Description

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

  
  
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  Skin redundancy and residual adiposity noted on the central trunk.

Work-up

Treatment

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  Liposuction is a contouring procedure.

  
  
  
  
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    Best in areas of thick, elastic skin with underlying contour irregularity of fat.

    
    
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    Does NOT address cellulite or obesity.

    
    
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    Does NOT resect skin.

  
  
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  Perform preoperative markings with patient upright to determine treatment areas and asymmetries, and outline zones of adherence.

  
  
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  Target deep fat layer and cross-tunnel to prevent contour irregularities.

  
  
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  Wetting solution technique (Table 33.1)

  
  
  
  
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    Lidocaine, epinephrine, and bicarbonate solution added to saline or lactated Ringer solution.

    
    
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    Provides anesthesia and hemostasis.

    
    
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    Maximum lidocaine with epinephrine: 35 mg/kg.

  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

  Wetting solutions for liposuction

  Technique	Infiltrate	Estimated blood loss (% volume)
  Dry	None	20–45
  Wet	200–300 mL per area	4–30
  Superwet	1 mL of infiltrate per 1 mL of aspirate	1
  Tumescent	2–3 mL of infiltrate per 1 mL of aspirate (or to skin turgor)	1

  
  
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  Liposuction modality

  
  
  
  
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    Suction-assisted liposuction (SAL): Traditional liposuction technique.

    
    
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    Power-assisted liposuction (PAL): Motorized oscillating hand piece.

    
    
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    Ultrasound-assisted liposuction (UAL): Ultrasonic energy is applied after wetting solution to emulsify fat before aspiration.

    
    
    
    
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      Ideal for fibrous regions: Buttocks, lumbar region, gynecomastia.

      
      
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      Precautions to avoid cutaneous thermal injury.

    
    
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    Laser-assisted liposuction (LAL).

  
  
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  Fluid management for large-volume liposuction (critical safety issue)

  
  
  
  
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    Replace preoperative deficits.

    
    
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    Employ superwet or tumescent technique.

    
    
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    Administer maintenance intravenous fluid (IVF) + IVF replacement of 0.25 mL/1 mL of aspirate over 5 L.

    
    
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    Titrate IVF to patient′s clinical picture (e.g., urine output, vital signs).

    
    
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    Maintain intraoperative fluid ratio: (IVF + infiltrate)/aspirate = 1.2.

    
    
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    Older technique (Pitman): IVF + infiltrate = 2 × aspirate.

    
    
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    25 to 30% of infiltrate is removed with aspirate.

  
  
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  If large-volume liposuction (≥ 4 to 5 L) is performed, it must be done in an acute-care hospital or accredited facility.

  
  
  
  
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    Monitor vital signs and fluid balance with Foley catheter. Overnight inpatient observation.

    
    
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    Warm patient, fluids, and operating room to avoid hypothermia.

    
    
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    Dilute lidocaine further if greater volume of infiltration is necessary.

  
  
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  Deep venous thrombosis (DVT) prophylaxis

  
  
  
  
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    Mechanical: sequential compression devices.

    
    
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    Ambulate day of surgery.

    
    
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    Chemoprophylaxis not standardly required.

  
  
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  Postoperative care

  
  
  
  
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    Early ambulation.

    
    
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    Compression garments for 4 to 6 weeks.