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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_591_Библиотеки_им_академика_М_И_Перельмана
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Table 30.2 Conclusions made in 2012 by the consensus on liposuction in the Committee of Body
Contouring Surgery of the Brazilian Society of Plastic Surgery [31]
1. Is advanced age a contraindication No
2. What are the absolute contraindications? > ASA II, high risk for
3. What is the most common anaesthesia used?
4. Is liposuction to be performed in dry conditions? No
5. What is the proportion of injected physiological solution and
adrenaline?
6. What is the ideal volume to be aspirated? 5–7% of total body weight
7. What is the maximum acceptable volume of aspirate without the
risk of complications?
8. Is the ICU used routinely in the postoperative period? No
9. What analgesics are routinely used in the postoperative period? Dipyrone, codeine and
10. Are compressive garments used? Yes
11. What cannula diameter is used? 05-Feb
12. What is the preferred liposuction technique? Superwet (1:1)
+
The authors prefer general anesthesia
+
thrombosis
Epidural
1:500 to 1:1000
4000 to 10,000ml
ketoprofen
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Surgical Technique
No “orthodox” technique exists for liposuction, and each individual surgeon has a
personal method and own technique reecting artistic style and technical
specications.
The sequence of liposuction surgery is as follows:
• Markings
• Anesthesia
• Asepsis and antisepsis
• Inltration of vasoconstricting solution
• Liposuction
• Dressing
Nowadays, there are multiple options of liposuction to perform such as suctionassisted liposuction (SAL), power-assisted liposuction (PAL), ultrasound-assisted
liposuction (UAL), and laser-assisted liposuction (LAL). Since PAL, UAL, and
LAL require a greater investment in technology and a greater learning curve,
suction- assisted liposuction still remains the most common modality among plastic
surgeons. The disadvantages of SAL include more physical work involved to break
up and remove fat.
Power-assisted liposuction uses an externally powered cannula that oscillates at
rates of 4000–6000 cycles/minute, which is the authors’ preferred technique. In our
daily routine, we choose the superwet technique using 0.9% saline solution or
Ringer’s lactate solution associated with adrenaline with different concentrations
depending on the area to be treated as described in the following paragraphs.
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Fig. 30.2 Marking is performed prior to surgery in the erect position. The lines resemble the topographic map showing localized fat, focal depressions, and dimples
L. F. de Córdova and R. CavalcantiRibeiro
Markings are performed with the patient in the standing position using specic
anatomical references as follows: the median longitudinal furrow, the iliac crest, the
sacral triangle, the iliac line, and the supracristal plane (Fig.30.2).
Following anesthesia, placement of a Foley catheter is to be done to closely
monitor uid output (minimum 0.5 ml/kg of body weight). Antisepsis rst with 2%
chlorhexidine with the sterile technique is performed. The next step is a new
degermation of the area with 0.2% aqueous chlorhexidine solution, carried out by
the surgical assistant, already duly attired.
The next step is the placement of sterile surgical drapes, where the areas to be
liposuctioned are delimited. It is of utmost importance to choose access points that
can treat multiple areas preventing incisions that could disrupt zones of adherence
through the suctioning. If with the existing markings the access results are insufcient, do not hesitate in placing additional incisions. Asymmetric incisions may
camouage their appearance, therefore offering a better cosmetic result. The incisions are made, after inltration of 0.5ml of lidocaine (2%) with epinephrine with
a surgical blade #11 with a mean longitude of 0.5cm. For beginning plastic surgeons, we suggest following Hunstad’s approach to specic regions of treatment
(Table30.3).
During a body contouring surgery, the patient should be positioned in four ways
during the procedure when full lipoplasty is to be performed: prone position, supine
position, left lateral decubitus, and right lateral decubitus. In our surgical practice,
we chose to start by placing the patient in the prone position (Fig.30.3).
With the patient properly prepared, the procedure can nally be started. First, we
mark the incision areas with a sterile surgical pen for the inltration procedures of the
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Table 30.3 Recommendations of entry sites and patient position to treat different areas of the
body [8, 13]
The Hunstad’s approach to specic regions of treatment
Location Entry sites Position
Abdomen Groin, umbilicus, inframammary Supine
Back Bra-line, buttocks, axilla Prone
Hip rolls Buttocks Prone/supine
Outer thigh Gluteal crease, groin Prone
Circumferential thigh Groin, gluteal crease, knee Prone/supine
Neck Postauricular, submental Supine
Arms Axilla, elbow Supine
Buttocks Infragluteal, apical buttocks Prone
Inner thigh Groin, infragluteal Prone/supine
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Fig. 30.3 The prone position for the patient gives access to all the posterior regions of the body
making it possible to combine the technique with lipotransfer to the gluteal region. Safety recommendations such as the use of a thermic blanket and appropriate padding to rectify the surgical area
and avoid intraoperative complications are to be considered and applied always
tumescent solution and subsequent access to the liposuction cannulas. In our clinical
surgical practice, we observed that the scars from the incision areas do not present a
great aesthetic concern to patients in the late postoperative period, which is not a
major concern of the team, focusing on the nal result of the procedure (Fig.30.4).
As marking the incision areas, we always choose to look for transition areas
between different areas to perform liposuction (thus facilitating access to larger
areas) and also areas that have some aesthetic alteration (whether scars or stretch
marks), thus avoiding new scars. The average longitude of the incisions is 0.5–1.0
cm, performed with a no. 11 scalpel blade, after applying intradermically 2% lidocaine. Afterward, the inltration process of the previously prepared solution begins.
It is emphasized here the importance of minimizing the time to prepare such a solution until its use in the surgical act, thus avoiding inactivation of adrenaline and also
a possible contamination when being exposed after preparation (Table30.4).
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Fig. 30.4 (a) The inltration is performed by zones/quadrants. Using reference points for incisions as the intersection of the iliac line and an inferior projection of the scapular line, the posterior
axillary line, and the midvertebral line in the thoracic and lumbar regions. (b) With Klein cannulas
attached to 60ml syringes. With this resource, an equal inltration is carried out in the different
areas. At the end of the inltration, we adopted as a rule the 20-minute wait for an effective action
of the inltrated solution, thus reducing the blood loss associated with the method, generating a
faster recovery of the patient in the postoperative period and lower rates of complications. The red
stars represent the localization of the incision
L. F. de Córdova and R. CavalcantiRibeiro
Table 30.4
Recommendations for
volume inltrated depending
on the area to be treated
Area to be treated Inltration volume (ml)
Abdomen 1500 -2000
Back 1500 -2000
Neck 2000
Gluteal region
Arms
Hips
a
When the inltration volume is less than 1000 ml 1, the
authors work with epinephrine in 0.5 mg/1000 dilution
injected into 200 cc of 0.9% Ringer’s lactate solution
a
There are a variety of inltration systems, either manually or mechanical inltration, which is an electrically operated pump system. In our practice, we perform
the inltration process using 60 cc syringes in a fan-shaped pattern. The deeper
layers of subcutaneous adipose tissue are inltrated rst, to avoid build-up pressure
close to the surface complicating the access to the whole thickness of adipose tissue
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to be treated. During inltration, skin turgor is monitored by continual palpation.
After a 20-min window for the vasoconstrictor effect to begin, liposuction may begin.
Depending on the legislation of each country and if ofce-based procedures are
allowed, local anesthesia may be used for small-volume liposuction cases associated with or without mild sedation.
The process of liposuction requires that the surgeon’s hands work in concert with
the one hand denominated sensory hand and the other the motor hand. The sensory
hand has several functions, being the most importantto maintainthe tip of the cannula between pinch manœuvre performed bythe thumb and ngers, ensuring the
surgeon not to penetrate anydeepertissues,and facilitating a safe and gentle liposuction byimmobilizing the targeted fat makingitpossibleto aspirateby preventing
it to oscillate to and fro in unison with the cannula.
The motor hand provides the force and moves the cannula through the targeted
subcutaneous fat. The authors prefer the PAL using cannulas of 3, 3.5, 4, and 5mm
progressively depending on the thickness of fat tissue in the area to be treated
respecting the selected areas and avoiding, if possible, returning to areas that have
already been liposuctioned. This measure prevents further blood loss, as it impedes
the clotting process body to be interfered by a new passage of the cannula. The
supercial layer is rarely treated aiming to avoid contour irregularities, vascular
compromise, and the risk of hyperpigmentation. The cannulas with the wider diameters are used for the deeper planes, and cannulas with diameters 3.5 mm and
smaller are used for contour renement in our practice.
With the motor hand, the cannula is inserted, and the adipose tissue is broken
loose from the brous stoma with multiple crisscross movements creating tunnels in
the subcutaneous tissue. For the body, cannulas with lengths from 15 to 45cm are
preferred, whereas for the face and other delicate areas, diameters chosen go from 1
to 3mm and 10 to 20cm in length.
In our practice, we routinely take a blood sample and test for hemoglobin and
hematocrit when performing combined procedures such as lipoabdominoplasty or
large-volume liposuctions.
Once the lipoplasty is done, we use Nylon 5-0 to suture the incisions and apply
a gauze dressing before placingthe compression garment.
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Postoperative Care Protocol
Body contouring procedures can result in signicant uid shifts, and the following
formula mentioned by Rohrich et al. aids in uid management for liposuction
patients:
1. Replace losses from preoperative oral intake as needed.
2. Maintain uid throughout the procedure and manage it based on vital signs and
urine output.
3. Employ the superwet inltration technique.
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L. F. de Córdova and R. CavalcantiRibeiro
4. Administer crystalloid replacements 0.25ml for each ml of lipoaspirate over 5L.
In order to achieve better results and minimize complications after liposuction, a
comprehensive postoperative protocol should be described aiming to:
• Identify and treat complications.
• Monitor and promote the healing process.
• Prevent and treat brosis or a pathologic scar process.
A compression garment is placed at the conclusion of the surgery, customized
based on surgeon preference. Patients are encouraged to ambulate the day of the
surgery, and sequential compression devices are placed on the patient until discharge. Showering is allowed 1 or 2 days postoperatively, and patients are instructed
to keep the compression garment on 24 h/day during 4 weeks. Initial postoperative
visits are scheduled weekly for the rst month starting 4 days after hospital discharge. Return to activity can occur, depending on the procedure as early as 4 days
or at 2 weeks. In our practice, we schedule visits at 7 days for suture removal, 15
days for rst postop pictures, and 30, 60, and 90 days for nal pictures (Fig.30.5).
Volume changes and swelling may translate in an initial weight gain during the
rst days postop with edema peaking from 3 to 7 days after surgery. Patients should
start to appreciate changes in their waist and contour by 2 weeks and at 6 weeks be
able to perceive signicant changes in their shape. The nal aesthetic result can be
seen at 6 months, and as patients improve their activity level and make lifestyle
changes, further changes may be noticed.
Manual lymphatic drainage is encouraged to help manage the swelling and
soften tissue induration due to brosis or brosclerosis, stimulate circulation and
lymphatic ow, stimulate the immune system, and improve cellular nutrition and
tissue recovery, often starting in the rst 3–7 days after surgery.
Besides encouraging early ambulation to reduce venous stasis and help prevent
thromboembolism, low molecular weight heparin should be considered if large volumes are removed or in patients who have combined surgical procedures. The incidence of deep venous thrombosis in liposuction has been reported at 1%, but a
marked increase is demonstrated when combined with other surgeries such as
abdominoplasty. Subcutaneous enoxaparin can be administered 1 hour after surgery
without precipitating signicant bleeding. The applicationof 40mg per day for 6–11
days is recommended although the existing uncertainty of an optimal timing and
duration of chemoprophylaxis. The Caprini Risk Assessment Module can be used as
a guide for establishing a deep venous thrombosis prophylactic protocol (Table30.5).
As a preventive measure for postoperative fevers and/or cellulitis, rst- generation
cephalosporins are administered perioperatively within 1 h of the incision and continued for 5 days, as well as dipyrone 500 mg 6/6 h and nimesulide 12/12 h
for 3 days.
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Fig. 30.5 21 days postoperative liposuction male patient
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Table 30.5 Risk factors for venous thromboembolism based on the 2005 Caprini Risk Assessment
Model and the measures to prevent thromboembolism in patients undergoing surgery under general
anesthesia lasting more than 60 min [7-31]
1 point for each risk factor 2 points for each risk factor
Age 41–60 years Age 60–74 years Age over 75 years
Minors surgery planned Malignancy (previous or
present)
History of prior surgery (<1 month) Major surgery (>45 min) Family history of
Varicose veins Patient conned to bed (>72 h)Positive Factor V
History of inammatory bowel disease Central Venous access Positive prothrombin
Swollen legs Elevated serum
Obesity Positive Lupus
Sepsis (<1 month) Elevated anticardiolipin
Abnormal pulmonary funcion Heparin-induced
Other risk factors Other congenital or
For women only
Oral contraceptives or HRT
Pregnancy or postpartum (<1 month)
History of unexplained stillborn infant,
recurrent spontaneous abortion,
premature birth with toxemia or
growth-restricted infant
2005 caprini RAM score Recommendations
3–6 Consider the option to use postoperative LMWH or
unfractionated heparin
3 or more Consider the option to use mechanical prophylaxis
throughout the duration of chemical prophylaxis for
nonambulatory patients
7 or more Strongly Consider the option to use extended LMWH
postoperative prophylaxis
L. F. de Córdova and R. CavalcantiRibeiro
3 points for each risk
factor
History of DVT/PE
thrombosis
Leiden
20210A
homocysteine
anticoagulant
antibodies
thrombocytopenia
acquired thrombophilia
Discussion
Complications can be classied by when they occur, i.e., perioperative and postoperative, and by the area or system(s) affected, i.e., local or systemic. Local complications may be: insatisfactory results due to poor diagnostic and wrong liposuction
indication, contour irregularities secondary to bad technique and skin hyperpigmentation when the vascular supercial plexus is compromised after liposuction in a
supercial plane or untreated ecchymosis.
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When it comes to systemic complications, hypovolemia or hypovolemic shock is
of utmost importance although using the tumescent or superwet technique allows an
almost bloodless surgical eld. A bloody aspirate may be obtained in dense brotic
areas such as the back, upper abdomen, or male breasts; if the aspirate is excessively
bloody, avoid that region, or more tumescent uid should be inltrated.
Preoperatively, patients should be advised not to take any medications, vitamins, or
herbal supplements with antiplatelet effects for at least 7 days prior to the surgery.
Postoperative complications may occur in three different windows, being the
perioperative period from 0 to 48 h, and can include anesthesia and cardiac complications, cannula trauma to the skin and/or internal organs, and volume-related
anomalies from bleeding or uid administration.
During the early postoperative period, from days 1 to 7, complications can
include perforation, venous thromboembolism, infection, seroma, and skin necrosis. Several cases of intestinal perforation after liposuction have been reported causing peritonitis that may lead to sepsis and eventually death. Perforation can result
from the cannula passing through a defect in the abdominal wall, an undiagnosed
abdominal hernia, or careless movement of the cannula in vertical rather than a horizontal direction. Intraoperatively, the nondominant hand should always feel the tip
of the cannula, or at the beginning of the learning curve, the use of pinch maneuver
is encouraged. The use of an axillary incision for treatment of the upper back
reduces the risk of intrathoracic penetration.
Classical clinical signs of DVT include Homan’s sign, chest pain, shortness of
breath, tachycardia, and lower extremity swelling. When properly diagnosed and
treated, DVT/pulmonary embolism is an uncommon cause of death.
Infection is unusual following liposuction; however, wound infections including
necrotizing fasciitis have been reported. Properly sterilized instruments and sterile
technique help keep the incidence of infection at its lowest. Immunocompromised
patients have an increased risk of infection, and if not excluded from consideration
for lipoplasty, they should receive close monitorization in the perioperative period.
Necrosis may occur following aggressive supercial liposuction and is more
likely if the patient at hand is a smoker. To minimize the incidence of necrosis,
supercial maneuvers should be limited and excessive postoperative compression
avoided.
Late complications include seroma, edema and ecchymosis, paresthesias, hyperpigmentation, and contour irregularities. A seroma is an abnormal collection of uid
as a result of trauma, burns, or friction. Seromas are more common in overweight or
obese patients. The diagnosis could be made either clinically or through ultrasound
examination and treated bydrainage by needle aspiration followed by compression
to avoid capsular formation. In our practice, we see seromas in the lower back during the rst 7 days since we do not leave drains as a routine procedure.
Postoperative edema and ecchymosis occur in all patients. Prolonged edema may
be present up to 3 months post-surgery and is treated with lymphatic massage and
supportive care. The challenge with ecchymosis is the hemosiderin deposition that
evolves to hyperpigmentation.
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L. F. de Córdova and R. CavalcantiRibeiro
Table 30.6 Lipoplasty is one
of the most popular aesthetic
procedures worldwide;
however, it involves risks and
complications that should be
avoided by following
systematic protocols and
select combined procedures
when needed for better
results [1-35]
Key points for safe and successful body contouring surgery
Adequate patient evaluation
Proper procedure indication
Do not try to “create new techniques”
Analyze pre- and postop pictures with the patient
Use of the superwet technique
Identify and treat complications
Always be aware of the location of the tip of your cannula
Know when to stop
Commitment to a positive lifestyle change
Paresthesias can occur in all forms of liposuction and are usually reversible during the rst 10 weeks post-surgery, patients generally report recovery to be quicker
with SAL than with UAL.
The most common late postoperative complication is contour irregularities, present in up to 20% of patients. Careful preoperative analysis, planning, and proper
informed consent all help to minimize the risk of complaints due to contour irregularities. The treatment can be directed at re-injecting fat in the over-aspirated region
or suctioning the adjacent areas in order to reduce the prominence and achieve a
blending effect (Table30.6).
Conclusions
Liposuction representsA versatile technique whichprovides, along with an adequate
diagnosis and patient selection, the correction of body contouring, elimination
of unwanted fat deposits and the improvement on the patient’s self-esteem. Powerassisted liposuction is the authors’ preferred approach,and has the following advantages:
• Less bruising, swelling, and trauma.
• Increased patient comfort and improved safety.
• Greater cell viability for autologous fat grafting and reinjection.
• Faster healing process because the connective tissue is not destroyed.
• Studies indicate that PAL produces high concentrations of adipose-derived stem
cells, which hold great promise for a variety of medical therapies.
• PAL is not heat based, so patient burns are not a concern.
Technology-assisted liposuction needs expertise on conventional-assisted liposuction as well as investment from the plastic surgeon to buy the technology that
most appeals to them.
Declaration of Conicts of Interests The authors declare no potential conicts of interest with
respect to the research, authorship, and/or publication of this chapter.
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