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Liposuction Guidelines for Plastic Surgeons

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Liposuction has undergone a series of evolutionary steps since its introduction in the 1980s. It is proven to be the cosmetic surgery procedure that patients request the most. In 2014, liposuction replaced breast augmentation as the most frequently performed surgical procedure, with a 16 percent increase over 2013 and more than $1 billion being spent on the procedure in the United States alone.

The article “Evidence-Based Medicine: Liposuction”, published in Plastic and Reconstructive Surgery –Journal of the American Society of Plastic Surgeons (January 2017 – Volume 139 – Issue 1 – p 267e–274e) by plastic surgeons at bodySCULPT®Dr. Spero Theodorou and Dr. Christopher T. Chia along with Dr. Ryan M. Neinstein provides a literature-supported overview on liposuction techniques with an emphasis on preoperative assessment, medicines used, operative technique, and outcomes.

Intended primarily for plastic surgery practitioners, residents, and other healthcare professionals interested in translating expanded knowledge into practice for the improvement of patient outcomes in plastic and reconstructive surgery, it also addresses recent trends regarding energy-assisted liposuction, and body contouring local anesthesia use.

This article would help the participant to –

  1. Review the appropriate indications and techniques for suction-assisted lipectomy body contouring surgery.
  2. Accurately calculate the patient limits of lidocaine for safe dosing during the tumescent infiltration phase of liposuction.
  3. Determine preoperatively possible “red flags” or symptoms and signs in the patient history and physical examination that may indicate a heightened risk profile for a liposuction procedure.
  4. Provide an introduction to adjunctive techniques to liposuction such as energy-assisted liposuction, and to determine whether or not the reader may decide to add them to his or her practice.

Let us look at the key points discussed:

  • Preoperative Assessment
    It is important for a physician to clearly evaluate the patients’ motivation for surgery and the degree of concern they have about their current physical state. The current recommendation is that to undergo liposuction, the patient should be within 30 percent of the ideal body mass index. However, whether liposuction can be a contributing factor to weight loss in individuals with a high body mass index is still an area of controversy.In a recent study regarding the interaction between liposuction volume and body mass index, the authors’ risk assessment model demonstrates that volumes in excess of 100 ml per unit of body mass index may bring an increased risk of complications.
  • Medical History
    Many patients take vitamins, minerals, and supplements and do not report this to their practitioner. Stopping all nonessential agents before surgery can reduce the risk of a bleeding-related complication. It is crucial that drugs that potentially interfere with lidocaine metabolism should be discontinued at least 2 weeks before using tumescent technique for local anesthesia when high doses of lidocaine are anticipated.
    Certain factors that affect post-operative results include usage of first-line antidepressants, smoking, and diabetes mellitus. Venous thromboembolism has been shown to be the single largest cause of mortality in patients undergoing high-volume liposuction. Using regional or tumescent anesthesia alone has been shown to have statistically significant lower incidences of postoperative deep vein thrombosis.
  • Physical Examination
    A carefully directed history and physical examination should look for stigmata and sequelae of chronic disease. When examining the abdomen, the physician should pay particular attention to surgical scars as potential sources of hernias. Skin quantity and quality should be assessed, and differences between excisional procedures and liposuction should be discussed with the patients.
  • Informed Consent and Photography
    Accurate photographic documentation has become essential in reconstructive and cosmetic plastic surgery for both clinical and scientific purposes. The surgeon should also inform the patient of the risks of treatment, the prognosis, and alternative treatments before consenting to treatment.
  • Location of Surgery
    Most surgical procedures are performed in one of three outpatient settings: hospitals, free-standing ambulatory surgery centers, or office-based surgery facilities. Office-based surgery has several potential benefits over hospital-based surgery, including cost reduction, ease of scheduling, and convenience to both patients and surgeons. It has been proven that office-based surgery with intravenous sedation, performed by board-certified plastic surgeons and nurse anesthetists, is safe. Physicians should follow state-specific regulations on total aspirate permitted in a surgical setting.
  • Medications in Wetting Solutions
    • Lidocaine - Although it is generally accepted that lidocaine doses up to 50 mg/kg and even 55 mg/kg are safe to use in tumescent liposuction, the American Society of Plastic Surgeons guidelines recommends 35 mg/kg as the maximum dose. It is also suggested that for patients undergoing general anesthesia with the superwet technique, the lidocaine component may be eliminated without an increase in postoperative pain.
    • Epinephrine - Epinephrine causes vasoconstriction, resulting in hemostasis and delayed absorption of the anesthetic agent. It is recommended that epinephrine doses not exceed 0.07 mg/kg, although doses as high as 10 mg/kg have been used safely.
    • Bupivacaine - Of all the amide local anesthetics, bupivacaine is said to be the most cardiotoxic. However, an online survey of members of the American Society of Plastic Surgeons revealed that 7 percent of respondents were using bupivacaine in their tumescent solutions, with no reported cases of toxicity.
  • Wetting Solutions
    The existing options for wetting solutions are dry, wet, superwet, and tumescent. Most plastic surgeons report using a wetting solution that is a variation of superwet anesthesia (1:1 infiltrate to aspirate).
  • Operative Considerations
    • Cannulas - In general, blunt-tip cannulas are used to minimize perforation risk, and smaller diameter cannulas are used to minimize contour irregularities. Non–blunt-tip cannulas are typically used for breaking up scar or discontinuous undermining
    • Operative Techniques - Specific depths of subcutaneous fat should be suctioned, which vary from different body locations and patient-specific goals.
  • Adjunctive Liposuction Technology/Techniques
    • Power-assisted - The major advantages of this commonly used technology are treatment speed, economy of motion, and reduced operator fatigue.
    • Laser-assisted - Although there is no conclusive evidence for the use of lasers in liposuction, the recent adoption of the 1440-nm laser may prove to be efficacious for emulsification. The longer wavelength has 20 times more absorption in adipose tissue than the 1064-nm/1320-nm and 40 times more absorption than 924-nm/980-nm wavelengths.
    • Ultrasound-assisted - With the growth of autologous fat transfer, the use of ultrasound to selectively target and remove fat cells from the fatty tissue matrix may help improve fat viability and retention.
    • Radiofrequency-assisted - A study on arm contouring with radiofrequency-assisted liposuction by Dr. Spero Theodorou and Dr. Christopher T. Chia of bodySCULPT®, used three independent plastic surgeons’ evaluations of the post-op and preoperative images and showed the improvement in arm contouring to be – excellent, 8%; good, 72%; moderate, 18%; and poor, 2%. The degree of skin-tightening was determined to be excellent, 11%; good, 46%; moderate, 38% and poor, 5%.
    • Water-assisted Liposuction - Water-assisted liposuction uses a dual-purpose cannula that emits pulsating, fan-shaped jets of tumescent solution, followed by simultaneous suctioning of the fatty tissue and the instilled fluid.
  • Postoperative Care
    Traditionally, prolonged use of elastic compression garments was promoted. Prolonged compression can cause skin creases, hyperpigmentation, pain, and swelling. Some ways to minimize swelling and postoperative compression include minimally traumatic surgical techniques, not suturing the incisions, and applying large absorbent dressings for the initial 24 to 48 hours to allow any excess remaining fluid and serous reaction to flow out.

With appropriate patient selection and minimally traumatic techniques, many complications can be avoided. Certain major risk factors for the development of severe complications are poor standards of sterility, the infiltration of multiple liters of wetting solution, permissive postoperative discharge, and selection of unfit patients.

To read more about the liposuction trends, techniques and outcomes discussed in the article, click here.

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