The ideal patient for liposuction has been described as a young person with excellent skin tone and localized areas of fat. I, however, have performed liposuction on patients from the age of 14 through 84 with excellent results. Many of these patients did not appear to have good skin texture and actually appeared to have significant flaccidity. Following superficial liposuction, often through contracture, once the localized fat has been removed the skin becomes firm and a more aesthetic appearance is achieved. Liposculpturing will vary with the localization of the fat, the flaccidity of the skin and the underlying musculature without a lot of regard to the age of the patient. A discussion of the ideal liposuction patient must include the fact that in most instances obesity is not an indication for liposuction.
Elective procedures, especially cosmetic procedures, must always have patient safety as a number one core concept. There are many guidelines that state that in most patients up to 5,000 ml of supranatant fat can safely be removed using the tumescent technique. The ideal candidate, therefore, is a patient who has localized areas of fat that he or she wishes to have removed to give the perceived contour that they desire. Liposuction can be performed safely on most patients. Since this is an elective procedure the patient should be ASA class I or II and occasionally class III. I would personally avoid class IV anesthesia risks for liposuction. The criteria that one uses in conventional liposuction is expanded and modified when choosing the patient that will benefit from superficial liposuction. Substantial results can occur when one debulks and minimizes the overlying skin flap. The use of superficial liposuction expands the patient population and includes some individuals that would have been considered unacceptable in our original liposuction criteria. A combination of superficial liposuction and occasional lipoaugmentation can give remarkable results.
There are conceptually three layers of subcutaneous fat. Practically we only work in two layers. There is a thin layer of fat attached to the deep dermis. To attempt to remove this layer of fat will result in injuries to the dermis and significant contour and surface irregularities. The severest of these complications is full-thickness dermal necrosis. The superficial layer of fat is a layer of vertically oriented fat cells arranged in columns. This layer of fat is just beneath the reticular dermis as opposed to the intradermal or apical layer of fat. The superficial layer of fat is a compact, dense type of fat that is well organized with fibrous septa. A discrete sheet of fibrous fascial tissue separates the superficial layer of fat and the deep layer of fat. Superficial fat can be found throughout most of the body. It is much thicker in such areas as the abdomen, hips, thighs and buttocks. Below the knee and elbow the deep layer of fat phases out and only the superficial layer remains. In these areas one needs to modify his or her liposculpture technique. It is in the superficial layer that one needs to learn to work to do the final sculpturing that will allow the art of the technique to evolve. The deep layer of fat, which is the only fat we originally removed in the early days of liposuction is more areolar, looser and arranged with a haphazard type of septae. The deep layer of fat is more prominent in pari-umbilical, para-lumbar, gluteal-thigh, and lower abdomen areas.
As the deep layer of adipose tissue extends laterally from the abdomen to the flanks or midriff and distally over the lower extremities it gradually attenuates and essentially disappears, with its fascia merging with the superficial muscle fascia. This leaves only the superficial layer of fat in these areas. The superficial layer also becomes very thin. Care must be taken when carrying out liposuction in those areas with only superficial fat. The pattern of fat distribution is to a large degree genetic. In general, the pattern of distribution of lipodysmorphia in the female (gynoid) fat is most commonly deposited in the lower trunk, hips, upper thighs and buttocks. In men the deposition is evenly around the trunk, a thickness around the torso, in the upper abdomen and the male breasts (pseudo-gynecomastia). The deep layer has to be reduced and modified to change genetic conformations. To hold the changes requires superficial liposculpturing.
The preoperative workup should include a complete history and physical examination. Liposuction surgery is an elective procedure and for that reason patient safety is the number one concern. Attention should be directed to any previous surgical complications. Bleeding and/or clotting problems should be addressed. The physical examination should be complete and special attention should be given to the possibility of hernias, flaccid musculature, excess skin and previous surgical scars. The laboratory evaluation that I presently use is extensive. If the patient has not had a complete hematologic workup within the 12 months preceding the proposed procedure I order a complete blood count, a basic metabolic screen, an EKG for patients over the age of 40, and a chest X-ray. I also order a partial thromboplastin time, a prothrombin time and a bleeding time. As part of the informed consent I instruct my patients to stop taking any aspirin or non-steroidal antiinflammatory agents. I also have them stop taking any herbal medicine. Patients are strongly encourage to stop smoking and all smokers sign a form that they have been well informed of the risks of continuing to smoke.
The original Gasparotti technique of liposculpture was mainly performed with the syringe technique using a beveled end-holed cannula. Another important part of his technique included replacement of the autologous fat in certain superficial areas to improve surface contour. My modification of this technique includes aspiration of some of the fat with the syringe to be used for the correction of defects. The bulk of my procedure, however, is carried out with the use of the vacuum pump. To accomplish superficial liposuction I have used the ultrasonic technique of liposuction, routine liposuction and today I mainly use mechanically assisted liposuction. The cannulas I use at the present time include a multiple-holed cannula, a spatula-tipped one or two-holed cannulas and a ventral three-holed cannula. I will describe the cannulas in further detail later in the article.
Any vacuum pump used for aspiration that can generate negative 1 atm of pressure is acceptable. Traditional cannulas of the multiple-holed, spatulashaped and the Saylan type are my choices for superficial liposuction. I tend to use the Mercedes cannula and other more aggressive cannulas in the deeper fat to debulk. In the late 1980s Klein introduced the small microcannula technique with excellent results. For most procedures the largest cannula that I use is 3.0 mm in diameter. For finesse the cannulas are even smaller in diameter. The exception is occasionally a 4.0-mm one-holed flat spatula that is used to remove very deep fat in the midriff, paralumbar area and the area below the brassiere line (an area I refer to as “bat wings”). It is recommended that those who are just beginning the use of superficial liposuction use routine liposuction only. Until you get the “feel,” the syringe technique might be preferable. As your skill improves you can switch to the aspiration pump. I presently use the mechanical reciprocating device. In my hands I believe it is easier to sculpture with the reciprocating cannula.
The patient initially is marked in the upright position using permanent markers. Marking the patient in the upright position is important because in most cases the lipodysmorphia that we are trying to correct is very gravity dependent. Once the markings have been made the fat will move with the skin. Each cosmetic surgeon develops his or her own marking technique. My technique is to draw topographically much as one would draw a topographic map. Approximately 1 h prior to liposuction surgery the intravenous fluid administration is started and preoperative antibiotics are given. My personal preference, if there are no allergies, is 1 g of Kefzol or Ancef. Other antibiotics could be substituted if there are allergies to the cephalosporins. The patient is prepped with Betadine. If i.v. sedation or general anesthesia is used, it is administered prior to the prepping. In cases of pure tumescent local anesthesia we still use the i.v. and the preoperative antibiotics. Sterile ace wraps are used from the feet to the knees if there is no anticipated liposuction of calves. This is helpful to prevent venous stasis and also allows us to move the patient in a sterile manner. The patient is then placed in the appropriate position. Tumescent infiltration is then accomplished using the Klein pump. There are other modifications of this pump and they are perfectly acceptable. The tumescent fluid used includes normal saline (0.9%) and 50 ml of 1% lidocaine per 1,000 ml of saline and 1 mg technique with no i.v. sedation or general anesthesia the concentration of lidocaine is increased to 100 ml of 1% lidocaine.
The concentrations of lidocaine are 0.05 and 0.1%. However, the more appropriate specification is 500 mg of lidocaine in 1,000 mg per liter. According to Klein, the current recommendations for tumescent liposuction totally by local anesthesia is 500–1,500mg of lidocaine per liter and 0.65–1.0 mg of epinephrine per liter of normal saline. The addition of 12.5 mEq of sodium bicarbonate will decrease the pain associated with infiltration of the tumescent fluid.
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