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Achieving Symmetry with Liposculpture
Tumescent liposuction, developed and perfected by dermatologists, is now the state of the art with respect to body contouring. Advances in this operation have maximized patient safety and minimized unwanted difficulties.

 

Great strides have been made with respect to local anesthesia, infusion and suction pumps, micro incisions, microcannulas, and postoperative care. However, relatively little has been said about one facet of the outcome that the patient notices the most: the achievement of bilateral symmetry. The author would therefore like to provide the liposuction surgeon with a number of tried and true "nuts and bolts" methods for achieving a symmetrical, even result with tumescent liposculpture. Ten important steps are described by which the dermatologic surgeon can utilize a variety of techniques to produce natural contours, generate even results, and enhance patient satisfaction. Improved instrumentation and operative techniques can result in beautiful outcomes with tumescent liposculpture. The fine results now possible should result in ever-increasing public awareness of, and demand for, this cosmetic sculpting.

TABLE 1

Ten Commandments for Symmetrical Results

  1. Preoperative evaluation
  2. Premarking
  3. Photography
  4. Suctioning sequence
  5. Recording suction volumes
  6. Pinch technique
  7. Cannula sequence
  8. Intraoperative inspection
  9. Postoperative inspection
  10. Final touch up
1. Preoperative Evaluation: A patient should not go directly from a brief consultation to the actual surgery, but should be given the benefit of a preoperative visit. High quality reproducible photographs should be obtained by the surgical staff, and a weight obtained. In addition, careful measurements of all areas to be treated should be performed. The patient's priorities and concerns can be voiced. A history may reveal areas that come and go with exercise. A patient can, of course, also be warned about barriers to a perfectly even outcome, including preexisting cellulite, stretch marks, sun damage, skin folds, dimples, scars and irregularities. Since most of the tunnels are placed in the deeper fat compartments in order to avoid surface changes, the patient must realize that most of these defects will not disappear (though some improvement may be seen) following the body contouring.
Female patient before liposculpture with excess fat on inner thighs, knees and saddle bags giving her a "bow-legged" appearance. Markings shown immediately preoperatively with fat to be removed in these areas. Note that patient has brought her bikini to the office to allow the surgeon to attempt to hide the tiny incisions under the areas to be covered by clothing. Note excellent final result from tumescent liposculpture with improvement in all areas.
2. Premarking: In the patient prep area, prior to the procedure, and prior to any sedation or local anesthesia, the patient is examined in the upright position. All areas to be contoured are delineated with a surgical marker. Regions are marked according to both visual inspection and by palpation. The patient can voice concerns about asymmetry and can give his or her approval to the areas to be suctioned. Symmetrical incision sites, feathering zones, and areas targeted for maximum fat removal are inscribed. These markings are then recorded diagrammatically on the operative report sheet.
3. Photography: 35mm photographs are obtained in the upright position prior to, and after, affixing the surgical markings. In addition, good quality Polaroid photographs should be obtained preoperatively. These Polaroid photos can be viewed intraoperatively by the surgeon to facilitate the goal of bilateral symmetry. Patients are often quite impressed when this preoperative Polaroid is viewed adjacent to an immediate postoperative one.
Polaroid photos viewed immediately postoperatively. On the left is the preoperative appearance of a male in his 30's with a "spare tire" and "love handles" as well as fat in the abdomen and midriff. On the right note the extreme improvement seen moments after the surgery was completed. Inspection in the standing position allows achievement of symmetry and uniform results.
4. Suctioning Sequence: Ideally, liposuction of individual body areas should be performed in the same order that the tumescent anesthesia was administered in order to optimize the surgeon's rhythm and concentration. Typically, liposuction takes longer to perform than does the infusion of local anesthesia. However, the maintenance of an exact sequence will hopefully catch the tissues in a similar state of tumescence each time.
5. Recording Suction Volumes: This obvious concept can be quite helpful if performed on a routine basis. However, some limitations do exist. Fatty areas suctioned initially tend to contain more fluid than those encountered near the conclusion of the procedure. This is due to the fact that tumescence (though not local anesthesia) tends to disappear after 1-2 hours, although, of course, the surgeon could choose to reinject immediately prior to suctioning a given area. Varying amounts may have been suctioned from adjacent areas (for example, the abdomen adjoining each flank), resulting in different postoperative volumes. Finally, preexisting asymmetry will, of course, generate dissimilar postoperative volumes.

Note thickness of existing abdominal fat

Pinch technique demonstrates that most of fat has been removed

Pinch comparison on contralateral side leads to symmetrical results

6. Pinch Technique: Body areas undergoing treatment can be continuously evaluated preoperatively, intraoperatively, and postoperatively for symmetry, depth, and adequacy of fat removal. With this method, the nondominant pinching hand is the "smart hand" whereas, the dominant hand serves more as a piston. The pinch technique can be used to direct the cannula to the proper depth, protect deeper or adjacent structures (such as the neck or face), maintain the proper angle, bring pockets of fat to the tip of the cannula, immobilize "squirrely" areas, "roll" the cannula from area to area, feel the fat actually disappear with each stroke, and compare the residual thickness of contour in lateral or opposing areas.
7. Cannula Sequence: It is a useful discipline to attempt to deploy the same cannula designs and sizes and the same sequence for each body area. The flow rates, depth, level of penetration, and facility of use can, of course, vary greatly from cannula to cannula, and among different sizes of the same cannula. A dermatologic surgeon might perform pretunneling with a 14 or 12 gauge cannula, moving then to a 10 or 12 gauge, followed by a 3mm instrument, then a 12 gauge cannula, and concluded with the use of a 14 gauge cannula for fine feathering, for each side. This technique can, of course, be modified according to specific goals or needs, but it is a useful concept to consider.
8. Intraoperative Inspection: In spite of the presence of tissue tumescence, the dermatologic surgeon should learn to appreciate subtle differences in tissue thickness and contours for opposing body areas. The finished product should look "even" without elevations or depressions, and should have a contour similar to the contralateral side. One learns, of course, to mentally subtract the tumescence present in feathering zones or in anesthetized areas immediately beyond areas that were suctioned, especially on the thighs. Experience in positioning will enable the dermatologic surgeon to extrapolate the final result in a horizontal patient to the preoperative and postoperative standing appearance.

38 year old white female with unwanted fat on abdomen, hips, saddle bags and inner thighs.

Beautiful symmetrical results seen after tumescent liposculpture by Dr. Swinehart

10. Final Touch-up: Should the standing examination reveal any irregularity or asymmetry, these can be evened out with a few strokes with a 12 or 14 gauge cannula. This maneuver, taking only a minute or two, can make a significant difference in the final result.

39 year old white male with "love handles" and excess of nominal fat which he cannot remove through exercise

Thin, perfectly even contour following the procedure.

At the conclusion of the procedure, the patient is generally well awake, and the recovery period is usually short. Final vital signs are taken, and the intravenous line is removed. A paired comparison study recently performed in San Diego, with sutures inserted only on one side, revealed decreased scarring on the non-sutured side, presumably because of the absence of stitch marks. Therefore, sutures are generally not inserted unless the patient has plans to immediately travel a distance.

Instead, special high absorbency pads are secured over each incision. These pads are held in place by custom designed post liposuction elastic washable garments. Drainage generally ceases within 24 to 48 hours. By encouraging removal of excess fluid, the dermatologic surgeon and patient alike will appreciate the greatly decreased incidence of postoperative swelling, bruising, and soreness. Patients walk out of the surgical suite under their own power, and follow up phone calls often reach a relative who informs the staff that the patient has left to run an errand!

These patients often are able to work the following day. Gentle exercise can be commenced within two to three days, with more vigorous exercise by the end of the first week.

Because of the rapid healing, quite often after two to three weeks no one but the patient will be aware of the fact that liposculpture has been performed (except, of course, for the fact that the body shape is dramatically different!).

Post operative problems have been rare since the advent of tumescent liposuction. Indeed, no serious complications have been recorded anywhere in the country in a survey of over 15,000 patients who have undergone this procedure. No procedure, of course, is perfect, and occasional irregularities or untoward results must be anticipated, especially in those patients with preexisting imperfections. However, careful attention to the maneuvers described in this treatise should enable the dermatologic surgeon to maximize patient satisfaction following tumescent liposculpture.

NEXT ISSUE: We plan to focus on treatment of specific body areas in both male and female patients. In addition, we will explore the issues of fat transplantation, ultrasonic liposuction, and cellulite release.Dr. Swinehart specializes in Tumescent Liposculpture at 950 E. Harvard Avenue, #630, Denver, CO 80210 - Phone (303) 744-1202. Copyright 1997 CDC.

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