Liposuction Principles and Practice - part 9 pot

457 67.8 Concluding Remarks Large-volume liposuction is a procedure that can remove substantial amounts of subcutaneous fat, including fat from the localized fat depot that has many biochemical features reminiscent of those found in the visceral adipose tissue that is tightly linked to the conditions of syndrome X. Liposuction and lipectomy have been used in some cases as adjuncts to more es- tablished bariatric surgery, and recent developments have raised the possibility of the utility of liposuction as a primary surgical option for obesity management. The effects of large-volume liposuction on AVD risk still require intensive, detailed investigation as there are two opposing theories as to what happens to AVD risk following this procedure. On the basis of clinical and animal data it appears that there is a threshold effect: where removal of excessive subcutaneous fat may result in AVD risk improvement, while removal of significantly greater amounts may result in delete- rious effects. Clear definition of what determines this threshold in the individual patient is an important issue that needs to be resolved. The results of ongoing human and animal studies on this subject are eagerly awaited. Acknowledgement. This research was supported by the National Institute of Child Health and Human Devel- opment, NIH (ZO1 HD-00641). References 1. American, Heart, Association. Heart and Stroke facts: 1995 statistical supplements, 1995 2. Gillum RF. New considerations in analyzing stroke and heart disease mortality trends: the Year 2000 Age Stan- dard and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision. Stroke 2002;33:1717–1722 3. Reaven GM. Role of insulin resistance in human disease (syndrome X): an expanded definition. Annu Rev Med 1993;44:121–131 4. Reaven GM. Syndrome X: is one enough? Am Heart J 1994;127:1439–1442 5. Reaven GM, Lithell H, Landsberg L. Hypertension and associated metabolic abnormalities–the role of insulin resistance and the sympathoadrenal system. N Engl J Med 1996;334:374–381 6. Fontbonne A. Insulin-resistance syndrome and cardiovascular complications of non-insulin-dependent diabetes mellitus. Diabetes Metab 1996;22:305–313 7. Wajchenberg BL, Malerbi DA, Rocha MS, Lerario AC, Santomauro AT. Syndrome X: a syndrome of insulin resistance. Epidemiological and clinical evidence. Diabetes Metab Rev 1994;10:19–29 8. Bahr V, Pfeiffer AF, Diederich S. The metabolic syndrome x and peripheral cortisol synthesis. Exp Clin Endocrinol Diabetes 2002;110:313–318 9. Roth JL, Mobarhan S, Clohisy M. The Metabolic Syn- drome: where are we and where do we go? Nutr Rev 2002;60:335–337 10. Ascott-Evans B. The metabolic syndrome, insulin resistance and cardiovascular disease. Cardiovasc J S Afr 2002;13:187–188 11. Lombard L, Augustyn MN, Ascott-Evans BH. The metabolic syndrome – pathogenesis, clinical features and management. Cardiovasc J S Afr 2002;13:181–186 12. Ford ES, Giles WH, Dietz WH. Prevalence of the metabolic syndrome among US adults: findings from the third Na- tional Health and Nutrition Examination Survey. J Amer Med Assoc 2002;287:356–359 13. Mokdad AH, Ford ES, Bowman BA, Nelson, D.E., Engel- gau, M.M., Vinicor, F., Marks, J.S. Diabetes trends in the U.S.: 1990–1998. Diabetes Care 2000;23:1278–1283 14. Mokdad AH, Ford ES, Bowman BA, Nelson, D.E., Engel- gau, M.M., Vinicor, F., Marks, J.S. The continuing increase of diabetes in the US. Diabetes Care 2001;24:412 15. Friedland O, Nemet D, Gorodnitsky N, Wolach B, Eliakim A. Obesity and lipid profiles in children and adolescents. J Pediatr Endocrinol Metab 2002;15:1011–1016 16. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Preva- lence and trends in obesity among US adults, 1999–2000. J Amer Med Assoc 2002;288:1723–1727 17. Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan JP. The continuing epidemics of obesity and diabetes in the United States. J Amer Med Assoc 2001;286: 1195–200 18. Mokdad AH, Serdula MK, Dietz WH, Bowman BA, Marks JS, Koplan JP. The spread of the obesity epidemic in the United States, 1991–1998. J Amer Med Assoc 1999;282:1519–1522 19. Mokdad AH, Serdula MK, Dietz WH, Bowman BA, Marks JS, Koplan JP. The continuing epidemic of obesity in the United States. J Amer Med Assoc 2000;284:1650–1651 20. Ford ES, Williamson DF, Liu S. Weight change and diabetes incidence: findings from a national cohort of US adults. Am J Epidemiol 1997;146:214–222 21. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduc- tion in the incidence of type 2 diabetes with lifestyle inter- vention or metformin. N Engl J Med 2002;346:393–403 22. Pan XR, Yang WY, Li GW, Liu J. Prevalence of diabetes and its risk factors in China, 1994. National Diabetes Pre- vention and Control Cooperative Group. Diabetes Care 1997;20:1664–1669 23. Pan XR, Li GW, Hu YH, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study. Diabetes Care 1997;20:537–544 24. Tuomilehto J, Lindstrom J, Eriksson JG, Valle, T.T., Ham- alainen, H., Ilanne-Parikka, P., Keinanen-Kuikaanniemi, S., Laakso, M., Louheranta, A., Rastas, M., Salminen, V., Uusitupa, M. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001;344(18):1343–1350 25. Chiasson JL, Josse RG, Gomis R, Hanefeld M, Karasik A, Laakso M. Acarbose for prevention of type 2 diabetes mellitus: the STOP-NIDDM randomised trial. Lancet 2002;359:2072–2077 References 458 67 Cardiovascular Risk Profile Improvement with Large-Volume Liposuction 26. Buchanan TA, Xiang AH, Peters RK, Kjos, S.L., Mar- raquin, A., Goico, J., Ochoa, C., Tan, S., Berkowitz, K., Hodis, H.N., Azen, S.P. Preservation of pancreatic beta- cell function and prevention of type 2 diabetes by phar- macological treatment of insulin resistance in high-risk hispanic women. Diabetes 2002;51(9):2796–2803 27. Heymsfield SB, Segal KR, Hauptman J, Lucas, C.P., Bold- rin, M.N., Rissanen, A., Wilding, J.P., Sjostrom, L. Effects of weight loss with orlistat on glucose tolerance and pro- gression to type 2 diabetes in obese adults. Arch Intern Med 2000;160(9):1321–1326 28. Greenway FL. Surgery for obesity. Endocrinol Metab Clin North Am 1996;25:1005–1027 29. Scheen AJ, Desaive C, Lefebvre PJ. Therapy for obesity– today and tomorrow. Baillieres Clin Endocrinol Metab 1994;8:705–727 30. Lawrence N, Coleman WP, 3rd. Liposuction. Adv Derma- tol 1996;11:19–49 31. Kral JG. Surgical treatment of regional adiposity. Lipecto- my versus surgically induced weight loss. Acta Med Scand Suppl 1988;723:225–231 32. Matarasso A, Hutchinson OH. Liposuction. J Amer Med Assoc 2001;285:266–268 33. Kenkel JM, Gingrass MK, Rohrich RJ. Ultrasound-assisted lipoplasty. Basic science and clinical research. Clin Plast Surg 1999;26:221–234; vii 34. Courtiss EH, Choucair RJ, Donelan MB. Large-volume suction lipectomy: an analysis of 108 patients. Plast Re- constr Surg 1992;89:1068–1079; discussion 1080–1082 35. Albin R, de Campo T. Large-volume liposuction in 181 patients. Aesthetic Plast Surg 1999;23:5–15 36. Skouge JW. The biochemistry and development of adipose tissue and the pathophysiology of obesity as it relates to liposuction surgery. Dermatol Clin 1990;8:385–393 37. Illouz YG. Study of subcutaneous fat. Aesthetic Plast Surg 1990;14:165–177 38. Goodpaster BH, Thaete FL, Kelley DE. Thigh adipose tissue distribution is associated with insulin resistance in obesity and in type 2 diabetes mellitus. Am J Clin Nutr 2000;71:885–892 39. Despres JP. Dyslipidaemia and obesity. Baillieres Clin En- docrinol Metab 1994;8:629–660 40. Frayn KN. Visceral fat and insulin resistance–causative or correlative? Br J Nutr 2000;83 Suppl 1:S71-S77 41. Seidell JC, Perusse L, Despres JP, Bouchard C. Waist and hip circumferences have independent and opposite effects on cardiovascular disease risk factors: the Quebec Family Study. Am J Clin Nutr 2001;74:315–321 42. Lamarche B, Lemieux S, Dagenais GR, Despres JP. Viscer- al obesity and the risk of ischaemic heart disease: insights from the Quebec Cardiovascular Study. Growth Horm IGF Res 1998;8 Suppl B:1–8 43. Must A, Spadano J, Coakley EH, Field AE, Colditz G, Di- etz WH. The disease burden associated with overweight and obesity. J Amer Med Assoc 1999;282:1523–1529 44. Barzilai N, She L, Liu BQ, et al. Surgical removal of visceral fat reverses hepatic insulin resistance. Diabetes 1999;48:94–98 45. Jensen MD. Regional glycerol and free fatty acid metabolism before and after meal ingestion. Am J Physiol 1999;276:E863-E869 46. Meek SE, Nair KS, Jensen MD. Insulin regulation of regional free fatty acid metabolism. Diabetes 1999;48:10–14 47. Weber RV, Buckley MC, Fried SK, Kral JG. Subcutaneous lipectomy causes a metabolic syndrome in hamsters. Am J Physiol Regul Integr Comp Physiol 2000;279:R936-R943 48. Kral JG. Surgical reduction of adipose tissue in the male Sprague-Dawley rat. Am J Physiol 1976;231:1090–1096 49. Liszka TG, Dellon AL, Im M, Angel MF, Plotnick L. Ef- fect of lipectomy on growth and development of hyper- insulinemia and hyperlipidemia in the Zucker rat. Plast Reconstr Surg 1998;102:1122–1127 50. Mauer MM, Harris RB, Bartness TJ. The regulation of total body fat: lessons learned from lipectomy studies. Neu- rosci Biobehav Rev 2001;25:15–28 51. Larson KA, Anderson DB. The effects of lipectomy on remaining adipose tissue depots in the Sprague Dawley rat. Growth 1978;42:469–477 52. Bailey JW, Anderson DB. Rate of fat compensation and growth efficiency of lipectomized Sprague Dawley rats. J Nutr 1980;110:1785–1792 53. Ochi M, Furukawa H, Yoshioka H, Sawada T, Kusunoki T, Hattori T. Adipocyte dynamics in hypothalamic obese mice during food deprivation and refeeding. J Nutr Sci Vi- taminol (Tokyo) 1991;37:479–491 54. Ochi M, Yoshioka H, Sawada T, Kusunoki T, Hattori T. New adipocyte formation in mice during refeeding after long-term deprivation. Am J Physiol 1991;260:R468-R474 55. Kasubuchi Y, Mino M, Yoshioka H, Kusunoki T. An au- toradiographic study of new fat cell formation in adipose tissue in adult mice during malnutrition and refeeding. J Nutr Sci Vitaminol 1979;25:419–426 56. Chlouverakis C, Hojnicki D. Lipectomy in obese hypergly- cemic mice (ob-ob). Metabolism 1974;23:133–137 57. Dark J, Forger NG, Stern JS, Zucker I. Recovery of lipid mass after removal of adipose tissue in ground squirrels. Am J Physiol 1985;249:R73-R78 58. Dark J, Forger NG, Zucker I. Rapid recovery of body mass after surgical removal of adipose tissue in ground squirrels. Proc Natl Acad Sci U S A 1984;81:2270–2272 59. Mauer MM, Bartness TJ. Photoperiod-dependent fat pad mass and cellularity changes after partial lipectomy in Si- berian hamsters. Am J Physiol 1996;270:R383-R392 60. Hamilton JM, Wade GN. Lipectomy does not impair fat- tening induced by short photoperiods or high-fat diets in female Syrian hamsters. Physiol Behav 1988;43:85–92 61. Faust IM, Johnson PR, Hirsch J. Noncompensation of adipose mass in partially lipectomized mice and rats. Am J Physiol 1976;231:539–544 62. Palmieri B, Bosio P, Catania N, Gozzi G. Ultrasonic suction lipectomy. A mini-invasive treatment of obesity. Re- cent Prog Med 1995;86:220–225 63. Gonzalez-Ortiz M, Robles-Cervantes JA, Cardenas-Ca- marena L, Bustos-Saldana R, Martinez-Abundis E. The effects of surgically removing subcutaneous fat on the metabolic profile and insulin sensitivity in obese women after large-volume liposuction treatment. Horm Metab Res 2002;34:446–449 64. Uwaifo GI, Giese SY, Bulan EJ, Commons G, Spear SL, Yanovski JA. Clinical and metabolic effects of large volume liposuction (Abstract). Obesity Research 2000;8:55 S, O-165 65. Giese SY, Bulan EJ, Commons GW, Spear SL, Yanovski JA. Improvements in cardiovascular risk profile with large- volume liposuction: a pilot study. Plast Reconstr Surg 2001;108:510–519; discussion 520–521 459 66. Giese SY, Neborsky R, Bulan EJ, Spear SL, Yanovski JA. Improvements in cardiovascular risk profile after large volume lipoplasty: A 1 year follow-up study. Aesthetic Surg J 2001;21:527–531 67. Cazes L, Deitel M, Levine RH. Effect of Abdominal Li- pectomy on Lipid Profile, Glucose Handling and Blood Pressure in Patients with Truncal Obesity. Obes Surg 1996;6:159–166 68. Enzi G, Cagnoni G, Baritussio A, De Biasi, F., Favaretto, L., Inelman, E.M., Crepaldi, G. Effects of fat mass reduction by dieting and by lipectomy on carbohydrate metabolism in obese patients. Acta Diabetol Lat 1979;16(2):147–156 69. Talisman R, Belinson N, Modan-Moses D, Canti, H., Orenstein, A., Barzilai, Z., Parret, G. The effect of reduction of the peripheral fat content by liposuction-assisted lipectomy (SAL) on serum leptin levels in the postoperative period: a prospective study. Aesthetic Plast Surg 2001;25(4):262–265 70. Samdal F, Birkeland KI, Ose L, Amland PF. Effect of large-volume liposuction on sex hormones and glucose- and lipid metabolism in females. Aesthetic Plast Surg 1995;19:131–135 71. Berntorp E, Berntorp K, Brorson H, Frick K. Liposuction in Dercum‘s disease: impact on haemostatic factors associated with cardiovascular disease and insulin sensitivity. J Intern Med 1998;243:197–201 72. Hauner H, Olbrisch RR. The treatment of type-1 diabet- ics with insulin-induced lipohypertrophy by liposuction. Dtsch Med Wochenschr 1994;119:414–417 73. Hardy KJ, Gill GV, Bryson JR. Severe insulin-induced lipohypertrophy successfully treated by liposuction. Diabe- tes Care 1993;16:929–930 74. Samdal F, Amland PF, Sandsmark M, Birkeland KI. Dia- betic lipohypertrophy treated with suction-assisted lipectomy. J Intern Med 1993;234:489–492 75. Kral JG. Surgical reduction of adipose tissue hypercellu- larity in man. Scand J Plast Reconstr Surg 1975;9:140–143 76. Premkumar A, Chow C, Bhandarkar P, Wright, V., Koshy, N., Taylor, S., Anioglu, E. Lipoatrophic-lipodystrophic syndromes: the spectrum of findings on MR imaging. Am J Roentgenol 2002;178(2):311–318 77. Arioglu E, Duncan-Morin J, Sebring N, Rother, K.I., Gott- lieb, N., Lieberman, J., Herion, D., Kleiner, D.E., Reynolds. J., Premkumar, A., Sumner, A.E., Hoofnagle, J., Reitman, M.L., Taylor, S.I. Efficacy and safety of troglitazone in the treatment of lipodystrophy syndromes. Ann Intern Med 2000;133:263–274 78. Reitman ML, Arioglu E, Gavrilova O, Taylor SI. Lipoatro- phy revisited. Trends Endocrinol Metab 2000;11:410–416 79. Smith U, Digirolamo M, Blohme G, Kral JG, Tisell LE. Possible systemic metabolic effects of regional adiposity in a patient with Werner’s syndrome. Int J Obes 1980;4: 153–163 80. Powell EE, Searle J, Mortimer R. Steatohepatitis associated with limb lipodystrophy. Gastroenterology 1989;97:1022– 1024 81. Kozak LP, Rossmeisl M. Adiposity and the development of diabetes in mouse genetic models. Ann N Y Acad Sci 2002;967:80–87 82. Lambert EV, Hudson DA, Bloch CE, Koeslag JH. Metabol- ic response to localized surgical fat removal in nonobese women. Aesthetic Plast Surg 1991;15:105–110 83. Cohen G. When liposuction goes wrong, the result can be deadly. US News World Rep 2000;128:56–58 84. Rao RB, Ely SF, Hoffman RS. Deaths related to liposuction. N Engl J Med 1999;340:1471–5 85. de Jong RH, Grazer FM. “Tumescent” liposuction alert: deaths from lidocaine cardiotoxicity. Am J Forensic Med Pathol 1999;20(1):101 86. Fedorov I, Rozanova LS. Liposuction. Khirurgiia 1998;5:48–49 87. Samdal F, Aasen AO, Mollnes TE, Hogasen K, Amland PF. Effect of syringe-assisted liposuction on activation of cas- cade systems and circulating cells when using the superwet or tumescent technique. Ann Plast Surg 1995;35:242–248 88. Smith KA, Levine RH. Influence of suction-assisted lipectomy on coagulation. Aesthetic Plast Surg 1992;16: 299–302 References Liposuction for Gynecomastia Enrique Hernández-Pérez, Hassan Abbas Khawaja, Jose A. Seijo-Cortes C  68 68.1 Introduction Male breasts are one of the four most requested areas for liposuction in men (after love handles, abdomen, and submaxillary fat) [1]. This is true not only in teenagers but also in adult men. The reason being the cosmetic inconvenience and the loss of self-confi- dence produced by a feminine self-image. Pseudogynecomastia is defined as an excessive amount of adipose tissue in the male breast, along with a normal amount of glandular breast tissue [1]. True gynecomastia is the increase in size of male breasts due to glandular tissue proliferation [2, 3]. A mixed variety combines excessive fatty and glandular tissue. 68.2 Pathogenesis Pseudogynecomastia is typically an idiopathic con- dition [1]. A central issue in the evaluation of breast tissue in adult men is the separation of the normal from the abnormal. A common belief is that no breast tissue is palpable in the normal adult man; however, gynecomastia (less than 4–5 cm in diameter) may oc - cur in normal men [4]. Physiological gynecomastia occurs in at least three circumstances: (1) at a few weeks of age (transitory enlargement); (2) in adolescence (median age onset is 14, it is grossly asymmetric, frequently tender, and regresses spontaneously) [5]; and (3) gynecomastia in elderly men (40% have gynecomastia). There also exists a pathological gynecomastia that can result from one of four basic mechanisms [1–4, 6]: 1. Deficiency in testosterone production or action (congenital anorchia, Klinefelter syndrome, testicular feminization syndrome). 2. Increase in estrogen production (aberrant produc - tion of chorionic gonadotropin by testicular or by bronchogenic carcinoma or even estrogen production caused by true hermaphroditism) [5, 7]. 3. Increased conversion of androgens to estrogens in peripheral tissues (congenital adrenal hyperpla- sia, hyperthyroidism, and feminizing adrenal tumors). 4. Drugs such as digitalis, alkylating agents, spi- ronolactone, cimetidine, busulfan, isoniazid, tri- cyclic antidepressants, -penicillamine, anabolic steroids, phenytoin, clomiphene, and diazepam. Abuse of heroin and marijuana also may cause gynecomastia. 5. Consecutive to trauma [5, 7]. When the physician discovers unilateral enlargement in a male breast with obvious asymmetry it is mandatory to rule out a primary breast tumor and a mammogram must be ordered [1]. 68.3 Surgical Anatomy Breast tissue has increased vascularity and the ten- dency for bleeding with breast liposuction is greatly attenuated by tumescent anesthesia [1]. However, it is important that the surgeon remember the proximity of the pectoralis muscle because it makes this tissue vul- nerable (by either infiltration or liposuction) to trauma during male breast liposuction with the potential risk of bleeding and hematoma [8]. Therefore, a careful exploration is important in order to locate the breast tissue–pectoralis interface [1]. In this sense, the patient is asked to tighten the pectoralis muscle so that the surgeon can appreciate the textural difference between soft fat, the firm muscle, and the glandular tissue. An- other way to distinguish it is by asking the patient to put his hands behind his head in the supine position. This maneuver will stretch the pectoralis muscle and again the palpation will reveal which tissue is fat. Another important point is in relation to the adipose tissue; the male breast is very fibrous and therefore additional effort will have to be made in order to perform reduction with liposuction [1]. Finally, true breast glands in men are located subja- cent to the nipple-areolar complex and are firmer than 461 the surrounding fatty tissue. When glandular tissue predominates (true gynecomastia), liposuction will not be as successful as with only fatty tissue. A rou- tine mammogram may facilitate the assessment of the amount of glandular tissue versus adipose tissue [1]. 68.4 Preoperative Preparation An extensive discussion about patient expectations related with the procedure is important as well as photographic documentation. Also, it is useful to draw on the patient in order to define the objectives of the proposed surgery. The increase of male pseudogynecomastia with age and degree of obesity as well as with increasing obesity means that fat may also be augmented along the anterior axillary area and on the lateral chest wall. Therefore, it is important to treat those areas at the same time in order to reach a satisfactory result. All patients, irrespective of age, are sent to the cardiologist for a complete cardiac and vascular checkup, mentioning especially that we are going to use epinephrine for the procedure. Only patients in categories ASAI or II should be included. Patients with congestive cardiac failure are excluded. Patients undergo a complete hematological checkup which includes especially liver function tests, fasting blood sugar fasting, hepatitis B and C profile, and HIV studies [9]. A detailed history of drugs and other etio- logic factors are taken into consideration. Patients are advised to use an antiseptic soap bath 3 days prior to surgery, especially in the areas to be liposuctioned. The authors use povidone iodine or clorhexidine. All medications especially aspirin, β-blockers, vitamin E, and herbal drugs are discontinued 10 days prior to surgery [9]. Patients are advised not to smoke 2 weeks prior to surgery. An oral antibiotic (cefadroxil mono- hydrate) is started 1 day before surgery and contin - ued for 7 days postoperatively. Clonidine (0.1 mg), as a premedication, is given 1 h prior to surgery to those patients whose blood pressure is greater than 90/60 mmHg. As an α2 adrenergic agonist (besides its hypotensive action), clonidine has hypnotic, sedative, and analgesic actions; therefore, this drug has a synergistic sedative effect which decreases the re- quirements and the total dosage of intravenous sedation–analgesic medication, with the obvious benefits in the postoperative period [10]. The authors also use 150 mg of ranitidine in a suspension and 10 mg of methoclopramide orally in order to reduce the risk of postoperative vomiting [10]. 68.5 Operative Technique A careful cleaning of the areas is done using povidone iodine from the neck, including the axillae to the um- bilicus. A second cleaning of the breasts with povidone iodine is done starting from the nipple and areola and moving centrifugally. After careful scrub-up using a double-brush technique and 10 min for scrubbing us - ing povidone iodine and disposable gowns and sterile disposable gloves, the procedure is started. A sterile operating room technique is mandatory. Using insulin syringes, 1% lidocaine/1:400,000 epinephrine is injected intradermally in the incision sites in the anterior axillary line. The incision sites are incised using a no. 11 blade. The infiltration is started with a 10-ml syringe using a Lamis infiltration syringe system and chilled Klein’s solution [11, 12]. Light intravenous sedation using midazolam and fentanyl is performed by an experienced anesthesiologist, who monitors carefully the patient during the surgery [11]. Immediately prior to surgery, an 1 g of antibiotic (from the same group as a cephalosporin) is administered by the anesthesiologist. If there is excessive hypertrophy, and the procedure exceeds 3 h, the same dose of antibiotic is repeated. A very small incision is made with the tip of a no. 11 blade scalpel. The placement of the incision is different when working in gynecomastia or in pseudogynecomastia (Fig. 68.1). An infiltration pump for the anesthesia is hardly ever necessary. A modification of Klein’s solution without bicarbonate (0.05% lidocaine 0.05%, 1:1×10 6 epinephrine) is used [9, 11]. We believe bicarbonate in Klein’s solution causes excessive inflammation and shortens the anesthetic period. Triamcinolone is not used [11]. The infiltration is carried out not in the gland, but in the retromammary space between the gland and the muscle (pectoralis major). While one hand is inject- ing, the other hand feels the tumescence [11–14]. The Fig. 68.1. The placement of the incisions is different in a pseudogynecomastia and b gynecomastia 68.5 Operativce Technique 462 68 Liposuction for Gynecomastia infiltration is stopped only when the breasts become stony hard. Liposuction is started using 3-mm keel cobra tip cannulas working in the retromammary space [9, 14]. Liposuction is started using a machine at a pressure of –30 mmHg. Syringe liposuction can also be car - ried out using a Toomy or a Tulip system and 60-ml syringes. The base of the cannulas is protected with a gauze to prevent damage to the lips of the incision sites. Gentle homogeneous movements are carried out. While one hand performs the liposuction, the other hand lifts the breast tissue upwards in order to prevent unnecessary damage to the breast tissue itself and for smooth working of the cannula in the retromammary space. The idea is not to perform liposuction in the breast tissue itself, but to perform it in the retromammary space that is filled with fat between the gland and the pectoralis major muscle. Tunnels are created centrally from below and from the lateral edge of the breasts [9, 14]. The axillary approach for liposuction is not used. A number of complications (vascular, nerve) can take place with that approach and when using the ultrasonic method of liposuction, especially internal ultrasound [15]. A touch-up is pro- vided with a 2-mm cannula. After the procedure, all the remaining fluid, as much as possible, is pushed out of the incision sites using roller towels. The incision sites are not closed. Sterile padding and French tape are applied over areas of liposuction. The French tape is applied in the form of a plus, corresponding to the direction of the tunnels [9, 14]. The pressure garment is applied on top of the French tape. Steroid injection, 4–8 mg of dexamethasone, perioperatively and an antiemetic injection in the immediate postoperative period are given by the anesthesiologist. The situation with true gynecomastia is a little different. Once the incision has been made several pass- es of the cannula are made to dissect and liberate the glandular tissue. The tissue is grasped with a Kocher forceps and all adhesions are dissected carefully and gently. Special care must be taken with the nipple and the areola. All the remaining fluid is removed at the end. 68.6 Postoperative Considerations All the garments and dressings are removed on the second day postoperatively and the areas are exam- ined and cleaned. Only pressure garments are advised for the next week [16]. Postoperative tenderness usually settles quickly [17]. Low-dose steroids are pre- scribed, if necessary, which decrease the inflammation. Urea (10%) and 1% hydrocortisone cream, to be used twice daily, is applied over areas of liposuction to improve the inflammation and decrease the hardness. The results are generally excellent (Figs. 68.2–68.5). A touch-up is hardly ever necessary. An anti-inflamma- tory ultrasound procedure is started after 1 week and is repeated once a week for 4–6 weeks. Most patients are able to go back to work the day after surgery and can resume full sport activities in 2weeks. 68.7 Complications 68.7.1 Hematoma Hematoma can take place if the tumescent technique is not utilized or ultrasonic liposuction is used. In- ternal ultrasound is dangerous and can damage the Fig. 68.2. a Preoperative patient with gynecomastia. b Postoperative patient a b 463 vasculature of the breast via penetrating rays. On the other hand, seroma and/or hematoma are/is avoided with the correct compression. 68.7.2 Edema/Irregularities Postoperative edema usually settles down quickly. Ir- regularities are generally not seen unless the operation is performed by an inexperienced surgeon [18]. 68.7.3 Vascular Injuries Damage to the perforating branches of the internal thoracic artery, intercostal arteries, lateral thoracic and thoracoacromial branches of the axillary artery, and corresponding veins can take place over the breast, leading to hematoma formation [19, 20]. Damage to the axillary artery, its branches, and the axillary vein can occur if the axillary approach is used with either conventional cannulas or ultrasonic ones. Ultrasonic cannulas over the left breast are very dangerous owing to the close proximity of the heart, while on the right side, damage to the lung and liver can take place. 68.7.4 Nerve Injuries Damage to the roots, trunks, and divisions or cords of the brachial plexus can take place if an axillary approach is used [15, 20]. 68.7.5 Dysesthesia There also exists the possibility of some degree of nipple hyperesthesia or, on the other hand, loss of nipple sensation. Both are transient. 68.8 Conclusions Male breast liposuction usually offers very nice results for this common problem of gynecomastia. Improve- ment in the body contouring as well as in the self-es- teem constitutes the aim of this operation. References 1. Klein JA: Tumescent Technique. Tumescent Anesthesia & Microcannular Liposuction. Mosby, St Louis, 2000: 404–412 2. Carlson HE. Gynecomastia. N Eng J Med 1980; 303;795 3. Wilson JD, Aiman J, Mc Donald PC. The Pathogenesis of Gynecomastia. Adv Intern Med 1980; 25:1–32 4. Nuttall FQ. Gynecomastia as a Physical Finding in Nor- mal Men. J Clin Endocrinol Metab 1979; 48:338 5. Mann CV, and Russell RCG: Bailey and Loves Short Prac- tice of Surgery, 21 st Edition. London: Chapman and Hall, 1992:820–821 6. Spence RW et al. Gynecomastia Associated with Cimeti- dine. Gut 1979;20:154 7. Kirk RM, and Williamson RCN: General Surgical Op- erations, 2 nd Edition. London: Churchill Livingstone, 1987:339 8. Ratz JL, Geronemus RG, Goldman MP: Textbook of Der- matologic Surgery, 1 st edition. Philadelphia: Lippincott Raven, 1998:547–564. 9. Hernández-Pérez E, and Lozano-Guarin C: Volume lipo- sculpture: variations on a technique. Cosmet Dermatol 1999; 35–39 10. Hernández-Pérez E, Espinoza-Figueroa D. Clonidina en Liposucción ¿Es realmente util? Act Terap Dermatol 2003;26:60 11. Hernández-Perez E, and Henríquez A: Clarifying concepts in modern liposuction. Int J Aesth Restor Surg 1994;4: 65–67 12. Klein JA: The tumescent technique for liposuction surgery. Am J Cosm Surg 1987; 4:263–267 13. Klein JA: Anesthesia for liposuction in dermatologic surgery. J Dermatol Surg Oncol 1988; 10: 1124–1132 Fig. 68.3. a Preoperative patient with pseudogynecomastia. b Postoperative patient a b References 464 68 Liposuction for Gynecomastia 14. Fournier PF: Therapeutic megalipoextraction or megali - posculpture: indications, technique, complications and results. Am J Cosm Surg 1997;14:297–310 15. Shiffman MA, and Mirrafati S: Possible Nerve injuries in the Axillary Approach to Breast Augmentation Surgery. Am J Cosm Surg 2001; 18(3):149–151 16. Fulton JE, Rahimi AD, Abuzenik P. Breast Reduction with Tumescent Liposuction. Am J Cosm Surg 200;18:15 17. Baxt S. The Scarless Breast Reduction. Plastic Surgery Products July, 2000. 18. Fodor PB. Breast Reduction Liposuction- only attracts at- tention. Cosmetic Surgery Times 2000;3:1 19. Snell RS: Clinical Anatomy for Medical Students, 4 th Edi- tion. Boston: Little, Brown and Company 1992:440–448 20. Chaurasia BD: Human Anatomy Regional and Applied, 2 nd Edition. Delhi: Jain Bhawan, 1992:22–32 Axillary Approach in Suction-Assisted Lipectomy of Gynecomastia Antonio Carlos Abramo C  69 69.1 Introduction Gynecomastia or hypertrophy of breast tissue is a serious cosmetic compromise for either adolescent or adult men. Male breast enlargement is a relatively common occurrence during puberty. In the majority of patients no pathologic cause for the problem can be found. A minimal degree of hypertrophy of breast tissue is a normal happening in the adolescent man, re- gressing spontaneously with maturity. Maintenance of the breast enlargement addresses surgical treatment of the gynecomastia. Breast enlargement in the adult man occurs owing to excess adipose tissue or to combination of adipose and glandular tissue. Sponta- neous regression in adult men is occasional and surgical treatment is indicated most of the time. 69.2 Anatomy The breast is rudimentary in men, although the structure is identical with that of the female breast. The glandular tissue distributes radially from the nipple in fifteen to twenty lobes, which are composed by multiple small ducts of lobules [1]. Adipose tissue fills the interstices between the lobules but is absent or in small amount at the nipple-areola complex. A framework of fibrous strands transverses the breast supporting its lobules, connecting with the skin as the suspensory ligaments of Cooper and reaching back to the pectoralis fascia. Layers of adipose tissue infiltrate into the framework of fibrous strands also extending around the glandular tissue [1]. This rudimentary structure becomes enlarged in gynecomastia with prevalence of either glandular or adipose tissue regarding the etiology of the gynecomastia. 69.3 Etiology The etiology of gynecomastia is not completely as- certained. In late adolescence and in the adult man gynecomastia can be associated with endocrine dis- orders, usually related to tumors of the adrenal gland. Hormonal imbalance increases both glandular and adipose tissues. The indiscriminating use of anabolic steroids causes gynecomastia, including its recur- rence after clinical or surgical treatment [2]. Con- genital anomalies, such as the Klinefelter syndrome, affect men with gynecomastia and feminine fat distribution, exhibiting elevated amounts of estrogen and progesterone receptors [3]. The Peutz–Jeghers syndrome associated with feminizing Sertoli cell tumor, also affects men with prepubertal gynecomastia [4]. Various medications or medical conditions, such as tumors of the prostate gland, develop glandular gynecomastia with moderate acinar and lobular formation. Patients presenting idiopathic gynecomastia have an obscure or unknown cause, with the breast enlargement arising spontaneously owing to the development of adipose tissue, glandular tissue, or both adipose and glandular tissue. 69.4 Classification Propositions to arrange into classes the multiple expressions of gynecomastia include an oversimplifica- tion of the male breast deformities regarding the size of the breast enlargement and the etiology of the dis- order. Simon et al. [5], on the basis of morphological deformities, classify the size of the male breast enlargement according to the breast volume and the skin redundancy, distributing the gynecomastias into four grades: 1. Grade 1: Minimal enlargement of the breast tissue 2. Grade 2A: Moderate enlargement of the breast tis - sue without skin redundancy 466 69 Axillary Approach in Suction-Assisted Lipectomy of Gynecomastia 3. Grade 2B: Moderate enlargement of the breast tissue with moderate skin redundancy 4. Grade 3: Massive enlargement of the breast tissue with expressive skin redundancy Geschikter and Copeland [6] associate etiological and parenchymal disturbances of the male breast to classify the breast enlargement, distributing the gynecomastias in four types regarding the influence of etiological and parenchymal disturbances in the morphological deformity: 1. Type 1 or diffused hypertrophic form: usually oc - curs during adolescence owing to hormonal imbalance with feminine characteristics for the male breast 2. Type 2 or fibroadenomastosa form: similar to the diffuse hypertrophic form with nodules of either glandular or fibrous tissue spread in the breast 3. Type 3 or true gynecomastia: increase of both glandular and adipose tissue, resembling the female breast in size and shape 4. Type 4 or pseudogynecomastia or adipose form: increase of adipose tissue without compromise of the glandular tissue, usually encountered in the adult man 69.5 Indications Indication for the surgical correction of gynecomastia by use of suction-assisted lipectomy through the axillary approach is based on careful patient selection and accurate diagnosis of the breast deformity. Clini- cal examination in conjunction with ultrasonogra- phy and mammography is capable of determining the consistency and density of the breast enlargement, making a distinction between soft or adipose gynecomastia, firm or glandular gynecomastia and adipose– glandular gynecomastia. Examination of the patient with the arms in an upright position is helpful to define the limits of the glandular tissue in the breast enlargement. Skin compromise such as flaccidity, redundancy, and striations rather than the breast enlargement must be appraised in detail during clinical examination. Young patients with good skin tone are the ideal candidates for suction-assisted lipectomy; however, old age is not a contraindication. Although a decrease in skin elasticity occurs with increased age, the ability of the skin to shrink still remains. Pa- tients with less than ideal indication are more commonly encountered, but recovery of the chest contour with suction-assisted lipectomy through the axillary approach is almost the same as for those with ideal indication. 69.6 Surgical Procedures Surgical correction of the multiple expressions of gynecomastia involves subcutaneous mastectomy and/or suction-assisted lipectomy with individual ap- proaches. The commonest approach for direct subcutaneous mastectomy in the treatment of gynecomastia is the semicircular intra-areolar incision described by Webster [7]. Balch [8] proposed the transaxillary approach to avoid noticeable scars after subcutaneous mastectomy in surgical correction of gynecomastia. Ohyama et al. [9] used the transaxillary approach for endoscope-assisted en bloc removal of fat and glandular tissue in treating gynecomastia. However, unpleasing scars, skin redundancy, irregularities on chest contour, and deformities of the nipple-areola complex, as result of subcutaneous mastectomy, ad- dress surgical correction of gynecomastia to mini- mally invasive procedures. According to Abramo [10] combination of the axillary approach with suction-assisted lipectomy decreases, significantly, the morbidity in the treatment of multiple expressions of gynecomastia, avoiding these disagreeable results. 69.6.1 Suction-Assisted Lipectomy Through the Axillary Approach Suction-assisted lipectomy through the axillary approach can be performed with or without fluid infiltration of the breast tissue. The «dry technique» that does not use preinfiltration of fluid is accompanied by a higher percentage of blood in the aspirate. The «wet technique» uses preinfiltration of fluids with a low-dose of epinephrine and dilute local anesthetic added, regardless of the breast enlargement. Applica- tion of the wet procedure reduces the blood loss to approximately 4–8% of the aspirate [11]. 69.6.2 Equipment Accurate selection of appropriate equipment is of utmost importance in suction-assisted lipectomy through the axillary approach. The standard instrumentation technique and the syringe technique are the most commonly employed procedures in surgical correction of gynecomastia because of the excellence of aesthetic results and the very low rate of complications. The standard instrumentation procedure uses an electric pressure vacuum pump connected to the suction cannula by non-collapsible tubing. The syringe technique utilizes a syringe directly connect - ed to the suction cannula, generating the negative pressure required to aspirate breast tissue drawing back the syringe plunger. The repetitive and linear [...]... morbus Madelung Handchir Mikrochir Plast Chir 199 2;24: 93 96 References 9 Martinez-Escribano JA, Gonzalez R, Quecedo E, Febrer I: Efficacy of lipectomy and liposuction in the treatment of multiple symmetric lipomatosis Int J Dermatol 199 9;38:551–554 10 Zocchi M: Ultrasonic liposculpturing Aesth Plast Surg 199 2;16:287– 298 11 Faga A, Valdatta LA, Thione A, Buoro M: Ultrasound assisted liposuction for... bilaterally; abdomen 1300 ml aspirated) 4 79 480 70 Ultrasound-Assisted Liposuction for Gynecomastia Fig 70.7 a Pre-op frontal view: 25-year-old boy already operated of mixed gynecomastia with standard liposuction Note still permanence of tissue, cutaneous ptosis and skin laxity b Pre-op oblique right view view: 25-year-old boy already operated of mixed gynecomastia with standard liposuction Note still permanence... abdomen 90 0 ml aspirate) h Post-op lateral left view: 2 months after VASER liposelection (breasts 1110 ml aspirate bilaterally; abdomen 90 0 ml aspirate) 70.5 Conclusions Fig 70.6 a Pre-op frontal view: 28-year-old man with pure gynecomastia and lipodystrophy of abdomen b Pre-op oblique right view: 28-year-old man with pure gynecomastia and lipodystrophy of abdomen c Pre-op lateral right view: 28-year-old... 197 8;61(1):13–16 9 Ohyama, T., Takada, A., Fujikawa, M., Hosokawa, K.: Endoscope-assisted transaxillary removal of glandular tissue in gynecomastia Ann Plast Surg 199 8;40(1):62–64 10 Abramo, A.C.: Axillary Approach for gynecomastia liposuction Aesth Plast Surg 199 4;18(3):265–268 11 Fodor PB Editorial Wetting solutions in aspirative lipoplasty A plea for safety in liposuction Aesth Plast Surg 199 5; 19( 4):3 79 380... multiple symmetric lipomatosis Int J Dermatol 199 9;38:551–554 Carlin, M.C., Ratz, J.L.: Multiple symmetric lipomatosis: treatment with liposuction J Am Acad Dermatol 198 8;18:3 59 362 Basse, P., Lohmann, M., Hovgard, C., Alsbjorn, B.: Multiple symmetric lipomatosis: combined surgical treatment and liposuction Case report Scand J Plast Reconstr Surg Hand Surg 199 2;26:111–112 Adamo, C., Vescio, G., Battaglia,... Ultrasound-Assisted Liposuction for Gynecomastia Fig 70.5 a Pre-op frontal view: 33-year-old man with lipodystrophy of abdomen with pure gynecomastia Note extreme laxity of abdominal skin b Pre-op oblique right view: 33-year-old man with lipodystrophy of abdomen combined with pure gynecomastia c Pre-op lateral right view: 33-year-old man with lipodystrophy of abdomen with pure gynecomastia d Pre-op lateral... technique Ann Plast Surg 199 8;40(3):241–245 20 Khan, J.I., Ho-Asjoe, M., Frame, J.D.: Pectoralis major rupture postsuction lipectomy for surgical management of gynecomastia Aesth Plast Surg 199 8;22(1):16– 19 21 Tebbets, J.B.: Minimizing complications of ultrasound-assisted lipoplasty: an initial experience with no related complications Plast Reconstr Surg 199 8;102(5):1 690 –1 697 22 Cedidi, C.C., Berger,... a liposuction cannula 71.8 Liposuction Liposuction for the treatment lipomas is the commonest non-cosmetic use of liposuction The use of liposuction to treat lipomas was first described in 198 5 by Rubenstein et al [9] The advantages of liposuction over open techniques in addition to smaller scars include shorter operative times, diminished postoperative pain, and decreased incidents of hematomas and. .. and fibrous tissue around the central portion of the breast, defining the glandular tissue resistant to the round-pointed suction cannula The 2.0-mm round-pointed suction cannula aspirates fat tissue at the outlined boundary of the breast enlargement, refining the chest contour Finally, the 4.0-mm sharp-pointed suction cannula dissects and aspirates the residual glandular tissue underneath and sur-... recommend liposuction just for minor fatty masses [7 9] Actually liposuction, both conventional and superwet, tumescent, or by the syringe technique can be too rough in some particular areas such as deep neck compartments where gross vessels and vital structures are present Ultrasound-assisted liposuction (UAL), compared with traditional liposuction, allows the surgeon to use more delicate and precise . treated by liposuction. Diabe- tes Care 199 3;16 :92 9 93 0 74. Samdal F, Amland PF, Sandsmark M, Birkeland KI. Dia- betic lipohypertrophy treated with suction-assisted lipectomy. J Intern Med 199 3;234:4 89 492 75 insulin resistance. Diabetes 199 9;48 :94 98 45. Jensen MD. Regional glycerol and free fatty acid metabolism before and after meal ingestion. Am J Physiol 199 9;276:E863-E8 69 46. Meek SE, Nair KS,. Re- constr Surg 199 2; 89: 1068–10 79; discussion 1080–1082 35. Albin R, de Campo T. Large-volume liposuction in 181 patients. Aesthetic Plast Surg 199 9;23:5–15 36. Skouge JW. The biochemistry and

Định dạng
Số trang	58
Dung lượng	2,27 MB