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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_511_Библиотеки_им_академика_М_И_Перельмана
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6 Lower- Limbs
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Fig. 6.72 Post-operative garment
119
6.14 Complications
Complications include hematomas and seromas, which are
rare. Bruising can be minimized by giving patients bromelain (Fig.6.73), which is a pineapple extract, pre-operatively.
Patients should be asked to refrain from taking aspirin and
other nonsteroidal anti-inammatory agents.
Other immediate post-operative complications include
bruising, [35] swelling, irregularities, unevenness, puckering,
and asymmetry. The most common complication following
liposuction is contour irregularities (Figs. 6.74 and 6.75).
This can be avoided by performing liposuction in a deeper
plane and using small cannulas.
If this complication is recognized intra-operatively, then
analogous fat transfer can be done by using what I call “liposhifting” [36]. This is done by turning off the vacuum pump
and using the power-assisted liposuction to emulsify the surrounding fat and then molding it into the area of irregularity.
Secondary correction will require fat grafting (Fig.6.76).
Infection and cellulitis are rare complication. The patient
should be given antibiotics pre-operatively and for 5 days
post-operatively.
Other complications include hyperpigmentation, which is
due to hemosiderin deposits from ecchymosis and due to
prolonged compression. Patients should avoid sun exposure
and certain medications, such as iron supplements and
estrogens.
The most feared, and possibly fatal, complications after
liposuction is the development of deep vein thrombosis and
pulmonary embolism. [37] Acute awareness of this issue is
Fig. 6.73 Post-operative
bruising
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Fig. 6.74 Rippling due to cannula being too supercial
K. Bhangoo
Fig. 6.76 Post-operative
depression medial thigh
corrected with fat grafting
Fig. 6.75 Post-operative depressions and dimpling
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121
important. Unlike deep vein thrombosis in conventional surgery which usually occurs 7–10 days after surgery, acute
deep vein thrombosis can occur following liposuction within
24 h or so. This is because considerable tissue damage
results during the liposuction and many toxic and thrombogenic substances are released which can cause acute thrombosis. A sequential compressive device should be used
during the surgery. Ambulation should start on the day of
surgery. TED stockings should be used for a few days after
post-operatively.
A high degree of awareness and early detection of deep
vein thrombosis is important. Calf pain and acute swelling
of the legs and ankles, calf tenderness, Homan’s sign, and
distended veins on the dorsum of the foot post-operatively
should raise a suspicion of deep vein thrombosis and a
venous Doppler should be immediately obtained.
Fat embolism can occur. This happens with very large
volume liposuction and with large caliber cannulas. The
patient will complain of chest discomfort and shortness of
breath. A chest X-ray should be ordered. It can be easily
diagnosed by putting a few drops of urine under the microscope which will show fat globules. Use of steroids intraoperatively can help prevent this complication. Steroids can
also be used therapeutically. The author uses IV steroids,
such as decadron, intra-operatively which is the treatment for
fat embolism. In addition, it is also euphoric and antiemetic.
6.15 Pitfalls
1. Complications frequently result from the use of large can-
nulas. The cannulas with a diameter of 4mm for supercial areas and 5mm for the deeper layers should be used.
Avoid using larger cannulas.
2. End hits should be avoided as this will result in dimpling.
3. The holes of the cannulas should be pointed toward the
deeper surface to avoid irregularities and puckering.
4. When performing liposuction around curves, it is impor-
tant to avoid end hits and, if necessary, more incisions can
be made to allow access.
5. Asymmetry is another complication which should be
avoided. This can be avoided by ensuring that the deformity is symmetrical. Care should be taken to ensure that
equal amounts of fat are removed from corresponding
areas and compensation made in case of asymmetry.
6. Avoid excessive suctioning in gluteal areas as this will
result in sagging.
7. Avoid tight tting garments, particularly along the upper
edges, as this may cause excessive compression and result
in femoral vein thrombosis.
8. Care should be taken to keep in mind gender variations.
In females, there is a less amount of lipodystrophy in the
waist areas and excess in the hips and buttocks. In males,
there is excess lipodystrophy in the ank areas. Care
should be taken to ensure gender variations and prevent
feminization or masculinization.
6.16 Personal Tips andPearls
1. When multiple areas are treated, care should be taken to
treat these areas segmentally rather than treating all
areas concomitantly. Each segment should be inltrated
with the wetting solution and suctioned before
proceeding to the next segment. This will avoid uid
overload and also conserve heat and prevent
hypothermia.
2. Enough time should be allowed for the tumescent solu-
tion to result in vasoconstriction before commencing the
procedure.
3. Small cannulas should be used. For supercial areas,
4 mm cannulas and, for deeper areas, no larger than
5mm cannulas should be used.
4. During liposuction of the supercial layer, the holes of
the cannula should face toward the deeper tissues.
5. Avoid end hits, particularly around curves.
6. When treating an area, liposuction should be performed
systematically in a fan-shaped manner, commencing
from one extremity of the deformity to the other. Doing
liposuction in a haphazard manner will result in irregularities and unevenness.
7. When doing large volume liposuction, a layered
approach should be used. The supercial layer should be
liposuctioned rst and then the deeper layer should be
suctioned with a larger cannula.
8. One should monitor the aspirate. When the aspirate
becomes bloody that indicates the end point. Care should
be taken to suction around curves and, if necessary, additional incisions should be made in order to avoid end hits
and resultant dimpling.
9. The cannula tip should be constantly felt with the non-
dominant hand to determine its location in the tissue
plane.
10. The suction cannula should be kept constantly in motion
to prevent excessive suction in one area.
11. At the end of the procedure, before closing the incisions,
all uids should be expressed from the tissues as this
will prevent uid accumulation post-operatively and
prevent seromas.
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K. Bhangoo
6.17 Conclusion
Liposuction has evolved signicantly since its inception in
the 1980s. With improvements in patient selection, uid
management along with guidelines for both pre- and postoperative monitoring, prevention of deep vein thrombosis
and together with the technological advances in equipment,
it is a safe and effective treatment for lipodystrophy and body
sculpting.
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Back Rolls andTheir Treatment Options
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MohanThomas andJamesD’silva
Shaping of the abdomen, buttocks, and thighs by lipocontouring has been prevalent for a long time but not much
attention was given to the shape of the back particularly
because the area is hidden. The back of a female has particularly become a concern due to the changing styles in their
outts. The skin–fat envelope of the back normally adheres
tightly to the underlying musculoskeletal anatomy of the rib
cage. This envelope is held in place by facial attachments
which are akin to the “zones of adherence” described by
Rohrich etal. [1] Most patients associate these bulges with
just fat deposits whereas in reality it may be a combination of
fat as well as skin excess.
From an aesthetic point of view the back, waist, and hips
of a female body looks like an “hourglass gure” [2]. Any
tissue bulge that obliterates this shape will make the female
form look more cylindrical and will have to be treated to
restore the curve. Several surgical and non-surgical procedures for reducing the waist size as well as the back rolls
have been described but by far the most commonly used
technique includes use of Ultrasound-assisted lipocontouring which is minimalistic with a shorter healing period.
Deep connective tissue attachments to the underlying
muscle and/or periosteum divide the fat deposits on the back
into multiple visual compartments (Fig.7.1). Their nomenclature is based on the anatomical area from where they have
originated. Only the dorsal hump present at the base of the
cervical and upper thoracic spines and the sacral fat pad are
considered to be discretely localized fat compartments while
the other areas can be considered as a rather uniform layer of
subcutaneous fat [3].
M. Thomas · J. D’silva (*)
Cosmetic Plastic Surgery, Breach Candy Hospital and D.Y. Patil
University, Mumbai, Maharashtra, India
7
Fig. 7.1 Multiple soft tissue folds on the back formed by the connec-
tive tissue attachments to the deeper musculoskeletal structures. The fat
bulge on the scapular area (yellow) is categorized as a “Posterior axillary or Back fold,” the bulge below the scapula is the “subscapular fold”
and the bulge that covers the waist area is the “Hip fold”
7.1 Supra-Iliac Area (Hip Fold)
• This is the most frequent site of adipose tissue accumulation in both men and women but very prominent in men.
• There is a considerable growth of fat in the lamellar layer
which is responsible for the loss of the body’s contour in
this region (Fig.7.2).
• The increased fat deposit in this layer gives the typical
apple shape to the mid riff. This causes loss of narrowing
at the waist line specially in females having polycystic
ovary disease.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
M. Thomas, J. D’silva (eds.), Manual of Cosmetic Surgery and Medicine, https://doi.org/10.1007/978-981-19-4997-5_7
123
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Fig. 7.2 The typical fat
deposits in the supra-iliac and
the lumbar area
M. Thomas and J. D’silva
7.2 Lumbar Area (Subscapular Fold)
• The anatomical constitution of the lumbar area includes a
very thin lamellar layer which does not increase in thickness with fat deposits as much as on the suprailiac region
(Fig.7.2).
• This is the primary back roll which most patients are concerned about.
• It is bound superiorly by the extension of the inframammary crease which rises superiorly as it traverses towards
the spine.
• Inferiorly it is bound by the brous extensions to the oating ribs.
• Posteriorly the zone of adherence is to the midline spine.
• During weight gain, zones of adherence prevent fat deposits in the midline anteriorly and posteriorly and the maximum fat deposits are laterally.
• During massive weight loss the lateral tissues being
unsupported and located at the maximum distance from
the zones of adherence anteriorly and posteriorly tend to
descend. The degree to which this deformity occurs may
vary in patients and depends on fat deposit and loss pattern, quality and tone of overlying skin, body mass index,
and the genetic predisposition [4].
7.3 Scapular Region (Post-axillary or Back
Fold)
• The third area of the torso to present accumulation of fat
is the scapular region.
• The thickness of the lamellar layer increases greatly and
often one can observe asymmetry of the fat bulges.
• The areolar layer shows some alterations but never as
much as the lamellar layer.
• When the lamellar layer shows localized adiposity, the
subcutaneous panniculus is rm and does not slide easily
over the muscular plane.
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125
7.4 Surgical Anatomy ofBack Tissues
1. The skin on the back is very susceptible to hyperpigmentation. This is due to injury to the dermo-epidermal junction during the process of liposuction especially at the
access points. Use of VASER and other technologies
without adequate protection can predispose to postinammatory hyperpigmentation.
2. The dermis in the area is thick and since only supercial
fat is present with no lamellar layer, it is important to
keep the cannula moving during liposuction.
3. Deep and aggressive liposuction in this area can damage
the cutaneous branches arising from the muscles causing
a bloody liposuction return. Use of VASER technology is
safer due to the density of the subcutaneous tissue as well
as the ease of the surgery.
7.5 Blood Supply
The primary blood supply to the areas of back rolls is from
the perforating branches of the underlying muscles as seen in
Fig.7.3.
7.6 Treatment Options
1. Non-surgical—Injection Lipolysis.
2. Suction-assisted Liposuction along with Use of VASER
and RFAL or J-Plasma.
3. Lipectomy as Part of Upper Body Lift.
7.7 Management ofBack Rolls
1. Assessment: Patients usually present with complaints
that the area below the bra is bulgy and looks unsightly
specially with nick names used as “back boobs.” They
might also complain of discomfort when wearing tight
clothes which makes the back look wider as these bulges
fall out of the brassiere [5]. Once the patient has shown
concern with regard to the back bulges, a complete clinical evaluation of the back skin is carried out. Special care
to be taken when assessing the following:
(a) Quality of skin: Toned and plumpy skin in the area
will have good skin retraction whereas crepey skin
will not improve much with minimalistic
procedures.
(b) Presence of stretch marks: This denotes that the skin
in the area has undergone stretching multiple times
due to weight gain.
(c) Extent of subcutaneous adiposity—best assessed
with a pinch test.
(d) Extent of hanging skin. Area to be examined with
hands by the side of the body and also with arms
raised.
(e) Assess the number of folds and whether they are
deep or supercial. Deeper folds are cause by dense
adhesions and they compromise a smooth transition
of the upper back (Fig.7.4).
Fig. 7.3 Blood supply of the back rolls
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Fig. 7.4 The common
concerns with regard to back
rolls in a female. The points
of assessment are mentioned
in the photograph
M. Thomas and J. D’silva
1. Number of
Folds
2. Depth of
folds
3. Pinch test
4. Skin tone
5. Skin
laxicity
7.8 Injection Lipolysis
Subcutaneous injection of phosphatidylcholine (PC) solubilized in deoxycholate (DC) has been purported to eliminate body fat by fat cell lysis which was conrmed in a
study by Rotunda and colleagues [6]. Phosphatidylcholine
is a glycerophospholipid while sodium deoxycholate is a
bile salt that is also used as a laboratory detergent and is
used to solubilize phosphatidylcholine by forming mixed
micelles composed of phosphatidylcholine and
deoxycholate.
We have used the PC-DC mixture in varied age group
patients. The maximum dose of PC used in one sitting is 5g
and the minimum interval between two subsequent sittings
is suggested to be not less than 4weeks. The depth of the
injection in the back is 10mm [7]. The maximal appreciable
effect is achieved in 80% of patients by day 10; however, the
drug continues to act for 6–8weeks. The injection sites are
guided by a custom-made predesigned grid, which ensures
that the injections are adequately spaced, and the projected
cone of lipolysis has a minimal overlap ensuring a smoother
transition into zone of neighboring injection (Fig.7.5). The
most common complaint after the procedure is a stinging
type of a pain. Other complaints after the procedure were
erythema, edema, induration, and formation of subcutaneous nodules, which resolved over a period of time. Accidental
injection into the muscle causes excruciating pain due to
myonecrosis and hence we recommend pinch technique for
injections [8].
Indications: For early back rolls with no loose skin.
In people with excellent skin tone.
Patients with small amounts of excess fat volume (up to
250mL). Results are encouraging if the nature of excess fat
is easily compressible and of uniform texture.
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127
a
b
c
Fig. 7.5 (a) Marking of the grid pattern, (b) injection of the lipolytic solution using a pinch technique, (c) hyperemia in the injected area imme-
diately following the injection
7.8.1 Mechanism ofAction
1. Phosphatidylcholine emulsies fat, component of apolipoproteins and component of cell wall.
2. Injection causes cell wall destruction.
3. Stored triglycerides are emulsied and transported to
liver for metabolism.
7.8.2 Procedure Steps (Fig.7.5)
1. This procedure is usually carried out under the inuence
of EMLA (Eutectic mixture of local anesthesia) application. Only if patients have a very low pain threshold or if
they are considering any other associated surgery do we
undertake it under complete anesthesia.
2. The rst step of the procedure includes marking of the
area of fat deposit. This is undertaken in the standing
position and the area requiring injection lipolysis is conrmed with hands by the side and then with the arms
raised. Once the topography of the fat bulge has been
marked, a preformed grid pattern with holes 1cm apart is
used to mark the points of injection (Fig.7.5a). This is
required so that the drug can be injected uniformly in the
whole area. A pain killer injection (Diclofenac sodium) is
injected to reduce the pain and burning caused by the
caustic solution.
3. Once the area has become numb due to application of
EMLA (wait for atleast 30min with occlusive dressing), 50% dilute solution of PC+DC is injected in
the area. The tissue is pinched (Fig.7.5b) in between
the thumb and the forefinger following which the
lipolytic solution is injected into the depth of the
fold, taking care that the drug is not injected into the
muscle.
4. 0.5mL of the lipolytic solution is injected at the center of
the marked area while 0.3mL of solution can be injected
at the periphery.
5. This injection causes intense burning and redness in the
injected area due to the lysis of the lipocytes. Application
of ice cold compresses on the area helps the patient manage this discomfort.
6. Patients may require up to 4 sessions of lipolysis for the
best result which should be carried out at intervals of
6–8weeks (Figs.7.6, 7.7, and 7.8).
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M. Thomas and J. D’silva
a c
Fig. 7.6 (a) Pre-treatment photograph of the back roll seen in this 45years old lady. (b) Bruising in the area of lipolysis after 7days of treatment.
(c) Same lady 6weeks after the rst session of lipolysis
a
b
b
Fig. 7.7 (a) Pre-treatment photograph of a young girl who was concerned about her back rolls. (b) Reduction in bulges seen after 3 sessions of
injection lipolysis undertaken over 4months
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