Before the advent of modern plastic surgery, body contour alterations were reluctantly accepted and hidden under heavy clothing. Not until the second half of the last century did medical advances permit, for the first time, the surgical correction of contour deformities. Currently, the exposure of the body by revealing attire together with the desire to demonstrate fitness and youthfulness in an increasingly competitive society have created a stereotype model of slimness that is constantly reinforced by mass media and propaganda. This greater consciousness of the human form is further emphasized by the high value placed on physical beauty, especially as regards the female body, where social and professional success is often a consequence of attractiveness. On the other hand, sedentary lifestyle and dietary excesses, associated with factors such as genetic determination, pregnancy, and the aging process, contribute to alterations of body contour that create a strong psychological motivation for their correction. Localized fat deposits and skin flaccidity are sometimes resistant to the sincerest effort in weight loss and sport activities. This ever-increasing request for contour surgery has been favorably met by safe anesthesiology and efficient surgical techniques, resulting in a high degree of patient satisfaction.
Correct diagnosis of contour deformities should include a detailed history of weight fluctuation, endocrinologic status, careful physical, and photographic inspection. The relationship between “content and container,” that is, the amount of excess fat and skin flaccidity, is an important aspect that will determine between a procedure with minimal incisions, such as liposuction (also called suction-assisted lipectomy), and surgical resection of excess tissue (i.e., dermolipectomies). Finally, the patient’s psychological motivation should be investigated in detail, in order to avoid expectations that are unacceptable or impossible to accomplish. Whenever a dermolipectomy is deemed necessary, the position and extent of scars should be carefully described and demarcated. Explanation regarding the healing process helps patients understand how scars will become more acceptable over time. The possibility of combining procedures should be considered. Factors that determine the feasibility of operating on more than one anatomical region in a single operation include the patient’s status (general health, age), anesthetic considerations (total amount of drugs, accumulative blood loss), and the correct training of the surgical team. In combined procedures, it is most important that the cosmetic surgeon act as the leader in directing his or her assistants and nurses, so that each step is anticipated, with no loss of movement or time. The senior cosmetic surgeon has described this as an “orchestration” of the surgical team.
There has been an evolution of the different techniques for the correction of body contour deformities, as performed by the senior cosmetic surgeon in over 4 decades of experience. While it is true that liposuction has attained a position of great popularity owing to its efficacy and safety when well-indicated, redundant skin and adipose tissue may only be removed by surgical resection. This is particularly true of secondary cases that have been initially treated with liposuction alone and are seen to have a poor aesthetic result.
The number of indications for excisional body contour surgery has decreased substantially since the advent of liposuction in the late 1970s. For example, dermolipectomy of the trochanteric region as well as the medial thigh, which were relatively common, have become more limited. Nevertheless, this approach is still indicated in cases where significant skin flaccidity is present, either alone or associated with increased adiposity. On the other hand, there are a few cases in which we do not indicate aspiration, such as below knee level. Ultrasound-assisted liposuction, although shown to have good results in the hands of some colleagues, has not been adopted in our service.
Liposuction has proved to be an excellent technique in cases of moderate fat accumulation with no cutaneous flaccidity. This may be performed in many different anatomical regions simultaneously, in association with other procedures or by itself. In the gynecoid type of fat distribution, which is typical of the female patient, fat cells are actually hyperplastic, and accumulate on the lower abdomen, thighs, and buttocks. This explains why women have greater difficulty in mobilizing this type of adiposity. Suctionassisted lipectomy is particularly efficient in treating this form of lipodystrophy. Patients that present with accentuated lipodystrophy are informed that staged procedures will be planned in two or more sessions. An interval of at least 6 months between each session is considered ideal. This program avoids removing large amounts of fat, and minimizes metabolic, electrolytic, and hemodynamic alterations. Just as importantly, this staged approach permits a more gradual accommodation of the skin. Demarcation of the areas to be treated is done preoperatively with then patient in a standing position and preoperative photographs are taken at the office from different angles, which will serve to guide the cosmetic surgeon during the actual procedure.
On the day of liposuction surgery the patient is marked and then lightly sedated before entering the surgical suite. After appropriate anesthesia, local infiltration is done with 0.25% lidocaine and epinephrine (1: 500.000), even if the patient is under general anesthesia. The amount that is infiltrated depends on how much is expected to be aspirated. The wet technique is indicated for small-to medium-volume aspiration, whereas the tumescent technique is reserved for removal of large quantities of fat. The appropriate cannula is chosen and inserted through a stab incision in a natural crease. Pretunneling (passing of the cannulas with no vacuum) serves to establish the correct planes. Care should be taken to preserve connections between the subcutaneous tissue and the skin to avoid interrupting superficial innervation and vascularization, allowing for adequate lymphatic drainage. Therefore, superficial liposuction has to be done with moderation. With the cannulas connected to the aspirator, smooth strokes are applied in a fan-shaped fashion, in different planes of the subcutaneous tissue. Inspection of the regions and palpation serve as guides to check for adequate and equal removal of adiposity. By introducing the cannula from a different incision, crisscrossing is established. A feathering pattern should be applied, so as to smooth the edges of the demarcation. With experience, the cosmetic surgeon will “feel” how much fatty layer should be left. This is approximately 1–2 cm (depending on the anatomical region) and serves to protect the overlying skin while avoiding unsightly depressions and adherence of skin to muscle. It is better to err on the side of less removal, than to have to proceed to immediate correction of irregularities with fat injection. In our service, the largest case has been the removal of 9.8 kg, from a patient weighing 83 kg.
This was done under the tumescent technique. In the postoperative period, fluid replacement is dependent on the preoperative status, the amount aspirated, and hematocrit in the first 24 h. The following routine has been established. Replacement is done with saline solution, Ringer’s lactate, or glucose for small-to medium-volume aspiration. Plasma expanders may be indicated for larger volumes. In the patient that presents with a low red-cell count, blood replacement is utilized. This may be planned ahead, by either autologous transfusion or by hemodilution, which is done immediately before liposuction surgery. Collection of autologous blood for transfusion is begun 30 days preoperatively by banking 600 ml of concentrated red cells in two stages (15 days apart) or 800 ml of whole blood, also in two stages. Hemodilution implies the removal of whole blood before liposuction surgery, with rapid infusion of Ringer’s lactate or normal saline. This causes a decrease in blood loss in the aspirate and retains 400 ml of whole blood to be infused at the end of the procedure. The patient is given large amounts of isotonic fluids in the first week postoperatively. Dermotony (mechanical deep massage) is begun after 10 days, to free fascial adherences and even out small irregularities. The use of compressive, elastic garments is continued from the immediate postoperative period through the first 2 months.
Our website is not responsible for the information contained by this article. Webworldarticles.com is a free articles resource thus practically any visitor can submit an article. However if you notice any copyrighted material, please contact us and we will remove the article(s) in discussion right away.
This article was sent to us by:
Otto M. at
01282010
1. Nose Surgery or Rhinoplasty
All articles in this directory are property of their respective authors. Additionally, read our Privacy Policy
© 2010 WebWorldarticles.com - All Rights Reserved. Partners: Gunblade Saga