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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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M. D. Soriano
Fig. 8.1 (1) Sacrum V zone; (2) Flank; (3) Upper buttock; (4) Lower
dorsum; (5) External of the leg; (6) Buttock; (7) Diamond zone; (8)
C-point; (9) Back of the leg; (10) Upper dorsum. (Courtesy:
C. Mendieta. Buttock remodeling with liposuction and fat injection.
Body sculpting and liposuction. J. Peter Rubin, Ed. Elsevier, 2014;
447-460)
Fig. 8.2 Marking of the interest zones with typography references
while standing and photographic documentation
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Fig. 8.3 Photography and preoperative marking arranged with the patient in the standing position
8.3 Patient Selection (Personal Approach)
With the aim of decreasing probable complications and bad
results, I prefer to do at least two preoperative consults in
which I document medical and surgical history, physical
examination, and other considerations to take into account
concerns such as psychiatric disorders body dysmorphic
disorder (BDD), unreal expectations with regard to the
liposculpture, and relevant details.
Patients who are considered suitable for this procedure
must be healthy and understand the treatment completely.
Furthermore, they must be conscious about their active role
in the postoperative stages, and lastly they must follow the
surgeon’s postoperative instructions. People under 18 years
of age; active smokers who have more than 5 cigarettes a
day; people with a body mass index (BMI) over 30; people
who are diagnosed with diabetes; people who present with
blood dyscrasia, blood thinners, and anti-aggregates; and
people with a history of coronary artery disease, deep vein
thrombosis (DVT), stroke, and pulmonary thromboembolism are excluded.
The procedure will be explained in detail by the surgeon
and both the operating surgeon and the patient must sign the
preoperative consent form.
The surgeon takes pictures of the patient and also the
patient will be marked when standing with indelible ink
before entering the operation room either the day before the
surgery or on the same day.
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8.4 Preparation ofthePatient
A nasal swab is done in order to rule out nasal colonization
of Staphylococcus [3]; in addition, the patient must shower
every day for a week prior to surgery with 2% chlorhexidine gluconate shampoo. The patient should shave 7 days
before the procedure [4]. A dose of enoxaparin sodium is
administrated to the patient 12 h before the procedure
according to his or her weight and depending on the risk
factors. Low- molecular- weight heparin (LMWH) may be
administered.
When the procedure is completed and when the patient
fully recovers his or her mobility (approximately 3 or 4h
later), relative rest is recommended, without long relaxation
breaks. It is highly recommended that the initial compression
garment be somewhat lax [5].
Patient should maintain good hydration for 5 days previously with isotonic drinks. Furthermore, the day the procedure is done the person must remain on clear uids for up
to 3h before and 6 h fasting for solids according to the
ERAS—Enhanced Recovery After Surgery—protocol, in
which it is allowed to ingest solid food even 6h before the
procedure, and also drink tea, coffee, and fruit juice without pulp up until 2h before the procedure, so as to decrease
peripheral insulin resistance that is produced by preoperative fasting, without increasing the risk of bronchial aspiration, and moreover decreasing thirst, hunger, and
preoperative anxiety [6, 7].
8.5 Anesthesia
The anesthetic techniques used include sedation with propofol and remifentanil with intravenous sedation, combined
with epidural anesthesia or spinal anesthesia depending on
the particular case. A Board-certied anesthetist choses the
best anesthetic procedure for the patient, whether it be
regional, local, epidural, or full general anaesthesia (GA).
When liposuction is required in the upper back and in
cases in which a revision of small areas are required, we use
local tumescent anesthesia (Fig.8.4) that is made of [8]:
– 60 mL of 2% lidocaine solution
– 1mL 1:1.000 epinephrine
– 1000mL 0.9% NaCl solution
– 15mL 8.4% NaH2CO3 solution
Continuous cardiac and venous oxygen saturation monitoring along with administration of oxygen if required is
undertaken. I only use general anesthesia if the anesthesiologist suggests so and moreover after the patient´s evaluation [9].
M. D. Soriano
Fig. 8.4 Tumescent solution inltrate (with syringes and in other cases
with perfusion pump)
8.6 Surgical Procedure
The patient is made to lie down on the operative stretcher in the
lateral decubitus that is better suited for the type of lipocontouring that will be done. Changes in the decubitus are always done
respecting the sterile eld and the operation room.
Inltration of tumescent solution is undertaken, which is
made of 1mL epinephrine per liter of saline at 1:1.000, and
the maximum quantity injected is 4L, which is strategically
distributed through small skin incisions so that access to
every spot is guaranteed.
The lipocontouring is undertaken in a crisscross manner
using 5 mm cannulas in the deepest zones controlling the
color, quantity, and quality of the blood in the suction aspirate,
and using 3 and 4mm cannulas supercially. A pinch test of
the skin is undertaken continually when supercial liposuction is undertaken to achieve evenness (Fig.8.5).
Then, I highlight the core, the lunate line, obliques, and
the iliac crest in case the patient wants a better denition of
the anterior region.
In liposuction of the back and trochanteric region I tend to
use suction-assisted liposuction with traditional equipment,
reserving the assisted liposuction with diode 910 laser for
those cases where the loose skin is predominant and that in
my view results in more postoperative skin retraction.
Lastly, I undertake the 2-cm skin-fold test especially in
denition zones to compare the right to the left side (Fig.8.6).
Once the 2cm pinch is achieved, I start the ne-denition
liposuction for supercial renement using ner cannulas
and also using diode laser. As a general statement, I do not
perform liposuctions over 4L provided that the preoperative
conditions and lab values are normal, even though there are
no regulations in Argentina to prohibit it.
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Fig. 8.5 Supercial lipo-aspiration using a 4mm cannula and the other
hand controlling the depth
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8.7 Fat Grafting oftheButtocks
Once the liposuction and the ne-denition process are successfully completed, we will proceed with the fat grafting in
the gluteal zone. It is extremely important to know the anatomy of the gluteal region and the precautions to avoid fatal
complications.
Over the last few years, I have practiced decantation, ltering, and the centrifugation of the adipose tissue prior to
inltration. According to the global references, there are no
signicant differences in between the reabsorption rate and
survival of grafted fat. Nowadays, I use simple decantation
that is quite simple and I consider that tissue manipulation
and contact with the open air is much less and also does not
require extra equipment.
Two years ago I incorporated carbo–pneumo dissection of
the subcutaneous space (Fig.8.7), which simplied the procedure and allows safe grafting above muscles, generating the
effect of tunneling and expansion of the receptive area as
advocated by Rigoni in breast fat grafting. It generates oxygen gradients in the zones with angiogenesis due to high level
of CO2 being inltrated and as a result of the Bohr effect [10].
Fig. 8.6 A 2-cm pinch test, which indicates the starting point of the
supercial renement
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M. D. Soriano
Fig. 8.7 Carbo–pneumo dissection prior to fat graft of the buttocks
8.8 Personal Approach
I use a 4mm cannula with two linear access points that are
directed toward the skin surface during the injection; with a
Toomey syringe, the placement of fat is done in small aliquots in a retrograde manner and during this process I try to
avoid leaving big bolus of localized fat. I inject 2cc of fat
over a 10cm distance during withdrawal of the syringe.
The patient’s position during the procedure will be prone
decubitus with the thorax falling slightly off the table
(Fig.8.8). I try not to add new access points for the liposuction in case they are not needed.
According to the latest reports, it is not advisable to graft
fat at the level of gluteal muscles due to the overwhelming
number of deaths that have been reported. This puts the mortality risk from gluteal fat augmentation as 10–20 times
higher than the average mortality rate for aesthetic surgical
procedures [11, 12].
In Argentina, large amount of gluteal fat graft is not popular due to demographic and cultural reasons. On an average, 500cc is injected in each gluteal cheek. It is a technique
that is frequently combined with the placement of butt
implants, known the world-over as “composite buttock
argumentation” (Fig.8.9). It includes insertion of small butt
Fig. 8.8 Prone decubitus of the patient with the direction of the syringe
during fat transfer into the buttocks
implants intramuscularly and grafting fat in the periphery to
improve the contour of the gluteal region in a more natural
way, and without the risk of fat embolism. Grafting large
amounts of semi liquid fat exerts pressure on the gluteal
muscle resulting in migration of fat deep into the muscle
into the vascular space along the muscle septa [13].
Figures8.10, 8.11, and 8.12 show pre- and post-procedure
photographs of patients who have undergone back and gluteal contouring.
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Fig. 8.9 Composite gluteal augmentation. Intramuscular 225cc POLYTECH round smooth gluteal implant plus 100cc fat graft each side. 1 year
postoperative
Fig. 8.10 Fat graft to buttocks; 600 cc each side; lateral view; 1 year postoperative. Fat graft to buttocks; 600 cc per side; 1 year postoperative
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M. D. Soriano
Fig. 8.11 Med-denition lipocontouring and fat grafting of 180 cc per side; 8 months postoperative
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Fig. 8.12 Med-denition lipocontouring; 1 month postoperative; no gluteal graft
8.9 Postoperative Care
Early mobilization after the blocking effect of spinal anesthesia wears away is the fundamental requirement in order to
prevent the patient from DVT.In the same way, as I have
mentioned in the postoperative period depending on the
comorbidities, low-molecular-weight heparin may be
injected depending on the patient’s weight.
At least for 5 days there should be no pressure in the gluteus region as shown in Fig.8.13, and it is suggested that
during the rst month of postoperative period the patient try
to use the glute region just for minimal movement and with
short intervals of support.
For the rst 8 weeks postoperatively, patients are asked to
place a pillow under the hamstring muscles when sitting, in
order to elevate the buttocks and keep pressure off the incisions and the grafted areas (Fig.8.13). Postoperative compression girdles are used for at least 20 days. The garment
helps to reduce swelling, might reduce seroma formation,
and speeds attainment of the nal contour.
Sometimes continuous suction drains are left in place,
and in others, with prior discussion and consent of the
patient, the liposuction incisions are left open to allow free
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Fig. 8.13 Avoiding pressure on the fat-grafted gluteal region
M. D. Soriano
– Make access points within the bikini line and natural
creases.
– Access point should be at least 1 mm larger than the
diameter of the cannula to decrease friction injury to the
skin.
– Use a smaller cannula.
– Use plastic sleeves on the access points (especially with
energy-based devices).
– Liposuction should be done in a slow and meticulous
fashion to decrease friction burns at the access points.
Surgical complications of liposuction are well known.
The emphasis until now, and legitimately so, has been on
life-threatening complications mainly related to anesthesia
and deep venous thrombosis. Preventive measures must be
taken against most of the complications caused directly by
surgical trauma. Tissue handling and technical nesse are
equally important in minimal-access procedures as in open
surgery.
Unfortunately, many plastic surgeons consider liposuction to be an easy, entry-level procedure in aesthetic surgery.
With due diligence, complication levels can be brought down
to acceptably low levels, thus increasing the general condence in this procedure.
With regard to supercial liposuction, ultimate care must
be taken in order not to injure the subdermal venous plexus,
and also we must try not to reduce the supercial fat compartment drastically.
In laser-assisted liposuction, burns and subsequent postinammatory pigmentation may occur, which are extremely
difcult to treat. This happens because of the lack of care
and, moreover, the lack of experience of the surgeon with
regard to this technology and technique [14].
Fig. 8.14 First day postoperative when anterior closed suction drain
was left in and open sacral drainage for free drainage
drainage of uids from the wounds, which occurs for approximately 2–3 days, with closure of the wound when the drainage stops (Fig.8.14).
One week after the procedure the patient is sent to the
physical therapist where carboxytherapy, ultrasound, radio
frequency, and manual drainage are done (2 months minimum), and appropriate steps shall be taken to customize the
patient’s postoperative care.
8.10 Lipocontouring ofBack
Complications
Hyperpigmentation of the scars is the most frequent undesired sequelae to a procedure, but the impact can be minimized by the following measures:
8.11 Complications ofGluteal Fat Grafting
Like any surgical procedure, it is not exempt from general
and specic complications of this type of procedure, which
can range from mild to fatal, such as pulmonary fat embolism (PFE). The very rst case report of a fatal PFE from
gluteal fat grafting was published in the pathology literature
in 2015.
The fat embolism syndrome is caused by a systemic
inammatory response. In contrast, fat embolism is essentially a mechanical effect. Although the fat embolism syndrome is serious, timely intervention can resolve the
manifestations without major sequelae. In fat embolism, the
problem is immediately caused by blockage of medium and
large vessels, which occurs during lipoinjection when signs
and symptoms indicate a blockage at the cardiac level or in
pulmonary vessels, and the patient usually dies despite
immediate attention [15].
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The methodologies used to calculate the risk of death
yielded estimates from a low of 1:6214 to a high of 1:2351.
Surgeons who answered the survey of Aesthetic Surgery
Education and Research Foundation (ASERF) task force
reported injection of fat into the subcutaneous plane and into
the supercial to mid-muscular plane experienced 63% and
82% risk reductions, respectively, of pooled fatal and nonfatal PFEs. In contrast, those reporting injections into the deep
muscular plane experienced a 403% increase in the risk of
pooled fatal and nonfatal PFEs [16, 17].
The reabsorption of the graft, which can generate asymmetries, may be due to poor compliance of patients to postoperative advice to protect the gluteal region in the early
postoperative weeks.
In the same way, oil cysts can occur due to the lack of
vascularization and fat necrosis as a result of large fat deposits causing compression of the structures. Aesthetically, one
of the biggest problems that can occur is mycobacterial
infections that should be suspected in the face of an insidious
and rather asymptomatic course with multiple stulization
and drainage of “grains of sulfur” through the orices. This
requires surgical drainage on multiple occasions, and prolonged courses of antibiotics after a tissue culture repeated at
3, 6 and 9-week intervals showing the mycobacterial strain
and its sensitivity.
Another possible complication is hyperpigmentation that
occurs due to intradermal hemosiderin deposition, which can
be a major issue for the patient and may not be fully resolved
or may last up to more than a year.
An important precaution that we must take into account
before performing a gluteal fat graft procedure is to ensure
that there has not been a previous injection of allogenic
substances (llers), which could be the cause of future
problems.
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