 |
|
|
|
| Achieving Symmetry with Liposculpture |
 |
Tumescent liposuction, developed and perfected
by dermatologists, is now the state of the art with respect
to body contouring. Advances in this operation have maximized
patient safety and minimized unwanted difficulties. |
Great
strides have been made with respect to local anesthesia,
infusion
and suction pumps, micro incisions, microcannulas,
and postoperative care. However, relatively little has
been said about one facet of the outcome that the patient
notices
the most: the achievement of bilateral symmetry. The
author would therefore like to provide the liposuction
surgeon
with a number of tried and true "nuts and bolts" methods
for achieving a symmetrical, even result with tumescent
liposculpture. Ten important steps are described by which the dermatologic
surgeon can utilize a variety of techniques to produce natural
contours, generate even results, and enhance patient satisfaction. Improved instrumentation and operative techniques can result
in beautiful outcomes with tumescent liposculpture. The fine
results now possible should result in ever-increasing public
awareness of, and demand for, this cosmetic sculpting. |
TABLE 1
Ten Commandments for Symmetrical Results |
- Preoperative evaluation
- Premarking
- Photography
- Suctioning sequence
- Recording suction volumes
- Pinch technique
- Cannula sequence
- Intraoperative inspection
- Postoperative inspection
- Final touch up
|
| 1.
Preoperative Evaluation: A patient should not go directly
from a brief consultation to the actual surgery, but should
be given the benefit of a preoperative visit. High quality
reproducible photographs should be obtained by the surgical
staff, and a weight obtained. In addition, careful measurements
of all areas to be treated should be performed. The patient's
priorities and concerns can be voiced. A history may reveal
areas that come and go with exercise. A patient can, of course,
also be warned about barriers to a perfectly even outcome,
including preexisting cellulite, stretch marks, sun damage,
skin folds, dimples, scars and irregularities. Since most of
the tunnels are placed in the deeper fat compartments in order
to avoid surface changes, the patient must realize that most
of these defects will not disappear (though some improvement
may be seen) following the body contouring. |
 |
 |
 |
| Female patient
before liposculpture with excess fat on inner thighs,
knees and saddle bags giving her a "bow-legged" appearance. |
Markings shown immediately preoperatively with fat to
be removed in these areas. Note that patient has brought
her bikini to the office to allow the surgeon to attempt
to hide the tiny incisions under the areas to be covered
by
clothing. |
Note excellent final result from tumescent liposculpture
with improvement in all areas. |
|
| 2.
Premarking: In the patient prep area, prior to the procedure,
and prior to any sedation or local anesthesia, the patient
is examined in the upright position. All areas to be contoured
are delineated with a surgical marker. Regions are marked according
to both visual inspection and by palpation. The patient can
voice concerns about asymmetry and can give his or her approval
to the areas to be suctioned. Symmetrical incision sites, feathering
zones, and areas targeted for maximum fat removal are inscribed.
These markings are then recorded diagrammatically on the operative
report sheet. |
| 3.
Photography: 35mm photographs are obtained in the upright
position prior to, and after, affixing the surgical markings.
In addition, good quality Polaroid photographs should be obtained
preoperatively. These Polaroid photos can be viewed intraoperatively
by the surgeon to facilitate the goal of bilateral symmetry.
Patients are often quite impressed when this preoperative Polaroid
is viewed adjacent to an immediate postoperative one. |
 |
 |
Polaroid
photos viewed immediately postoperatively. On the left
is the preoperative appearance of a male in
his 30's
with a "spare tire" and "love handles" as well as fat in
the abdomen and midriff. On the right note the extreme improvement seen moments
after the surgery was completed. Inspection in the standing position allows achievement
of symmetry and uniform results. |
|
| 4.
Suctioning Sequence: Ideally, liposuction of individual
body areas should be performed in the same order that the tumescent
anesthesia was administered in order to optimize the surgeon's
rhythm and concentration. Typically, liposuction takes longer
to perform than does the infusion of local anesthesia. However,
the maintenance of an exact sequence will hopefully catch the
tissues in a similar state of tumescence each time. |
| 5.
Recording Suction Volumes: This obvious concept can be
quite helpful if performed on a routine basis. However, some
limitations do exist. Fatty areas suctioned initially tend
to contain more fluid than those encountered near the conclusion
of the procedure. This is due to the fact that tumescence (though
not local anesthesia) tends to disappear after 1-2 hours, although,
of course, the surgeon could choose to reinject immediately
prior to suctioning a given area. Varying amounts may have
been suctioned from adjacent areas (for example, the abdomen
adjoining each flank), resulting in different postoperative
volumes. Finally, preexisting asymmetry will, of course, generate
dissimilar
postoperative volumes. |
|
Note thickness of existing abdominal
fat
|
Pinch technique demonstrates that most
of fat has been removed
Pinch comparison on contralateral side
leads to symmetrical results
|
|
| 6.
Pinch Technique: Body areas undergoing treatment can be continuously evaluated
preoperatively, intraoperatively, and
postoperatively for symmetry, depth, and adequacy of fat removal.
With this method, the nondominant pinching
hand is the "smart hand" whereas, the dominant hand serves more as
a piston. The pinch technique can be used to direct the cannula to the proper
depth, protect deeper or adjacent structures (such as the neck or face), maintain
the proper angle, bring pockets of fat to the tip of the cannula,
immobilize "squirrely" areas, "roll" the cannula from area
to area, feel the fat actually disappear with each stroke, and compare the residual
thickness of contour in lateral or opposing areas. |
| 7.
Cannula Sequence: It is a useful discipline to attempt
to deploy the same cannula designs and sizes and the same sequence
for each body area. The flow rates, depth, level of penetration,
and facility of use can, of course, vary greatly from cannula
to cannula, and among different sizes of the same cannula.
A dermatologic surgeon might perform pretunneling with a 14
or 12 gauge cannula, moving then to a 10 or 12 gauge, followed
by a 3mm instrument, then a 12 gauge cannula, and concluded
with the use of a 14 gauge cannula for fine feathering, for
each side. This technique can, of course, be modified according
to specific goals or needs, but it is a useful concept to consider. |
| 8.
Intraoperative Inspection: In spite of the presence of tissue tumescence,
the dermatologic surgeon should learn to
appreciate subtle differences in tissue thickness and contours
for opposing body areas. The
finished product should look "even" without elevations or depressions,
and should have a contour similar to the contralateral side. One learns, of course,
to mentally subtract the tumescence present in feathering zones or in anesthetized
areas immediately beyond areas that were suctioned, especially on the thighs.
Experience in positioning will enable the dermatologic surgeon to extrapolate
the final result in a horizontal patient to the preoperative and postoperative
standing appearance. |
|
38 year old white female with unwanted
fat on abdomen, hips, saddle bags and inner thighs.
|
Beautiful symmetrical results seen after
tumescent liposculpture by Dr. Swinehart
|
|
| 10.
Final Touch-up: Should the standing examination reveal
any irregularity or asymmetry, these can be evened out with
a few strokes with a 12 or 14 gauge cannula. This maneuver,
taking only a minute or two, can make a significant difference
in the final result. |
|
39
year old white male with "love
handles" and excess of nominal fat which he cannot
remove through exercise
|
Thin, perfectly even contour following
the procedure.
|
|
At the conclusion of the procedure, the patient
is generally well awake, and the recovery period is usually
short. Final vital signs are taken, and the intravenous
line is removed. A paired comparison study recently performed
in San Diego, with sutures inserted only on one side, revealed
decreased scarring on the non-sutured side, presumably
because
of the absence of stitch marks. Therefore, sutures are
generally not inserted unless the patient has plans to immediately
travel a distance.
Instead, special high
absorbency pads are secured over
each incision. These pads are held in place by custom
designed post liposuction elastic washable garments. Drainage
generally
ceases within 24 to 48 hours. By encouraging removal
of excess fluid, the dermatologic surgeon and patient alike
will appreciate
the greatly decreased incidence of postoperative swelling,
bruising, and soreness. Patients walk out of the surgical
suite under their own power, and follow up phone calls
often reach a relative who informs the staff that the patient
has
left to run an errand!
These patients often are able
to
work the following day. Gentle exercise can be commenced
within two to three days,
with more vigorous exercise by the end of the first
week.
Because of the rapid healing, quite often after two
to
three weeks no one but the patient will be aware of the
fact that liposculpture has been performed (except, of
course, for the fact that the body shape is dramatically
different!).
Post operative problems have been rare since the advent
of
tumescent liposuction. Indeed, no serious complications
have been recorded anywhere in the country in a
survey of over 15,000 patients who have undergone this procedure.
No
procedure, of course, is perfect, and occasional
irregularities or untoward results must be anticipated,
especially
in
those patients with preexisting imperfections. However,
careful attention to the maneuvers described in this
treatise
should
enable the dermatologic surgeon to maximize patient
satisfaction following tumescent liposculpture.
NEXT
ISSUE: We plan to focus on treatment of specific
body areas in both male and female patients. In addition,
we
will explore the issues of fat transplantation, ultrasonic
liposuction, and cellulite release.Dr. Swinehart specializes
in Tumescent Liposculpture at 950 E. Harvard Avenue,
#630, Denver, CO 80210 - Phone
(303) 744-1202. Copyright 1997 CDC. |
|
|
