Brief introduction

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  Suction-assisted lipectomy, or liposuction, continues to be one of the most popular means of body contouring and overall treatment modalities offered in aesthetic surgery today.

  
  
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  With greater understanding of the biochemical and physiologic properties of liposuction, as well as biomedical technological advancements, suction-assisted lipoplasty has undergone tremendous evolution, leading to overall improvements in technique, patient safety, and outcomes.

  
  
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  Over the past 2 decades, it has grown from a procedure that facilitates small or spot reductions to one that has become an almost irreplaceable tool in neck, breast, and circumferential body contouring.

  
  
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  A number of important innovations and modifications to the standard suction-assisted liposuction (SAL) have progressively refined the procedure, including the use of wetting solutions, advances in cannula design, ultrasound-assisted liposuction (UAL), power-assisted liposuction (PAL), vibration amplification of sound energy at resonance (VASER)-assisted liposuction, and laser-assisted liposuction (LAL).

  
  
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  There has been a strong movement concentrated on defining appropriate safety guidelines for liposuction and other body contouring procedures focusing on deep venous thrombosis (DVT) prophylaxis and fluid resuscitation, ensuring safety and efficacy of the different treatment modalities for our patients.

Preoperative considerations

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  A successful body contouring patient must satisfy four key elements to achieve and maintain optimal results:

  
  
  
  
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    Lifestyle change.

    
    
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    Regular exercise.

    
    
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    Well-balanced diet.

    
    
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    Body contouring.

  
  
  
  
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  Liposuction is contraindicated in patients who are pregnant or in poor general medical health. Likewise, patients with morbid obesity, cardiopulmonary disease, body image perception issues, unrealistic expectations, wound healing difficulties, or who have extensive or poorly located scars should be excluded from consideration for liposuction.

  
  
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  Patient goals must be clearly elucidated, and realistic expectations must be established.

  
  
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  A detailed physical exam is performed, with specific attention to prior scars, presence or absence of hernias, evidence of venous insufficiency, and presence of preexisting asymmetry or contour irregularity.

  
  
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  For liposuction candidates, six key elements are documented:

  
  
  
  
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    Evaluation of areas of lipodystrophy and contour deformities.

    
    
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    Skin tone and quality.

    
    
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    Asymmetries.

    
    
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    Dimpling and cellulite.

    
    
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    Myofascial support.

    
    
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    Zones of adherence.

  
  

Anatomical pearls

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  Anatomy texts divide subcutaneous fat throughout the body into superficial and deep layers or compartments separated by Scarpa fascia or the superficial fascial equivalent.

  
  
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  For the purposes of liposuction and body contouring, subcutaneous fat is arbitrarily divided into three layers: superficial, intermediate, and deep ( Fig. 8.1 ) .

  
  
  
  
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    The intermediate and deep layers are the most commonly treated areas.

    
    
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    The superficial layer is one that should be approached with caution, as aggressive or improper treatment of this layer may result in injury to the subdermal plexus and/or contour irregularities.

    
    
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    The relative consistency and thickness of each of these separate layers varies for different anatomic areas: fat of the back has a more fibrous, compact superficial and intermediate layer, with an underlying loose, areolar layer, while fat of the inner thigh is not as fibrous and is less compact.

  
  

  
  

  
  

  

  
  

  
  

  Surgical layers of subcutaneous fat: superficial, intermediate, and deep.

  
  
  
  
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  Anatomic “zones of adherence” are areas of relatively dense fibrous attachments to underlying deep fascia and help to define the natural shape and curve of the body ( Fig. 8.2 ) .

  
  
  
  
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    Important to identify during the preoperative consultation, as they are high-risk areas for contour irregularities after surgical intervention if not properly respected.

  
  

  
  

  
  

  

  
  

  
  

  The zones of adherence are areas where the fibrous support structures of the subcutaneous fat and skin are adherent to the underlying deep fascia. These attachments create adherence and depressions contributing shape of the body’s surface.

  
  

Classification

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  It is helpful to classify patients based on the three types of lipodystrophy and skin redundancy ( Fig. 8.3 ) :

  
  
  
  
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    Type I: localized lipodystrophy. Often younger patients with good skin tone and minimal skin irregularities.

    
    
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    Type II: generalized lipodystrophy. Patients with lightly diminished skin tone, some skin irregularities, and circumferential lipodystrophy throughout their trunk and extremities.

    
    
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    Type III: skin redundancy and lipodystrophy. Patients with significant skin redundancy that would be more amenable to excisional surgical techniques. However, liposuction may be a useful adjunct in order to achieve an optimal result.

  
  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  

  
  

  
  

  Patient examples of three types of patients (I–III): first six images, patient type I; second six images, patient type II; third six images, patient type III.

  
  
  
  
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  Cellulite: dimpling of the skin, particularly in the areas of thighs and buttocks thought to be related to fibrous, dermal attachments to the underlying fascia surrounding hypertrophied fat.

  
  
  
  
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    There is no predictable, long-term treatment of cellulite.

    
    
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    Liposuction in areas of overlying cellulite may soften or accentuate the superficial deformity.

  
  

Operative technique

Marking and positioning ( Fig. 8.4 )

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  Guiding marks are performed prior to surgery with the patient in the erect position. Marking the patient in front of a mirror allows the patient to contribute to the process and further confirms exactly what will be addressed during the procedure.

  
  
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  Areas to be suctioned are marked with a circle, while zones of adherence and areas to avoid are marked with hash marks.

  
  
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  Asymmetries, cellulite, and dimpling are marked for their respective treatment and to allow patients to see problem areas.

  
  
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  Access incisions are also marked at this setting. Often, two incisions are needed per area to be suctioned, and these incisions should be placed adjacent to suctioned areas and not too distant.

  
  
  
  
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    Avoid placing access incisions in or adjacent to zones of adherence.

    
    
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    The surgeon should not hesitate in placing additional incisions if access is insufficient with the existing markings.

  
  

Patient has been marked prior to surgery. Markings demonstrate the contours of the areas to be suctioned as well as the planned incision sites.

Anesthesia technique/location of operation

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  It is up to the surgeon to determine the optimal surgical setting for each patient undergoing liposuction. Factors that influence this decision are the amount of expected lipoaspirate, length and extent of procedure, patient positioning, operating surgeon preference, anesthesiologist preference, and overall health of the patient.

  
  
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  As a general rule, small-volume liposuction cases can be performed with local anesthesia, with or without mild sedation, while complex, large-volume liposuction and combined cases should be performed under general anesthesia or regional block.

  
  
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  The anticipated postoperative course and the need for possible overnight observation both factor into choice between inpatient observation or outpatient hospital settings.

  
  
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  Awake liposuction has been performed in the office-based setting with a tumescent technique, and the authors prefer to do such procedures only for single-area treatments or in small revisions.

  
  
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  To prevent the patient from being cold during the operation, all areas not being treated should be covered by a forced warm air blanket, and the wetting solutions should be warmed and not administered cold

Wetting solutions and perioperative fluid management

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  Infiltrating wetting solutions (saline or lactated Ringer’s mixture with dilute amounts of epinephrine and lidocaine) prior to suctioning provide hydrodissection, improve hemostasis, and potentially provide some perioperative analgesia.

  
  
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  There are four different terms used to describe the types of wetting technique based on the volume of infiltrate as a ratio of the volume suctioned: dry , wet , superwet , and tumescent ( Tables 8.4 and 8.5 ).

  
  
  
  
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    The dry technique uses no wetting solution and has few, if any, indications in liposuction.

    
    
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    The wet technique involves pre-infiltrating 200–300 mL of solution per region to be treated, regardless of the anticipated amount to be aspirated.

    
    
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    The superwet technique employs an infiltration of 1 mL of solution per estimated 1 mL of expected aspirate.

    
    
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    The tumescent technique involves extensive infiltration of wetting solution that creates significant tissue turgor and results in total infiltration of ~3 mL of wetting solution per 1 mL aspirated.

  
  
  
  

  Table 8.4

  
  

  Estimated blood loss with different liposuction techniques ¹⁹

  
  

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  Technique	Estimated blood loss as % of volume aspirated
  Dry	20–45
  Wet	4–30
  Superwet	1
  Tumescent	1

   
  

  (Data from Fodor PB. Wetting solutions in aspirative lipoplasty: a plea for safety in liposuction. Aesthet Plast Surg . 1995;19(4):379–380.)
  
  
  
  

  Table 8.5

  
  

  Techniques of liposuction and infiltrates ¹⁹

  
  

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  Technique	Infiltrate	Volume aspirate
  Dry	No infiltrate	To treatment endpoint
  Wet	200–300 mL/area	To treatment endpoint
  Superwet	1 mL infiltrate:1 mL aspirate	1 mL aspirate/infiltrate (treatment endpoints)
  Tumescent	Infiltrate to skin turgor	2–3 mL aspirate/mL

   
  

  (Data from Fodor PB. Wetting solutions in aspirative lipoplasty: a plea for safety in liposuction. Aesthet Plast Surg . 1995;19(4):379–380.)
  
  
  
  
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  Regardless of the technique used, the infiltrate should be allowed to set for 10 min and no longer than 30 min prior to suctioning.

  
  
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  Most wetting solutions utilize lidocaine as the local anesthetic component to be included in the wetting solution.

  
  
  
  
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    It can provide analgesia for up to 18 h postoperatively when injected in dilute concentrations into the subcutaneous space.

    
    
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    Toxicity from lidocaine affects the heart and central nervous system most commonly, with initial signs and symptoms including circumoral numbness, tinnitus, and lightheadedness.

    
    
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    Increasing levels can yield tremors, seizures, and eventually cardiopulmonary arrest.

    
    
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    The traditional recommended maximum dose of lidocaine with epinephrine is 7 mg/kg; however, in the liposuction setting, numerous studies have documented the safety of lidocaine in concentrations >35 mg/kg and as high as 55 mg/kg in large-volume cases.

  
  
  
  
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  The epinephrine contained in wetting solutions, with its vasoconstrictive properties, is the key to minimal blood loss during liposuction. This effect also decreases the rate of vascular absorption of lidocaine, potentiating the local anesthetic effect.

  
  
  
  
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    Epinephrine toxicity can result in tachycardia, hypertension, and arrhythmias.

    
    
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    Most commonly, epinephrine in 1 mg with 1/1000 dilution is injected into a 1-L bag of infiltrate, either normal saline (NS)/lactated Ringer’s (LR).

  
  
  
  
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  Perioperative fluid management during liposuction procedures requires attention to maintenance of intravenous fluids, third-space losses, wetting solution infiltration, and lipoaspirate.

  
  
  
  
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    Liposuction is considered a moderate surgical stress; therefore, 3–5 mg/kg per h of crystalloid solution is adequate volume for maintenance replacement and third-space losses.

    
    
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    Additional fluid may be given during procedures in which the lipoaspirate amount is more than 5 L, with the ratio of 0.25 mL of crystalloid solution for each aspirated mL over 5 L considered appropriate.

  
  
  
  
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  Body contouring procedures can result in significant fluid shifts and intravascular volume changes for the patient.

  
  
  
  
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    Awareness of four key elements will guide the intraoperative fluid management of liposuction patients: intravenous fluid maintenance (body weight dependent), third-space losses, volume of wetting solution infiltrated, and total lipoaspirate volume.