The patient lies supine only for treatment of the abdomen, while the frog position is preferred for inner thighs and knees, and a supine or lateral position for calves and ankles. When we operate on hips and the lateral femoral region the patient lies laterally, perfectly in line, with a cushion placed between the thighs so that the protruding area to be removed is emphasized to the maximum. The supine and prone positions may prevent us achieving correct liposculpture of hips and outer thighs. In the lateral position, in fact, the defect to be corrected is not changed by the underlying pressure of the lateral muscles of the thigh, flattened as they are by the weight of the patient in the supine or the prone position. The lateral position also allows for a better view of the surgical area and less bleeding through alternative compressive hemostasis by change of position.
Two longitudinal incisions of 3 mm are made with a no. 11 scalpel blade. The first is on the upper part of drawing, the second on the bottom, where the fat pad starts decreasing. The region is infiltrated with a solution of 500 ml of saline plus 1 ml of epinephrine by means of a multihole needle, until the contour of the region to be treated is clearly shown. For local anesthesia in minor deformities, 25 ml of 1% Xylocaine and 7 ml of sodium bicarbonate are added to the solution. Ice is then placed on the areas to be treated for better vasoconstriction. After 10–15 min, the time necessary to obtain an effective ischemia of the region, the operation is begun.
Tumescent infiltration with Klein solution is used only for removal of more than 4 l of pure fat. Fifty- milliliter syringes are used or a suction pump with 2–4-mm bent Mercedes-type or one-hole cannulas, and 5 ml syringes with 2-mm cutting-edge cannulas for refinements in the case of hard fat. Bent cannulas help us to work more easily parallel to the skin. After undermining intermediate and superficially in the area to be treated with a free cannula, we defat through tunnels in the intermediate plane first, using a 4-mm cannula until a substantial reduction of the deformity is obtained .
At this point, where traditional liposuction ends, the superficial liposculpturing begins. After intermediate (in the middle of the fat pad thickness) fat removal the area is improved; however, with a few maneuvers, some untreated residual fat can be seen to remain and will be visible only when the patient is in the orthostatic position. By pushing the gluteus downward to simulate the effect of gravity, subdermal superficial fat is seen along the whole area of the treated region. Using a 3-mm cannula, a number of crisscrossing tunnels are made to remove this residual fat, by aspirating very superficially.
The treated area and the surrounding zones are then refined by superficial aspiration with a 2.5-mm cannula. The skin of the treated region, and the areas close to it for approximately 10-cm around, must be widely undermined to allow a perfect redistribution of the skin flap, evoking a more harmonious retraction of the thin flap, especially in very flaccid skin patients and in secondary lipoplasty. In case any minor irregularities still remain, it is preferable not to persist with cannulas but to digitally mold the fat. The flap thickness has to differ slightly from the various points of the treated areas, to achieve a harmonious three-dimensional design of curves and volumes. The superficial adipose layer remaining after the suction is extremely thin, and lies on the intermediate fat previously treated.
So-called banana folds can be corrected by superficial liposculpturing. Aspirating superficially good skin retraction can be obtained without removing the deep fat supporting the gluteus weight, avoiding gluteal fall. Another good evaluation of the profile is done “eyeballing” the patient at thigh level. This method allows adjustment for any asymmetry. Each side must look the same, although different quantities of fat will be removed. A final pinch test helps to determine if there is symmetry of both sides. Afterwards, a vacuum drain is inserted through a cannula driven through the lower incision, to avoid excessive bruising and possible permanent hyperpigmentation. The subcutaneous area is irrigated with 160 mg of gentamycin diluted in 50 ml of saline. While bandaging the area with Tensoplast, the skin is lifted upward according to Langer’s skin tension lines to ensure a perfect readaptation of the flap. T
he bandages are reinforced with tape. Bandages are only used for the lateral femoral region. Reston foam is used for dressing other areas and then the patient wears a compressive garment at the end of the operation. The patient who undergoes general anesthesia is hospitalised for 12 h, during which time the vacuum drains are kept in place. Tensoplast and Reston foam stay for 4 days. When they are removed, the patient wears a more compressive elastic garment for 30 days during the daytime only. The garment we designed (Lipopanty or Liposhape, Medestea Internazionale, Italy) has elastic reinforcements specifically conceived to support, not only to compress, the most critical areas. The contraction of the skin flaps of the treated areas lifted upward by tape first and then by the garment will determine a slight elevation and rotation of the gluteus upward. Patients wear compressive stockings for 30 days during the daytime when liposuction of the knees, calf, and ankles is performed. The cosmetic surgeon used to stay a little bit deeper when treating the abdomen because irregularities of the skin occur more easily. If large retraction of skin is needed in flaccid skin abdomens, skin is widely undermined as far as the flanks and the suprapubic and inguinal regions. Slight liposuction of the groin and suprapubic area produces a rejuvenating effect on women over 40 years of age.
In 5,103 cases of superficial liposculpture, 98% of the cosmetic surgeon’s patients were very satisfied, and the longterm results in terms of body reshaping and skin tone were maintained, even in patients who became pregnant (5%) or either lost or gained weight (37%). In the remaining 2% of patients, the following complications occurred:
– One major mycobacterium infection caused most likely by a contaminated lipofilling that resolved after antibiotic therapy.
– Twenty minor asymmetries that were corrected 6 months later under local anesthesia.
– Eighteen minor skin irregularities in the earliest cases improved later with lipofilling.
– One case of phlebitis in a 70-year-old patient.
– Six cases of transitory (6–12 months) hyperpigmentation of the skin, before routine use of vacuum drains in large fat removal in pale-skin patients.
– Two cases of transitory (8 and 10 months) paresthesia.
In the cosmetic surgeon’s experience in liposculpture we have constantly obtained a significant reduction of the circumference of hips, abdomen, buttocks, and thighs by having the patient wear a special postoperative garment properly designed for this purpose. These results are due to the lymphatic and venous micromassage produced by the two layers of the garment during the first month postoperatively.
Interstitial fluid drainage is stimulated by a harmonious compression and subdermal capillary microcirculation is increased, also improving the aspect of the so-called cellulite. Moreover, the same circumferential reduction on buttocks and thighs has been enhanced lately by giving to the patient two tablets daily of dietary phytotherapeutic preparation (Cellulase Gold, Medestea Internazionale, Italy) for a period of 30 days before liposuction surgery and 60 days after superficial liposculpture.
This phytotherapeuticic preparation is based on Centella asiatica, Melilotus officinalis, Ginko biloba, bioflavonoids, Recapta- Cell, bladderwrack, and Ruscus aculeatus.
The strong antioxidant effect of this formulation increases the cell membrane fluidity for better intra–extra cellular exchange, stimulates microcirculation, activates free radical defenses, contracts blood vessels permeability, enhances drainage of the excess of fluids in the tissues, and has a lipolytic effect, reducing the peroxidation of the lipid membrane of adipocytes, increasing the lipolytic hormones (adrenalin, thyroid, etc.) inside the cells, therefore taking their metabolism to a new normal level.
As a result, the use of the phytotherapeutic formulation helps to prevent the fibrous and sclerotic conditions of the connective tissue reducing the “orange skin” appearance of the skin, and helps reduce volumes and circumferences.
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09132010
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