Advanced Techniques in Dermatologic Surgery - part 4 ppsx

fluid is removed, manual tissue stabilization (discussed below) performed by an assistant compensates the developing laxity of the skin turgor. Postoperatively, a thorough drainage of tumescent solution must be achieved by leaving the incision sites open and wearing compression garments. Figure 7 Endoscopic picture after complete liposuction of the lateral lower leg demon- strating of persisting fibrous tissue without adipocytes. Figure 8 Formation of a subcutaneous scar 12 months after liposuction. Photograph taken during abdominoplasty. 106 Sattler Technical Developments To obtain an atraumatic suction technique, technical developments led to an improvement of cannulas and liposuction-assisting devices. Manual Liposuction, 24-Hole Cannulas If correct tumescent local anesthesia is performed, then suction can be done with thin, blunt-tipped cannulas. The connective tissuecan further be spared when cannulas with multiple suction holes are used (24-hole cannulas). After building up the suction force, a number of holes (10–12,12–16) will be occluded by fibrous tissue. The remaining holes stay effective in lipo- suctioning, so the cannula cannot build up a higher suction force due to occlusion of the holes. As the suction force decreases, the holes that were previously blocked will reopen. When using two- or three-hole cannulas, it easily happens that all holes are occluded simultaneously. In this case, the suction force increases rapidly thus reinforcing the occlusion. Liposuction can be con- tinued only after cleaning of the cannula or destruction of the blo cking tissue. The developed suction force in a 24-hole cannula is just strong enough to remove the fat cells but too weak to suck in and destroy fibrous tissue or vessels. In this way, blockage of the cannula and destruction of the connective tissue is prevented and the treatment is subtler. Ultrasound-Assisted Liposuction (UAL) To facilitate fat aspiration in difficul t areas such as the male breast or back or in secondary sites, a number of new suction devices were devel- oped starting in the late1980s. In 1987, Scuderi and DeVita (12) and Zocchi (13) first described a method of homogenizing the fat with ultrasound waves. The suction cannu- laswereattachedtoanultrasoundgeneratorandultrasoundwavessentinto the ti ssue supposedly destroy the ad ipocytes. There are some severe disadvantages when using this technique. The cannulas must have a comparatively larger volume. A large number of seromas and skin burns and persisting hypo- or hyperaesthesias as a result of destruction of the myelin sheath of peripheral nerves were reported (14). There was even speculation about a potential carcinogenic risk. Therefore, the American Society of Dermatologic Surgery rates ultrasound assisted liposuction as an experimental method with no extended clinical use (15,16). Powered Liposuction/Vibrating Cannulas In 1995 , Charles Gr oss (17), an ENT surgeo n at the University of Virginia, described a new technique he used in liposuction of the neck called ‘‘lipo- shaving.’’ An engine-powered cannula with an integrated rotating blade was used to d estroy ad ipocytes under d irect vi sual o r endoscopic co ntrol. Liposuction 107 This idea started the invent ion of a new generation of cannulas, first with rotating blades but late r with oscillating blades. The latest development is cannu las without blades but with a vibrat- ing grip that leads to vibration of the cannula when passing through the tissue (Fig. 9). One rationale behind the use of vibrating cannulas is the different inertness of various materials wher eas, the cannula passes fibrous tissue without damaging it, the homogenized fat can be aspirated. The other aspect that aids this effect is the difference in velocity of the vibra- tion and the presence of the suction force. If the vibration speed is higher than the speed of the airflow of the suction, the suction can only withdraw the liberated, homogenized fat. The cannula will escape and spare the tissue structures that have tight attachments. Vibrating cannulas facilitate the treatment of fibrous or pretreated areas. Because they pass easily through the tissue and do not tangle with the fibers, they make the procedure more comfortable for the patient and the surgeon. Severe complications have not been reported. Further improvements of the cannulas and grips are expected, which will lead to a wide spread usage of this suction device as it shows greater benefits in achieving good operative outcome (18). Figure 9 Demonstration of vibrating cannula technique. Table 3 Sattler’s Tumescent Solution with Reduced Prilocaine Prilocaine 1% 40.0 mL Epinephrine 1:1000 1.0 mL Sodium bicarbonate 8.4% 6.0 mL Triamcinolon-acetonide 10 mg 1.0 mL Physiologic saline (NaCl 0.9%) 1000.0 mL 1048.0 mL solution 0.038% 108 Sattler Endoscopic Liposuction Liposuction is an operation without direct visual control. Endoscopic liposuction can be used to visualize what is happening in the subcuta- neous space during liposuction. This method helped to control the tech- nique and quality of liposuction and to give a further understanding of physiodynamic processes in the adipose tissue. It is not routinely used clinical procedure, but has helped in the development of new, useful lipo- suction devices. Refinements of the Tumescent Solution In the course of time, the original Klein tumescent solution was modified by various working groups. We first replaced lidocaine as local anesthetic with prilocaine because of its lower systemic plasma levels, which is relevant when using large volumes. As a resul t of clinical observations, prilocaine could be reduced by 20% from the initial 50 mL/L to 40 mL/L, which resulted in a reduced local anesthetic concentration of 0.038% (Table 3). Table 4 Tumescent Solution After Schneider-Affeld and Friedrich Prilocaine 2% 10.0 mL Lidocaine 2% 10.0 mL Epinephrine 1:1000 0.66 mL Sodium bicarbonate 8.4% 6.0 mL Triamcinolon-acetonide 40mg 0.33 mL Physiologic saline (NaCl 0.9%) 1000.0 mL 1026,99 mL solution 0.037% Table 5 Volumes of Tumescent Solution: Comparison of 1992 and 1997 Recommendations 1992 1997 Abdomen 800–1000 mL 5000 mL Hips (both sides) 400–1000 mL 5000 mL Waist (both sides) 400–1000 mL 3000 mL Lateral thigh (both sides) 500–1200 mL 4000 mL Ventral thigh (both sides) 600–1200 mL 4000 mL Medial thigh (both sides) 255–700mL 3000 mL Knee (both sides) 200–500 mL 2000 mL Male breast (both sides) 300–800 mL 3000 mL Neck 100–200 mL 800 mL Liposuction 109 In clinical trials, Schneider-Affeld and Friedrich combined lido- caine and prilocaine to decrease the side effects of a single agent. Their solution is shown in Table 4. As a consequence of reduction of the local anesthetic concentration and the growing knowledge of delayed absorption, the quantities of tumescent solution used in one session could be raised. The possibility to use more quantities of tumescent solution widens the therapeutic range. Today, up to 6 liters of tumescent solution are used in one session. Figure 10 Modern liposuction equipment with infiltrating pump connected to a Stenger distributor, a suction system, and warming devices for tumescence solution. 110 Sattler Clinical experience showed the better effects of super-tumescence when using large volumes; because of the reduction of tissue traumatization, the complication rate is also reduced. Table 5 gives a comparison of the initially recommended amounts of solution and the amounts used in 1997 and are still used today. The use of trimacinolone in the solution is discussed, many physi- cians do not add it any more. The initial rationale for its use, the prevention of postoperative inflammation, is no longer relevant. Meanwhile, other effects like psychovegetative stabilization as well as a regulative effect on the blood circulation play more important roles. Over the past years, the tumescent technique has evolved from a mainly anesthetic procedure to an essential part of successful liposuction, as it is crucial for the described processes of physiodynamics and wound healing, and d etermines the course of the surgery and postoperative outcome. Improved Operating Techniques and Positioning of Patient Besides technical and pharmacological improvements, clinical experience led to improvements in the operation procedure. The operative outcome can mainly be improved through active cooperation of the patient who is awake. It helps the suction process if the patient is able to contract the underlying muscles to build a firm base and change positions if necessary. Figure 11 (A) Preoperative findings in a 20-year-old patient with lipomatosis of the thighs. (B) Postoperative results four months after liposuction via tumescence technique with 24-hole cannulas. Liposuction 111 Figure 12 (A) and (B) Lipomatosis of hip, medial and lateral thighs in a 42-year-old patient, preoperative findings. (C) and (D) Postoperative result one year later. 112 Sattler The operative outcome can significantly be improved by a correct positioning of the patient on the operating table and an easy access to the surgery site. Experience has shown that it is better to treat the medial thighs not with the patient lying on his or her back but on the side with the leg to be treated stretched out on the operating table and the other leg in a 90 degree angle, to stabilize the position. With this positioning, there is a far better access to the fat deposits. When treating the back or flanks, it is better to position the patient on the side, with the back overstretched. With this improved positioning, the overlying skin as well as the underlying muscles are stretched, which makes the aspiration of subcutaneous fat easier. Manual assisted skin stabilization technique (MASST).Everyone performing liposuction surgery in tumescent technique has experienced that the stabilizing effect of the tumescent solution on the tissue decreases con- stantly because it is removed along with the fat by the suctioning process. Thus, liposuctioning gets more difficult as shearing forces on the tissue get stronger. This can be counteracted efficiently when the tissue is bimanu- ally stabilized by stretching it with the help of an assisting person (nurse). Last but not least, all the minor improvements that give the patient more comfort during the whole procedure should be provided. They include devices to warm sheets, blankets, and the tumescent solution to body temperature as well as a pleasant atmosphere created by music Figure 13 (A) Marked saddle bag deformity in 52-year-old patient. (B) Result after three liposuction sessions using tumescence anesthesia in yearly intervals, 6 years after the last liposuction. Liposuction 113 Figure 14 (A) and (B) Preoperative finding before liposuction of the hip, medial and lateral thigh as well as the knee region with vibrating cannulas. (C) Postopera- tive result after 12 months. 114 Sattler and room furnishing. When planning the surgery suite, it is important to include a bathroom within the easy reach of the patient (Fig. 10). SUMMARY The invention of the tumescent technique by Jeffrey Klein revolutionized the history of liposuction. This technique formed the basis on which numerous developments in the field of liposuction took place within the last 25 years. Today, lipo- suction in tumescent local anesthesia (a term coined by our group) is the most commonly performed cosmetic procedure worldwide. Owing to the improved operation techniques as well as refinements in the tumescent solution and the cannulas used, a sub stantial reduction of risks and side effects could be achieved. Thanks to all these improve- ments, we have reached a point today where this operation technique can offer a predictable and highly satisfactory cosmetic result with minimal risk. To show the extent of cosmetic outcomes , we include some pre- and postoperative findings (Figs. 11–14). Further progress can be expected through the development of more effective but at the same time more subtle cannulas. To find the best tumescent solution, pharmacological studies are planned. Liposuction 115 [...]... static wrinkling is to be treated Herniated lower eyelid fat pads may be present (Fig 18C) Chemical peeling as a medium-depth chemical peeling or deep phenol peeling will achieve the same result, but there are several advantages in using laser skin resurfacing over chemical peeling: an 136 Fratila Figure 17 The injection points for botulinum toxin type A periorbitally immediate tightening of the skin occurs... area are bruising, diplopia, drooping of the lateral lower eyelid, ectropion, and an asymmetric smile, if the effect of the toxin is spreading into zygomaticus major (19) Botulinum toxin A maybe injected 2 weeks before laser skin resurfacing or after healing The idea of using Botulinum toxin A before surgery is that the resurfaced skin will heal at rest and the risk of wrinkle recurrence is low However,... techniques may be advisable Botulinum Toxin Type A The indication for treatment with botulinum toxin type A is the occurrence crow’s feet when smiling If wrinkling around the eye persists at rest and/or moderate dermatochalasis is present, botulinum toxin type A is recommended in combination with UPCO2 laser skin resurfacing of the periorbital area (Fig 17) Usually, subcutaneously injection of 12 units of... laser, allowing the incision to heal better For laser skin resurfacing of the periorbital skin, the author Figure 12 (Facing page) (A) A skin-muscle flap is raised centrally and nasally (B) David-Baker retractor is replaced with stainless steel shield to avoid pressure trauma and prolonged edema of the pretarsal skin (C) The septum is opened over the Rabkin spatula as a backstop (D) Using Rabkin spatula... Liposuction Surgery (ASLSS) and American Academy of Cosmetic Surgery (AACS): Guidelines for Liposuction Surgery, 2001 2 Fischer A, Fischer G Revised technique for cellulitis fat reduction in riding breeches deformity Bull Int Acad Cosmet Surg 1997; 2 :40 41 3 Illouz Y Bodycontouring by lipolysis: a 5-year experience with over 3000 cases Plast Reconstr Surg 1983; 72:511–5 24 4 Fournier P Body Sculpturing Through... for most individuals The total dose for each eye is divided into four injection points: 3 U to the lateral sub-brow region, 4 U at the level of the lateral canthus and 2 cm lateral to the lateral canthus, 3 U 1.5 cm inferior and slightly medial to the second point, and 2 U infraorbitally, with avoidance of the pretarsal orbicularis The main complications owing to injection in this area are bruising, diplopia,... The advantages and disadvantages of using the CO2 laser as an incisional tool in blepharoplasty have been discussed in several articles (6,7), but today, there is no doubt that laser-assisted blepharoplasty of the upper and lower eyelid (transconjunctivally) in combination with UPCO2 laser skin resurfacing of the periorbital skin is the state-of-the-art technique in esthetic eyelid rejuvenation (personal... after turning into levator aponeurosis, inserts into the anterior surface of the tarsal plate Anterior extension of the aponeurotic fibers inserts into the eyelid skin beginning 2 mm above the superior margin of the tarsus, thereby creating the supratarsal crease (Fig 4) Deep below the levator palpebrae superioris muscle lies Muller’s muscle, an extension of the levator muscle that inserts into the superior... laser skin resurfacing periorbitally, and injection of botulinum toxin type A for the crow’s feet area This combination procedure helps reducing the operation and healing time as well as the cost of the operation, giving an even and better cosmetic outcome simultaneously (Fig 19C) When we combine chemical peeling and laser skin resurfacing for rejuvenation of the face, first, the chemical peeling is... simultaneously) thus producing almost perfect postoperative symmetry The advantages of using the UPCO2 laser are evident: minimal intraoperative bleeding and, thus, superior visualization, shorter operating time, and reduced postoperative bruising and swelling HISTORY Although the initial use and presentation of the laser-assisted blepharoplasty technique was first demonstrated by Sterling Baker in 1983 at the . mL Liposuction 109 In clinical trials, Schneider-Affeld and Friedrich combined lido- caine and prilocaine to decrease the side effects of a single agent. Their solution is shown in Table 4. As a consequence. laser-assisted blepharoplasty of the upper and lower eyelid (transconjunctivally) in combination with UPCO 2 laser skin resurfacing of the periorbital skin is the state-of-the-art technique in. and after turning into levator aponeurosis, inserts into the anterior surface of the tar- sal plate. Anterior extension of the aponeurotic fibers inserts into the eyelid skin beginning 2 mm above