Major Liposuction



10.1055/b-0034-97723

Major Liposuction

Justin B. Cohen & Terence M. Myckatyn
A 41-year-old woman presents to the clinic to discuss possible surgical options to improve the appearance of her “saddlebags.”


Description




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



  • Skin redundancy and residual adiposity noted on the central trunk.



Work-up



History




  • Weight stability.



  • Medical comorbidities.



  • Patient concerns, expectations, and goals of treatment.



Physical examination




  • Evaluate regions of suboptimal contour, asymmetry, lipodystrophy.



  • Evaluate skin quality and tone (thickness and elasticity): Pinch test.



  • Examine for hernias, diastasis.



Treatment




  • Liposuction is a contouring procedure.




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



    • Does NOT address cellulite or obesity.



    • Does NOT resect skin.



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



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



  • Wetting solution technique (Table 33.1)




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



    • Provides anesthesia and hemostasis.



    • 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



  • Liposuction modality




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



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



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




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



      • Precautions to avoid cutaneous thermal injury.



    • Laser-assisted liposuction (LAL).



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




    • Replace preoperative deficits.



    • Employ superwet or tumescent technique.



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



    • Titrate 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 × aspirate.



    • 25 to 30% of infiltrate is removed with aspirate.



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




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



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



    • Dilute lidocaine further if greater volume of infiltration is necessary.



  • Deep venous thrombosis (DVT) prophylaxis




    • Mechanical: sequential compression devices.



    • Ambulate day of surgery.



    • Chemoprophylaxis not standardly required.



  • Postoperative care




    • Early ambulation.



    • Compression garments for 4 to 6 weeks.

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Jun 18, 2020 | Posted by in General Surgery | Comments Off on Major Liposuction
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