Liposuction Principles and Practice - part 7 pot

337 50.3.5 Loose Skin Liposuction of certain areas of the body is prone to the development of loose skin because of the amount of fat that needs to be removed and the lack of com- plete skin retraction. Those areas most likely to have this problem include: 1. Abdomen: especially with large panniculus 2. Arms: especially elderly patients and very fat pa - tients 3. Medial thighs: postoperative loose skin is a major problem in a large percentage of patients Treatment for the loose skin requires a surgical ap- proach with significant scars. Abdominoplasty, usually modified, may have to be performed to resolve loose hanging skin of the lower abdomen, brachioplasty to resolve loose hanging skin of the arm, and thigh plasty for the loose skin of the medial thigh. 50.3.6 Necrosis There may be skin necrosis after liposuction if the cannula comes too close to the skin and disrupts the subdermal plexus of vessels. Chronic smokers who do not stop smoking before and after surgery have a high incidence of necrosis. Necrosis is more likely to occur with the use of cannulas with sharp edges and turn- ing the openings toward the skin surface. Combining excessive liposuction of the mid upper abdomen and full abdominoplasty increases the risk of necrosis of the abdominoplasty flap. Necrotizing fasciitis has been reported following liposuction (Table 50.1) [22–24]. This disorder is an infection with fulminant streptococcal group A in - fection or mixed bacterial infection frequently with anaerobes that involves the subcutaneous tissues and deep fascia producing thrombosis of the subcutaneous vessels and gangrene of the underlying and surround- ing tissues. Treatment requires surgical debridement, antibiotics, and, when necessary, hyperbaric therapy. 50.3.7 Need For Further Surgery Since the surgeon can ordinarily improve the con- tour deformities by about 50%, the patient may not be satisfied with the results. There also may be need to refine or correct the original procedure because of complications such as irregularities (grooves, wavi- ness, and indentations), asymmetries, perforation of vessel or viscus, excessive scarring, bleeding, he- matoma or seroma, loose skin, necrosis, necrotizing fasciitis, and infection. The patient should be warned preoperatively of this possibility. 50.3.8 Neurologic problems Decreased sensation or sensory loss may occur but is almost always temporary. Chronic pain may be due to a small neuroma but is more often due to injury to the underlying fascia or muscle. Injection of local anesthetic into the area of pain will usually relieve the complaint for a short period of time. Multiple injections may be necessary to relieve the pain permanently. A neuroma can be surgically resected. If a scar in the tissues (subcutaneous fat, fascia, or muscle) is tethered to the skin, there may be chronic unrelieved pain. The pain may have to be treated by release of the scar. 50.3.9 Perforation of Vessel or Viscus Perforation of the abdominal wall is most likely to oc- cur in t he presence of hernia or a n abdominal wa ll scar that can divert the direction of the cannula [37–39]. The non-dominant hand should always feel the end of the cannula. When the cannula is not palpable, the surgeon should reassess the technique and consider the possibility of perforation. Under local tumescent anesthesia, perforation can be detected at the time of surgery by the presence of abdominal pain. If there is unusual abdominal pain or chest pain postoperatively such as increasing pain or severe pain, perforation must be considered. It may be dif- ficult to examine the abdomen directly by pressure because liposuction alone will cause pain in the area. The presence of rebound tenderness usually indicates peritonitis. Flat plate and upright abdominal X-rays may show free air if the bowel is perforated. The pa- tient may have to be observed in the hospital if there is the possibility of viscus perforation. Vascular perforation that causes significant blood loss will result in abdominal pain, orthostatic hypo- tension, and shock. Insertion of a small catheter (An- giocath) into the abdominal cavity and the instillation of some sterile saline can produce bloody drainage consistent with vascular injury. If the blood is totally retroperitoneal, a CT scan may be necessary. Emer- gency exploratory laparotomy is usually indicated. Liposuction over the ribs can be aided by the use of pressure on the lower ribs with the flat portion of the non-dominant hand that will result in the cannula easily going over the ribs instead of under with per- foration into the chest. Severe chest pain, especially with dyspnea, may indicate perforation into the chest. 50.3 Evaluation and Treatment 338 50 Prevention and Treatment of Liposuction Complications Chest X-ray will usually show a pneumothorax. Inser- tion of a chest tube will relieve the pain and dyspnea. 50.3.10 Pulmonary Edema Pulmonary edema has been reported [40] that was presumed to be from rapid and high-volume hypo- dermoclysis. Pitman [41], commenting on this case, believed that the cause of the pulmonary edema was from excessive parenteral fluids being given. Ordi- narily, most individuals can tolerate large amounts of intravenous fluids, up to 2,000 ml/h, since the fluids enter the extravascular tissues within 15 min of ad - ministration. However, where there is a large amount of subcutaneous fluid from the tumescent technique, the pressure of the fluid in the tissues does not allow a gradient for the intravenous fluid to diffuse out of the vessels. 50.3.11 Scars Significant scars following liposuction are not fre- quent. It is rare to see hypertrophic scars or keloids. Poor placement of incisions may result in easily vis- ible scars. Some scars may become depressed if the suction on the cannula is maintained each time the cannula is withdrawn from the incision. If using a machine for vacuum, either stop the machine before withdrawal or use cannulas with a vent hole in the thumb portion of the handle for easy release. Incision sites may be irritated by the multiple fast passes of the cannula resulting in a reddening around or in the scar. Steroid cream will resolve the problem. The incision performed should be slightly larger than the cannula. Some surgeons use a plastic plug in the incision while performing liposuction that will pre- vent the cannula from rubbing on the skin. The use of large incisions is not indicated since most cannulas are 6 mm or less and more often than not are 4 mm or less. Some surgeons use microcan - nulas (under 2 mm) but their use requires many more skin incisions and the liposuction takes longer to per- form. The treatment of hypertrophic or keloid scars in- cludes steroid injection, radiation, reexcision, silicone gel sheeting, pressure therapy, or a combination of these [43]. The combination of steroid and 5-fluo- rouracil has been helpful in treatment. None of the treatments are permanently effective for keloids in a large percentage of patients; however, hypertrophic scars have a tendency to resolve on their own over a period of time. Skin necrosis will usually result in a significant scar. Treatment may require excision and careful closure. 50.3.12 Seroma The collection of serous fluid in the liposuction area may be due to irritation of the tissues by the trau- matic procedure but is more frequently the result of concomitant oversuctioning of a single area with un- dermining of a flap allowing a cavity to form. Some- times a hematoma may appear first and be replaced over time with serosanguinous fluid and then serous fluid. A persistent collection of fluid following liposuc- tion may be treated with needle aspiration followed by adequate compression dressings. This may need to be repeated every few days. If the collection can be reached through one of the liposuction incisions, a drain can be inserted to reduce the fluid and kept in place with compression dressings that need to be changed every couple of days. Prophylactic antibiotics may be used during the time the drain is in place. If the collection becomes chronic (over 4 weeks), the fluid should be aspirated and an equal amount of room air injected into the cavity to cause irritation (Fig. 50.3). Compression dressings are necessary after each such treatment. Another method that is available but that requires adequate anesthesia is curetting the lining of the cavity through a small incision or through one of the liposuction scars. If the liposuction is combined with abdominoplasty and a chronic seroma occurs, the pseudocyst may be excised through the abdomi- nal scar but this may leave a visible deformity. 50.3.13 Thromboembolism Superficial thrombophlebitis (an inflamed vein) ap- pears as a red, tender cord. Deep-vein thrombosis may be associated with pain at rest or only during exercise with edema distal to the obstructed vein. The first manifestation can be pulmonary embolism. There may be tenderness in the extremity and the temperature of the skin may be increased. Increased resistance or pain on voluntary dorsiflexion of the foot (Homan’s sign) andtenderness of the calf on pal- pation are useful diagnostic criteria. Pulmonary embolism is usually manifested by one of three clinical patterns: (1) onset of sudden dyspnea with tachypnea and no other symptoms; (2) sudden pleuritic chest pain and dyspnea associated with find- ings of pleural effusion or lung consolidation; and (3) sudden apprehension, chest discomfort, and dyspnea with findings of cor pulmonale and systemic hypo- tension. The symptoms occasionally consist of fever, arrhythmias, or refractory congestive heart failure. Medium- and high-risk patients for thromboem- bolism [37] (over the age of 40 years, prior history of thromboembolic disorder, surgery over 1 h, obesity, 339 postoperative immobilization, estrogen therapy) should have the necessary precautions taken in the perioperative period [43]. These include compression stockings (TEDS) or intermittent compression gar- ments. Failure to warn female patients to stop taking estrogens (birth control pills or replacement therapy) at least 3 weeks prior to surgery and 2 weeks after sur - gery increases the risk of thromboembolism [44].The combination of liposuction of the abdomen n with abdominoplasty is especially risky for the occurrence of pulmonary embolism. Thromboembolism has to be diagnosed early if death is to be prevented. Any postoperative patient who develops shortness of breath or chest pain must be considered to have the possibility of pulmonary embolism and a ventilation–perfusion lung scan should be obtained. The use of intravenous heparin can be life-saving and, at times, may be started even before the diagnosis is confirmed. 50.3.14 Toxic Shock Syndrome There have been reports of toxic shock syndrome, which is a potentially fatal disorder [25–27]. The syn- drome is caused by the exotoxins (superantigens) se- creted with infection from Staphylococcus aureus and group A streptococci [45]. Knowledge of the criteria for diagnosis is important in order to treat this poten- tially fatal disease. This includes [46]: Fig. 50.3. A 43 year-old patient with history of liposuction of thighs 6 years previously had circumferential liposuction of thighs. a Areas of seroma marked after 5 months of repeated needle aspirations and use of drains. b Ultrasound scan of seroma (arrow) in the right thigh at 5 months postoperatively. c Ultrasound scans of right thigh seroma (arrow) 1 week following one injection of room air into the seroma. This shows a marked decrease in the size of the cavity. The left thigh was injected once with room air and had complete closure of the seroma. A second injection of room air into the right seroma resulted in complete closure 50.3 Evaluation and Treatment 340 50 Prevention and Treatment of Liposuction Complications 1. Fever (above 102°F) 2. Rash (diffuse, macular erythroderma) 3. Desquamation (1–2 weeks after onset, especially of palms and sole) 4. Hypotension 5. Involvement of three or more organ systems: (a) Gastrointestinal (vomiting, diarrhea at onset) (b) Muscular (myalgia, elevated creatine phospho - kinase) (c) Mucous membrane (conjunctiva, oropharynx) (d) Renal (blood urea nitrogen or creatinine more than 2 times normal) (e) Hepatic (bilirubin, serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transami- nase more than 2 times normal (f) Hematologic (fewer than 100,000 platelets) 6. Negative results from the following studies (if ob - tained): (a) Blood, throat or cerebral spinal fluid cultures (b) Serologic tests for Rocky Mountain spotted fe - ver, leptospirosis, measles Treatment consists of surgical debridement for ne- crosis, antibiotics, circulatory and respiratory care, anticoagulant therapy for disseminated intravascular coagulation, and immunoglobulin [47]. Experimental approaches have included use of antitumor necrosis factor monoclonal antibodies and plasmapheresis. Acute median nerve compression has been re- ported [48] in three patients from the administra- tion of large amounts of intravenous fluids during liposuction. The edematous compression of the nerve resolved with elevation of the extremities and use of diuretics. The range of intravenous fluids was 4,000– 6,000 ml. Obviously the anesthesiologist in each case did not understand that small amounts of intravenous fluids should be administered in liposuction cases, limiting the amount to 250 ml/h or less. 50.4 Conclusions Complications of liposuction are best avoided when possible. The surgeon should be aware of methods to prevent the various complications and the treatments available. Aggressive liposuction by removing very large amounts of fat and doing very superficial lipo- suction in order to get more skin retraction can be associated with an increase in complications. It may be preferable to remove less than 5,000 ml of fluid and fat at each sitting and repeat the procedure at a later date than perform large-volume liposuction or megaliposuction. The risk of complications may then be reduced. References 1. Illouz, Y-G.: Principles of the technique. In Illouz,Y- G. (ed), Body Sculpturing By Lipoplasty, Edinburgh, Churchill Livingstone 1989:67 2. Fournier, P.: Autologous fat for liposuction defects dur- ing and after surgery. In Autologous Fat Transplanta- tion, Shiffman, M.A. (ed), New York, Marcel Dekker, Inc. 2001:233–242 3. Saylan, Z.: Liposhifting: Treatment of post liposuction ir- regularities. Int J Cosm Surg 1999;7(1):71–73 4. Ross, R.M., Johnson, G.W.: Fat embolism after liposuc- tion. Chest;93(6):1294–1295 5. Abbes, M., Bourgeon, Y.: Fat embolism after dermoli- pectomy and liposuction. Plast Reconstr Surg 1989;84(3): 546–547 6. Laub, D.R. Jr., Laub, D.R.: Fat embolism syndrome after liposuction: a case report and review of the literature. Ann Plast Surg 1990;25(1):48–52) 7. Dillerud, E.: Fat embolism after liposuction. Ann Plast Surg 1991;26(3):293) (Fourme, T., Vieillard-Baron, A., Loubieres, Y., Julie, C., Page, B., Jardin, F.: Early fat em- bolism after liposuction. Anesthesiology 1998;89(3): 782–784 8. Scroggins, C., Barson, P.K.: Fat embolism syndrome in a case of abdominal lipectomy with liposuction. Md Med J 1999;48:116–118 9. Bulger, E.M., Smith, D.G., Maier, R.V., Jurkovich, G.J.: Fat embolism syndrome: A 10-year review. Arch Surg 1997;132(4):435–439 10. Estebe, J.P.: From fat emboli to fat embolism syndrome. Ann Fr Anesth Reanim 1997;16(2):138–151 11. Paris, D.M.,, Koval, K., Egol, K.: Fat embolism syndrome. Am J Orthop 2002;31(9):507–512 12. Arakawa, H., Kurihara, Y., Nakajima, Y.: Pulmonary fat embolism syndrome: CT findings in six patients. J Compu Assist Tomogr 2000;24(1):24–29 13. Heyneman, L.E., Muller, N.L.: Pulmonary nodules in ear- ly fat embolism syndrome: a case report. J Thorac Imaging 2000;15(1):71–74) 14. Ravenol, J.G., Heyneman, L.E., McAdams, H.P.: Comput- ed tomography diagnosis of macroscopic pulmonary fat embolism. J Thorac Inaging 2002;17(2):154–156 15. Parizel, P.M., Demey, H.E., Veweckmans, G., Verstreken, F., Cras, P., Jorens, P.G., Schepper, A.M.: Early diagnosis of fat cerebral embolism syndrome by diffusion-weighted MRI (starfield pattern). Stroke 2001;32(12):2942–2944 16. Dominguez-Moran, J.A., Martinez-San Millan, J., Plaza, J.F., Fernandez-Ruiz, L.C., Masjuan, J.: Fat embolism syn- drome: new MRI findings. J Neurol 2001;248(6):529–532 17. Richards, R.R.: Fat embolism syndrome. Can J Surg 1997;40(5):334–339 18. Kubota, T., Ebina, T., Tonosaki, M., Ishihara, H., Matsuki, A.: Rapid improvement of respiratory symptoms associ- ated with fat embolism by high-dose methylprednisolone: a case report. J Anesth 2003;17(3):186–189 19. Huemer, G., Hofmann, S., Kratochwill, C., Koller- Strametz, J., Hopf, R., Schlag, G., Salzeer, M.: Therapeutic approach to the management of fat embolism syndrome. Orthopade 1995;24(2):173–178 20. Medical Board of California v Greenberg, Case No. 04-97- 76124, OAH No. L-1999020165, 1998 341 21. Medical Board of California v O’Neill, No. 09-03-26899, 1998 22. Alexander, J., Takeda, D., Sanders, G., Goldberg, H.: Fatal necrotizing fasciitis following suction-assisted lipectomy. Ann Plast Surg 1988;29(6):562–565 23. Gibbons, M.D., Lim, R.B., Carter, P.L.: Necrotizing fa- sciitis after tumescent liposuction. Am Surg 1998;64(5): 458–460 24. Heitmann, C., Czermak, C., Germann, G.: Rapidly fatal necrotizing fasciitis after aesthetic liposuction. Aesthet Plast Surg 2000;24(5):344–347 25. Rhee, C.A., Smith, R.J., Jackson, I.T.: Toxic shock syn- drome associated with suction-assisted lipectomy. Aesth Plast Surg 1994;18:161–163 26. Umeda, T., Ohara, H., Hayashi, O., Ueki, M., Hata, Y.: Toxic shock syndrome after suction lipectomy. Plast Re- constr Surg 2000;106(1):204–207 27. Cawley, M.J., Briggs, M., Haith, L.R., Jr., Reilly, K.J., Guil- day, R.E., Braxton, G.R., Patton, M.L.: Intravenous im- munoglobulin as adjunctive treatment for streptococcal toxic shock syndrome associated with necrotizing fasci- itis: case report and review. Pharmacotherapy 1999;19(9): 1094–1098 28. Farber, G.A.: Personal communication, January 18,1999 29. Kim, Y., Hirota, Y., Shibutani, T., Sakiyama, K., Okimura, M., Matsuura, H.: A case of anaphylactoid reaction due to methylparaben during induction of general anesthesia. J Jpn Dent Soc Anesthesiol 1994;22(3):491–500 30. Bircher, A.J., Surber, C.: Anaphylactic reaction to lido- caine. Aust Dent J 1999;44(1):64 31. Kennedy, K.S., Cave, R.H.: Anaphylactic reaction to li- docaine. Arch Otolaryngol Head Neck Surg 1986;112(6): 671–673 32. Zimmerman, J., Rachmilewitz, D.: Systemic anaphylactic reaction following lidocaine administration. Gastrointest Endosc 1985;31(6):404–405 33. Anibarro, B., Seoane, F.J.: Adverse reaction to lidocaine. Allergy 1998;53(7):717–718 34. de Jong, R.: Titanic tumescent anesthesia. Dermatol Surg 1998;24:689–692 35. Shiffman, M.A.: Medications potentially causing lidocaine toxicity. Am J Cosm Surg 1998;15(3):227–228 36. Fodor, P.B.: Lidocaine toxicity issues in lipoplasty. Aesthet Surg J 2000;20(1):56–58 37. Grazer, F.M., de Jong, R.H.: Fatal outcomes from liposuc- tion: Census survey of cosmetic surgeons. Plast Reconstr Surg 2000;105(1):436–446 38. Teillary v Pottle, New Hanover County (NC), Superior Court. In Medical Malpractice Verdict, Settlements & Ex- perts 1996;12(8):47 and 1996;12(11):46 39. Talmor, M., Fahey, T.J.,Wise, J., Hoffman, L.A., Barie, P.S.: Large-volume liposuction complicated by retroperitoneal hemorrhage: Management principles and implications for the quality improvement process. Plast Reconstr Surg 2000;105(6):2244–2248 40. Gilliland, M.D., Coates, N.: Tumescent liposuction complicated by pulmonary edema. Plast Reconstr Surg 1997;99(1):215–219 41. Pitman, G.H.: Tumescent liposuction complicated by pulmonary edema. Plast Reconstr Surg 1997;100(5):1363– 1364 Correspondence 42. Shiffman, M.A.: Causes of and treatment of hypertrophic and keloid scars with a new method of treating steroid fat atrophy. Int J Cosm Surg Aesthet Derm 2002;4(1):9–14 43. European Consensus Statement of the prevention of ve- nous thromboembolism. Int Angiol 1992;11:151 44. Estate of Marinelli v Geffner, Ocean County (NJ), Supe- rior Court. In Medical Malpractice Verdicts, Settlements & Experts 1999;16(10):54–55 45. Rhee, C.A., Smith, R.J., Jackson, I.T.: Toxic shock syn- drome associated with suction-assisted liposuction. Aes- thet Plast Surg 1994;18(2):161–163 46. McCormick, J.K., Yarwood, J.M., Schlievert, P.M.: Toxic shock syndrome and bacterial superantigens: an update. Annu Rev Microbiol 2001;55:77–104 47. Baracco, G.J., Bisno, A.L.: Therapeutic approaches to streptococcal toxic shock syndrome. Curr Infect Dis Rep 1990;1(3):230–237 48. Lombardi, A.S., Quirke, T.E., Rauscher, G.: Acute median nerve compression associated with tumescent fluid ad- ministration. Plast Reconstr Surg 1998;102(1):235–237 References Disharmonious Obesity Following Liposuction James E. Fulton Jr., Farzin Kerendian C  51 51.1 Introduction Liposuction is considered an excellent technique for body sculpting by removing unwanted fat [1–3]. The method has achieved much popularity in the past decades and is now one of the commoner elective cosmetic surgical procedures in the USA [4]. Liposuc- tion is considered safe and effective [5, 6]. Although major complications associated with liposuction are rare, the potential for early and delayed complica- tions exists. The early postoperative complications are extensively described in the literature and they include bleeding or unusual bruising, seroma forma- tion, infections, lidocaine toxicity, skin necrosis, fat embolism, and perforation of major organs or vessels [7]. However, the long-term complications or sequelae are not so well established. One of the sequelae is the development of disharmonious obesity after liposuc- tion. After removing one portion of the body’s fat cells, the other fat cells may pick up the burden of fat storage. This may lead to an unusual area of fat bulg- ing that becomes unattractive. 51.2 Authors’ Experience A retrospective study was completed on 125 patients who had undergone liposuction in the last 5 years. Histories, physicals, and photographs were reviewed and 15 patients were found that had developed un- usual hypertrophic fat pockets (Table 51.1, Fig. 51.1). There were examples of hypertrophic fat pockets in the submental area, upper back, arms and legs, breasts, anterior and posterior flanks. No particu- lar fat deposits were exempt. After obtaining an in- formed consent, the patients were placed on a low- carbohydrate diet, aerobic exercise and scheduled for repeat liposuction. 51.3 Case Histories Case 1: This 44-year-old woman had undergone lipo- suction and abdominoplasty 5 years previously fol - lowing three pregnancies. The abdominal wall was defatted with liposuction, the abdominal muscles were plicated and the skin was closed in three lay- ers. Over the next few years the anterior abdomen remained flat. However, there was a gradual bulging of the flanks, which became disfiguring (Fig. 51.2). Table 51.1. Foci of disharmonious obesity after liposuction Area Number Area Number Submental 2 Upper abdomen 3 Upper arms 3 Mesenteric fat 3 Breasts 6 Interthighs 2 Upper back 4 Knees 2 Lower flank 5 Ankles 1 There were 31 sites. The breasts, upper backs and flanks were the commonest areas of fatty hypertrophy; however, no fatty foci were exempt. There was an average of two sites per patient. Fig. 51.1. Potential areas of hypertrophic fatty deposits. Any of these fatty foci can hypertrophy following body sculpting with liposuction. (Courtesy of Coleman et al. [8]) 343 After the patient developed an exercise program, re- duced her carbohydrate intake and underwent lipo- suction of these hypertrophic flanks the condition improved. Case 2: This 45-year-old woman had an abdominal pannus, which was removed with liposuction and ab- dominoplasty (Fig. 51.3). She noticed a reduction in waist size and a flat abdomen. However, over the next few years her breasts became hypertrophic and caused chronic back pain and depressions of the shoulders from the bra straps. After breast reduction with lipo- suction her figure became more harmonious. Case 3: This 52-year-old woman underwent extensive liposuction 4 years previously. She came in for an evaluation of tumors that had developed on the upper flank (Fig. 51.4). After developing an aerobic exercise program, using a low-carbohydrate diet and undergo- ing liposuction of the residual fatty deposits the body became more harmonious. Case 4: This 43-year-old woman had undergone two previous liposuction surgeries to contour the body. The areas of the liposuction improved; however, she developed fatty deposits of the arms (Fig. 51.5). After reducing carbohydrate intake and having liposuction of these fatty deposits the arms became more propor- tional. Case 5: This 38-year-old woman had extensive lipo- suction 5 years previously. Over the intervening years she had developed a “buffalo hump,” bilateral tumors on the upper abdomen and a tail on both breasts Fig. 51.2. Disharmonious obesity after liposuction and abdominoplasty. a Before liposuction and abdomino- plasty. b After liposuction and abdominoplasty. The flanks gradually became hypertro- phic and displeasing to the patient Fig. 51.3. Breast hypertro- phy following liposuction. a Prior to liposuction. b Patient developed breast hypertro- phy that was associated with chronic back pain following liposuction 51.3 Case Histories 344 51 Disharmonious Obesity Following Liposuction (Fig. 51.6). These were improved with additional liposuction, aerobic exercise and a low-carbohydrate diet. Case 6: This patient demonstrated hypertrophy of anterior and posterior flanks after liposuction (Fig. 51.7). Fig. 51.4. Hypertrophic fat deposits of the upper flank. a Patient prior to liposuction. b Patient developed unusual fatty tumors of the upper flanks following liposculpture 4years previously Fig. 51.5. a Patient prior to liposuction. b The arm fat pad became hypertrophic following liposculpture of other areas Fig. 51.6. After liposuction 5 years previously this patient developed bilateral fatty deposits on the upper abdomen and a fatty tail on both breasts and a buffalo hump on the upper back. These were improved with additional liposuction, aerobic exercise and a low-carbohydrate diet a c b 345 Case 7: This patient developed mesenteric fat hyper- trophy after liposuction (Fig. 51.8). Case 8: This patient developed bulging of the lateral buttocks after liposuction (Fig. 51.9). 51.4 Discussion These cases demonstrate one of the sequelae of lipo- suction, hypertrophy of residual fat pockets that have been untreated or inadequately treated with liposuc- tion. Previous authors have also documented areas of fatty hypertrophy following liposuction. Matarasso et al. [9] studied fat distribution between subcutaneous and visceral adipose tissue after large-volume (more than 1,000 ml) liposuction. They found that liposuc - tion of subcutaneous fat led to a 12% increase in the proportion of visceral adipose tissue. The authors also found this clinically. There was often an increase in mesenteric fat after subcutaneous liposuction. Scarborough and Bisaccia [10] were the first to document breast hypertrophy following liposuction. Yun et al. [11] also documented that one third of their 73 subjects reported breast hy- pertrophy after liposuction. This phenomenon results from a decrease in the number of fat cells in the area treated by liposuction and a compulsory increase in fat deposition in residual fatty pockets. This prefer- ential fatty hypertrophy results in the appearance of disharmonious obesity. Larson and Anderson [12] discovered that visceral depots were compensated by an increase in average fat cell size, whereas subcuta- neous depots were compensated by an increase in fat cell numbers. Also, when fat deposits with hormone receptors such as the outer flanks are removed the same level of circulating estrogen has a more pro- found effect on the residual fat cell receptor sites, such as the breasts. There is relatively more estrogen avail- able at the residual hormone-dependent fat cells after liposuction [13]. Obviously, the adipose tissues not only store fat but also participate in the general metabolic processes. The rate of fat deposition and its use is determined by diet intake and energy expenditure. In addition to corrective liposuction, the therapeutic program must include aerobic exercise and a low glycemic diet. The reduction in refined carbohydrate intake will reduce the insulin levels so sugars will not be directly con- verted to fat [14]. It is important to discuss the risk of this occur- rence preoperatively with the liposuction candidate. The physician must stress the necessity of weight con- trol and the benefits of exercise. It is much easier to develop inappropriate fat pockets when other areas of body fat have been eliminated and the patient main- tains a high glycemic diet. With this patient aware- ness and education it may be possible to avoid these sequelae. ab Fig. 51.7. Note the hypertro- phy of the flanks after lipo- suction 51.4 Discussion 346 51 Disharmonious Obesity Following Liposuction References 1. Fischer G: Liposculpture: The “correct” history of liposuc- tion. Dermatol Surg, 1990;16:1087–1089 2. Klein JA. The tumescent technique for liposuction sur- gery. Am J Cosm Surg. 1987;4:263–267 3. Fulton JE, Rahimi AD and Helton P. Modified tumescent liposuction. Dermatol Surg 1999;25:755–766 abc Fig. 51.8. After liposuction of the subcutaneous fat of the abdomen, this patient developed extensive mesenteric fat hypertrophy 4. Hanke CW, Bullock S, Bernstein G. Current status of tu - mescent liposuction in the United States. Dermatol Surg 1996:22:595–598 5. Rohrich RJ Beran SJ: Is liposuction safe? Plast Recon Surg. 1999; 104:819–822 6. Hanke CW, Bernstein G, Bullock S: Safety of tumescent liposuction in 15,336 patients. Dermatol Surg 1995;21: 459–462 7. Teimourian B, Rogers WB: A national survey of compli- cations associated with suction lipectomy; Plast Reconstr Surg 1989;84(4):628–631 8. Coleman WP, Hanke CW, Cook WR, Narins RS: Body Contouring. Carmel, IN, Cooper Publishing Group 1997 9. Matarasso A, Kim RW, Kral JG: The impact of liposuction on body fat. Plast Reconstr Surg 1998;102:1686–1689 10. Scarborough DA, Bisaccia E: The occurrence of breast en- largement in females following liposuction. Am J Cosm Surg 1991;8:97–99. 11. Yun PL, Bruck M, Felsenfeld L, Katz RE: Breast enlarge- ment observed after power liposuction. Dermatol Surg 2003;29:165–167 12. Larson KA, Anderson DB. The effects of lipectomy on re- maining adipose tissue depots. Growth 1978;42:469–477 13. Killinger DW, Perel E, Daniilescu D, Kharlip L, Lindsay WR, The relationship between aromatase activity and body fat distribution. Steroids 1987;50:61–72 14. Steward HL, Morrison CB, Andrews SS, Balart LA, Sug- ar Busters! Cut Sugar to Trim Fat. New York, Ballantine Books 1998 Fig. 51.9. Note the lateral bulging of the buttocks after liposuc- tion. This was corrected with weight loss following aerobic exercise and a low-carbohydrate diet [...]... Percent mass extracted Percent mass extracted per surgery minute 186a 1691 1681 1 87 1 87 1 87 1 87 1 87 1 87 13.13 11.22 −1. 87 41.28 79 .80 153. 97 5.02 6.09 0.04 1.00 1.36 1. 37 10.54 17. 76 68.59 2 .73 2 .71 0.02 9.30 6.30 −6.83 21.00 47. 63 35.00 0.35 0.58 0.01 15.00 14.20 1. 07 72.00 1 27. 01 475 .00 12.85 12.41 0.09 Hgb hemoglobin, SD standard deviation a Missing data reduced n b The hierarchical linear model estimates... complications and results Am J Cosm Surg 19 97; 14:2 97 310 62 Fulton JE: Breast contouring by autologous fat transfer Am J Cosm Surg 1992;9: 273 373 374 56 Liposuction Practitioner Profile and Current Practice Standards and Patient Safety 63 Gruner CL: Aesthetics of liposuction Am J Cosm Surg 1995;12 :77 64 Gasparotti M: Superficial liposuction: a new application of the technique for aged and flaccid skin... 1995;21:459–462 71 Hernandez-Perez E: Is it safe to aspirate large volumes of fat? The present experience in El Salvador Am J Cosm Surg 1989;6: 97 72 Hetter GP: Blood and fluid replacement for lipoplasty procedures Clin Plast Surg 1989;16:245 73 Hildreth B: Liposuction and serum lipids Am J Cosm Surg 19 97; 14:345–346 74 Howes Rm: The “Howes” and whys of liposuction surgery Am J Cosm Surg 1986;3 (Suppl 1) :7 75 Illouz... anesthesia accidents and related severe injury through safety monitoring Anesthesiology 1989 ;70 : 572 – 577 6 Cardenas-Camarena, L.: Lipoaspiration and its complications: A safe operation Plast Reconstr Surg 2003; 112(5):1435–1441 7 Gazet, J.C., Pilkington, T.R.E.: Surgery of morbid obesity Br Med J 19 87; 295(6590) :72 73 8 Prys-Roberts, C.: Hypertension and anesthesia – fifty years on Anesthesiology 1 979 ;50(4):281–284... 1999;25:343–3 47 26 Coleman, W et, al: The Efficacy of Powered Liposuction Dermatol Surg 2001; 27: 735 27 Cristomo RF Jr: Hyperhidrosis axillae treated by liposuction corettage Am J Cosm Surg 1989;6:1 17 28 Cristomo RF JR: Combined liposuction and mini-abdominoplasty Am J Cosm Surg 1990 ;7: 1 67 29 Davis PL, Narayanan K, Liang MD, Futrell JW: Magnetic resonance imaging of facial lipodystrophy: preand post-adipose... Surg 1 977 ;59(4):513–5 17 16 Courtiss, E.H.: Suction lipectomy: complications and results by survey Plast Reconstr Surg 1985 ;76 (1) :70 17 Pitman, G.H., Teimourian, B.: Suction lipectomy: complications and results by survey 1985 ;76 (1):65 72 References 18 Christman, K.D.: Death following suction lipectomy and abdominoplasty Plast Reconstr Surg 1986 ;78 (3):428 19 Bernstein, G., Hanke, C.W.: Safety of liposuction: ... Illouz Y-G, de Villers YT: Body Sculpting by Lipoplasty Edinburg, Churchill Livingstone, 1989 76 Illouz Y-G: Refinements in the lipoplasty techniques Clin Plast Surg 1989;16:2 17 77 Jackson RF: Frozen fat—does it work? Am J Cosm Surg 19 97; 14:339–344 78 Jackson RF, Dolsky RL: Liposuction: A Practitioner Profile Am J Cosm Surg 1999;16:13–15 79 Jackson RF, Dolsky RL: Current Practice Standards in Liposuction. .. blood loss and to apply these variables to create a statistical model to predict blood loss preoperatively 52.2 Studying Blood Loss Blood loss in liposuction surgery has been evaluated superficially Blood losses among different methods of liposuction including suction-assisted liposuction, pneumatic-power-assisted liposuction and ultrasound-assisted liposuction were found to be similar [2, 7] The common... Respondents’ current and original discipline(s) 3 67 368 56 Liposuction Practitioner Profile and Current Practice Standards and Patient Safety According to surveys conducted by the American Academy of Cosmetic Surgery and the American Society of Plastic Surgery as well as others the majority of liposuction practitioners perform procedures in clinic-based surgical facilities or freestanding surgical centers... 19 87; 4:1 47 Felman G: Fat suction and fat reinjection Am J Cosm Surg 19 87; 4:189 48 Ferreira JA: Complications in liposuction Am J Cosm Surg 1993;10:259 49 Ferreira JA: Lipoplasty in the treatment of obesity Am J Cosm Surg 19 97; 14:251–256 50 Field L: The dermatologist and liposuction, a history J Dermatol Surg Oncol 19 87; 13:1040–1041 51 Field LM, Spinowitz AL: Flap elevation and mobilization by blunt liposuction . 15.00 Postsurgery-Hgb 169 1 11.22 1.36 6.30 14.20 Change coefficient in Hgb units b 168 1 −1. 87 1. 37 −6.83 1. 07 Age (years) 1 87 41.28 10.54 21.00 72 .00 Weight (kg) 1 87 79.80 17. 76 47. 63 1 27. 01 Surgery. of liposuction including suction-assisted liposuction, pneumatic-power-assisted liposuction and ultra- sound-assisted liposuction were found to be similar [2, 7] . The common factor among these. 1995;24(2): 173 – 178 20. Medical Board of California v Greenberg, Case No. 0 4-9 7- 76 124, OAH No. L-1999020165, 1998 341 21. Medical Board of California v O’Neill, No. 0 9-0 3-2 6899, 1998 22. Alexander,