BASIC AND CLINICAL DERMATOLOGY - PART 8 ppt

Drs. Di Giuseppe and Leibaschoff demonstrate lipoplasty with VASER 1 . Before and after VASER 1 . Source: Courtesy of Alberto Di Giuseppe, M.D. SURGICAL TREATMENT B: VASER â & 221 Lipoplasty has a threefold target: aesthetics, functionality, and restoration. But only surgeons properly trained in liposculpture may achieve this target. Lipoplasty is a surgical technique performed through mini-incisions. Thin tools, a few millimeters in diameter, are used under tumescent local anesthesia. Operations should be performed by surgeons who have experience in this field, under the control of anesthetists or cardiologists specialized in surgical monitoring. & DEFINITION Some specialists define liposculpture as a technique for fat tissue extirpation using blunt 2 mm to 5 mm cannulae. Suction may be carried out with 20 cc or 60 cc syringes or through minicannulae (2–4 mm) with suction equipments (1 atm). The name ‘‘liposuction’’ is used for the same technique carried out for fat removal using suction equipment with larger cannulae. Fournier said that ‘‘liposculpture is the technique that uses disposable syringes to aspirate localized fat deposits and, if necessary, reinject it where needed (19).’’ We personally believe that the term ‘‘lipoplasty’’ is all inclusive, and that the term ‘‘lipoplasty liposculpture’’ includes all surgical, medical, or rehabilitative therapeutic prac- tices. It is sheer nonsense to assume that results are guaranteed after surgical procedures. The lack of comprehensive treatments is precisely what caused dissatisfaction in most patients submitted to liposuction some years ago. We define ‘‘lipofilling’’ as the method of reinjection at different locations of the adipose tissue previously extracted through liposculpture and subsequently washed with physiologic salt solution to preserve adipocyte integrity (20). 222 & DI GIUSEPPE We de fine autologous tissue ‘‘implanting’’ (‘‘autolipofilling’’) as the method that employs fat tissue extracted through liposculpture and submitted to adipocyte lysis. After subsequent decanting, it is possible to obtain a compact tissular extract corresponding to the support structure of the adipocyte. & FAT TISSUE VASCULARIZATION It is important to recall adipose tissue vascularization. There are three vascular networks laid horizontally and separated by different structures within the space between the muscular aponeurosis and the capillary dermis. From deep to superficial levels, we may find: & the musculoaponeurotic vascular network & the superficial fascia vascular network & the dermic subpapillary vascular network There are also perforating vessels across the deep fatty tissues that have no ramifica- tions. They connect to the superficial fascia through communicating branches that constitute a wide network from which small communicating vessels emerge and reach the capillary der- mis for skin irrigation. It has been demonstrated that the adipose tissue blood flow varies according to the nutritional status and body weight, and that it increases in fasting conditions. AREOLAR FAT It is located on the superficial fascia and is crossed by small perforating vessels for skin irrigation. It is adipose tissue affected by the liposclerosis process, causing the typical peau d’orange condition, related to deep skin layers. At the abdominal wall level, the thickness ranges from 0.8 cm to 2.1 cm in slim individuals, and from 1.5 cm to 2.5 cm in obese indi- viduals. It corresponds to a safety fascia that should be preserved during liposuction and liposculpture; hence, surgical operations should never alter it. DEEP FAT Deep fat is located under the superficial fat, separated by the superficial fascia. The biggest blood vessels and lymphatic vessels may be found at this level. Fat excess, altering body contour and corresponding to different steatomeries, is located at this level, where fat may suffer hypertrophy in the event of general weight increase. Its thickness may range from an average of 0.5 cm in normal individuals to 4 cm or 5 cm in obese individuals. This is the fatty tissue that should be removed through liposuction and liposculpture. It is important to remember that adipose tissue is not only a reserve tissue but also has an important hormonal function: autocrine regulation, paracrine regulation, and endocrine regulation (21). & PATIENT SELECTION Liposculpture sometimes may be carried out under local anesthesia and as an ambulatory procedure because of its characteristics as a less aggressive method. A wide variety of SURGICAL TREATMENT B: VASER â & 223 patients may be submitted to it. In each case, the following rules should be observed in order to prevent future compli cations or the patient’s disappointment: & Liposculpture is a technique aimed at localized adiposity, but it is not a slimming tech- nique. Hence, patient selection as well as the study of body contours and steatomeric areas is essential. & No more than 3000 cc of tumescent anesthesia solution should be used. & Maximal dose of lidocaine should be 50 mg/kg. & A maximum of 3 L of fat should be extracted. & No more than 25% of the body surface should be treated. & Mega-liposculpture should be avoided. If aspirating more than 5000 mL of fat, one should follow the recommendations of the American Academy of Cosmetic Surgery (22,23). & It is particularly indicated in patients showing good trophism and good cutaneous elasticity. & The technique should not be applied to patients with a history of blood dyscrasia; renal, hepatic, or cardiac affections; hypertension; diabet es; and those suspected of having psychic disorders. & Patients with general obesity showing clear signs of muscular or cutaneous flaccidity may be treated. It must always be kept in mind that an association of methods will be necessary in rehabilitation. PRESURGICAL VISIT First the physician should have a long conversation with the patient to understand the real motivation for the visit, the referral, the patient’s knowledge of the technique, and especially the expectations and fantasies about the resul ts. It is very important to ascertain what the patient expects as the possible outcomes of the operation. Then, the patient should be examined naked to detect examination areas and get a general impression of body and proportions assess possible outcomes according to body harmony. The examination should be carried out with the patient in a standing position and in different decubitus positions. In fact, we should remember that the fat tissue mass has its own mobility and changes according to different positions. The patient should be required to contract different muscle groups in order to distinguish muscular flaccidity from ‘‘false cullote de cheval,’’ to differentiate rectus abdomicus dehiscence or flaccidity from swelled or dilated abdomen, and thus define the appropriate indications and techniques. The history of previous treatments such as iontophoresis, electrolipolysis, and mesotherapy should be investigated, as well as all methods that might have changed fatty tissue characteristics: drugs or other therapies such as ozone therapy or massotherapy. We should examine skin quality and muscle group tonicity. Then we must provide our impres- sion, suggest indications, and give advice on possible risks. In the event that intervention is possible or indicated, we should provide a brochure with complete information on the methodology and techniques to be used, including details on the anesthesia and possible sensations to be experienced by the patient during the operation. We should explain the method in detail, how the fat is extracted, the instru- ments used, and the risks and possible outcomes of the intervention. Two photographs in each position should be taken with an instant camera. One of each pair wi ll be modified, 224 & DI GIUSEPPE drawing different body contours in black ink to serve as a real estimate of the possibl e outcome according to our personal view and experience. A digital camera and image editing software may also be used, but it is advisable to warn the patient that the results predicted by computer are impossible to reproduce exactly. The difference when the patient contracts the gluteus muscle. Real ‘‘cullote de cheval’’ does not change with the contraction of the gluteus muscle. SURGICAL TREATMENT B: VASER â & 225 Big lipodystrophy. The patient was informed about the possibilities of a second procedure and the use of additional postoperative treatments. Same patient after 2 months of ultrasonic liposuction. 226 & DI GIUSEPPE Factors in determining safety of liposuction include: & the number of areas treated & volume of supranatant fat removed & percent of body fat removed & ratio of body weight to the weight of fat removed & dosage (mg/kg) of lidocaine & volume of intravascular fluid infused & duration of surgical procedure It should be remembered that in many cases there is a gap between the fantasies of the patient and the real medical possibilities. This may lead to discontent, disappointment, and complaints, and also legal procedures. The patient should be informed that immediate and late postoperative periods are not identical. Specific care for each period and the possible limitations in each should be remarked on. Once explanations are given, all elements should be assessed and the indicated tech- nique described again. If necessary, the patient may take some photographs home to come to a decision in private or with her family. In the event of a favorable decision, routine laboratory tests, protein and albumin content (lidocaine carrier), coagulation tests, cardiovascular surgical risk assessment, and hepatitis and HIV tests should be required. Other fact ors to be investigated include possible allergies to substances—especially to anesthetic drugs and skin disinfectants— and history of previous surgery, type of incision, and formation of keloids. DETAILED PHYSICAL EXAMINATION & abdomen: hernias , scars, and diastasis & skin alterations Retractions and bumps. SURGICAL TREATMENT B: VASER â & 227 & varicose veins and hemorrhage & edema & retractions and bumps & flaccidity & PRESCRIPTIONS Aspirin administration should be discontinued at least seven days before the operation to avoid coagulation disorders. The use of all other unnecessary drugs should also be suspended 1 week prior to the operation. Broad-spectrum antibiotics should be prescribed, such as ciprofloxacin 500 mg, 1 g/day for 5 days after the operation. If necessary, an analgesic or a nonsteroidal anti- inflammatory drug (diclofenac potass ium) may also be prescribed. Exercise and sports should be interrupted at least for 2 weeks, but the patient must walk every day after the liposculpture (1 mile per day the first week after the second day); and also avoid sun exposure of treated areas for approximately 15 days. Care during immediate and late postoperative periods is very important. When lipo- plasty is finished, bimodal compression with absorbent pads is fundamental, because it contributes to the patient’s comfort and to a uniform skin and cellular subcutaneous tissue retraction. This is accompanied by adequate compression and a supporting binder. After 24 hours, the pads are removed and replaced by a supporting noncompressive binder (hence allowing lymphatic precollector functioning). In case of lower limb surgery, the patient should start wearing graduated compression stockings (15 mmHg) 1 week after the operation. Immediate physical therapy consists of manual lymphatic drainage, 1 and 3 MHz external ultrasound, and magnetotherapy for 1 week. Then, subderma l therapy and carboxytherapy are introduced or continued. Forty-eight hours postoperative. 228 & DI GIUSEPPE & POSTOPERATIVE SCHEME & Day 1: The patient is advised bed rest. Mobilization must be only with bimodal elasto- compression using absorbent pads and compression and supportin g binder. & Day 2: The patient may start moving about. Wound healing is checked. Elastocompres- sion is applied using a light compression binder. Bandages are remove d. The patient may walk. Manual lymphatic drainage is performed. & Day 3: Treated areas and the wounds are examined. The patient undergoes lymphatic drainage, external ultrasound 3 MHz, and magnetotherapy. In the event of hematoma formation, medical phlebotonics and specific local therapies are prescribed. The patient may shower with due precautions taken to protect the treated areas. & Day 4–7: Same procedures as in day 3 are performed, followe d by diet therapy. & Day 15: Subdermal therapy is started aimed at connective tissue restructuring. & Day 21: This therapy may now be associated with carboxytherapy. Patients should be reminded that the best results may be observed only after some months (today we know that the first result will be at 4 months and the second at 14 months) (24). Subdermal therapy with Endermologie 1 (liquid petroleum gas) or TriActive 1 (DEKA) associated with microcirc ulation cleansing and stimulant oral therapy (Cellulase Gold 1 ) has an added value in a suc cessful surgical intervention. Liposhape TM compression garment. SURGICAL TREATMENT B: VASER â & 229 & CONCLUSION Safety is the state of being free from danger and exempt from harm. The foremost ethical principle of medicine is ‘‘primum non nocere’’—first, do no harm. In lipoplasty, this principle is paraphrased by the statement ‘‘excessive liposuction is unsafe and therefore unethical.’’ 230 & DI GIUSEPPE [...]... Surg 2001:233–239 18 Jewell M, Fodor P, Bolivar de Souza Pinto E Clinical application of Vaser assisted lipoplasty Aesthet Plast Surg 2002; 131–146 19 Fournier P Liposculpture-ma technique Paris: Arnette, 1 989 20 Fournier P Facial recontouring with fat grafting Dermatol Clin 1 989 ; 8: 523 21 Mohamed-Ali V, Coppack SW Adipose tissue as an endocrine and paracrine organ Int J Obesity 19 98 22 Fournier P Therapeutic... the treatment of cellulite (Figs 1 and 2) and in 2000, presented a detailed step-by-step guide to the procedure, based on the use of Subcision1 in 232 female patients (3) & INDICATIONS AND MECHANISMS OF ACTION Subcision1 can be used in the treatment of all conditions where subcutaneous septa pull on the skin surface These include wrinkles and folds and depressed scars and lesions (4), in addition to cellulite... Klein JA The tumescent technique for liposuction surgery Am J Cosmet Surg 1 987 ; 4:263 7 Zocchi ML Ultrasound-assisted lipoplasty: technical refinements and clinical evaluations Clin Plast Surg 1996; 23:575 8 Schefflin M, Tazi H Ultrasonic-assisted body contouring Aesthet Surg Quart 1996; 16:117 ´ 9 Bacci PA Lipoplastia utilizando MicroAire: Ventajas, complicaciones y metodologıa XXVI ´ Simposio Anual... movement is sufficient Such a method, with a 1 .8 to 2.4 mm cannula, is used in the treatment of lymphedema and lipolymphedema, particularly at the level of ankle, calf, or arm This methodology is extremely useful given its easy use and its rare side effects ( 38, 39) D: Lipofilling S V Savchenko, Marlen A Sulamanidze, and George M Sulamanidze Moscow, Russia As early as 189 3 (Neuber), there have been publications... smoothing of facial wrinkles and fold, improvement of the congenital contours of the face and body, as well as those induced by involutional alterations and soft-tissue ptosis, and removal of individual defects such as cicatrices following acne, hypotrophy of posttraumatic and postoperative scars, leveling of roughness after a failed liposuction, as well as those induced by the so-called cellulite We infiltrate... bottom of the sea, and gather information on its stratigraphic composition through the echo technique (echo-sounding), and as a means of subaquatic telecommunication Ultrasound has been developed as a technique to search and localize faults in mechanical and manufactured pieces Ultrasound is used for the measurement of propagation constants (velocity of sound, absorption, etc.) and related parameters... treatment area has been covered The dressing that covers the wounds should be disinfected and sprayed ULTRASOUND APPLICATION Conductor gel is spread on the treated area and ultrasound emission equipment is turned on at a 3 MHz frequency Emission is selected in continuous mode and power is turned to maximum (state-of-the-art equipment enables us to exceed 5 W/cm2) The ultrasound emission probe is applied... the multi-injector multiplied by two [e.g., 10 punctures (10 needles) in the multi-injector require a 20-minute time period], and emission is initiated.The ultrasound probe is moved slowly in order to cover the whole infiltrated area, going over the area again and again until the end of the time period The operation is repeated on the contralateral side To finish the treatment, the gel is removed and the... and a part reaches the liver where it is conjugated into lipoproteins To enable a full elimination of the reactive edema, it is recommended that sessions are repeated at 1 5- to 20-day intervals (shorter intervals, if manual lymphatic drainage is performed) SIDE EFFECTS Almost none SURGICAL TREATMENT E: ULTRASONIC HYDROLIPOCLASIS & 247 Ultrasound before and after ultrasonic hydrolipoclasis Before and. .. introduction of ultrasound-assisted liposcultpure and the patented vibro-assisted method Microaire1 the possibilities have been multiplied (36,37) The benefits obtained from the reduction of interstitial pressure due to the adipocyte decrease is characterized by an improvement in microcirculation (arterial and lymphovenular) and tissue metabolism The reduction in adipocyte number and size prevents the evolution . drainage, 1 and 3 MHz external ultrasound, and magnetotherapy for 1 week. Then, subderma l therapy and carboxytherapy are introduced or continued. Forty-eight hours postoperative. 2 28 & DI. the treatment of lymphedema and particularly, lipolymphedema. Lipolymphosuction allows the reduction of lymphedema and can be performed on the ankle, knee, and/ or calf. & THE VIBRO-ASSISTED METHOD The. of facial wrinkles and fold, & improvement of the congenital contours of the face and body , as well as those induced by involutional alterations and soft-tissue ptosis, and & removal