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_1417_Библиотеки_им_академика_М_И_Перельмана
.pdf
156
https://t.me/med1917
Fig. 3.37 Seromes
Z. Jandali et al.
– Legs up.
– Early mobilization.
– Exercise therapy, such as bed exercises.
You will be put on the compression suit after the surgery in the operating room,
sometimes with an additional wrapping bandage. In bed, your legs should be elevated. After the operation, it is important that you mobilize as soon as possible. As
soon as you can sit at the edge of the bed without any problems, they should move
to standing as early as possible, rst under escort and then alone. Stop short of the
bed and listen to your body. It will tell you if you can already take your rst steps,
rst at room level and then at ward level. Walking is of immense importance, as it
3 Treatment ofLipedema
https://t.me/med1917
Fig. 3.38 Exercise for
thrombosis prophylaxis
157
not only stimulates circulation but also activates the muscle pump in the calves.
The muscle pump in the calves supports a return ow of blood from the legs to
the heart.
But also movement exercises in bed help to prevent thrombosis. For this purpose,
we would like to give you two exercises that you can do alone in bed.
Exercise number 1 (Fig.3.38): You lie relaxed in bed with your arms placed
loosely beside your body. Your legs are stretched out in bed and the tips of your
toes point upwards. Now bend and stretch your toes as shown in Fig. 3.38
15 times.
Exercise number 2 (Fig.3.39): As soon as you can sit, sit on a chair and place
your feet on the oor. Press the heels of both feet rmly on the oor and lift the tops
of the feet vigorously. Keep the tips of your toes up briey. Then roll over the tips
of your toes with pressure. Repeat this exercise 15 times as well. Try to do the exercises several times a day.
Summary thrombosis prophylaxis
– Take in sufcient uids (drinking, infusions).
– Movement and exercises for the muscles of the lower legs.
– Prophylaxis injection for at least 4days.
– Compression garments.
158
https://t.me/med1917
Z. Jandali et al.
Fig. 3.39 Exercise for thrombosis prophylaxis
Symptoms of Possible Thrombosis
– Increasing swelling of the legs with a feeling of heaviness and/or tension.
– Pain in the leg, often especially in the lower legs in the area of the calves
(pressure pain).
– Overheating or blue discoloration of the skin.
If you have symptoms that make you suspect you may have a
c
thrombosis, please present to your doctor or an emergency room
immediately.
A thrombosis can develop into a pulmonary embolism with far-reaching
consequences, such as intensive medical treatment or, in the worst case, death.
A patient dying during liposuction is an extremely rare complication, and we
3 Treatment ofLipedema
https://t.me/med1917
don’t want to scare you. However, the rare complications must also be
addressed, because no one can rule out a complication in advance.
“Take a deep breath” is the motto. After a procedure, pain can be responsible for your inability to breathe properly. This can lead to lung ventilation
problems or, even worse, pneumonia. But not only deep breathing, but also
exercises with the so-called Triow help to ventilate the lungs well.
Ask the hospital for a Triflow to do your breathing exercises.
c
To perform the lung ventilation exercise with the Triow, place the mouthpiece of the Triow in your mouth (Fig.3.40), seal the mouthpiece with your
lips and inhale so deeply that the balls slowly rise up one after the other
(Fig.3.41). It is better to hold only one or two balls up for as long as possible
than to hastily try to pull all three balls up. It is best to repeat this exercise
every hour, trying to pull the balls up more than 5 times. Rotate the Triow
and exhale. Likewise, try to keep all the balls up as long as possible.
If you have trouble breathing or any of the symptoms listed in the
c
overview, please present to your doctor or an emergency room
immediately.
This was an excerpt of possible complications and risks. Before surgery, a
detailed discussion will take place in which you will be informed about these
and other risks.
159
Fig. 3.40 Triow
exercise: Inserting the
mouthpiece
160
https://t.me/med1917
Fig. 3.41 Triow
exercise: take a deep breath
Z. Jandali et al.
Possible Symptoms of Pulmonary Artery Embolism
– Shortness of breath when inhaling or exhaling, possibly accelerated
breathing.
– Pain when breathing and chest pain, which may also radiate.
– Palpitations.
– Anxiety, possibly with sweating.
– Dizziness, fatigue, fainting.
– Cough and/or hemoptysis.
– Unusual sounds when breathing.
3.7.6 Course oftheComplex-Operative Therapy Plan
Many people wonder in which order the liposuctions is performed. Let us now go
into the sequence of the complex surgical therapy plan and especially the sequence
of the planned liposuctions integrated into it.
The complex-surgical treatment plan includes:
1. Conservative treatment of lipedema with compression therapy, if necessary lymphatic drainage, if edema should be present (optional).
2. Weight analysis and, if necessary, treatment of concomitant obesity (from lifestyle modication to metabolic surgery).
3. Liposuctions for the treatment of lipedema.
4. Tightening surgery for foreseeable, physically limiting skin-soft tissue excess.
In the following, we will discuss point 3, how the individual liposuctions proceed.
3 Treatment ofLipedema
https://t.me/med1917
161
Many providers of liposuction for lipedema have their own concept of how and
in what sequence liposuction is performed. We have our own names for the different
procedures: the “bottom-up concept,” the “outside-in concept,” the “holistic suction
concept,” the “lipedema compression concept” and the concept of SRL liposuction,
systematic-regional liposuction.
“Bottom-up” Concept
In the “bottom-up“concept, the lower parts of the body are suctioned rst and the
upper part of the body in subsequent operations. An example would be suctioning
the lower legs and knee region in one operation; the thighs would be suctioned in a
second and nally the hips in a third.
“From the outside in” Concept
In the “from the outside to the inside” concept, liposuction of the outer sides is performed in a rst operation and liposuction of the inner sides in another operation.
An example here would be liposuction of the lower legs, knees, thighs, and outer
sides of the hips rst. In the follow-up surgery, the inner sides of the lower leg, knee,
and thigh would be suctioned.
“Concept of Holistic Suction”.
The “concept of holistic liposuction” suctions all body areas, as the theory is that
lipedema “migrates” after liposuction and then affects other areas.
“Lipedema Compression Concept”
The “lipedema compression concept” is interpreted differently. Many suction all
areas “somewhat” and again and again in different interventions until a satisfactory
result is achieved.
“SRL Liposuction Concept”.
SRL stands for “systematic regional liposuction.” This concept has emerged after
many years of searching for the best approach for us and many plastic surgery colleagues. It includes, among other things, the systematic working off of the affected
regions, the sequence of procedures, and the technique of how liposuction is to be
performed. It does not matter whether we perform WAL, PAL, or other liposuction.
SRL stands for “systematic-regional liposuction” in which we try to
c
close regions if possible and not suction them twice.
To understand our concept, it is necessary to consider many individual factors. It
is necessary to consider how the anatomy is, how liposuction works and is performed, what happens in the body as a result of liposuction and what the healing
process is like. Our concept of systematic regional liposuction (SRL liposuction),
due to the reasons listed above, always tries to close off regions as much as possible
to avoid second and third liposuction of a region. At the same time, we must not
disregard aesthetics and must continuously suction the transitions as well. This does
not mean that small corrections here and there or even second aspirations cannot
162
https://t.me/med1917
Z. Jandali et al.
occur, but we try to completely aspirate and close a region in one procedure if
possible.
But now it still depends on the fat deposits present. If these exceed an appropriate
volume, secondary liposuction must be performed in any case. However, in about
70% of cases, we can avoid this.
If we look at a classic case and see that lipedema is signicantly located in the
hip–thigh region and lower legs, often with a moderate expression, we can reach all
affected areas in two liposuctions. One liposuction would then be performed in the
supine position and another in the prone position.
Supine position means that you lie on your back during the operation.
c
In the prone position, it is the other way around accordingly.
During these individual liposuctions, we suction off a maximum amount of fatty
tissue according to medically justiable criteria. Of course, transitional areas are
always suctioned as well, to obtain a harmonious transition between the regions as
far as possible. It is not possible to suction off the entire fatty tissue, that is, completely, without leaving any fatty tissue behind. Those colleagues who advertise or
even make these statements must be questioned very critically. However, as little as
possible fatty tissue should remain.
A statement like “we can remove all the fatty tissue or all the diseased
c
fatty tissue” is not serious. Give a wide berth to such users.
In the rst operation in the supine position, we nally get good access to the outer
sides of the hips, the thighs (front, outer, and inner sides) and also the inner sides of
the knees. If there is also lipedema on the lower legs, we can treat the front, outer and
inner sides of the lower legs as well. This is done until we reach our reasonable volume limits or the maximum duration of surgery (for volume limits Section 0).
The second operation is liposuction in the prone position. In this session, the
outer sides of the hips (buttocks if necessary) are again treated and completed as a
transitional region. The same applies to the inner thighs. Suction is applied to the
backs of the thighs and the transitional region of the inner sides of the knees and the
inner and outer sides of the lower legs. We often pay special attention to the lower
leg region in this operation. This region, which is the most challenging to suction,
requires highly precise work and a lot of experience.
Depending on the extent of the rst liposuction, the second liposuction can follow at the earliest after 2 months, better after 3–6 months. A too short interval
between liposuctions is not recommended for medium to pronounced liposuctions,
since the physical strain is quite high and the bruises and scarring need time to
recede. Likewise, personal–social aspects such as career and family should also be
taken into account.
If the affected person also suffers from lipedema in the arms, the arms could be
combined with liposuction of the backs, but only if it ts from the circumference.
Otherwise, the arms would have to be liposuctioned in a separate procedure.
3 Treatment ofLipedema
https://t.me/med1917
Fig. 3.42 Flowchart of liposuction
163
A three-stage treatment plan is shown in Fig.3.42. In the rst step, liposuction of
the fronts is performed, in the second step, liposuction of the backs is performed,
and in the third step, liposuction of the arms is performed.
We recommend an interval of at least 2–3months between two operations involving the same transition areas. If liposuction of an area is planned more than once due
to a strong manifestation of lipedema, we recommend an interval of at least 6months
between the operations.
Some colleagues recommend whole-body liposuction to treat lipedema, that is,
liposuction of all areas of the body, because otherwise, lipedema will spread elsewhere on the body. On the one hand, it is nonsensical to argue this way; on the other
hand, the approach makes perfect sense, and always when liposuction is used as the
sole surgical component. Especially in the case of obese people, the approach is
understandable, but it does not promise long-lasting success.
We also very often advise liposuction of more regions than just the arms, buttocks, hips, and legs. However, the overall treatment plan must be correct, and the
recommendation of extensive liposuction is purely for aesthetic reasons, and we
stand by that. Through extensive liposuction, including the back area, anks, abdomen, and lateral thoracic wall, we can shape an aesthetic and sophisticated body
contour beyond the goal of pure pain treatment.
We often recommend suctioning other areas of the body for purely
c
aesthetic reasons.
In Table3.5 you will nd a few examples of typical liposuction plans to help you
understand our planning. Although the treatment plan is xed, it is exible in the
course and can be readjusted after each procedure. Sometimes this reduces the
164
Z. Jandali et al.
https://t.me/med1917
Table 3.5 Typical liposuction plans
Stage
Lipedema type 4 stage
I (hips, legs, and arms)
Lipedema type 3 stage
II (hips and legs)
Lipedema type 3 stage
III
Lipedema type III stage
II plus abdominal
region, anks, and back
Location Quantity
Supine
position
Prone
position
Supine
position
Prone
position
Supine
position
Prone
position
Supine
position
Prone
position
Supine
position
Extraction area
1 Hips
Outer, anterior, and inner thighs
Front and inner sides of the knee
Lower leg front, outer, and inner sides
1 Hips
Outer, back, and inner thighs
Inside knee
Back, outer, and inner sides of the lower leg
Poor
1 Hips
Outer, anterior, and inner thighs
Front and inner sides of the knee
Lower leg front, outer, and inner sides
1 Hips
Outer, back, and inner thighs
Inside knee
Back, outer, and inner sides of the lower leg
2 or
more
2 or
more
1–2 Hips
1–2 Hips
1 Belly
Hips
Outer, anterior, and inner thighs
Front and inner sides of the knee
Lower leg front, outer, and inner sides
The regions can be further subdivided per
OP.
Hips
Outer, back, and inner thighs
Inside knee
Back, outer, and inner sides of the lower leg
The regions can be further divided per
surgery. We would alternate between front
and then back suction every 2–3months.
Outer, anterior and inner thighs
Front and inner sides of the knee
Lower leg front, outer and inner sides
The regions can be further subdivided per
OP.
Outer, back, and inner thighs
Inside knee
Back, outer and inner sides of the lower leg
Plus liposuction of buttocks, back, and
anks if necessary.
The regions can be further subdivided per
OP.
Flanks
3 Treatment ofLipedema
https://t.me/med1917
Table 3.5 (continued)
Stage
Lipedema type IV
stage II plus abdominal
region, anks, and back
Location Quantity
Supine
position
Prone
position
Supine
position
Supine
position
1–2 Hips
1–2 Hips
1 Belly
1 Arms (with liposuction on the abdomen and
Extraction area
Outer, anterior, and inner thighs
Front and inner sides of the knee
Lower leg front, outer, and inner sides
The regions can be further subdivided per
OP.
Outer, back, and inner thighs
Inside knee
Back, outer, and inner sides of the lower leg
Plus liposuction of buttocks, back, and
anks if necessary.
The regions can be further subdivided per
OP.
Flanks
anks, if necessary).
165
number of liposuctions planned as the procedure progresses. Any necessary tightening operations are performed after 6months.
A very frequently asked question is when is the best time for surgerywhen planning to have children. There are different opinions on this and we do not have a
general answer. The fear of further aggravation of lipedema is justied and is frequently observed. However, we have also observed worsening of lipedema after
liposuction and subsequent pregnancy.
We hold the following opinion: A desire to have children always comes rst. For
those who do not want to have children for fear of aggravation, we would like to point
out that this fear is unjustied, as much can be corrected and achieved afterwards.
It is, therefore, necessary to consider performing liposuction before pregnancy or
afterwards. The aim of liposuction before pregnancy would be to remove as much
fatty tissue as possible so that there is no signicant increase in volume during pregnancy. Liposuction after pregnancy would have the advantage of removing areas
that may have worsened.
Following thoughts:
– Not every pregnancy is associated with an exacerbation (probability is high,
however).
– Despite liposuction in advance, there may be a signicant increase in lipedema.
– Pregnancy often leads to signicant tissue sagging, whether with or without lipo-
suction beforehand.
– Much more important than liposuction in advance is a perfect diet and lifestyle
during pregnancy. There are special courses and concepts for this.
– After the completion of the childbearing process, a holistic approach to body
shape correction, including lipedema treatment, can be created if needed.
Соседние файлы в папке Библиотека им академика М.И. Перельмана