Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_511_Библиотеки_им_академика_М_И_Перельмана
.pdf
9 Male Breast
https://t.me/medicina_free
171
a
c
b
d
Fig. 9.28 A 30-year-old male having Grade IV gynecomastia (a, b)
having lost 30kg by diet and exercise underwent suction-assisted liposuction along with a “boomerang technique” excision of the excess tis-
sue with the NAC based on the inferior pedicle. (c, d) Photographs
taken 12months after the surgery when he put on 15kg weight and had
scar hypertrophy
172
https://t.me/medicina_free
M. Thomas and J. D’silva
a
c
b
d
Fig. 9.29 A 20-year-old male having Grade IV gynecomastia (a, b) secondary to massive weight loss due to sleeve gastrectomy underwent power-
assisted liposuction with skin excision and Free NAC graft. (c, d) Photographs taken 6 months after the surgery
References
1. Mathur R, Braunstein GD. Gynecomastia: patho-mechanisms and
treatment strategies. Horm Res. 1997;48:95–102.
2. Braunstein GD.Gynecomastia. N Engl J Med. 2007;357(12):1229–
37. https://doi.org/10.1056/nejmcp070677.
3. Blau M, etal. Anatomy of the gynecomastia tissue and its clinical
signicance. Plast Reconstr Surg Glob Open. 4(8):e854. https://doi.
org/10.1097/GOX.0000000000000844.
4. Yue D, Cooper LRL, Kerstein R, Charman SC, Kang NV.Dening
normal parameters for the male nipple-areola complex: a prospective observational study and recommendations for placement
on the chest wall. Aesthet Surg J. 2018;38(7):742–8. https://doi.
org/10.1093/asj/sjx245.
5. Agarwal CA, Wall VT, Mehta ST, Donato DP, Walzer NK.Creation
of an aesthetic male nipple areolar complex in female-to-male transgender chest reconstruction. Aesthet Plast Surg. 2017;41(6):1305–
10. https://doi.org/10.1007/s00266- 017- 0935- 7. Epub 2017 Jul 11.
PMID: 28698936.
6. Rohrich RJ, Ha RY, Kenkel JM, Adams WP Jr. Classication and management of gynecomastia: dening the role of ultrasound-assisted
liposuction. Plast Reconstr Surg. 2003;111(2):909–23. ; discussion
924–5. https://doi.org/10.1097/01.PRS.0000042146.40379.25.
7. Hurwitz DJ. Boomerang pattern correction of gynecomastia.
Plast Reconstr Surg. 2015;135(2):433–6. https://doi.org/10.1097/
PRS.0000000000000933. PMID: 25626790.
Large-Volume Liposuction
https://t.me/medicina_free
MohanThomas andJamesD’silva
10
Increased awareness about cosmetic surgery has made liposuction a popular plastic surgical operation and it has become
one of the most common cosmetic surgery procedure
performed.
However, there have been reports of adverse outcomes
specially when very large volumes of fat are extracted, so the
surgeon should understand the pathophysiology of obesity
and uid management during liposuction and be aware of the
complications.
Liposuction as a procedure has evolved over many
decades to become a much safer procedure due to the various
pioneers, the foremost among them being Dr. Jeffery Klein
(a dermatologist in the US) who described the “tumescent
technique” of liposuction in the mid-1980s. It was associated
with decreased blood loss, thus making it possible to perform liposuction as a day care procedure.
The word tumescence means “to swell.” In this technique,
very large volumes of dilute local anesthetic along with epinephrine and sodium bicarbonate are injected into the subcutaneous tissue to expand the tissues and make them rm,
swollen, and turgid, with constricted blood vessels, that is,
the nal endpoint being strong tissue turgor. This creates a
plane from where suction of fat becomes easier, with lesser
blood loss [1].
Liposuction is broadly discussed under two categories:
• High-volume liposuction (LVL): >5000 mL of aspirate
(fat plus wetting solution)
• Low-volume liposuction: <5000mL of aspirate
Due to high chances of uid shifts post-liposuction, with
a risk of developing pulmonary edema, high-volume liposuction is considered to be more prone to complications than the
tumescent liposuction. Therefore, the intravenous (IV) uids
must be used cautiously during large-volume liposuction
cases.
10.1 Safety andBenets ofLarge-Volume
Liposuction [2]
According to a study by Kanapathy etal., the incidence of
major surgical complication was 3.35% (95% condence
interval [CI]=1.07–6.84%) with blood loss requiring transfusion being the commonest complication followed by pulmonary embolism (PE), hematoma, necrotizing fasciitis, and
deep vein thrombosis (DVT). The incidence of minor surgical complication was 11.62% (95% CI=6.36–18.21%) with
seroma being the commonest minor complication followed
by contour irregularities, scar hyperpigmentation, skin
necrosis, persistent induration, bruising, garment-induced
pressure sore, surgical site infection, prolonged pain,
hypopigmentation, and wound dehiscence. A general
improvement in lipid and glucose proles as well as reductions in body weight and hematocrit was observed following
LVL.This study consolidates current available evidence on
LVL.
Generalized inclusion criteria for safe large-volume liposuction are as follows [3]:
Supplementary Information The online version contains supplementary
material available at [https://doi.org/10.1007/978- 981- 19- 4997- 5_10].
M. Thomas (*) · J. D’silva
Cosmetic Plastic Surgery, Breach Candy Hospital and D.Y. Patil
University, Mumbai, Maharashtra, India
© 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_10
• Patient free of comorbidities
• Lipodystrophy over most body parts
• No signicant medical conditions
• No history of preexisting thromboembolic events in the
family or patient
Generalized exclusion criteria for safe large-volume liposuction are as follows:
173
174
https://t.me/medicina_free
M. Thomas and J. D’silva
• Signicant medical conditions like diabetes, cardiac,
renal, endocrinal, gastrointestinal, hepatic, or body dysmorphic disorders
• Cocaine addiction
10.2 Considerations inLarge-Volume
Liposuction
10.2.1 Anesthesia Considerations
10.2.1.1 Physiological Changes inLarge-
Volume Liposuction
Study by Jeffery Kenkel etal. [4] in 2004
• Sustained increase in heart rate
• Decrease in mean arterial pressure
• Steady increase in mean pulmonary artery pressure lasting up to 24h
• Central venous pressure (CVP) showed slight increase but
no statistically signicant uctuation
• Dramatic increase in cardiac index
• Sustained elevation of stroke volume index
• Signicant increase in right ventricular stroke work index
• Peak plasma levels of epinephrine observed at late intra
operative period returning to baseline over 20h
• Decrease in systemic vascular resistance
• Signicant tendency for hypothermia in spite of precautionary measures
10.2.1.2 Preoperative Assessment
• A thorough medical history and drug history are essential
to rule out possible risk factors for surgery.
• Body mass index (BMI) evaluation is essential. A distinction has to be made between who come for weight loss and
who require body shaping with large-volume liposuction.
• A CT scan of abdomen is advised and evaluated to rule
out possibility of any hernias or any intra-abdominal
pathology. The extent of intra-abdominal and extraabdominal fat has to be assessed. LVL is most effective
when the extra-abdominal fat is maximum.
• Assess smoking and pulmonary function test.
• Assess hormonal levels and rule out PCOS.
• Family history of obesity should be considered as a relative contraindication for LVL.
• Motivation of the patient should be assessed and if
required a psychiatric consultation is recommended.
• Reverse-transcription polymerase chain reaction (RTPCR) test and HR CT scan of the chest is recommended to
rule out coronavirus disease 2019 (COVID-19) infection.
10.2.1.3 The Night Before andtheDay
ofSurgery
• Patient is admitted to the hospital the day before surgery.
It is strongly recommended that all LVL cases be carried
out at a well-equipped hospital and monitored for 48 h
after surgery.
• Vital parameters are noted,
• Nil by mouth usually for 6 h as advised by the
anesthesiologist.
10.3 Step 1: Premedication
The patients may be prescribed an anxiolytic, for example,
0.25–0.5mg alprazolam the night before. Preoperative medi-
cation diminishes anxiety and the hemodynamic changes, for
example, tachycardia, hypertension, and arrhythmias associated with liposuction. Clonidine, an alpha 2 receptor agonist,
is gaining popularity as a premedicant due to its sedative,
anxiolytic, sympatholytic, and antisialagogue actions. The
recommended oral dose of clonidine is 2–5 μg/kg. Proton
pump inhibitors the night before and the morning of the surgery day with a sip of water are recommended to reduce the
acid secretion.
10.4 Step 2: Consent andMarking—Crucial
Aspect ofSurgery
• The areas to be treated are always marked with patient in
a standing position.
• Areas to be liposuctioned are marked with blue and the
areas that have to be left untouched or have deformities
are marked with red color as seen in Fig.10.1a.
• It is preferable to limit the number of areas to be under-
taken for liposuction during large-volume liposuction. We
usually divide the body into upper and lower half or front
and back. By limiting the area of surgery, it is possible to
evacuate maximum fat from the treated areas as well as
limit the use of drugs used for the inltration.
• Any previous scars or adhesions are marked and checked
for hernias.
• The treatment plan is thoroughly discussed with the
patient one last time on the day of surgery. A video consent along with a written consent is taken and conrmed.
Patient is asked to examine himself/ herself in a fulllength mirror to verify areas to be treated.
• This step makes sure that the doctor and the patient are on
the same page as to what needs to be done and what can
be done.
10 Large-Volume Liposuction
https://t.me/medicina_free
a
175
b
Fig. 10.1 (a) Patient being marked in the standing position so that the elevations and depressions are well established according to topography.
(b) Patients body has been divided into front and back and all areas in the front of the body have been marked
176
https://t.me/medicina_free
M. Thomas and J. D’silva
10.5 Step 3: Anesthesia Technique
10.5.1 Goals ofAnesthesia
• To choose a technique which will be comfortable for both
the surgeon and the patient
• No compromise on safety
• Selection of drugs and agents to achieve early, pleasant
and complication free recovery
• Maintain normothermia
• Continued monitoring for at least 24h
Liposuction may be performed under local, regional, or
general anesthesia. The anesthetic technique will vary
according to the areas being operated upon; arms, thighs,
abdomen, or buttocks and the volume of liposuction being
performed.
10.5.2 Monitored Anesthesia Care
The following parameters have to be monitored during largevolume liposuction:
• Electro cardio gram (ECG), saturation pulse of oxygen
(SpO2), non-invasive blood pressure (NIBP), end tidal
carbon dioxide (EtCO2), fraction of inspired oxygen
(FiO2), anesthetic agent, peripheral nerve stimulators and
bispectral index (BIS) monitoring.
• Core temperature monitoring.
• Hourly ET cuff pressure measurement.
• Time out every hour to check urine output, pressure
points, connections, body temperature etc.
• Careful tabulation of amounts of inltrate, infusions, and
aspirate
• Inltration with vasoconstrictor and local anesthetic
reduces bleeding and provides intraoperative analgesia,
respectively. Thus, it allows liposuction to be performed
under light sedation, implying a short recovery time, earlier discharge, and low cost to the patient.
• However, if infiltration is not uniform, some areas
will have a lack of analgesia, thus requiring more
sedation.
• Sedation with midazolam (1–3 mg) and analgesia
with fentanyl (25–50 mg) or remifentanil (12.5–
25 mg) is commonly employed for small-volume
liposuction.
• Propofol (0.5–1mg/kg) may be given intermittently for
monitored anesthesia care.
• Ketamine in low doses (0.25–0.5mg/kg) along with midazolam signicantly decreases the use of opioids in the
intraoperative period and of analgesics in the postoperative period.
• Clonidine 2–5 mg/kg is also a useful adjuvant during
sedation techniques.
10.5.3 General Anesthesia
• This is recommended for large-volume liposuction or if
the patient desires it.
• Orotracheal tube is used for intubation.
• Muscle relaxation is usually achieved with a nondepolarizing drug—atracurium, rocuronium, or vecuronium.
• Analgesia is provided by short-acting opioids such as fentanyl or remifentanil and inltration of lidocaine in the
subcutaneous tissue.
10.5.4 Anti-inammatory Additives
• Steroids have a benecial effect when added to the tumescent solution because of their anti-inammatory effects
and also their stabilizing action on the circulatory system.
They are routinely used prior to starting the surgery and
usually 8mg of dexamethasone is injected.
10.5.5 Tranexamic Acid
Administration of 10 mg/kg (upto 500 mg) of intravenous
tranexamic acid preoperative and postoperative along with 500
mg of Tranexamic acid in each liter of infusion uid seems to
reduce the volume of blood loss for every liter of lipoaspirate.
10.5.6 Heparin [5]
The use of a low molecular weight heparin is recommended
every 12h in a large-volume liposuction patient specially if
combined with abdominoplasty and/or breast procedures and
continued until ambulation of patient.
10.5.7 Temperature Control
(Thermoregulation) [6]
The hemodynamic and thermoregulatory changes usually
persist for about 24h after beginning of surgery; hence, it is
important to maintain normal body temperature of the patient
during surgery. Normothermic core body temperatures were
evident before induction of anesthesia (37 °C+/− 0.1 °C).
Temperature reduction is normally observed during general
anesthesia which should come back to normothermic (36.6°C
_ 0.6°C) once general anesthesia was stopped. Hypothermia
(temperature below 35 °C) should not be allowed and it
should be monitored by the use of a temperature probe
(Fig.10.2) as shown placed in the mouth in Fig.10.3.
Preventative measures should be taken as follows:
1. Betadine solution used for surgical site preparation
should be warmed;
10 Large-Volume Liposuction
https://t.me/medicina_free
177
2. intravenous and wetting solution uids should be placed
in a warmer or microwave for heating;
3. Exposed body areas should be kept covered using a warmed
drape or towel over the area to help prevent heat loss;
Fig. 10.2 A temperature monitoring system to monitor the body temperature and prevent hypothermia
4. Forced warm air (Bair Hugger) with a blanket should be
used; and
5. The temperature of the operating room should be raised
while the patient is exposed, particularly in large-volume
cases. If these measures are not taken, patients may
become severely hypothermic, subjecting them to unnecessary complications such as postoperative infection,
arrhythmias, and coagulation abnormalities [7].
10.6 Step 4: Patient Positioning
andPreparation
• The usual position for surgery is supine. However, the
position varies according to the area to be operated upon.
Liposuction of buttocks, anks, and back of the thighs
generally requires prone position.
• When a large area of the body is planned for liposuction,
that is, both the frontal and dorsal aspects, it is better to
start with the back area rst with the patient positioned in
a prone position.
• The patient is intubated in a supine position. All monitors
for cardiac monitoring are rst connected. The para nasal
sinuses (PNS) and/or BIS monitor is now connected.
• A urinary catheter is placed while in supine position and
used to assess the urine output during and after the procedure with an Urovac in place. It is much easier to assess
the possible uid overload with a urinary catheter in place.
• The endotracheal tube is secured and its cuff pressure is
monitored. The temperature probe is placed and xed in
position as shown in Fig.10.3a.
• Protection of the eyes (Fig.10.3) using a cotton pad is of
paramount importance to prevent pressure on the eyeballs. This is important to prevent the Oculocardiac reex,
also known as Aschner phenomenon. A decrease in pulse
rate is associated with traction applied to extraocular
a
Fig. 10.3 (a) Endotracheal tube securely xed along with the temperature probe (white probe). (b) Eyes have been covered with cotton pads to
prevent trauma or pressure on the eyeball
b
178
https://t.me/medicina_free
M. Thomas and J. D’silva
muscles and/or compression of the eyeball. This reex is
mediated by the ophthalmic branch of the trigeminal cra-
nial nerve via the ciliary ganglion, and the vagus nerve of
the parasympathetic nervous system [8].
• After the intubation and catheterization, the patient position is changed to prone with appropriate precautions and
care (Fig.10.4).
• While in prone position, the face and the endotracheal
tube are protected using a prone support system.
(Fig.10.5a, b).
• Care needs to be taken with regard to the positioning
of arms, if they are to be treated. Care should be
Fig. 10.4 Patient placed in prone position on a spinal frame
(inset) and all pressure points well supported and padded
taken to avoid injuries to brachial plexus and ulnar
nerve.
• All the pressure points are supported with padded cushions so as to prevent postoperative pain (Fig.10.6).
• Standard preparation is done without disturbing the marking lines, as they cannot be recreated as the patient is
already intubated.
• Regular time outs are suggested to clock all parameters
including pressure points.
• Pneumatic compression devices are used for large- volume
liposuction and for procedures lasting more than an hour,
to prevent deep vein thrombosis (DVT) (Fig.10.7).
a
Fig. 10.5 (a) Prone support system to protect the face while keeping the endotracheal tube intact (source: https://www.mercurymed.com/product/
face- cradle- prone- support- system/). (b) Patient placed on the prone gel with eyes and tube well supported and secured
b
10 Large-Volume Liposuction
https://t.me/medicina_free
Fig. 10.6 Protection with silicone gel pillow under the knees, hips, and
arms
Fig. 10.7 DVT prophylaxis using TED stocking and sequential compression device for the calf
10.7 Step 5: Intraoperative Fluid
Administration
179
10.8 Step 6: Inltration oftheInfusate
A superwet solution is used for inltration. The following
usually form the components of the infusate
1. Normal saline.
2. Lidocaine—as local anesthetic.
3. Adrenaline—as vasoconstrictor.
4. Sodium bicarbonate—as buffer.
5. Hyaluronidase—increase the permeability to uids and
thus aids in liposuction.
10.8.1 Local Anesthesia
• The recommended maximum dose of lignocaine is 55mg/
kg, with a range of 35–55mg/kg in most patients undergoing liposuction.
• Louis Habbema [10] has reported in a series of 3430 lipo-
suction procedures that a maximum lignocaine concentration of 500mg/L of normal saline solution allows infusion
of a large volume of wetting solution, without any risk of
lignocaine toxicity.
• The toxicity of local anesthesia is a function of its peak
plasma concentration. Peak levels of lidocaine and its
active metabolite monoethylglycinexylidide occur within
8–32h of inltration, but are well below the toxic concentration of 6mg/mL.
• Addition of epinephrine to lignocaine prolongs the dura-
tion of analgesia obtained from tumescent lignocaine
extending it by many hours.
• Rohrich etal. [9] modied the replacement uid delivery
at 0.25 mL of intravenous uid for each milliliter aspirated over 5000mL.The intraoperative uid volume ratio
with this modication is 1.8 for small-volume aspirates
(<5000 mL) and 1.2 for large-volume aspirates
(>5000mL).
• The adequate use of epinephrine in the tumescent solution theoretically allows blood loss to be 1–2% of the
total volume aspirated. Patients who are trying to lose
weight use recognized or unrecognized (natural remedies) medications and “herbal aids.” These type of
drugs ranges from amphetamines, thyroid hormones,
and ephedrine and a very big list of herbs and teas that
alter the coagulation system or facilitate the interactions with epinephrine. Therefore, the patient should
be instructed to cease all these medications and naturopathic remedies at least 2weeks before surgery [5].
• The liposuction removes approximately 30% of the
infused tumescent solution, so for each liter of inltrated
tumescent solution, 700mL are absorbed, so they should
be considered as part of the uids administered to the
patient.
Factors that reduce peak lignocaine plasma levels
(a) Subcutaneous fat, due to its low volume of blood ow.
(b) Dilute epinephrine, which produces a prolonged and
profound degree of vasoconstriction preventing absorp-
tion of infused uid.
(c) Lignocaine, due to its lipophilic nature.
(d) A part of the infused uid is aspirated out along with the
fat.
10.8.2 Vasoconstrictor
• Adrenaline is the most commonly used vasoconstrictor
and the recommended concentration in tumescent solution is 0.25–1mg/L depending on the tissue vascularity.
• In the more vascular tissues, the concentration is 1mg/L
and is decreased to 0.5mg/L in the less vascular areas of
the body.
• The dose should not exceed 50μg/kg. If the maximum
dose is expected to exceed this amount, then the procedure should be undertaken in stages.
180
https://t.me/medicina_free
M. Thomas and J. D’silva
10.8.3 Buers
Sodium bicarbonate is used as a buffer to decrease the pain
sensation associated with injection of local anesthesia. This
is specially required when undertaking tumescent liposuction/super wet lipo in an awake patient.
10.8.4 Hyaluronidase
Hyaluronidase enzyme helps in breaching the tissue integrity
and makes it easy for the tumescent uid to diffuse and also
to nd planes during liposuction.
10.9 Step 7: Liposuction
• Surgical procedure begins with the cleaning and painting
of the areas to be operated. We only use Povidone iodine
5 or 10% solution for painting the area.
• Access points which can be 3–4mm in size made with a
stab knife or a skin punch are usually placed in such a way
that they are hidden as well as provide easy access to all
areas of fat removal as seen in Fig.10.8.
Fig. 10.8 Access points marked in red are placed in hidden areas from
which different areas can be accessed for liposuction as marked by yellow arrows
• The areas to be treated which have been pre marked are
selectively inltrated. These areas can be premarked with
numbers to indicate the sequence of inltration to the
team as seen in Fig.10.9.
• In a full body liposuction, the back is treated initially and
hence the patient is placed in a prone position. Inltration
is performed using a blunt tip inltration needle of 2.5mm
diameter one area at a time.
• For example, when performing the liposuction of back,
only the outer thighs are inltrated. While one outer thigh
is being worked on, the only other body part inltrated
would be the opposite outer thigh or if the chest is worked
upon then the upper abdomen is inltrated and so forth.
The other areas of the body wouldn’t be inltrated as seen
in Fig.10.10.
• Usually 1–2L of tumescent uid is only inltrated at a time
with a ow rate of 100cc/min. Only “Super wet technique”
of inltration is used to limit the amount of uid inltrated.
• The basic premise of this technique is segmental and
sequential uid infusion with fat extraction to prevent
uid over load, electrolyte changes, third spacing, and
hypothermia.
• There are many techniques to liposuction. Standard
suction- assisted liposuction is performed most of the
times. The use of technology-based liposuction methods
like VASER liposuction and water jet liposuction can
minimize the insult to the tissues and thereby intraoperative complications and is easier on the operator.
• Inltration Phase—A peristaltic inltration pump was
used for inltration in all areas except for the face and
neck, and inltration was stopped when the tumescent
state was reached in the deep and supercial planes in the
marked area. This results in an even total blanching, representing vasoconstriction by epinephrine.
• Resting Phase—After inltration, 15–20min was required
to allow the solution to diffuse evenly between the fat lobules and to optimize the efcacy of epinephrine and
lidocaine.
• Aspiration Phase—Technology such as VASER may be
used followed by suction-assisted liposuction to evacuate
the fat from targeted areas in a sequential manner.
• Large saddle bags may need placement of drains to prevent seroma formation commonly seen when technology
such as VASER assistance is utilized (Fig.10.11).
• After the liposuction of the back in the prone position is
completed, the access points are sutured loosely using
non absorbable sutures and adequate padded dressing are
placed.
• The patient is then carefully turned over to the supine
position. The same elective inltration technique is used.
Соседние файлы в папке Библиотека им академика М.И. Перельмана