Case 43 Major Liposuction

Dardan Beqiri and Rachel R. Sullivan

Case 43 Major Liposuction

**Case 43 (a, b)** A 46-year-old female presents to the clinic to discuss possible surgical options to improve the appearance of the “saddlebags” on her thighs.

43.1 Description

Significant, diffuse lipodystrophy noted bilaterally in saddlebag regions of upper lateral thighs

43.2 Work-Up

43.2.1 History

Weight stability
Medical comorbidities
Patient’s concerns and goals of treatment

43.2.2 Physical Examination

Identify regions of suboptimal contour, asymmetry, and lipodystrophy
Evaluate skin quality and tone (thickness and elasticity): Pinch test
Abdomen: Examine for hernias and diastasis

43.3 Patient Counseling

Discuss risk/benefit profiles of each procedure
Ensure the goals of the patient align with the goals of the procedure
- Liposuction is a contouring procedure
  - Best in areas of thick, elastic skin with underlying contour fat irregularity
  - Does not address cellulite or obesity: Cellulite thought to be due to hypertrophy of superficial fat within septa and/or increased skin laxity
  - Does not resect skin
Set expectations in regards to pain and swelling during the postoperative period

43.4 Treatment

Make preoperative markings with patient upright: To determine treatment areas and asymmetries, and outline zones of adherence
- Distal iliotibial tract
- Gluteal crease
- Lateral gluteal depression
- Middle medial thigh
- Distal posterior thigh
Preoperative considerations
- Complete blood count (CBC) if expecting to perform large volume procedure
- Deep vein thrombosis (DVT) prophylaxis (see Chapter 42)
- Hypothermia and necessary precautions
- Positioning
Target deep fat layer and cross tunnel to prevent contour irregularities
Wetting solution technique (see Table 43-1)
- Four types of liposuction techniques described based on the volume of infiltration or wetting solution injected: Dry, wet, superwet, and tumescent techniques
- Lidocaine, epinephrine, and bicarbonate solution added to saline or Ringer’s Lactate
- Provides anesthesia and hemostasis
- Maximum lidocaine with epinephrine: 35 mg/kg
Liposuction modality
- Suction-assisted liposuction (SAL): Traditional liposuction technique
- Power-assisted liposuction (PAL): Motorized oscillating hand piece
- Ultrasound-assisted liposuction (UAL): Ultrasonic energy applied after wetting solution to emulsify fat before aspiration
  - Ideal for fibrous regions: Buttock, lumbar, and gynecomastia
  - Precautions to avoid cutaneous thermal injury
- Laser-assisted liposuction (LAL)
  - Possible skin tightening effect due to heating of subdermal tissue
Fluid management for large-volume liposuction (Critical safety issue)
- Replace preoperative deficits
- Employ superwet or tumescent technique
- Administer maintenance fluids + replacement of 0.25mL per 1mL of aspirate over 5L
- Titrate intravenous fluid (IVF) to patient’s clinical picture (e.g., urine output, vital signs)
- Maintain intraoperative fluid ratio: [(IVF + infiltrate)/aspirate] ≈ 1.2
  - Older technique (Pitman): (IVF + infiltrate) = 2 x (aspirate)
- With aspirate, 25 to 30% of infiltrate is removed
If large-volume liposuction (≥4–5L) is performed, it must be done in acute-care hospital or accredited facility
- Monitor vitals and fluid balance with Foley catheter; overnight inpatient observation
- Warm patient, fluids, and operating room (OR) to avoid hypothermia
- Dilute lidocaine further if greater volume of infiltration is necessary
DVT prophylaxis (see Table 42.2 for risk stratification)
- Mechanical: Sequential compression devices
- Ambulate on postoperative day 0 (day of surgery)
- Chemoprophylaxis not routinely required, but should be considered

Postoperative care

Early ambulation

Compression garments 4 to 6 times in a week

Table 43.1 Wetting solutions for liposuction
Technique	Infiltrate	EBL (% volume)
Dry	None	20–45
Wet	200–300 mL/area	4–30
Superwet	1 mL infiltrate: 1 mL aspirate	1
Tumescent	2–3 mL infiltrate: 1 mL aspirate (or to skin turgor)	1
Abbreviation: EBL, estimated blood loss.