Textbook of Liposuction (Series in Cosmetic and Laser Therapy)

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Textbook of Liposuction

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SERIES IN COSMETIC AND LASER THERAPY Published in association with the Journal of Cosmetic and Laser Therapy

Already available David Goldberg. Fillers in Cosmetic Dermatology ISBN 9781841845098 Philippe Deprez. Textbook of Chemical Peels ISBN 9781841844954 Of related interest Robert Baran, Howard I Maibach. Textbook of Cosmetic Dermatology, 3rd edn ISBN 9781841843117 Anthony Benedetto. Botulinum Toxin in Clinical Dermatology ISBN 9781842142448 Jean Carruthers, Alistair Carruthers. Using Botulinum Toxins Cosmetically ISBN 9781841842172 David Goldberg. Ablative and Non-Ablative Facial Skin Rejuvenation ISBN 9781841841755 David Goldberg. Complications in Cutaneous Laser Surgery ISBN 9781841842455 Nicholas J Lowe. Textbook of Facial Rejuvenation ISBN 9781841840956 Shirley Madhere. Esthetic Mesotherapy and Injection Lipolysis in Clinical Practice ISBN 9781841845531

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Textbook of Liposuction Edited by

C William Hanke

MD MPH FACP

Director, Laser and Skin Surgery Center of Indiana, Indianapolis, IN, USA Past-President, International Society for Dermatologic Surgery Past-President, American Society for Dermatologic Surgery Past-President, American Academy of Cosmetic Surgery Past-President, International Society of Cosmetic and Laser Surgeons

Gerhard Sattler

MD

Director, Rosenparkklinik, Center for Cosmetic Dermatologic Surgery and Plastic Surgery, Darmstadt, Germany Founder/Director, Live Surgery Symposium, Darmstadt, Germany President, International Society for Dermatologic Surgery President, German Society for Dermatologic Surgery and Aesthetics Treasurer, Society for Cosmetic Surgery of Germany

Boris Sommer

MD

Private practice, Frankfurt, Germany Board of Directors, International Society for Dermatologic Surgery President, German Society for Cosmetic Botulinum Toxin Therapy

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© 2007 Informa UK Ltd First published in the United Kingdom in 2007 by Informa Healthcare, 4 Park Square, Milton Park, Abingdon, Oxon OX14 4RN. Informa Healthcare is a trading division of Informa UK Ltd. Registered Office: 37/41 Mortimer Street, London W1T 3JH. Registered in England and Wales number 1072954. A German version of much of this material was originally published in 2003 by Georg Thieme Verlag, Stuttgart as Sattler G, Sommer B, Hanke CW, eds. Lehrbuch der Liposuktion. Tel: +44 (0)20 7017 6000 Fax: +44 (0)20 7017 6699 Email: [email protected] Website: www.informahealthcare.com All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of the publisher or in accordance with the provisions of the Copyright, Designs and Patents Act 1988 or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P 0LP. Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be glad to acknowledge in subsequent reprints or editions any omissions brought to our attention. A CIP record for this book is available from the British Library. Library of Congress Cataloging-in-Publication Data Data available on application ISBN-10: 1 84184 532 9 ISBN-13: 978 1 84184 532 6 Distributed in North and South America by Taylor & Francis 6000 Broken Sound Parkway, NW, (Suite 300) Boca Raton, FL 33487, USA Within Continental USA Tel: 1 (800) 272 7737; Fax: 1 (800) 374 3401 Outside Continental USA Tel: (561) 994 0555; Fax: (561) 361 6018 Email: [email protected] Distributed in the rest of the world by Thomson Publishing Services Cheriton House North Way Andover, Hampshire SP10 5BE, UK Tel: +44 (0)1264 332424 Email: [email protected] Composition by C&M Digitals (P) Ltd, Chennai, India Printed and bound in India by Replika Press Pvt Ltd

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Contents List of Contributors Preface to the English Edition

vii ix

1

The history of liposuction G Sattler, B Sommer, CW Hanke

1

2

The status of liposuction today G Sattler, B Sommer

7

3

Development, anatomy, and physiology of adipose tissue M Podda, R Kaufmann, D Bergfeld

13

4

Tumescent technique B Sommer, D Bergfeld

21

5

Anesthesiological aspects T Hübner

39

6

Physiodynamic concept of tumescence G Sattler, S Sattler

43

7

Concept of wound healing after liposuction using tumescent technique G Sattler, S Sattler

47

8

Patient evaluation and planning of the procedure B Buxmeyer, D Bergfeld

49

9

Indications and contraindications for liposuction B Sommer, G Sattler

61

10

Instruments R Jokisch

73

11

Spatial and technical requirements R Jokisch, D Bergfeld

79

12

Operating technique G Sattler, B Sommer, CW Hanke, G Blugerman, AL Leonard

83

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Contents

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Adjuvant and secondary procedures G Sattler, B Sommer, G Blugerman

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14

Endoscopic aspects of liposuction G Sattler

149

15

Aftercare R Jokisch, D Bergfeld

153

16

Safety of liposuction surgery CW Hanke, G Sattler, AL Leonard

161

17

Liposuction guidelines G Sattler, B Sommer, CW Hanke

169

18

Complications and risks of tumescent liposuction surgery G Sattler, B Sommer, CW Hanke

175

19

Documentation and archiving G Sattler, S Sattler

189

20

Tips and tricks G Sattler, B Sommer

195

21

Avoidance of errors G Sattler, B Sommer

199

22

Expert report issues G Sattler

203

23

Marketing G Sattler, S Sattler, G Blugerman

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24

Patient clientele and patient satisfaction M Augustin, K Maier, B Sommer

211

Index

215

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Contributors Mattias Augustin MD Department of Dermatology Freiburg University Hospital Freiburg Germany

Thomas Hübner MD Rosenparkklinik Center for Cosmetic Dermatologic Surgery and Plastic Surgery Darmstadt Germany

Dorothee Bergfeld Private Practice Frankfurt Germany

Rainer Jokisch MD Rosenparkklinik Center for Cosmetic Dermatologic Surgery and Plastic Surgery Darmstadt Germany

MD

Guillermo Blugerman MD B&S Centro de Excelencia en Cirugía Plástica Buenos Aires Argentina

Roland Kaufmann MD Department of Dermatology Johann-Wolfgang-Goethe University Frankfurt Germany

Birgit Buxmeyer MD Rosenparkklinik Center for Cosmetic Dermatologic Surgery Plastic Surgery Darmstadt Germany

Aimee L Leonard MD Laser and Skin Surgery Center Carmel, IN USA

Loek Habbema MD Medisch Centrum’t Gooi Busum The Netherlands

Kristina Maier MD Department of Dermatology Freiburg University Hospital Freiburg Germany

C William Hanke MD FACP Director, Laser and Skin Surgery Center of Indiana Indianapolis, IN USA

Maurizio Podda MD Department of Dermatology Johann-Wolfgang-Goethe University Frankfurt Germany

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List of Contributors

Boris Sommer Private Practice Frankfurt Germany

Gerhard Sattler MD Director, Rosenparkklinik Center for Cosmetic Dermatologic Surgery and Plastic Surgery Darmstadt Germany Sonja Sattler MD Rosenparkklinik Center for Cosmetic Dermatologic Surgery and Plastic Surgery Darmstadt Germany

viii

MD

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Preface to the English Edition Live Surgery Symposium, an international postgraduate course held in Germany in 1992, 1994, 1996, 1998, 2000, 2002, 2004, and 2006. Tumescent local anesthesia has been applied to many new procedures by German physicians from various specialties. Further, every liposuction surgeon knows that the most difficult aspects of the procedure to learn are the preoperative planning, patient positioning, incision placement, and cannula direction.A great strength of this book is the multitude of high-quality photographs which demonstrate these key concepts. It should be noted that the majority of the tunnels are made in the long axis of the body to avoid unnecessary injury to the lymphatics and neurovascular structures which lie within the fat septa.This minimizes postoperative morbidity and allows patients to return to normal activities within a few days. Third, many new concepts and discoveries are presented. These include new indications for liposuction, new information on the science of tumescent local anesthesia, and a major advance, powered liposuction using reciprocating cannulas. With powered liposuction, patients can be treated more rapidly without discomfort. Patient and surgeon fatigure is reduced, and the results are better. However, a learning curve is required for the liposuction surgeon to make the transition from standard cannulas to powered cannulas. Another major

The first written description of the tumescent technique was published by Klein in 1987. The first book on Tumescent Local Anesthesia was published in German by Sattler, Sommer, and Hanke in 1999, and in English in 2000. Klein’s comprehensive book Tumescent Technique was also published in 2000. Liposuction using tumescent local anesthesia is performed on patients who are totally conscious; general anesthesia or intravenous sedation is unnecessary; patients are awake and comfortable intraoperatively and postoperatively. Multiple large studies have reported complications to be minor and uncommon; no fatalities have been documented. Patients prefer the simplicity of liposuction using tumescent local anesthesia to the complexities of liposuction using general anesthesia. A number of books have been written on liposuction, but this one is different and unique in many ways. First, it is the product of the German– American experience in performing liposuction using tumescent local anesthesia. Although invented in the United States, liposuction using tumescent local anesthesia has undergone significant development and refinement by Gerhard Sattler and his colleagues in Germany. Sattler initially learned about liposuction using tumescent local anesthesia at the ISDS Congress in Barcelona in 1987. He began treating patients with the new technique in 1989. Liposuction has been the centerpiece of the

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The editors and authors of hope that physicians will utilize the presented to maximize patient satisfaction with the tumescent technique.

advance has been the manually assisted skin stabilization technique (MASST). This technique is carried out by the nurse or first surgical assistant who applies manual circumferential pressure to the skin during suctioning.The MASST helps to minimize tissue trauma and encourages precise, uniform fat removal.

this book information safety and liposuction

CWH, GS, BS

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seroma, and formation of indentations. In 1976, Kesselring and Meyer developed a large, sharp curette with which they aspirated fat from the lateral thigh (‘saddlebags’) after detaching it from the fascia lata with a pair of long scissors. They too achieved unsatisfactory surgical results, despite the use of modified operating techniques and equipment3. The method introduced by Teimourian et al. in 1981 using a fascia stripper also used the basic principle of large-scale detachment of subcutaneous adipose tissue from the muscles, and had similar complications4. Yves-Gerard Illouz from Paris made major advances in the development of liposuction, turning it into a safe, routine procedure. Illouz replaced the sharp-edged curette with a blunt, less traumatizing cannula. In fact, he used a suction system which had until then only been used in the gynecological field for pregnancy terminations: the Karman aspirator with uterine cannulas. This equipment was much easier for interested colleagues to obtain than the prototype designed by the Fischers, resulting in the popularization of this method. Illouz further developed the concept of treating the tissue in several layers, using what is known as the ‘wet technique’.This involved injecting saline mixed with hyaluronidase into the adipose tissue prior to treatment. Through these improvements, it

Reports of operative attempts to remove unwanted fat appeared sporadically even before the beginning of the 20th century, but always referred to extensive surgical procedures with en bloc removal of adipose tissue via large incisions. The first attempt to remove fat via small incisions was described in 1929.The French surgeon Dujarrier removed accumulations of fat from the calves of a dancer using a curette.Tragically, damage to larger blood vessels resulted in the amputation of one leg1. The next documented attempts to remove fat via small incisions were performed in 1968 by the American physician Wilkinson and in 1972 by the German surgeon Schrudde, who first described the use of an aspiration curette1. However, in both cases the treatment method was soon abandoned because of extensive side-effects. The generally accepted pioneers of the modern form of liposuction are Georgio Fischer and his father Arpad Fischer. In the mid1970s, they developed an instrument (the ‘cellusuctiotome’) consisting of a hollow curette with a blade, attached to a suction pump2. The curette detached the fat to be aspirated by severing it with a motor-driven blade. The fat was then transported away through a system of tubes. This method had a high complication rate in the form of bleeding, postoperative hematoma,

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extensive liposuction procedures under local anesthesia on an outpatient basis. At the same time, because of the specific pharmacological and physical interaction with the tissue to be treated, it rendered liposuction considerably safer, and enabled further development. Because of the low complication rate and excellent cosmetic results, liposuction by tumescent local anesthesia is currently the method of choice9. In the mid-1980s, a range of developments were initiated with the aim of making the aspiration of fat even easier, particularly in difficult areas such as the male breast and flanks, and in the case of repeat procedures. In 1987, Italian physician groups first described a new technique utilizing ultrasound waves to remove homogenized fat10–13. The cannulas were attached to an ultrasound generator in order to cause the adipocytes to burst. However, this method soon showed some significant disadvantages: it required relatively large cannulas, and relatively high rates of seroma and skin burns were recorded14. Recently, there have been increased reports of persistent postoperative hypesthesia and hyperesthesia as a result of damage to the lipoproteins of the neural sheaths. In 1995, Charles Gross, an ENT surgeon at the University of Virginia, first described the use of motor-driven cannulas with an internal rotating blade to destroy fat cells, and referred to this method, which was used in neck liposuction under direct endoscopic control, as ‘liposhaving’15. Based on this idea, cannulas with rotating blades were developed, and later, better-suited oscillating blades emerged. The latest developments are cannulas without oscillating blades which are made to vibrate via a handpiece.

was possible to reduce the complication rate considerably5,6. Another pioneer in the field of liposuction was Pierre Fournier, who gave considerable momentum to the development of the liposuction technique.To avoid non-uniform operating results, he recommended use of the ‘criss-cross’ technique, which consisted of overlapping treatment of the area to be aspirated at various levels, from various incisions, and from various angles. In order to achieve a cryoanesthetic effect he injected cooled saline solution after adoption of the ‘wet technique’. In the mid-1980s Fournier published his work on the technique of fat transfer as a means of tissue augmentation. This involved extraction of the fat, first with microcannulas and later with cannulas of larger diameter, attached to a syringe. Fournier also advocated the manual aspiration of fat, using syringes, for body-shaping (syringe-assisted liposculpturing)7.Together with Illouz, Fournier played a major role in making liposuction internationally known. At the end of the 1970s, numerous US physicians visited the French pioneers, who were also invited to the USA to teach physicians there2. In 1982, Illouz introduced his operating procedure at a meeting of the American Academy of Cosmetic Surgery. Also in 1982, the first workshops for liposuction surgery were held initially in Paris and then in the USA1. In 1983, the American Society of Liposuction Surgery was founded5. The 50 founding members included not only plastic surgeons, but also ENT specialists and ten dermatologists.Another milestone in the development of modern liposuction surgery was the introduction in 1985 of tumescent anesthesia by Jeffrey Klein, who first published the procedure in 19878 (see below). The tumescent technique enabled the performance of more

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pharmacologist and dermatologist from San Juan Capistrano, California, developed a specific form of local anesthesia for liposuction known as the tumescent technique18. In this method, large quantities of physiological saline are mixed with a local anesthetic to achieve a concentration of local anesthetic between 0.05 and 0.1%. Injection of the tumescent solution, besides ensuring sufficient anesthesia while avoiding the risks of general anesthesia, offers a large range of other advantages (see Chapter 4). The introduction of the tumescent technique enabled liposuction to be carried out on an outpatient basis. Dermatologists, who were the first to adopt this new anesthetic technique, became one of the driving forces behind the further development of liposuction.The unusually low-risk profile of this method of liposuction was confirmed in a study conducted by Hanke et al. in 19949. Of 15 336 patients who underwent fat removal using the tumescent technique, none required a blood transfusion or hospitalization due to complications. Moreover, the tumescent technique was also adapted for other dermatological indications: Field et al. demonstrated the possibility of mobilizing repositioned flaps19, and Roenigk and others utilized this technique to operate on multiple or giant lipoma20 (see Chapter 9). From the end of the 1980s onward there was a ‘reimport’ of liposuction into Europe.The technique of fat transfer was developed by both American and German physician groups21–23.

These vibrating cannulas take advantage of the different oscillating characteristics of the metallic cannulas and the more torpid adipose tissue.The vibrating cannula glides past the tissue structures, with only the fat homogenized by the tumescent solution being sucked into the cannulas (vibration-assisted liposuction)16. Vibrating cannulas facilitate the procedure for the surgeon even in fibrous or previously operated sites.Vibrating cannulas also appeal to patients, since they glide through the tissue more easily and rarely catch on the connective tissue. So far, no serious complications have been observed. Development of the cannulas and handpieces is not yet complete, but it is expected that the advantages of these systems in both handling and the achievement of good operating results will result in widespread use15,16. THE ROLE OF DERMATOLOGISTS IN THE HISTORY OF LIPOSUCTION Because of dermatologists’ increasing interest in liposuction, symposia and courses on the subject were offered at the congresses of major American associations (American Academy of Dermatology and American Society for Dermatologic Surgery). In 1983, Stegman and Tromovitch gave the first presentation on liposuction at the American Academy of Dermatology17. In numerous hospitals, liposuction surgery was added to the specialty training programs for dermatologists. However, increasing rivalry between specialty groups made it progressively more difficult for dermatologists to use the operating facilities. Influenced by the development, and following reports of deaths during liposuction conducted under general anesthesia, Jeff Klein, a

DEVELOPMENT IN GERMANY In 1989, Gerhard Sattler was the first German dermatologist to perform liposuction using the tumescent technique at the Darmstadt

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Dermatology Clinic (Hautklinik des Klinikums Darmstadt)22.The introduction of this method, new to the German-speaking countries, was marked by various difficulties, in part due to the lack of an established infrastructure for obtaining the appropriate instruments. Many developments had to be ‘reinvented’. Beginning in 1991, fat aspirations using tumescent local anesthesia were performed regularly and in steadily increasing numbers.The technique was used initially in the dermatology department at the Rosenpark Clinic in 1997, as well as at other centers. The method was introduced to an everincreasing circle of interested German practitioners from a wide range of disciplines in the form of workshops and numerous congress presentations by the major German specialty associations. Also, the Darmstadt Live Symposium has been held regularly since 1992.As a result of the international exchange that takes place here and in the course of numerous other events, this method is now performed at a high and internationally comparable standard. German physician groups working with Sattler and others have increasingly introduced new developments and ideas. These include extension of the surgical spectrum to cover noncosmetic indications24, further developments in and studies of the tumescent solution25 and technical improvements (see Chapters 4 and 10).

DEVELOPMENTS IN RECENT YEARS In the 1990s there were several technical innovations, including the development of better cannulas and new liposuction-assisting procedures (see Chapter 10)24,25.There were also developments in the composition and dosing quantities of the tumescent solution (see Chapter 4). Moreover, the volume of clinical use and experience resulted in changes in the concepts of physiodynamics and wound healing, which were applied to the planning and performance of liposuction procedures (see Chapters 6 and 7). STATISTICS ON THE DEVELOPMENT OF LIPOSUCTION The statistics of major American specialty associations clearly show the enormous increase in liposuction, which is now the most commonly performed cosmetic procedure worldwide. According to the American Academy of Cosmetic Surgery (www.cosmeticsurgery.org), the number of liposuction procedures performed in the USA was 71 632 in 1990, 599 430 in 1999, and 672 793 in 2000. Between 1999 and 2000, an increase of 12.2% was observed in the number of procedures performed. Of the patients treated in the year 2000, 114 375 were male, which represents a proportion of 17%.The average treatment age was 40 years.

REFERENCES 1. Asken S. Liposuction Surgery and Autologous Fat Transplantation. East Norwalk, Appleton & Lange, 1988

3. Kesselring V, Meyer R. A suction curette for removal of excessive fat deposits of subcutaneous fat. Plast Reconstr Surg 1978; 62: 305–6

2. Fischer A, Fischer G. Revised technique for cellulitis fat reduction in riding breeches deformity. Bull Int Acad Cosmet Surg 1977; 2: 40–1

4. Teimourian B, Adham MN, Gulin S, Shapiro C. Suction lipectomy – a review of 200 patients over a six-year period and a study

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of the technique in cadavers. Ann Plast Surg 1983; 11: 93–8

Congress, Munich, 2001. Bologna: Monduzzi Editore, 2001:

5. Coleman WP III. The history of liposuction. Dermatol Clin 1990; 8: 381–3

17. Stegman SJ, TromovitchTA, Glogan RG, eds. Cosmetic Dermatologic Surgery, Second Edition, Chicago: Year Book Medical Publishers, 1990.

6. Illouz Y. Body contouring by lipolysis: a 5-year experience with over 3000 cases. Plast Reconstr Surg 1983; 72: 511–24

18. Ottani F, Fournier P. A history and comparison of suction techniques until their debut in North America. In Hetter G, ed. Lipoplasty: The Theory and Practice of Blunt Suction Lipectomy. Boston: Little, Brown and Company, 1984: 19–23

7. Fournier P. Body Sculpturing Through Syringe Liposuction and Autologous Fat Re-injection. Corona Dee Mar, CA: Samuel Rolf International, 1987 8. Klein JA. The tumescent technique for liposuction surgery. Am J Cosmet Surg 1987; 4: 236–67

19. Field L, Skouge J, Anhalt T, et al. Blunt liposuction cannula dissection with and without suction assisted lipectomy in reconstructive surgery. J Dermatol Surg Oncol 1988; 14: 1116–22

9. Hanke CW, Bernstein G, Bullock BS. Safety of tumescent liposuction in 15336 patients – national survey results. Dermatol Surg 1996; 22: 459–62

20. Coleman WP III. Non-cosmetic applications of liposuction. J Dermatol Surg Oncol 1988; 14: 1085–90

10. Scuderi N, De Vita R. Nuove prospettivo nella liposuzione: la lipoemulsificazione. Giorn Chir Plast Riconstr Estet 1987; 1: 33

21. Sattler G, Sommer B. Liporecycling: a technique for facial rejuvenation and body contouring. Dermatol Surg 2000; 26: 1140–4

11. Zocchi ML. Ultrasonic liposculpturing. Aesthet Plast Surg 1992; 16: 287–98

22. Sattler G, Sommer B.Tumescent liposuction in Germany: history and new trends and techniques. Dermatol Surg 1999; 25: 221–3

12. Newman J. Liposuction surgery: past, present, future. Am J Cosmet Surg 1984; 10: 1–2 13. Scheflan M,Tazi H. Ultrasonically assisted body contouring.Aesthet Surg J 1996; 16: 117–22

23. Sommer B, Sattler G. Current concepts of fat graft survival: histology of aspirated adipose tissue and review of the literature. Dermatol Surg 2000; 26: 1159–66

14. Topaz M. Possible long-term complications in ultrasound-assisted lipoplasty induced by sonoluminescence, sonochemistry and thermal effect. Aesthet Surg J 1998; 18: 19–24 15. Coleman WP III. Powered liposuction. Dermatol Surg 2000; 26: 315–18

24. Sattler G, Hasche E, Rapprich S, et al. Neue operative Behandlungsmöglichkeitren bei benignen Fettgewebserkrankungen. Z Hautkr 1997; 72: 579–82

16. Sommer B, Sattler G.Vibration assisted liposuction (VAL) in tumescent local anesthesia (TLA). In Ring J, et al., eds. Skin and Environment – Perception and Protection. 10th EADV

25. Sattler G, Rapprich S, Hagedorn M.TumeszenzLokalanästhesie – Untersuchung zur Pharmakokinetik von Prilocain. Z Hautkr 1997; 72: 522–5

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meaning and understanding of liposuction since the beginning of modern liposuction surgery. The ideal patient for corrective esthetic use of liposuction is a patient of normal weight with localized, diet-resistant pockets of fat due to genetic–hormonal factors. This is the real domain of liposuction surgery as a body-shaping method; however, other patients can benefit from fat aspiration in cases of specific indications (see section below on ‘What can liposuction achieve?’ and Chapter 9). Postoperative complications often seen in the early stages of the development of liposuction surgery, such as dimpling or seroma development, baggy skin, and excessive fat removal with skeletization or asymmetry, can now, for the most part, be avoided by using the appropriate operating techniques (Figures 2.1 and 2.2).At the same time, efficient procedures have been developed to optimize aesthetically displeasing results by means of specific touch-ups or corrective surgery (see Chapters 13 and 18).

Liposuction is one of the most frequently performed cosmetic surgery procedures worldwide. The number of procedures has risen steadily over the past 15 years (statistics of the American Academy of Cosmetic Surgery, www.cosmeticsurgery.org). Liposuction via tumescent local anesthesia is currently the method of choice. The high safety standard using this technique has been confirmed during the past 15 years in large numbers of patients (see Chapter 18)1,2. The central role that the tumescent technique has assumed in liposuction surgery is based, in part, on the ability to perform the procedure on an outpatient basis, avoiding the risks of general anesthesia (see Chapter 4)3,4. It has also been shown that the tumescent technique has a significant positive impact on wound healing (see Chapters 6 and 7). The safety of the tumescent solution has been enhanced by improvements in composition and application (e.g. ‘super tumescence’) (see Chapter 4). In the future, further optimization of the tumescent solution composition can be expected. Liposuction should not be viewed purely as a fat-removing procedure. Its role is more in the harmonization of body contours through liposculpture or ‘body-shaping’, which has brought about a considerable change in the

WHAT CAN LIPOSUCTION ACHIEVE? Liposuction is not a procedure for overall weight reduction in obese patients (body mass index (BMI) > 30–40). Nevertheless, it can be useful in

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Figure 2.2 Patient with excessive aspiration of the lateral thigh area Figure 2.1 Dimpled thighs of a patient who underwent liposuction in 1975, using the dry technique

specialty disciplines. Good results have been reported, for instance, with the use of stomach balloons, which enable lasting weight reduction. Thus, specific medically supported weight reduction can precede liposuction in the treatment of persistent fat deposits. Liposuction via the tumescent technique is also used in a range of adipose tissue disorders, for the mobilization of skin transplants in tumor surgery, and also for the treatment of lipolymphedema (see Chapter 9)5.

this patient group as a reduction treatment for the removal of mechanically troublesome fat deposits. Experience with these patients has often shown that, after the removal of localized fat deposits, a further general weight loss ensues. To what extent this is due to psychological changes (increased motivation for dietary change and exercise) or even hormonal changes in metabolism is still being investigated (see Chapter 3). Obese patients seeking help must also be offered other methods of weight reduction that will not further aggravate their physical condition through yo-yo dieting or ‘quackery’. Sensible measures for weight reduction and nutritional education can be offered across a range of

MAJOR DEVELOPMENTS IN RECENT YEARS In the 1990s, numerous technical innovations emerged as a result of the development of new cannulas and liposuction-assisting procedures (see Chapters 10 and 12). In the field of cannula 8

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systems will become widely accepted due to their advantages in handling and their achievement of good operating results3. Ultrasound-assisted liposuction (UAL), developed in Italy in the mid-1980s8–10, aimed to homogenize the adipose tissue using ultrasound waves.The handpiece, containing piezoelectric crystals, is controlled by an electrical generator. This causes the crystals to oscillate rhythmically at a defined frequency. Mechanical energy is transferred from this piezoelectric transducer to the actual suction cannulas (sonotrodes). The oscillation energy applied to the tissue leads to the rupture of fat cells due to what are known as cavitation processes. Due to the frequently observed side-effects in the form of seroma and skin burns, as well as hypesthesia and hyperesthesia as a result of damage to lipoproteins in the nerve sheaths, this method has not become widely used. Discussion about a possible carcinogenic risk caused the American Society for Dermatologic Surgery to term this procedure experimental11,12. Another method which must also be considered experimental is the procedure known as lipopulsing or high-frequency pulsing, used to soften adipose tissue by the application of low-energy, highfrequency electrical impulses, because the postulated effect of softening of the adipose tissue is disputed. Another method is fat aspiration using the water-jet technique developed by Taufig. Here, the fat is fragmented and immediately aspirated by a high-pressure jet of physiological saline solution with added adrenaline (epinephrine)13. Advantages are a rapid effect and the ability to assess the results immediately. The surgeon working with the tumescent technique is able to assess the results accurately only with experience, because of tissue swelling. Disadvantages are the need for general anesthetic with all the attendant

technology, refinement of the tumescent technique enabled the use of small-caliber cannulas, which led to more uniform postoperative results.The introduction of blunt cannulas with multiple suction openings (24-hole cannulas) enabled tissue trauma to be considerably reduced, with significantly improved wound healing and postoperative results. Distribution of the suction force over multiple openings reduces the suction force and consequent damage to supportive connective-tissue apparatus. In 1995, Charles Gross, an ENT specialist at the University of Virginia, first described the use of motor-driven cannulas, which destroyed fat cells by means of an internal rotating blade. This method, which was used for neck liposuction under direct and indirect endoscopic control, was referred to as ‘liposhaving’6. Based on this idea, the development of what became known as powered liposuction2 continued, first via cannulas with oscillating blades, then using vibrating cannulas in which a blunt cannula is made to vibrate using a handpiece. Vibration-assisted liposuction (VAL)7 makes use of the varying physical torpidity of human tissue: only the adipose tissue homogenized by tumescence can respond to the suction force of the metal cannulas vibrating at high frequency, whereas connective-tissue structures are not drawn in because of their greater torpidity.The oscillation frequency of the cannulas is so high that the suction force that develops at a localized site cannot affect firm structures. As a result, the cannula glides smoothly past tissue structures. Vibrating cannulas also facilitate the surgical procedure in previously operated fibrous areas. Since they do not get caught in the connective tissue, the procedure is comfortable for patients. No severe complications have been observed. Development of the cannulas and handpieces is not yet complete, but it is expected that these 9

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a

b

Figure 2.3 (a) and (b) Photographs of a patient with outer-thigh lipomatosis prior to liposuction

a

b

Figure 2.4 (a) and (b) Condition after aspiration of patient using new liposuction techniques

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a

Figure 2.5

b

(a) and (b) Photographs of a patient before and after abdominal liposuction

considered a low-risk surgical procedure which, with the combined use of improved instruments (e.g. vibration cannulas; see Chapter 10) and operating techniques (see Chapter 12), can achieve largely predictable and esthetically pleasing results. With accurate establishment of the indication, and operative planning and performance, modern liposuction surgery can achieve high-quality results in almost 100% of cases (Figures 2.3 and 2.4). It is also possible in the case of less extreme clinical findings to achieve symmetry of the body silhouette through liposculpturing (Figure 2.5).

risks, as well as potentially greater trauma to the connective-tissue support apparatus by the pressure jet, in comparison with vibration-assisted aspiration using the tumescent technique. It remains to be seen how widespread this and other new techniques will become.

SUMMARY By correct use of the tumescent technique (see Chapter 4), liposuction surgery today can be

REFERENCES 1. Hanke CW, Bernstein G, Bullock BS, et al. Safety of tumescent liposuction in 15336 patients – national survey results. Dermatol Surg 1996; 22: 459–62

3. Coleman WP III. Powered liposuction. Dermatol Surg 2000; 26: 315–18 4. Sommer B, Sattler G, Hanke CW. TumeszenzLokalanästhesie Berlin: Springer, 1999

2. Klein JA.The tumescent technique for liposuction surgery.Am J Cosmet Surg 1987; 4: 236–67

5. Sattler G, Hasche E, Rapprich S, et al. Neue operative Behandlungsmöglichkeitren bei

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benignen Fettgewebserkrankungen. Z Hautkr 1997; 72: 579–82

9. Scuderi N, DeVita R. Nuove prospettivo nella liposuzione: la lipoemulsificazione. Giorn Chir Plast Ricostr Estet 1987; 1: 33

6. Gross CW, Becker DG, Lindsey WH, et al.The soft tissue shaving procedure for removal of adipose tissue. Arch Otolaryngol Head Neck Surg 1995; 121: 1117–20

10. Zocchi ML. Ultrasonic liposculpturing.Aesthet Plast Surg 1992; 16: 287–98 11. Task Force on Ultrasonic Liposuction of the American Society for Dermatologiy Surgery. Statement on ultrasonic liposuction. Dermatol Surg 1998; 24: 1035

7. Sommer B, Sattler G. Vibration assisted liposuction (VAL) in tumescent local anesthesia (TLA). In Ring J., eds. Skin and Environment – Perception and Protection. 10th EADV Congress, Munich, 2001. Bologna: Monduzzi Editore, 2001:

12. Topaz M. Possible long-term complications in ultrasound-assisted lipoplasty induced by sonoluminescence, sonochemistry and thermal effect. Aesthet Surg J 1998; 18: 19–24

8. Scheflan M,Tazi H. Ultrasonically assisted body contouring. Aesthet Surg J 1996; 16: 117–22

13. Taufig AZ. Fettabsaugung zur Korrektur von Körperformen. Kosmet Med 2002; 2: S68–72

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postnatal growth phase, there is differentiation of mesenchymal cells and lipoblasts. These initially resemble fibroblasts. These fat droplets (pre-adipocytes) collect and join to form a large fat vacuole (univacuolar, white adipose tissue). Mature adipocytes are large round cells with a parietal nucleus and distinct cell membrane. These often have a diameter of over 100 µm. Each fat cell is encased in thin collagen fibrils and surrounded by a network of capillaries.The thin layer of cytoplasm which surrounds the fat cell contains the cellular organelles. Fat transport in the cells is by micropinocytosis, which can be seen under the electron microscope in frozen sections as invagination and evagination. Presumably, the typical univacuolar fat cells can also develop in adults from multivacuolar fat cells by further fat storage. This process is rare, however. The majority of univacuolar fat cells stem from the lipoblasts formed in early childhood during secondary fat tissue formation. It is assumed that mature adipocytes are generally no longer capable of division after puberty. Therefore, the intake of more food leads to the hypertrophy of existing cells rather than multiplication (hypertrophic adiposity). In the case of extreme adiposity, however, the formation of new adipocytes from reticuloendothelial cells is possible via the release of an ‘adipogenetic’ factor (hyperplastic adiposity)6–9.

It would be beyond the scope of this book to present a complete account of the development and metabolism of adipose tissue. For this, the reader is referred to the appropriate textbooks. The purpose of this chapter is to describe the development, anatomy, physiology, and pathology of adipose tissue to the extent that it is relevant to liposuction surgery.

DEVELOPMENT Adipose tissue can be considered a specific form of reticular connective tissue in which the fat cells (adipocytes) are stored grapelike in an alveolar framework of connective tissue1,2. According to the current state of knowledge, there are two methods by which embryonic adipose tissue is created1–4. In the case of primary fat formation, epithelioid lipoblasts are formed in the early embryonic stages, and are arranged like glands. These can be detected as the primitive fat organ from the fourth embryonic month5. The accumulation of many small fat droplets initially forms multivacuolar brown adipose tissue, less common in humans, which later converts to the typical univacuolar white adipose tissue. In secondary adipose tissue formation, which occurs in the later fetal period and early

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Subcutaneous tissue not only provides heat regulation and mechanical protection and serves as an energy reservoir, but also determines individual physical appearance. The most accurate knowledge possible of the microscopic and macroscopic subcutaneous adipose tissue distribution in various parts of the body is a precondition for the removal of adipose tissue by way of liposuction without causing structural damage. Microscopically, the adipose tissues of the subcutis is divided into lobules by fibrous septa which form a complex three-dimensional network. Unlike many other mammals, in humans, the division between the dermis and subcuits is not a straight line, but rather is interwoven by upward-reaching adipose tissue sections surrounding eccrine and apocrine glands. In the fibrous septa are blood vessels and nerves, and each microlobe represents a terminal region, so that there are no capillary connections between neighboring microlobes. The macroscopic structure of the subcutaneous tissue is a subject to which relatively little attention has been paid, and which is disputed among both anatomists and surgeons10,11. Some authors adhere strictly to the description by the anatomist Henry Gray: a surface adipose tissue layer and a deeper layer separated by a single layer of fascia. Others, however, reject such a distinction on the basis of their observations in cadavers and liposuction patients. They propose one single surface layer of adipose tissue12. Nevertheless, there have been few comparative studies of changes in amounts of adipose tissue in either fat-distribution disorders or obesity13. In 1910, Sterzi14 observed a significant difference between ‘fat-rich’ and ‘lean’ individuals. In the latter, he described a shrinkage of fascial structures with reduced amounts of fat. The extent of the subcutaneous fascia is altered with an increase in the number of fat cells stored.

Figure 3.1

Fat lobule

These varying fascial conditions, dependent on the quantity of fat, could explain the various and sometimes contradictory descriptions of the subcutaneous anatomy. In support of the theories of Wassermann, many scientists view the so-called adipose tissue not as tissue in the normal sense, but rather as an organ or as a complex with organic properties. The fat lobules function as ‘reticuloendothelial organs in a hormone-controlled state of fat storage or release depending on nutritional conditions’4. According to this theory, there are indistinct boundaries between the small reticular and larger macroscopically definable fat organs and the subcutaneous adipose tissue or panniculus adiposus (Figure 3.1). The role of adipose tissue as a hormoneforming organ is described in detail below.

PHYSIOLOGY OF ADIPOSE TISSUE Adipose tissue is found mainly in the subcutis. It has important functions as structural fat (e.g. 14

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Figure 3.2

Anatomy of subcutaneous tissue

cells is dependent on insulin. In order to release stored triglycerides, they are converted back into free fatty acids and glycol by the enzyme lipase. In 1994, the ‘obese’ gene (ob) was successfully identified. Its gene product leptin (leptos = thin) has been intensively studied with regard to its role in the regulation of body weight15. Leptin, which is produced and secreted only in adipose tissue, has a considerable influence on the regulation of body weight. Leptin secretion occurs in a controlled manner. There is an almost linear relationship between the body mass index (BMI) and plasma leptin levels. Thus, the plasma leptin level reflects fat mass, and weight reduction leads to a reduction in leptin production. The exact significance of leptin is not yet clear, but it can affect the repletion system via hypothalamic receptors. Leptin provides the brain with information on the amount of peripheral fat stores, and can influence further food intake via a feedback system. Human obesity is accompanied by a resistance to autologous leptin15–18. Leptin receptors have also been found outside the central nervous system (heart,

sole of the foot), as an energy store, and in mechanical protection and heat insulation (fat stores). The subcutis, in addition to its function as a fat storage medium, connects the skin to the underlying structures via connective-tissue bands (retinacula cutis), and supplies them via nerves, blood, and lymphatic vessels (Figure 3.2). In addition to the mechanical cushioning function of structural fat, the larger quantities of stored fat in the body serve basically as an energy reserve. Adipose tissue metabolism consists of lipogenesis, which leads to the storage of excess triglycerides in the adipocytes, and lipolysis, in which these are made available to the body as fuel9. Fat cells store nutritional fat in the form of triglycerides, which are synthesized from free fatty acids and glucose. The absorption of fatty acids from the blood is made possible by the enzyme lipoprotein lipase, which converts triglycerides from chylomicrons and VLDL (very-low-density lipoproteins) into free fatty acids and glycerol. After absorption into the adipocytes, triglycerides are synthesized again from the free fatty acids with the assistance of glucose. The absorption of glucose into the fat 15

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Its origin is largely exogenous. Hormonal disorders such as Cushing’s disease or hyperinsulinism can also result in purely endogenous adiposity1. As a result of individual gender- and age-dependent changes in endocrine function, endogenous factors can have a considerable influence on weight development, even in the case of moderate hormonal disorders. Adoption and twin studies suggest a genetic predisposition for weight development. Twin studies show that there are ‘good’ and ‘bad’ food burners as an expression of these endogenous hereditary factors. A genetic predisposition to obesity is assumed to be at the level of about 30%. Fat cells do not disappear once formed. Diet can only reduce the size of the existing adipocytes.The lipolysis required for this occurs by receptor stimulation.There is regional variation in the distribution of hormone-sensitive surface receptors on the adipocytes19,20. As well as generalized adiposity, local accumulations of storage fat can lead to the formation of fat pockets in people who are not obese. In these people, sex hormones play a major role, which is expressed as gender-specific fat distribution. In women, the thighs, hips, and buttocks are particularly affected (gluteal–femoral ‘pear shape’). Men store excess fat mainly as trunk and abdominal fat (abdominal–visceral ‘apple shape’). Variations in fat distribution are due to the fact that the adipocytes are morphologically and functionally different in different parts of the body. They react differently to the nutritional fat that is available and to lipolytic stimuli due to the presence of different receptors. Lipase activity in the gluteal–femoral region is controlled by progesterone and estrogen receptors. Lipase activity in the abdominal area is controlled

lung, liver, thyroid gland), but the exact function of these receptors is still largely unknown. Numerous other hormones play a role in fat metabolism9,16. Insulin and glucocorticoids stimulate both leptin levels and lipogenesis.Activation of the sympathetic nervous system with the release of catecholamines leads to a reduction in the level of leptin and stimulates lipolysis9. Lipolysis is further stimulated by glucagon, adrenocorticotropic hormone (ACTH), thyroidstimulating hormone (TSH), growth hormone, and vasopressin. Sex hormones play an essential role in fat distribution. PATHOPHYSIOLOGY OF ADIPOSE TISSUE When a long-term excess supply of calories occurs, there is an increase in adipose tissue due to enlargement of the fat cells. Obesity is the most common nutritional and metabolic disorder of industrialized nations, and increases the risk for cardiovascular disease and diabetes mellitus. Obesity is defined as excess weight of more than 20%. In the case of generalized obesity, increased fat accumulation is found mainly in the subcutaneous adipose tissue, the panniculus adiposus. While stored fat can be increased or reduced as required, structural fat remains relatively constant even in underweight patients in order to fulfill its mechanical functions. In the case of obesity, fat accumulations also occur in the mesentery, the greater omentum, and the fat capsules of internal organs such as the kidneys and heart1,2,9. General obesity in most cases is due to an excess intake of calories, particularly carbohydrates (‘carbohydrate gorging’), and less as a result of an increased intake of nutritional fat.

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Table 3.1 Different receptor distributions in adipose tissue2 Abdominal fat (in men) and outer thigh fat (in women)

Fat on upper half of body (face, arms)

Distribution genetically determined Numerous α2 and insulin receptors → antilipolytic activity Hardly any response to diet and/or exercise Good response to liposuction

Distribution influenced by external factors Numerous β1 receptors → lipolytic activity Good response to diet and exercise Good response to liposuction

genetically induced. Benign fat tumors (lipomas) can be isolated or multiple (lipomatosis). Large and numerous lipomas can lead to mechanical symptoms, and can be very unsightly. Adenolipomatosis is the name given to extensive symmetrical lipomatosis on the neck and back. Allen–Hines syndrome is a symmetrical, painful lipomatous swelling found on the legs. An underlying hereditary metabolic disorder with abnormal composition of the subcutaneous skin fat may be present. In terms of diagnosis, this should be distinguished from adiposalgia (Dercum’s disease), which is characterized by multiple painful lipomas. Treatment options for pathological adipose tissue disorders are presented in Chapter 9.

mainly by food intake, growth hormone, and testosterone. Catecholamines are generally the most powerful lipolytic stimuli. Fat cells in different body regions are also distinguished by a varying number of adrenergic receptors, which in turn cause various effects. Catecholamine bonding to β1 receptors stimulates lipolysis by activating adenyl cyclase, with the formation of cAMP.The bonding of catecholamines to the α2 receptors can inhibit adenyl cyclase. The different reactions of fat deposits to periods of diet or hunger can be explained by regional differences in the distribution and concentration of hormone-sensitive receptors on the adipocytes (Table 3.1)6. This explains why diet has no effect on some fat deposits (e.g. women’s lateral thigh, which the body tends to retain as ‘nursing fat’).

SYSTEMIC DISORDERS Numerous studies have demonstrated the link between generalized obesity and metabolic syndrome, which expresses itself clinically as type II diabetes, dyslipidemia, and hypertension (Figure 3.4). These disorders are dangerous mainly due to damage to the cardiovascular system. Although it is recognized that obesity plays a central role in the development of metabolic syndrome, its precise pathophysiology has not been fully clarified. However, some observations have led to the assumption that the adipose tissue itself, altered by obesity, plays a

PATHOLOGICAL ADIPOSE TISSUE DISORDERS Disorders of the subcutaneous adipose tissue cover a multitude of inflammatory changes (panniculitides) which can occur in association with systemic conditions, trauma, or medication17,21.Another large group (lipoatrophies) usually occur locally as a result of inflammation, or as non-inflammatory localized lipoatrophies. In lipodystrophy syndromes, the atrophy of adipose tissue affects part or all of the body and can be

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Mouse Figure 3.3

Pig

Human

Hyperplasia of adipose tissue

PR

OO

F

major role in the development of metabolic syndrome16. For example, the type of fat distribution (abdominal–visceral or gluteal–femoral) is relevant; gynoid fat deposits on the thighs and buttocks present a significantly lower health risk (‘fat is not fat’).Also, the adipose tissue produces a range of hormones and hormone-like bonds. Hormones released by the adipose tissue itself and hormone-like bonds create a metabolic state which is favorable to the development of metabolic syndrome. Liposuction is not a procedure for the direct and ultimate treatment of general obesity22.A fat aspiration procedure can remove a maximum of 10–15% of a patient’s adipocytes, but generally the amount removed is far less. To what extent this affects the overall fat metabolism and the metabolic state is unclear9.

Figure 3.4 syndrome

Relationship between obesity and metabolic

Nevertheless, the removal of pockets of fat can have an astonishing effect on obese patients. In some patients there is continued weight loss

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following liposuction. This may be due to a psychological factor: the removal of particularly disturbing and stubborn fat deposits is an incentive to live more actively and healthconsciously. Reduction of the adipose tissue can have an effect on fat accumulation and body weight in the form of a negative feedback mechanism on neuroendocrine regulation systems (Figure 3.5)6. The extent to which the reduction of adipocytes by liposuction has a positive effect on the metabolic state (by reducing the adipose tissue secretion products that encourage the development of metabolic syndrome) cannot yet be fully assessed. There are at present no studies which document the effect of liposuction on the metabolic state and the health of the patient. The influence of liposuction on hyperlipidemia has yet to be supported by clinical studies.

Hypothalamus

Reduction of food intake

Leptin

Increase

Decrease

Fat tissue

Figure 3.5 Relationship between leptin and stability of adipose tissue mass

REFERENCES 6. Considine RV, Nyce MR, Morales LM, et al. Paracrine stimulation of preadipocyte-enriched cell cultures by mature adipocytes. Am J Physiol 1996; 270: 895–9 7. Dabelow A. Die Entwicklung der Fettorgane im subcutanen Gewebe menschlicher Feten. Anat Anz 1957; 104: 83–96 8. Eder M, Gedigk P. Lehrbuch der allgemeinen Pathologie und der pathologischen Anatomie, 31st edn. Berlin: Springer-Verlag, 1984 9. Greenwood MR, Johnson PR. Genetic differences in adipose tissue metabolism and regulation. Ann NY Acad Sci 1993; 676: 253–69 10. Hausman DB, DiGirolamo M, Bartness TJ, et al. The biology of white adipocyte proliferation. Obes Rev 2001; 2: 239–54 11. Requena L, Yus ES. Panniculitis. Part I. Mostly septal panniculitis. J Am Acad Dermatol 2001; 45: 163–83

1. Albright AL, Stern JS. Adipose tissue. In Fahey TD, ed. Encyclopedia of Sports Medicine and Science. Internet Society for Sport Science, http//sportsci.org, 1998 2. Asken S. Liposuction Surgery and Autologous Fat Transplantation. Norwalk–San Mateo: Appleton & Lange, 1988 3. Avelar J. Regional distribution and behavior of the subcutaneous tissue concerning selection and indication for liposuction. Aesthet Plast Surg 1989; 13: 155–65 4. Bjorntorp P, Karlsson M, Pettersson P, Sypniewska G. Differentation and function of rat adipocyte precursor cells in primary culture. J Lipid Res 1980; 21: 714–23 5. Bluher M, Khan BB, Kahn CR. Extended longevity in mice lacking the insulin receptor in adipose tissue. Science 2003; 299: 572–4

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12. Junqueira LC, Carneiro J. Adipose tissue. In Basic Histology: Text and Atlas, 10th edn. New York: McGraw-Hill, 2002: 129–34

17. Requena L,Yus ES. Panniculitis. Part II. Mostly lobular panniculitis. J Am Acad Dermatol 2001; 45: 325–61

13. The American Society of Liposuction Surgery (ASLSS) and the American Academy of Cosmetic Surgery (AACS). 2001 Guidelines for Liposuction Surgery

18. Stallmeyer B, Kampfer H, Podda M, et al. A novel keratinocyte mitogen: regulation of leptin and its functional receptor in skin repair. J Invest Dermatol 2001; 117: 98–105

14. Löffler G. Pathophysiologie des Fettgewebes. Dt Ärzteblatt 1997; 30: 162–3

19. Skouge JW. The biochemistry and development of adipose tissue and the pathophysiology of obesity as it relates to liposuction surgery. Dermatol Clin 1990; 8: 385–93

15. Löffler G. Biochemie und Molekularbiologie des Fettgewebes. In Wechsler JG, ed.Adipositas: Ursachen and Therapie. Berlin: Blackwell, 2003: 83–100

20. Sterzi G. I Tessuto Sottocutaneo. Florence: Niccolai, 1910 21. Roncari D, Lau DC, Kindler S. Exaggerated replication in culture of adipocyte precursors from massively obese persons. Metabolism 1981; 30: 425–7

16. Lockwood TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg 1991; 87: 1009–18 17. Heufelder AE, Spitzweg C. Physiologische und pathophysiologische Bedeutung von Leptin beim Menschen. Cologne: Dt Ärzteblatt 1997; 94: 2359–64

22. Moore KL, Persaud TV. The Developing Human: Clinically Oriented Embryology, 6th edn. Philadelphia, PA:WB Saunders Co, 1998

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tissue. A local anesthetic, highly diluted in a large volume of carrier solution, is injected under pressure via thin cannulas into the area to be anesthetized.The term tumescence is derived from the Latin ‘tumescere’ (to swell), and refers to the typical firm, swollen appearance of the anesthetized area.The associated blanching effect on the anesthetized area is attributed to vasoconstriction as a result of pressure, and the addition of adrenaline (epinephrine) (see ‘Composition of tumescent solution’and Figure 4.2). The tumescent technique allows procedures that could formerly only be carried out under general anesthesia, due to the extent of the operating area, to be performed using local anesthetic6,7. Liposuction utilizes not only the anesthetic effect of the solution but also other effects of tissue interaction (see Chapter 6).

As mentioned in the preceding chapters, liposuction using tumescent local anesthesia is currently the method of choice1. The evaluation of numerous studies2–5 has repeatedly shown the high safety record of this method. Based on our own clinical experience spanning 15 years, we consider the tumescent technique to be a definitive component of the performance of liposuction surgery with the highest possible level of patient safety and the best possible cosmetic results. This chapter reviews the development of the method, its special features, and pharmacological and safety aspects. Tumescence plays an important role in terms of the operating technique and instruments used, but particularly in the physiodynamics of the aspiration process and postoperative wound healing. For this reason, its significance is repeatedly stressed in the relevant chapters. Complications of the tumescent technique are dealt with in the section below on ‘Pharmacology and toxicology’ and in Chapter 18.

HISTORY OF THE TUMESCENT TECHNIQUE The fat removal procedures performed in Rome in 1977 by Arpad and Georgio Fischer are considered the direct predecessors of today’s liposuction surgery. Until the end of the 1980s, liposuction was performed under general or epidural anesthesia, or under strong systemic sedation with small amounts of local anesthesia. This was the method that dermatologist and

DEFINITION OF TUMESCENT LOCAL ANESTHESIA Tumescent local anesthesia is a regional method of anesthetizing the skin and subcutaneous adipose

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replaced lidocaine with prilocaine, which has less systemic toxicity7,16–18 (see ‘Pharmacology and toxicology’ below). The simultaneous development of automatic infiltration pumps now enabled the application of larger quantities of tumescent solution (e.g. between 3 and 5 l) (Table 4.1). These developments were the preconditions for creation of the ‘super wet technique’, or ‘super tumescence’. Use of the largest possible volume of tumescent solution leads to a state of ‘super tumescence’ (see Chapters 6 and 12), enabling the achievement of maximum tissue protection and thus a significant reduction in complications.

pharmacologist Jeffrey A. Klein from Irvine, California learned in 19858–10.As a result of pressure on operating dermatologists in the USA to restrict themselves to procedures that could be performed on an outpatient basis under local anesthesia, he developed the ‘tumescent technique’11 (see Chapters 1 and 12), which was a method of anesthesia involving a local anesthetic (lidocaine) highly diluted in a carrier solution. In January 1987, Klein described ‘The tumescent technique for liposuction surgery’10 in the American Journal of Cosmetic Surgery. It soon transpired that this method of local anesthesia also offered other advantages in terms of intraoperative and postoperative safety and efficacy12,13 (see ‘Advantages and disadvantages of tumescent local anesthesia’ below). Specialty groups with a great deal of experience in surgery performed using local anesthesia, particularly dermatologists, adopted this method very quickly.This led to the procedure becoming rapidly established, first in the USA and soon after in Europe14,15. Initially, the standard solution suggested by Klein was used, with lidocaine concentrations of 0.1–0.2% (see section below). Because of this relatively high concentration of local anesthetic, the amount of tumescent solution able to be infiltrated in one procedure was limited to 0.5–2 l. In addition, the use of manual pump syringes for infiltration restricted treatment to a relatively small area in a single session. Increasing experience with the tumescent method led to the discovery that if the concentration of local anesthetic was reduced, first to 0.08% and then to 0.05%, sufficient anesthetic effect remained15. The group working with Gerhard Sattler at the Dermatology Clinic in Darmstadt, Germany, coined the phrase ‘tumescent local anesthesia’, abbreviated to TLA6,7. In 1994, they

COMPOSITION OF TUMESCENT SOLUTION The original 0.1% solution described by Klein was made up as given in Table 4.28,10. Rationale for components used Adrenaline (epinephrine) causes hemostasis by vasoconstriction, which is one of the factors that contributes to the significantly lower blood loss in tumescent liposuction compared with other methods. It slows systemic absorption of the lipophilic local anesthetic, which tends to be rather torpid in the subcutaneous fat. This results in a prolonged local anesthetic effect, and also a delayed increase in plasma level, which is crucial to the pharmacological and toxicological behavior of the tumescent solution (see below). Sodium bicarbonate, added as a buffer to the acidic local anesthetic, reduces the burning sensation which might otherwise be felt upon infiltration.

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Table 4.1 Increase in amount of fluid used for specific areas

Hips (both sides) (ml) Waist (both sides) (ml) Lateral thighs (both sides) (ml) Abdomen (ml)

1992

2002

400–1000 400–1000 500–1200 800–1000

5000 3000 4000 5000–6000

Table 4.3 0.05% TLA solution after Klein Lidocaine (ml) 50.0 Adrenaline (epinephrine) 1 : 1000 (ml) 1.0 Sodium bicarbonate 8.4% (ml) 12.5 Triamcinolone acetonide 1.0 10 mg (ml) NaCl 0.9% (ml) 1000 Total (ml) 1064.5 = 0.047% solution

Table 4.2 Original TLA solution after Klein

Table 4.4 0.05% TLA solution after Sattler

Lidocaine (ml) 100.0 Adrenaline (epinephrine) 1 : 1000 (ml) 1.0 Sodium bicarbonate 8.4% (ml) 12.5 Triamcinolone acetonide 1.0 10 mg (ml) NaCl 0.9% (ml) 1000 Total (ml) 1114.5 = 0.094% solution

Prilocaine 1% (ml) 40 Adrenaline (epinephrine) 1 : 1000 (ml) 1 Sodium bicarbonate 8.4% (ml) 6 Triamcinolone acetonide 1 10 mg (ml) NaCl 0.9% (ml) 1000 Total (ml) 1048 = 0.038% solution

Klein recommended the addition of triamcinolone acetonide in order to prevent the inflammation he often observed 5–10 days after liposuction and referred to as ‘post-liposuction panniculitis’9. Due to its low water solubility, the added steroid remains at the injection site and prevents inflammatory reactions for around 6 days by inhibiting prostaglandin synthesis. Because of a potential immunosuppressive effect, the addition of triamcinolone is disputed today. Due to improvements in cannulas and operating techniques, the panniculitis that Klein observed is no longer a common complication. Some users suspect that the steroid additive has a psychostabilizing effect. Physiological saline solution is the most commonly used carrier solution, although some practitioners also use Ringer’s solution19. Besides the 0.1% solution, Klein also described a solution with 0.05% lidocaine concentration (Table 4.3). For this 0.05%

solution, studies documented adequate intraoperative safety up to 35 mg/kg body weight (see ‘Quantities and safety’ below)20. Tumescent solution after Sattler Lidocaine was replaced by prilocaine because prilocaine showed a lower serum level and thus lower toxicity due to its faster elimination (see ‘Pharmacology and toxicology’ below). Moreover, clinical experience showed that even with a 20% reduction in the proportion of local anesthetic, an adequate effect could be achieved7,19 (Table 4.4). A number of studies are currently in progress with the goal of optimizing the composition of TLA solution or developing a standardized and approved solution. New approaches include: halving the adrenaline (epinephrine) dosage, leaving out triamcinolone acetonide, and using another local anesthetic with fewer side-effects.

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Table 4.5 Tumescent solution after Schneider-Affeld and Friedrich (‘Hamburg solution’) Prilocaine 2% (ml) 10.0 Lidocaine 2% (ml) 10.0 Epinephrine (adrenaline) 1 : 1000 (ml) 0.66 Sodium bicarbonate 8.4% (ml) 6.0 Triamcinolone acetonide 40 mg (ml) 0.33 Physiological saline solution 1000.0 (NaCl, 0.9%) (ml) Total (ml) 1026.99 = 0.037% solution

The combination of various local anesthetics to reduce the side-effect rates of the individual components is also a current research approach (Table 4.5).

METHOD OF INFILTRATION Before infiltration of the TLA solution is initiated, photographic documentation of the patient from at least two perspectives must occur (see Chapter 19). The physician then marks the operating area, with specific marking of irregularities or pre-existing indentations, since these will be masked by infiltration of the TLA solution (see Chapter 12). After positioning of the patient, a venous access line is prepared prior to infiltration in order to administer intravenous drugs in case of emergency. In addition, skin spray disinfection is performed using a standard product. At the edges of the infiltration area, small subcutaneous blebs may be created using undiluted local anesthetic, into which the larger infiltration needles can then be inserted painlessly. In order to cover as large an area as possible with a single injection, it is a good idea to use long injection cannulas, e.g. one inch injection needles with 20 gauge and diameter 0.9 mm.

Figure 4.1 Liposat® with electronic pump and warming dishes for the tumescent solution

There are a variety of infiltration systems: • Manual pump injection system with bulb capacity of 2–10 ml (also available as disposable syringes); used for the anesthesia of smaller operating areas, no longer used routinely for liposuction surgery; • Mechanical infiltration: electrically operated roller pump system, available from various manufacturers; there is currently only one CE-certified pump with automatic milliliter-precision display of quantity infiltrated and electronically controlled prewarming of solution (Liposat®) (see Chapter 10) (Figure 4.1). With the mechanically driven roller pump systems, the volume to be transported per minute

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initiated too close to the surface it can be difficult to reach the deeper layers due to the build-up of pressure in the layers above. The position of the needles is altered at frequent intervals so that in the case of accidental intravascular injection, a significant amount of local anesthetic will not enter the blood vessel. During infiltration, skin turgor is monitored by continual palpation. Verbal contact with the patient is maintained to monitor the state of consciousness. Infiltration is complete when a firm, elastic (‘water-melon-like’) state is reached. The infiltrated area stands out from the surrounding area due to its swollen state and the blanching effect (see above) (Figure 4.2). It is important for both the efficacy of the TLA and the further course of the operation to observe the time dynamics of the fluid distribution (see Chapter 6).This has an impact on the anesthetic effect, the duration of the effect, and the effects of the solution on the tissue to be removed (Figure 4.3). A period of approximately 15–45 min must be allowed for optimal distribution of the solution in the tissue. In addition, the excessive dilution of the local anesthetic also extends the time until onset of the analgesic and anesthetic effect to approximately 20–30 min (see ‘Pharmacology and toxicology’ below). Before fat removal is begun, however, an additional injection of TLA solution should be given to re-establish the state of total tumescence.The amount required must be taken into account when calculating the total quantity of TLA available. Should the maximum amount of solution be used in primary infiltration, reinfiltration may be done with pure physiological saline solution. If all of these aspects are observed, the high safety and low complication rate of liposuction using the tumescent technique can be achieved.

Figure 4.2 Tumescent operating area with blanching effect and Stenger–Sattler distributor

can be set in milliliters and, thus, the infiltration speed varied. An infiltration speed that is too rapid is unpleasant for the patient due to the rapid build-up of pressure, and it is also detrimental to the tumescent effect (see Chapter 6). In addition, it can lead to a more rapid increase of local anesthetic concentration in the plasma, with increased risk of side-effects. In order not to prolong infiltration, the TLA solution can be infiltrated via several needles in parallel, e.g. using the Stenger–Sattler distributor (Figure 4.2). Infiltration is carried out in a fan-shaped pattern starting from the injection site. Infiltration cannulas generally cause pain when inserted into the non-anesthetized tissue due to their blunt tips and relatively large diameter. The use of fine, long injection cannulas which are honed sharp, such as 20-gauge spinal needles, is preferable. In order to avoid the unpleasant sensation when the skin is punctured, several small blebs are first created with normal-concentration local anesthetic, and infiltration is initiated via these. First, the deeper layers of subcutaneous adipose tissue below Camper’s fascia (see Chapter 3) are infiltrated. If infiltration is

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• Antibacterial effect of TLA solution; • Replacement of intraoperative fluid loss through subcutaneous infiltration of carrier solution; • Optimal preparation of adipose tissue for removal due to physiodynamic interaction of TLA solution with the tissue; • Active co-operation of patient in intraoperative repositioning (multipositional liposuction) or visual checks with patient standing; • Immediate postoperative mobilization of patient with reduction of thrombosis risk.

Figure 4.3

The use of extremely diluted solutions as well as delayed systemic absorption minimizes toxic systemic plasma concentrations (see ‘Pharmacology and toxicology’ below). Therefore, large areas of the body can be anesthetized using tumescent local anesthesia. Due to the high tissue pressure following infiltration of the TLA solution, as well as the addition of vasoconstrictors, blood circulation through the operating area is reduced. This prevents major hemorrhaging and also reduces the formation of hematomas. Because of the dilution effect and subsequent rinsing effect on the solution still in the tissue, the formation of hematomas is additionally reduced and resorption accelerated. The rinsing effect of the solution discharged postoperatively through the incisions is probably more important in preventing postoperative infection than any antibacterial effect of the local anesthetic (see below). The anesthetic effect of the TLA solution can persist for up to 8 h after the operation.The protracted analgesic effect of the TLA solution is a result of the slow infiltration, which, in conjunction with the marked lipophilia of the local anesthetic, slows down systemic absorption. Postoperative analgesics are not required for most patients.

Adipose tissue with tumescent solution

ADVANTAGES AND DISADVANTAGES OF TUMESCENT LOCAL ANESTHESIA The following aspects are considered specific advantages of tumescent local anesthesia5,13,21,22: • Complete anesthesia of a large operating area; • Reduced tendency to bleed; • Decreased risk of hematoma; • Better hematoma resorption; • Protracted effect of local anesthetic; • Less postoperative pain; 26

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For patients with a fear of needles or the operating room environment, or for those who are anxious or nervous for any reason, additional sedation can be given.This is done using oral or intravenous benzodiazepine (see ‘Supplementary anesthesia procedures’ below). The constant patient management required in the case of wakeful patients can sometimes be strenuous, especially in the case of challenging, difficult procedures which require more concentration on the part of the surgeon. However, constant verbal contact with the patient enables monitoring of the level of consciousness and the patient’s general condition, in addition to the appropriate technical monitoring options (see Chapter 11).

Active repositioning of the patient and checking progress with the patient standing up before the procedure is completed are definitive advantages in terms of achieving uniform postoperative results. The technique has the following advantages in comparison with liposuction using general anesthesia: • Fewer preoperative diagnostics required (ECG, chest X-ray); • Operations can be performed even on patients with increased risk of intubation narcosis; • Decreased hematoma formation; • Lasting pain-free state; • Independent intraoperative patient positioning, immediate postoperative mobilization.

PATIENT SELECTION AND PREPARATION

Besides the possible complications (see ‘Pharmacology and toxicology’ below and Chapter 18), tumescent local anesthesia for liposuction surgery has the following specific disadvantages:

A complete history must be obtained for every patient, including details of previous illnesses, especially those affecting the heart, lungs, liver, central nervous system, and thyroid gland. In addition, known allergies and medications must be ascertained. The following previous illnesses require increased care and observation:

• Time needed for infiltration and time to take effect; • Difficulties in assessing the anesthetized area; • In the case of anxious or nervous patients, a potential source of stress for both patient and surgeon due to lack of sedation; • Need for patient management during the procedure (‘talkesthesia’).

• Heart: in the case of known heart insufficiency, there is a risk of volume strain upon infiltration of larger amounts of TLA; in the case of a known tendency to arrhythmia, ECG monitoring must be done because of the pro-arrhythmogenic effect of local anesthetic, and dosage should be limited; • Lungs: in the case of a tendency to bronchospasm or excessive smoking, care must be taken before prescribing respiratorysuppressive supplementary medication;

Depending on the size of the area to be treated, the time for application of the TLA solution can be between 30 min and 1.5 h. Then a period 20–45 min must be allowed for the solution to take effect, and reinfiltration may be required. Often, application of the tumescent local anesthetic takes longer than the actual fat removal.

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also be considered, since these bottles contain para-hydroxybenzoic acid as a preservative. When using prilocaine as a local anesthetic, particularly in the case of patients of Mediterranean origin, attention must be paid to the possibility of glucose-6-phosphate-dehydrogenase deficiency (favism), with increased risk of methemoglobin formation. This can now be easily ruled out by chemical laboratory tests. It should also be determined that no methemoglobin-forming medications are being taken (chlorates, sulfonamides, nitrates).

Table 4.6 Classification of physical status 1 Normal healthy patient 2 Patient with mild systemic disease with no impaired performance 3 Patient with severe systemic disease and impaired performance 4 Patient with debilitating systemic disease which is life-threatening 5 Moribund patient

•

• •

•

monitoring of oxygen saturation should be done; Liver: in the case of liver function disorders, the clearance of lidocaine may be impaired since this is metabolized mainly in the liver (cytochrome P450 system); prilocaine offers greater safety in these cases (see below), and dosage should be limited; Kidneys: in the case of renal insufficiency, fluid and metabolite retention may occur; CNS: dosage should be decreased if there is an increased risk of convulsions, since high doses of local anesthetic can increase the likelihood of convulsions; Thyroid: there is an increased risk of arrhythmia in the case of poorly controlled hyperthyroidism.

PHARMACOLOGY AND TOXICOLOGY The pharmacological behavior of the tumescent solution depends largely on the local anesthetic (LA) it contains. It is considerably different in many respects from the use of conventional infiltration anesthesia methods, and is described in detail below. In the case of large volume infiltration, the adrenaline (epinephrine) component can lead to side-effects from systemic absorption, and this must be kept in mind. The most common side-effects are tachycardia and increased blood pressure, which can be readily identified and treated if using the recommended patient monitoring. Generally, adrenaline-induced sideeffects are rarely seen with TLA23. Adrenaline (epinephrine) becomes unstable at higher pH values.Therefore, the pH level of LA solutions containing adrenaline (epinephrine) is generally 3.5.With regard to storage of the TLA solution, it must be borne in mind that the addition of sodium bicarbonate, which lowers the pH, reduces the longevity and stability of the TLA solution. This should only be added immediately before use.

If there are clinical indications of any of these conditions, preoperative laboratory tests and an ECG or chest X-ray should be carried out. In order to assess the risks before surgery, the classification of the American Society of Anesthesiology for the assessment of physical status can be used (Table 4.6). Cosmetic procedures such as liposuction should only be performed on patients in categories 1 and 2. The only absolute contraindication to TLA is a known allergy to the local anesthetic drug.When using 50-ml bottles, para-group allergies must

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Table 4.7 Physicochemical characteristics of lidocaine and prilocaine

Lidocaine Prilocaine

pKa

Onset of action

Plasmaprotein bonding (%)

Length of effect

Lipophilia*

Relative strength of effect†

7.8 8.0

Rapid Rapid

65 55

Average Average

366 129

2 1.8

*Octanol/buffer division coefficient; †procaine = 1 (data from experiments in animals)

differences are the lack of vasodilatory effect and lower systemic toxicity. However, there is a risk of prilocaine-induced formation of methemoglobin (see below). The LA’s main paths of action are voltagedependent Na+ channels, which are responsible for the rapid Na+ influx when the action potential is conducted along the axon of non-myelinated nerve fibers or certain areas of myelinated nerve fibers17. The channels consist of transmembranous proteins which are penetrable only for Na+ ions, and can exist in three different functional states: closed at rest, open and conductive following depolarization, and inactive and nonconductive during the subsequent refractory period.The effect of the LA is based upon stabilization of this inactive state of the Na+ channels in which it cannot be stimulated.Through maintenance of refractory inactivity, the depolarization-induced Na+ influx is reduced or inhibited. For this, LA molecules bind to an intracellular receptor in the channels. Non-myelinated nerve fibers and small-diameter fibers react faster than fibers with a larger diameter. This is caused by the known differential block of the LA: pain and temperature sensation recede faster than touch sensation and motor activity23. Local anesthetics injected into tissue are not broken down locally to a great extent.As a result, the reduction of the LA tissue concentration depends on systemic absorption and elimination. Absorption into the bloodstream generally

Local anesthetics are substances which block the creation and transport of action potentials at the nerve endings. They work not only on peripheral nerves but on all structures sensitive to action potentials, such as the central nervous system, myocardium, and smooth and skeletal muscles, resulting in possible side-effects22,24,25. Since most LAs are weak bases, and free bases have poor water solubility, they are usually offered in ionized form as acidic solutions which are water soluble (lidocaine or prilocaine hydrochloride salts with a pH of 4.4–6.4). After injection into the body, physiological buffer systems lead to an increase in pH and increase of the free lipophilic bases.These can penetrate biological membranes to reach their site of action. When injected into inflamed, acidotic tissue, the efficacy of LAs is reduced, because the acidic pH results in a smaller amount in base form and is able to penetrate biological membranes. The duration of effect increases with the level of protein bonding and lipophilia. The lipophilia also determines the potency of a local anesthetic. The most commonly used local anesthetic is lidocaine, both in conventional local and regional anesthesia and in TLA. Lidocaine was developed by Löfgren in 1942, and has been in clinical use since 1947. It is a versatile substance with good tissue absorption, rapid onset of action and a good balance between efficacy and toxicity. Prilocaine is comparable to lidocaine in many respects (Table 4.7). The main clinical

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erythromycin), protease inhibitors (e.g. ritonavir), antidepressants that selectively block serotonin uptake (SSRIs) such as sertraline and many others.The main metabolites of lidocaine are monoethylglycinexylidide (MEGX) and glycinexylidide, which are both pharmacologically active. Around 75% is excreted as 4hydroxy-2,6-dimethylaniline in the urine. Prilocaine does not have the vasodilatory characteristics of lidocaine, and is absorbed more slowly in comparison.Thus, vasoconstrictors are generally not required when this is used as an infiltration anesthetic. This substance is subject to even more extensive lung uptake than lidocaine. It is metabolized in the liver to o-toluidine, which is then oxidized to aminophenol. The aminophenol metabolites oxidize hemoglobin, and are responsible for the potential formation of methemoglobin by prilocaine16. In comparison with lidocaine, prilocaine is metabolized faster and has considerably higher clearance (2.37 l/min). This is due, in part, to additional metabolization in the lungs and kidneys17. The slower absorption, high pulmonary uptake, and rapid metabolism lead to lower blood concentration and lower systemic toxicity in comparison with lidocaine and other LAs. The TLA solution is generally prepared using pure LA solutions and additional adrenaline (epinephrine) 1 : 1000 as separate components of the solution.The usual formulas yield an adrenaline (epinephrine) concentration of 1 : 1 000 000 (1 µg/ml) or 1: 000 000 (0.5 µg/ml). Some authors have also used the commercially available 2% lidocaine solution with adrenaline (epinephrine) supplement. It should be noted that a drenaline (epinephrine) can also cause dose-related side-effects following systemic absorption.

occurs by way of diffusion through blood vessel walls. Because of the LA’s lipophilia, this diffusion is fairly slow, which has proved to be an advantage in tumescent local anesthesia. After systemic absorption, the LA binds to a varying extent with plasma proteins. In the case of high systemic concentration, there is a saturation effect, which is relevant with regard to LA toxicity. Besides plasma bonding, there is a significant uptake in the lungs, which is also a critical factor in LA distribution. After passage through the lungs, a balance is established between the blood and organs. Initially, the concentration rises in the organs with good blood circulation, such as the heart, liver, spleen, and kidneys, with subsequent redistribution into less well-supplied organs (muscles and adipose tissue).This distribution reduces the concentration in the blood. Lidocaine has considerable vasodilatory characteristics, and is rapidly absorbed by most tissue. The addition of vasoconstrictors such as adrenaline (epinephrine) can significantly delay systemic absorption. Lidocaine is subject to powerful firstpass metabolism in the liver: 70% of the lidocaine is broken down here.Thus, lidocaine breakdown is critically dependent upon hepatic blood flow. Its conversion is done by way of N-dealkylation and subsequent hydrolysis by the CYP3A4 isoenzyme of the P450 complex. Conversion by CYP3A4 is subject to saturation kinetics in the case of large doses of lidocaine. The activity of CYP3A4 is influenced by a large range of medications, since it is the isoenzyme of the cytochrome P450 complex, which metabolizes most medications in the human body23. Thus, lidocaine breakdown is inhibited, for instance, by the following substance classes: antifungals (e.g. ketoconazole), benzodiazepines (e.g. diazepam), calcium channel blockers (e.g. verapamil), macrolide antibiotics (e.g.

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are injected with solution containing LA, this effect is maximal, leading to a long-lasting and pronounced conduction block26. Because of the large amount of fluid required, the infiltration speed of the LA when the TLA solution is applied is generally slow. Slow infiltration leads to lower systemic LA absorption and thus creates the advantage of lower systemic toxicity. In tumescent local anesthesia with the use of heavily diluted solutions, the time to achievement of the peak plasma level is considerably prolonged, and is between 4 and 14 h. This must be taken into consideration in the case of outpatient procedures, since systemic lidocaine concentrations can still rise hours after the patient is sent home. With few exceptions, the peak concentration of TLA remains under the toxicity threshold of 5 µg/ml. In the case of the administration of prilocaine in a dosage of 35 mg/kg, plasma peaks of around 0.91 µg/ml are reached after 5–6 h16. Side-effects of LAs depend on blood plasma levels (see below) and on the speed with which the blood plasma level rises. The speed of increase in plasma concentration depends upon the absorption rate in the systemic circulation, which in turn depends on the site and type of the local anesthetic procedure. In the case of tumescent local anesthesia, absorption and thus the increase in plasma concentration is delayed by17,23:

Before introduction of the tumescent technique, a lidocaine or prilocaine concentration of 0.5–2% (5–20 mg/ml) was viewed as the optimal dosage for infiltration anesthesia to achieve an anesthetic effect. In the tumescent technique, large volumes of a LA solution diluted by a factor of 10–20 with LA concentrations of between 0.05 and 0.1% (0.5–1 mg/ml) are used. Full anesthesia comparable to infiltration anesthesia is reached after a 10–20-min delay (onset time).The relationship between the onset of effect and the LA concentration of the TLA solution is such that the onset time is prolonged with increasing dilution of the solution. Another important factor for onset of action of the LA is the target tissue. In the dermis there are a large number of free nerve endings in comparison with the subcutaneous adipose tissue. This can mean that, when using tumescence, there is incomplete surface anesthesia while the subcutaneous tissue is already sufficiently numb. Before development of the TLA solution, lidocaine and prilocaine were considered to be local anesthetics with an average duration of effect (60–120 min). It was assumed that the analgesic and anesthetic effect would last only a few hours. Practical experience with the tumescent technique has shown, however, that the application of a large volume of diluted solution enables the achievement of a longacting analgesia of up to 18 h. This phenomenon can perhaps be explained on the basis of the study results of Raymonds et al.: they were able to show that the extent of the conduction block in individual nerve fibers exposed to a constant LA concentration increased with the length of the fibers exposed. In the case of tumescent local anesthesia, in which large areas

• Reduced blood flow through subcutaneous adipose tissue; • Vasocompression due to increased tissue pressure and vasoconstriction due to the addition of adrenaline (epinephrine); • Slow infiltration speed due to large volume of diluted solution;

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Table 4.8 Clinical pharmacology of lidocaine and prilocaine in conventional infiltration anesthesia and tumescent local anesthesia Conventional infiltration anesthesia

Tumescent local anesthesia

0.5–2 % solutions (5–20 mg/l) Use of low volumes (< 100 ml) Recommended maximum dosages: lidocaine with adrenaline (epinephrine) 7 mg/kg (500 mg) prilocaine 10 mg/kg (600 mg) Average duration of effect (60–120 min) Higher concentrations result in longer duration of effect Time to maximum plasma concentration: lidocaine 2–150 min prilocaine 15–30 min LA absorption rate independent of concentration

0.05–0.1% solutions (0.5–1 mg/ml) Use of large volumes (up to 6 l) Recommended maximum dosages: lidocaine 55 mg/kg prilocaine 35 mg/kg Long duration of effect (18–36 h) Greater dilution results in longer duration of effect Time to maximum plasma concentration: lidocaine 4–14 h prilocaine 5–6 h LA absorption rate increases with concentration

• Delayed diffusion out of the subcutaneous adipose tissue into the blood vessels due to high lipophilia of the LA; • Dilution because the absorption rate is dependent upon the LA concentration.

than the speed with which the plasma concentration increases.The tumescent technique confirms this effect, since the slow administration of high doses normally causes no or only minor systemic side-effects in comparison to lower doses, with severe systemic effects following intravenous bolus injection. The occurrence of systemic side-effects is also dependent on the substance used, pH and pCO2 levels in the tissue, serum potassium concentration, and individual patient make-up. Lidocaine and prilocaine in the plasma are mainly protein-bound. In the case of very high systemic concentrations, however, the proteinbinding capacity becomes saturated, and the proportion of free, non-binding LA increases accordingly. The proportion of free LA is mainly responsible for systemic toxicity. This is expressed particularly in two organic systems: the central nervous system and the cardiovascular system. In everyday clinical practice, side-effects related to the central nervous system are considerably more common than cardiovascular problems. Both lidocaine and prilocaine can pass the blood–brain barrier and reach comparatively

These peculiarities of TLA are the reason for the particular pharmacological behavior of the solution and the clinically proven high safety of using higher LA doses2–5,27. Because of the favorable pharmacological characteristics, toxic reactions appear only at relatively high overall doses, unlike other LA procedures (Table 4.8). Toxic reactions to local anesthetics can be divided into the following categories: • • • •

CNS reactions; Cardiovascular reactions; Hypersensitivity reactions; Methemoglobin formation (prilocaine).

It can be seen from Table 4.9 that the occurrence of systemic toxic reactions correlates strongly with the LA plasma concentration.The absolute dose administered can be less critical

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Table 4.9 Toxicity of lidocaine in relation to plasma concentration Lidocaine plasma concentration (µg/ml) 3–6 5–9 8–12 > 12 > 20 > 26

Symptoms Subjective toxicity: confusion, euphoria, digital and perioral paresthesia, agitation, drowsiness Objective toxicity: nausea, vomiting, tremors, impaired vision, tinnitus, psychotic symptoms, muscle tics Convulsions, cardiac symptoms (negative inotropic effect, bradycardia), decreased respiratory rate, arrhythmia, block formation Coma Respiratory failure Heart failure

LAs also have a direct effect on the peripheral vessels and can cause extreme vasodilatation at high doses, which can, in turn, lead to a drop in blood pressure or ultimately cardiovascular shock. There are considerable differences between the various LAs regarding their cardiotoxicity. Prilocaine has the lowest relative toxic potency (RTP = dose/plasma concentration of lidocaine/ analgesic potency × dose/plasma concentration of the comparative substance)17. The treatment of cardiovascular side-effects must be according to the individual symptoms. Besides securing a free airway and sufficient oxygen supply, if required, catecholamines, atropine, antiarrhythmics, and/or electrical stimulation (cardioversion or pacemaker) may be used. Hypersensitivity reactions including anaphylaxis due to the LA are normally caused by one of the following:

high concentrations in the central nervous system17,18,24,25. The CNS side-effects depend on the concentration.The most common symptoms of incipient CNS toxicity are confusion, dizziness, and lightheadedness. At these lower doses, lidocaine has accompanying therapeutic effects such as central analgesia and, paradoxically, anticonvulsive activity. Higher plasma levels cause excitatory side-effects. Initial sensory disturbances such as tinnitus, blurred vision, or a metallic taste in the mouth are followed by motor disturbances from trembling, tremors, and myoclonia to generalized tonoclonic convulsions. At still higher plasma concentrations there may be generalized weakness, loss of consciousness, cardiovascular failure, and even death (see Chapter 18). LAs have a dose-dependent negative inotropic effect on the myocardium. This can lead to significant impairment of contractility, and in severe cases to massive drops in blood pressure and cardiovascular collapse. More commonly, however, the LA causes a disruption of conduction in the heart muscle. While low doses have an antiarrhythmic effect (but still with a proarrhythmogenic potential), higher doses lead to the deceleration of impulse conduction.This can lead to various ECG changes from widening of the QRS complex to total AV block. Clinically, this is expressed as bradycardia and hypotension.

• Reaction to para-aminobenzoic acid (PABA), an amino ester metabolite; • Reaction to methylparaben, a preservative substance with a similar structure to PABA; • Reactions to sulfites (e.g. sodium atrium metabisulfite), a group of antioxidants. In comparison with the amino esters, hypersensitivity reactions to LAs of the amino amide

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group such as lidocaine and prilocaine are relatively rare and restricted to individual case reports. It must be borne in mind, however, that larger bottles contain parabens as a preservative substance, which can induce allergic reactions. With lidocaine, small-scale methemoglobin formation has been described. Prilocaine can induce methemoglobinemia to a clinically significant extent.This is not due to the prilocaine itself but rather to its metabolite o-toluidine, which is formed at higher doses, from 10 mg/kg body weight, by hydroxylation (Figure 4.4).This metabolite inhibits reduction of the methemoglobin constantly produced in the metabolism of hemoglobin, so that larger amounts of methemoglobin result. The enzyme responsible for this is glucose-6-phosphate-dehydrogenase (G6PDH), which is present in erythrocytes. For this reason, when using prilocaine, particular note must be taken of any existing lack of glucose-6-phosphate-dehydrogenase, an X-linked recessive enzyme defect present in 5–20% of all Southern Europeans and male Afro-Americans. Patients with sickle-cell anemia or other hemoglobinopathies also have an increased risk of prilocaine-induced methemoglobinemia. The reduction process can be supported by the administration of methylene blue or vitamin C. With a total dose of more than 600 mg of prilocaine, the methemoglobin concentration can rise to 25%. Patients with normal initial blood values and a healthy cardiovascular system are able to tolerate this without any major problem, because a methemoglobin concentration of 10% with an initial Hb of 12 g/dl reduces the latter to 10.8 g/dl, which rarely causes complications. However, from a blood concentration of 3–5 g/dl (approximately 15–30%), the methemoglobinemia becomes clinically apparent as a dangerous-looking

Hydroxylation at > 10 mg/kg o -Toluidine

Prilocaine

Clinically noticeable at 3–5 g/dl due to cyanotic skin discoloration

Figure 4.4 prilocaine

Met-Hb

G6PDH Vitamin C Methylene blue

Hb

Methemoglobin (Met-Hb) formation due to

cyanosis, which is, however, not clinically relevant in healthy patients (for therapy see Chapter 18)16. QUANTITIES AND SAFETY Tumescent local anesthesia is not without controversy, since the maximum amounts recommended as safe by the manufacturers are often exceeded when large volumes are used. Numerous clinical studies confirm the safety of the method on the basis of large numbers of cases2–5,26,27. Despite these studies, which have clinically proved the safety of higher doses of 35–55 mg/kg in the use of diluted solutions in the tumescent technique, the manufacturers have still not extended their approval to include tumescent local anesthesia. In addition, the term tumescent anesthesia has come under attack in the media through reports of complications and even deaths in connection with liposuction using the tumescent technique (see Chapter 18). Since there is an urgent need for terminological misunderstandings to be explained, this is discussed separately in Chapter 18. In the above section, the theoretical background is presented to explain why, when using the tumescent technique, pharmacological characteristics make it possible to administer large

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Table 4.10 Recommended lidocaine maximum dosages for tumescent local anesthesia American Academy of Dermatology (AAD) American Society for Dermatologic Surgery (ASDS) American Academy of Cosmetic Surgery American Society of Plastic Surgery

55 mg/kg 45–55 mg/kg 55 mg/kg 35 mg/kg

that because of the methods of metabolism of prilocaine, the risk of side-effects is not as high as with lidocaine.The dose reduction of 30–40% recommended by Klein when using lidocaine in conjunction with other medications which interfere with the breakdown of the lidocaine is therefore unnecessary23. Until officially approved standardized solutions are available, appropriate safety measures are recommended for all users (see Chapter 17):

volumes exceeding the manufacturer’s recommendations for maximum dosage. At present, two safety standards are generally accepted4,27: • The manufacturer’s information for commercially available, undiluted local anesthetic (7 mg/kg body weight for lidocaine with added adrenaline (epinephrine) in the standard dosages of 0.5–2%, maximum 200 mg, or 5.7 mg/kg body weight for prilocaine or maximum 400 mg); • In tumescent anesthesia with heavily diluted local anesthetic (lidocaine 500–1500 mg/l or 0.05–0.15%), quantities of up to 35 mg/kg are considered safe, with quantities of up to 55 mg/kg as the therapeutic limit20,28.

• Adequate preoperative screening and laboratory evaluation; • Precise documentation and control of quantities injected (see also Table 19.1); • Performance of major procedures (LA dosage > 35 mg/kg body weight) only in centers with relevant monitoring and treatment facilities in case of emergency; • Because of possible drug interactions when using lidocaine, limitation of overall dosage to 35 mg/kg when other drugs being taken have a systemic effect; • When using prilocaine, bear in mind the risk of methemoglobin production (initial Hb); • Dosages of more than 55 mg/kg should only be exceeded in exceptional cases.

Table 4.10 offers an overview of the current recommendations (as of 2002) of various specialty associations regarding maximum lidocaine dosages for the tumescent technique. Klein recommends a weight-related individual approach in establishing the maximum dosages for young healthy female patients23: • 45 mg/kg in the case of thin patients; • 50 mg/kg in the case of normal to overweight patients.

POSSIBLE FURTHER DEVELOPMENTS

Table 4.11 gives a detailed overview of the concentrations of local anesthetic achieved when using the 0.038% Sattler solution relative to body weight. It must also be borne in mind

The goal is optimization of the tumescent solution to increase safety further. Approaches

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Table 4.11 Highest concentrations of LA reached according to patient body weight (mg/kg) during TLA Weight (kg) 50 55 60 65 70 75 80 85 90 95 100 105 110 115

1000 ml

2000 ml

3000 ml

4000 ml

5000 ml

6000 ml

7000 ml

8000 ml

9000 ml

400* 8.000 7.273 6.667 6.154 5.714 5.333 5.000 4.706 4.444 4.211 4.000 3.810 3.636 3.478

800* 16.000 14.545 13.333 12.308 11.429 10.667 10.000 9.412 8.889 8.421 8.000 7.619 7.273 6.957

1200* 24.000 21.818 20.000 18.462 17.143 16.000 15.000 14.118 13.333 12.632 12.000 11.429 10.909 10.435

1600* 32.000 29.091 26.667 24.615 22.857 21.333 20.000 18.824 17.778 16.842 16.000 15.238 14.545 13.913

2000* 40.000 36.364 33.333 30.769 28.571 26.667 25.000 23.529 22.222 21.053 20.000 19.048 18.182 17.391

2400* 48.000 43.636 40.000 36.923 34.286 32.000 30.000 28.235 26.667 25.263 24.000 22.857 21.818 20.870

2800* 56.000 50.909 46.667 43.077 40.000 37.333 35.000 32.941 31.111 29.474 28.000 26.667 25.455 24.348

3200* 64.000 58.182 53.333 49.231 45.714 42.667 40.000 37.647 35.556 33.684 32.000 30.476 29.091 27.826

3600* 72.000 65.455 60.000 55.385 51.429 48.000 45.000 42.353 40.000 37.895 36.000 34.286 32.727 31.304

*Amount of LA in mg

the performance of stress-free and pain-free liposuction. In addition, the complication rate is reduced by using as few potentially interacting medications as possible. ‘Tumescent liposuction performed totally using local anesthesia’23 is a safe procedure which is regularly cited27. Nevertheless, there are patients with high pain sensitivity, and there are also areas of the body in which nearly all patients are particularly sensitive to pain (e.g. the periumbilical area), where treatment using purely tumescent anesthesia is often very stressful for the patient and very demanding for the surgeon in terms of patient management. In order to fulfill increasing patient demand for a pain-free, stress-free, low-risk procedure, supplementary anesthesia procedures have been developed with the help of anesthetists for such cases, and have proved to be safe and very effective. These are discussed in detail in Chapter 5. In our patients, the additional use of painkillers and sedatives, if required, has contributed to a reduction of surgical stress for the patient as

include, for example, the combination of local anesthetics to reduce their overall sideeffects (Hamburg solution, see Table 4.5). The quantity of adrenaline (epinephrine) added must also be critically examined due to possible interactions and side-effects. Studies currently under way are aimed at substantiating the clinical experience gained in a large number of patients with valid pharmacological data. To ensure that this method progresses beyond the field of empirical medicine, multicenter pharmacokinetic and toxicological studies must also be carried out in large numbers of patients. The goal is to gain approval of a standardized, officially approved, tumescent solution29. SUPPLEMENTARY ANESTHESIA PROCEDURES The use of pure tumescent local anesthesia for more than 15 years has shown that for most patients, the narcosis achieved is sufficient for

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use of LAs with little potential for drug interaction, such as the classic lidocaine or prilocaine, has given wider scope for action. The technical and staffing requirements for emergencies including cardiopulmonary resuscitation must, of course, still be met.

well as the surgeon, and has never caused severe complications. However, strict patient monitoring is essential, since the combined administration of local anesthetic (LA), sedatives, and analgesics can also cause undesirable drug interactions and side-effects (see Chapter 11). The

REFERENCES 1. American Academy of Cosmetic Surgery. 2000 guidelines for liposuction surgery. Am J Cosmet Surg 2000; 2: 79–84

and Microcannular Liposuction. St Louis, MO: Mosby, 2000; 3–8 10. Klein JA.The tumescent technique for liposuction surgery. Am J Cosmet Surg 1987; 4: 236–67

2. Hanke CW, Lee MW, Bernstein G. The safety of dermatologic liposuction surgery. Dermatol Clin 1990; 8: 563–8

11. Illouz Y. Body contouring by lipolysis: a 5-year experience with over 3000 cases. Plast Reconstr Surg 1983; 72: 511–24

3. Hanke CW, Bernstein G, Bullock BS. Safety of tumescent liposuction in 15 336 patients – national survey results. Dermatol Surg 1996; 22: 459–62

12. Klein JA. The tumescent technique: anesthesia and modified liposuction technique. Dermatol Clin 1990; 8: 439–50

4. Klein JA. Clinical biostatisitcs of safety. In Tumescent Technique. Tumescent Anesthesia and Microcannular Liposuction. St Louis, MO Mosby, 2000: 121–9

13. Lillis PJ. Liposuction surgery under local anesthesia: limited blood loss and minimal lidocaine absorption. J Dermatol Surg Oncol 1988; 14: 1145–8

5. Klein JA. Tumescent technique for local anesthesia improves safety in large volume liposuction. Plast Reconstr Surg 1993; 92: 1085–98

14. Coleman WP III. The history of liposuction. Dermatol Clin 1990; 8: 381–3

6. Sommer B, Sattler G. Einleitung und Definition. In Sommer B, Sattler G, Hanke CW, eds. Tumeszenz-Lokalanästhesie. Berlin: Springer-Verlag, 1998: 3–4

15. Sattler G, Sommer B, Bergfeld D, Sattler S. Tumescent liposuction in Germany: history and new trends and techniques. Dermatol Surg 1999; 25: 221–3

7. Sommer B, Sattler G. Tumesenzlokalanästhesie, Weiterentwicklung der Lokalanästhesieverfahren für die operative Dermatologie. Hautarzt 1998; 49: 351–60

16. Sattler G, Hagedorn M. TumeszenzLokalanästheise. Untersuchungen zur Pharmakokinetik von Prilocain. Z Hautkr 1997; 7: 522–7

8. Klein JA. Anesthesia for liposuction in dermatologic surgery. J Dermatol Surg Oncol 1988; 14: 1124–32

17. Schwarz S, Rapprich S. Toxicology. In Hanke CW, Sommer B, Sattler G, eds.Tumescent Local Anesthesia. Berlin: Springer-Verlag, 2001:

9. Klein JA. History of tumescent liposuction. In Tumescent Technique: Tumescent Anesthesia

18. Skidmore RA, Patterson JD,Tomsick RS. Local anesthetics. Dermatol Surg 1996; 22: 511–22

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19. Sommer B, Breuninger H. Zusammensetzung der Lösung für die Tumeszenzlokalanästhesie. In Sommer B, Sattler G, Hanke CW, eds. Tumeszenz-Lokalanästhesie. Berlin: SpringerVerlag, 1998: 10–14

25. Tryba M. Pharmakologie und Toxikologie der Lokalanästhetika – klinische Bedeutung. In Tryba M, Zenz M eds. Regionalanästhesie, 3rd edn. Stuttgart: Gustav Fischer Verlag, 1989: 26. Raymond SA, Steffensen FC, Gugino LD, Strricharz GR. The role of length of nerve exposed to local anesthetics in impulse blocking action. Anesth Analg 1989; 68: 563–70

20. Klein JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction surgery. J Dermatol Surg Oncol 1990; 16: 248–63 21. Lillis PJ.The tumescent technique for liposuction surgery. Dermatol Clin 1990; 8: 439–50

27. Parish T.A review: the pros and cons of tumescent anesthesia in cosmetic and reconstructive surgery. Am J Cosmet Surg 2001; 18: 83–93

22. Sommer B. Vorteile und Nachteile der Tumeszenz-Lokalanästhesie. In Sommer B, Sattler G, Hanke CW, eds. Tumeszenz-Lokalanästhesie. Berlin: Springer-Verlag, 1998: 40–4

28. Ostad A, Cageyama N, Moy RL. Tumescent anesthesia with a lidocaine dose of 55 mg/kg is safe for liposuction. Dermatol Surg 1996; 22: 921–7

23. Klein JA. Clinical pharmacology. In Tumescent Technique: Tumescent Anesthesia and Microcannular Liposuction. St Louis, MO: Mosby, 2000: 121–96

29. Thompson KD, Nelykyj S, Massa MC. Antibacterial activity of lidocaine in combination with a bicarbonate buffer. J Dermatol Surg Oncol 1993; 19: 216–20

24. de Jong RH. Local Anesthetics. St Louis, MO: Mosby, 1994

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5

T Hübner

an increased risk of drug interaction or other complications. In the case of excessive risk factors, an elective aesthetic operation should not be performed (see Chapter 9). In cases at increased risk for complications, working with an anesthesiologist may be useful in order to increase the safety margin. Poor crisis management is an avoidable factor of risk for the patient. Possible side-effects and their treatment are dealt with in Chapter 18, and the necessary monitoring equipment is described in Chapter 11. This chapter deals mainly with the presentation of possible supplementary anesthesia procedures whose application requires appropriate experience in handling the substances discussed and, in particular, expertise in dealing with potential side-effects and complications. In the initial consultation, it should be determined which types of patient will require additional anesthesiological procedures or special monitoring, and explanations regarding anesthesia should be given at this time.

As discussed in Chapter 4, many years of experience with the tumescent technique confirm that, with tumescent local anesthesia (TLA) alone, liposuction procedures can be carried out with generally adequate analgesia and relatively high safety. However, precisely this experience leads to such treatment being offered increasingly to older patients with other associated conditions. In addition, the observation of low side-effect and complication rates can lull practitioners into a false sense of security. Lack of experience and practice in emergency situations and lack of emergency equipment can be a safety risk for patients. Individual factors during the liposuction procedure, such as increasing anxiety or pain sensitivity, or the treatment of particularly painful areas, could mean that additional systemic medications may be required for sedation or analgesia. Other factors which can render anesthesiological support desirable are very extensive operations, or known risk factors or underlying conditions in the patient. In the case of extensive procedures, there is an increased risk of side-effects due to the use of larger amounts of TLA which, in turn, increases the need for monitoring and requires the ability to respond rapidly to possible complications. Also, in the case of known underlying conditions with continuous long-term medication, there is

ANESTHESIA INFORMATION The initial consultation is a chance for the physician and the patient to get to know one another, reducing anxiety and fear by establishing the appropriate relationship of trust. The physician

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A recommended basic laboratory work-up can include the following parameters, and thus corresponds more or less to the recommended laboratory tests to be carried out before liposuction (see Chapter 8):

also needs to evaluate the physical and psychological condition of the patient at the initial consultation. Clinical assessment of the cardiovascular system, respiratory organs, central and peripheral nervous systems, renal and liver function, and the coagulation system must be performed. This may require additional laboratory tests (see below). In order to assess the anesthesia risk, a detailed personal and family anesthetic history must be obtained.Any unusual events during previous anesthesia, transfusion treatments, existing allergies, current medications, and known previous illnesses are also discussed. The possibility of pregnancy must be ruled out. Before a planned intubation anesthesia, dental status must also be checked. On the basis of the information obtained, and after assessment of the patient’s condition, the most appropriate and least stressful method of anesthesia is selected for the planned procedure. The general rule is that no elective procedure should be carried out in the case of considerably reduced physical tolerance or excessive risk (see Chapter 4). All patients should be appropriately informed and educated about the planned procedure prior to the initiation of anesthesia.

• Complete blood count including hemoglobin, packed cell volume, and platelets; • Electrolytes (sodium, potassium, urea, creatinine); • Coagulation parameters (prothrombin time (PTT)). There is generally no binding medical requirement for laboratory tests for young or middleaged patients with healthy organs and with no specific medical history or clinical findings, but for forensic reasons these should still be carried out for elective procedures. If there are no indications of coronary risk factors, a routine ECG is not necessary for patients under 40 years of age. On the other hand, if there are indications for heart conditions (e.g. specific medication, hypertension, or electrolyte disorders), an ECG should always be performed prior to surgery, regardless of age. In the case of asymptomatic patients under 60 years of age, a chest X-ray is also unnecessary. Here too, the anesthetic history and clinical indications will dictate whether this is necessary in each individual case. In the case of prior pulmonary conditions, it may be necessary to perform a pulmonary function test with determination of the forced expiratory vital capacity (FVC), the 1-s capacity (FEV1), and the inhalation vital capacity (VC) (‘partial spirometry’), and supplementary blood analysis. Severely impaired pulmonary function generally rules out surgery for aesthetic reasons (see Chapter 9).

PRELIMINARY EXAMINATIONS The extent to which other examinations besides laboratory tests (described in Chapter 8) are required prior to liposuction in tumescent local anesthesia depends on the anesthetic history, clinical examination, and the type of procedure planned. At present there are no binding regulations regarding the laboratory parameters to be tested as a matter of routine before an operation.

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require additional medication for surgery carried out under local anesthesia such as tumescence. The patient is afraid of possible pain and the surgical environment, but not of staying awake. If it is foreseeable that sedation will be necessary, a comprehensive explanatory discussion should be held in good time to establish trust. As a premedication, a tranquilizer can be given orally on the evening before surgery, e.g. diazepam 10–20 mg. However, sedation should never be given as a matter of routine. Calm preparation and constant communication with the conscious patient during the procedure can contribute significantly to easing patient anxiety. During the operation, short-acting benzodiazepines, e.g. midazolam 5–10 mg IV and/or short-acting hypnotics, such as propofol 20–30 mg IV as bolus can be used for temporary sedation. All of these measures require constant monitoring of respiratory function. It must always be borne in mind that sedatives and hypnotics are not pain-killers. Therefore, if the patient complains of pain, additional analgesics must be administered, e.g. short-acting opiates such as remifentanil. The combination of continual administration of hypnotics (e.g. propofol) with short-acting opiates (e.g. remifentanil) via syringe pumps, with retained spontaneous respiration and on rousable patients, leads to seminarcosis.This represents the last resort as a therapy option supplementary to tumescent anesthesia. An absolute requirement is constant monitoring of circulatory and respiratory function. The patient must be able to be roused and have sufficient independent respiration. It is therefore necessary to maintain constant contact with the patient for monitoring purposes. This method should only be used with an anesthetist on stand-by, because the patient

PREMEDICATION To premedicate correctly, the usual drugs of the patient have to be analyzed to ensure they may be continued alongside the premedication, and, if necessary, to prescribe additional medications. Premedication drugs should be given orally on the evening before or the morning of the operation. Oral anticoagulants must be discontinued a sufficient time before the elective operation in conjunction with regular ProTime testing. Heparinization is initiated if necessary after coagulation normalizes (target PTT level 50–60 s). Thrombocyte aggregation inhibitors such as aspirin should be discontinued at least 7–10 days before the planned operation. Other goals of premedication are anxiolysis and sedation. Before planned intubation, anesthesia drugs to inhibit salivary and bronchial secretion are also given, as well as H2 blockers as an aspiration prophylactic. Food intake need not be stopped in the case of surgery to be performed under local anesthesia, but can be recommended, since there is always the chance of subsequent general anesthesia. If there is a chance that general anesthesia could be required due to high pain sensitivity and insufficient analgesia, or if general anesthesia is planned for an elective procedure, then food and fluid intake should be stopped 6–8 h before the operation. Premedication drugs can be taken with a sip of water. ANESTHESIA METHOD AND ADDITIONAL MEDICATION FOR LIPOSUCTION Sedation/analgosedation Anxious, pain-sensitive patients, or those who become agitated during the operation, often

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recognized and treated quickly, which requires appropriate monitoring. Ideally, the patient should therefore remain under observation in an appropriately equipped recovery room. In the case of procedures performed outside the hospital environment, the occurrence of hemodynamically relevant cardiovascular events or pulmonary complications which cannot be adequately controlled should give rise to prompt patient transfer to a center that is better equipped.

can drift into general anesthesia (non-rousable patient = narcosis).Accordingly, ventilation equipment must be available. General anesthesia with reversible depression of the central nervous system (loss of perception and reaction to external stimuli) cannot, in our opinion, be recommended as a standard anesthetic procedure in liposuction surgery in view of the issues described in Chapters 4 and 16. Exceptions may be very anxious patients who cannot be managed even with additional sedation. In these cases, total intravenous anesthesia (TIVA) may be required as a general anesthetic procedure. In this case, the patient should be given a gas mixture of oxygen and nitrous oxide or oxygen and air. The oxygen content should not fall below 30%.Administration must be done by an anesthetist.

CRITERIA FOR PATIENT RELEASE Before a patient can be released after an outpatient procedure with additional medication, it must be ensured that the cardiovascular condition and respiration are stable. The patient is released with full vigilance and orientation, and, in all cases, only with an accompanying person and an assurance of home care for the first 24 hours. The patient is given an emergency telephone number and written information on how to respond in the case of any problems or complications. After the administration of drugs, the patient’s driving ability is impaired for 24 hours. The patient must be informed of this in the explanatory consultation so that an accompanying person can be arranged.

POSTOPERATIVE PHASE With the administration of additional medication for sedation and/or analgesia, the patient requires more intensive subsequent observation than after just tumescent local anesthesia. The anesthetist retains responsibility until stabilization of the vital parameters (circulation, respiration, and consciousness). Early complications such as respiratory or circulatory disorders must be

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Physiodynamic concept of tumescence

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The physiodynamic process of tumescent fluid distribution after injection into the subcutaneous adipose tissue takes place in time-dependent stages because of the associated anatomical structures (see Chapter 3) and gradual build-up of pressure. It is recommended that the endpoint goal of infiltration should be the achievement of what is known as ‘super tumescence’, i.e. creation of the greatest possible tissue turgor. Of course, maximum total lidocaine doses must also be observed (see Chapter 4). Creation of the greatest possible tissue turgor enables the build-up of the appropriate interstitial pressure to achieve even distribution of the solution. Infiltration must be done slowly, otherwise it is painful for the patient, and fluid distribution would not be achieved in stages. To save time, infiltration can be done using several needles simultaneously, e.g. with a Stenger–Sattler distributor (see Chapter 4).

Figure 6.1

Diagram of native adipose tissue

In the first few minutes after infiltration begins, the solution flows suprafascially along the connective tissue septa separating the fat cell clusters. The separation of adipose tissue and connective tissue achieved in this early stage is known as suprafascial hydrodissection (Figure 6.2). Continued infiltration of the tumescent solution increases the pressure in the tissues. In the next stage, perilobular envelopment of the individual fat lobules occurs (Figure 6.3). If an appropriate time of 30–60 min is allowed for the solution to take effect, intralobular flooding then occurs as a result of the solution penetrating the fat lobules (Figure 6.4). The high interstitial pressure

STAGES OF TUMESCENCE As described in Chapter 3, in its initial state, the subcutaneous adipose tissue is found as grapelike clusters of fat cells in a connective-tissue network through which flow the numerous small blood and lymphatic vessels (Figure 6.1).

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Figure 6.2

Diagram of suprafascial hydrodissection stage

Figure 6.4

Figure 6.3

Diagram of perilobular envelopment stage

Figure 6.5 Diagram of homogenized fat dissolution with retention of connective tissue support structure

Diagram of intralobular distribution

period of at least 0.5–1 h is allowed for the solution to take effect and to soften the adipose tissue cell clusters.Then, before aspiration actually begins, fluid (tumescent solution or saline) should be injected again to re-establish the maximum tumescent effect (‘super tumescence’). ‘Super tumescence’ helps to avoid shearing forces during the suction process. This effect

induced by the tumescence and diffusion processes finally results in widespread homogenization of the adipose tissue area.‘Empty’ subcutaneous connective tissue with retained tissue fibers remains after aspiration of the fat cells (Figure 6.5). These effects play a significant role in the simplification and standardization of the suction process. It is essential that a sufficiently long

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the softened fat is able to react to the cannula suction, which is applied to a site only for a very short time. Firm structures resist the shortterm suction force because of their significantly higher torpidity. Therefore, blood vessels, lymphatic vessels, and the subcutaneous connective tissue support framework are not affected. The latter is of major significance to the further course of wound healing (see Chapter 7). The reduction of damage to the blood vessels and lymphatic vessels significantly reduces postoperative complications such as extensive hematoma, blood loss, or the formation of seromas due to lymph blockage. In summary, the correct use of tumescent local anesthesia in combination with suitable cannulas enables the avoidance of shearing force and tissue trauma as much as possible. This has been proved conclusively in endoscopic studies (see Chapter 14).

contributes considerably to tissue protection. If, during the course of the procedure, there should be a reduction in the tumescent effect and associated tissue stabilization, this can be compensated for by what is known as the MASST (manually assisted skin stabilization technique), in which the tissue is stabilized manually by trained assistants (see Chapter 12). What is essential for the most atraumatic operating technique possible (which is, in turn, the prerequisite for complication-free intraand postoperative progression) is, above all, homogenization of the adipose tissue by the tumescent solution, as described above. This enables the use of small-caliber cannulas and, thus, a reduction in tissue trauma, an effect which can be intensified still further by the use of specific instruments such as vibration cannulas (see Chapter 10). Due to the high oscillating frequency of vibration cannulas, only

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Concept of wound healing after liposuction using tumescent technique

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steps on the way from pure ‘fat removal’ with its initially high complication rate to today’s standard of liposculpture are presented in Chapter 2. In order to achieve optimal wound healing with corresponding optimal aesthetic results, we consider liposuction via the tumescent technique using the vibration cannula to be the best procedure at the present time since it guarantees maximum tissue protection (see Chapter 6). It is important to follow a certain standardized procedure in both the tumescent technique (see Chapters 4 and 6) and the suction process (see Chapter 12). For an optimal technique, the subcutaneous connectivetissue network should be retained and the vessels and nerve bundles should be largely unaffected. Removal of the fat cell clusters and multilayer aspiration at all levels at the same time produces a three-dimensional subcutaneous ‘wound space’ in which, as with all wounds, healing processes are initiated by mediators. Postoperatively, it must be ensured that there is proper drainage of the operating site by, for example, leaving incision sites open to enable

The progression of wound healing and, thus, the long-term postoperative results are fundamentally dependent upon the method of anesthesia and the operating technique. In the early days of liposuction surgery, severe complications such as massive bleeding and hematoma, with a potential risk of superinfection, or extensive seromas due to lymph blockage, were the result of massive tissue trauma caused by the suction techniques used at the time. The unprepared adipose tissue could only be detached from the connective tissue framework by the use of extreme mechanical force and large-caliber suction cannulas, so the framework and the vascular structures contained within it were severely traumatized. This also had a significant impact on the aesthetic result: the cannulas left dents and ripples in the tissue since even suction was virtually impossible to achieve, and destruction of the connective tissue framework often led to hanging of the skin (see Chapter 18). In the past 25 years countless improvements have been introduced, the goal of which has been the development of an increasingly atraumatic liposuction technique with marked reduction or elimination of the clinical and cosmetic complications mentioned. The definitive

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After complete drainage of the tumescent solution, adhesion of the aspirated area is supported by the connective-tissue framework (Figure 7.1). This leads to overall wound contraction corresponding to the various levels of aspiration, and then a horizontal scar. Maximum contraction is generally achieved after 4 months; however, overall wound healing will take approximately 18 months. Contraction of the retained connectivetissue strands also leads to skin retraction. Liposuction carried out in all layers of the subcutaneous connective tissue under tumescent local anesthesia ideally causes ‘interstitial skin reduction lobule plasty’. This is essential to the avoidance of postoperative ‘hanging’ of the skin. Overall, three-dimensional contraction takes place, which is considerably influenced by the operative procedure.

Figure 7.1 Intraoperative site during abdominoplasty 6 months after the performance of liposuction, with representation of the three-dimensional connective-tissue strands in the subcutaneous space as a result of wound healing

discharge of the solution. It is also important that a close-fitting compression garment is worn for a sufficiently long period.

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Patient evaluation and planning of the procedure

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• What complications can occur, and are there specific risks with the procedure? • How long will it take to recover after the procedure, and when can I resume work and sport? • When can I expect to see the final results of the treatment? • Are there visible scars or other traces after liposuction that indicate that the procedure has been performed?

The course for a successful medical procedure is essentially set during the patient’s initial contact with the treating facility (see Chapter 23). In order to prevent dissatisfaction and misunderstandings, with the resulting complications and need for correction, the prerequisites for trouble-free treatment must be established in the preoperative phase during the initial consultation and evaluation1,2. During a detailed consultation, it is necessary to rectify patient expectations and to identify any possible risks3. To facilitate the consultation, it is recommended that patients are sent information as soon as they make contact so that they can form an opinion on the method in advance, and the physician’s explanations can then build on basic knowledge. The information, besides explaining the method and possible indications, can also contain frequently asked questions (FAQs), such as:

CONSULTATION The consultation is generally the initial contact between the patient and treating physician. It is a central part of the overall treatment, and therefore should never be carried out in a rushed manner. One should allow approximately 1 hour for a comprehensive consultation prior to liposuction. Care should also be taken to create a pleasant ambience and an undisturbed discussion environment. The patient should feel free to bring a companion (partner or friend) to the discussion. In some cases, the patient needs the physician’s support in convincing the partner of the advantages of the procedure. Sometimes, discussion with the companion afterwards helps the patient to reach a final decision.

• Where can liposuction be used? • Can I achieve the same result as with liposuction through dieting? • Will I actually lose weight through liposuction? • Do the removed fat cells grow back? • What happens to the superfluous skin after removal of a fat deposit?

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In most cases, however, it is possible to establish a trusting and viable ‘working relationship’. Then the exact procedure can be discussed together. The physician assumes a guiding function here in order to incorporate the patient’s wishes into a realistic operating plan4,5. Since these factors are very important, we advise against consultation with several people at the same time (‘collective consultations’) or consultation with a third party (for instance, a colleague who will not personally perform the procedure on this patient). Consultation with a third party may only take place in exceptional cases where the procedure is clearly standardized and all medical personnel are in agreement. Usually there is a combined process of explanation, physical examination, and preparation. In order to ensure that nothing is forgotten in terms of documentation, it can be helpful to use a standardized consultation. The consultation should cover the following items.

The consultation has many functions. First the patient’s concerns must be stated, and it must be established to what extent the desired improvement can be achieved by the method offered, and the spatial and staffing possibilities available. Often, patients have unrealistic expectations as a result of media reports. Here, the comprehensive knowledge and honest advice of the physician is required, relating to both the requested form of treatment and alternatives to and limitations of the procedure proposed. Besides the exchange of factual information on the planned procedure and the discussion of consent declarations, the consultation also gives parties the opportunity to get to know one another and establish a relationship of trust. The treating physician should consider the following questions during the consultation. Is the ‘chemistry’ right between physician and patient? Will it be possible to establish a harmonious, trusting physician–patient relationship? Does the patient trust me? Indeed, it is often the patient’s trust which is decisive for subjective patient satisfaction: what the practitioner considers a good cosmetic result is not automatically a good result for the patient. What are the patient’s expectations? Are they realistic, or do they need to be corrected? Will the patient be able to deal with unrealistically high expectations? The physician should use the consultation as an opportunity to decide whether the patient can be treated. Problems can be avoided by bearing in mind that not every patient presenting for a consultation must be treated. It can be in the interests of both sides to refuse treatment. If there is a feeling that the patient does not have confidence in the treating physician, then experience shows that this patient will never be satisfied with the results achieved.

Question patients about their wishes and have them demonstrate the areas that concern them What does the patient want to have improved? Can the treatment objectively improve the findings? Is there a ‘good indication’?3 (See Chapter 9.) Patients often see themselves differently from the way an external observer sees them.What is an imperfection to the patient is sometimes not worthy of treatment to the treating physician. The physician’s experience sometimes enables him to see more objectively where the problem lies (e.g. liposuction of the buttocks is frequently requested, but the required effect can often be better achieved by

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treating the ‘saddlebags’). Here again, it is the guiding function of the physician that is required. At this point, it is generally appropriate to examine the patient directly. Besides the extent and distribution of unwanted fat pads, skin turgor and the overall appearance of the patient must be evaluated. It is necessary to discuss ‘touch-up’ liposuction to achieve an aesthetic overall appearance, and possible skin-tightening operations in the case of very slack tissue6. Not all patient requests can or should be granted. Some perfect figures can even be impaired by operative procedures. Not every liposuction request can be fulfilled. For instance, calves often have very little fat, so liposuction can achieve very little improvement (see Chapters 9 and 12)6.

Explanation of the procedure Only if the procedure has a good chance of success and can be performed with minimum risk should the physician go on to give a detailed explanation of the operating method7. What does the patient know already? What outstanding questions are there? Is there anything that is still unclear? The method can be explained more effectively using photographic material or diagrams. Many practitioners use ‘before-and-after’ images to demonstrate the results. These are suitable for demonstrating the possible results and to convince patients of the surgeon’s abilities. Showing pictures of other patients can be problematic if a patient is later not satisfied with the result of his or her own operation (see Chapter 23). If a patient was led to have certain expectations by being shown photos of successful operations, then he or she can insist on more than a typical result. The precise procedure should also be explained as well as the duration (3–4 h), and any expected discomfort or pain.

History Before discussing the procedure in detail or beginning to plan the operation, it must be ascertained whether a patient has any health risks or previous illnesses which would make the procedure more difficult or even impossible (see Chapter 9). Precisely because this is an ‘aesthetic’ procedure, benefits must be weighed carefully against risks7. These issues should be covered in a detailed history. Besides the usual questions on previous illnesses, medications taken, etc., the patient should be asked specifically about familial or personal thrombosis. It is also important to determine the possibility of increased tendency to bleed or the regular intake of anticoagulant drugs, and whether surgery has been performed on the same area before (see sections on ‘Medical history’ and ‘Physical examination’ below).

Information on complications and risks and informed consent It is well known that this is the most important part of every medical consultation, but particularly in the case of procedures not medically necessary such as liposuction. Information and documentation of information given is essential for medical–legal reasons. The protocols to be observed are presented in Chapters 19 and 22. Besides covering the generally known risks and complications of the procedure, informed consent must also deal with the individual special considerations of each patient. If preprinted

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forms are used to document informed consent, care must be taken that individual special considerations are entered. Only after the patient has been informed of all possible complications and risks and has been given sufficient time for consideration can he or she give legally required consent to the operation (Figure 8.1)).Aesthetic complications and potential adjuvant procedures (see Chapters 13 and 18) must also be explained. It is recommended that all the risks and complications be mentioned and explained; however, the overriding message is that liposuction using tumescent local anesthesia is a very safe method in which complications do not usually occur (see Chapter 16).

the connection, and later actively co-operate in the planning process. Other patients can be advised to stand in front of the mirror at home and imagine the planned changes to their bodies, perhaps together with a trusted companion. One common request is treatment of the lateral thighs (‘saddlebags’). The patient might not have considered the medial thighs or even the knees. If the saddlebags are treated in isolation, the untreated inner thighs will be more obvious after the operation (this is not to be confused with an actual weight gain). Depending on the extent of the findings, the height of the patient, and individual requirements, the extent and number of planned procedures can be determined.

Preparation of an operative plan (see also section below on ‘Establishing the extent of the operation’)

Expected results The patient should be informed that the final result does not depend solely on the skill of the surgeon: individual wound healing and tissue characteristics also play a large role. An effort should be made to give a realistic prediction of the results which can be achieved. The patient can then contribute to the final results by co-operation in the postoperative care by, for instance, wearing a properly fitting compression garment (e.g. formation of horizontal ridges on the abdomen can occur through an ill-fitting compression garment).

In some cases, the procedure is perfectly straightforward: a localized accumulation of fat with good overlying skin turgor can be removed easily in one session. However, it is often necessary to prepare an actual ‘plan’ if the area to be treated is too extensive, or if it is expected that secondary procedures will be required. Initially the patient may see one particular isolated site and only want this removed. The patient must be made aware that, after removal of an isolated area, other previously less obvious areas may prove bothersome. It is the practitioner’s job to educate the patient about ‘aesthetic units’. Aesthetic units are regions of the body which should be treated together. Patients should not initially be persuaded to have treatment of areas which they do not find problematic. Many, however, understand

Establishment of adjuvant procedures and anesthesia methods Some minor operations can sensibly be combined with liposuction (e.g. autologous fat transplantation or subcision of puckered scars in the operating area) (see Chapter 13). These may also be offered and discussed during the

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Consent Form for Liposuction Surgery in Tumescent Local Anesthesia Name

With my signature I agree to a Liposuction surgery in tumescent local anesthesia performed by Dr. …………………… The physician has explained to me precisely the surgical procedure, the risks, the side effects and complications as well as the local anesthesia (tumescent local anesthesia). Also, I have read the additional information sheet and I was able to ask any questions about my concerns, and all of them have been answered sufficiently. I also agree that preoperative photographs will be taken in order to be able to compare the before and after condition after the surgery. It was explained to me in detail about the special risks, side effects and complications of liposuction in tumescent local anesthesia: Pain, swelling, bleeding, hematoma, sequela, infection, wound healing disorders, undesired scarring, tissue infiltration, skin irregularities and cyst formation, hyper- and hypopigmentation, nerve and blood vessel injury, fat embolism, numbness and hyposensitivity of the skin, thrombosis and embolism as well as allergic reactions. Additional remarks:……………………………………………………………………………...……...……...……...……..... …………………………………………………………………………………………………...……...……...……...……....... O I was able to address all my concerns and I have no further questions. O I need additional information about

O method O risks of the surgical intervention as well as any necessary additional surgery.

O meaning O results

I also accept, that I have been given no definite promise of perfection of the liposuction surgery by Dr………………. . Therefore, I am also not able to ask for a special surgical result in detail as well as in the overall appearance. If needed, I also agree to have medication, and understand that blood could be taken for diagnostic purposes. I also accept by my signature, that in case of any undesired post surgical condition, I will immediately call my doctor or the emergency phone of the institution. The telephone number to call was given to me. I have explained to Dr. ………….the truth about my condition of health and my diseases (e.g. hypertension, bleeding disorders, heart, liver, lung and kidney diseases as well as allergies) as well as which medication I have taken recently. Only female patients: I declare, at this moment I am not pregnant as far as I know. I specifically request to have the liposuction surgery performed using tumescent local anesthesia. I also accept any medication that may be required as well as any additional examinations and surgical interventions. If it is necessary to extend the ongoing treatment or surgery, I also accept.

Signature of patient

date of the interview

Signature of the surgeon

date of the surgery

Figure 8.1

Declaration of consent to liposuction treatment by tumescent local anesthesia

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There are a few important basics for a successful consultation (‘success’ should not be equated with ‘customer acquisition’ at all costs):

consultation. It has proved helpful to ask patients about their sensitivity to pain. If patients report a high sensitivity to pain or extreme fear of local anesthetic procedures (tumescent technique), adjuvant analgesic or sedation methods should be discussed, perhaps in conjunction with an anesthetist (see Chapter 5).

• Expectations must be thoroughly explored. • Realistic information must be provided.The more realistic the information that is given to the patient, the more satisfaction will be experienced with the results. In the case of high expectations, a good result for the physician may be a disappointing one for the patient. • Do not promise the world. • Do not raise false hopes. • Discuss the risks. • Leave it to the patient to decide whether he or she wishes to undergo the operation; do not persuade him or her to have treatment. • Do not, on the other hand, allow yourself as the physician to be pressured by the patient into performing a procedure if you are not convinced that it is sensible or likely to be successful. • Do not pressure the patient, but correct false impressions when necessary (guiding function).

Establishment of preoperative studies What laboratory results are needed? What should the patient present on the day of the operation? Besides a few tests for which all patients must present up-to-date values, it may be necessary to carry out other diagnostic tests based upon individual predisposition (see section below on ‘Preoperative evaluation’). Explanation of postoperative course The patient should know precisely what to expect (see Chapter 15), how long he or she will need to rest, and when normal activities can be resumed, to enable optimal planning of the procedure and avoidance of difficulties. In addition, any possible unpleasantness (protracted discharge of the tumescent local anesthesia (TLA) solution, muscle stiffness, temporary swelling, lumps, numbness) should be mentioned, or even set out in the information and consent form. It may be useful to hand out an information leaflet on postoperative progression and instructions (see Chapter 15).

MEDICAL HISTORY As mentioned above, it can be useful to use a standardized history form to cover all the important points and document the results.The patient can fill out this form before the consultation so that only unclear issues, existing illnesses, or other actual problems need to be dealt with (Figure 8.2). The physician has to rely on information given by the patient. The following points should be asked about:

Costs and methods of payment If a treatment plan is prepared, the costs must also be discussed. This issue can also influence the planning of the operation and should therefore be considered separately.

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• Legs: extensive varicosities in operating area (beware of increased risk of extensive hematoma following liposuction in these areas); • Abdomen: hernias in the abdominal wall (see below); • Existing scars or dimples.

• Known diseases of internal organs (heart, liver, kidneys); • High blood pressure; • Metabolic disorders such as diabetes mellitus or thyroid problems; • Regular medications taken; • Coagulation disorders: bleeding tendency, susceptibility to hematoma; • Thrombosis susceptibility: thromboses in the family, personal history of thromboses, thrombosis risk factors (smoking, obesity, hormone therapy, varicosities); • Known allergies, particularly to local anesthetics (dental procedures); • Previous surgical operations, particularly in the area to be treated; • Hernias (e.g. umbilical hernia).

In order to enable comprehensive evaluation, the whole patient and the individual pattern of fat distribution should be examined. The wishes of the patient should be considered, but the patient must be made aware of the need to maintain proper proportions.The goal is a harmonious figure and not simply mechanical fat removal. In this respect, skin quality can be specifically considered:

If there are indications for specific risks in the history, these should be investigated. Fat removal is an aesthetic procedure; it is not an essential operation. It is necessary to exclude or minimize all possible risks. Neither economic pressures nor pressure from the patient should lead to this elective, cosmetic procedure being performed in haste.

• Striae after pregnancy or weight fluctuation; • Soft, sagging skin or firm appearance. If previous diseases of internal organs are reported, an examination of the heart and lungs should be carried out and blood pressure checks made in order to initiate further preoperative studies if required. If the abdomen is to be treated, a specific examination must be performed for extensive rectus diastasis (have patients sit up from a prone position and check for intestinal protrusion) and other gaps in the abdominal wall (check umbilical region and groin for hernias). In the case of unclear clinical findings, ultrasound and radiographic imaging should be carried out.

PHYSICAL EXAMINATION Firstly, a thorough examination is made of the area to be treated: • Check for the quantity of subcutaneous adipose tissue (‘pinch test’, see Chapter 9). What can realistically be achieved? Is the patient satisfied with this prediction? • Examination of tissue consistency (elastic, good retractability or soft and redundant due to previous weight loss); • Existing dimpling or differences between the two sides;

ESTABLISHING THE EXTENT OF THE OPERATION The patient should be informed that 100% fat reduction is neither possible nor desirable.What

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Dear Patient, You have arranged a consultation for possible treatment. In order to learn about your medical history and to lower the risk during potential treatment or surgery, we ask you to answer the following questions to the best of your knowledge: Name: …………………………………………………………………………………………………………………………… First name: ……………………………………………………………………………………………………………………… Date of birth: ……………………………………………………………………………………………………………………

Do you take any medication on a regular basis?

Yes / no

If yes, please list:……………………………………………………………………………… Do you have any disorders of the heart or circulation system, such as: High blood pressure: Low blood pressure:

yes / no yes / no If yes, how high ……………./…………..….….

since when ……………….….….

Disease of your coronary blood vessels: Angina pectoris: Cardiac arrest:

yes / no yes / no If yes, when ………………………………………………………

Do you or your family have a blood coagulation disorder? yes / no Have you ever had a thrombosis? yes / no If yes, when …………………………………………………………… Do you bruise easily? Do you have any allergies?

yes / no yes / no If yes, what kind of allergy: - medication, such as antibiotics, pain medication, local anesthetic drugs - dust, any food - pollen - others: ………………………………………………………....

(Continued)

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Have you ever had any disease of the: Lungs?

yes / no which: …………………………….. when ……………………..

Liver?

yes / no which: …………………………….. when ……………………..

Kidney?

yes / no which: …………………………….. when ……………………..

Intestines?

yes / no which: …………………………….. when ……………………..

Do you suffer with any disease of the skeleton? Joints:

yes / no

Spine:

yes / no

Others…………………………………………………………………………………………..

Do you suffer with any disorder of your nervous system? Numbness:

yes / no

Reduced mobility:

yes / no

where:

Others…………………………………………………………………………………………..

Have you ever had any surgery?

yes / no

Kind of surgery:

when:

…………………………………………………..

………………………

……………………………………………………

……………………...

……………………………………………………

………………………

I know that all my answers are used to minimize the risk of a potential treatment or surgery and should be handled discretely. If there are any new changes in my health condition, I will report this to my physician.

……………………………………

…………………………………….

(date)

(signature of patient)

Thank you for your help!

Figure 8.2

Rosenpark Clinic history form

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see Chapter 4) are explained to patients, good sense usually prevails and the patient understands the need for several sessions. There are also upper limits regarding the quantities of fat removed: mega-liposuction with removal of more than 6000 ml of native adipose tissue is currently considered experimental (see Chapter 17). If several operations are necessary, appropriate units should be treated together, for example, first session: medial thighs and medial knees, and second session: lateral thighs and hips. In this way the TLA solution available can be distributed over the adjacent areas, thus achieving relative fluid conservation and safety. Since the exact quantity required cannot always be anticipated, treatment of the most problematic area can be agreed upon with the patient. Then, if there is any remaining solution, neighboring areas can be also treated (e.g. symptoms in upper and lower abdomen, both hips and waist: infiltration is started in the upper and lower abdomen if this is the patient’s chief complaint, with the possibility of extending the procedure to the hips and waist in the case of sufficient TLA). The aesthetic units should be explained to the patient and taken into consideration. The more thoroughly all these issues are explained in the consultation, the smaller is the risk of unnecessary discussions and ‘additional negotiations’ on the day of surgery.

is reasonable and technically possible with satisfactory results is a 50–70% reduction (‘70% rule’, see Chapter 12). Very extensive subcutaneous fat deposits generally can not be satisfactorily reduced in a single session.The patient should be made aware of the need for follow-up operations during the initial consultation. Mentioning this at the outset prevents the misconception that necessary secondary procedures are ‘error corrections’ or admissions of incorrect medical treatment. If a patient desires only a localized procedure, aesthetic units must be pointed out, and the patient made aware of these to avoid later disappointment (guiding function). Most patients have expectations that may not be satisfied completely in one session. The limiting factor in establishing the extent of an operation is the quantity of tumescent solution (TLA) available. Guidelines for accurate determination of the upper limit are given in Chapter 4. Besides considering the local anesthetic limit represented by mg/kg body weight, a maximum upper limit of 7000 ml of tumescent solution per patient and procedure can be taken as a rule of thumb. In order to estimate the quantity of TLA required, as well as the size of the operating area, the state of the tissue must be considered (see Chapter 20). In addition to the quantity and thickness of the unwanted adipose tissue, it can often be helpful to ask about frequent weight fluctuations.Tissue that has been stretched many times due to fluctuating weight can absorb a far greater volume of fluid.An experienced surgeon is often surprised by the actual quantity of TLA solution required, and hence it is advisable to take a certain variation into account. If the risks of using too much TLA solution (arrhythmia, blood circulation problems, etc.,

PREOPERATIVE EVALUATION The following laboratory results should be obtained as a matter of routine before liposuction is performed: • Complete blood count: white blood cells, hemoglobin level, hematocrit, platelets;

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• Coagulation: ProTime®, PTT (note: not sufficient to recognize all coagulation disorders); • Creatinine, AST, ALT (indication of liver and renal function); • Electrolyte panel: sodium, potassium.

examination results should not be older than 14 days. If there are pathological findings, these must be investigated and liposuction delayed until normalization is achieved. If prilocaine is used as a local anesthetic in the tumescent solution, particularly in the case of Mediterranean patients, the glucose6-phosphate-dehydrogenase level should be checked and in case of deficiency alternative anesthesia methods and medications selected (see Chapter 4). In the case of pre-existing heart or vascular disease, an ECG should be performed and possibly also an exercise stress test (exclusion of coronary heart disease) or long-term ECG (Holter monitor) to identify arrhythmia. The obligatory chest X-ray required for general anesthetic is usually not necessary. If clinical examination suggests abnormalities in the abdominal wall, such as hernias, an ultrasound examination should be carried out for exclusion purposes. Should a suspected hernia be confirmed, this must be considered as a relative contraindication due to the potential risk of damage to the intestinal loops, and the procedure performed with the appropriate care. Before liposuction of the legs, existing varicosities should be investigated by duplex ultrasound. It is useful to treat the varicose veins surgically before liposuction to avoid extensive hematoma.

In the case of organic disorders or underlying diseases, specific laboratory tests should be performed accordingly (e.g. thyroid hormone in the case of known dysfunction, blood sugar daily profile in the case of diabetes mellitus). Particularly in the case of increased susceptibility to thrombosis, a complete coagulation status should be obtained: • • • • • • • • • • • • •

APC resistance; If reduced: exclusion of factor V Leiden; ATIII; Protein S; Protein C; Plasminogen; TPA (tissue plasminogen activator); PAI (plasmin activator inhibitor); Anticardiolipin antibodies; Antiphospholipid; Factor XII deficiency; Homocysteine; In the case of prothrombin mutation G20210A: IPCR (inverse PCR).

Ideally, the patient should have these tests carried out by the primary care physician. The REFERENCES 1. Asken S. Liposuction Surgery and Autologous Fat Transplantation. East Norwalk: Appleton & Lange, 1988

Corona Del Mar, CA: Samuel Rolf International, 1987 3. Hanke CW, Lee MW, Bernstein G.The safety of dermatologic liposuction surgery. Dermatol Clin 1990; 8: 563–8

2. Fournier P. Body Sculpturing Through Syringe Liposuction and Autologous Fat Re-injection.

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4. Pitman GH. Consultation and patient selection. In Pitman GH (ed), Liposuction and Aesthetic Surgery. St Louis, MO: Quality Medical Publishing, 1993: 45–73

Aesthetic Surgery. St Louis, MO: Quality Medical Publishing, 1993: 45–73 7. Klein JA. Ethical considerations. In Klein JA (ed), Tumescent Technique:Tumescent Anesthesia and Microcannular Liposuction. St Louis, MO: Mosby, 2000: 12–15

5. Sattler G, Sommer B. Tumescent liposuction in Germany: history and new trends and techniques. Dermatol Surg 1999; 25: 221–3 6. Pitman GH. Operative planning and surgical strategies. In Pitman GH (ed), Liposuction and

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9

B Sommer, G Sattler

Before the performance of any elective surgical procedure, it must be established that the procedure can be carried out on the specific patient with the desired treatment outcome and with minimal risk1.A reputable physician should perform the operation only if these preconditions are fulfilled and any contraindications excluded. Liposuction is usually performed for aesthetic–cosmetic reasons. There are also a number of medical indications which can be treated with liposuction surgery.

Dermis

Superficial fat layer Deep fat layer

LIPOSUCTION FOR AESTHETIC REASONS What can be treated using liposuction with an aesthetic–cosmetic aim? In principle, adipose tissue can be removed from anywhere that is subcutaneous, from the cheeks to the ankles. Whether an unsightly protrusion is due to subcutaneous fat and thus theoretically able to be removed can be ascertained by means of a simple pinch test: the fat that the physician can pinch between forefinger and thumb is subcutaneous and can be removed by aspiration (Figure 9.1). This test has proved useful, for instance, in the case of the male abdomen: often the actual subcutaneous layer is relatively thin. The fat

Figure 9.1

Pinch test

stores are in the omental appendages and are therefore not accessible to liposuction surgery. In Chapter 12, all the possible operating sites are discussed with their specific considerations. More suitable and less suitable initial findings are presented for each region. As a rule of thumb, it can be assumed that some regions can generally be aspirated easily. Because of a more favorable retraction, aesthetically high-quality results are easier to achieve in

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this ‘ideal image’. Even patients who are not ideally suited can be operated on with the appropriate care and experience. Realistic expectations of both patient and physician are of particular importance3,4.

some areas than in other areas, although in principle, today, any region can be treated. Generally ‘good indications’ are: • • • • • •

Neck, cheeks, chin; Male breast; Upper and lower abdomen; Waist; Inner sides of knees; Lower legs and ankles.

Patient types • Ideal patient: (see above), slim with isolated pockets of fat and firm skin turgor. If there are no other contraindications, liposuction for aesthetic–cosmetic reasons is possible without limitations. • Obese patient: liposuction cannot achieve perfect results, but it can remove mechanically troublesome fat pads; this may provide the incentive for a change of lifestyle and may, in the long term, lead to lasting weight loss (see Chapter 3). Long-term obesity results in stretching that increases the risk of skin laxity after aspiration. It is important to create realistic expectations. • Formerly obese patient with retained fat pads after dieting: the troublesome pads can be removed using liposuction, but there is a very high risk of redundant skin after many years of obesity and subsequent weight loss; appropriate explanation and operating technique are required (vibration lipolysis is essential). Beware: there is often extremely high absorption of tumescent solution, which can literally pool in soft tissue. This should be factored into the operation plan. • Poor skin turgor, ‘weak’ connective tissue: if soft connective tissue is evident at the preliminary examination or if the skin is soft and saggy, the patient must be warned of the risk of continued sagging of the skin and the operation performed accordingly. Additional procedures may be necessary to tighten the skin.

More difficult areas to treat are: • • • • •

Upper and lower back; Upper arms; Hips and flanks; Outer and inner thighs; Buttocks.

Patient selection ‘Successful liposuction surgery begins with appropriate patient selection’.This statement by Hanke et al. shows the responsibility of the practitioner: it is his duty to recognize suitable patients and accurately establish the indication even in the case of ‘purely’ cosmetic improvement2. A thorough evaluation covers all the usual risk factors for surgical procedures such as medications taken or systemic illnesses and contraindications, as well as a physical examination and laboratory tests (see Chapter 8). The liposuction surgeon should consider two aspects: localization and distribution of fat deposits, and skin turgor. The ‘ideal’ liposuction patient is slim and has only isolated unwanted pockets of fat, and firm skin turgor2,3. Liposuction is least complicated when performed on such patients, but there can be and are constant individual deviations from

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Women

Figure 9.2

Men

Arrangement of subcutaneous connective tissue in women and men

The grid-like arrangement of the connective tissue fibers in men leads to the formation of small polygonal fat units. In addition, the male dermis is thicker than in women. Cellulite formation can be divided into three stages:

CELLULITE Cellulite, commonly known as ‘orange-peel skin’, is a non-pathological skin change which occurs mainly on the buttocks and thighs. The cosmetically unsightly formation of dimples on the skin occurs almost exclusively in women as a result of gender-specific architecture of the adipose tissue (cellulite can also develop in men in the case of inadequate production of androgen). It usually develops over time with increasing age, but with a relevant predisposition, it may also be seen in young girls. Cellulite usually forms on the thighs and buttocks and is a result of the specific architecture of the subcutaneous connective tissue (retinacula cutis). In female subcutaneous adipose tissue, the septa run vertically as connective structures between the dermis and deeperlying fat fasciae. In men they form a grid pattern (Figure 9.2). For this reason, women develop small ‘fat chambers’ standing vertical to the surface. A relatively thin corium in the affected ‘problem zones’ further encourages the spread of the clinically striking ‘mattress phenomenon’ caused by protrusion of the fat cells on the surface between the connective tissue septa. Microscopic examination of biopsies from the thigh has shown a three-layer structure of the adipose tissue in this area.

• Stage I: the ‘mattress phenomenon’ occurs only when the skin is flexed; • Stage II: the mattress phenomenon occurs spontaneously when standing; • Stage III: the mattress phenomenon is visible when sitting and standing. Treatment approaches include using stimulation current, ultrasound, or endocrinological therapy. Fat removal with liposuction represents a treatment option for cellulite because of specific changes to the subcutaneous space. Treatment of the affected adipose layer directly under the dermis is not required at all; removal of the underlying fat deposits reduces the pressure on this layer and thus the tendency toward protrusion of the surface ‘fat parcels’. The tissue-tightening effect due to healing of the deeper layers of the adipose tissue has an indirect positive effect on the uppermost layer.This prevents the sinking of this layer when standing, which is part of the reason for the mattress phenomenon.

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Dercum’s disease (adiposis dolorosa)

Direct liposuction treatment of the surface ‘cellulitic’ layer of fat requires very superficial aspiration with the potential risk of skeletization. When performing aspiration in this layer, particular care must be taken that the connective tissue septa, which are also partly responsible for the formation of cellulite due to their enmeshing of fat lobules, are not destroyed. They represent an important dermal support apparatus and their destruction would lead to sagging of the dermis.Vibration lipolysis carried out with appropriate care can be successful in reduction of the fat lobules. In the case of larger dimples, specific individual areas can be mobilized (see Chapter 13).

In this disease, first described by Dercum in 1892, a defined or diffuse deposit of extremely painful accumulation of fat in the subcutaneous space develops mainly on the lower extremities. These changes often occur symmetrically in postmenopausal obese women.The etiology of the disease is unknown. The pain can be so extreme that the regular administration of pain killers or even intravenous administration of narcotics is required5,6. The affected areas can be aspirated with the usual operating technique using anesthesia with tumescent solution. Following removal of the painful altered adipose tissue, patients have no further symptoms7,8.

MEDICAL INDICATIONS FOR LIPOSUCTION

Benign symmetrical lipomatosis (Launois–Bensaude syndrome)

The range of indications for liposuction, which was initially developed for cosmetic–aesthetic procedures, has been extended to other treatment areas. In combination with tumescent local anesthesia, the procedure is suitable for successful treatment of benign adipose tissue disorders involving pathological tissue increase and/or increased sensitivity to pain. Other medical indications are gynecomastia, axillary hyperhidrosis, the mobilization of skin flaps for plastic concealment, and the treatment of multiple lipomas. One relatively new indication with major potential for treatment is lipedema.

This is a symmetrical subcutaneous proliferation of fat which occurs in male adults. It typically occurs sporadically but can occasionally run in families. The doughy, soft or elastic adipose deposits are found cerviconuchally (type I, adenolipomatosis syndrome (Figure 9.3) in the area of the thoracic girdle; type II, pseudoathletic type), or around the pelvic girdle (type III, gynecoid type). In cases of unclear etiology, it is suspected that there is a disturbance in the lipid metabolism of adipocytes and a link with increased alcohol consumption5. The surgical removal of lipomas by conventional operating methods is very difficult. Liposuction using the tumescent technique, particularly vibration lipolysis, is currently the most effective procedure to remove accumulations of fat. In the case of extensive or extremely fibrous findings, several sessions may be required8.

Adipose tissue disorders Below are presented some benign adipose tissue disorders in which liposuction using tumescent anesthesia can be used for successful causal treatment by removing pathologically altered areas.

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a

b

Figure 9.3 (a) and (b) Adenolipomatosis syndrome

significantly improve the mismatch between dystrophic and hypertrophic areas8. In the case of progressive lipodystrophy syndromes, there is a need for continuous treatment of newly affected areas9.

Lipodystrophy syndrome The causes of lipodystrophy (Figure 9.4) can vary enormously.They range from rare congenital lipodystrophy syndromes (such as congenital diffuse lipomatosis), fat distribution disorders in the form of imperfect osteogenesis, hereditary forms with unclear etiology and varying rates of progression, to acquired lipodystrophy. In clinical practice, localized acquired lipodystrophy (lipoatrophia circumscripta) is the most common. In the case of partial lipodystrophy syndromes, localized wasting of the adipose tissue occurs in some areas. The more hypertrophic areas of remaining adipose tissue result in an unsightly irregular appearance of the affected areas. This can lead to acute psychological stress and increasing social isolation. Aspiration of the prominent areas and injection of the fat obtained into the atrophic areas (see Chapter 13) can

Gynecomastia Gynecomastia is defined as unilateral or bilateral enlargement of the male breast. In these cases, it must be established prior to treatment whether the patient has ‘genuine’ gynecomastia with enlargement of the mammary gland as an expression of a hormone disorder (e.g. due to a gonadal disorder) or pseudogynecomastia as a result of increased fat accumulation. The genuine forms require thorough investigation and treatment of the underlying disorder. Breast enlargement as a result of fat accumulation can be treated very successfully

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Figure 9.4

Lipodystrophy syndrome

of injectable botulinum toxin, and systemic treatment with extracts of sage or anticholinergic drugs, in the case of severe suffering surgical treatment can also be performed.An ellipse consisting of the affected skin areas and subcutaneous tissue can be excised.This procedure can, however, lead to mechanically impaired underarm scars. Another approach is to fold open the skin after an appropriate incision is made and scrape out the subcutaneous adipose tissue and sweat glands it contains; this, too, causes scarring. At the end of the 1980s, axillary liposuction for the treatment of hyperhidrosis was first described11. It is now an established therapeutic approach. Following preoperative establishment of the area affected using Minor’s sweat test (intensity test), the area is injected with tumescent solution.Aspiration is done via 2–3 incisions on the

with liposuction10. Here, in particular, the use of vibration lipolysis is an advantage which can make treatment of this area considerably easier. Reduction of the female breast can also be achieved by experienced surgeons using liposuction; the relevant techniques are described in Chapter 12. Axillary hyperhidrosis Axillary hyperhidrosis is a form of focal, pathologically increased sweating without cause.This idiopathic disorder, which can also affect other regions such as the palms or soles of the feet, is probably due to vegetative regulatory disorders. These are very unpleasant for the sufferer, and difficult to control with therapy. Besides the administration of creams and lotions containing aluminum chloride, the use 66

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edge of this area, which is treated in a fan-shape using a criss-cross technique. The use of short cannulas with a somewhat large diameter (up to 4 mm) and an opening on the side has proved successful. During aspiration, this opening is turned toward the skin side and, with the use of manual counter-pressure, as much adipose tissue as possible is removed (‘scraped out’) from directly under the skin.The endpoint is reached when the skin appears ‘fat free’ and thinner, and can be raised easily. Even if this procedure cannot remove all of the sweat glands, in many cases it is possible to achieve a normalization of sweating. Recurrence is due to regrowth of the glands from the remains of secretion tubes, and must be distinguished from what is known as ‘pseudorecurrence’, in which patients doubt the success of treatment when they still sweat to a physiological extent after the procedure. Figure 9.5

Skin flap mobilization Local flap-plasty is often used to conceal larger skin defects, e.g. following tumor resection.This requires mobilization of the skin for the intended flap, which is normally done using scissors. The use of blunt liposuction cannulas has proved to be a minimally traumatizing, fast, and effective procedure for the mobilization of large skin flaps. It may also be possible by removing small quantities of fat from the flap by aspiration to reduce the tension when closing the skin12.

Lipoma

predisposition. Histologically, lipomas consist of normal adipose tissue which is usually surrounded by a fine capsule.The connective tissue content varies enormously. Lipomas with high connective tissue content are referred to as fibrolipomas. Extirpation of a lipoma leaves an indentation in the skin depending on its size, but recurrence in the same place is unlikely because of complete removal.Aspiration can never result in total removal, and hence recurrence is possible. In the case of a solitary lipoma, there may be an indication for liposuction if the diameter is particularly large (> 10 cm); smaller isolated lipomas can be removed faster and more effectively using a small excision.To ensure that liposarcoma (rare) is not overlooked, a cytological

Lipoma Lipomas are the most common benign connective-tissue tumor, with a prevalence in the population of 2.1 : 1000 (Figure 9.5). These lesions can occur as solitary lipomas or as multiple lipomas, possibly with a familial 67

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a

b

Figure 9.6 (a) and (b) Lipedema

examination of the material aspirated should be carried out after the removal of a large lipoma. In order to remove multiple lipomas by liposuction, the lipomas are first marked and then the lipomas and surrounding area are injected with tumescent solution.A waiting time of at least 30 min enables the tumescent solution to soften the lipoma and make it more accessible for aspiration. After fragmentation of the tumor, the fat lobules of the lipoma are removed by the cannulas via a single incision using 4–6-mm cannulas.The surgeon exercises constant manual stabilization with his free hand. The capsule is also destroyed in the process.After removal of the lipoma a tight compression dressing is applied to achieve hemostasis and prevent the formation of fresh irregularities of the subcutaneous tissue13. In the case of increased connective tissue content, the use of vibration cannulas can facilitate aspiration.

Lipedema Lipedema is a relatively new addition to the list of medical indications for liposuction surgery, with enormous treatment potential. It has received significant attention in recent years. According to the current definition, this is a clinical syndrome characterized by increased deposition and edematous changes in the subcutaneous adipose tissue, particularly in the thighs and lower legs (Figure 9.6). The involved areas have increased pain sensitivity and sensitivity to touch, as well as increased capillary fragility.The disease occurs almost exclusively in women, and usually manifests itself at the end of puberty. It commonly occurs within families. The exact etiology is unclear14,15. Patients tend to develop orthostatic leg edema which seems to be due to a capillary permeability disorder. Untreated, the swelling

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• Exclusion of venous and arterial diseases as well as lymphedema.

increases over the years. As a result of the increasing dynamic insufficiency of lymphatic transport, lymphostatic edema develops in the advanced stages followed by transition to lymphedema (lipolymphedema). It is important to distinguish by differential diagnosis between lipohypertrophy, which is never painful, and lymphedema, which always affects the back of the feet (positive Kaposi– Stemmer’s sign). For many years, a complex decongestive physical therapy program with subsequent application of tight compression garments or class III compression stockings was the only treatment option for lipedema. Because of the generally young age of most of the affected patients, the need for lifelong continuation of treatment imposed an enormous strain on these individuals. For many years surgical procedures were advised against, for fear of destroying lymphatic vessels with subsequent worsening of the condition. In the past 5 years, this condition has been increasingly treated using liposuction. Certain guidelines should be followed16. Besides the clinical criteria for diagnosis, the following procedures are recommended in order to confirm the diagnosis prior to the performance of liposuction:

If, on the basis of clinical findings and examination results, there is no doubt of the diagnosis of lymphedema, the disease can be treated with good success by one or several liposuction procedures using tumescent local anesthesia5,14,17. In order to avoid complications, particularly damage to lymphatic vessels, the following are essential: • Treatment by an experienced liposuction surgeon; • Treatment using the latest, maximally tissueprotecting operating technique (tumescence or super tumescence; vibration cannulas; see Chapter 12); • Aspiration strictly along the body’s longitudinal axis; • Always symmetrical treatment of extremities. Pre- and postoperative lymph drainage is recommended. Compression dressings should be worn for at least 8 weeks. Assessment of an operated area can be made after 6–8 months, and then a decision should be made on any follow-up procedures. The pathophysiological development of lymphedema occurs in long-standing lipedema. There is a need for early diagnosis and treatment in order to operate in the early stages when the lymphatic system is still intact. Progression to lymphedema can be prevented. Many previous requests for liposuction of ‘fat legs’, which were termed ‘cosmetic’, were actually made by lipedema patients for whom liposuction represents a medical therapy. Increasing knowledge of this disease will, in many cases, lead to a shift in treatment measures.

• Indirect lymphography: feather- or flameshaped contrast-medium deposits; • Functional lymphscintigraphy: deceleration of lymphatic transport, recognizable by delayed arrival of the isotope and reduced storage in inguinal lymph nodes; • Duplex-ultrasound examination of adipose tissue for morphological evaluation: homogeneous expansion of the subcutis with uniform multiplication of echogenicity (‘snowstorm’);

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into account, as this has a major impact on the risk of the procedure.The method of anesthesia must be selected based on the existence of any contraindications. If a procedure is planned to be performed using tumescent anesthesia, the absolute and relative contraindications of tumescent anesthesia (see Chapter 4) must be excluded. An absolute contraindication for tumescent anesthesia specifically is a known allergy to one of the constituents of the tumescent solution (local anesthetic, preservatives). If prilocaine is used as a local anesthetic, glucose-6-phosphatedehydrogenase deficiency must be ruled out. If systemic narcosis or general anesthesia is planned, any contraindications for the relevant medications and procedures must be ruled out (see Chapter 5). In some cases, patients at increased risk under general anesthesia can be operated on using tumescent anesthesia or vice versa: if there are contraindications for tumescent anesthesia, the operation may be carried out using another form of narcosis.

LIPOSUCTION CONTRAINDICATIONS Absolute contraindications Any relatively severe disease the patient has which increases the risk of the operation must be considered an absolute contraindication for an aesthetic operation.This does not apply only to liposuction, but also in general for all esthetic surgical procedures. In order to assess the risks before surgery, the classification of the American Society of Anesthesiology for the assessment of physical status can be used (Table 9.1). Cosmetic procedures such as liposuction should only be performed on patients in categories 1 and 2. Table 9.1 Classification of physical status of the patient 1 Normal healthy patient 2 Patient with mild systemic disease with no impaired performance 3 Patient with severe systemic disease and impaired performance 4 Patient with debilitating systemic disease which is life-threatening 5 Moribund patient

Relative contraindications Liposuction is not a method of treatment for generalized obesity (see Chapter 3 and the section on ‘Patient selection’ above).This must be considered a relative contraindication, the exception being specific removal of localized fat pads. Well-compensated or drug-regulated diseases of the internal organs (heart, lungs, kidneys, liver) as well as metabolic disorders (thyroid, diabetes mellitus) must be considered relative contraindications, which allow performance of the procedure only with the appropriate precautionary measures. In the case of patients on long-term medication, possible interactions with the anesthetic

Other absolute contraindications are severe personality disorders or unrealistic expectations which cannot be satisfied. In these cases, there is an extremely high likelihood that the desired goal of treatment cannot be reached for either the physician or the patient. Liposuction cannot be performed in cases of acute illnesses such as systemic infections or local infections at the operating site, nor on pregnant women or nursing mothers.The standard contraindications for elective surgery apply. In the exclusion of contraindications, the relevant method of anesthesia must also be taken

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existence of such disorders must be clarified through preoperative coagulation studies, particularly in the case of relevant patient history. Relative contraindications against purely tumescent anesthesia can be increased anxiety or sensitivity to pain, or a known ‘needle phobia’. For these patients, an alternative method of anesthesia should be established during the consultation and the relevant preliminary examinations initiated.

substances must be considered (see Chapters 4 and 5). Advanced age is not an independent contraindication. An individual decision must be made according to the patient’s general state of health and skin elasticity. Even patients over 70 years of age can be treated successfully with tumescent liposuction4. It is important that coagulation disorders resulting in increased risk of bleeding or thrombosis susceptibility are considered. The REFERENCES

benignen Fettgewebserkrankungen. Z Hautkr 1997; 72: 579–82

1. Klein JA. Pathophysiology and complications. In Klein JA (ed),Tumescent Technique:Tumescent Anesthesia and Microcannular Liposuction. St Louis, MO: Mosby, 2000: 25–120

9. Berenguer B, de la Cruz L, de la Plaza R. Liposuction in atypical cases.Aesthet Plast Surg 2000; 24: 13–21

2. Hanke CW, Lee MW, Bernstein G. The safety of dermatologic surgery. Dermatol Clin 1990; 8: 563–8

10. Dolsky R. Gynecomastia: treatment by liposuction. Dermatol Clin 1990; 8: 469–78

3. Matarasso SL. A regional approach to patient selection and evaluation for liposuction. Dermatol Clin 1990; 8: 401–13

11. Lillis PJ, Coleman WP III. Liposuction for treatment of axillary hyperhidrosis. Dermatol Clin 1990; 8: 479–82

4. Pitman GH. Consultation and patient selection. In Pitman GH (ed) Liposuction and Aesthetic Surgery. St Louis, MO: Quality Medical Publishing, 1993: 3–29

12. Field ML, Spinowitz AL. Flap elevation and mobilization by blunt liposuction cannula dissection in reconstructive surgery. Dermatol Clin 1990; 8: 493–9

5. Braun-Falco O, Plewig G, Wolff HH, eds. Dermatologie und Venerologie, 4th edn. Berlin: Springer-Verlag, 1997

13. Pinski KS, Roenigk HH Jr. Liposuction of lipomas. Dermatol Clin 1990; 8: 483–91 14. Marsch WCH. Ist das Lipödem ein lympholo gisches Krankheitsbild? J Lymphol 2001; 1: S22–4

6. Petersen P, Kastrup J. Dercum’s disease (adipositas dolorosa).Treatment of the severe pain with intravenous lidocaine. Pain 1987; 28: 77–80

15. Wienert V. Diagnose und Therapie des Lipödems. Dtsch Dermatol 2001; 9: 614–17

7. DeFranzo AJ, Hall JH Jr, Herring SM. Adiposis dolorosa (Dercum’s disease): liposuction as an effective form of treatment. Plast Reconstr Surg 1990; 85: 289–92

16. Cornely ME. Die Liposuction des Lipödems. J Lympho 2002; 2: S52–3

8. Sattler G, Hasche E, Rapprich S, et al. Neue operative Behandlungsmöglichkeiten bei

17. Lipödem der Register, 1999

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Instruments R Jokisch

infiltration cannulas, known as percutaneous sticks3 (Figure 10.1). For anesthesia of smaller areas, syringe pumps with a capacity of 2–10 ml are still used today. Although manual infiltration enables more precise and easily variable infiltration speed, the infiltration of larger areas is physically demanding and enormously time-consuming. The use of increasingly large volumes of tumescent solution therefore soon led to the development of electrically operated infiltration systems4 (Figure 10.2). There are now available a range of technically perfected systems which propel the tumescent solution automatically with roller pumps (Figures 10.3 and 10.4). The instruments used should have finely adjustable flow quantity and displays for infiltration speed (ml/min) and total amount (ml). Noise is often a problem with roller pumps. It

For liposuction using tumescent local anesthesia, the surgeon needs, in addition to manual dexterity and experience, a range of specific instruments which, like the operating and anesthetic techniques, have developed since the beginning of liposuction surgery. Improvements in instrumentation have been a major contribution to the current operating standard. Requirements are pump systems to inject the large amounts of tumescent solution and a range of suction cannulas and aspirators for actual liposuction. The high standard currently achieved does not represent the endpoint. There will be continuing further developments and improvements in this area (see Chapter 2).

PUMP SYSTEMS In its early stages, tumescent anesthesia was developed from the ‘wet technique’ introduced by Illouz, in which saline solution mixed with hyaluronidase was injected into the subcutaneous fat before treatment1.The infiltration was carried out using normal syringes.The introduction of tumescent anesthesia by Jeffrey Klein2 saw the development of manual syringe pumps which propelled the tumescent solution out of infusion bags. The tumescent solution was injected into the tissue via relatively thick special

Figure 10.1

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Figure 10.2

The Klein pump Figure 10.4

Liposat® infiltration pump

tumescent solution per needle per minute flows into the tissue (see Figure 4.2).Three-liter bags containing tumescent solution warmed to body temperature in the warming cupboard are placed in preheated dishes during infiltration. This ensures that the patient does not become chilled due to infiltration of the cold isotonic saline. In addition, the use of warming blankets and/or heating mats is recommended. Figure 10.3

Electronic roller pump by Blugermann

ASPIRATOR should be ensured that instruments are approved for use in human medicine. The tumescent solution is injected into the tissue via attached infiltration cannulas. The duration of infiltration depends on the infiltration speed. If the speed is too high, the consequent rapid build-up of tissue pressure can be unpleasant for the patient. Use of a distribution system (e.g. Stenger–Sattler distributor) (see Chapter 4) enables infiltration to be carried out rapidly but in a manner that is tolerable for the patient. The distributor system has between three and 12 outlets, and 7 cm long Sterican® needles (0.90 × 70 mm BL/LB, 20G × 2.75 in) serve as infiltration cannulas. Ten milliliters of

In order to facilitate the removal of fat through small incisions, the cannulas used must be connected to an appropriate aspiration system.The complicated machines used by Fischer, and the Karmann aspirator that Illouz used (which was generally used for abortions), have now been replaced by a range of different units developed specifically for liposuction. The units must be able rapidly to build up sufficient suction.A manometer must be available to test the negative pressure. In addition to approval and certification, noise level must also be considered. The ability to converse with the patient and listen to music are critical factors in calming the patient and facilitating the operation.

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Figure 10.6

Diverse microcannulas

Use of these relatively large cannulas (macrocannulas) led to very widespread tissue traumatization and often to unsatisfactory postoperative results with irregularities. Improvements in the operating results were achieved by continuous reduction of the caliber of cannulas to a diameter of less than 2.5 mm.At the same time, reduced traumatization of subcutaneous connective tissue by the microcannulas facilitates the healing process7. Use of these thin-caliber cannulas is possible only after appropriate preparation of the adipose tissue (e.g. with the tumescent technique) (see Chapter 6). Microcannulas can be categorized by configuration of the tip and by the number and arrangement of the suction holes. The length of the cannulas used depends on the region being treated. Shorter cannulas are easier to control, while longer ones enable more distant fat deposits to be reached via small incisions8 (Figure 10.6). If there are only a small number of suction holes on the tip of the cannula, there is a correspondingly more powerful suction through each hole. Besides increased damage to the tissue fibers, there is also a risk of over-suction with such cannulas. In the effort to develop as atraumatic a suction technique as possible, cannulas with many suction holes were created (24-hole cannulas) (Figure 10.7). These cannulas show reduced suction

Figure 10.5 Combined liposuction instruments with infiltration pump, warming dishes for the tumescent local anesthesia solution, aspirator, and collection vessels

Ideally, the aspirator and infiltration pump should form a unit which can be moved easily on rollers (Figure 10.5). This unit should also have at least two collection vessels so that during liposuction there are no unnecessarily long interruptions while containers are replaced. The use of sterile throw-away bags enables the fat extracted to be prepared for autologous fat injection (see Chapter 13).

CANNULAS Sharp curettes were initially used to detach the adipose tissue5. Illouz was the first to use blunt, less traumatizing cannulas1 (see Chapter 1). The blunt detachment of the adipose tissue was made considerably easier by the ‘wet technique’. The cannulas used initially had a diameter of 8–10 mm. Fournier initially used cannulas with a diameter of 5–6 mm for his syringe technique6.

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Figure 10.7

Figure 10.8 MicroAire® system: handpiece, cannula, and attachable suction tube

24-hole cannula

through the aspiration openings, which means that the connective-tissue fibers are not sucked into the lumen on the cannula as they are with one-, two-, or three-hole cannulas.This results in a less traumatic and more uniform treatment3.

POWERED LIPOSUCTION AND VIBRATION CANNULAS As a further development to the manually guided liposuction cannulas, in the mid-1990s, motordriven cannulas emerged. In the ‘liposhaving’ method, otolaryngologist Charles Gross used a motor-driven cannula with an internal rotating blade to destroy fat cells. The latest developments are cannulas without oscillating blades, in which the cannulas themselves are made to vibrate using a handpiece (Figures 10.8 and 10.9)9. The advantages of vibration are already known through the hammer drill technique (axial vibration) and the electric toothbrush (lateral vibration). It was only logical to apply these principles to liposuction. In the MicroAire® system, these principles are combined, and it is possible, with a minimum of effort, to remove fat cells with very little tissue trauma.This system takes advantage of the different oscillation characteristics

Figure 10.9 units

Vibrasat®: handpiece, cannula, and operating

of metallic vibrating cannulas compared with the more torpid adipose tissue. The vibrating cannulas glide past the tissue structures without sucking them in. Only the fat homogenized by the tumescent solution is collected by the cannulas (see Chapter 6). Several studies have now demonstrated the superiority of vibration lipolysis.Vibration cannulas make it easier for the surgeon to perform the procedure even on fibrous or previously operated sites. Healing is faster, with fewer complications. The procedure is also more pleasant for the patient because the cannulas

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Table 10.1 Comparison of various vibration cannula systems

Xomed KMI Numed Becker–Rojas Vibrasat MicroAire

Weight of handpiece

Weight of cables (g/cm)

Maximum output (rpm/min)

Stoppage of motors with applied load

Adapter for Luerlock cannulas

380 420 340 200 580 480

0.555 0.612 0.928 0.622 0.315 1.225

6000 ? 7000 8000 5000 4000

No (Yes) Yes Yes Yes No

No No Yes Yes No Yes

Development of the cannulas and the handpieces is not yet complete, but ‘powered liposuction’ is proving to be a significant step forward in liposuction surgery, and will probably be used widely10,11.

glide through the tissue more easily and rarely get caught up in the connective tissue.There are now a range of vibration cannulas on the market with variable features, such as weight of the handpiece (Table 10.1). REFERENCES

7. Klein JA. Microcannulas. In Klein JA (ed) Tumescent Technique: Tumescent Anesthesia and Microcannular Liposuction. St Louis, MO: Mosby, 2000: 235–47

1. Illouz Y. Body contouring by lipolysis: a 5-year experience with over 3000 cases. Plast Reconstr Surg 1983; 72: 511–24 2. Klein JA.The tumescent technique for liposuction surgery. Am J Cosmet Surg 1987; 4: 236–67

8. Pitman GH. Instrumentation. In Pitman GH (ed) Liposuction and Aesthetic Surgery. St Louis, MO: Quality Medical Publishing, 1993: 31–43

3. Sattler G, Sommer B. Tumescent liposuction in Germany: history and new trends and techniques. Dermatol Surg 1999; 25: 221–3 4. Bergfeld D, et al. Technik der Infiltration. In Sommer B, et al., eds. TumeszenzLokalanästhesie. Praktische Anwendung. Berlin: Springer-Verlag, 1999: 47–52

9. Sommer B, Sattler G.Vibration assisted liposuction (VAL) in tumescent local anesthesia (TLA). In Ring J, et al., eds. Skin and Environment – Perception and Protection. 10th EADV Congress, Munich, 2001. Bologna: Monduzzi Editore, 2001:

5. Fischer A, Fischer G. Revised technique for cellulitis fat reduction in riding breeches deformity. Bull Int Acad Cosmet Surg 1977; 2: 40–1

10. Coleman WP, III. Powered liposuction. Dermatol Surg 2000; 26: 315–18

6. Fournier P. Body Sculpturing Through Syringe Liposuction and Autologous Fat Re-injection. Corona Del Mar, CA: Samuel Rolf International, 1987

11. Katz BE, Bruck MC, Coleman WP III. The benefits of powered liposuction versus traditional liposuction: a paired comparison analysis. Dermatol Surg 2001; 27: 863–7

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11

R Jokisch, D Bergfeld

• • • • •

Besides the necessary liposuction appliances presented in Chapter 10 on ‘Instruments’, there are several factors to consider when designing the operating area. First, there are legal regulations and provisions setting out the minimum standards for patient safety.These may vary from state to state. In general, it can be said that spatial design is determined by the type or types of procedure to be carried out1. In the case of invasive procedures, a distinction must be made with regard to their extent and, thus, the level of risk between:

Only one operating table; An anteroom with washing facilities; Staff and patient changing areas; Supply and waste disposal facilities; A recovery room.

There are also specific requirements for the surfaces and building components to be used (flooring, walls, ceilings, wash-basins, etc.). All surfaces and technical equipment must be easy to clean and disinfect, and edges must not collect dirt. Since many electrical appliances are used, flooring must be conductive to protect against electric shocks. Since there are regulations for walls, ceilings, and wall coverings as well as glazing and visibility protectors, it is recommended that an architect experienced in this field be consulted1. Another consideration is that, particularly in the case of liposuction using tumescent local anesthesia, the increased subcutaneous fluid intake and consequent absorption of fluid often necessitates that patients frequently have to go to the toilet during the waiting time between anesthetic application and the actual aspiration. Therefore, a toilet should be within easy reach (e.g. connected to the patient changing area).

• Invasive examinations and similar measures; • More minor invasive procedures; • Surgical operations. These categories also apply to operations carried out on an outpatient basis, and, according to the recommendations of the RobertKoch Institute, the following also applies to outpatient operations. Ambulatory operations must not incur a more acute infection risk for patients than surgical procedures carried out on an inpatient basis2. Liposuction can, like most aesthetic procedures, be carried out in what is known as a procedure room. A procedure room should have:

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Figure 11.2 Foot pedal for smooth adjustment of operating table

Figure 11.1

Surgical setting with operating table

asymmetries and indentations (Figure 11.3). The marking of areas to be treated is done with the patient standing in front of a wall mirror.The skin markings made by the surgeon must coincide with the patient’s wishes and ideas. The surgeon must have the patient confirm the plan before beginning the infiltration phase. Patient–physician communication is paramount. Ignoring or misunderstanding the patient’s wishes often results in dissatisfaction with the results. In order to avoid long discussions in the procedure room, the surgeon and patient should reach a basic agreement and understanding with regard to the size and extent of the planned procedure during prior consultations. The lighting should be bright and friendly; installation of a special operating lamp can be considered for the operating area. This is, however, not essential for liposuction since it is not so much the eye as the hands that control the treatment results (see Chapter 12). A photographic area should be set up to enable standardized views with a uniform background (e.g. extra-long pull-down background rolls) and standardized lighting conditions. It can

SURGICAL SETTING The surgical setting must offer optimal operating conditions (Figure 11.1). It is important for procedures carried out on conscious patients that a pleasant and relaxed atmosphere is created in the treatment area3. The most important piece of equipment is a functional and versatile operating table, adjustable electrically via a foot pedal (Figure 11.2).The table should not be too wide, so that the operating site is easily accessible to the surgeon at all times. The table should also be adjustable to all necessary settings for optimal patient positioning (see Chapter 12). On the other hand, it must be sufficiently comfortable for patients to endure lying on it for several hours. An appropriate surgical preparation table must also be available. A sufficiently large mirror is important during preoperative marking of the treatment area to allow the surgeon to demonstrate the planned procedure to the patient and to point out existing

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Figure 11.4 Warming blankets to prevent the patient becoming cold while the anesthetic is taking effect

often become cold even after the injection of prewarmed solution; a warm air blanket minimizes patient discomfort (Figure 11.4). Light, pleasant background music can contribute considerably to the well-being of the conscious patient.The installation of a television can also be considered for the patient. However, these measures must never interfere with patient communication during the procedure. Figure 11.3 Large mirror for preoperative marking and discussion of findings and black photographic background roll

STERILIZATION

sometimes be helpful to add markings to optimize the positioning of the patient and camera. Sufficient storage space and preparation surfaces should be created, and all materials required for the procedure should be readily available in the room. Care should be taken that the procedure room is not used as a storage area, so that supplies are not fetched or stowed away while procedures are in progress. Patients find it very pleasant to lie on prewarmed towels, particularly during the later stages of the operation when leaking tumescent solution means that patients are often lying on a wet surface.A warming cupboard can be used to warm operating cloths or cotton towels. While the anesthetic is taking effect, patients

For the sterilization of instruments which have been in contact with blood, internal tissue, or organs through penetration of the skin or mucosa, strict regulations exist, and may vary from state to state4. The preparation of instruments from unclean to sterile must be done according to a strictly validated and controlled procedure. A suitable sterilizing unit would be, for instance, a steam sterilizer. Since on-site sterilization can be both time-consuming and expensive, it may be more efficient to have this done elsewhere (outsourcing). It must be ensured that the service provider has the relevant quality assurance standards.

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POWER AND EMERGENCY POWER In order to be able to complete procedures in progress in the event of a power outage, and to enable the monitoring of vital functions or to maintain these in emergencies, there must be an emergency power supply.

TREATMENT OF EMERGENCY CASES AND MONITORING EQUIPMENT

Figure 11.5

Continuous monitoring of vital functions, for example pulse and blood pressure, as well as monitoring of oxygen saturation by a pulse oximeter should be carried out in the procedure area. The installation of various monitors should be taken into consideration in the planning stage of setting up an operating area (Figure 11.5). In addition to the staffing requirements mentioned in Chapter 17, to ensure adequate emergency care the following must also be available: infusion stands with multiple hangers,

Monitoring of vital parameters

a standardized emergency case (e.g. ULM case) or ideally a medicine box with drugs for emergency resuscitation, and a defibrillator. There must also be ventilation equipment, at least a bag-mask ventilation unit. If other methods of anesthesia are used in addition to pure tumescent local anesthesia, which can result in progression to general anesthesia (see Chapter 5), oxygen and pressurized air must be available.

REFERENCES 1. Büchel W. Raumplanung, Hygiene und Qualitätssicherung [Spatial design, hygiene and quality assurance]. In Dirschka TH, Sommer B, Usmiani J, eds. Leitfaden Ästhetische Medizin [Manual of Esthetic Medicine], 1st edn. Munich: Urban & Fischer, 2003: 1–20

3. Dirschka TH. Grundausstattung des Behandlungsbereiches [Basic equipment for treatment area]. In Dirschka TH, Sommer B, Usmiani J, eds. Leitfaden Ästhetische Medizin, 1st ed. Munich: Urban & Fischer, 2003: 21–32

2. Federal Health Letter of Germany 2000; 43: 644–8

4. Federal Health Letter of Germany 2001; 44: 1115–26

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12

G Sattler, B Sommer, CW Hanke, G Blugerman, AL Leonard

Every patient must submit a written consent form and current laboratory results before the actual procedure can be started (see Chapter 19).

In the introductory chapters on ‘The history of liposuction’ and ‘The status of liposuction today’, an overview was given of the important milestones in the development of the operating technique. Because of the numerous advantages and high safety, liposuction using the tumescent technique is currently the method of choice. Since the first description by Jeffrey Klein, this method has been continually improved1. In many body areas, a further improvement of the intraoperative and postoperative course can be achieved by using the vibration-assisted liposuction technique. In the first part of this chapter there is a general presentation of the current operating technique for liposuction using tumescent local anesthesia. In the second part, the individual areas of the body are discussed with their special considerations.

Marking of the operation area In the procedure room, the area to be treated is marked out in accordance with the operating plan, using a waterproof skin marker, while the patient is standing. The prominent fat deposits are marked as ‘height lines’, and the borders of the area to be treated are outlined. If several regions are to be treated in one session, the socalled transitional zones must be taken into consideration: these are regions from which no fat should be removed in order to maintain a natural body silhouette. Any existing irregularities and indentations, which will be hidden by the tumescence, should be marked separately (see Chapter 21). It is recommended that marking be carried out in front of a large mirror so that the patient can follow the planned procedure. However, it is important that the patient has already grasped the possibilities and limitations of liposuction, as well as the extent of what is possible in one session, at the explanatory consultation, so that no unwelcome discussions (‘Can’t that be done at the same time?’) arise directly before the procedure.

GENERAL OPERATING TECHNIQUE For every liposuction procedure using the tumescent technique, it is recommended that a standardized format is used which begins with an explanatory consultation and resulting operation concept and plan (see Chapter 8)2.

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made possible by further development of the solution with reduced concentration of the local anesthetic components, but it is nevertheless important that maximum volumes are considered when planning the operation. During preoperative estimation of the required quantity of TLA, the tissue type of the patient is also relevant, a factor whose assessment requires some experience on the part of the surgeon (see Chapter 20)3. In order to prevent the patient from becoming too cold due to the large volume of TLA solution, the use of solution warmed to body temperature is recommended. During the waiting period, while the anesthesia is taking effect, the patient is kept warm by a warming blanket (see Chapter 11). Due to redistribution of the tumescent solution and a certain amount of fluid running out again, by the end of the waiting time the water-melon-like ‘super tumescent effect’ is often receding. Since, however, this is an essential aspect of tissue protection, reinfiltration should be carried out before the procedure is started. If the safe volume of TLA solution for the patient has already been used up, physiological saline solution can be used.

Photographic documentation Before or after the marking, photographs are taken of the standing patient from at least two perspectives.This is essential for documentation purposes (see Chapter 19). Care should be taken to ensure consistent lighting and background as well as the same positions so that the photographs are comparable (see Chapter 11). Digital image management can help to achieve optimal archiving of the photographs.

Tumescent local anesthesia After the patient is positioned on the operating table, intravenous access is established. If required, intravenous sedation is administered at once (see Chapter 5). For monitoring purposes, the attachment of a pulse oximeter is recommended. In the case of more major procedures or planned stronger systemic sedation, continuous blood pressure and ECG monitoring should also be carried out. The first important phase of the procedure is the correct ‘setting’ of the tumescent local anesthesia (TLA). The exact procedure is described in Chapter 4. The goal is the achievement of ‘super tumescence’, i.e. maximally firm elastic infiltration status of skin and subcutaneous tissue.The tissue consistency in the stage of super tumescence is comparable to that of a water-melon. This is an indication that sufficiently high pressure has built up in the tissue to achieve a gradual distribution of tumescent solution within the context of the 30 minutes waiting time, and thus that the adipose tissue is optimally prepared (see Chapter 6). The large volumes of tumescent solution required for this were only

Liposuction The positioning of the patient before aspiration depends on the areas to be treated. Before final positioning it is recommended that the bedding under the patient that is soaked with tumescent solution is changed for fresh, warmed bedding to make the patient more comfortable. During the procedure the patient is repositioned frequently, which is easily achieved with conscious patients in tumescent local anesthesia. This is known as active positioning.The goal of regular

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(see Chapter 10). In our experience, aspiration can be carried out most gently using vibration cannulas (see Chapter 6)4.The length of the cannula depends on the area to be aspirated. The actual aspiration process takes place far from the incision at the end of the cannula in order to avoid over-aspiration. Aspiration is begun in the deeper layers, in the abdominal area for instance below Camper’s fascia. Starting from the incision site, the cannula is guided forward in a fan shape.The ‘crisscross’ technique first introduced by Fournier must, under no circumstances, be understood as ‘aspiration in all directions’5. What is important is aspiration in different layers. Attention should be paid to the fact that adipose tissue at most sites of the body, but particularly in the case of larger accumulations of fat, is divided by a fat fascia into at least two compartments, a superficial one and a deep one. Aspiration is started in the deep compartment. Then, aspiration is carried out at several levels, always in a fan shape, gradually working one’s way to the surface. The direction of suction should basically be parallel to the longitudinal axis of the body.This optimizes protection of the lymphatic vessels and reduces the risk of indentations. Too superficial an aspiration must be avoided in order to ensure that there is no skeletization impression or unsightly ridges.A layer of subcutaneous tissue of at least 1–1.5 cm in thickness should be left under the dermis.The boundaries to the neighboring untreated area should be smoothed by less aspiration in this area. One hand (normally the right) guides the cannula through the tissue, thus performing ‘mechanical’ work. The free hand has a ‘sensory’ function: it guides the aspiration cannula within the tissue and detects the layers and direction of aspiration as well as the aspiration

repositioning is to gain access to the relevant fat deposits from different angles, a procedure also known as the ‘multipositional approach’. Defined patient positioning is decisive in the development of an individual systematic operating routine in order to avoid undesirable increases in tissue pressure in the operating area due to underlying bony structures. Overstretching (e.g. of the trunk) can also achieve a toning of the skin covering in the waist area, and specific flexing of underlying muscle groups avoids an underlay of soft muscle. After the patient is positioned on the operating table and areas not being treated are covered with sterile cloths, another thorough skin disinfection is carried out. Even if the risk of infection is not high, the normal hygiene standards should be observed.This also includes the wearing of sterile operating clothing and gloves by the surgeon. Incisions for insertion of the aspiration cannulas are made at the edge of the area to be aspirated using a disposable scalpel. The best accesses are presented separately for each region in the second part of this chapter. If possible, the accesses should be positioned in skin folds or regions covered with hair, even though the scars are ultimately small. The size of the incisions depends on the size of the apiration cannulas; however, they should be large enough so that the cannulas do not rub or crush the edges too much, to avoid postinflammatory hyperpigmentation. Every practitioner must decide for himself which types of cannulas and aspiration devices are best for him. However, generally, according to the current state of knowledge, only the thinnest possible caliber, blunt, and therefore atraumatic cannulas should be used. Multihole cannulas give more gentle aspiration than single-hole models

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The relationship between the amounts of fat and blood that are removed during liposuction

Volume Time

Figure 12.1 technique)

MASST (manually assisted skin stabilization Fat

Blood

Figure 12.2 Relationship of lipoaspiration to hemoaspiration according to duration of operation

status by continually checking the remaining subcutaneous tissue. In addition, if required, it can also stabilize the tissue or raise it to enable the cannula to reach all levels (Klein). As the aspiration process progresses, the tumescent solution is aspirated along with the adipose tissue, whereby the stabilizing and thus tissue-protecting aspect of the tumescent anesthesia recedes and more shearing force is exerted. In order to achieve additional skin stabilization in this phase of the operation, use of what is termed MASST, the manually assisted skin stabilization technique, is recommended (Figure 12.1). In this technique, a trained assistant stretches the softening tissue firmly with both hands, to provide again a firm base for the aspirating cannula. During aspiration, as well as patient repositioning, another check of progress and a comparison of sides can be made with the patient standing.This is the best method of discovering residual pockets of fat or asymmetrical areas and carrying out specific correction. The endpoint of liposuction is recognizable by various criteria. One sign is when hemoaspiration begins to outweigh lipoaspiration (Figure 12.2).

In the ‘pinch test’, a gentle manual pinching together of the skin and subdermis is used to check the remaining tissue.With a certain operating experience, one can test ‘blind’ whether sufficient fat has been removed (Figure 12.3). The removal of too much adipose tissue, known as ‘over-aspiration’, must certainly be avoided, since it can lead to numerous aesthetic complications (see Chapters 18 and 21), and fat cells, once removed, do not grow back6. Pierre Fournier’s rule applies:‘It is not important what you take out but what you leave’.As a guide for treatment of a region, the 70% rule applies: in one treatment area during one session generally a maximum of 70% of the existing fat cells are removed (Figure 12.4). If after final healing (at the earliest 6 months) the patient wants further reduction of the same site, 70% of the remaining 30% can be aspirated again, which is another approximately 21% of the original findings. After two aspiration treatments in the same area, it is therefore to be assumed that 90% of the fat has been removed.

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70% Rule

70

70% 97

21

30 1 year

1. Treatment

Figure 12.3

Pinch test

9

70% 1 year

2. Treatment Aspirate

A more controversial procedure is what is known as ‘mega-liposuction’, with the removal of more than 6000 ml of fat in one session. The more fat that is removed in one operation, the higher is the complication rate. In the guidelines on liposuction produced by American specialty associations, an upper limit of 5000 ml of pure fat is classified as the maximum safe upper limit. Larger quantities should only be removed in specialized centers with the relevant postoperative monitoring (see Chapter 17). At the end of the liposuction procedure an examination is made with the patient standing. If no further corrections are required, a large proportion of the remaining TLA solution is pressed out of the caudal incisions in the direction of gravity by milking the treatment area while the patient is standing. The incisions are not sutured closed, so that the solution can flow out unchecked. Not placing sutures has eliminated the panniculitis-like reaction often seen in the initial stages of tumescent anesthesia7. Instead, the incisions are closed with suture strips, and a sterile plaster is applied (Figure 12.5).

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70%

3. Treatment Rest

Figure 12.4

Diagram of 70% rule

Figure 12.5

Closure of incision with suture strips

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(double chin) and fat in the lower cheek area (hanging jowls). These accumulations of fat usually appear as a result of aging, but can also occur to some extent in younger patients due to hereditary factors. They can make an otherwise slim person appear older and fatter. A clearly defined cervicomental angle makes for a youthful appearance. Because of the rapid, uncomplicated postoperative healing, this region is particularly well-suited to liposuction treatment. In the neck area, liposuction can be used as a treatment for older patients, but also in connection with diseases affecting fat metabolism, such as Cushing’s syndrome, which lead to increased accumulations of fat.

Afterwards, the patient is given a compression garment,which is lined with absorbent pads during the first 2 days to absorb the tumescent solution. The subsequent follow-up measures are described in Chapter 15. OPERATING TECHNIQUE ACCORDING TO REGION Before liposuction treatment, an overall plan must be devised for each patient. It is important to make the patient aware that isolated treatment of the main problematic area of the lower abdomen without combined treatment of the upper abdomen and perhaps the waist will not yield a harmonious result. The patient should understand the concept of aesthetic units, so that physician and patient together can work out a sensible treatment plan. Regions of the body which should be treated together as aesthetic units in most patients are: inner thigh–knee–inside of lower leg, calf–ankle, neck– chin–cheeks, hip–flank, etc. If one region is treated in isolation, this can result in non-physiological proportions and patient dissatisfaction. Below, the individual regions of the body are presented in isolation as far as this is sensible. In some cases, however, there are fluid boundaries due to consideration of the aesthetic units. The images illustrating preoperative marking and the operating procedure are taken using a model and hence do not show pathological findings. Instead, a more systematic representation of the operating technique is depicted.

What can be achieved Younger patients with round faces or hereditary double chins want to ‘look different’, i.e. they want to change their appearance by achieving a narrower face. Older patients, on the other hand, want the operation to help them regain their youthful appearance. It must be borne in mind that, with increasing age, involutional processes lead to a constant reduction in subcutaneous tissue.Therefore, one must be cautious in establishing the indication. In principle, with realistic expectations on the part of patients, both wishes can be fulfilled by liposuction treatment. Through modeling of the lower part of the face and the associated skin retraction induced by the healing process, along with the removal of unsightly fat accumulations, a considerably youthful effect can be achieved. The method presents a low-complication alternative to lifting operations in this area. Even in the case of agerelated sagging of the skin, astonishingly good retraction can be achieved.

Neck–chin–cheeks–back of neck Indication Tumescent liposuction is the method of choice for the removal of superfluous submental fat

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Figure 12.6

Marked operating area on neck–cheeks–chin

Figure 12.8

Marked out operating area on back of neck

On the back of the neck, the fat deposit is usually central above the lower cervical vertebrae (Figure 12.8). Tumescence

Figure 12.7 neck–chin

Tumescent local anesthesia of the neck area is performed in three stages using thin cannulas (24 G) with minimal pressure. In the first stage, initial numbness is achieved by the injection of a small amount (approximately 100–150 ml), without creation of the tumescent effect. After approximately 30 min the second infiltration is carried out until taut tumescence is achieved, which is then no longer unpleasant for the patient. After a further 30 min, taut tumescence is re-established and liposuction is begun. Total amounts, depending on findings, are between 250 and 1000 ml.This three-stage method prevents an error associated with this area, which is establishing tumescent anesthesia too rapidly and beginning aspiration prematurely (see Chapter 6).

Marked out operating area with focus on

Marking The areas generally treated are above the larynx, the submental region, and the caudal third of the cheeks (Figure 12.6 and 12.7).

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b

a

Figure 12.9

(a) and (b) Positioning of patient with head stretched back

Positioning

Operating procedure

Patient positioning must enable optimal access to the operating area. Positioning with the upper body slightly raised and the head stretched back is ideal (Figure 12.9). For aspiration of the back of the neck, the patient is positioned face down with the head tilted slightly forward.

In order to guide the cannula more easily, the surgeon stabilizes and slightly raises the skin over the adipose tissue with his free hand, in effect holding it against the cannula.

Cannulas used

Treatment of the neck Figure 12.14–12.17.

Special microcannulas have been developed for liposuction of this region.These have a diameter of 1.5–2 mm for manual use, and for vibration lipolysis diameters of up to 3 mm can be used.

Treatment of the back of the neck in Figures 12.18 and 12.19.

Treatment of the cheeks Figures 12.10–12.13.

This is shown in

This is illustrated in

This is shown

Dressings and postoperative procedure

Incisions

Postoperatively, it is recommended that a pressure dressing be worn for 1 day, and for an additional week at night.

For the neck and chin, five incisions are made: mental, subauricular on both sides, and paramedial on both sides above the sternocleidomastoid muscle. For cheeks, three incisions are made on each side: submandibular lateral, submandibular medial, and temporal medial (over the cheekbone). For the back of the neck, incisions are made above the second or third thoracic vertebra, at both sides on the lower edge of the trapezius muscle.

Special considerations Liposuction in this area should be limited to the subcutaneous fat above the platysma to prevent damage to major nerves or blood vessels. Similarly, to prevent damage to the thyroid, aspiration should not be done too far caudal of the thyroid cartilage; however, attention must be 90

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Figure 12.10

Cheek aspiration: distal

Figure 12.11

Cheek aspiration: temporolateral

Figure 12.12

Cheek aspiration: temporomedial

Figure 12.13

Cheek aspiration: lateral

to the accompanying facial artery can be prevented by careful lifting of the adipose tissue in these areas. The expansion of the subcutaneous space by tumescence also further reduces the risk of damage. Care should be taken not to remove too much fat from the area of the nasolabial crease to avoid hollows.

paid to the subplatysmal adipose tissue around the angle of the neck so as not to compromise the desired aesthetic result. Damage to the third division of the trigeminal nerve (mental nerve), which emerges at the chin, and to the marginal mandibular branch of the facial nerve, which crosses the lower jaw at the front edge of the masseter muscle, and 91

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a

Figure 12.14

c

b

(a)–(c) Aspiration from mental access: ‘fan-shaped’ treatment of the neck

(a)

(b)

Figure 12.15 cular access

(a) and (b) Subauri-

ligaments surrounding it; nevertheless, excessive TLA solution should be avoided in this area in order to avoid laryngeal edema or paralysis of the laryngeal nerves. Subsequent bleeding carries the risk of laryngeal or tracheal compression and cannot be stopped by the application of pressure as,

Possible complications If aspiration is restricted to adipose tissue located above the platysma, severe complications due to nerve and blood vessel damage can be avoided. The larynx is protected from penetration of the tumescent solution by the fascias and

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recommended by some authors, with the rationale that additional thermal trauma will increase skin retraction. This is controversial because, in some cases, it has led to extensive dermal damage and interference with wound healing9.

Male breast Indication

Figure 12.16 nerve)

By definition, gynecomastia is an enlargement of one or both sides of the male breast. It must be ascertained prior to treatment whether the patient has ‘genuine’ gynecomastia, with enlargement of the mammary gland as an expression of a hormone imbalance (e.g. due to a gonadal disorder), or ‘similar’ gynecomastia as a result of increased adipose tissue accumulation, which is also referred to as pseudogynecomastia. While the genuine forms require thorough investigation and treatment of the underlying disorder, breast enlargement due to increased fat accumulation can be successfully treated using liposuction. In the case of one-sided breast enlargement in men, tumors must be excluded via mammography.

Raising of the ‘jowls’ (beware of the mental

for instance, on the extremities. It is therefore particularly important to make sure through the history that the patient is not taking any bloodthinning agents, such as aspirin, or non-steroidal anti-inflammatory drugs. Possible adjuvant procedures In the case of prominent platysmal bands, tumescence liposuction can be combined with plication of the platysma via a small submental incision1. In the case of pronounced folds, subsequent performance of full-face CO2 laser resurfacing or chemical peeling in combination with this procedure can often achieve better results than a facelift4. Even older patients with severely sagging skin, in whom the excess skin is no longer capable of retraction after liposuction, can, in the case of a planned neck- or facelift, benefit from the aspiration of excess submental or cheek fat8. Additional ‘inner’ CO2 laser treatment of the cervical wound surface via incision has been

What can be achieved If the breast enlargement is caused by the accumulation of fat, liposuction treatment for volume reduction is possible. The goal, in these cases, is to remove as much fat as possible and achieve as natural an appearance as possible.The amount of removable adipose tissue can be estimated by palpating while the greater pectoral muscle is flexed. Since it is not always possible to achieve 100% reduction of the accumulated tissue, it is

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b

c

d

e

f

g

h

i

Figure 12.17

(a)–(i) Fan-shaped operating technique on neck via paramedian cervical access, right and left

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Figure 12.18

Figure 12.19

Treatment of back of neck: caudal

Treatment of back of neck: lateral

important that the patient be given an honest explanation of the results that can potentially be achieved. Marking This is shown in Figure 12.20. Tumescence TLA should be administered slowly and carefully since the tissue is very sensitive; therefore, pressure should not build up too rapidly. Infiltration should be achieved using the thinnest possible needles (20G). On the other hand, to enable pain-free aspiration, anesthesia must be very thorough. A period of 30 min should be allowed for optimal preparation of the tissue for operation.

Figure 12.20 Marked out operating area on the male breast

Cannulas used Because the male breast tissue is very fibrous, the use of vibration-assisted cannulas is particularly effective, since these glide more easily through fibrous tissue.

Positioning The patient is placed in the supine position, preferably with the upper body slightly raised.

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a

b

Figure 12.21 (a) and (b) Aspiration of the male breast: medial caudal

24 h after the operation, an effective compression garment should be applied.

Incisions In order to prevent keloid formation, the incisions should not be made too close to the region of the sternum and xiphoid cartilage. Three or four incisions are made in an arc at convenient intervals around the breast.

Special considerations To distinguish fat from glandular tissue in advance, and thus predict the results achievable, a preoperative mammography can be carried out.

Operating procedure Aspiration is started in the deep layers of the adipose tissue. To stabilize the tissue, it is particularly important that the left hand is used to exert a controlled counter-pressure to that of the fibrous tissue. Using the criss-cross technique, and in the various layers, as much fat as possible should be aspirated (Figures 12.21 and 12.22). After removal of most of the fat the mammary gland can be lifted and the cannula passed underneath to aspirate the adipose tissue here as well.

Possible complications In the case of work that is too aggressive, there is a theoretical risk of pneumothorax, which can be avoided with proper cannula guidance. Female breast Indication Liposuction using the tumescent technique enables the successful treatment of fat-induced mammary hyperplasia, provided the desired result does not require reduction in excess of 50% of the initial volume and the breasts are not severely hanging or of a low-fat fibrous consistency.

Dressings and postoperative care In order to prevent the formation of hematomas and ecchymosis, particularly in the first 96

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be removed and any existing asymmetry must be carried out to ensure that there is no asymmetry afterwards. Before the tumescent solution is administered, the area is marked with a waterproof surgical marker (Figure 12.23 (a) and (b)). Tumescence When infiltrating the breast with tumescent solution it must be ensured that uniform and complete infiltration is achieved, maintaining the relative size and shape of the breast. Up to 3000 ml may be required for each breast (Figure 12.23(c)). Figure 12.22

Aspiration of the male breast: caudal lateral

Positioning Liposuction is only sensible for breasts with a high proportion of fatty tissue.

The routine position is supine with a somewhat raised upper body.

What can be achieved

Cannulas used

The aim of the operation is to achieve symmetrical, harmonious reduction of the existing breast form. The volume of the breast can be reduced by 30–50% of the initial state, and in the case of very fatty breasts, by 60%. A lifting effect is achieved as a result of the reduced volume and weight of the breast and less strain on the elastic suspending Cooper’s ligaments as well as retraction of the collagen fibers in the subcutaneous adipose tissue with wound healing. This retraction is greater in younger patients, but overall the lifting effect is not as pronounced as in the case of standard reduction mammoplasty. This is something patients should be made aware of.

Specific cannulas have been developed for breast liposuction1, although standard cannulas that have a low traumatic effect on the tissue can also be used without a problem. In general, cannulas that are too thick and aggressive should not be used, to keep tissue traumatization to a minimum. Incisions As on the male breast, three or four incisions are made in an arc at convenient intervals. Operating procedure Aspiration is initiated in the deepest layers above the rib-cage. Aspiration should be performed radially from the incisions in several layers, although the cannulas should not stay in one spot or one layer for

Marking More than in the case of other body areas, very precise preoperative planning of the volume to 97

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b

c

d

e

f

Figure 12.23 (a) Marking of the operation area with ‘height line’ on the breast; (b) in the case if existing asymmetry, particularly careful operative planning is required; markings on the trunk are recommended for comparison of sides; (c) appearance after complete tumescent infiltration of one breast; (d) appearance after aspiration of one breast; (e) appearance after aspiration of both breasts (note symmetrical result of operation despite different amounts of fat); (f) applied compression dressing with fleece inserts. Images kindly supplied by Loek Habbema, ’t Gooi Medical Centre

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There is a theoretical risk of pneumothorax, especially during administration of the tumescent anesthesia. More prolonged swelling and lumpiness can result, especially from the use of cannulas that are too thick. Lumps persisting over a longer period must also be distinguished from other potential changes in the breast tissue, particularly malignancies. In order to enable a comparison in these cases, prior to aspiration an initial mammography should be considered. This can also serve to identify preoperatively extreme fibrous changes to the breast tissue which cannot be treated using liposuction.

long. In order to achieve uniform removal of adipose tissue, an overlapping criss-cross technique should be used. In deeper layers, somewhat thicker cannulas can be used, then thinner ones more superficially. It is very important to ensure absolute symmetry (Figure 12.23 (d) and (e)). Dressings and postoperative care In order to avoid subsequent bleeding, a sufficiently tight compression should be applied after the operation (Figure 12.23 (f)). Should swellings or lumps appear, lymphatic drainage can be recommended. Special considerations An advantage of breast reduction by liposuction using the tumescent technique, in comparison with standard reduction mammoplasty, is the relatively low trauma of the procedure, associated with minimal scarring, carried out purely under local anesthetic. Severe complications of reduction mammoplasty, such as hypertrophic scars, unnatural or asymmetrical appearance, disturbed sensitivity, or even necrosis, are not expected. Another advantage is the rapid postoperative recovery. The use of relatively high volumes of tumescent solution enables minimal traumatization of blood vessels and a protracted drainage effect, which counters the formation of hematomas. It is very important to ensure absolute symmetry.

Possible adjuvant procedures Liposuction can be planned in combination with or supplementary to reduction mammoplasty.

Upper arms, forearms, and shoulders Indication With increasing age and/or relevant predisposition, there can be, typically in women, the formation of unattractive fatty deposits on the backs of the upper arms and laterally over the biceps, which prove completely resistant to exercise. For a long time, this region was hardly ever treated. Now, more and more women find ‘fat’, unshapely upper arms worthy of treatment5. If the unsightly upper-arm disfiguration is due to the accumulation of fat, liposuction represents a very good treatment option. If, however, the cause is rather an excess of skin, also a result of aging, this must be removed. Often in these cases there is also an anterior axillary fat deposit which bulges out laterally from the bra and medial to the axillae. In treating

Possible complications The application of the tumescent solution and actual aspiration can be challenging due to fibrous areas in the breast tissue. The actual glandular tissue is around the nipple. Since the fourth intercostal nerve responsible for sensation also branches here, this area should be treated very cautiously during liposuction. 99

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this region, combined treatment of the shoulder area can also be considered. Successful treatment of the forearm region is also possible with liposuction if unsightly fat pockets have formed there as well. What can be achieved Older liposuction techniques often required additional brachioplasty. With modern aspiration and cannula technology, it is, in most cases, possible to achieve a well-proportioned, harmonious result using purely liposuction. Important here is the appearance of the arm when hanging down, as this is the most common physiological position.This requires above all a ‘weight reduction’ by removal of the larger subcutaneous fat deposits which pull the tissue down due to the effect of gravity.

Figure 12.24 Marked operating area of upper arms and forearms: frontal view

Marking

Positioning

The subcutaneous adipose tissue of the upper arm normally extends over the biceps and triceps, and thus around three-quarters of the circumference of the arm (laterally and dorsally with the arm hanging down). Hence, in order to create a harmonious three-dimensional image of the upper arm, three-quarters of the circumference of the upper arm (270°) must be treated. The volar side, which in most patients contains very little subcutaneous adipose tissue, can usually be left untreated. On the forearm there are often circumferential accumulations of fat (Figures 12.24–12.26).

It is important to consider the threedimensional appearance of the upper arm, which makes it particularly important that aspiration is carried out in various positions to achieve symmetry of all sections. The patient is positioned in a relaxed supine position, and the arm is placed in a wide variety of positions (see ‘Operating procedure’ below). Cannulas used The cannulas used should have a diameter of 3–4 mm and a length of at least 25 cm in order to achieve uniform results by avoiding incisions within the area to be treated.

Tumescence The infiltration quantities for the upper arms vary between 400 and 1500 ml, and for the forearms between 200 and 600 ml. In the case of circumferential findings, it must be ensured that the solution is evenly distributed.

Incisions For the forearm, two incisions are made: dorsal over the wrist and dorsolateral over the lateral epicondyle.

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Figure 12.25 Marked operating area of upper arms and forearms: lateral view

Figure 12.26 Marked operating area of upper arms and forearms: dorsal view

For the upper arm, five incisions are made: on the caudal edge of the axillary fat deposit, over the lateral and medial epicondyles, and in the dorsal axillary crease ventral and 10 cm distal to the posterior axillary line above the scapula.

done along the longitudinal axis of the body to protect the lymphatic vessels. If, in the case of extensive adiposity, aspiration is necessary on the volar side too (i.e. circumferential liposuction), it is particularly important to ensure that aspiration is done along the longitudinal axis to protect the lymphatic vessels and avoid postoperative lymph drainage problems. Treatment of the insides of the upper arms can also be indicated due to cellulitic skin changes in this area. Too aggressive an aspiration should be avoided at all costs, as arms that are too thin appear disproportionate and thus unattractive. In this mostly older patient group, with thinner skin due to age, excessively superficial and radical aspiration must also be avoided. In comparison with the skin of the lower extremities, that of the upper extremities is generally thinner, and thus does not yield comparable standard aesthetic results.

Operating procedure Treatment of the upper arms Figures 12.27–12.33. Treatment of the forearms Figures 12.34–12.37.

This is shown in

This is illustrated in

Dressings and postoperative care Pressure dressings or specially produced compression garments can be applied to the arm. Special considerations Despite repositioning and treatment from various angles, it must be ensured that aspiration is

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Figure 12.30

Repositioning with arm bent

Figure 12.27 Treatment of the inner side of the upper arms from the elbow

Figure 12.31 Treatment of the dorsal and lateral aspects of the upper arm with upper arm bent Figure 12.28 Repositioning for treatment of the inner side of the arm with arm outstretched

Figure 12.32 Combined treatment of the shoulder blade area if necessary

Figure 12.29 Positioning with assisted posture with arm outstretched

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Figure 12.33 Combined treatment of fat deposits on side of the thorax wall (edge of bra) if necessary

Figure 12.35 proximal

Treatment of the inside of the forearm:

Figure 12.36 proximal

Treatment of the volar side of the forearm:

Particular attention must be paid to the region directly over the olecranon process, which shows atypical soft-tissue deficits in the case of over-aspiration which can be considered very unsightly.

Figure 12.34 Treatment of the inside of the forearm: distal

Particularly in the case of older patients, there is often fat accumulation in the anterior and/or posterior axillary line, which should, if necessary, be treated at the same time (see Figure 12.33).

Possible complications Complications are extremely rare, and are limited to the general complication risks (see 103

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Fibrous tissue in the waist area Deep fascia Superficial fat layer Camper’s fascia Middle fat layer Scarpa’s fascia

Figure 12.37 distal

Treatment of the volar side of the forearm: Deep fat layer

Chapter 18).The large veins run along the volar side of the upper arm, which generally does not require treatment, and are thus not typically exposed to any increased risk of damage.

Figure 12.38 Representation of fascial conditions of the abdominal subcutaneous tissue in sagittal section

Possible adjuvant procedures In the case of very soft skin with limited retractability, brachioplasty may be required to reduce the excess skin. An incision is made on the inner aspect of the upper arm, since the resulting large scar cannot be seen when the arm is in the normal hanging position. An ongoing Z- or W-plasty is recommended as an operating technique, since this creates a zig-zag scar pattern as opposed to the prominent lineal scar.

and lower abdomen is approximately at the level of the navel. The subcutaneous adipose tissue of the abdomen is divided by fascias into three layers on the upper stomach and four on the lower stomach. Between the two regions is a more fibrous zone, where connective-tissue fibers of the dermis insert into the deeper muscle fascia. This zone can be recognized as the waist (Figures 12.38 and 12.39). Within this more fibrous zone is the periumbilical region. This area contains residual anatomical structures from embryological development. Aspiration works differently here than in the surrounding regions and is often more painful. Increased fat deposits can be found in isolation on the upper or lower abdomen. Fat deposits generally develop in parallel in both

Upper abdomen and lower abdomen, and flanks Statistically, the abdomen is the most commonly aspirated region5. Because of the somewhat different anatomical requirements, it has proved useful to make a distinction between the upper and lower abdomen.The dividing line between the upper

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regions. When fat deposits are extensive, successive liposuction of the upper and lower abdomen is required.

there are sometimes supracostal fat deposits on the lower costal arch. This borders the zone of epigastric fat deposits. In the case of severe obesity, there is no clear distinction between these regions. The lower abdomen is also a typical site for the accumulation of diet-related fat. Extensive fatty cushions present in this area for a long period and which tend to result in sagging are known as an ‘apron’ of fat. The area defined as the flanks is that between the iliac crest and the lower costal arch. From the front view, the flanks begin at the abdomen and extend to the back. From the back view, an increased accumulation of fat forms an unsightly fatty bulge on the flanks. Certain distinctions can be made between fat accumulations on male and female flanks. In men, there is generally an isolated ridge-like accumulation of fat at belt level which is known as a ‘love handle’. In women, the fat is generally found more cranially and dorsally.

Indication

What can be achieved

The fat deposits of the upper abdomen extend from the lowest rib to the waist/periumbilical region. Here, generally as a result of excessive food intake, fat stores are found as ‘energy reserves for lean times’. Particularly in men, fat stores in the upper abdomen prove resistant to diet due to a gender-specific arrangement of receptors. Also particularly in men, however, it must be accurately ascertained whether the fat is subcutaneous (and thus accessible for liposuction) or whether it is around the intestines (in the greater omentum and omental appendages), and cannot be aspirated.Various zones can be distinguished within the upper abdomen. More superiorly,

In the case of subcutaneous adipose tissue, this can be very successfully aspirated. Unlike on the lower abdomen, the upper abdomen has no pronounced tendency toward hanging skin. Therefore, it can be difficult to achieve a smooth, regular postoperative result. Because of the smaller proportion of connective tissue, aspiration of the lower abdomen is usually much easier than that of the upper abdomen. If the patient has good skin elasticity, the lower abdomen is generally one of the best indications for fat aspiration. The flanks are generally a good indication, where an aesthetically pleasing result can be obtained with very good safety. The abdomen

Subcostal fat pocket Epigastric fat pocket

Fibrous tissue in waist area Peripheral extent of Scarpa’s fascia

Figure 12.39 Representation of proliferation of fibrotic subcutaneous tissue around the waist

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a

Figure 12.40

c

b

(a)–(c) Marking of upper and lower abdomen and flanks

after previous long-standing obesity), the subcutaneous adipose tissue of the abdomen can absorb large amounts of tumescent solution.” In order to achieve sufficiently firm infiltration using a safe total lidocaine dose (see Chapter 4), careful preoperative planning is essential. Infiltration must be started deep enough to achieve infiltration of deep-lying fat deposits. Infiltration of the abdomen, particularly the periumbilical region, is sometimes unpleasant. Here, it is recommended almost as a matter of routine that additional systemic analgesics are administered, with appropriate monitoring.

is rarely treated in isolation. Usually the aspiration is part of an overall plan in which the abdomen–hips and perhaps the back are also involved. The goal and endpoint of aspiration is not removal of all fat from the abdomen. In order to achieve a natural appearance, the surface contours of the aspirated abdomen should correspond approximately to the contours of the underlying muscles, without the muscles becoming visible. A thin layer of fat should be left under the skin (70% rule). Marking

Positioning

The prominent areas of fat are marked before infiltration (Figure 12.40).

The patient is placed in the supine position for aspiration of the upper or lower abdomen. For aspiration of the upper abdomen, folding the arms behind the head can stretch this area and make it more accessible (Figures 12.41–12.44).

Tumescence Depending on the tissue type and the history (e.g. pronounced weight loss prior to liposuction

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Figure 12.43 Over-stretched lateral position for treatment of the flanks

Figure 12.41 aspiration

Positioning of the patient for abdominal

Figure 12.44 the flanks

Patient in prone position for treatment of

the lower abdomen, at least three incisions around the suprapubic abdominal line; for the upper abdomen, two incisions around the submammary fold at the level of the 10th rib; for the flank, three incisions around the posterior axillary line, at the level of the 10th rib, medial at waist level, and half-way between the iliac crest and greater trochanter.

Figure 12.42 Patient in lateral position for treatment of the hips and flanks

Cannulas used Cannulas are generally 30 cm long with a diameter of 3–4 mm. Particularly around the periumbilical region, the use of vibration cannulas has proved successful.

Operating procedure Treatment of the lower abdomen in Figures 12.45–12.47.

Incisions A total of 11 incisions will be made for the combined treatment of abdomen and flanks: for

This is shown

Treatment of the upper abdomen This is illustrated in Figures 12.48–12.50.

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a

Figure 12.45

b

c

(a)–(c) Aspiration of lower abdomen from medial distal access

Treatment of the periumbilical region shown in Figure 12.51.

areas is often required as well. The patient must be made aware of this in the explanatory consultation. The adipose tissue of the upper abdomen has a higher connective tissue content than that of the lower abdomen. The aspiration of such fibrous areas is made considerably easier by the use of vibration cannulas.The periumbilical fat is particularly fibrous. There is a risk of peritoneal perforation in the case of overly aggressive treatment.Therefore, treatment with vibration cannulas provides a considerable advantage in this area. The risk of minor postoperative skin irregularities in the lower abdomen is considerably less than in the upper abdomen. Severely prestretched skin is more prone to develop a hanging apron of skin postoperatively. The use of modern liposuction techniques has reduced the need for abdominoplasty or other additional procedures. Vibration-assisted liposuction can tighten the skin (see Chapter 13). In men, the adipose tissue of the flanks can be somewhat fibrous, and vibration cannulas

This is

Treatment of the flanks Intraoperative repositioning of the patient is important to enable flank fat in dorsal areas to be reached (Figures 12.52 and 15.53). Dressings and postoperative care A compression garment can be fitted easily to the abdomen following aspiration. It should be worn for at least 1 week during the day and night. Most patients find the garments quite comfortable to wear. Compression garments may be worn for up to 4 weeks. In specific cases, the use of Reston® foam can be helpful to stabilize hyperelastic areas of the postoperative concave abdominal region. Special considerations Isolated treatment of the upper or lower abdomen does not always produce a satisfactory overall aesthetic result.Treatment of the adjacent

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a

b

c

d

Figure 12.46 (a)–(c) Aspiration of lower abdomen from lateral distal access on left side

be avoided since there is a risk of diaphragm perforation. The most common cosmetic complication in the lower abdomen is postoperative hanging of the skin.This occurs in very severe and longstanding obesity and/or soft skin. Occasionally, peritoneal perforation has been reported in connection with liposuction. This complication is more likely to occur under general anesthesia, because of the relaxation of abdominal wall muscles and lack of reflux pain. Liposuction carried out on a conscious patient using the tumescent local anesthesia technique is a safer method.

have proved superior. Aspiration is usually straightforward. It is important that the posterolateral flank region be treated. Possible complications Small creases and indentations can occur in the upper abdomen after the removal of fatty deposits.This is particularly true if the abdomen has been prestretched over many years due to extensive cushions of fat. Excessive superficial aspiration in this area must be avoided. In addition, forceful cranial insertion of the cannulas in the direction of the costal arch is to

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a

b

c

d

Figure 12.47 (a)–(d) Aspiration of the lower abdomen from lateral access on right side

The pooling of residual tumescent solution in some patients can lead to temporary postoperative edema of the labia or scrotum. Ecchymosis can also develop.This complication occurs more often if distal incisions have healed too quickly. The patient should be informed during the explanatory consultation.

(or abdominoplasty) can be planned as a secondary procedure (see Chapter 13). The subsequent planning provides the advantage of seeing the effect of the liposuction procedure prior to considering abdominoplasty.

Possible adjuvant procedures

Indication

If insufficient skin retraction is achieved by liposuction alone due to pronounced skin laxity or extensive excess of skin, a mini-abdominoplasty

Increased accumulations of fat are mostly found in obese patients on the upper back, over the rib-cage, and on the shoulder blades. Sometimes

Back

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a

Figure 12.48

a

Figure 12.49

b

c

(a)–(c) Treatment of the upper abdomen from lateral access on left side

b

c

(a)–(c) Treatment of the upper abdomen from medial access

disks. This results in a sinking of the soft-tissue coating of the skin of the back which is fixed over the spine, and forms lateral ‘Christmas tree’ bulges of soft tissue.

smaller fat deposits are found in the sacral region. These fat deposits are not the primary problem, but are noticed as being unharmonious during planning, or after aspiration in neighboring areas, such as the flanks. Similar to the changes seen in osteoporosis, older patients may experience a reduction in body length, which is exacerbated by a hunched posture. This is due to vertebral shrinkage and the wearing down of vertebral

What can be achieved The back is an area where isolated fatty deposits can be removed without complications to achieve harmony of the overall

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Positioning The patient is first placed in the lateral position. After repositioning, the patient is in the prone position with arms down (see illustrations in ‘Operating procedure’ below). Marking This is shown in Figure 12.54. Tumescence Slow infiltration of the tumescent solution is recommended, since there are no natural anatomical boundaries between the individual layers of connective tissue. Infiltration at a higher pressure produces distribution over the whole area of the back.

Figure 12.50 Treatment of the upper abdomen from lateral right side

a

b

Figure 12.51 (a) and (b) Treatment of the periumbilical region from central access

Cannulas used

appearance. Treatment of the entire back is required to achieve extensive adhesion of the treated areas. Isolated aspiration of localized areas on the back will not achieve the desired result.

Cannulas of approximately 30 cm in length, approximately 4 mm in diameter, should be used, since fine-caliber cannulas are too fragile for the rigid conditions of the back.

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Figure 12.52 Treatment of the flank from proximal ventral access

Figure 12.54

Marking of the back

Operating procedure On side with bent arm Figures 12.55–12.57.

This is shown in

On stomach This is illustrated in Figures 12.58 and 12.59. Dressings and postoperative care A compression garment is fitted postoperatively. It should be worn for 1 week during the day and night, then for 4 weeks during the day only. Special considerations

Figure 12.53 dorsal access

The further cranial it is, the more fibrous the tissue may be. Over the scapula, the subcutaneous tissue often has a high connective tissue content.This can be removed more easily with vibration-assisted liposuction. To ensure that the desired result is achieved, aspiration must be done between the layers of connective tissue in order to facilitate scar adhesion.

Treatment of the flank from proximal

Incisions A total of three incisions are made: in the dorsal axillary crease, over the distal scapula, and at waist level near the posterior axillary line.

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Figure 12.55 point

Figure 12.57 Treatment of the back from proximal anterior access in median axillary line

Treatment of the back from distal access

Figure 12.56 Treatment of the back from proximal access point to dorsolateral axillary crease

Figure 12.58

The MASST (manually assisted skin stabilization technique) can be used on the back to reach fatty deposits directly under the skin, by firmly grasping the skin to create resistance.

Possible complications

Treatment of the back from distal access

Perforation is always theoretically possible near the pleural space. If liposuction is performed correctly, deep insertion of the cannula is

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a

b

Figure 12.59 (a) and (b) Treatment of the back and flank from proximal access in various directions

What can be achieved

extremely unlikely. The underlying shoulder blade and the ribs offer additional natural protection. If aspiration up to shoulder level is required, consideration should be given to the lung apices, which are at risk in some patients. Incisions on the back are more likely to form hyperpigmented scars and should be kept to a minimum.

Re-contouring of the hips is often the prerequisite for a harmonious result in the abdomen or legs. In general, it is not difficult to achieve highquality results.The hips are a good indication. The hip area in relation to the waist can be taken as a prime example of body contouring. The overall effect is created by the harmonious co-ordination of high and low contours, which accentuate one another in their proportions. If over-aspiration of the hips is performed, any improvement to the waist may be minimal. Thus, the overall treatment plan often needs to include treatment of the waist.

Possible adjuvant procedures No adjuvant procedures are used in this region. Hips–waist Indication

Marking

Women tend to store fat in the hip area (i.e. in the lateral aspect of the wing of the ilium). This frequently accompanies lipomatosis of the thighs (‘saddlebags’). Sometimes this zone is not seen as a problem until following successful treatment of the outer thighs. Patients should be made aware of this in the initial consultation.

Unsightly fat deposits are usually observed along the upper edge of the hips, and in the area of the iliac crest extending dorsally to the back. Cranially they reach the waist area. Marking and treatment is often carried out in conjunction with the waist (Figure 12.60).

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Dressings and postoperative care A compression garment is fitted postoperatively, similar to abdominal liposuction. Special considerations

Figure 12.60

The outer thighs and aspirated area of the hips contain a transitional zone which can be largely spared during aspiration. Slight aspiration by the cannulas in this area can improve wound healing in the entire area. Before isolated treatment of the hips, the whole unit, consisting of flanks–waist–hips– thighs, must be evaluated. Isolated liposuction in just one of these areas will not produce a harmonious result.

Side view with marking of the waist and hips

Tumescence

Possible complications

When administering tumescence, it must be kept in mind that the fat deposits on the hips are relatively deep.

Carelessness or incorrect positioning can lead to over-aspiration in the area of the iliac crest. Possible adjuvant procedures

Positioning

No adjuvant procedures are carried out in this area.

The hips are treated with the patient in the lateral position, slightly hyperextended. Cannulas used

Gluteal region

Three- or 4-mm diameter fine-caliber cannulas of medium length are used.

Indication Often, fat deposits around the buttocks (hips, ‘saddlebags’) are unsightly, and more relevant to the overall appearance than the fat that lies directly over the gluteal muscles. If a patient complains of having large buttocks, it must be established exactly what he or she means.The naturally round shape of the buttocks is essentially due to deposits of fat. Often the problem is not too much fat, but rather age-related structural changes resulting in sagging and drooping of the buttocks.The result is a flat or soft appearance of the buttocks.

Incisions A total of two or three incisions should be made dorsally half-way between the iliac crest and greater trochanter and proximally in the median axillary line at the lower costal arch. Operating procedure Treatment is often carried out in combination with treatment of the waist (Figure 12.61). 116

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a

b

Figure 12.61 (a) and (b) Treatment of the hips: distal

Marking

The shape of the buttocks changes as a result of increased weight and reduced tissue tone due to advancing age.The patient develops a general drooping of the gluteal cheeks and a more pronounced gluteal fold. In the medial buttock, tissue displacement leads to a compression effect whereby the gluteal cheeks touch.This leads to lateral tissue displacement.This effect can cause formation of ‘pseudo-saddlebags’. Sometimes a ‘banana-shaped’ fat deposit under the horizontal infragluteal fold is observed.

The buttocks cannot be treated in isolation, but can be treated satisfactorily in conjunction with the adjacent area of the backs of the thighs (Figure 12.62). Tumescence Tight tumescence should be obtained, the required volume being approximately 2000– 3000 ml per side. Subsequent infiltration is required in all cases.

What can be achieved Positioning For a long time, aspiration of the gluteal fat was considered inadvisable, since removal of the fatty pads had often tended to make the overall appearance worse. Liposuction in this area can create buttocks which are low in fat, but also saggy and skeletal-looking.With modern liposuction techniques and strict observance of transitional zones (which should not be treated), good results can be achieved while retaining the critical suspension ligaments. However, the buttocks are one of the more difficult indications.

The patient is placed in the prone position. The back should not be hollow. A cushion may be placed under the buttocks or the operating table adjusted accordingly. Cannulas used Atraumatic cannulas, with a diameter of 3–4 mm and of medium length, should be used. This is one of the best regions for use of vibration lipolysis. 117

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Figure 12.62 Marking buttocks–back of thighs

of

the

aesthetic

unit

Figure 12.63 Aspiration of dorsal thigh and buttocks from lateral to medial (from gluteal fold)

of

Incisions A total of five incisions are made: two medial and lateral incisions at the outer edge of the gluteus maximus, at the upper pole of the medial compression zone (where the gluteal cheeks touch), and 2–3 cm distal to the gluteal fold medially and laterally. Operating procedure Even more than in other regions, here the rule is: ‘It is not important what you take but what you leave’. In patients with severely sagging buttocks and a markedly thick gluteal fold, accurate removal of fat is crucial. Because of its localization, this adipose tissue consists of small, solid, lentil-like lobules with a high proportion of connective tissue (Figures 12.63–12.66).

Figure 12.64 Middle access as drainage point for paramedian gluteal region

Dressings and postoperative care Special considerations

It is important to stabilize the operative site by use of supportive dressings. Reston foam dressings which facilitate adhesion of the operating area have proved effective.

It is essential for a harmonious appearance that the physiological infragluteal horizontal fold be retained as the distal demarcation of the 118

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a

b

c

d

e

f

g

Figure 12.65

(a)–(g) Gluteal liposuction from proximal point

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If too much of the ‘banana-shaped’ fat deposit on the back of the thighs is removed, a double buttock crease may develop. Possible complications The most common problems are ‘aesthetic’ complications due to extreme sagging of the buttocks, or loss of the physiological round shape due to too much fat removal. Damage to the sciatic nerve is avoidable and unlikely, since it is deep within the gluteal muscles. Possible adjuvant procedures In certain cases, previous formations of excess skin cannot be made to retract despite correctly performed liposuction. Pure skin resection in the area of the gluteal fold is indicated in these cases.This should be carried out subcutaneously in several layers using absorbable sutures, and closed with a continuous suture material (preferably Vicryl®4.0).

Figure 12.66 Deep aspiration of lateral gluteal fold incision with the purpose of harmonizing transition to the gluteal region

buttocks at the boundary to the thigh. This is created by condensation of fascial sections of the gluteal muscles (Luschka’s ligament), which insert into the dermis at this point. In order to avoid sagging of the skin following liposuction over the buttocks, the fibrous suspension ligaments must be retained.These ligaments transect the fat compartments and thus anchor the dermis with the muscle fascias. The cannulas are always inserted vertically; never aspirate horizontally in the gluteal area! To achieve as complete a removal of fat as possible in the areas rich in connective tissue, the following procedure is recommended: if no more adipose tissue can be aspirated in one area, treat another area and return to the original site after a few minutes. The redistribution of the remaining tumescent solution that has occurred enables further fat cell bundles to be removed.

Thighs Indication Accumulations of fat on the outer thighs, known as ‘saddlebags’, are typical in women. They form part of the so-called ‘feeding fat’, i.e. fat reserves that are only broken into in absolute emergencies (e.g. feeding infants in periods of hunger), and therefore prove extremely resistant to diet due to the specific arrangement of receptors (see Chapter 3). Not uncommonly, there is also significant disproportion between the slim upper body and thick thighs.This ‘division’ can make a difference of up to two dress sizes between, blouses and pants. In men, fat deposits on the

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a

c

b

d

Figure 12.67 (a)–(d) Overview of legs from all perspectives

What can be achieved

lateral thighs occur almost exclusively as a result of hormonal imbalances. Depending on the extent, fat accumulations on the inner thighs may be mechanically disturbing while walking. Primarily the outer thighs are considered a problem, but in most cases, treatment of the inner thighs must also be performed to achieve harmonization of the overall result.

This is a common indication which is wellsuited to treatment by liposuction. In this region, little can be achieved through diet and exercise even when programs are rigidly adhered to. However, the outer thigh is not one of the ‘easy’ regions since it is a three-dimensional structure. It affects the lateral aspect of the

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body’s silhouette and should harmonize with the adjacent regions of hip, buttock, and front and back of the thigh. The inner thighs can generally be treated without complications.The tissue is usually soft and easily accessible to aspiration. Soft or saggy tissue is at increased risk of postoperative sagging of the skin. These patients should be treated very cautiously and with vibrationassisted liposuction. The front of the thigh is also part of the aesthetic unit. Aspiration of the anterior thigh was long considered inadvisable. This region is still one of the most difficult indications.The backs of the thighs are often treated together with the gluteal region (see above).

Figure 12.68

Front of thighs

accumulation of fat. If as much fat is aspirated from the protruding trochanter as from the surrounding area, indentation can develop postoperatively due to over-aspiration. In treatment of the thighs, co-operation of the conscious patients in repositioning (multipositional approach) is essential.

Marking Figures 12.67–12.71. show the marking of operating zones on the thighs. Tumescence It must be kept in mind that depending on tissue type, a comparatively large tumescent anesthesia volume is required for treatment of the thighs. This must be taken into consideration in planning the operation. If necessary, the operation is divided into several sessions.

Cannulas used Long, 3–4 mm in diameter, fine-caliber atraumatic cannulas with high stability are used, to ensure accurate guidance over their length.

Positioning

Incisions

In the case of the lateral thighs, positioning is crucial. Flexion, extension, or rotation of the hips has a considerable effect on the shape and distribution of the subcutaneous adipose tissue due to the flexing of various muscle groups. With the patient in the lateral position, the protruding greater trochanter can cause a bulge which can be incorrectly assumed to be an

For the anterior, a total of four incisions are made: medial and lateral at the upper edge of the patella, one in the middle of the ventral thigh, and another over the junction point of the sartorius muscle in the inguinal fold. For the outer thighs, three incisions are made: 5 cm above the greater trochanter, middle of the lateral thigh, and in the lateral

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Figure 12.69

Anterior thighs

Figure 12.71

Inner thigh markings

Figure 12.70

Lateral thigh markings

Figure 12.72

Representation of patient in supine position

above the position of the great saphenous vein, and dorsally near the gluteal fold. In order to achieve optimal drainage of the tumescent solution postoperatively with prevention of hematoma, an incision should be made at the distal point of aspiration.

gluteal fold; if required, a fourth incision can be made at the proximal junction point of the lower leg in the lateral knee area. For the inner thighs, four incisions are made: distal to the medial fatty bulge of the knee, in the middle of the thigh, around the inguinal fold

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Beginning of operation from distal point of

Figure 12.75

Access from distal point of incision

Figure 12.74 Patient is positioned with support on one arm

Figure 12.76

Access from median point of incision

Operating procedure

Repositioning in the altered side position (similar to the ‘stable side position’) is shown in Figures 12.79 and 12.80. Repositioning prone is illustrated in Figures 12.81 and 12.82. Renewed repositioning onto the side is shown in Figure 12.83.

Figure 12.73 incision

Treatment of the inner thighs This is shown in Figures 12.72 and 12.73 for the supine position. The first repositioning onto one side is shown in Figures 12.74–12.76. Repositioning for treatment of the other side is shown Figures 12.77 and 12.78.

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Figure 12.77

Figure 12.79 Positioning of patient in altered lateral position

Access from distal point of incision

Figure 12.80 Treatment of medial thigh: proximal dorsal, with patient in lateral position

Figure 12.78

Access from median point of incision

Treatment of the back of the thighs illustrated in Figures 12.91–12.94.

Treatment of the outer thighs This is shown in Figures 12.84–12.87 for side positioning. Repositioning prone is shown in Figures 12.88–12.90.

Treatment of the front of the thighs in Figures 12.95–12.99.

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Figure 12.81

Figure 12.83

Treatment of the other medial thigh

Figure 12.82 Treatment of the other side with patient prone

Figure 12.84

Representation of lateral position

Dressings and postoperative care

Special considerations

Postoperatively, the patient is fitted with a compression garment that extends sufficiently far down.This should be worn for a week during the day and night, then for 3–4 weeks just during the day only.

Over-aspiration, particularly over the greater trochanter and medial epicondyle, must be avoided. Horizontal aspiration results in the formation of unsightly grooves when using cannulas that are too large in diameter.

Treatment of the medial thigh

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Figure 12.85

Figure 12.86

Treatment of the lateral thigh: distal

Figure 12.87

Treatment of the other side: distal

Figure 12.88

Treatment of the lateral thigh: proximal

Treatment of the other side: proximal

The ‘saddlebags’ must be treated as an aesthetic unit with the lateral thigh. Also, the whole outer side down to the knee must be treated to maintain the aesthetic unit and avoid irregularities.

Possible adjuvant procedures

Possible complications These are usually aesthetic (see above). Occasionally, large veins are damaged, which can lead to extensive hematomas.

In patients where adequate tissue tightening cannot be achieved purely with aspiration, inner leg lifting with elliptical-shaped excision

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a

Figure 12.89

Treatment of the lateral thigh: distal b

Figure 12.90 Figure 12.91

(a) and (b) Treatment of the other side

Treatment of back of thigh proximal lateral.

of excess skin may be required. However, this results in a relatively large scar, which will not be acceptable to all patients. Overall, as with the other lifting procedures, the necessity of excision has been significantly reduced due to new cannula and aspiration techniques.

Knee Indication On the inner side of the knee, an isolated fatty deposit due to heredity can develop. Usually the inner knees have excess fat if the inner thighs have excess fat. Both zones are

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Figure 12.92

Treatment of back of thigh: proximal lateral

Figure 12.94

Treatment of back of thigh: distal lateral

Figure 12.93

Treatment of back of thigh: proximal medial

Figure 12.95

Treatment of back of thigh: distal lateral

What can be achieved

usually treated in one session. Sometimes a small suprapatellar accumulation of fat may be treated also.

The unwanted adipose tissue can usually be easily removed and an improved contour obtained.

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Figure 12.96

Treatment of front of thigh: proximal central

Figure 12.98

Treatment of front of thigh: proximal medial

Figure 12.97

Treatment of front of thigh: proximal medial

Figure 12.99

Treatment of front of thigh: distal lateral

Marking

solution to take effect. Subsequent infiltration is also required because of the fibrous nature of the fat.

This is shown in Figures 12.100–12.102. Tumescence

Positioning

It is essential that firm standard tumescence be achieved and sufficient time allowed for the

The patient is usually supine. The leg is pulled to both sides as required.

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Figure 12.100

Front view of thigh

Figure 12.101

Figure 12.102

Lateral view of knee

Figure 12.103 Treatment of suprapatellar fatty pads: lateral

Medial view of knee

Cannulas used

Operating procedure

Short, strong, 3- or 4-mm cannulas are used.

Treatment of the suprapatellar fatty pads shown in Figures 12.103 and 12.104.

Incisions A total of three incisions are made: two distal–medial and lateral to the knee, and a third at the distal edge of the patella.

Treatment of inner sides of knees in Figure 12.105.

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Figure 12.104 Treatment of suprapatellar fatty pads: medial

Figure 12.105 (a)–(c) Treatment of inner sides of knees from various angles

Dressings and postoperative care

Lower legs, calves, and ankles

The patient is provided with compression stockings postoperatively.

Indication Preoperatively, it should be determined what proportion of excessive lower-leg circumference is due to accumulation of fat and what is caused by increased muscle mass.This should be ascertained by pinch tests on the lower leg when relaxed and flexed. It is important to many women to have ‘slim ankles’. The region is mainly visible when wearing skirts. Treatment of the ankle area is generally performed in conjunction with treatment of the calves.

Special considerations Simultaneous treatment of the inner thighs and knees requires attention to a transitional zone which often exists between the two areas. This zone should not be aspirated, or at least not extensively. Just as for the inner thighs, attention must be paid to the lateral fatty pad of the knee as a ‘pseudo extension of the saddlebags’. Treatment of the prepatella bursa using tumescent local anesthesia can be carried out without any complications.

What can be achieved If an undesirable increased circumference of the leg is caused by subcutaneous adipose tissue, this can be removed.

Possible adjuvant procedures

Marking

Adjuvant procedures in this region should be avoided.

This shown in Figures 12.106–12.109.

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a

b

Figure 12.106

Treatment of medial part of the knee

Figure 12.107

Frontal view of lower leg

c

Figure 12.108

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Figure 12.109

Dorsal view of lower leg

Figure 12.111 Treatment of lower leg from distal point of incision

Figure 12.110

Lateral view of lower leg

Figure 12.112 incision

Treatment of lower leg medial point of

Tumescence

Positioning

Slow infiltration of the tumescent solution results in uniform distribution of the solution between the two sides.

The treatment is started in the supine position and the patient is later treated in both lateral positions. The prone position

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a

b

c

Figure 12.113 (a)–(c) Treatment of lower leg from proximal point of incision with fan-shaped treatment of operating area.This point of incision can be used to treat the inner ankle region also

is used to enable easy access to the entire circumference. Cannulas used Small-caliber atraumatic cannulas, 3–4 mm in diameter with a length of 20–30 cm, are used. Incisions A total of nine incisions are made: four ventral and dorsal to the lateral and medial malleolus, three incisions on the lateral tibial plateau, under the medial tibial plateau, and in the middle of the lower leg in an arc medial, dorsal, and lateral. Operating procedure Figure 12.114

Treatment of inner side of lower leg This is shown in Figures 12.110–12.112. Repositioning onto the side follows. Treatment of outside of lower leg in Figures 12.113–12.117.

Treatment of lower leg from distal incision

Repositioning to prone follows. Treatment of the posterior lower leg in Figures 12.118–12.120.

This is shown

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Figure 12.115 Treatment of lower leg from medial incision with proximal direction of aspiration

a

Figure 12.116 Treatment of lower leg from proximal incision with proximal direction of aspiration

b

Figure 12.117 (a) and (b) Treatment of lower leg from middle incision with distal direction of aspiration

Dressings and postoperative care

Special considerations

The patient is provided with compression stockings to wear postoperatively.

The structure of the muscle fascia and bone on the legs helps the surgeon to assess the four

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a

b

c

Figure 12.118 (a)–(c) Treatment of lower leg from proximal incision with fan-shaped treatment of operating area. From this incision the outer ankle region can also be treated

areas that must be treated. Excessive fat removal can result in a skeletonized appearance with muscles becoming too visible. Possible complications Distal open drainage is used to prevent hematoma from occurring. If an organized hematoma is allowed to develop, prolonged ankle swelling may occur. Possible adjuvant procedures This does not apply to this area.

Figure 12.119

Treatment of lower leg: proximal lateral

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a

b

Figure 12.120 (a) and (b) Treatment of lower leg proximal medial

Figure 12.121 medial

Treatment of lower leg: middle incision,

REFERENCES 1. Klein JA.The tumescent technique for liposuction surgery.Am J Cosmet Surg 1987; 4: 236–67

3. Sommer B, Sattler G, Hanke CW. TumeszenzLokalanästhesie. Berlin: Springer, 1999

2. Matarasso SL. A regional approach to patient selection and evaluation for liposuction. Dermatol Clin 1990; 8: 401–14

4. Sommer B, Sattler G.Vibration assisted liposuction (VAL) in tumescent local anesthesia (TLA). In Skin and Environment – Perception and

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Protection. 10th EADV Congress, Munich, 2001. Bologna: Monduzzi Editore, 2001:

7. Klein JA. Pathophysiology and complications. In Tumescent Technique:Tumescent Anesthesiaand Microcannular Liposuction. St Louis, MO: Mosby, 2000: 25–120

5. Fournier P. Body Sculpturing Through Syringe Liposuction and Autologous Fat Re-injection. Corona Del Mar, CA: Samuel Rolf international, 1987

8. Pitman GH. Operations by anatomic areas. In Liposuction and Aesthetic Surgery. Quality Medical Publishing, St Louis, MO: 1993: 3–29

6. Asken S. Liposuction Surgery and Autologous Fat transplantation. East Norwalk: Appleton & Lange, 1988

9. Goodstein WA. Superficial liposculpture of the face and the neck.Plast Reconstr Surg 1996;98:988–96

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13

G Sattler, B Sommer, G Blugerman

treated using older liposuction methods often desire to have unsatisfactory results corrected. Various procedures that were frequently necessary a few years ago, such as lifting operations, are rarely required now as a result of modern cannula and suction techniques. On the contrary, skin lifting can be achieved by vibration-assisted liposuction itself. For the treatment of aesthetically unsatisfactory results, a range of secondary procedures can be performed, such as variously extensive forms of abdomino- and brachioplasty or inner leg lifting, a detailed description of which would fill a textbook on its own. Some of these methods are associated with major operative effort and risk6. In the past few years, it has been possible to develop corrective procedures that are less invasive for patients and thus carry fewer risks. We restrict ourselves here to description of those that we use routinely and successfully as secondary procedures:

Numerous studies of the safety of liposuction confirm that the combination of liposuction with other major procedures such as abdominoplasty or breast augmentation, particularly under general anesthesia, results in a significantly higher operating risk (see Chapter 16)1–5. The performance of more minor, supplementary procedures is, on the other hand, sensible in conjunction with liposuction surgery. The adjuvant procedures that can be performed usefully and without risk in conjunction with liposuction using tumescent local anesthesia include: • Extraction of fat for autologous fat transplantation (liporecycling); • Subcision of scars or cellulitic skin changes. With today’s standards of liposuction surgery, it is usually possible to achieve highly satisfactory aesthetic results with aspiration alone. Nevertheless, there are still cases in which the treatment result of the first procedure does not satisfy the expectations of the patient or the physician. It is often clear during the initial consultation that, because of individual characteristics (such as lax connective tissue or massive weight loss with severely prestretched skin), a second operation will be required for skin reduction. In addition, patients who have been

• Liposhifting; • Dermatolipectomy; • Vibration-assisted re-liposuction for skin tightening. More extensive plastic surgery procedures and liftings are still indicated in some cases. In our opinion, however, the patient can be spared

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that the majority of adipocytes extracted by mechanical lipoaspiration survive. Removal with a sharp 14-gauge cannula or a blunt atraumatic liposuction cannula yields similar results. Anesthesia of the extraction site with 1% or 0.05% local anesthetic does not affect vitality. Slow freezing to –20 to –40°C has little influence on adipocyte survival rate, whereas sudden ‘shock freezing’ makes the cells burst. More recent studies comparing adipose tissue extracted by vibration-assisted liposuction with material obtained by conventional manually performed liposuction indicate that vibration-assisted liposuction results in an even higher rate of survival for the adipocytes. In liporecycling (adipose tissue transfer according to Sattler and Sommer), the transplantation material is extracted during reduction liposuction and then either used immediately for soft tissue augmentation or first frozen and then used after a latent period12. The aspirated fat is collected in sterile bags. After the completion of reduction liposuction, the adipose tissue to be reinjected is taken out of the bags; to separate the tumescent solution, it is dripped onto sterile compresses. This enables the removal of residual connective tissue clusters by sight (Figure 13.1). The risk of contamination of the transplant material during this ‘open’ preparation method is the same as in the closed transfer methods16. The adipose tissue is then drawn up into sterile 5-cm3 plastic syringes (Figure 13.2) and either reinjected immediately or frozen for later use. This is done slowly to at least –20°C or, if it is to be stored for a longer period, at even lower temperatures of between –40 and –70°C. Clinical experience shows that adipose tissue can be safely stored in this way for up to 2 years.

these large procedures, in many cases, by the use of less invasive secondary procedures7.

LIPORECYCLING The major pioneer in the field of autologous fat transplantation for tissue augmentation was Pierre Fournier8–10. He developed the ‘syringe technique’, whereby adipose tissue is extracted with 20- or 14-gauge cannulas and a syringe in order to inject it into tissue defects. Autologous fat transplantation has an established role in augmentation procedures11–14. The ability to obtain almost unlimited amounts of augmentation material, even for large defects, and the lack of allergic potential confer major advantages. There is no consensus on the extent to which the success of autologous fat transplantation depends upon: • • • •

The extraction site; The method of anesthesia used for extraction; The extraction technique; The vitality of the fat cells transplanted.

A meta-analysis of the existing literature carried out by Sommer and Sattler, together with histological and biochemical examination of aspirated adipose tissue, yielded the following observations13. The durability of the therapeutic effect of the transplanted fat is determined by fibrosis induction and the number of surviving fat cells15. Survival of the transplanted fat cells depends on anatomical localization, mobilization, and vascularization of the receptor site. The deeper that the material is implanted, the better the fat cells survive. Adipocytes are relatively stable, and survive extraction by liposuction apparatus well. Biochemical studies show

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Figure 13.1

Adipose tissue with connective tissue fibers

Figure 13.2

Autologous fat in syringes

The injection technique depends on the target area: in the case of large scars and/or other deep defects, the adipose tissue is injected subcutaneously; in the case of facial reconstruction, however, it is applied sub- or intradermally. The liporecycling method can be used for all types of soft tissue augmentation, including treatment of larger defects such as lipodystrophy (see Chapter 9) or tissue atrophy in the case of connective-tissue disease14,16. With regard to cosmetic results, autologous fat transplantation is comparable to the use of other resorbable materials such as collagen, hyaluronic acid, or polylactate. Since the injected adipose tissue consists of ‘mini-fat transplants’, this results in better anchoring of the material in its environment than is the case with liquid-viscous augmentation materials, with less risk of displacement through facial expression. The material should not be distributed in the tissue in large deposits, but rather as ‘microdroplets’ (droplet injection distribution). If the deposits are too large there is a risk of central cyst-like collection of the material. With regard to the duration of the therapeutic effect, there is great individual variation as well as differences depending on indication and depth of injection. The effect lasts longest for injection into atrophic areas, as in the case of scleroderma or sunken scars, and in areas which are subject to little facial expression activity, such as under the eyes. This is probably due to the deep injection technique used in such cases (‘fat works best when injected into fat’13). Generally, treatment initially needs to be repeated every 2–3 months. In most cases, however, after the third or fourth treatment there is a lasting result, probably due to fibrosis induction or survival of adipocytes at the injection

To be used again, the material should be carefully thawed at room temperature. Under no circumstances should the thawing process be accelerated by measures such as heating (e.g. microwaving), since there is a risk that the fat cells could denature. For reinjection, the area to be treated is first marked out and then locally anesthetized and disinfected. Reinjection is done using 1-ml Luerlock syringes with 14- to 11-gauge needles.

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a

Figure 13.3

b

(a) Patient before and (b) after three perioral autologous fat transplants

layer, which should not be treated in liposuction. It must be kept in mind, especially if there is extensive or older scarring, that larger blood vessels may have ingrown and could be severed during undermining, and, in exceptional cases, even lead to life-threatening bleeding. Patients should therefore be monitored for 6–8 h afterwards and subsequently examined. Subcision has also proved successful in the case of very extensive cellulitic skin puckering, a technique developed largely by the Brazilian doctor, Doris Hexsel. Since here the surface topography is significantly affected by the arrangement of connective tissue fibers (see Chapter 9), the severing of these contributes to visual improvement (Figure 13.4).

site (Figure 13.3).There are cases where corrections were reported to have remained constant for several years. One tempting approach which is regularly attempted is fat transplantation into breast tissue for augmentation. Unfortunately, this technique cannot be routinely used, unlike in other areas of the body, because it very often leads to complications in the form of fat necrosis and oil cysts.

SUBCISION Particularly in the abdominal area, there are often puckered scars for example following appendectomy or Cesarean sections. These scars make aspiration more difficult, and are also visible after liposuction as unsightly indented areas. This effect is due to the increased posttraumatic formation of collagen tissue, which starts directly under the dermis and extends, depending on the depth of scarring, into the subcutaneous tissue and muscle fascias. In subcision, after the tumescent anesthesia is administered and before actual liposuction is begun, a 14-gauge cannula or suture scalpel is passed under such an area of scarring to sever the scarred connective tissue strands at all levels. Particular attention is paid to the superficial

LIPOSHIFTING The internal mobilization and redistribution of adipose tissue is a relatively new method which was originally described by Saylan for the minimally invasive correction of irregular fat distribution17. Such irregularities can also occur as primary idiopathic accumulations of fat, or in the case of adipose tissue disease.The method is also suitable for the correction of irregularities such as indentations following liposuction. 144

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(a)

(b)

Figure 13.5 (a) Aspiration of micrografts by the micrograft cutter; (b) transport of micrografts through the cannula Figure 13.4 changes

Subcision of thigh in the case of cellulitic skin

If there is a larger distance between the donor and receptor regions, the micrografts from the donor region can be aspirated into syringes using light suction and then brought to the receptor region and distributed with largecaliber cannulas. In order to keep the redistributed fat in the desired position, tight tape dressings are applied above and below the treatment site after the operation. The most common complication of the procedure is hematoma, and in some cases hyperpigmentation which can persist for several months17. Figure 13.7 shows a clinical example of correction of a subcutaneous tissue defect using liposhifting.

Here the superfluous fat is mobilized by cannulas or spatulas and redistributed mechanically in the receptor regions. Blugerman developed a special instrument set for the performance of internal fat mobilization to create in vitro adipose tissue micrografts and transpose these to the receptor site18. The set comprises an atraumatic spatula for tunneling of the receptor region in several layers to prepare for receipt of the micrograft. Using a special cannula developed by Blugerman, the mobilization of vital micrografts in areas of increased fat accumulation can be achieved. This instrument is called a micrograft fat cutter (MGFC), and is available in three different varieties for different regions of the body. The micrograft fat cutter cuts micro-fat grafts out of the tissue via small holes in its front section.These are not aspirated out of the body, but rather replaced in the tissue as micro-fat transplants through a larger hole at the end of the cutter (Figure 13.5). Redistribution in a directly neighboring receptor area can be done from the outside by gentle massage using an instrument similar to a rolling pin (Figure 13.6).

DERMATOLIPECTOMY IN TUMESCENT LOCAL ANESTHESIA (Modified mini-abdominoplasty using tumescent local anesthesia according to Blugerman19) In our view, the main indication for performance of a pure abdominoplasty is in extreme

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Figure 13.7 Clinical example of correction of a subcutaneous tissue defect by liposhifting

Juarez Avelar as a new abdominoplastic technique under general anesthesia20,21. Argentinean Guillermo Blugerman then developed a technique using tumescent local anesthesia to achieve even higher patient safety, which resulted in a significantly shorter hospitalization period19. In this method, the area of skin to be excised, if possible suprapubic, is first identified. This site is marked and anesthetized with tumescent solution along with the surrounding tissue, whereby the planned incision lines should be additionally injected with more highly concentrated local anesthetic to ensure that there is absolutely no pain. Using a liposuction cannula, the subcutaneous tissue under the planned excision site is completely freed of fat and the surrounding area mobilized. Then, just the epidermis is resected, preserving the dermis.The de-epithelialized area is then invaginated and the skin defect sutured (Figure 13.8). Since this method does not involve the creation of a large wound cavity, there is a significantly lower risk of seroma or infection. In addition, the blood vessels and lymphatic vessels

Figure 13.6 Mechanical redistribution of severed micrografts from neighboring donor zones into the defect

cases, following vibration-assisted liposuction and after a sufficient period for the healing process to take place, where there is still a significant excess or sagging of the skin. The classic abdominoplastic procedures involve extensive operations with a comparatively high rate of complications, including infection, formation of seroma or wound dehiscence, and in rare cases even skin necrosis. Dermatolipectomy is a modified, less traumatizing, and less invasive reduction plastic procedure.A similar method was described by Grazer in 1990 for brachioplasty2. A modified application of this technique for abdominal wall plastic surgery was first described by the French physician Bernard Crunelle, and further developed by his Brazilian colleague

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this procedure can also be scheduled and carried out at the time of the initial liposuction.

(a)

VIBRATION-ASSISTED RE-LIPOSUCTION Until recently, the liposuction-induced destruction of the subcutaneous connective-tissue support apparatus often led to sagging of the skin. Today, as a result of modern vibration cannula techniques, liposuction can be used specifically to achieve tissue tightening. Since, as described in Chapters 6 and 7, vibration-assisted liposuction enables maximum protection of the connective-tissue framework and support apparatus of the dermis, one can make use of the tissuetightening effects induced by vibration-assisted liposuction during the healing process: the tissue stimulation applied is sufficient to induce mediator-initiated healing processes, and in the long-term to effect formation of a threedimensional scar, which leads to tissue retraction. This enables the achievement of effects such as those of reduction plastic procedures.

(b)

Figure 13.8 Schematic diagram of (a) de-epithelialized area of skin with fat removed and (b) wound closure

supplying the area which would be severed in conventional reduction plasty are preserved, resulting in much better healing. In cases where it is clear at the initial consultation that, even using the newest methods, there is likely to be non-retractive excess skin,

REFERENCES Anesthesia and Microcannular Liposuction. St Louis, MO: Mosby, 2000: 12–15

1. Bernstein G, Hanke CW. Safety of liposuction: a review of 9478 cases performed by dermatologists. J Dermatol Surg Oncol 1988; 14: 1112–14

5. Klein JA. Problems in reporting liposuction deaths. In Klein JA (ed) Tumescent Technique: Tumescent Anesthesia and Microcannular Liposuction. St Louis, MO: Mosby, 2000: 20–3

2. Grazer FM. Body contouring. In McCarthy JG, ed. Plastic Surgery. Philadelphia, PA: WB Saunders, 1990: 3981–8 3. Hanke CW, Lee MW, Bernstein G.The safety of dermatologic liposuction surgery. Dermatol Clin 1990; 8: 563–8

6. Hanke CW, Bernstein G, Bullock BS. Safety of tumescent liposuction in 15336 patients – national survey results. Dermatol Surg 1996; 22: 459–62

4. Klein JA. Ethical considerations. In Klein JA (ed), Tumescent Technique: Tumescent

7. Klein JA.Two standards of care for liposuction. In Klein JA (ed) Tumescent Technique:

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Tumescent Anesthesia and Microcannular Liposuction. St Louis, MO: Mosby, 2000: 9–11

autologous fat transplantation. Facial Plast Surg 1997; 13: 119–24

8. Fournier PF. Body Sculpturing Through Syringe Liposuction and Autologous Fat Transplantation. Corona Del Mar, CA: Samuel Rolf International, 1987

16. Sommer B, Sattler G. Current concepts of fat graft survival: histology of aspirated adipose tissue and review of literature. Dermatol Surg 2000; 26: 1159–66

9. Fournier PF. Facial recontouring with fat grafting. Dermatol Clin 1990; 8: 523–37

17. Saylan Z. Liposhifting instead of lipofilling: treatment of postlipoplasty irregularities. Aesthets Surg J 2001; March/April: 137–41

10. Fournier PF. Microlipoextraction et microlipoinjection. Rev Chir Esthet Lang Franc 1985; 10: 36–8

18. Blugerman G. Liposhifting. Presented at the Kongress der Deutschen Gesellschaft für Ästhetische Chirurgie, Heidelberg, 2002

11. Asken S. Liposuction Surgerey and Autologous Fat Transplantation. East Norwalk: Appleton & Lange, 1988

19. Blugerman G. Modified abdominoplasty, a new South American technique. Presented at the Kongress der Deutschen Gesellschaft für Ästhetische Chirurgie, Heidelberg, 2002

12. Asken S. Microlipoinjection and autologous fat transplantation for aesthetic enhancement of the aging face. J Dermatol Surg Oncol 1990; 19: 965–70

20. Avelar JM. A new technique for abdominoplasty-closed vascular system of subdermal flap folded over itself combined with liposuction. Rev Brasil Cir 1999; 88/89: 3–20

13. Klein AW. Skin filling. Collagen and other injectables of the skin. Dermatol Clin 2001; 19: 491–508, ix

21. Crunelle B. A new alternative to the lower transverse abdominoplasty – dermolipoplasty. Presented at the World Congress of Liposuction, Dearborn, 2000

14. Sattler G, Sommer B. Liporecycling: immediate and delayed. Am J Cosmet Surg 1997; 14: 311–16

22. Drake LA, et al. Guidelines of care for soft tissue augmentation: fat transplantation. J Am Acad Dermatol 1996; 34: 690–4

15. Schuller-Petrovic S. Improving the asthetic aspect of soft tissue defects on the face using

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endoscopic method was also tested in liposuction surgery. However, endoscopic liposuction as an operating technique has not become established to date. Instead, the role of endoscopy in liposuction is in enabling visualization of the subcutaneous tissue during the operation. As explained in Chapter 3, the subcutaneous space is made up of a honeycombed connectivetissue framework in which the fat cells are embedded, with a network of blood vessels, lymphatic vessels, and small cutaneous nerves. The vascular and connective tissue structures of the subcutaneous tissue form the structural framework for the organ of the skin. Over the course of time, the role of these structures, particularly the often overlooked connective tissue fibers, in the healing process and in the final liposuction results has become clearer (see Chapter 7). In the endoscopic procedures performed by us, we used the units developed for subcutaneous endoscopic perforating vein dissection. In this way, it was possible to show the anatomical relationships within the tumescent adipose tissue. Connective tissue, blood vessels, and nerve strands run as a network between the muscle fascias and the corium. In addition, it was possible to show the influences of the operating technique and instruments on the behavior of various structures in the subcutaneous space. Endoscopy

Endoscopy was initially developed as a procedure for the inspection of body cavities and hollow organs using tube-like optical instruments. The possibility of using specific optically controlled procedures without having to open surgically the part of the body to be treated has now led to endoscopic procedures becoming firmly established in numerous medical disciplines in the form of minimally invasive surgery. Our working group gained its initial experience with the endoscopy of subfascial tissue in the field of phlebology. Endoscopic imaging of insufficient perforating veins in the subfascial space of the lower leg enabled their specific location and ligation (Figure 14.1)1,2. In the search for the most tissue-protective method possible, to preserve the connectivetissue apparatus during liposuction, use of the

Figure 14.1

Rigid endoscope used in vascular surgery

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a

Figure 14.2

b

Endoscopic image of the subcutaneous space after liposuction with preservation of connective tissue fibers

such as connective tissue and blood vessels resist it owing to their greater turgidity (Figure 14.2). This process, as well as the effortless gliding of the cannulas past these structures, has been impressively demonstrated in endoscopic film sequences. The remaining blood and lymphatic vessels and the subcutaneous connective-tissue support apparatus are essential to the further process of wound healing, and can also be visualized endoscopically after completion of the liposuction procedure. The endoscopic information was thus crucial for further development of atraumatic operating techniques, and led to today’s physiodynamic concept of tumescence and wound healing (see Chapters 6 and 7). Procedures using endoscopic components (e.g. endoscopic abdominoplasty or miniabdominoplasty) should be mentioned, and, in the opinion of numerous surgeons, are useful in selected cases. These involve the combination of ‘normal’ abdominal liposuction with endoscopically monitored reconstruction of muscle-fascia defects in the abdominal wall (e.g. rectus diastasis) in order to achieve abdominal wall reconstruction without the need for skin excision2–5.

enables visualization of how the fat cells are detached from the tissue mass and to what extent the other structures are preserved.These endoscopic findings gave new insights into the anatomy of the subcutaneous adipose tissue and enable in vivo examination of new techniques and the investigation of working hypotheses. If the endoscopic lens and suction cannula are inserted via two different incisions, the aspiration process can be visualized and documented in vivo; insertion of the suction cannula and lens through the same incision enables examination of the anatomical relationships. Besides the behavior of the adipose tissue under the influence of the tumescent solution, the characteristics of the various types of cannula during the aspiration process were shown. Thus, it was possible endoscopically to provide definitive proof of the superior tissue protection achieved by using blunt, atraumatic, multihole cannulas, and in recent times, through the use of vibration cannulas. The high oscillation frequency of the cannulas results in suction that is effective on any one site for only a fraction of a second. This transitory suction is responded to only by the fat cells detached from the tissue mass by tumescence, whereas solid structures 150

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REFERENCES 1. Fischer R, Sattler G. Die Indikation zur subfaszialen Endoskopie der Cockettschen Venae perforantes. Phlebologie 1994; 23: 174–9

4. Zuckowski ML, Ash K, Spencer D, et al. Endoscopic intracorporal abdominoplasty: a review of 85 cases. Plast Reconstr Surg 1998; 102: 516–27

2. Sattler G. Subfascial endoscopic perforator surgery. Curr Probl Dermatol 1999; 27: 190–4

5. Lockwood T. Rectus muscle diastasis in males: primary indication for endoscopically assisted abdominoplasty. Plast Reconstr Surg 1998; 101: 1658–91

3. Eaves FF 3rd, Nahai F, Bostwick J 3rd. Endoscopic abdominoplasty and endoscopically assisted miniabdominoplasty. Clin Plast Surg 1996; 23: 599–616

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consultation so that they can prepare themselves and make the necessary arrangements.Although the patient should start with careful mobilization in the form of short walks directly after the procedure, major physical exertion should be avoided in the first 1–2 weeks. Usually it is sensible to allow a recovery period of 1–2 days before resuming professional activities since, during this time, there is likely to be discharge of tumescent solution and the need to change dressings. In the case of extremely physically demanding work or long periods of standing, it may be necessary to plan for a somewhat longer break of 3–4 days. A compression garment or dressing applied directly after the operation should, depending on the area of the body, be worn for between 1 and 4 weeks, initially both day and night. It should be ensured that there is not excessive friction, which can lead to permanent bumps or indentations. The patient should drink a lot of water in the immediate postoperative period (i.e. 2–3 l per day).This facilitates the excretion of medications and contributes to circulatory stabilization and thrombosis prophylaxis by the blood thinning effect.A written prescription should be given for any medications to be taken (see below). Patients may shower immediately after the operation. Swimming, saunas, and solariums should be avoided until any bruising and the

Upon completion of the actual liposuction procedure and subsequent check of the result by the surgeon, the aftercare phase of the patient begins.This can be divided into the direct postoperative phase lasting a few days and the healing process over several months. In general, it can be said that with the use of tumescent local anesthesia postoperative care is made easier by a reduced complication rate1–3.The patients can be mobilized immediately and recover more rapidly after the procedure.Their active participation in the ‘elimination of problem zones’ is experienced by most patients as a psychologically positive event. All of these factors contribute to rapid convalescence after liposuction. It must be borne in mind that the foundations for postoperative progression are set during the initial consultation: the better the patient is informed about the stages of wound healing to be expected and the result that can realistically be expected, the less problematic postoperative care will be.

POSTOPERATIVE CARE What the patient should know and bear in mind It is sensible to give patients a detailed explanation of postoperative progression at the initial

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Figure 15.1

Application of suture strips to the incisions

Figure 15.2

incision sites have healed (this should be taken into account, for instance, in the case of planned holidays). Approximately 10–14 days after the operation, at the conclusion of the immediate postoperative phase, a ‘medical’ check-up is carried out. However, the final result cannot reasonably be evaluated for at least 4–5 months. The patient should be informed that the overall healing process takes 12 months, and they will need to be patient and understanding. It is sensible to give patients an information leaflet with the most important behavioral rules, as well as an emergency telephone number. In order to avoid unnecessary calls, the patient should be told about ‘normal’ postoperative appearance, such as the temporary swelling of distal body parts due to pooling of the tumescent solution (see above).

Sterile plaster is applied over suture strips

be left without suture strips until the first change of dressing, in order to encourage discharge of the tumescent solution. The suture strips stay on for 5–6 days and are then removed by the patients themselves. Usually they need to be changed again on the first postoperative day. This form of wound closure enables the remaining tumescent solution to flow out unhindered. This procedure has proved more successful than the suturing of incisions, which was standard in the early days of liposuction surgery. At that time the retention of blood and tumescent solution often led to panniculitislike inflammation after liposuction, which almost never occurs now with open drainage4. The draining tumescent solution also rinses out remaining blood, thereby reducing hematoma formation (Figure 15.3). In addition, the associated rinsing function prevents the entry of germs5. During final checks with the patient standing, a large proportion of the tumescent solution still in situ can be stroked out manually through the open incisions prior to the application of plasters and the pressure dressing.This is particularly useful after aspiration of the legs.

Dressings and compression garments The incision sites are closed with suture strips after the procedure, over which a sterile plaster can be fixed to cover them (Figures 15.1 and 15.2).The most distal incision sites can initially

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Figure 15.3

Typical discharge of blood-tinged tumescent solution from incision sites

solution and reducing postoperative edema (see below), and in the later stages it stabilizes the newly forming connective-tissue strands in the aspirated area and, thus, plays a major role in scar formation and skin retraction (see Chapter 7). Any slipping, cutting in, or excessive friction should be avoided at all costs, since this can lead to lasting indentations. During the first 2–3 days, when tumescent solution is still being discharged, the garment is lined with gauze-covered absorbent pads (Figure 15.5). Recommendations for the length of time that pressure dressings should be worn vary somewhat according to the region treated. As a rule of thumb, the garment should be worn day and night for a week, then just during the day for 3 additional weeks. Most patients find the garments comfortable to wear.

Figure 15.4 Example of a pressure dressing following liposuction of the neck and cheeks

Various companies offer specific compression products for the different areas of the body. A well-fitting compression garment is essential for the healing process (Figure 15.4). Initially, it is helpful for mobilizing the remaining tumescent

Perioperative medication Since liposuction is, in most cases, a procedure carried out electively, complications should be

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Figure 15.5 Legs with gauze-lined pads and compression garments following liposuction

Figure 15.6 Patient 2 weeks after liposuction with residual hematoma in treatment area

minimized as much as possible. In this respect, the perioperative prophylactic administration of certain medications has become established, even if these are not strictly necessary. Because of the advantages of tumescent anesthesia already mentioned, the risk of thrombosis is already considerably reduced in comparison with liposuction under general anesthesia. Perioperative antibiotic prophylaxis is optional. Suggested antibiotics include ciprofloxacin 500 mg bid × 3–5 days or cephalexin 500 mg bid × 3–5 days. Any postoperative pain can generally be treated adequately with mild pain-killers such as acetoaminophen. Because of the increased risk of bleeding, ASA and NSAIDs should be avoided.

outpatient basis6. However, the patient should remain in the office or clinic for an observation period of 1–2 h. During this time, the patient can take short walks with an accompanying person. Afterwards the cotton pads are changed for the first time, so the patient can see how this is done. After a final check of pulse and blood pressure, the patient can go home with an accompanying person (the need for an accompanying person should also be discussed at the initial consultation). If quantities in excess of 5000 ml of tumescent solution are to be used, or if there are risk factors such as diabetes mellitus or other severe underlying conditions, it is recommended that patients spend the first night in the clinic for observation. In the case of problem-free postoperative period, the patient returns in 10–14 days for a medical check of the healing process (receding of

Subsequent observation Most liposuction procedures using tumescent local anesthesia can be performed on an

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• Any hematomas formed are drained with the outflow of the tumescent solution; • The risk of postoperative lymphatic blockage or even the formation of seroma is reduced; • The preserved connective-tissue framework facilitates retraction and contributes to optimal wound healing.

bruising and postoperative swelling) (Figure 15.6) and to check the fit of the pressure dressings. Should problems arise in the meantime, every patient must be able to reach a competent advisor at any time via an emergency phone. A final examination (‘cosmetic check’) cannot sensibly be carried out until at least 4–5 months after the operation. At this time, the ‘before’ photographic images can be used to compare the result achieved and ascertain patient and surgeon satisfaction. Postoperative photos can be taken at this time.

The use of lidocaine and prilocaine, in particular, can produce a protracted analgesic effect often persisting for up to 8 h after the operation. Afterwards, slight pain resembling aching muscles can occur, for which the patient should be prepared.This recedes spontaneously within a few days. If necessary, a mild painkiller such as acetoaminophen may be prescribed. Temporarily, there are a few other common side-effects of liposuction, but these are selflimiting and harmless. There can be disturbed sensitivity of the skin in the aspirated region (a feeling of numbness or tingling), due to the irritation of small nerves. This ceases spontaneously after 2–3 weeks. Only in the case of persistent sensitivity disturbance in an area typical for nerve damage after this period should actual nerve damage be considered (see Chapter 18). Another ‘normal’ reaction is increased swelling between the third and fifth postoperative day, which is due to postoperative edema. This post-liposuction edema is the result of increased capillary fluid infiltration due to tissue traumatization, which almost always starts within the first postoperative days and spontaneously disappears within a few weeks. This should not be confused with seroma caused by damage to lymphatic vessels or persistent postoperative lymphedema (see Chapter 18).

Normal progression of the postoperative phase Progression of the immediate postoperative phase is determined by the operating technique, and, most importantly, by the type of anesthesia used. In the case of liposuction using tumescent local anesthesia, the patient can be mobilized directly after the operation5,7. Mobilization begins with standing the patient up to check the results of the procedure. This contributes quite considerably to prevention of one of the most dangerous complications of liposuction surgery, namely thrombosis and pulmonary embolism. With the use of tumescent local anesthesia combined with modern cannula techniques, intraoperative blood and lymphatic vessels are not damaged8. This aspect also results in a significant reduction in complications: • Intraoperative blood loss is minimized, which means that there should be no circulatory problems induced by bleeding and there is generally no extensive hematoma formation;

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In the aspirated area, lumps may also appear within the first 2 weeks, which are probably a result of temporary lymphatic blockage. These disappear in the course of the healing process. Through gentle massage, patients themselves can help accelerate reduction of the swelling. In extreme cases, a few professional lymphatic drainage treatments may be helpful. Another unpleasant but harmless side-effect is the pooling of tumescent solution in distal areas of the body, resulting in swelling. Thus, following abdominal liposuction there may be swelling of the scrotum or labia, or following aspiration of the thighs there may be swelling of the lower legs. In the latter case, differential diagnostics must, of course, be used to investigate and exclude the possibility of thrombosis.

HEALING PHASE As healing progresses, the risk of acute complications moves increasingly into the background. In this phase, ‘aesthetic complications’ assume increasing importance, and these are also described in Chapter 18. It is very important to convey to patients that they should not become impatient too quickly. Healing takes months. In most cases, the result is foreseeable as soon as the postliposuction edema recedes. It can take up to 12 months until wound healing is complete. For this reason, corrections should not be undertaken too quickly9. Many patients want to support the healing process, but the often requested, guaranteed successful, miracle method to achieve optimal healing does not exist. The following recommendations have, however, proved helpful:

Possible complications in the immediate postoperative phase These are described in detail in Chapter 18. During early mobilization of the patient, the possibility of circulatory instability must be kept in mind. Syncope may be induced by too rapid ‘decompression’ when removing the compression garment, or even by the sight of bloodtinged pads in susceptible patients. In order to prevent over-production of methemoglobin after the use of prilocaine, the patient may be administered prophylactically, at the end of the operation, 1 g of vitamin C po in water-soluble form. In the immediate postoperative phase, other side-effects must be borne in mind, depending on what drugs the patient was administered (see Chapter 5). The less common but more severe complications include deep vein thrombosis and embolisms, infections, subsequent bleeding, extensive hematomas, and skin necrosis.

• Sporting activities according to inclination and instinct; • Sauna at the earliest 4 weeks after the operation, since the heat can cause increased swelling; • Sun-bathing and solarium only after healing of the hematomas and incision sites, to prevent postoperative hyperpigmentation; • Compression garment worn for a sufficiently long period; • Gentle massage of the aspirated area to dissipate edema; • Timely initiation of lymph drainage in the case of suspected persistent lymphedema; • For rapid resorption of hematomas, ointments containing heparin or vitamin K can be used.

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REFERENCES 1. Hanke CW, Lee MW, Bernstein G.The safety of dermatologic liposuction surgery. Dermatol Clin 2001; 8: 563–8

G, Hanke CW, eds. Tumeszenz-Lokalanästhesie. Berlin: Springer-Verlag, 1998: 40–4 6. Coleman WP 3rd, Glogau RG, Klein JA, et al. Guidelines of care for liposuction. J Am Acad Dermatol 2001; 45: 438–47

2. Hanke CW, Bernstein G, Bullock BS. Safety of tumescent liposuction in 15336 patients – national survey results. Dermatol Surg 1996; 22: 459–62

7. Sommer B, Sattler G.Tumeszenz-Lokalanästhesie, Weiterentwicklung der Lokalanästhesieverfahren für die operative Dermatologie. Hautarzt 1998; 49: 351–60

3. Klein JA. Tumescent technique for local anesthesia improves safety in large volume liposuction. Plast Reconstr Surg 1993; 92: 1085–98

8. Lillis PJ. Liposuction surgery under local anesthesia: limited blood loss and minimal lidocaine absorption. J Dermatol Surg Oncol 1988; 14: 1145–8

4. Klein JA. Pathophysiology and complications. In Tumescent Technique: Tumescent Anesthesia and Microcannular Liposuction. St Louis, MO: Mosby, 2000: 25–120

9. Sattler G, Sommer B. Bedeutung und gegenwärtiger Stand der Liposuktion. MÄC 2001; 1: 32–43

5. Sommer B. Vorteile und Nachteile der Tumeszenz-Lokalanästhesie. In Sommer B, Sattler

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guidelines by renowned professional associations designed to prevent the occurrence of complications, and a strong recommendation that they are followed7–9.

Over the years, there has been much anxiety and uncertainty among the media, patients, and medical practitioners following reports of complications and even deaths due to liposuction. In this respect there is a considerable need for clarification, because a multitude of misunderstandings and misinterpretations have unjustifiably brought the procedure into disrepute. There is often confusion about the definition of the anesthesia method used. At present, there is still insufficient official epidemiological data on the actual frequency of severe complications or deaths as a result of liposuction1–3. Nevertheless, in the USA, as a result of partly unfounded sensational reporting in the press, statutory measures were discussed for the limitation of outpatient procedures. There are now numerous studies under way to obtain official data on the alleged higher complication rates. The data published thus far have proved that there is no higher risk in the case of operations performed in an office setting4–6. Below is a summary and evaluation of the results of some of the current best-known studies on this topic. In addition, the data of major professional associations and reports by liability insurers on compensation cases have been collated, some covering a very large number of cases. The outcome of the studies presented is the establishment of detailed

STUDY RESULTS Teimourian and Rogers10 collated the data from a survey of 935 plastic surgeons performing 112 756 liposuction treatments.The procedures were broken down as follows: actual liposuctions 75 591, dermatolipectomies 10 603, abdominoplasties 26 562. The treatments were carried out between January 1984 and January 1988. For the liposuction treatment they observed a mortality rate of 2.6/100 000, for the dermatolipectomies of 18.0/100 000, and for abdominoplasties of 41.4/100 000. Overall, there were 15 deaths reported. The most common non-fatal complications were deep vein thromboses, anesthesia incidents, transfusion complications, and pulmonary embolisms. In 1988, Bernstein and Hanke11 examined data from 9478 patients, in whom 24 643 areas of the body were treated with liposuction. Seventyone per cent of these cases were treated under local anesthesia, and 29% were given general anesthetic. In this patient group, there were no severe complications or deaths. In the cases of three required hospital admissions, the affected

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a mortality rate of 19.1/100 000. Another disturbingly high rate was reported in 1998 by the ASPRS Task Force on Lipoplasty, with a ratio of 20.6/100 00014. The authors attributed the rise in the number of deaths to the use of larger quantities of infiltration fluid, underestimation of the operation, poorly trained surgeons, and possible lidocaine/adrenaline (epinephrine) toxicity. However, there were no documented cases of lidocaine/adrenaline (epinephrine) toxicity reported in the study. In addition, the authors were unable to establish any connection between the quantity of fat removed and fatal complications.The trend was established that deaths occurred, above all, during the first postoperative night, and they therefore recommended medical observation for this period, with care by an ambulatory nursing service and/or the use of home pulse oximeters. The most frequent causes of death were thromboembolisms (23.1%), visceral perforations (14.6%), narcosis/sedation/medication (10%), fat embolisms (8.5%), cardiovascular failure (5.4%), severe infections (5.4%), and bleeding (4.6%). Because of the high mortality rate, the authors concluded that guidelines on the extent of operation and postoperative release from medical care should be prepared. The authors also establish ed that some factors could contribute to a reduction in the mortality rate: careful patient selection, the use of smaller quantities of fluid and local anesthetic, and the avoidance of complex combination procedures. In 2001, a study by Hughes6 was published in which the complication rate and number of deaths in the case of 94 159 liposuctions, carried out by 754 plastic surgeons in the period between September 1998 and August 2000, were collated. The goal of the study was to establish to what extent plastic surgeons

patients recovered completely. In the first case hospital admission was on account of extensive muscle weakness after the administration of succinylcholine. In the second case, 24-h monitoring was carried out after the intraoperative occurrence of a left bundle-branch block. The third patient had prolonged subsequent bleeding from an incision site on the left flank, which ceased spontaneously after 48 h. Blood transfusion was not required. In 1995 a survey was carried out by the same work group within the American Society of Dermatologic Surgery12. In the case of 15 336 patients in whom liposuction was performed with tumescent local anesthesia, there was not a single death.A total of 44 014 body regions were treated. There were also no reports of severe complications, such as embolisms (fat or pulmonary), hypovolemic shock, perforation of the peritoneum or thoracic cavity, thromboses, convulsions, or toxic drug reactions. No blood transfusions or hospital admissions were required. Two patients required treatment for cardiac arrhythmia, and two others required extended monitoring due to tachycardia. Overall, the complications described in this large patient cohort were infrequent and mild. Jackson and Dolsky1 examined data from the American Academy of Cosmetic Surgery in 1999. Here, data from almost 200 000 liposuction patients operated on between 1995 and 1999 were collated. In this patient group there was one death, which translated to a mortality rate of 2.4/100 000. Media sensationalism resulted after the publication in 2000 of the study by Grazer and de Jong13 of deaths due to liposuction. Here, the data of 917 plastic surgeons in the period between 1994 and 1998 were examined. With 95 deaths in the patient group treated, this gave

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There was no evidence to conclude that any deaths occurred as a result of the strict use of tumescent anesthesia. An ever-present discussion topic is the extent to which complications during liposuction are reported. For this reason, Coleman et al.16 and Bruner and de Jong17 examined, in two independent studies, the data from American insurance companies with regard to the treatment failures of liposuction reported to them. In 1999, Coleman et al. analyzed the data of the Physicians Insurance Association of America (PIAA) on liability claims related to liposuctions between 1995 and 199716.There were 253 cases reported, whereby 226 claims were made against plastic surgeons, two claims being against dermatologists. Astonishingly, at 71%, there were more claims related to procedures carried out in hospitals than the 21% carried out in office practices. Bruner and de Jong, in 2001, also published data of the liability insurer PIAA relating to claims following liposuctions in the period between 1995 and 199817. Some 255 of 292 claims made were against plastic surgeons, but 67% of these were claims relating to contractual issues. The authors concluded that the higher complication rate following liposuction in hospitals was attributable to the fact that more complicated and extensive procedures were carried out in that setting. In a study by Housman et al. published in 2002, the lower complication rate of liposuction procedures carried out in office practices as opposed to those carried out under hospital admission was also confirmed5.They conducted a survey of 261 members of the American Society of Dermatologic Surgery (ASDS) with regard to more severe complications or deaths in connection with liposuction. No deaths were

had changed their approach to reduce the complication and mortality rates established in previous studies. In addition to complication and mortality rates, data on combined procedures, patient selection, and changes in anesthesia method and liposuction technique were also analyzed. The following data were obtained. In 66% of cases, liposuction alone was carried out, and in 20%, additional surgical procedures (excluding abdominoplasty) were performed simultaneously. In 14% of cases, abdominoplasty and other procedures were carried out along with liposuction in the same session.The mortality rate in the case of pure liposuction was 1/47 415. It rose to 1/7311 in cases where liposuction was combined with other procedures, excluding abdominoplasty. In the case of a combination of liposuction and abdominoplasty and possibly other procedures, the rate rose further to 1/3251. Subsequently, in an article entitled ‘Deaths related to liposuction’ published in the New England Journal of Medicine in 1999, Rao et al.15 created many misconceptions. Here, they falsely assumed that five deaths during liposuction were a result of lidocaine toxicity from tumescent anesthesia. Four of the relevant procedures were carried out by plastic surgeons, and one by a general surgeon.All of the patients were administered accompanying general anesthesia or intravenous sedation. In all cases, an autopsy was performed, and no indications for lidocaine toxicity were found in any of them. Three of the patients received intraoperative administration of 1.7, 3.0, or 7.3 l of intravenous fluid. Two patients had a treatment time of 4.5 or 7 h and underwent aspiration of multiple areas of the body. These two patients suffered pulmonary embolism. One patient received breast implants during the same procedure.

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healed without consequence. Other severe complications in the form of thromboses, pulmonary embolism, severe infections, necrotizing fasciitis, skin necroses, toxic drug interactions or lidocaine toxicity, severe hemorrhaging, or nerve damage were not reported.

reported. Overall, the rate of more severe complications in the form of infections, thromboses, etc. was 0.68 per 1000 cases. Complications occurred more frequently when, along with tumescent anesthesia, intravenous or intramuscular sedatives were administered as well. In February 2000, the State of Florida mandated a duty to report all severe incidents during procedures carried out in office practices (not just liposuctions). All data on deaths, damage to the central nervous system, treatment errors, or hospital admissions were collated by a central reporting agency (Agency for Health Care Administration).The data collected in the period from February 2000 to September 2001 were evaluated by Coldiron4. During the 19month observation period, 43 complications and eight deaths were reported. Among these, there was not a single case related to liposuction using tumescent local anesthesia. There were also no deaths reported in connection with intravenous or intramuscular sedation or analgesia. The three deaths reported in connection with liposuction occurred as a result of pulmonary embolism following fat aspiration under general anesthesia. Coldiron concluded that liposuction under general anesthesia in particular represents a greater risk for patients. In addition, these data demonstrated that the safety of procedures is not improved by virtue of being carried out in a hospital rather than in an office environment. The above studies are summarized in Table 16.1. The data from the AAAHC from a prospective study carried out in the period between February 2001 and August 2002 of 688 liposuction cases also showed a low complicatio rate. Severe complications reported included a single pneumothorax following liposuction of the flanks, which

SUMMARY OF THE STUDY RESULTS If one examines the data from the above studies on the safety of liposuction, one comes to the following conclusions. One reason for the numerous misconceptions is a – conscious or unintentional – distortion of the definition of the term tumescent anesthesia2. Klein distinguished between ‘tumescent liposuction totally by local anesthesia’ and ‘tumescent liposuction with systemic anesthesia’18. Pure local anesthesia exclusively by tumescence without the administration of other systemic medications is often distinguished from combined narcosis procedures by use of the term ‘true tumescent technique’. Systemic anesthetics are understood as not only inhalation gases, but also all parenterally administered drugs which can affect respiration and patient consciousness. Liposuction carried out under pure tumescent local anesthesia displays a higher safety profile than that of other methods. For liposuction using tumescent local anesthesia (‘true tumescent technique’), there have been, so far, no deaths reported19,20. The following factors increase the mortality risk if liposuction is carried out under general anesthesia or strong intravenous sedation: • Performance of several procedures in the same session;

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Table 16.1 Overview of major safety studies on liposuction

Study/authors

Year

Number of procedures evaluated

Bernstein and Hanke11 Teimourian and Rogers10 Hanke et al.12 ASPRS Task Force on Lipoplasty14 Jackson and Dolsky1

1988

9478

Dermatologists

0

0

1989

112 756

Plastic surgeons

15

12.7/100 000

1995 1998

15 336 24 295

Dermatologists Plastic surgeons

0 5

0 20.6/100 000

1999

200 000

1

2.4/100 000

2000

496 245

Cosmetic surgeons (dermatologists, ENT surgeons, etc.) Plastic surgeons

95

19.1/100 000

2001

94 159

Plastic surgeons

Unknown

Dermatologists All specialties

0 8 (3 after liposuction under general anesthetic; 0 after liposuction with tumescent anesthesia)

Grazer and de Jong13 Hughes6

Housman et al.5 Coldiron4

2002 66 570 2002 118 ‘incidents’ following outpatient procedures

Specialist groups

Number of deaths

• Long operating time of several hours; • Aspiration of large quantities of fat (‘mega-liposuction’) in one session; • Administration of excessive intravenous fluid resulting in fluid overload; • Administration of high doses of lidocaine in combination with general anesthesia.

Mortality rate

1/47 415 in the case of pure liposuction 1/7311 in the case of liposuction combined with other procedures 1/3251 in the case of liposuction combined with abdominoplasty 0 Not specified according to the various procedures

For this reason,‘true tumescent local anesthesia’ is currently seen as the method of choice in liposuction surgery for intraoperative anesthesia and postoperative pain control18,21. Patients treated by this method feel comfortable after the procedure and recover completely within a few days.The aesthetic results are excellent.

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safety precautions in the form of limiting total lidocaine dose, and the presence of trained staff and monitoring and emergency treatment equipment (see Chapter 5). The low complication rate for procedures carried out in office practices or outpatient treatment centers has been confirmed in numerous studies4,5,17. However, there is still a strict requirement for adherence to the safety criteria (see Chapter 17) to maintain this exceptionally high safety profile.

Practitioners who carry out liposuction are required to maximize patient safety.The tumescent technique has played a large role in minimizing the complications of liposuction and, at the same time, achieving excellent results. Liposuction is generally safe both using purely local anesthesia with exclusive administration of tumescence and also with the combined administration of systemic anesthesia18. However, the additional administration of systemic anesthetics requires considerably more

REFERENCES 1. Jackson RF, Dolsky RL. Liposuction and patient’s safety. Am J Cosmet Surg 1999; 16: 21–3

9. Laurence N, Clark RE, Flynn TC, Coleman WP 3rd. American Society for Dermatologic Surgery Guidelines of Care for Liposuction. Dermatol Surg 2000; 26: 265–9

2. Klein JA. Ethical considerations. In Tumescent Technique: Tumescent Anesthesia and Microcannular Liposuction. St Louis, MO: Mosby, 2000: 12–15

10. Teimourian B, Rogers WB. A national survey of complications associated with suction lipectomy: a comparative study. Plast Reconstr Surg 1989; 84: 628–31

3. Newman J, Dolsky RL. Evaluation of 5458 cases of liposuction surgery.Am J Cosmet Surg 1984; 1: 25–80

11. Bernstein G, Hanke CW. Safety of liposuction: a review of 9478 cases performed by dermatologists. J Dermatol Surg Oncol 1988; 14: 1112–14

4. Coldiron B. Office surgical incidents: 19 months of Florida data. Dermatol Surg 2002; 28: 710–13

12. Hanke CW, Bernstein G, Bullock BS. Safety of tumescent liposuction in 15 336 patients – national survey results. Dermatol Surg 1996; 22: 459–62

5. Housman T, Lawrence N, Mellen BG, et al. The safety of liposuction: results of a national survey. Dermatol Surg 2002; 28: 971–8

13. Grazer FM, de Jong RH. Fatal outcomes from liposuction: Census Survey of Cosmetic Surgeons. Plast Reconstr Surg 2000; 105: 436–46

6. Hughes CE. Reduction of lipoplasty risks and mortality: an ASAPS survey. Aesthet Surg J 2001; 21: 120–5

14. ASPRS Task Force on Lipoplasty. 1997 Survey Summary Report. Arlington Heights: American Society of Plastic and Reconstructive Surgeons, 1998

7. Coleman WP 3rd, Glogau RG, Klein JA, et al. Guidelines of care for liposuction. J Am Acad Dermatol 2001; 45: 438–47 8. Drake LA, Ceilley RI, Cornelison RL, et al. Guidelines of care for liposuction. Committee on Guidelines of Care. J Am Acad Dermatol 1991; 24: 489–94

15. Rao RB, Ely SF, Hoffman RS. Deaths related to liposuction. N Engl J Med 1999; 340: 1471–5

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16. Coleman WP III, Hanke CW, Lillis P, et al. Does the location of the surgery or the speciality of the physician affect malpractice claims in liposuction? Dermatol Surg 1999; 25: 343–7

19. Hanke CW, Lee MW, Bernstein G. The safety of dermatologic liposuction surgery. Dermatol Clin 1990; 8: 563–8

17. Bruner JG, de Jong RH. Lipoplasty claims of US insurance companies. Plast Reconstr Surg 2001; 107: 1285–91

20. Klein JA. Problems in reporting liposuction deaths. In Klein JA (ed),Tumescent Technique: Tumescent Anesthesia and Microcannular Liposuction. St Louis, MO: Mosby, 2000: 20–3

18. Klein JA.Two standards of care for liposuction. In Klein, JA (ed), Tumescent Technique: Tumescent Anesthesia and Microcannular Liposuction. St Louis, MO: Mosby, 2000: 9–11

21. Parish T. A review: the pros and cons of tumescent anesthesia in cosmetic and reconstructive surgery. Am J Cosmet Surg 2001; 18: 83–93

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17

G Sattler, B Sommer, CW Hanke

In the past few years, guidelines have been established for many medical indications. Guidelines are systematically developed recommendations which support doctors and patients in deciding on appropriate therapeutic measures in specific medical circumstances. Guidelines reflect the state of knowledge on effective and appropriate patient therapy at the time of publication. Guidelines must undergo periodic revision, replacement, and alteration in view of the inevitable advances in scientific knowledge and technology.The guidelines cannot be used in all circumstances.The decision as to whether a certain recommendation should be followed must be made by the doctor after consideration of the situation of the individual patient. In the case of guidelines prepared by specialty societies, a group of experts from the association’s board of directors is appointed to prepare the consensus guideline. The following guidelines are based, with revisions, upon the 2002 American Academy of Cosmetic Surgery Guidelines for Liposuction Surgery1. These are revised in the following section and presented as 2003 guidelines2,3.

A. GUIDANCE ON TRAINING, EDUCATION, AND PERFORMANCE Physicians who perform liposuction must have appropriate training and experience in the field of liposuction. Basic requirements for this are: 1. Completed specialty surgical training in the field of general surgery, otolaryngology, gynecology, dermatology, or plastic surgery; 2. Certificate of further training in liposuction: a. Introductory course; b. Advanced course; c. Certificate of attendance at lectures; 3. Knowledge to treat cardiovascular, surgical, and pharmacological complications; 4. Liposuction should be carried out by specialists on those regions of the body which correspond to their main field of activity. Introductory training should cover the following: 1. A complete didactic theory course; and 2. An operating room (OR) training course with live surgery certified by a recognized association.

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5. Explanation and consent at least 24 hours before the operation; a period of 4 weeks before surgery is recommended (see Chapter 22); 6. Thorough physical examination of the patient, particularly the area to be treated, taking into consideration, among other things, hernias, scars (previous operations), and the state of the skin (cellulite, striae, skin elasticity). 7. Precise standardized preoperative photo documentation (see also Point I, ‘Documentation’).

The basic training should be supplemented by: 3. Attendance at lectures, including liposuction performed under supervision; 4. Advanced refresher courses every 2–4 years. For physicians who have gained appropriate experience in the course of their clinical activity as surgeon or first assistant, the attendance at didactic courses, live surgery workshops, and lectures is generally not necessary. However, it is recommended that this group regularly attend refresher courses. Physicians with minimal clinical experience must complete theoretical and practical courses, including OR demonstrations and attendance at lectures by a surgeon experienced in the method and its application.

A thorough history, physical examination, and laboratory tests must be carried out before every liposuction procedure. Particular attention should be paid here to coagulation disorders, drug interactions, thrombosis risk, and generally significant surgical risks (concomitant conditions, age). The data collected must be carefully documented.The content and object of the explanatory consultation and consent of the patient to the operation must, in all cases, be recorded in writing.

B. ESTABLISHING PREOPERATIVE STATUS Required preoperative measures include: 1. Documentation of a thorough history with particular consideration given to current medications, familial susceptibility to thrombophilia, and collagen disorders; 2. Documentation of preoperative laboratory parameters; the extent of laboratory tests should also be based upon each patient’s specific health status and history; 3. It is recommended that the Guidelines of the American Society of Anesthesiology are followed for establishing the indication (see Chapter 19); 4. Detailed explanation by the surgeon, recommended duration at least 30 minutes;

C. ESTABLISHMENT OF INDICATION Liposuction is indicated for the removal and reduction of locally isolated adipose tissue deposits. This encompasses the cosmetic removal of fat accumulations in the area of head and neck, trunk, and extremities. Fat removal is not indicated for weight reduction. The aspiration of fat cannot replace diet and exercise, but it can be a sensible adjunctive measure.

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of TLA with increasing body weight is only safely possible up to a total weight of approximately 60 kg body weight. A total amount of 4 g local anesthetic per session and a maximum TLA volume of 8000 ml should not be exceeded regardless of body weight. Ultrasound-assisted liposuction (UAL) should only be used by doctors who have considerable experience in the field of conventional liposuction techniques and have received specific additional training in this area.

Further indications for liposuction are: 1. Treatment of pathological changes in the adipose tissue such as lipoma, gynecomastia, pseudogynecomastia, lipodystrophy, and axillary hyperhidrosis; 2. Preparatory flap mobilization or flap elevation in the case of skin reconstruction; 3. Fat extraction for autologous transplantation for augmentation and scar correction.

D. LIPOSUCTION OPERATING TECHNIQUE E. MEGA-LIPOSUCTION AND DETERMINATION OF VOLUME

The method of choice for liposuction is considered to be use of the tumescent technique. This has been used successfully and safely over the past 15 years with the shortest recovery period and lowest complication rate. Tumescent local anesthesia produces a significant reduction in blood loss. In addition, the effect of the tumescent solution on the adipose tissue optimizes the shaping of body fat (body contouring) by the use of small-caliber cannulas and preservation of connective tissue structures. As local anesthetics, lidocaine, prilocaine, and articaine are recommended.The safe maximum dosage depends on the overall volume of body fat and the physical size of the patient. The dosage recommendation for lidocaine is 45–55 mg/kg; dosages in excess of 55 mg/kg should not generally be used (see Chapter 4). In very heavy patients, this theoretically results in a high injectable volume of tumescent local anesthesia (TLA) solution when using standard dilutions (0.05 or 0.04% solution). On the basis of clinical experience, however, a proportionally linear increase in the injectable quantity

Mega-liposuction is defined as the removal of over 6000 ml of body fat in one operation. Fat removal with a pure fat aspirate of more than 4000 ml per session should be considered surgically experimental, and should only be carried out in specific operating centers with in-house intensive care facilities. For outpatient procedures, a maximum aspiration amount of 4000 ml of pure adipose tissue is recommended.

F. PROCEDURE ROOM EQUIPMENT Liposuction must be carried out in a procedure room or operating room which conforms to local regulations. The operation is performed under sterile conditions and requires patient monitoring with pulsoximetry and ECG. An established venous access and ready accessibility of emergency equipment for cardiopulmonary resuscitation are basic requirements for the performance of liposuction.

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antibiotic therapy should be given. Postoperatively, rapid mobilization of liposuction patients is recommended to avoid venous stasis, reduce the postoperative recovery time, and act as active thrombosis prophylaxis.

G. POSSIBLE COMPLICATIONS 1. Common postoperative problems: edema, hematoma, dysesthesia, hypesthesia, formation of scars and slight contour irregularities; 2. Rare postoperative problems: persistent edema and dysesthesia, hyperpigmentation, itching, asymmetry, hematoma, seroma, drug reactions, allergy to dressing materials, major contour irregularities; 3. Rare complications: skin necrosis due to technical problems or infections (occasionally in the case of ultrasound-assisted fat removal), burns at access sites (from ultrasound technique or in the case of conventional liposuction from friction heat), extensive hematoma, seroma, nerve lesions, infections. Hypovolemic shock, intraperitoneal and intrathoracic perforations, deep vein thrombosis, and pulmonary and fat embolism are very rare, but are reported in isolated cases. Fatalities are very rare.The risk evaluation relates to tumescent local anesthesia; other methods of anesthesia increase the operating risk (see Chapter 16).

I. DOCUMENTATION Standardized pre- and postoperative photographic documentation should be prepared for liposuction patients. Body weight should be recorded before the operation. The surgical report should record the following information: 1. Type and quantity of the infused tumescent solution; 2. Type and dosage, including overall dosage, of the medications administered; 3. Total volume aspirated; 4. Fluid and fat content of the total volume; 5. Method used; 6. Type of anesthesia; 7. Body regions treated; 8. Type and localization of drains; 9. Difficulties and particular considerations; 10. Type of postoperative dressing.

H. POSTOPERATIVE CARE AND MEDICATION

The analysis of pre- and postoperative photographic documentation enables evaluation of the results of the work as well as internal quality assurance. Critical observation of the progression and evaluation of the final results is required.

The application of pressure dressings in the form of bandages, compression garments, and tape and foam dressings encourages healing and is particularly necessary in the first 7 days after the operation.Thereafter, patients can be advised individually whether pressure dressings should be worn. Open drainage of the tumescent solution reduces the risk of infection and is considered to be the method of choice. It is left to the judgment of the surgeon to decide whether prophylactic perioperative

J. DOCUMENTATION OF COMPLICATIONS It is the duty and responsibility of the surgeon to document undesirable events and complications including morbidity and mortality, and inform the appropriate specialty associations.

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REFERENCES 1. American Academy of Cosmetic Surgery. 2002 Guidelines for Lipo-Suction Surgery. Chicago, IL: AACS, 2002

3. Sattler G. GÄCD Leitlinien zur Liposuktion. MÄC 2002; 3: 33–5

2. American Academy of Cosmetic Surgery. 2003 Guidelines for Lipo-Suction Surgery. Chicago, IL: AACS, 2003

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• Risks and complications due to anesthesia; • Risks and complications due to actual liposuction.

For all operations performed mainly for aesthetic reasons, it is important that complications are avoided and that the risk to the patient is minimal. Only if there is an appropriate level of safety can a responsible physician offer a cosmetic–aesthetic procedure with a clear conscience. In addition to patient safety, the ethical issues must be considered. Is the method offered suitable for the particular patient and in his or her best interest? (See Chapter 8.) It must be ensured that the method offered leads to the desired postoperative result. The method must be executed to technical perfection using the latest standards of technology13. These aspects must be considered in the case of liposuction surgery which is not carried out for a medical indication. Thus, it is essential to prevent risks and complications. A safe and effective anesthesia method must be selected specifically for each patient. Intraoperative complications must be avoided by using optimal operating techniques, instruments, and monitoring. The operating technique used is also important for postoperative progression, and is responsible for the aesthetic result. The complications and risks that may occur in the course of tumescent liposuction surgery can be categorized as follows:

Jeff Klein, who is considered the inventor of the tumescent technique, formulated this, in a considerably abbreviated form, as follows: tumescent liposuction has two potential problems: too much lidocaine and excessive liposuction2. Complications and risks due to the liposuction must in turn be divided into: • Intraoperative risks and complications during liposuction; • Postoperative complications. In terms of postoperative complications, a distinction can be made between medical and aesthetic complications. This chapter provides a comprehensive account of the possible complications of tumescent liposuction and their treatment as well as how they can be avoided. (With regard to the avoidance of aesthetic complications, please also see Chapter 21.) It can be seen from Tables 18.1 and 18.2 that if the relevant precautionary measures for the avoidance of complications are observed, these are very limited. Improved operating techniques have also led to a further reduction of some complications in comparison with previous major studies.

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Table 18.1 Frequency of complications in liposuction using tumescent local anesthesia in 4831 patients in the period 1997–2000. From reference 3 Complication

Frequency (number of patients)

Seroma Deep vein thrombosis Irregularities of the skin Wound infection/erysipelas Scar formation at the incision site Significant asymmetry Infected hematoma Pulmonary or fat embolism Electrolyte imbalance Blood loss requiring transfusion

15 5 2 2 1 0 0 0 0 0

recommendations and quantity information (see Chapters 4 and 17). The side-effect spectrum of the tumescent local aneshesia (TLA) solution is determined to a great extent by the local anesthetic (LA).The pharmacological and toxicological behavior of the LA is described in Chapter 4.

In order to minimize operative risk, possible individual risks must be identified and excluded at the preoperative stage by correct patient selection and establishment of the indication, thorough history, physical examination, and laboratory tests. Ensuring that the patient has realistic expectations, informing patients about possible risks, and obtaining written patient consent can also help to avoid complications and problems (see Chapter 8)5.

Reactions to local anesthetic These can occur in the CNS or as cardiovascular reactions as an expression of the systemic interaction of the LA with the sodium channels of the cells (see Chapter 4).

RISKS AND COMPLICATIONS DUE TO METHOD OF ANESTHESIA The anesthesia method is the most significant factor with regard to the safety of liposuction surgery2,6. As described in Chapter 16, on the basis of the studies available at this time, pure tumescent anesthesia without the supplementary administration of systemic anesthetics must be considered the safest method of anesthesia for liposuction. However, since this method can also have side-effects, it is important to observe the safety

CNS As already presented in Chapter 4, the LA achieves relatively high concentrations in the CNS and can cause dose-related side-effects. Indications of incipient CNS toxicity can be confusion, giddiness, or ‘light-headedness’. Upon these first signs, administration of the LA should be stopped and the patient clinically monitored until disappearance of the symptoms (vital

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Table 18.2 Complications in 15 336 patients with tumescent liposuction in a survey of 66 dermatologists in 1994. From reference 4 Complication Postoperative swelling or ecchymosis of scrotum or labia Infection Lasting skin irregularities Postoperative ‘panniculitis-like’ inflammation* Hematoma/seroma Allergic reactions to drugs or plasters Persistent postoperative edema Patient dissatisfaction due to unrealistic expectations Nausea not caused by the narcotic drugs Vasovagal reaction/syncope Extreme or persistent postoperative pain Fever Permanent hyper- or hypopigmentation Above-average ecchymosis Extreme postoperative fatigue Damage to sensory nerves Prominent scarring Ecchymosis persisting for more than 6 weeks Cardiac arrhythmia requiring treatment Tachycardia delaying discharge by more than 2 h Skin ulceration or necrosis Liability claim Anemia Complications requiring hospital admission Loss of blood or fluid requiring treatment Pulmonary or fat embolism Hypovolemic shock Perforating thoracic or abdominal damage Seizures Thrombophlebitis Toxic side-effects of intravenous sedatives or anesthetic Fatalities

Number of patients

Percentage

59 52 40 30 26 18 15 13 11 11 9 8 6 5 5 5 3 2 2 2 2 1 0 0 0 0 0 0 0 0 0 0

0.3847 0.3391 0.2608 0.1956 0.1695 0.1174 0.0978 0.0848 0.0717 0.0717 0.0587 0.0522 0.0391 0.0326 0.0326 0.0326 0.0196 0.0130 0.0130 0.0130 0.0130 0.0065

* This inflammation was initially often seen following liposuction and was probably a result of the suturing of incision sites. After introduction of the practice of open drainage this type of inflammation was no longer seen1

If there should be indications of LA intoxication, the main goal of treatment is to ensure sufficient oxygenation by keeping airways open and administering oxygen. Should seizures occur they are usually only of short duration. In the case of longer-lasting epileptic symptoms,

functions, state of consciousness). No other measures are required. Higher LA levels induce excitatory side-effects (trembling, tremors) up to generalized tonic–clonic seizures. Such extreme CNS side-effects have not been reported to date in conjunction with tumescent anesthesia.

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The CNS and cardiovascular side-effects of LAs depend on the blood plasma levels and the speed at which the plasma level in the blood increases. This is dependent upon the absorption rate into the systemic circulatory system, which depends on the site and type of local anesthesia method. In the case of tumescent local anesthesia, absorption and the increase in plasma level are delayed (see Chapter 4). It is important to ensure that the rate of infiltration is not too fast. Regular monitoring of vital functions and level of consciousness is carried out in order to be able to recognize any side-effects at their initial stages7,8. Potential drug interactions due to concomitant medications must be excluded by way of thorough history, or taken into account preoperatively (see Chapter 4). Preoperative blood tests must be done to rule out any significant liver or kidney dysfunction, which could impair metabolism of the substances.

these can be treated with succinylcholine, benzodiazepines (e.g. diazepam) and/or barbiturates (e.g. thiopental). Cardiovascular Severe cardiovascular side-effects are also very rare with purely tumescent anesthesia. It is important to know that LAs have a doserelated negative inotropic effect on the myocardium. This can lead to massive blood pressure reduction and circulatory collapse. Cardiovascular symptoms occur in the following sequence: bradycardia, hypotension, conduction blocks, arrhythmia, asystole. More often, however, LAs cause conductive dysfunction of the heart muscle. This can lead to various ECG changes from widening of the QRS complex to total AV nodal block. Clinically, this is expressed as bradycardia and hypotension. LAs also have a direct effect on the peripheral vessels and can at high doses lead to severe vasodilatation, which can in turn cause a drop in blood pressure and even cardiovascular shock. There are considerable differences between the various LAs as regards cardiotoxicity. The most favorable characteristics are those of prilocaine, which shows the lowest relative toxic potency as regards cardiovascular effects (RTP = dosage/plasma level of lidocaine/ analgesic potency × dosage/plasma level of comparative substance). The treatment of cardiovascular side-effects must be based upon the specific symptoms. In addition to securing a free airway and sufficient administration of oxygen, catecholamines, atropine, antiarrhythmics, and/or electrical stimulation (cardioversion or pacemaker) can be used if required.

Allergic reactions to local anesthetics In comparison with the amino esters, hypersensitivity reactions to LAs of the amide group such as lidocaine and prilocaine are relatively rare, and are limited to isolated case reports. However, some ampules contain parabens as a preservative, which can cause allergic reactions. Anaphylactic reactions, depending on the severity, can appear as skin rashes, itching, rhinitis, cardiovascular dysfunction (tachycardia, drop in blood pressure, arrhythmia), bronchospasm, and cardiovascular and respiratory failure. In the case of a suspected allergic reaction, administration of the allergen must be immediately discontinued. This is adequate in itself

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in the case of mild reactions. In the case of more severe reactions, the blood pressure must be stabilized by stabilization of the volume. Depending on the severity of the symptoms, an H1- and H2-receptor antagonist can be administered (e.g. Fenistil® and Tagamet®) and, if necessary, further measures initiated for the treatment of anaphylactic shock (administration of adrenaline (epinephrine), cortisone, etc.). However, allergic reactions are extremely rare overall.

Reactions to adrenaline (epinephrine) In the course of systemic absorption of the adrenaline (epinephrine) added to the solution, there could theoretically be catecholaminetypical side-effects. The most common sideeffects are tachycardia and increased blood pressure which can be quickly recognized and treated. In general, adrenaline-induced side-effects are seldom seen with TLA10,11. The treatment of catecholamine-induced side-effects must be symptomatic. In the case of supraventricular tachycardia, carotid sinus massage and the Valsalva maneuver can be tried. Additional medications such as verapamil, or adenosine in the case of supraventricular tachycardia, and lidocaine in the case of ventricular arrhythmia, should only be administered under ECG control by an experienced physician.

Methemoglobin production with prilocaine With an overall dosage of more than 600 mg of prilocaine, the methemoglobin level can increase by up to 25%. Patients with normal initial blood counts and a healthy cardiovascular system can tolerate this without difficulties. A methemoglobin level of 10% with an initial Hb of 12 g/dl reduces this to 10.8 g/dl, which only rarely leads to complications. However, methemoglobin anemia becomes clinically apparent with a blood level of 3–5 g/dl (approximately 15–30%) as an alarming-looking cyanosis. This is not clinically relevant in healthy patients. Prophylactically, the patient can be given oral vitamin C postoperatively (e.g. as an effervescent tablet). As a treatment, methylene blue can be given intravenously in a dosage of 1–3 mg/kg body weight or vitamin C (2 mg/kg body weight) orally7,9. Preoperatively, laboratory tests should be performed particularly on patients from Southern Europe or Africa to exclude glucose6-phosphate-dehydrogenase deficiency. The initial Hb level should be checked in all patients.

Possible side-effects due to concomitant medication In the case of very anxious patients or those with extremely high pain sensitivity and in the treatment of painful areas, it may be necessary to limit the operating stress for both doctor and patient by the administration of additional medication (see Chapter 5). Since this increases the risk of drug interactions and possible side-effects, particular care must be taken to ensure that, besides equipment for monitoring vital functions, the spatial and staff conditions are adequate to deal with sideeffects or emergencies. The additional administration of sedating benzodiazepines or hypnotics, like that of short-acting opioids for analgesia, can cause

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respiratory depression which may require temporary ventilation.

likelihood of vascular damage with associated bleeding has been dramatically reduced by the introduction of the tumescent technique. This is a result of:

RISKS AND COMPLICATIONS DUE TO LIPOSUCTION

• Vasocompression due to tumescence pressure, which is sufficient to compress veins; • Vasoconstriction due to the added adrenaline (epinephrine); • Blood vessels buoyed up by fluid being better able to ‘take avoiding action’.

Intraoperative complications and their treatment Circulatory instability Circulatory instability can occur, as discussed above, as a side-effect of anesthesia. It is fairly rare as a result of intraoperative fluid loss due to the tumescent solution. On the contrary, when additional infusion fluid is administered, the risk of hyperhydration with pulmonary edema is possible1. What is important for the prevention of circulatory instability is limiting the size of the operating area and observance of the 70% rule (see Chapter 12). In the case of constant monitoring of vital functions, circulatory instability can be established in the early stages and treated specifically according to the cause. Postoperatively, it is important to ensure careful mobilization to avoid vagovasal syncope. Most patients’ circulation is so stable a few minutes after the operation that they have no difficulties for example in climbing stairs or taking short walks.

In addition, improvements in the cannula technique have reduced the risk of vascular damage. These include the use of blunt, atraumatic cannulas.Vascular protection is even more effective using vibration cannulas. Due to their faster oscillation movement, they do not suck in the more torpid vascular structures (see Chapters 10 and 12). The additional use of manual skin stabilization (MASST) in the more advanced surgical stages and observance of the 70% rule can also help to prevent vascular damage (see Chapter 12). Nevertheless, should damage to larger vessels occur, which would be evident by an extremely bloody aspirate, the procedure must be stopped. In most cases, the bleeding can be stopped by compression (pressure dressing); opening the site to apply a vascular ligature is necessary only in isolated cases. Patients with suspected damage to large blood vessels should be monitored for a sufficiently long period to enable intervention if required (bleeding does not stop under compression). Increased susceptibility to bleeding and the associated risk of major blood loss must be considered in the case of known coagulation disorders or the administration of a range of

Vascular damage Theoretically, it is possible that blood vessels, primarily veins running through the subcutaneous adipose tissue, can be damaged during liposuction. Vascular damage and severe bleeding was a dangerous problem in liposuction carried out using the ‘dry technique’12,13. The

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examination should be carried out. In the case of smaller hernias with no prolapse of intestinal organs, the operation can be carried out with appropriate care relative to the findings. Should there be at any time during or after liposuction an indication of abdominal wall perforation or intestinal damage with the relevant pain symptoms (‘acute abdomen’), the patient must be transferred immediately for emergency care. Pain, nausea, and vomiting in patients already released must be regarded as serious. Patients must be informed that in this case they should seek medical help immediately (emergency telephone number).

drugs. Therefore, it must be ascertained through the history whether coagulation disorders are present or anticoagulants, particularly aspirin, are being taken. The taking of non-steroidal anti-inflammatory drugs or cyclo-oxygenase inhibiting agents, such as vitamin E, can also lead to an increased susceptibility to bleeding. Nerve damage Like the blood vessels, the nerves running through the subcutis can also be damaged. Damage to major nerves is extremely unlikely. Similar to blood vessels, the risk of damage has been reduced by the tumescent technique and the use of atraumatic and vibration cannulas. A common occurrence at the treatment area following liposuction is temporary paresthesia of the skin, which is probably due to irritation of the sensory nerves. This disappears spontaneously after a few weeks. Should there be extreme sensitivity disturbances postoperatively, the administration of vitamin B products can encourage nerve regeneration. If there is a suspicion of actual longterm nerve damage, the patient should be examined by a neurologist.

Postoperative medical complications Deep vein thrombosis and pulmonary embolism As with all procedures requiring immobilization of a patient for surgery lasting several hours, the risk of deep vein thrombosis and consequent pulmonary embolism must be considered. Patients particularly at risk are those with hereditary coagulation disorders. For this reason, the history must thoroughly investigate previous thromboses, thrombosis susceptibility in the family, and varicosities. Other risk factors leading to increased thrombosis susceptibility (adiposity, smoking, hormone treatments) must also be considered. It is recommended that complete coagulation diagnostics be carried out preoperatively to rule out thrombophilia (see Chapter 8). Since patients can and should be mobilized immediately after liposuction performed using TLA, the risk of deep vein thrombosis is considerably lower than with procedures carried out under general anesthesia. Fatal pulmonary

Perforation of the abdominal wall This extremely dangerous complication is more likely in the case of procedures under general anesthesia with the associated lack of protective reflexes. A conscious patient treated with tumescent local anesthesia has intact peritoneal sensitivity. The preoperative physical examination must check for abdominal wall hernias or extensive rectus muscle diastasis in the planned operating area. If clinical findings are unclear, an ultrasound

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liposuction in the area of the lower legs. In the case of liposuction purely using the tumescent technique (without additional procedures), there have to date been no instances of fat embolism reported1. Measures are described above for the prevention of vascular damage and low adipose tissue traumatization due to the tumescent and super-tumescent technique. Gentle operating techniques and advanced cannula technology are an essential requirement for the prevention of fat embolisms (see Chapter 12). Constant intraoperative lipoaspiration and open drainage of the incision sites postoperatively ensure the constant removal of dissected fat clusters. In mild cases characterized by slight dyspnea and a slight reduction of pO2, symptomatic therapy with oxygen is sufficient. The diagnosis and treatment of a fat embolism with severe clinical indications (e.g. a feeling of tightness, acute dyspnea, tachycardia, motor agitation, central nervous system dysfunction or thoracic petechial bleeding) must be carried out under intensive medical care.

embolisms have been reported mainly in connection with general anesthesia (see Chapter 16). In addition, the performance of extensive ‘megaliposuction’ and the treatment of several areas, with the associated major trauma and extended treatment time, can increase the risk of thrombosis1. Therefore, a less traumatizing operating technique (see Chapter 12) can reduce the risk of thrombosis. Because of the possible sequelae of pulmonary embolisms, deep vein thromboses must be avoided at all costs. Routine thrombosis prophylaxis with low-dose heparin can be given on the day of the operation and for the next 5 days (see Chapter 15). Patients with stable circulatory systems should also be carefully mobilized immediately after compression garments (corset, stockings) have been applied to the operating area, which also helps to prevent venous stasis. In the case of clinical suspicion of deep vein thrombosis, diagnostic confirmation phlebography and/or duplex sonographic examinations are carried out and further therapy is decided in conjunction with a phlebologist or angiologist. In a case of suspected pulmonary embolism, immediate pulmonary perfusion scintigraphy should be used for confirmation of the diagnosis, and appropriate therapy initiated under hospitalized conditions.

Hematoma Smaller hematomas or widespread ecchymoses are relatively common postoperative side-effects. The occurrence of larger hematomas is avoided through intraoperative vascular protection. Open drainage allows blood and tumescent solution to flow out, preventing the accumulation of large quantities of blood. Pressure dressings applied postoperatively ensure that residual bleeding is quickly stopped. As a result of these measures, large hematomas with the risk of infection or need for incision are extremely rare.

Fat embolism A much-feared, but in practice, rare complication is fat embolism. The exact etiology of this syndrome is not yet fully understood. In addition to the transport of fat into the lungs or other capillary areas via the circulatory system, this can also be caused by the coagulation of blood fats into fat embolisms. Fat embolisms seem to be a slightly greater risk in the case of

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Infections

In order to achieve the rapid dissipation of hematomas, patients can apply a cream containing heparin or vitamin K.

This is a standard complication with nearly every procedure, but preventable overall and relatively rare (see Chapter 16)1. Prevention is the first priority. Proper hygiene standards and instrument sterilization must be observed. Every patient in the operating area is regularly disinfected by the repeated application of spray disinfectant. Perioperative antibiotic prophylaxis is given as a matter of routine by most surgeons (see Chapter 15). Open drainage of the incision sites with the continuous discharge of tumescent solution prevents the entry of pathogens and the formation of large hematomas. Should infections occur despite the measures described, therapeutic intervention must be carried out according to severity.The application of local antibiotics may be considered in the case of small, surface infections with no indication of systemic involvement (fever, lymph node swelling). In most cases, specific antibiotic treatment should be given. If there are indications of more extensive infections (e.g. erysipelas), hospital treatment must be considered. Massive infections (e.g. necrotizing fasciitis) are reported very rarely after severe wound contamination as a result of perforating abdominal injury. These certainly require immediate intensive care treatment.

Seroma and persistent lymphedema As a result of damage to lymphatic vessels, postoperative lymphatic congestion can occur, leading to seromas or persistent lymphedema. The latter must be distinguished from a ‘physiological’ postoperative swelling (post-liposuction edema due to increased capillary fluid infiltration as a result of tissue trauma), which almost always stops by the end of the first postoperative day and spontaneously disappears after a few weeks (see Chapter 15). In the case of persistent lymphedema, on the other hand, there is damage to the lymphatic system1. These complications must be prevented intraoperatively by an appropriate atraumatic operating technique using tumescence (preferably super tumescence, see Chapter 12), vibration lipolysis, and protection of the lymphatic vessels by directing cannulas along the longitudinal axis of the body. Manual skin stabilization (MASST) can also play a role here. Postoperatively, lymphatic circulation is encouraged by the application of pressure dressings. However, the pressure should not compress the lymphatic vessels, so it should not be too high. Should seromas occur despite a gentler operating technique, they are drained, and a pressure dressing then applied to the site. In the case of postoperative swelling lasting for more than 12 weeks, there is a chance that this could be persistent lymphedema. Besides further consistent application of compression, these patients should be given lymphatic drainage. With a little patience, such measures can usually ensure harmonization of lymphatic flow within a few months.

Skin necrosis, scarring Skin necrosis as an expression of massive skin damage is not expected if the rules of the atraumatic operating technique are followed (tumescence, atraumatic cannulas, vibration lipolysis, observance of 70% rule, avoidance of skeletization; see Chapter 12).

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the initial findings (see Chapter 19). It is well known that, as a rule, medical treatment does not legally constitute a contract for work and services, so the practitioner is not obliged to deliver success but merely a certain treatment. This can, however, be different if a particular treatment result (e.g. ‘we can get rid of that stomach completely’) is promised, or photographs of third parties are shown with perfect treatment results. In these cases, there is an assurance given, which the patient can insist upon having fulfilled. The routine showing of ‘before and after’ photos of other patients with perfect treatment results can have negative consequences. Of course the dissatisfied patient must be taken seriously and given the opportunity for a detailed discussion. Free revision treatment only makes sense in the case of objectively unsatisfactory results (see below). In addition, a sufficiently long healing period of a few months must be allowed, since in this time there are often further changes due to the continued healing process. If, as a practitioner, one is honestly confident of having done good work and therapeutically having achieved that which the method offers, one should not be persuaded to perform another operation. This risks the development of a vicious circle of dissatisfaction, the root of which often lies not in the treatment result, but rather much deeper. One should explore all avenues to achieve an amicable resolution, but there are cases in which it is sensible to discontinue treatment.

Should skin necrosis occur, secondary healing must be awaited, and then if necessary the scar tissue excised and the defect concealed with a local flap. In rare cases, visible scars develop at the incision sites which may require treatment (e.g. injection of crystalline steroid suspension). In the case of persistent hyperpigmentation at the incision sites, a cream containing vitamin K can be used. Postoperative aesthetic complications These are of central importance in a procedure carried out primarily for aesthetic reasons. In this chapter, the possible aesthetic complications are listed. The avoidance of aesthetic errors is dealt with separately in Chapter 21, with specific tips, and consequences of the operating technique. Dissatisfied patient These are patients who, despite objectively satisfactory operating results, are subjectively dissatisfied. Usually this is due to very high, unrealistic expectations, which should be recognized and corrected during preoperative consultations (see Chapter 8).The treating physician assumes a guiding function, and helps the patient to understand the basic principles of physical proportions and to visualize these using relevant photographs. Patients must be involved in the process of establishing the indication and realize what is actually achievable. The operative concept and a treatment plan must be worked out together. Another essential in every case is precise preoperative documentation of the results of discussions and photographic documentation of

Aesthetically unsatisfactory results As a practitioner, one must be honest and selfcritical enough to recognize and explore objectively unsatisfactory results: what do I need to improve in my technique, what went wrong? The following aesthetic errors can arise:

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• Loss of skin turgor and excess skin. How these errors can be avoided is dealt with in detail in Chapter 21. How can one help the patient? First, a sufficiently long healing process of at least 6 months must be allowed to enable objective assessment of the final result. During this time, restructuring processes are still taking place in the tissue (see Chapter 7). If after this period the findings are objectively aesthetically unsatisfactory, the patient should be offered a free corrective operation (touch-up). In addition to repeat liposuction for harmonization of the remaining irregularities or the smoothing of ripples, liposhifting (see Chapter 13) may be necessary to smooth out indentations. Particularly in the case of soft skin and lax connective tissue, the skin retraction achieved is often insufficient. In the case of a loss of skin turgor or even hanging skin, efforts can be made to achieve a tightening of the tissue through careful repeat aspiration using vibration lipolysis (protection of connective tissue fibers, see Chapter 7) (three-dimensional wound shrinkage and scar formation, see Chapter 7). If this is insufficient, skin resection must be considered (e.g.miniabdominplasty, see Chapter 13).

Figure 18.1 Extreme indentations following liposuction of the thighs using ‘old’ operating technique

COMPLICATIONS: AVOIDANCE AND TREATMENT IN LIPOSUCTION

Figure 18.2 Skeletization and hanging of the skin following over-aspiration of outer and inner thighs by an inexperienced surgeon

Sick patient • Deep vein thrombosis/pulmonary embolism: avoidance (thorough history, exclusion of familial traits, thrombophilia diagnostics, low-trauma operating technique); treatment: phlebography, pulmonary perfusion scintig-

• Irregularities in the skin surface (ripples, indentations (Figure 18.1)); • Over-aspiration (skeletization (Figure 18.2)) with the exposure of underlying structures (bone protrusions, muscles);

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•

•

•

•

•

•

• Perforation of abdominal wall: preoperative physical examination, ultrasound diagnostics, operation under local anesthesia, tumescent technique; diagnosis in case of suspicion: ultrasound; treatment: in case of intraoperative suspicion circulatory stabilization, emergency transfer for immediate surgery; • Skin necrosis: tumescent technique, atraumatic cannulas, vibration technique, observance of 70% rule; treatment: await secondary healing and scar resection, if necessary subsequent local flap repair; • Circulatory instability: tumescent technique, atraumatic cannulas, vibration technique, observance of 70% rule, restriction of size of operating area; treatment: blood-stabilizing measures (positioning, volume substitution, Effortil® drops (etilephrine)).

raphy, referral to angiologist, thrombophilia diagnostics, thrombolysis, and subsequent treatment with heparin; Thrombosis prophylaxis: operation under LA, low-molecular-weight heparin, compression, movement, screen for risk factors (family history, tobacco use, hormone therapy); Fat embolism: operation using tumescent technique, open drainage, lipoaspiration, avoidance of vascular damage; treatment: in mild cases symptomatic, intensive care if necessary; Vascular and nerve damage: utilize tumescent technique, vibration lipolysis, MASST, atraumatic cannula technique; treatment of vascular damage: if necessary opening of site and ligature, pressure dressing and compression, symptomatic treatment in mild cases; in the case of nerve damage vitamin B12 supplementation for regeneration may help; Hematoma, seroma, persistent lymphedema: utilize tumescent technique (preferably supertumescent technique), MASST, atraumatic cannula technique, cannula directed longitudinally along lymphatic vessels, compression and pressure dressing, lymph drainage; treatment of hematoma/seroma: needle aspiration, pressure dressing and cooling, antibiotic prophylaxis, in milder cases heparin ointments, ointments containing vitamin K, in the case of persistent lymphedema lymphatic drainage; Infection: tumescence, atraumatic, open drainage, antibiotic prophylaxis; treatment: antibiotics, possible hospitalization, if necessary intensive care treatment; Allergic reaction to anesthetic: history, if necessary preoperative testing, use of small quantities of LA; treatment: stop administration of allergen, treatment of anaphylactic shock reaction;

Dissatisfied patient (clinical photos during each patient visit) • Expectations not fulfilled (aesthetics subjectively unsatisfactory): thorough preoperative consultation, involvement of patient in establishing indication and assumption of guiding function by treating physician, preoperative documentation of findings, exact planning of surgery (prepare a treatment plan), instruction of patient in the principles of physical proportions, realistic expectations; treatment: comparison of initial findings with treatment result, thorough discussion, conciliatory offers depending on the situation (free corrective treatment in the form of a second procedure), discontinuation of treatment; • Aesthetics objectively unsatisfactory: for avoidance see operating technique; treatment: allow a sufficiently long healing period, repeat

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(vibration lipolysis) with autologous fat harvesting, intraoperative liposhifting and multiple adipose tissue transfers, subcision, extended endermology treatment, manual physiotherapy; overaspiration: see irregularities, plus avoidance of too rapid aspiration of fat, visual check, manual check (pinch test); treatment: see irregular skin surface; • Loss of skin turgor and excess skin: see skin irregularities, plus atraumatic cannula technique, vibration lipolysis, if necessary adjuvant simultaneous skin resection; treatment: repeat liposuction, skin resection.

consultation, recommendation for continuation of treatment; possible touch-up; • Irregularities in surface of the skin: operation using tumescent technique, preferably supertumescent technique, MASST, atraumatic cannula technique, cannulas directed along the lines of lymphatic vessels, if possible parallel to longitudinal body axis, preservation of a residual layer of fat (beware: superficial liposuction) of 0.5–1 cm under the dermis, crisscross technique from 2–3 accesses, work from center towards periphery; treatment: second MASST-supported liposuction procedure

REFERENCES 8. Sommer B, Sattler G.Tumeszenzlokalanästhesie, Weiterentwicklung der Lokalanästhesieverfahren für die operative Dermatologie. Hautarzt 1998; 49: 351–60

1. Coleman WP 3rd, Glogau RG, Klein JA, et al. Guidelines of care for liposuction. J Am Acad Dermatol 2001; 45: 438–47 2. Klein JA. Pathophysiology and complications. In Klein JA (ed),Tumescent Technique:Tumescent Anesthesia and Microcannular Liposuction. St Louis, MO: Mosby, 2000: 25–120

9. Sattler G, Lapprich S, Regedorn M. Tumeszenz-Lokalanästheise. Untersuchungen zur Pharmakokinetik von Prilocain. Z Hautkr 1997; 7: 522–7

3. Sattler G, Sommer B. Bedeutung und gegenwärtiger Stand der Liposuktion. MÄC 2001; 1: 32–43

10. Burk RW 3rd, Guzman-Stein G,Vasconez LO. Lidocaine and epinephrine levels in tumescent technique liposuction. Plast Reconstr Surg 1996; 97: 1379–84

4. Hanke CW, Bernstein G, Bullock BS. Safety of tumescent liposuction in 15336 patients – national survey results. Dermatol Surg 1996; 22: 459–62 5. Hanke CW, Lee MW, Bernstein G.The safety of dermatologic liposuction surgery. Dermatol Clin 1990; 8: 563–8

11. Klein JA. Clinical pharmacology. In Tumescent Technique: Tumescent Anesthesia and Microcannular Liposuction. St Louis, MO: Mosby, 2000: 121–96

6. Klein JA. Tumescent technique for local anesthesia improves safety in large volume liposuction. Plast Reconstr Surg 1993; 92: 1085–98

12. Lillis PJ. The tumescent technique for liposuction surgery. Dermatol Clin 1990; 8: 439–50

7. Sommer B. Vorteile und Nachteile der Tumeszenz-Lokalanästhesie. In Sommer B, Sattler G, Hanke CW, eds. Tumeszenz-Lokalanästhesie. Berlin: Springer-Verlag, 1998: 40–4

13. Lillis PJ. Liposuction surgery under local anesthesia: limited blood loss and minimal lidocaine absorption. J Dermatol Surg Oncol 1988; 14: 1145–8

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Particularly in the context of aesthetic procedures, precise documentation should be prepared beginning with the initial consultation. The advantages and disadvantages of the planned surgery, the risk of the procedure, the possibility of failure, and any alternative treatment options should be discussed and documented accordingly. This can be done by way of standard information forms, with the option to make additional personalized entries. Often the written consent of the patient is recorded on these forms. The patient should be given enough time to consider the information received. Consent forms can therefore also be given to the patient to take home, but should be brought back, signed at the time of the procedure, and also archived (see Chapter 8). For the history and documentation of physical examination findings, preprinted forms can be used and supplemented by individual entries. A separate file should certainly be prepared for each patient, in which all the findings are collected. This file is also the place where all laboratory results, imaging studies, and other diagnostic measures carried out before, during, and after the procedure are recorded. Standardized photographic documentation of the original findings is essential for aesthetic procedures.

According to professional regulations, every physician is bound by a duty to document their work1. The physician must keep the necessary records of findings made and measures taken in the exercise of his profession2.These are not just memory aids for the physician, but also serve the patient’s interest in proper documentation. The patient must be granted access to the medical records upon request. Medical records are to be kept for a period, usually 10 years, after the conclusion of treatment. The documentation form is not prescribed, but it is important that it is prepared soon after the event, i.e. subsequent entries in medical records or the preparation of a surgical report will not release the physician from his obligations in the case of court action. Records on electronic or other storage media require special protection and security measures to prevent unauthorized use. Those who do not observe this documentation duty, or do so inadequately or in an untimely fashion, and fail to maintain the medical records for a necessary time-frame risk considerable liability in the case of a medical negligence prosecution. In the case of missing documentation, a patient alleging treatment errors can be granted evidential relief or even a reversal of the burden of proof with regard to the treatment errors alleged.

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tumescent solution administered should be recorded on a separate sheet (Figure 19.1). It is recommended that advice for patients in the postoperative days and weeks be documented and given to the patient in written form (Figure 9.2). In the patient file, the postoperative release status and comments on postoperative progression at check-ups should be recorded.This can also be documented by photographs. The data collected and treatment reports should be archived for a sufficient period, comparable to that for other medical records in hospitals and office practices. The physician is responsible for the documentation and notification of any complications and side-effects of liposuction using tumescent local anesthesia. Because of frequently expressed doubts about the method, and widely circulated incorrect figures on the alleged frequency of complications, it should be in the interests of all users to document the low complication rate in order to create a rational basis for discussion. Practitioners should strive for improvement opportunities in the case of the regular occurrence of similar complications.

Preoperative photographs of the area treated should be taken from at least two different perspectives. The photos should be taken according to a standard method with a monochrome background, using consistent lighting conditions, and from a fixed photographic angle. The advantage of digital image technology is that the images can be evaluated immediately, and only the good ones selected. Furthermore, the preparation of an image file on a PC facilitates finding the images. However, it should be ensured that all images are labeled with name, date, etc. The patient owns the rights to his or her own photos; therefore, prior permission must be given in writing if the images are to be used in the context of publications. In order to document the course of surgery, an operation protocol should be prepared.This encompasses data on the course of the operation, any intraoperative events, and medications administered, and the documentation of vital signs. Any deviations from standard procedures should also be recorded. When using tumescent local anesthesia (TLA), the quantity and composition of the

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OR Protocol Patient: _________________________________________

_________________________ Date/signature of office staff

Kind of surgery: __________________________________

_________________________ Room no.

Consent form surgery......

date of birth ____________

Consent form anesthesiology……..

Size, weight ____________

Laboratory tests ( e.g. ECG)

Localisation ____________

___________________________________________________________________________________________________________________ Date of surgery Surgeon / infiltrating physician nurse ____________ Local anesthesia ____________ General anesthesia ____________ Tumescent local anesthesia

Infusion protocol for Tumescent Local Anesthesia (TLA): Tumescent Solution 0,038% Nacl 0,9% Prilocaine 2% Lidocaine 2% Bicarbonate 8,4% Triamcinolone 20 mg Epinephrine 1 : 1000 TLA-Volume in total in ml

Start of infiltration End of infiltration Time of Penetration

3.000 ml 30 ml 30 ml 20 ml 2 ml 2 ml

Aspirated volume:

total fluid supranatent

Compression garment Laboratory test Storage of frozen fat

Medication: Preoperative medication _____________________________________________________________________________________________ Intraoperative medication Time/Doses

Time/Doses

Time/Doses

Time/Doses

Remifentanyl Remifentanyl Propofol Propofol Midazolane Diazepame Beta blocker (Visken?) Post operative medication: Vitamine C Antibiotics Paracetamol Ibuprufen Thrombosis proph

Figure19.1

___________________ Signature physician

Infusion protocol for the TLA solution

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___________________ Signature nurse

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Name of Patient

__________________________________________________________

date/nurse

____________________

Room no.: ________________ Surgeon:

_____________________________________________________________________________________________________

Surgical intervention: _______________________________________________________________________________________ Post surgical protocol Medication, special remarks _________________________________________________________________________________________ Date: _______________

Time

BP/mm Mercury

Heart rate/min

Medication

Remarks

/ / / / / /

___________________________________________________________________________________________________________________ Signature of physician(s) signature of nurse

Date: _________________

Time

BP/mm Mercury

Heart rate/min

Medication

Remarks

/ / / / / /

___________________________________________________________________________________________________________________ Signature of physicians signature of nurse

Figure 19.2

Information leaflet for patients

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REFERENCES 1. Ehlers A, Schlund G. Rechtliche Aspekte im Rahmen der ästhetischen Medizin [Legal perspectives in esthetic medicine]. In Dirschka T, Sommer B, Usmiani J, eds. Leitfaden Ästhetische Medizin [Manual of Esthetic Medicine], 1st edn. Munich: Urban & Fischer, 2003: 33–47

2. Berufsordnung der Ärztinnen und Ärzte in Hessen [Professional Regulations for Medical Practitioners in Hessen, Germany], published 1 October 1998, as at 1.2.2003

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overall conception and planning of the operation and for advising the patient on the results to be expected. Since systematic categorization is difficult, we would like to describe a few particularly distinctive tissue types and constellations.

Many of the tips and tricks collected over what are now almost 15 years of personal liposuction experience have become almost fixed components of the operating procedure or the tumescent technique, and have therefore been included in the relevant chapters. This chapter is designed to give a short overview of aspects either which are not covered elsewhere in this book or which we consider particularly important; we make no claims as to systematic organization or completeness.

Patients of normal weight with firm tissue, stable weight, and localized fat pads This is the ideal patient.At the preliminary examination, the tissue proves firm at the pinch test and shows good retractability.With stable weight there have been no phases of tissue prestretching. For these patients it is very easy to estimate the quantity of tumescent solution required and thus the extent of the procedure possible at one session.The results can be predicted with a very high level of accuracy and will be highly satisfactory due to the unrestricted tissue retraction with the appropriate operating technique.

DIFFERENT TISSUE TYPES We all know that man is not a machine built according to a strict design. Everything can vary from hair color to the position of the appendix. Nevertheless, there are particularly significant differences in the expression of our external shape and the composition of our soft tissue which are very difficult to document and are not categorized in any textbook. In determining an indication for liposuction and deciding whether the wish expressed by the patient can be fulfilled using the methods available to us, one often encounters difficulties, particularly as a newcomer to the area of liposuction surgery. The individual tissue type obtained at the preliminary examination is essential to the

Patients of normal weight with soft connective tissue, stable weight, and localized fat pads In these patients the pinch test reveals soft, pliable connective tissue with little retraction. Examination may reveal the appearance of pregnancy striae.With this patient, one must expect 195

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retraction of the prestretched fibers. Cosmetically satisfactory results can only be achieved through an optimal operating technique; the patient must be informed of the possible need for a second operation to lift the skin.

to use somewhat more tumescent solution in order to achieve a turgid distended operating area. The operating technique must aim particularly towards retention of connective tissue fibers and controlled induction of scar tissue formation in order to achieve a tightening effect.Vibration lipolysis is appropriate here.

Previously overweight patients after weight loss with prestretched connective tissue

Overweight patients with firm connective tissue and localized disturbing fat pads

In general, patients should avoid preoperative weight loss before planned liposuction treatment. It is better to lose weight gradually after removal of the worst fat pads to give the tissue time to adapt to the altered conditions. Often, however, patients present with stubborn residual fat pads following weight loss. In these cases, the preoperative condition is often hanging skin with residual adipose tissue. Until a short time ago, these patients would have had to undergo a tightening operation by skin reduction surgery. Now the liposuctioninduced formation of scar tissue together with maximum retention of the connective-tissue support apparatus, as is possible using vibrationassisted liposuction, is often able to achieve a remarkable degree of skin retraction with additional removal of the residual fat pads. Therefore, in most cases primary liposuction is indicated. It must be borne in mind when planning the operation that the prestretched tissue can really ‘swallow up’ large amounts of tumescent solution, with high consumption for an operative area (particularly the abdominal area).

As already stated, liposuction is not indicated for overall ‘fat removal’ in the case of generally overweight patients. It can, however, be useful to remove accumulations of fat which represent a problem either mechanically or psychologically.This can then be an incentive for a change of lifestyle and diet, with continued sensible and lasting weight loss. According to experience, larger people can tolerate higher concentrations of local anesthetic (see Chapter 16). In planning the operative procedure, however, it must be borne in mind that the subcutaneous space is more extensive and therefore consequently requires more tumescence. Postoperatively, one can expect good healing progression and satisfactory results with these patients; lifting operations are generally not necessary. Overweight patients with soft tissue and localized disturbing fat pads If at the preliminary examination of an already obese patient there are indications of soft connective tissue, one must expect that a significantly increased quantity of tumescent solution will be required.When adipose tissue is removed from the subcutaneous space the remaining connective tissue has to ‘do’ a lot more to achieve

POSTOPERATIVE ACCUMULATION OF FLUID AND FAT One aspect which should perhaps be mentioned in the explanatory consultation is the postoperative 196

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subcutaneous adipose tissue directly under the dermis should only be removed in exceptional cases. In this context, it is important to refer to the planning of each individual case. The patient should be realistically informed of the operative procedure, the results that can be achieved, and the postoperative progression. In the case of a multistage operative plan, there will be interim stages for which the patient must be prepared in order to display the necessary patience and understanding. In addition to a timetable, a ‘finance plan’ must also be prepared so that the patient is prewarned.

accumulation of water in the tissue and the altered distribution of adipose tissue. Female patients who tend to suffer from edema formation depending on the menstrual cycle have to expect increased fluid accumulation in other areas following more extensive liposuction. If, for example, there was premenstrual accumulation of fluid in the thighs and breasts before the procedure, after the removal of adipose tissue from the thighs there will be increased accumulation of fluid in the breasts. It is assumed that this is due to the fact that hormone receptors responsible for fluid retention in the legs are removed along with the fat. As a result, the remaining receptors in the breasts are stimulated more, which can lead to increased swelling of the remaining hormone-sensitive adipose tissue. If a patient tended towards accumulation of fat in the thighs before the operation, the removal of this receptored region can, in the case of hyperalimentary nutrition, lead to the postoperative accumulation of fat in areas not previously seen as problem zones (e.g. the upper arms).

WHAT ARE THE POSTOPERATIVE CONSIDERATIONS? Full healing following liposuction is a process which takes up to 18 months. This must be explained to the patient. The varying healing times must be taken into account in the evaluation of the results at each point in time. Corrective measures taken too early in the case of not yet completed primary healing are counter-productive. Besides interindividual differences, there are also intraindividual differences depending on the region of the body. For example, in the abdominal area, healing and thus retraction is generally complete after 4 or 6 months. In general, it can be said that the longer is the interval after the procedure, the more reliably the actual result can be evaluated. In the case of excessive postoperative swelling, the healing process can be promoted by massage or lymph drainage. In the case of the popularly offered creams, more is achieved by the massage effect of their application than by the substances they contain. Extensive bruising can be

‘IT IS IMPORTANT WHAT YOU LEAVE . . .’ (PIERRE FOURNIER) Liposuction has developed from a mechanically oriented fat removal procedure to an aesthetically high-quality liposculpturing procedure with the creation of a harmonious body silhouette. Instead of simply removing mass, the goal is to create proportions. The goal of aspiration is therefore not to remove as much fat as possible. On the contrary, if too much is removed, underlying structures can create unpleasant surface contours (‘skeletization’) (see Chapter 21). We also recommend avoiding aspiration too close to the surface. In order to prevent irregularities of the skin surface and an unnatural appearance after the operation, the 1–1.5 cm of 197

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encouraged to heal more rapidly with external preparations containing vitamin K (Auriderm®).

tumescent effect during the course of the procedure is compensated for by the skin and subcutis being tightened manually by trained assistants in order to reduce the shearing force on the tissue. This method requires additional staff, but contributes to reducing stress on the tissuesupport apparatus of the skin and can help to facilitate and speed up the procedure overall.

MASST The manually assisted skin stabilization technique (MASST) has already been described in Chapter 12. The reduction of the tissue-stabilizing

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The main subject of this chapter is the avoidance of ‘aesthetic errors’, which ideally should not occur in the case of an elective procedure such as liposuction performed mainly for aesthetic reasons. Despite observance of the correct operating technique, this will not always be possible. Therefore, in Chapter 13, correction possibilities are also presented. In the case of results that are objectively not aesthetically satisfactory, the surgeon should be honest and self-critical and always try to make a conciliatory offer depending on the situation. Besides a detailed discussion (‘second consultation’) and a reminder of the need to allow a sufficiently long healing process of 6–12 months, ‘touchup’ procedures, i.e. corrections at a reduced price, must also be considered. It is important to avoid aesthetically unsatisfactory results in the first place. Overall, the phrase coined by Pierre Fournier applies: ‘It is important not what you take out, but what you leave behind’1. The goal of liposuction surgery is not to remove as much fat as possible but rather to achieve a cosmetically pleasing and natural-looking result2,3. Below is a short description of the most common errors and how to avoid them.

Figure 21.1 technique

Skin irregularities after liposuction using old

IRREGULARITIES ON THE SURFACE OF THE SKIN (RIPPLING) Irregularities of the skin’s surface such as the formation of ripples in the aspirated area are one of the most common aesthetic complications. The original operating techniques used large-diameter cannulas. Surface irregularities were difficult to avoid (Figure 21.1)4,5.

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Figure 21.3 Rippling on the inner thighs due to incorrect direction of aspiration

Figure 21.2 Preoperative marking of existing indentations or tissue irregularities

Skin irregularities can be avoided as follows. Pre-existing irregularities should be marked preoperatively (Figure 21.2). During aspiration, a localized bulge must be treated more intensively, an existing indentation less intensively. The easier aspiration of adipose tissue treated in advance with tumescent solution reduces tissue trauma, particularly when ‘super tumescence’ is used (see Chapter 12), and enables more uniform aspiration.The introduction of the tumescent technique enabled the risk of rippling (Figure 21.3) to be reduced considerably. At the same time, the tumescent technique enables the use of small-caliber cannulas, which also contribute to a considerably more uniform result. The atraumatic cannula technique was further improved by the introduction of tissue-protective vibration cannulas, and this enabled the achievement of even more uniform results. In terms of operating technique, the surgeon must always be sure to work parallel to the

Figure 21.4

Illustration of MASST

body’s longitudinal axis as much as possible.The ‘criss-cross’ technique proceeds in a fan-shape from two or three access points and in all layers, but ‘criss-cross’ must not be understood as ‘in all directions’, especially not at right-angles to the axes of the body. Correct positioning of the patient (see Chapter 12) can make an essential contribution to aspiration in the right direction. In the case of intraoperative reduction of the tumescent effect, manual skin stabilization (MASST) can be used to stabilize the tissue, to allow work to continue efficiently (Figure 21.4).

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A residual layer of fat of 0.5–1 cm should be retained under the dermis, because aspiration too close to the surface is more likely to result in irregularities on the skin’s surface. Should irregularities nevertheless occur, the following options are available for correction: repeat MASST-supported vibration lipolysis with intraoperative autologous fat harvesting, intraoperative liposhifting, and multiple adipose tissue transplants (see Chapter 13).

ASYMMETRY It is essential that existing differences between sides be thoroughly analyzed and documented, and that this is taken into account in the planning and performance of the operation. On the other hand, tumescent anesthesia with a conscious and co-operative patient offers advantages: the patient can help promote uniform aspiration by active repositioning. Most important are interim and final checks of the result achieved with the patient standing, which enable direct comparison of the two sides. If necessary, corrections can then be made immediately, which is not possible in the case of general anesthesia.

Figure 21.5 Example of over-aspirated patient with skeletization of muscles

underlying surface means that the fat is pushed against the cannula and there is a risk that more fat than necessary will be removed. Besides use of the correct operating technique in tumescence with intraoperative checks of the result achieved (see above sections), the individual endpoint of the liposuction procedure must be taken into account.The 70% rule, and clinical signs such as increased aspiration of blood and the manual pinch test, are methods to establish that the endpoint of the liposuction procedure has been reached (see Chapter 12).

OVER-ASPIRATION OF SUBCUTANEOUS TISSUE WITH SKELETIZATION

LOSS OF SKIN TURGOR

Here the rule is: beware too rapid fat aspiration! If aspiration is proceeding very rapidly and easily, there is a risk of removing too much fat and exposing the underlying structures (Figure 21.5). Care must be taken above bony protuberances such as the greater trochanter. The hard

This is a justifiably much-feared complication of fat aspiration, but one which can be avoided by improved cannula and operating technique (see Chapter 7). Correctly performed liposuction using the tumescent technique and the atraumatic or vibration cannula affects retraction and

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the three-dimensional shrinking and scarring process due to retention of the connective-tissue support apparatus of the subcutaneous tissue, which in most cases prevents sagging of the skin (see Chapter 7). There is an increased risk of skin turgor loss after liposuction in the case of patients aged > 40 years. Weak connective tissue after extensive prior weight fluctuations (‘yo-yo diets’) may have placed a major strain on the connectivetissue framework of the adipose tissue. In the case of pre-existing hanging skin, after assessment of the risks, an adjuvant simultaneous skin resection can be carried out. However, combined procedures usually involve a higher risk (see Chapter 16). In some cases, vibration lipolysis can be used to treat loss of skin turgor after liposuction if the condition is not too extensive, because of the subsequent wound contraction. Otherwise, skin resection must be considered (miniabdominoplasty, abdominoplasty, inner leg lift, or brachioplasty) (see Chapter 13).

NON-PHYSIOLOGICAL PROPORTIONS In the preliminary discussion, the patient is first asked about his or her wishes, in order to ascertain expectations. In his guiding role, the surgeon must first ensure that he encourages realistic expectations in the patient. At the same time, an overall plan must be established together with the patient. This also includes making the patient aware that isolated treatment of the main problem area of the lower stomach without simultaneous treatment of the upper abdomen and perhaps the waist will not produce a harmonious result.The patient should have a basic grasp of the concept of aesthetic units, so that patient and practitioner can create a sensible treatment plan together. Areas of the body which should be treated together are inner thighs–knees–inner lower legs, calves–ankles, neck–cheeks, hips–flanks, etc.These areas are also referred to as ‘aesthetic units’. If one region is treated in isolation, it can lead to non-physiological proportions and patient dissatisfaction.

REFERENCES 1. Fournier P. Body Sculpturing Through Syringe Liposuction and Autologous Fat Re-injection. Orona Del Mar, CA: Samuel Rolf International, 1987

Tumescent Anesthesia and Microcannular Liposuction. St Louis, MO: Mosby, 2000: 43–60 4. Asken S. Liposuction Surgery and Autologous Fat Transplantation. East Norwalk: Appleton & Lange, 1988

2. Coleman WP, Glogau RG, Klein JA, et al. Guidelines of care for liposuction. J Am Acad Dermatol 2001; 45: 438–47

5. Coleman WP III. The history of liposuction. Dermatol Clin 1990; 8: 381–3

3. Klein JA. Miscellaneous complications. In Klein JA (ed), Tumescent Technique:

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G Sattler

Because of the far-reaching consequences, one must ensure even before treatment at the initial consultation and during the explanatory discussions that a range of regulations are observed. The most essential element here is that the duty to inform is upheld. Over half of all compensation claims against physicians are based on the claim that the patient was not adequately or properly informed. In a malpractice case, the physician is obliged to prove that he informed the patient properly before the procedure on the method, possible complications, and alternative forms of treatment. This latter is the decisive point in the case of aesthetic elective procedures. General points which must be considered in the information process include:

According to the legal definition, the term malpractice includes any medical measure which fails to come up to the required standard of care in accordance with the general standard of medical knowledge and experience and, thus, appears improper. Such malpractice or a violation of the medical duty of care can generally, due to the wide definition of the term and the required specialist knowledge, be confirmed or ruled out only with the help of a medical expert. Such an error can occur at any stage of the physician–patient interaction, even in the time prior to and after the actual treatment. A physician fulfills the care standards of his profession and delivers that which is offered only if he is aware of the currently applicable standards in his field, is capable of performing them, and applies them.This results in a continuing legal duty to undertake professional training. If a physician is not aware of the latest standards in his field, then he is liable to pay compensation to his patients if they suffer damage as a result. If a physician exceeds his specialist knowledge and competence, he is guilty of what is called ‘assumption negligence’. Should it be proved – generally by means of an expert report – that the physician did actually commit malpractice, there is also the threat of criminal proceedings.

• Patient information can be imparted without any actual form requirements in the context of a physician–patient discussion; • It must be adapted to the mental and intellectual level of the patient; • It must list existing treatment alternatives; • It must be given in good time so that the patient has sufficient time to change his or her mind; in the case of procedures carried out on an outpatient basis, explanations given on the day of the procedure or in the procedure room are considered invalid;

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• The patient’s questions must be answered truthfully.

procedure in liposuction surgery. Many treatments are still carried out under general anesthesia. Many surgeons achieve very good results using these methods. Because of the lack of a ‘general standard of medical knowledge and experience’, the personal preferences of the relevant expert and his own, personal experience play a major role in the evaluation of possible malpractice. One aid in assessing the extent to which the required care was missing is to consult the guidelines of recognized specialty organizations (see Chapter 17). Some basic operating standards must be seen as generally valid for the prevention of intraand postoperative complications. Also as malpractice errors if they are not followed, it will lead to expert reports.These include a comprehensive explanation of the procedure in advance, with the appropriate documentation and a timely signature on a specifically adapted consent form. During liposuction, it is recommended that basic hygiene standards are observed, and the more extensive is the procedure, the more extensive the monitoring of cardiopulmonary function should be. In accordance with guidelines, trained staff should be on hand for possible emergencies. The avoidance of intraoperative complications is discussed in Chapter 21. Extremely high patient expectations can be set for the operative results.With mastery of the operating technique and the use of modern cannulas, pronounced dimpling and asymmetry between sides, or other aesthetic complications, can generally be avoided if the indication is correctly established. The use of cannulas with the smallest possible diameter can be considered a basic standard.

For reasons of simplification, standardization, and documentation, it is recommended that explanation forms are used with the possibility of individual adaptation (see Chapter 19). The following points are particularly important for cosmetic operations: • In the case of operations with an aesthetic– cosmetic goal which do not serve to cure a physical ailment, but rather to fulfill a psychological and aesthetic need, very high standards should be set for informing patients regarding chances of success and the risks of the procedure. • The patient must be informed that an aesthetically pleasing result cannot be guaranteed; the patient must be informed of the possibility of failure and the possible need for subsequent surgery. • As well as the risks, the patient must also be informed of the chances of success and the duration of the effect of the procedure. The evaluation of actual malpractice is very difficult. In addition to individual patient characteristics (e.g. lax connective tissue), which the experienced surgeon should recognize and point out in advance, there are still major differences in standards. In our opinion, liposuction using tumescent local anesthesia is superior to other techniques for fat aspiration due to the many advantages of the operating technique and patient safety. It is recommended as the first-choice method even by leading specialty societies such as the American Academy of Cosmetic Surgery. However, there is no generally accepted standard

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of at least 4–6 months, a self-critical assessment of the result and, if necessary, a revision operation (‘touch-up’) be carried out (see Chapter 13).

Complications still occur from time to time, despite experience and careful work. In order to avoid legal battles, it is recommended that after a sufficiently long healing period

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Marketing G Sattler, S Sattler, G Blugerman

Besides clarifying the basic identity of the facility, the physician must make an honest assessment of his personal attitude in order to develop a coherent and convincing overall message:

Liposuction is one of the most popular aesthetic procedures worldwide. Increasing numbers of physicians from various specialties are adding this procedure to their range of treatments. Competitive pressure and the need for efficient marketing are increasing. Most physicians working in the field of aesthetic medicine are not familiar with business management and marketing strategies. In order to succeed in the growing market, medical expertise alone is not sufficient1. It is important to develop a marketing strategy to stand out from the crowd. Before this is established with professional help, one should start by asking oneself a few questions. Helpful key questions to define the planned clinic identity are2:

• What am I qualified for and able to offer with a clear conscience? • What is my personal attitude to the issues of money, marketing, beauty, and lifestyle? • Will it give me professional satisfaction to carry out services which are not medically necessary? How do I see my role as ‘physician’? Moreover, there is the basic question of the type of patients who are interested in surgical cosmetic procedures. Overall it can be said that today’s society is more open to such procedures because of an altered perspective on life. Appearance is growing ever more significant in our actively aging society. Motives for having a procedure done vary depending on individual and gender. Some of the most common motives for undergoing aesthetic–corrective surgery are3:

• What are the core skills of the office or clinic operator, and what spectrum of services does he want to offer? • What services and benefits will be offered to patients by the medical services and what sort of patient clientele are these services trying to attract? • What staff or technical facilities are already in place or will be required? • How can the attention of the desired patient clientele be drawn to the office/clinic and how can we inspire trust in the facility?

• To look as young as one feels; • To escape genetically inherited stigmatizing physical proportions;

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• To correct physical asymmetry; • To give oneself a psychological boost after a change in life circumstances; • To maintain a youthful appearance.

must represent internal targets. A large-scale marketing campaign should, if possible, cover all areas comprehensively. A professional image of the facility must be established. A badly run advertising campaign can ruin a successful company. External advertising measures can be direct or indirect. Direct marketing strategies include3:

It is not just the rich celebrities who have aesthetic surgery performed. Nor is it, contrary to widespread prejudice, only the psychologically unstable, egotistical, overly vain, or otherwise unusual people (see Chapter 24), but rather normal people wanting to make specific improvements to their faces or bodies. In this respect, the motives are neither ‘good’ nor ‘bad’,‘right’ nor ‘wrong’. Overall, however, it can be said that patients undergoing surgery for one of these ‘typical’ reasons (namely improvement of appearance for personal reasons) are usually more satisfied with the course and result than patients with ‘non-typical’ motives (such as breast augmentation to save a marriage). Advertising measures must appeal to a wide target audience. The best marketing is the performance of good work. It is generally known that good results and personal recommendations can be far more effective than extravagant and costly marketing strategies. Patients who present themselves on the recommendation of other satisfied patients behave differently from those who have heard about the office or clinic through advertising campaigns. Generally, there is far more trust engendered in the former, while the confidence of the latter group in the abilities of the surgeon must first be gained. In order to establish efficient external marketing, it is recommended to consult or work with a firm specializing in this area. The goals of the planned campaign must be established together. What is important here is to remember the basic principle: external marketing

• Graphic media: newspapers; illustrated magazines with large or smaller distribution; free magazines; • Radio: interviews regarding specialty questions; • Television: reports on new techniques; • Internet: website; e-mail; chat; • Postcards or newsletter mailings to patients; • Information seminars for patients; • Information on the range of services of your own facility, or slide-shows of the services offered, in the waiting room (PowerPoint presentation); • Free information brochures; • Yellow Pages. Indirect marketing strategies include: • Independent press reports; • Specialty publications and scientific presentations; • Membership in professional associations; • Participation in congresses.

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television in interviews or short reports. In such cases (except in the case of live transmission), one has no influence over any editing of the report, which in some cases negatively distorts an issue. An increasingly important source of information is the Internet. An appealing and informative homepage must be set up. It is important to find a short, effective name which sticks in one’s mind and is easy to spell.The name must have a discernible connection to the range of services offered. The site should appear in the most important Internet browsers and should prompt users to call or e-mail.The extent to which the homepage arouses interest and leads to contact should be registered continually to enable the efficacy of the homepage to be monitored. It can be useful to dedicate a staff member specialized in the time-consuming task of dealing with e-mail inquiries to answer questions regularly. In anticipation of the most common questions, the homepage for the various procedures can include a presentation of the frequently asked questions (FAQs) and their responses. The procedures may be explained in appropriate clarity and detail. Nevertheless, there are still patients who will make repeated inquiries to have issues clarified. Whether it is worth establishing a chatroom for the exchange of patient information cannot yet be assessed, since this is a relatively new medium. The regular dispatch of a newsletter to patients ensures that they are constantly informed of new methods and maintains contact with the clinic or office. This can also be done in the form of an ‘electronic newspaper’ via e-mail. Experience with this medium varies, since many patients are already overwhelmed by a flood of e-mail every day. Information would

It must be ensured that there is no departure from the sphere of factual information, as stipulated in the professional standards regulations. Since it is generally cost-prohibitive, not all of the advertising measures mentioned can be used. One should consider the advantages and disadvantages of the various media. Graphic media have the advantage that they can convey a lot of information for a relatively low cost and enable effective presentation of the spectrum of performance (e.g. by way of ‘before and after’ photos). Advertising in newspapers and magazines must fulfill the requirements of the professional standards regulations.This means that the physician may present only factual, professionally related information. Misleading or comparative advertising, even through third parties, is forbidden. Any commercialization contrary to the image of the medical profession is to be avoided. The preparation of small, freely distributed patient guides in book form can be more sensible than the distribution of simple brochures. A book suggests greater integrity and is less easily thrown away. The production costs depend on the print quality and the number of illustrations, but experience shows that the investment is worthwhile. A book initiates numerous patient contacts, and it is often passed on to friends or acquaintances. Another advantage is that patients are already well informed about the procedure, which can make the initial consultation considerably easier and quicker. Specialized firms offer the creation and distribution of movie spots for local advertising. Here, too, the usual codes of professional conduct must be strictly observed. If one has established a certain identity in one area via indirect marketing (specialist publications, congresses), the opportunity sometimes arises to appear on

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One should consider the type of patient clientele that can be reached with the marketing measures discussed. Before a major external advertising campaign can be initiated, it must be ensured that there is sufficient capacity to deal with the increased demand. If this is not planned for in advance, many potential patients can be lost, and a negative image of the facility is created. Primarily important is the establishment of a perfectly functioning telephone service which can cope with the increased demand for services. The person on the telephone is the ‘business card’ of the practice or clinic, responsible for the caller’s first impression. It must be clear that every call or introduction as a result of the advertising campaign can be seen as a partial economic return on the investment made for this purpose. The act of reaching for the telephone requires an initial decision. It then depends on the practice team as to whether this call results in a consultation and finally an operation.The ratio between the calls received and the procedures actually carried out shows not only the quality of the administration staff but also the physician’s own ability. Every patient who decides against treatment represents an indirect loss through, in this case, fruitless investment.It can be useful in individual cases to ask why no operation resulted,in order to correct any errors in the practice procedure or consulting behavior.

have to be of exceptionally high quality in order to attract attention. Information events or lectures on a subject can bring the physician and his clinic to patients’ attention.Advertisements in the Yellow Pages are less meaningful, since most patients want more information about a clinic or office practice than just the telephone number before they are prepared to make contact. Besides advertisements in periodicals and magazines, the publication of an independent press report is a very effective marketing measure. Since only experts known as ‘opinion leaders’ get the opportunity, important for this method are continuous and convincing academic activity, the active participation in and organization of congresses and workshops, and the publication of scholarly work. What is important for the image of the clinic and patient loyalty (which can, after all, be an effective marketing aid by word-of-mouth referrals) is the establishment of a lasting and trusting relationship with each patient. This starts with patient-oriented communication from all of the staff (not just the physician, but also secretaries and assistants), and covers the entire time from the initial telephone contact to the operation itself. The postoperative care of the patient is also important, as is support in the case of any complications.

REFERENCES 1. Professional Regulations for Medical Practitioners in Hessen, Germany published 1 October 1998, as at 1.2.2003

Esthetic Medicine], 1st edn. München: Urban & Fischer, 2003: 83–94 3. Blugerman G. External marketing strategies. Personal communication

2. Tomas JK. Advertisement of cosmetic interventions. In Dirschka T, Sommer B, Usmiani J, eds. Leitfaden Ästhetische Medizin [Manual of

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legitimate, or merely tolerable, as there is on the issue of the boundaries of aesthetic medicine. The physician offering aesthetic surgical procedures finds himself constantly confronted with this discussion, and a certain compulsion to justify his actions. In this respect, it is remarkable with just how few facts the public discussion is conducted, and how few scientific studies have been performed on the issue of, the need for, and the benefits of aesthetic medicine. Therefore, in conjunction with the University Hospital of Freiburg, in 1999 a scientifically supported study was carried out to evaluate sociodemographic patient data and patient satisfaction following liposuction treatment using tumescent local anesthesia at the Rosenpark Clinic1. Starting points for the study were the questions:

In aesthetic medicine, we dealing with patients who want to change their external appearance. To what extent this desire is legitimate is a constant subject for discussion both in specialty circles and in the media. Is it ‘abnormal’ to reject the natural state of the body? Should not one work on one’s psyche and self-confidence rather than resort to ‘artificial change’ through outside intervention? Indeed, many ‘artificial changes’ to improve the ‘untreated’ natural state, with which few people are satisfied, are totally accepted by society and part of everyday life for the inhabitants of modern industrialized nations: starting with applying make-up every day, visiting the hairdresser or ‘dressing up’ in fashionable clothes, we are constantly trying to improve our appearance. Even ‘natural’ people have a tendency to change their appearance. However, unlike the everyday improvements described above, in aesthetic medicine an invasive procedure is selected to effect these changes.The violation of the body’s external integrity that one endures in these medical treatments, such as occurs for every blood test, and the associated minor or major risk of possible side-effects give these procedures another dimension. There is just as little consensus on the level of those external changes that are necessary,

• How can patients undergoing medical– aesthetic procedures be characterized psychologically? • What aesthetic attitudes do patients have and how does the procedure impact on their quality of life? For this, letters were sent to 300 randomized patients selected retrospectively from a list of

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for most patients, a low-stress and highly satisfactory procedure. The patient groups studied were not unusual from a psychopathological viewpoint. With regard to their attitude to aesthetics, the patients displayed a different picture, with group-specific differences. Quality of life for some patients was considerably reduced prior to the procedure. It was shown that medical–aesthetic measures can improve quality of life. To be able to conduct objective discussions in the future on the usefulness and benefits but also the limitations of aesthetic medicine, it would be desirable to conduct further comparable studies.

1200 patients who had undergone liposuction with tumescent anesthesia at the Rosenpark Clinic 3–25 months previously, requesting that the patients fill out a standardized questionnaire. The questionnaire was prepared by a working group of dermatologists and psychologists experienced in psychological test procedures (Freiburg questionnaire on aesthetic and cosmetic surgery). In part I, questions were asked regarding physical perception, personal hygiene, social contact or isolation, and selfconfidence. Part II consisted of questions on the results of the liposuction treatment, effects of the treatment on the body and the psyche, social effects, and satisfaction with treatment. Of the 300 patients approached, 159 (53.0%) returned the questionnaire. Of these, 92% were female, and the average age was 45 years. The average body mass index (BMI) was 24.5, and 61.7% of the patients had a normal BMI. With regard to sociodemographic factors, a comparatively high social status was observed. Most of the patients were so-called ‘white collar workers’ or self-employed. Education standards were basically in line with the national distribution in Germany, but with a very high proportion of academics at 27%. Seventy-five per cent of the patients were married or in a steady relationship. Statistical evaluation of the questionnaires showed a very high level of satisfaction, with 85% satisfied or very satisfied. Over 80% of patients considered that the procedure was not a stressful event. Ninety-one per cent reported a positive effect on their physical lives, 40% on their social lives, 57% on their attractiveness, and 20% on their professions. The study therefore concluded that liposuction using tumescent local anesthesia represents,

PERIOPERATIVE PATIENT MANAGEMENT IN THE CASE OF LIPOSUCTION Patients undergoing aesthetic medical treatment are generally very motivated and co-operative. In order to relieve a patient’s natural fear of a surgical procedure and increase their satisfaction, careful and detailed patient explanations are required in advance.The patient should be sufficiently informed of the course of the procedure and the anesthesia method. Postoperative behavior (e.g. how long should the compression garment be worn, are visits to the sauna or sunbathing allowed?) should be discussed. One should try to induce only realistic expectations, accurately assessing one’s own abilities, possibilities, and limitations and conveying these to the patient. The patient should understand the operating procedure; sketches are a better aid here than actual photographs. Very anxious patients who find it difficult to deal with the surgical setting may be given an

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Figure 24.1

Satisfied patient perioperatively

appropriate anxiolytic medication. Occasionally, this is requested by the patients themselves. Reasons for this can be fear of the operation, and associated nervousness and increased sensitivity to pain. During the operation, the patient should feel safe and comfortable (Figure 24.1). The surgeon should, if possible, maintain verbal contact with the patient throughout the whole period of anesthesia and aspiration. He should inform the patient of every step in the procedure, so that the patient is prepared for any unpleasantness or pain. Inquiries as to the patient’s well-being and explanations show the patient that the surgeon is focused on her and on the operation. For this reason, any unnecessary disturbances from outside should also be avoided. Besides enabling almost constant monitoring of the patient’s overall condition and the rapid discovery of any problems with the mental or physical state, constant contact also serves to distract the patient from the strange and often stress-inducing atmosphere of the procedure room. The powerful, positive effect of a pleasant ambience with a relaxed atmosphere and a

Figure 24.2

Satisfied patient postoperatively

distracting conversation with the surgeon or the surgical staff is generally not given enough weight in the literature. Experience shows, further, that suitable music, if possible with an adjusted metronome tempo of 60 beats/min, contributes to stress reduction and a lowering of the patient’s pain sensitivity without causing any side-effects. Music can be played softly in the background if the patient so wishes. After the operation the patient should be instructed in how to fit the appropriate compression garment. The patient should be thoroughly informed of the normal postoperative progression. She should be aware of what kind of pain can occur and where, how intense it may be, and how long it may last. She should be thoroughly informed on the timely progression of fluid discharge/drainage, otherwise she will anxiously return to the clinic. She must be aware of the most common complications, how to recognize them, and when it is advisable to return to the surgeon.A mobile phone number for emergencies, where nursing staff or the

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A check-up appointment arranged immediately after the operation also gives the patient the feeling that she is being looked after conscientiously, and allays the fear of having to cope with any complications alone (Figure 24.2).

surgeon can be reached, reassures the patient that she can get help at any time. An information sheet with the most important points, including the emergency number, is very helpful. It can include, for example, notes on the type and dosage of medications (e.g. antibiotics, pain-killers).

REFERENCE 1. Augustin. Dermatol Surg 2000;

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Index abdomen 11, 104–13 abdominal wall perforation 181, 186 adenolipomatosis 17, 65 adipocytes 13 adiposalgia 17 adipose tissue 13–20 development 13–14 disorders of 64–5 hyperplasia 18 pathological disorders 17 pathophysiology 16–17 physiology 14–16 postoperative distribution 196–7 adiposis dolorosa 17, 64 adjuvant/secondary procedures 52, 54, 141–8 dermatolipectomy 145–7 liporecycling 142–4 liposhifting 144–5 subcision 144 vibration-assisted re-liposuction 147 adrenaline 28–30 reactions to 179 aesthetic complications 184–5 Allen–Hines syndrome 17 allergic reactions 178–9, 186 analgosedation 41–2 anesthesia 39–42, 52, 54 complications 176–80 information 39–40 local anesthetics see local anesthetics patient release 42 postoperative phase 42 preliminary examination 40 premedication 41 sedation/analgosedation 41–2 ankles 132–8 archiving 189–93

aspiration volume 171 mega-liposuction 87, 165 aspirator 74–5 asymmetry 201 Avelar, Juarez 146 axillary hyperhidrosis 66–7 back 110–15 Blugerman, Guillermo 146 breast female 96–9 male 93, 95–6, 97 calves 132–8 cannulas 75–6 motor-driven 9 vibration 2–3, 76–7 cardiovascular reactions 178 cavitation processes 9 cellulite 63–4 cellusuctiontome 1 cheeks 88–93, 94 chin 88–93, 94 circulatory instability 180, 186 clientele 211–14 complications 51–2, 175–87 acute 158 aesthetic 158, 184–5 documentation 172 frequency of 176 guidelines 172 liposuction 180–5 intraoperative 180–1 postoperative 181–5 method of anesthesia 176–80 compression garments 154–5 consultation 49–54

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Index

adjuvant procedures and anesthesia methods 52, 54 complications and risks 51–2 costs and methods of payment 54 expected results 52 explanation of procedure 51 history 51 informed consent 51–2, 53 operative plan 52 patient’s wishes 50–1 postoperative course 54 preoperative studies 54 contraindications for liposuction 70–1 absolute 70 relative 70–1 criss-cross technique 2 Crunelle, Bernard 146

forearms 99–104 Fournier, Pierre 2, 142

deep vein thrombosis 181–2, 185–6 Dercum’s disease 17, 64 dermatolipectomy 145–7 dermatologists, role of 3 documentation 172, 189–93 photographic 84 dressings 154–5 dry technique 8

healing phase 158 hematoma 182–3, 186 Hexsel, Doris 144 hips 115–16 history 1–5 hyperplastic adiposity 13 hypertropic adiposity 13

Germany 3–4 gluteal region 116–20 Gross, Charles 2, 9 guidelines 169–73 complications 172 documentation 172 equipment 171 establishment of indication 170–1 mega-liposuction and volume 171 operating technique 171 postoperative care and medication 172 preoperative status 170 training, education and performance 169–70 gynecomastia 65–6

Illouz,Yves-Gerard 1 indications for liposuction 61–71, 170–1 aesthetic reasons 61–2 cellulite 63–4 establishment of 170–1 medical 64–9 infections 183, 186 informed consent 51–2, 53 instruments 73–7 aspirator 74–5 cannulas 75–6 guidelines 171–2 powered liposuction 76–7 pump systems 73–4 vibration cannulas 76–7

emergency cases 82 endoscopy 149–51 epinephrine see adrenaline equipment guidelines 171–2 errors, avoidance of 199–202 asymmetry 201 loss of skin turgor 201–2 non-physiological proportions 202 overaspiration 201 skin rippling 199–201 expert reports 203–5 fat accumulation 16 fat embolism 182, 186 feeding fat 120 Fischer, Arpad 1, 21–5 Fischer, Georgio 1, 21 flanks 104–13 fluid accumulation 196–7

Karman aspirator 1 Klein, Jeffrey 2, 3, 22 tumescent solution composition 23 knee 128–32

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Launois-Bensaude syndrome 64 leptin 15–16 lidocaine 29, 30, 157 clinical pharmacology 32 toxicity 33 lipase 16–17 lipedema 68–9 lipoatrophies 17 lipodystrophy syndrome 65, 66 lipoma 67–8 lipomatosis 10 liporecycling 142–4 liposhaving 2, 9 liposhifting 144–5 liposis, benign symmetrical 64 local anesthetics 28–30 infusion protocol 191 reactions to 176–9 see also anesthesia lower legs 132–8 lymphedema, postoperative 183, 186

abdomen and flanks 104–13 back 110–15 female breast 96–9 gluteal region 116–20 guidelines 171 hips and waist 115–16 knee 128–32 liposuction 84–8 lower legs, calves and ankles 132–8 male breast 93, 95–6, 97 marking of operation area 83 neck-chin-cheeks-back of neck 88–93, 94 photographic documentation 84 thighs 120–30 tumescent method 84 upper arms, forearms and shoulders 99–104 overaspiration 184–5, 201 panniculitides 17 patient dissatisfaction 184, 186–7 patient evaluation and planning 49–60 consultation 49–54 extent of operation 57–8 medical history 54–7 physical examination 57 preoperative evaluation 58–9 patient information 153–4, 192 patient satisfaction 211–14 perioperative management 212–14 perioperative medication 155–6 guidelines 172 side-effects 179–80 photographic documentation 84 pinch test 61 postoperative care 153–8, 197–8 complications 158 dressings and compression garments 154–5 guidelines 172 normal progression 157–8 observation 156–7 patient information 153–4 perioperative medication 155–6 postoperative complications 181–5 aesthetic 184–5 patient dissatisfaction 184 unsatisfactory results 184–5

malpractice 203 manually assisted skin stabilization technique (MASST) 86, 198 marketing 207–10 MASST see manually assisted skin stabilization technique medical history 54–7 mega-liposuction 87, 165 guidelines 171 metabolic syndrome 17–19 methemoglobin, prilocaine-induced 34, 179 micrograft fat cutter 145 monitoring equipment 82 mortality rates 165 motor-driven cannulas 9 neck 88–93, 94 nerve damage 181, 186 obese gene 15 obesity 7–8, 16 systemic disorders 17–19 operating technique 83–139

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fluid/fat accumulation 196–7 medical 181–4 deep vein thrombosis and pulmonary embolism 181–2 fat embolism 182 hematoma 182–3 infections 183 seroma and persistent lymphedema 183 skin necrosis and scarring 183–4 powered liposuction 76–7 power and emergency power 82 premedication 41 preoperative evaluation 58–9, 170 prilocaine 29, 30, 157 clinical pharmacology 32 toxicity 34, 179 procedure room 79–80 equipment guidelines 171 pulmonary embolism 181–2, 185–6 pump systems 73–4

subcision 144 subcutaneous tissue 14–16 super tumescence 7, 22, 43 surgical setting 80–1 syringe-assisted liposculpturing 2, 142 systemic disorders 17–19 thighs 120–30 inner 124–5 outer 10, 125–6 tissue types 195–6 training 169–70 tumescence 43–5 tumescent technique 7, 21–38 advantages and disadvantages 26–7 definition of 21 dermatolipectomy 145–7 history 21–2 infiltration method 24–6 local anesthetic dose 34–5, 36 operating technique 84 patient selection and preparation 27–8 pharmacology and toxicology 28–34 safety 34–5 solution composition 22–4 supplementary anesthesia procedures 36–7 wound healing 47–8 see also anesthesia

risks 51–2, 175–87 liposuction 180–5 method of anesthesia 176–80 see also complications saddlebags 1 see also gluteal region; thighs safety 161–7 Sattler, Gerhard 3, 22 tumescent solution composition 23–4 scarring 183–4 sedation 41–2 seroma 183, 186 shoulders 99–104 skeletization 184–5, 201 skin flap mobilization 67 skin necrosis 183–4, 186 skin rippling 199–201 skin turgor, loss of 201–2 sterilization 81

ultrasound-assisted liposuction 9 upper arms 99–104 vascular damage 180–1, 186 vibration-assisted liposuction 9 vibration-assisted re-liposuction 147 vibration cannulas 2–3, 76–7 waist 115–16 water-jet technique 9, 11 wet technique 1–2 wound healing 47–8

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