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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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10 Large-Volume Liposuction
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Fig. 10.9 The sequence marked on the body of this young female who underwent large-volume liposuction. The rst six regions are marked on
the back while the next six are marked on the front
181
a
b
Fig. 10.10 (a) One side outer thigh being inltrated at a time. (b) The
inltrated lower abdomen as the chest has been worked upon and
extraction of fat done
Fig. 10.11 Placement of drain in large-volume liposuction
Liposuction of this part may take more time due to relatively higher fat deposition in the ventral aspect of the
body.
• Also, one needs to be more careful while undertaking
liposuction in the abdomen and anks given the proximity
of vital structures.
• Once the liposuction is performed, the access points are
closed primarily in selected areas. Mupirocin cream was
applied at the incision sites. Absorbent pads were covered
rst with an elastic garment and then the patient’s
clothing.
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M. Thomas and J. D’silva
10.10 Step 7: Garment Placement
• Garment (Fig.10.12) is ideally placed while the patient is
still under general anesthesia.
• The garment is designed based on the areas operated.
• The garment is exible and is kept loose at areas of incision to accommodate absorbent pads.
• Provision has been made to leave opening to facilitate
micturition and bowel movements.
• Garment can be reasonably tight but not too tight, especially in the chest area. Beware of excessive abdominal
compression caused by a tight garment.
• The friction areas have to be carefully padded under the
garment.
• Garment should not be used if the vascularity of the area
is doubtful, patients who underwent LVL with abdominoplasty, smokers and people with diabetes. It can be used
after the rst dressing in 4–5days.
10.11 Step 8: Extubation
• Patient is carefully extubated and observed in the recovery area before moving to the patient room.
• ICU admission is usually not required.
• One common complaint while in the recovery would be a
sore throat, due to Endotracheal (ET) tube, headache, and
hypothermia.
• Once the vitals are stable the patient is moved out of the
recovery area.
• Furosemide (Lasix), a loop diuretic is usually administered at the end of the procedure to prevent third spacing.
10.12 Step 9: Postoperative Instructions
While inHospital
• The vitals are monitored every second hourly until the
next morning.
• The urinary catheter is retained and urine output is
evaluated.
• Patient is advised oral feeds 4–6 h after surgery if the
bowel sounds are normal.
• IV uids, antibiotics, analgesics, steroids (if necessary),
antacids, or proton-pump inhibitors are advised.
• Calf pump is used till the patient is fully mobilized and
stockings are kept in place for a week.
Fig. 10.12 Custom-made corset for multiple areas of liposuction and
large-volume liposuction
10.13 Follow-Up
• Patient are followed up the next day; urinary catheter is
removed after bladder training using cross clamping.
Feeling of two urinary urges is a good guide for catheter
removal and thus preventing secondary retention.
• Patients are asked to begin ambulation as soon as possible
and lower extremity muscle-contracting exercises are to
be encouraged, while they are in bed to minimize the risk
of DVT and pulmonary embolus.
• Patient is discharged when all the vital parameters are
stable and the patient is comfortable.
10.14 Postoperative Instructions After
Discharge fromHospital
• Oral medications are advised for 7days.
• Aggressive exercises and workout is not allowed for
4weeks.
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Fig. 10.13 The direction of lymphatic massage in the leg. The illustration also shows the group of lymph nodes towards which massage has to be
done
• Soft diet is advised during initial postoperative period.
• Patient has to follow a calorie restricted diet plan (change
of life style) which is coordinated by a dietician taking
into account patients medical issues.
• Garment must be left intact for at least 1 week following
lymphatic massages of the treated areas. The garment has
to be continuously used for at least 4 weeks after the
surgery.
• Lymphatic massage is undertaken once or twice a week after
the rst week in a gradual manner with tissues massaged
towards the groups of lymph nodes as shown in Fig.10.13.
10.15 Photographs ofLarge Volume
Liposuction Cases (Figs.10.14, 10.15,
and10.16)
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M. Thomas and J. D’silva
a
d
b
e
c
f
Fig. 10.14 Pre (a–c) and postoperative (d–f) comparison photographs of a large-volume liposuction case in whom 20.5L of fat was aspirated
from the abdomen, lateral an dinner thighs and buttocks
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Fig. 10.15 Pre- (a, b) and
postoperative (c, d)
comparison picture of a
large-volume liposuction (7L
of fat aspirated) in a male
patient who quit smoking to
undergo LVL of the chest,
abdomen and anks
a
c
b
d
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M. Thomas and J. D’silva
a
d
b
e
c
f
Fig. 10.16 Pre- (a–c) and postoperative (d–f) photograph of a large-volume liposuction in a 40years old lady. Eleven liters of fat were aspirated
with a drop in hemoglobin of 3gm%
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10.16 Medical Complications [1]
• The incidence of mortality associated with liposuction is
reported to be 0.003–0.02%.
• Pulmonary edema and over hydration—attributable to
absorption of the tumescent solution from subcutaneous
to the intravascular compartment.
• Pulmonary and abdominal viscous perforations.
• Wound infection and sepsis.
• Deep vein thrombosis (DVTs).
• Pulmonary embolism (PE).
10.17 Surgical Complications [11]
• Seroma/Serosanguinous collections.
– Ultrasound-assisted lipectomy (UAL) and concomi-
tant abdominoplasty could increase the incidence of
seroma.
– Serosanguinous collections have to be drained using a
cannula through the liposuction access point preferably
under general anesthesia. This can also be drained through
ultrasound guided aspiration under local anesthesia.
• Irregularity
– Causes
Can occur due to uneven removal of fat deposits
and from irregular skin retraction during healing
phase.
Can be seen when patient gains weight after surgery.
In few areas like lower abdomen retraction may be
irregular and unpredictable.
Organized and brosed hematomas.
Large-diameter cannulas and supercial
liposuction.
– Recommendations to prevent such complications
Use only blunt tipped cannula.
Always feel the tip of the cannula using the nondominant hand.
Rule out musculo-aponeurotic weakness
preoperatively.
Only one surgeon should operate at a time, even in
a team approach scenario.
Extreme caution should be exercised when dealing
with previous scars/surgeries.
While treating the upper abdomen, use a short cannula if access point is from inside the umbilicus and
longer cannula when the access point is at the inframammary crease.
• Hematoma (Figs.10.17 and 10.18).
• Asymmetry.
• Hyperpigmentation (Fig.10.19).
• External genital swelling (Fig.10.20). Liposuction in the
lower abdomen specially when undertaken on the mons
and labia majora of the female will cause swelling of the
genitals. Appropriate measures to be taken as the swelling
is not unusual. Patients must be forewarned.
Fig. 10.17 Clinical presentation of hematoma of the abdomen in a 45years old smoker who underwent LVL and abdominoplasty. Hematoma was
evacuated surgically and the abdominoplasty incision was sutured secondarily
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M. Thomas and J. D’silva
Fig. 10.18 Evacuation of hematoma of the abdomen in a 60years old lady who was on aspirin (which was stooped in advance). The hematoma
was evacuated and the area healed uneventfully
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Fig. 10.19 Post-inammatory hyperpigmentation which improved using anti-pigmentation creams and lasers
10.18 Special Precautions toBeTaken
During Large-Volume Liposuction
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Fig. 10.20 Swelling of a scrotum seen after a LVL of the abdomen,
thighs and pubic area. The tight garment further aids the swelling in the
scrotum/labia due to reduced lymphatic drainage to the inguinal lymph
nodes. This is managed by releasing the seam of the pressure garment
along with a scrotal support in a male and snug underwear in a female
10.18.1 DVTs andPE [5]
Factors leading to increased risk of PE
• The mechanical factors that favor blood stagnation in the
lower extremities, such as
– The surgical position,
– Abdominal compression, and
– The use of bandages and garments in the postoperative
period.
Following measures used for management of low-risk elective patients
• Prevention of DVT
• Comfortable position (legs in partial exion of knees and
extremities)
• Elastic compression stockings (TED stockings) to be
mandatorily used from the pre-operative period until
ambulation (Fig. 10.21)
• Intermittent pneumatic compression device during surgery (Fig. 10.22) and until discharge
• Judicious use of low molecular weight heparin where
indicated for 3–7days
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Fig. 10.21 TED (thromboembolic deterrent stockings) stockings
M. Thomas and J. D’silva
Fig. 10.22 Pneumatic compression device
Following patients should be considered to have an
increased risk of DVT
• Patients with a history of previous episode of DVT;
patients undergoing procedures lasting more than 5h.
• Patients with liposuction of large volumes (>5L).
• Patients who undergo combined procedures that include
abdominoplasty.
• Patients who arrive in cities of high altitude (>2000 masl)
2 or less days before surgery.
• Patients traveling in the immediate preoperative or aspire
to travel with a duration of 4h or more within the rst
week of the postoperative period.
• Patients who undergo gluteal lipoaugmentation.
10.18.2 Hypothermia
Fig. 10.23 Body warming unit
• Dermoclysis solutions have to be adequately heated to
prevent hypothermia.
• The betadine solution during the surgical preparation also
has to be warm.
• The room temperature has to be maintained at or above
25°C.
• Complications of hypothermia.
– Cardiac dysrhythmias
– Coagulopathies
– Oliguria
– Electrolyte imbalance
– Increase in oxygen consumption during chill phase
• Sequential area wise liposuction.
– A surgeon can minimize hypothermia by performing
liposuction of one area at a time.
– It is always safer to inltrate one area ahead. For
example, when the thigh section is performed, it is
safe to inltrate the thigh that is being worked on and
also the opposite thigh. This way inltrating other
areas like abdomen, mons area, back rolls, and saddle
bags is avoided and thus hypothermia can be
prevented.
• Body warmer should be used intraoperatively to maintain
the body temperature (Fig.10.23).
• Exposed areas should be immediately covered with a
warm towel.
Liposuction patients are prone to hypothermia due to exposure of large body surface area to temperature loss.
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