Liposuction Principles and Practice - part 4 doc

156 24 The Modern Lipoabdominoplasty tion with liposuction is effective for these patients. A type 3 patient has mild skin excess, lower abdominal laxity with diastasis of the recti and mild to moder- ate lipodystrophy inferior to the umbilicus. In addi- tion to the skin resection and liposuction placation of the rectus sheath from the pubis to the umbilicus is required. A type 4 patient has skin excess, signifi- cant laxity of the musculoaponeurotic layer and lipo- dystrophy. Skin resection, liposuction and plication along the entire rectus sheath offers improvement but may require transaction of the umbilical stalk. A type 5 patient presents with severe upper and lower ab- dominal skin excess and laxity. Diastasis of the recti is severe and the patient is often moderately obese. Traditional standard abdominoplasty with placation of the rectus sheath and defatting is necessary. 24.5 Surgical Technique 24.5.1 Preoperative Treatment Aesthetic improvement of the abdomen is achieved with a continuum of procedures ranging from lipo- suction alone to multistage belt lipectomy with repair of musculo-fascial defects. Modern abdominoplasty is a concept-oriented procedure to address lipodys- trophy, musculoaponeurotic laxity and redundant skin (Fig. 24.1). It combines aggressive liposuction of the abdomen and flanks with dermolipectomy in the suprapubic region. Undermining is limited to the midline to allow placation of the fascia. Preoperative evaluation and markings (Fig. 24.2) are made with the patient in the standing position. The anticipated area for skin resection is marked as are the areas for liposuction. Prior to induction of general anesthesia, lower extremity compression de- vices are placed and preoperative antibiotics are given. Once the patient is asleep and the Foley catheter has been placed, several small access incisions are made. Usually these are placed at the umbilicus, the top of the pubic hairline and laterally within the bikini or underwear line to minimize visible scaring; however, additional incisions are often used. Liberal placement of access incisions permits infusion of Klein’s solution and facilitates fat aspiration with the greatest control to improve the contour while limiting irregularities and asymmetries. Standard Klein solution is infused into the areas of planned suction-assisted lipectomy and dermolipectomy. The infusion volume is 1:1 with the anticipated aspiration volume. 24.5.2 Suction Lipectomy After allowing the epinephrine to take affect, lipo- suction is performed deep to Scarpa’s fascia beneath the planned skin resection. Major contouring of the remainder of the abdomen is performed by suction- Fig. 24.1. a Preoperative lipodystrophy, musculoaponeurotic laxity and loose skin. b Postoperatively 157 ing in both the deep and the superficial fat layers. A 4-mm cannula is typically used, with either the Luer- lock syringe system or vacuum aspiration. Aspira- tion volumes for the abdomen are usually between 2 and 4 l. If more than 4 l of fat is aspirated, in-patient observation is recommended. Once the result of the liposuction has been checked for irregularities and asymmetries and has been found to satisfactory, re- section of the redundant skin is performed. 24.5.3 Dermolipectomy The skin is incised with a scalpel along the preopera- tive markings. Sharp dissection is performed through the subcutaneous tissue continuing down through Scarpa’s fascia. The infiltration of the Klein solution minimizes bleeding and permits rapid dissection with serrated Mayo scissors. With the incision com- plete to each lateral margin, the ends of the skin pad- dle are grasped with Kocher clamps and the segment is avulsed. Even when aggressive suction lipectomy has been performed some adipose tissue will remain deep into Scarpa’s fascia. (Fig. 24.3) Additional deep contouring can be performed on the abdominal wall fascia using a flat cannula with the vacuum aspirator. However, to minimize the risk of seromas the fascia should not be stripped clean, but rather at least a fine layer of overlying soft tissue should be left intact. 24.5.4 Fascial Repair Management of the fascia is of even greater impor- tance when skin resection and undermining is lim- ited. Dissection is performed sharply to elevate the subcutaneous tissue from the midline fascia, creating an area 4–5 cm in width. The use of a lighted retractor or an endoscope allows visualization of the diastasis and facilitates the fascial placation. This can usually be performed while preserving the umbilical attach- ment to the fascia. Fig. 24.2 . a Preoperative evaluation in the standing position. b Markings in the standing position 24.5 Surgical Technique 158 24 The Modern Lipoabdominoplasty Correction of the diastasis is achieved by approxi- mating the fascia at the medial border of the rectus muscles; however, additional tightening can be per- formed. The amount of additional tightening which will be tolerated can be evaluated by grasping the fascia with two Kelly clamps and approximating the margins. The fascia can then be marked with methy- lene blue to allow precise placement of the sutures, tapering the amount of planned plication at the cephalad and caudal limits. The midline is closed us- ing several 0 Prolene simple interrupted sutures both above and below the umbilicus. Using interrupted sutures offers additional control over the degree of plication achieved. A running suture of 2-0 looped nylon is placed to imbricate the midline. The midline fascia can be plicated and imbricated from the level of the xyphoid to the suprapubic region. When no undermining of the superior flap is per- formed, transverse plication of the musculoaponeu- rotic tissue can be readily performed within the area that has been exposed by dermolipectomy. The fas- cia is readily exposed and significant abdominal wall tightening can be obtained. Plication and imbrica- tion is performed along a transverse line inferior to the umbilicus. Although this method avoids under- mining the superior flap, it tightens the abdomen in a longitudinal direction. Although it will not correct rectus diastasis, it is however helpful to further em- phasize the desirable contour of both the lateral and the anterior aspect of the lower abdomen. 24.5.5 Management of the Umbilicus Plication around the location of the umbilical stalk may compromise vascularity of the umbilicus and should therefore be performed carefully or avoided. Placement of the plication can be discontinued just above the umbilicus and then restarted below it. Per- manent knots should be buried using a smaller slow- absorbing suture such as Vicryl or polydioxanone. This avoids any palpable sutures in the thin tissue around the umbilicus. The umbilicus usually remains attached; however, if additional exposure is required, it can be “floated.” The periumbilical depression is re-created by using liposuction with a flat cannula 2–3 cm surrounding the umbilicus. If the umbilical stalk is long, tacking Fig. 24.3. Dermolipectomy 159 sutures can be used to attach the deep dermis of the umbilicus to the facial midline. If the umbilical stalk must be detached, use of landmarks, such as the iliac crest, is helpful to avoid resetting it too low. 24.5.6 Wound Closure Wound closure is facilitated by the liposuction in the upper abdomen, which creates mobility of the sliding flap [30]. In addition, because the subdermal thick- ness of the upper flap is reduced the wound edges align properly and give an aesthetic closure. Staples are used to temporarily approximate the skin edges and ensure that no dog-ears are created. Closure is in layers including the superficial fascial system and deep dermal layers. If any final touch-up contouring is required, it can be performed at this point prior to the subcuticu- lar closure. If needed, closed suction drains can be brought out through the lateral aspect of the incision and secured with nylon sutures. 24.6 Postoperative Care Immediately following the procedure, a light dressing and a compression garment are placed. This serves to hold the dressing in place without tape, decreas- ing edema, seroma formation and contour irregulari- ties. Drains are removed when drainage is less than 30 ml per 24 h and the binder can be discontinued a few weeks later. Rarely is Fowler’s position required, except for comfort. Ambulation is encouraged early and typically patients resume regular activities in 3– 4 weeks. Activity restrictions are for comfort only. 24.7 Complications and Contraindications Complications following modern lipoabdomino- plasty can range from minor undesirable aesthetic outcomes to potentially life-threatening problems. In general, they occur less frequently than with the standard abdominoplasty [31, 32]. The most frequent undesirable outcome is contour irregularity second- ary to liposuction, occurring in 10% of patients [33]. Careful cross-hatching and liberal access sites will limit this problem. The rate of seromas with standard abdominoplasty techniques is over 20%, while with the lipoabdominoplasty technique it is 2–4%. In addi- tion, rates of hematoma formation, wound separation and wound infection are similarly decreased. Since the umbilicus is not reinserted the umbilical necro- sis is almost non-existent. Postoperative skin necrosis has not been reported. References 1. Kelly HA. Report of gynecological cases. Johns Hopkins Med J 1899;10:197 2. Thorek, M.: Plastic Surgery of the Breast and Abdominal Wall. Springfield, IL, Charles C. Thomas 1924 3. Vernon G. Umbilical transplantation upward and abdom- inal contouring in lipectomy. Am J Surg 1957;94:490 4. Pitanguy, I. Abdominal lipectomy: An approach to it through an analysis of 300 consecutive cases. Plast. Re- constr. Surg. 1967;40(4):384–391 5. Regnault P. Abdominoplasty by the W technique. Plast Reconstr Surg 1975;55(3):265–274 6. Psillakis JM. Plastic surgery of the abdomen with im- provement in the body contour: Physiopathology and treatment of the aponeurotic musculature. Clin Plast Surg 1984;11(3):465–477 7. Schrudde, J.: Lipexeresis or a means of eliminating local adiposity. Aesthet Plast Surg 1980;4:215 8. Kesselring, U.K., Meyer, R.: A suction curette for removal of local deposits of subcutaneous fat. Plast Reconstr Surg 1978;62(2)305–306 9. Illouz, Y-G. Body contouring by lipolysis: a 5-year ex- perience with over 3000 cases, Plast Reconstr Surg 1983;72(5):591–597 10. Klein, J. Tumescent technique for local anesthesia im- proves safety in large volume liposuction. Plast Reconstr Surg 1993;92:1085–1098 11. Zocchi, M. Ultrasonic liposculpturing. Aesth Plast Surg 1992;16:287–298 12. Fodor PB,Vogt PA. Power-assisted lipoplasty (PAL): a clin- ical pilot study comparing PAL to traditional lipoplasty (TL). Aesthet Plast Surg 1999;23:379–385 13. Apfelberg DB, Rosenthal S, Hunstad JP., Achauer, B., Fodor, P.B.: Progress report on multicenter study of laser- assisted liposuction. Aesth Plast Surg 1994;18(3):259–264 14. Apfelberg DB. Results of multicenter study of laser-as- sisted liposuction. Clin Plast Surg 1996;23(4):713–719 15. Dillerud E. Suction lipoplasty: a report on complications, undesirable results, and patient satisfaction based on 3511 procedures. Plast Reconstr Surg 1991;88:239–249 16. Cardenas-Camarena L, Gonzales LE. Large-Volume Li- posuction and Extensive Abdominoplasty: A feasible al- ternative for improving body shape. Plast Reconstr Surg 1998;102:1698–1707 17. Gupta SC, Khiabani KT, Stephenson LL, Zamboni WA. Effect of Liposuction on Skin. Plast Reconstr Surg 2002;110(7):1748–1751 18. Osterhout DK. Combined suction-assisted lipectomy, sur- gical lipectomy and surgical abdominoplasty. Ann Plast Surg 1990;24:126–132 19. Saldanha OR, de Souza Pinto EB, Matos WN Jr., Lucon RL, Magalhaes F, Bello EML. Lipoabdominoplasty with- out undermining. Aesthetic Surg J 2001;21:518 20. Avelar JM. Abdominoplasty without panniculus under- mining and resection: analysis and 3-year follow-up of 97 consecutive cases. Aesthetic Surg J 2002;22:16 References 160 24 The Modern Lipoabdominoplasty 21. Singh, D. Adaptive significance of female physical attrac - tiveness: Role of waist-to-hip ratio. J Personality Soc Psy- chol 1993;65:293–307 22. Vague G, Finasse R. Comparative anatomy of adipose tis- sue. In: Handbook of Physiology. Washingon, American Physiology Society 1965 23. Lockwood, TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg 1991;87(6):1009–1018 24. Markman B, Barton FE Jr. Anatomy of the subcutaneous tissue of the trunk and lower extremity. Plast Reconstr Surg 1987;80(2):248–254 25. Salans LB, Cushman, S.W., Weismann, R.E.: Studies of human adipose tissue, adipose cell size and number in nonobese and obese patients. J Clin Invest 1973;52(4): 929–941 26. Querleux B, Cornillon C, Jolivet O, Bitoun J. Anatomy and physiology of subcutaneous adipose tissue by in vivo magnetic resonance imaging and spectroscopy : relation- ships with sex and presence of cellulite. Skin Res Technol 2002;8:118–124 27. Rosenbaum M, Prieto V, Hellmer J, et al. An exploratory investigation of the morphology and biochemistry of cel- lulite. Plast Reconstr Surg 1998;101:1934–1939 28. Matarasso A. Abdominolipoplasty. Clin Plast Surg 1989;16(2);289–303 29. Bozola AR, Psillakis JM. Abdominoplasty: a new con- cept and classification for treatment. Plast Reconstr Surg 1988;82:983–993 30. Brauman D. Liposuction abdominoplasty: an evolving concept. Plast Reconstr Surg 2003;112:288–298 31. Hensel JM, Lehman JA, Tantri MP, et al. An outcomes analysis and satisfaction survey of 199 consecutive ab- dominoplasties. Ann Plast Surg 2001; 46:357–363 32. Chaouat M, Levan P, Lalanne B, Buisson, T., Nmicolau, P., Mimoun, M.: Abdominal dermolipectomies: early posto- perative complications and longterm unfavorable results. Plast Reconstr Surg 2000;106(7):1614–1618 33. Pitman GH, Teimouran B. Suction Lipectomy: Com- plications and results by survey. Plast Reconstr Surg 1985;76(1):65–72 Abdominal Liposuction in Colostomy Patients Bernard I. Raskin C  25 25.1 Introduction The tumescent technique for liposuction is well estab- lished [1–5]. In this method as originally formulated by Klein [6], large volumes of dilute lidocaine anes- thetic are infiltrated into the subcutaneous tissue and the fat aspirated is by a small cannula. The procedure can be performed without further anesthetic [3–5] or with supplemental analgesia as required [3–5], or with the patient fully anesthetized at the discretion of the surgeon. Mortality, while extremely rare, has been re- lated to lidocaine toxicity especially when lidocaine is combined with other anesthetic or systemic medica- tions [7] and pulmonary embolism [8]. However fatal and near fatal morbidity have resulted from necrotiz- ing fasciitis [9] and cases involving intestinal perfora- tion [10, 11]. Overall the paucity of major complica- tions such as infection in abdominal liposuction with the tumescent technique is well documented [12]. Guidelines of care for liposuction have been well established by various specialties [1–5] although spe- cifics on preoperative use of antibiotics are lacking. Most surgeons utilize broad-spectrum antibiotics preoperatively; however, the antibacterial effect of lidocaine may be important in infection prevention [13]. Because of the potential for infection by exposed bowel in the colostomy patient, it is unusual for sur- geons to attempt cosmetic liposuction in those pa- tients. The concern would be bacterial seeding of ex- tensive areas of fat through the abdomen and flanks leading to severe infection. 25.2 Technique The author has performed two liposuctions on a 50- year-old 66-kg woman with a 5-year history of a left abdominal colostomy due to traumatic cauda equina syndrome, who was in otherwise excellent health [14]. The first lipectomy was of the flanks, saddlebags, and knees. The patient was given 1 g cefazolin preopera - tively and the colostomy site was covered with two layers of 3M Steri-Drape. The second layer of draping extended beyond the margins of the first layer. The ports were on the upper lateral buttocks and knees, and 2,300 ml of fat was removed. The procedure was completed without complications and recovery was uneventful. Several months later, an abdominal li- pectomy for cosmetic purposes was performed as de- scribed in the following. Again, a preoperative broad- spectrum antibiotic was utilized, and the stoma was double-draped using a wide border with adhesive surgical draping with the second layer of draping ex- tending beyond the first layer. 25.3 Procedure Liposuction was performed under local anesthesia. The patient had very minimal fat in the abdomen and no complaints of stool leakage. The procedure was planned to effect a smooth transition to the area of the stoma. She was meticulously scrubbed with Beta- dine from the neck to the knees. The stoma and bag were covered with 3M Steri-Drape no. 1010, which is a plastic drape that adheres tightly to skin. A larger Steri-Drape was then applied over the first (Fig. 25.1). Gloves were then changed by all personnel. Cefazolin Fig. 25.1. Steri-Drape applied 162 25 Abdominal Liposuction in Colostomy Patients (1 g) was given intravenously. Mild additional seda- tion and analgesia were accomplished with diazapam sublingual, a narcotic, and antihistamine intramus- cularly. Small stab incisions were made in the right inguinal fold and right upper abdomen (her stoma was on the left). Klein formulation [6] (50 ml of 1% lidocaine, 12.5ml of 8.4% sodium bicarbonate, 1ml of 1:1,000 epinephrine in 1 l of normal saline) was in- fused with a total of 1 l. Because of patient anxiety, the immediate area of the stoma was not addressed. Conservative-tip cannulas (3- and 4-mm diameter) were utilized and 250–ml of fat was obtained. A vol- ume of 250 ml of additional serosanguinous fluid was obtained. The postoperative course was uneventful. Although photographs were not dramatic, the patient was pleased with the result (Fig. 25.2). The author utilized the tumescent technique, which allows the procedure to be completed under local anesthetic and takes advantage of the known antibacterial effect of lidocaine [13]. The technique is to double-drape with adhesive surgical draping extending widely beyond the stoma edge, with the second drape overlapping and extending beyond the first drape. Both bag and stoma are covered. However, the patient did not have a leakage problem compared with other reported patients. 25.4 Discussion Use of liposuction for various other medical condi- tions is well established [15–23]. However, there are relatively few literature citations of abdominal lipo- suction in colostomy or urostomy patients. Samdal [24–26] reported treating eight patients with trouble- some colostomies and urinary stomas with syringe suction assisted lipectomy under local anesthesia. Margulies [27] documented five additional cases of suction lipectomy of the abdominal wall to improve stomal function. These 13 cases involved localized suction lipectomy of the peristomal region for func- tional improvement of a leaking stoma, although Margulies reported aspirating up to 1,600 ml of fat in one patient. An article in the nursing ostomy litera- ture [28] briefly describes a patient with liposuction around the stoma for stool leakage and indicated that the particular surgeon had performed the procedure on six other patients without further elaboration. There is only one article on cosmetic liposuction on a colostomy patient [14]. In Margulies’ [27] series of five patients, the ages ranged from 13 to 47. In each case, appliance fit was hampered by body habitus, obesity, irregular folds, and scars. Two patients had ileal conduit urinary di- versions. Three patients had end ileostomies for ul- cerative colitis and Crohn’s disease. The technique did not utilize tumescent anesthesia. In the series, a betadine-soaked sponge was placed in the stoma, the abdomen widely prepared, and a large transpar- ent adhesive drape applied over the stoma and ex- tending 6–8 in. (approximately 15–20–cm) from the stoma edge. Incisions were made outside the draped area, and the catheter was utilized in an undermining mode initially. Under direct visualization and pal- pation, fat was aspirated around the stoma. Patients were discharged the same day. Preoperative antibi- otics followed by 5 days of supplemental oral agents were utilized, and binders were worn for 2–3 weeks. Two of the patients underwent subsequent sessions. There were no complications. The authors summa- rize by stating that complications are avoided with a widely prepared sealed field, preoperative antibiotics, and stomal palpation while aspirating. They recom- mend excluding patients with a parastomal hernia owing to risk of injury to the bowel. Fig. 25.2. a Preoperative patient with colostomy. b Postoperative patient following abdominal liposuction 163 Samdal’s [25] discourse on eight additional pa- tients did not describe specific measures to address infection prevention in his series. All patients were treated with a 4- or a 5-mm outer diameter cannula in the Fournier technique utilizing bullet-shaped tips. The procedures were performed under local anesthe- sia with 0.1% lidocaine and 1:1,000,000 epinephrine. Five of the patients were treated in hospital and three as outpatients. Prophylactic antibiotics were provided to six of the eight patients. Postoperative dressings were elastic tape for 1 week and a compression gar - ment for two to three additional weeks. Seven of eight patients reported resolution of leakage or infrequent leakage less than once per month postoperatively. Samdal concludes that liposuction may correct sto- mal problems in selected cases, avoiding the potential morbidity of open revision. Caution is recommended when moving the cannula blindly adjacent to a stoma. Small surface irregularities that might be ignored in routine abdominal liposuction can ruin the function- al result according to the authors of the study . They consider the syringe-assisted method to be superior in these cases. 25.5 Conclusions Reports in the literature are few concerning abdomi- nal liposuction in ileostomy or colostomy patients, but there have been no reports of significant infec- tious complications or intestinal perforation. The procedure appears safe. The recommendation is to vigorously clean the patient’s skin from neck to knees, utilize the tumescent technique, which takes advan- tage of the antibacterial effect of lidocaine in buffered bicarbonate, inject an intravenous wide-spectrum an- tibiotic, and perform a wide double covering of the stoma site and bag with adhesive sterile drapes. References 1. The American Academy of Cosmetic Surgery. 2000 Guidelines for Liposuction Surgery. Am J Cosm Surg 2000;17(2):79–84 2. Parish TD. A Review: The Pros and Cons of Tumescent Anesthesia in Cosmetic and Reconstructive Surgery. Am J Cosm Surg 2001;18(2):83–93 3. Lawrence N, Clark RE, Flynn TC, Coleman WP III. Amer- ican Society for Dermatologic Surgery Guidelines of Care for Liposuction. Dermatol Surg 2000;26:265–269 4. Coleman WP III, Glogau RG, Klein JA, Moy RL, Narins RS, Chuang T, Farmer ER, Lewis CW, Lowery BJ, Ameri- can Academy of Dermatology Guidelines/Outcomes Committee: Guidelines of care for liposuction. J Am Acad Dermatol 2001;45:438–447 5. The American Academy of Cosmetic Surgery. 2003 Guidelines for Liposuction Surgery. Am J Cosm Surg 2003;20(1):7–12 6. Klein JA. Tumescent Technique for Regional Anesthesia Permits Lidocaine Doses of 35 mg/kg for Liposuction. Dermatol Surg 1990;16(3): 248–263 7. Rama BR, Ely SF, Hoffman RS. Deaths Related to Liposuc- tion. N Engl J Med. 1999;340:1471–1475 8. Grazer FM, de Jong RH. Fatal outcomes from liposuction. Census survey of cosmetic surgeons. Plast Reconstr Surg 2000;105:436–448 9. Barillo DJ, Cancio LC, Kim SH, Shirani KZ, Goodwin CW. Fatal and near-fatal complications of liposuction. South Med J. 1998;91(5):487–492 10. Ovrebo KK, Grong K, Vindenes H. Small intestinal perfo- ration and peritonitis after abdominal suction lipoplasty. Ann Plast Surg. 1997;38(6):642–644 11. Talmor M, Hoffman LA, Lieberman M. Intestinal perfora- tion after suction lipoplasty: a case report and review of the literature. Ann Plast Surg 1997;38(2):169–172 12. Hanke CS, Bullock S, Bernstein G. Current status of tu- mescent liposuction in the United States. National survey results. Dermatol Surg 1996;22:595–598 13. Thompson KD, Welykyj S, Massa MC. Antibacterial ac- tivity of lidocaine in combination with a bicarbonate buf- fer. J Dermatol Surg Oncol. 1993;19(3):216–220 14. Raskin BI. Abdominal Liposuction in a Patient with a Co- lostomy. Am J Cosm Surg 1999;16(4):317–319 15. Coleman WP 3rd. Noncosmetic applications of liposuc- tion. J Dermatol Surg Oncol. 1988;14(10):1085–1090 16. Apesos J, Chami R. Functional applications of suction-as- sisted lipectomy: a new treatment for old disorders. Aes- thetic Plast Surg. 1991;15(1):73–79 17. Lillis PJ, Coleman WP. Liposuction for treatment of axil- lary hyperhidrosis. Dermatol Clin 1990;8:479–482 18. Pinski KS, Roenigk HH. Liposuction of lipomas. Dermatol Clin 1990;8:483–492 19. O’Brien BM, Khazanchi RK, Kumar PAV, Dvir E, Peder- son WC. Liposuction in the treatment of lymphoedema: a preliminary report. Br J Plast Surg 1989;42:530–533 20. Martin PH, Carver N, Petros AJ. Use of liposuction and saline washout for the treatment of extensive subcuta- neous extravasation of corrosive drugs. Br J Anaesth 1994;72:702–704 21. Fahmy FS, Moiemen NS, Frame JD. Liposuction for drain- age of large hematoma. Injury 1993;24:61–68 22. Brorson H, Svensson H. Liposuction combined with con- trolled compression therapy reduces arm lymphedema more effectively than controlled compression therapy alone. Plast Reconstr Surg 1998;102:1058–1067 23. Ou LF, Yan RS, Chen IC, Tank YW. Treatment of axillary bromhidrosis with superficial liposuction. Plast Reconstr Surg 1998;102:1479–1485 24. Samdal F, Myrvold HE. A troublesome colostomy treated with liposuction. Eur J Surg. 1992;158(5):323–324 25. Samdal F, Amland PF, Bakka A, Aasen AO. Troublesome colostomies and urinary stomas treated with suction-as- sisted lipectomy. Eur J Surg 1995;161(5):361–364 26. Samdal F, Brevik B, Husby OS, Abyholm F. A troublesome urostomy treated with liposuction. Case report. Scand J Plast Reconstr Surg Hand Surg 1991;25(1):91–92 References 164 25 Abdominal Liposuction in Colostomy Patients 27. Margulies AG, Klein FA, Taylor JW. Suction-assisted li - pectomy for the correction of stomal dysfunction. Am Surg. 1998;64(2):178–181 28. Haugen V, Loehner D. Surgical and nonsurgical options for a patient with a retracted stoma and peristomal skin crease. J Wound Ostomy Continence Nurs. 2001;28(4):219–222 Liposuction and Lipotransfer for Facial Rejuvenation in the Asian Patient Tetsuo Shu, Samuel M. Lam C  26 26.1 Introduction The demand for cosmetic surgery has reached an all-time high in Asia. With the disproportionate in- fluence of the Western media throughout the world, Asian patients often yearn to emulate the Occidental models in their countenance by undergoing plastic surgery. However, Asians who reside in the Orient maintain different aesthetic ideals that only at times converge with Occidental standards. For instance, a fuller upper eyelid and lower malar prominence run counter to Western conceptions of beauty. Further- more, the Western surgeon who elects to operate on the Asian patient may attempt to extrapolate from his anatomic understanding cultivated from expe- rience with Caucasian patients. However, the bony structure, soft-tissue distribution, and skin quality all differ radically from the Caucasian anatomy. If the surgeon can understand the unique aesthetic and anatomic features of the Asian patient, he or she can embark on a successful surgical intervention in the Asian patient who seeks plastic surgery. Cervico-fa- cial liposuction and lipotransfer follow the tenets just outlined for the Asian patient. In this chapter, the authors will describe a methodology for liposuction and lipotransplantation that is designed for the Asian patient given the anatomic constraints and aesthetic objectives. Liposuction has proven its efficacy as a useful tool for body recontouring and has assumed a prominent role in the plastic surgeon’s armamentarium. In ad- dition, cervical liposuction has also become integral to facial rejuvenation with or without a concomitant cervico-facial rhytidectomy. Autologous fat trans- plantation has met with greater circumspection in professional circles. Many plastic surgeons have con- cluded that lipotransfer is an ineffective endeavor, as all the transplanted adipose tissue is bound for com- plete resorption over time. Accordingly, many tech- niques have been advocated for fat transplantation that have sought to maintain the viability of the fat cells after transplantation, including centrifugation, washing, and microinjection, to name a few. How- ever, controversy has persisted, and the popularity of adipose transplantation has waned somewhat. The authors would like to revive interest in this technique and to expound upon a surgical technique that has demonstrated value after 23 years of clinical experi - ence and to explain the philosophical underpinnings for this method. 26.2 Asian Anatomy and Aesthetics The Western surgeon must appreciate the subtleties that define the Asian face before he or she undertakes any kind of incision-based surgery or dermatologic resurfacing. The underlying bony structure of the Asian face differs dramatically from that of the Caucasian face. The forehead and brow region exhibit a narrow ex- panse and flat contour, with a posterior inclination superiorly. The temple region may appear more hol- lowed owing to the relative protuberance of the zygo- matic arch. The orbits are shallower by virtue of both a less recessed bony orbital cavity as well as a fuller eyelid. The midface tends to be flatter, as the malar bone exhibits less convexity. Conversely, the lower face is more convex than that of the Caucasian face owing to the relative maxillary-alveolar projection and lower mandibular recession. Greater accumulation of adipose is present in the malar region in the Asian patient, which upon de- scent accentuates the nasolabial fold at times even more prominently than in the Caucasian patient. However, the submental area tends to have less adi- pose accumulation in younger patients, as compared with Caucasians; but this difference markedly de- clines as Asians mature and acquire a greater amount of submental fat. Despite this progressive accretion of submental fat, the underlying platysma muscle is half as likely to be dehiscent in the midline and to exhibit the characteristic anterior platysmal banding as in Caucasian patients. The overlying skin is also thicker and more resil- ient in the Asian patient, which may obviate the need [...]... 26 .4 Surgical Technique The fat can be placed into 1-, 2. 5-, or 5-ml syringes depending on the intended area for lipotransfer The 1-ml syringe outfitted with an 18-gauge needle is ideal for upper-lid, temporal, frontal, and nasolabialfold augmentation; whereas the 2. 5- or 5-ml syringe outfitted with a 2-mm cannula is preferred for larger volume transfers into the cheek and possibly the frontal and. .. can be pinched between two fingers and gently massaged until the contour feels smooth and even the principles of liposuction and lipotransplant can apply to all ethnicities, nationalities, and races, given the proper understanding and experience with each particular background 26.5 Conclusions References Facial liposuction and lipotransfer have proven to be reliable and consistent techniques for facial... the arms, small cannulas, non-aggressive tips, and multiple interdigitating tunnels facilitate a satisfactory low-risk approach Lillis [28] describes the use of 1 2- and 1 4- gauge Klein cannulas or a 2.5-mm standard cannula The one technical difference in this area is that grasping and pinching can be difficult and is often not necessary as the fat is already compressed and relatively immobile Postoperative... mixture is 500 mg lidocaine (50-ml bottle of 1% plain lidocaine), 1 mg epinephrine, and 10 mEq sodium bicarbonate in 1 l of normal saline resulting in a 0.05% lidocaine concentration [4, 15] This concentration can be enhanced to 0.075, 0.1, or even 0.15% depending on the areas being treated and the total lidocaine dose and tumescent fluid volumes anticipated Different concentrations of lidocaine are chosen... thighs to ensure appropriate positioning [4] Three incision sites are made in the supero-posterior, supero-anterior, and infero-posterior positions correlating with the 2, 8, and 10 positions on the face of a clock Less aggressive cannulas, usually 1 2- or 14gauge Finesse cannulas, are preferred to gradually remove fat and sculpt the tissue evenly The end point of liposuction in this area can be determined... solid consistency and assumes a yellow-to-orange color (Fig 26 .4) Fig 26.2 The harvested adipose tissue is strained through two cotton-gauzes with saline Fig 26.3 After most of the saline has been filtered through the cotton gauze, the cotton gauze is picked up and the remaining saline is squeezed through the gauze Fig 26 .4 The harvested fat has been dried and has assumed a yellow-to-orange color ready... aspiration Dermatol Surg 2000;26 (4) :388–391 12 Bernstein G Instrumentation for liposuction Dermatologic Clinics 1999;17 :4 13 Chalekson C Liposuction, Techniques eMedicine.com Updated December 7, 20 04 14 http://crystalsand jewelry.com/jewelrymaking/gauge_ inches-mm.html 15 Kaplan B, Moy RL Comparison of room temperature and warmed local anesthetic solution for tumescent liposuction Dermatol Surg 1996;22:707–709... retrospective analysis Dermatol Surg;26:625–632 28 Lillis PJ Liposuction of the arms, calves, and ankles Dermatol Surg 1997;23:1161–1168 29 Klein JA Post-tumescent liposuction care open drainage and bimodal compression Dermatologic Clinics 1999;17 :4 30 Rao RB, Ely SF, Hoffman RS: Deaths related to liposuction N Engl J Med 1999; 340 : 147 1– 147 5 31 Housman TS, Lawrence N, Mellen BG, George MN, San Filippo... contour and for that reason incisions are placed wherever needed The deeper fat will need to be removed in a slightly superior medial plane The cannulas that I use here are the multiple-holed, ventral three-holed and the one- and two-holed spatula of 3.0–3.7 mm If superficial liposuction is required then the smaller 2.0–3.0-mm cannulas are used 28.9.2.3 Lateral Thighs One of the areas most requested for liposuction. .. Warning: traditional liposuction cannulas may be dangerous to your patient’s health Dermatol Surg 1988; 14: 1136–8 6 Collins PS Selection and utilization of liposuction cannulas Dermatol Surg 1988; 14: 1139 43 7 Hanke CW, Bullock S, Bernstein G Current status of tumescent liposuction in the United States Dermatol Surg 1996;22:595–598 8 Hanke CW, Coleman WP Morbidity and mortality related to liposuction Dermatologic . study of laser- assisted liposuction. Aesth Plast Surg 19 94; 18(3):259–2 64 14. Apfelberg DB. Results of multicenter study of laser-as- sisted liposuction. Clin Plast Surg 1996;23 (4) :713–719 15 Reconstr Surg 2000;105 :43 6 44 8 9. Barillo DJ, Cancio LC, Kim SH, Shirani KZ, Goodwin CW. Fatal and near-fatal complications of liposuction. South Med J. 1998;91(5) :48 7 49 2 10. Ovrebo KK, Grong. into 1-, 2. 5-, or 5-ml syringes depending on the intended area for lipotransfer. The 1-ml syringe outfitted with an 18-gauge needle is ideal for upper-lid, temporal, frontal, and nasolabial- fold