well as detrimental to a surgeon’s career.
Many celebrities have public relations (PR) team to take
care of their social media handles. One of the main roles of
the PR team is to make the pictures of those celebrities look
“perfect.” To get to that perfect tag, those pictures are obviously edited.
A detailed preoperative consultation is required to address
the above issues to select the right candidate as well as to
educate the patient before surgery. A good preoperative consultation that is recorded on paper as well as a video recording during explanation of procedure is ideal. Any last-minute
changes before surgery should also be recorded and signed
by patient. A detailed preoperative consult should be considered as an investment.
It is very important for the patient to understand at the
end of consultation that the body structure of each individual is unique and with surgery it can be aesthetically
improved by 50%, and that they should not expect their
body part to be made to t like their ideal celebrity. Also,
like other surgeries it does have its own complications,
which can be managed.
The purpose of a good consultation is also to build a rap-
port with the patient and to let them know that you are on
their side.
M. Thomas and J. D’silva
Fig. 3.9 6-month postoperative scar over the abdomen after abdominoplasty without umbilical repositioning procedure
3.8.1 Scars
• The cosmetic surgeon should have a detailed discussion
with the patient and make him/her understand about the
presence of scars after the procedure, which will be visible prominently before they fade. These will never
disappear.
• The position of the scars should preferably be drawn on
the patient to discuss its exact position.
• Scar migration with gain and loss of body fat and
weight, and relaxation of skin over time, should be
explained.
Fig. 3.10 10-month postoperative scar over abdomen and umbilicus
after abdominoplasty with umbilical repositioning procedure
• Change in appearance of scar over time (Figs.3.9 and
3.10), development of hypertrophic and keloid scars,
and treatment modalities for this should also be
discussed.
• There is a signicant possibility of skin irregularities and
residual deformities in body shape if the patients put on
weight after surgery (Fig.3.11), which will require further corrective surgery.
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Fig. 3.12 Pneumatic compression device
Fig. 3.11 Irregular fat deposition after liposuction due to postsurgical
weight gain
3.8.2 Thromboembolism (Discussion asPart
ofInformation During Consultation)
• This is a major cause of morbidity and mortality among
body contouring patients, especially those with MWL as
the risk of postoperative bleeding has to be weighed
against that of thromboembolic episodes.
• The physical prophylaxes such as intermittent pneumatic
compression (Fig.3.12) along with graded compression
stockings (Fig. 3.13) have to be routinely used before
induction of anesthesia and should be continued.
• These devices should be typically kept in place until the
patient is fully mobile after surgery.
• High-risk general surgical patients will require chemo-
prophylaxis with low-molecular-weight heparin (LMWH)
once daily. This should be continued for 3–5 days depending on the stability of the patient under the care of an
intensivist.
• Usually, chemoprophylaxis is combined with mechanical
prophylaxis using intermittent compression devices or
graded compression stocking in patients who have multi-
Fig. 3.13 Compression stockings
ple risk factors. Once daily dosing and decreased heparininduced thrombocytopenia are the advantages of LMWH;
however, it is more costly.
• LMWH should be started within 12 h of surgery and
maintained for 3–5 days. Incentive spirometry is encouraged, and patients are taught to use their devices ten times
per hour while awake.
3.8.3 Investment ofTime
• To achieve that perfect result in aesthetic surgery, it may
be required to undertake more than one surgery and
patients should be ready to invest their time and nances.
• If the patient has multiple areas to be contoured, then
multiple surgeries may be required for safety purposes.
• After belt lipectomy surgery, patients usually require a
minimum of 4 weeks to get back to limited activity and
about 8 weeks to resume full normal physical activity.
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This may be further extended in patients who have undergone muscle tightening or hernia repair procedures. Same
is true for other skin excision procedures as well.
3.8.4 Financial Considerations
A dedicated staff should be appointed to discuss nances and
if touch-ups are required postoperatively, the nancial policy
as per the clinic should be discussed.
3.8.5 Exclusion
• Medically or psychiatrically unstable patients should not
be undertaken for surgery.
• Patients with signicant cardiopulmonary disease and
active smokers should be excluded.
• Underage patients with no requirement for such
procedures.
• Noncompliant patients.
At the conclusion of consultation, the patient should
have a precise idea of what aesthetic surgery can, and more
importantly what surgery cannot, achieve and have realistic
expectations that will make them satised with the results.
Surgery is half accomplished in a preoperative
consultation.
3.9 Perioperative Patient Management
3.9.1 Pre-anesthetic Checkup
• Possible viable alternatives, risks and complications,
option of second opinion by another board-certied surgeon, and consent for photography and use of photos for
other patient education and publication in journals.
• Informed consent is updated on timely basis as required.
Diagrams wherever necessary should be drawn for
documentation.
• Medical records should contain the patient’s requirement
preferably in their own hand writing and the doctor’s recommendations with the reasons for advising the same.
• Preoperative photographs of the patient highlighting their
concern should be taken along with the postoperative
photographs every time they visit, which should be kept
in a secure place on the computer or preferably in an
external drive with a backup.
• The patient should be explained about the procedure in
lay terms and also given scientic name of the procedure
so that they can read about it on the Internet.
• The risks and complications associated with the procedure and/or the technology used must be explained in
detail to the patient, as well as any viable options, surgical
or nonsurgical, with their possible advantages or disadvantages along with risks, should be discussed.
• The patient must make a knowledgeable decision concerning the surgery.
• The areas to be treated must be listed completely, for
example, different areas for liposuction, various steps of
the circumferential body lift, etc., so that there is no inference that particular areas were not treated.
• If any addition is done to the previously discussed and
documented surgical plan on the day of surgery, then it
should be recorded with an explanation and the procedure
recorded in the written consent.
• Explain that the tests are done to assess and prevent
complications.
• Should be done after lab and cardiopulmonary tests to
determine American society of anaesthesiologists (ASA)
grade, tness for surgery, and if any specialist referral is
required. A written clearance should always be obtained
from cardiologist, pulmonary physician, and psychiatrist.
• Rohrich etal. suggested that central body lifts be limited
to patients with ASA grades of 1 (healthy) or 2 (mild systemic disease) [8].
3.9.2 Informed Consent [11]
A consent paper signed by patient does not amount to
informed consent. It can be challenged in court of law.
• Informed legally valid consent includes explanation of the
proposed procedure, and need for multiple procedures.
3.10 Preoperative Instructions
• Preoperative instructions should be given in detail not
only orally but also in a written format. Risks and complications should also be explained orally as well as in
writing.
• Liposuction preoperative instructions.
• Information on liposuction [11]
– Blood transfusions are rare.
– Preoperative chest X-ray, electrocardiogram (EKG),
and blood tests are necessary.
– Always assess for varicose veins before undertaking
liposuction of the legs. If present it should be treated 3
months before liposuction of the legs.
– Absolutely do not gain weight before surgery.
– Cessation of smoking for at least 2 weeks before to 4
weeks after surgery.
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– Report history of excessive bruising and non-stoppage
of bleeding to the physician.
– Report prior mental disorder, drug or alcohol addic-
tion, or any treatment taken for the same to your
physician.
– Please inform if you have high blood pressure and on
medication, diabetes and on medication, thyroid and/
or asthma and on treatment.
– Anticoagulants (blood thinners) should be stopped
after discussion with the physician who prescribed
them at least 5 days prior to surgery, with INR to be
checked prior to surgery.
– Medications such as aspirin, and vitamins such as vita-
min C and E should be discontinued 2 weeks before
surgery and can be started 1 week later.
– It is preferable not to schedule body contouring sur-
gery in a female close to/during the menstrual
period.
– Take a shower with chlorhexidine or povidone iodine
skin cleansers a day prior to and on the day of
surgery.
– All birth control pills and hormone replacement ther-
apy having estrogen must be stopped 4 weeks prior to
surgery to 2 weeks after it.
– Cytochrome P450 (CYP3A4) inhibitors:
Cytochrome P450 3A4 inhibitors compete with
enzymes that break down lidocaine; hence drugs
like benzodiazepines can cause lidocaine toxicity
during tumescent anesthesia even at a much lower
dose. These medications should be avoided for 3–7
days prior to surgery.
Carbamazepine, Cimetidine, Clarithromycin,
Dexamethasone (Decadron), Diltiazem,
Erythromycin, Flurazepam, Halcion, Medrol,
Metoprolol (Lopressor), Metronidazole (Flagyl),
Midazolam (Versed), Procardia, Propranolol
(Inderal), Propofol (Diprivan), Restoril, Sertraline,
Tetracycline, Thyroxine, Valium, and Xanax.
– Herbal Supplements: The American Society of
Anesthesiologists recommend that patients should
stop taking diet and herbal supplements 2–3 weeks
before surgery since these interact with anesthetic
drugs and may cause prolonged anesthesia.
• Any bright red bleeding as opposed to blood-stained
soakage has to be reported at the earliest. Blood-stained
soakage after liposuction is expected especially on the
rst day. Any shortness of breath, pus discharge, or
unusual pain should be immediately communicated.
– Prescription will be provided for antibiotics, painkill-
ers, antacids, and a B-complex. Diet plans and limited
physical activities are communicated to the patient in
advance.
– Patient should be home bound for 2–3 days when only
ambulation to the bathroom or within her/his room
with help is recommended. Some soakage from the
access points is to be expected.
– A review is usually recommended at 3–5 days after
which showers can be started with waterproof dressings on.
– The garment (Fig.3.14) can be removed and washed at
any time after 5h postoperative day. This garment can
be gradually downsized over the next 4 weeks for a
snug t.
– Lymphatic drainage can be instituted after the third
day. This can smoothen out any lumps as well as helps
in reduction of the swelling. Edema in liposuctioned
areas may last for many weeks.
3.11 Postoperative Instructions
(Discussion asPart ofInformation
During Consultation)
These should be discussed with the patients before surgery.
These should be reiterated post-surgery as well, to the patient
and his/her relative. This becomes more important if patient
is undergoing day care surgery.
Fig. 3.14 Pressure garment worn after full body liposuction surgery
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– Ambulation can cause swelling of the legs, which can
be relieved by elevation of the legs. If it is due to constriction of the lower edge of the garment, then the
constriction should be released.
– Surgeon has to be notied about any fainting
incidents.
– Emotional depression after surgery is common.
– All medications as prescribed and instructed have to be
taken.
– Weight gain will cause fat deposition in all areas with
a preponderance of fat deposition in non-operated
areas.
– Final result after liposuction may take up to 3 months
and any touch-up or revision resculpting should only
be done after that period.
– No guarantees given or implied.
– All known benets and options discussed in great
length and all queries and concerns addressed.
3.12 Postoperative Concerns (Discussion
tobePart ofInformation During
Consultation)
Postoperative concerns need to be brought to the notice of
the patients. Discuss these with patients so that patient knows
that you can manage these.
13. Dissatisfaction with the outcome leading to touch-up
procedures may be required to correct post-surgery
problems.
14. Psychological disorders may appear during the recovery
period.
15. Major complications such as lung and abdominal organ
perforation are possible with injury to bowel, liver, and/
or bladder, which requires early diagnosis and major
surgery. Lung perforation will cause breathing difculties with lung collapse and emergency intervention.
16. Death is extremely rare but possible.
3.13 Summary
Body contouring by liposuction is one of the most common
elective cosmetic surgeries that is being performed world
over. Though the outcomes are based on the art and craft of
the surgeon, the safe perioperative phase depends on thorough evaluation of the patient and the right choice of patient.
For any cosmetic procedure, the success depends largely on
the consultation process and perioperative management. The
result, good or bad, usually gets overshadowed by it. For a
succesful procedure and an acceptable outcome, the surgical
expectations of the patient need to be brought to a practical
level wherein the expectations are realistic.
1. Anesthesia and surgical drug complications, which may
include lignocaine toxicity, nausea and vomiting, drug
allergies, etc.
2. Swelling and seroma (visible as localized uid
deposition).
3. Bruising and hematoma, especially in smokers.
4. Pain initially followed by a feeling of numbness, itching,
and burning as the sensation returns.
5. Nerve damage; decrease or loss of sensation;
paresthesia.
6. Delayed healing and prolonged drainage caused by
infection, which may be limited to the incision or may
spread causing septicemia (blood infection), cellulitis,
and toxic shock syndrome.
7. Extensive skin necrosis with loss of skin (necrotizing
fasciitis) is possible.
8. Thrombosis of the veins with or without pulmonary
embolism, fat embolism, and pulmonary infarction.
9. Scar can be atrophic, hypertrophic, or keloidal, with pigmentation of the scar and/or overlying skin.
10. Hypotension and or bleeding may require uid or blood
transfusion.
11. Labial and scrotal edema may occur, which is
temporary.
12. Blisters due to contact dermatitis or reduced supercial
skin vascularity are possible.
References
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